|
Oncovin 1 mg Charge
|
Facility
|
IP
|
$59.00
|
|
|
Service Code
|
HCPCS J9370
|
| Hospital Charge Code |
2958927
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.91 |
| Max. Negotiated Rate |
$54.28 |
| Rate for Payer: Aetna Commercial |
$53.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$50.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$31.27
|
| Rate for Payer: Cash Price |
$17.70
|
| Rate for Payer: Cigna Commercial |
$54.28
|
| Rate for Payer: Health EOS Commercial |
$52.51
|
| Rate for Payer: HFN Commercial |
$54.28
|
| Rate for Payer: Multiplan Commercial |
$47.20
|
| Rate for Payer: NAPHCARE Commercial |
$35.40
|
| Rate for Payer: Preferred Network Access Commercial |
$54.28
|
| Rate for Payer: Quartz Beloit One Network |
$28.91
|
| Rate for Payer: Quartz Commercial |
$35.40
|
| Rate for Payer: WEA Trust Commercial |
$32.45
|
| Rate for Payer: WPS Commercial |
$43.70
|
|
|
Oncovin 1 mg Charge
|
Facility
|
OP
|
$59.00
|
|
|
Service Code
|
HCPCS J9370
|
| Hospital Charge Code |
2958927
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.47 |
| Max. Negotiated Rate |
$236.00 |
| Rate for Payer: Aetna Commercial |
$53.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$50.74
|
| Rate for Payer: Aetna Managed Medicare |
$16.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$38.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$29.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$28.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$31.27
|
| Rate for Payer: Cash Price |
$17.70
|
| Rate for Payer: Cash Price |
$17.70
|
| Rate for Payer: Cigna Commercial |
$54.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10.47
|
| Rate for Payer: Health EOS Commercial |
$52.51
|
| Rate for Payer: HFN Commercial |
$54.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44.25
|
| Rate for Payer: Multiplan Commercial |
$47.20
|
| Rate for Payer: NAPHCARE Commercial |
$35.40
|
| Rate for Payer: Preferred Network Access Commercial |
$54.28
|
| Rate for Payer: Quartz Beloit One Network |
$28.91
|
| Rate for Payer: Quartz Commercial |
$38.35
|
| Rate for Payer: Quartz Medicare Advantage |
$35.40
|
| Rate for Payer: The Alliance Commercial |
$236.00
|
| Rate for Payer: WEA Trust Commercial |
$32.45
|
| Rate for Payer: WPS Commercial |
$19.78
|
|
|
Ondansetrion hcl inj 1 mg J2405
|
Professional
|
Both
|
$2.00
|
|
|
Service Code
|
HCPCS J2405
|
| Hospital Charge Code |
3935359
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$1.90 |
| Rate for Payer: Aetna Commercial |
$1.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1.72
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna Commercial |
$1.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$0.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.10
|
| Rate for Payer: Health EOS Commercial |
$1.82
|
| Rate for Payer: HFN Commercial |
$1.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$0.15
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1.90
|
| Rate for Payer: Quartz Beloit One Network |
$0.88
|
| Rate for Payer: Quartz Commercial |
$1.14
|
| Rate for Payer: The Alliance Commercial |
$1.00
|
| Rate for Payer: United Healthcare Medicaid |
$0.10
|
| Rate for Payer: WEA Trust Commercial |
$1.10
|
| Rate for Payer: WPS Commercial |
$0.24
|
|
|
Ondansetrion hcl inj 1 mg J2405
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
HCPCS J2405
|
| Hospital Charge Code |
3935359
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$8.00 |
| Rate for Payer: Aetna Commercial |
$1.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1.72
|
| Rate for Payer: Aetna Managed Medicare |
$0.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$0.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1.06
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna Commercial |
$1.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.13
|
| Rate for Payer: Health EOS Commercial |
$1.78
|
| Rate for Payer: HFN Commercial |
$1.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1.50
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
| Rate for Payer: NAPHCARE Commercial |
$1.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1.84
|
| Rate for Payer: Quartz Beloit One Network |
$0.98
|
| Rate for Payer: Quartz Commercial |
$1.30
|
| Rate for Payer: Quartz Medicare Advantage |
$1.20
|
| Rate for Payer: The Alliance Commercial |
$8.00
|
| Rate for Payer: WEA Trust Commercial |
$1.10
|
| Rate for Payer: WPS Commercial |
$0.24
|
|
|
Ondansetrion hcl inj 1 mg J2405
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
HCPCS J2405
|
| Hospital Charge Code |
3935359
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.98 |
| Max. Negotiated Rate |
$1.84 |
| Rate for Payer: Aetna Commercial |
$1.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1.06
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna Commercial |
$1.84
|
| Rate for Payer: Health EOS Commercial |
$1.78
|
| Rate for Payer: HFN Commercial |
$1.84
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
| Rate for Payer: NAPHCARE Commercial |
$1.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1.84
|
| Rate for Payer: Quartz Beloit One Network |
$0.98
|
| Rate for Payer: Quartz Commercial |
$1.20
|
| Rate for Payer: WEA Trust Commercial |
$1.10
|
| Rate for Payer: WPS Commercial |
$1.48
|
|
|
Ondansetron 1 mg = 1 unit
|
Professional
|
Both
|
$2.00
|
|
|
Service Code
|
HCPCS J2405
|
| Hospital Charge Code |
4071964
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$1.90 |
| Rate for Payer: Aetna Commercial |
$1.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1.72
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna Commercial |
$1.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$0.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.10
|
| Rate for Payer: Health EOS Commercial |
$1.82
|
| Rate for Payer: HFN Commercial |
$1.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$0.15
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1.90
|
| Rate for Payer: Quartz Beloit One Network |
$0.88
|
| Rate for Payer: Quartz Commercial |
$1.14
|
| Rate for Payer: The Alliance Commercial |
$1.00
|
| Rate for Payer: United Healthcare Medicaid |
$0.10
|
| Rate for Payer: WEA Trust Commercial |
$1.10
|
| Rate for Payer: WPS Commercial |
$0.24
|
|
|
Ondansetron 1 mg = 1 unit
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
HCPCS J2405
|
| Hospital Charge Code |
4071964
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.98 |
| Max. Negotiated Rate |
$1.84 |
| Rate for Payer: Aetna Commercial |
$1.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1.06
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna Commercial |
$1.84
|
| Rate for Payer: Health EOS Commercial |
$1.78
|
| Rate for Payer: HFN Commercial |
$1.84
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
| Rate for Payer: NAPHCARE Commercial |
$1.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1.84
|
| Rate for Payer: Quartz Beloit One Network |
$0.98
|
| Rate for Payer: Quartz Commercial |
$1.20
|
| Rate for Payer: WEA Trust Commercial |
$1.10
|
| Rate for Payer: WPS Commercial |
$1.48
|
|
|
Ondansetron 1 mg = 1 unit
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
HCPCS J2405
|
| Hospital Charge Code |
4071964
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$8.00 |
| Rate for Payer: Aetna Commercial |
$1.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1.72
|
| Rate for Payer: Aetna Managed Medicare |
$0.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$0.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1.06
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna Commercial |
$1.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.13
|
| Rate for Payer: Health EOS Commercial |
$1.78
|
| Rate for Payer: HFN Commercial |
$1.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1.50
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
| Rate for Payer: NAPHCARE Commercial |
$1.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1.84
|
| Rate for Payer: Quartz Beloit One Network |
$0.98
|
| Rate for Payer: Quartz Commercial |
$1.30
|
| Rate for Payer: Quartz Medicare Advantage |
$1.20
|
| Rate for Payer: The Alliance Commercial |
$8.00
|
| Rate for Payer: WEA Trust Commercial |
$1.10
|
| Rate for Payer: WPS Commercial |
$0.24
|
|
|
Ondansetron 2mg/ml [Med]
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
HCPCS J2405
|
| Hospital Charge Code |
5298683
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.94 |
| Max. Negotiated Rate |
$5.52 |
| Rate for Payer: Aetna Commercial |
$5.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.18
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$5.52
|
| Rate for Payer: Health EOS Commercial |
$5.34
|
| Rate for Payer: HFN Commercial |
$5.52
|
| Rate for Payer: Multiplan Commercial |
$4.80
|
| Rate for Payer: NAPHCARE Commercial |
$3.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5.52
|
| Rate for Payer: Quartz Beloit One Network |
$2.94
|
| Rate for Payer: Quartz Commercial |
$3.60
|
| Rate for Payer: WEA Trust Commercial |
$3.30
|
| Rate for Payer: WPS Commercial |
$4.44
|
|
|
Ondansetron 2mg/ml [Med]
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
HCPCS J2405
|
| Hospital Charge Code |
5298683
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$24.00 |
| Rate for Payer: Aetna Commercial |
$5.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5.16
|
| Rate for Payer: Aetna Managed Medicare |
$1.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.18
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$5.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.13
|
| Rate for Payer: Health EOS Commercial |
$5.34
|
| Rate for Payer: HFN Commercial |
$5.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4.50
|
| Rate for Payer: Multiplan Commercial |
$4.80
|
| Rate for Payer: NAPHCARE Commercial |
$3.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5.52
|
| Rate for Payer: Quartz Beloit One Network |
$2.94
|
| Rate for Payer: Quartz Commercial |
$3.90
|
| Rate for Payer: Quartz Medicare Advantage |
$3.60
|
| Rate for Payer: The Alliance Commercial |
$24.00
|
| Rate for Payer: WEA Trust Commercial |
$3.30
|
| Rate for Payer: WPS Commercial |
$0.24
|
|
|
Ondansetron Charge
|
Professional
|
Both
|
$2.00
|
|
|
Service Code
|
HCPCS J2405
|
| Hospital Charge Code |
4506657
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$1.90 |
| Rate for Payer: Aetna Commercial |
$1.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1.72
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna Commercial |
$1.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$0.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.10
|
| Rate for Payer: Health EOS Commercial |
$1.82
|
| Rate for Payer: HFN Commercial |
$1.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$0.15
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1.90
|
| Rate for Payer: Quartz Beloit One Network |
$0.88
|
| Rate for Payer: Quartz Commercial |
$1.14
|
| Rate for Payer: The Alliance Commercial |
$1.00
|
| Rate for Payer: United Healthcare Medicaid |
$0.10
|
| Rate for Payer: WEA Trust Commercial |
$1.10
|
| Rate for Payer: WPS Commercial |
$0.24
|
|
|
Ondansetron Charge
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
HCPCS J2405
|
| Hospital Charge Code |
4506657
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.98 |
| Max. Negotiated Rate |
$1.84 |
| Rate for Payer: Aetna Commercial |
$1.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1.06
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna Commercial |
$1.84
|
| Rate for Payer: Health EOS Commercial |
$1.78
|
| Rate for Payer: HFN Commercial |
$1.84
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
| Rate for Payer: NAPHCARE Commercial |
$1.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1.84
|
| Rate for Payer: Quartz Beloit One Network |
$0.98
|
| Rate for Payer: Quartz Commercial |
$1.20
|
| Rate for Payer: WEA Trust Commercial |
$1.10
|
| Rate for Payer: WPS Commercial |
$1.48
|
|
|
Ondansetron Charge
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
HCPCS J2405
|
| Hospital Charge Code |
4506657
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$8.00 |
| Rate for Payer: Aetna Commercial |
$1.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1.72
|
| Rate for Payer: Aetna Managed Medicare |
$0.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$0.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1.06
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna Commercial |
$1.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.13
|
| Rate for Payer: Health EOS Commercial |
$1.78
|
| Rate for Payer: HFN Commercial |
$1.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1.50
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
| Rate for Payer: NAPHCARE Commercial |
$1.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1.84
|
| Rate for Payer: Quartz Beloit One Network |
$0.98
|
| Rate for Payer: Quartz Commercial |
$1.30
|
| Rate for Payer: Quartz Medicare Advantage |
$1.20
|
| Rate for Payer: The Alliance Commercial |
$8.00
|
| Rate for Payer: WEA Trust Commercial |
$1.10
|
| Rate for Payer: WPS Commercial |
$0.24
|
|
|
Ondansetron JW Waste Charge
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
HCPCS J2405 JW
|
| Hospital Charge Code |
5246653
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.98 |
| Max. Negotiated Rate |
$1.84 |
| Rate for Payer: Aetna Commercial |
$1.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1.06
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna Commercial |
$1.84
|
| Rate for Payer: Health EOS Commercial |
$1.78
|
| Rate for Payer: HFN Commercial |
$1.84
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
| Rate for Payer: NAPHCARE Commercial |
$1.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1.84
|
| Rate for Payer: Quartz Beloit One Network |
$0.98
|
| Rate for Payer: Quartz Commercial |
$1.20
|
| Rate for Payer: WEA Trust Commercial |
$1.10
|
| Rate for Payer: WPS Commercial |
$1.48
|
|
|
Ondansetron JW Waste Charge
|
Professional
|
Both
|
$2.00
|
|
|
Service Code
|
HCPCS J2405 JW
|
| Hospital Charge Code |
5246653
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$1.90 |
| Rate for Payer: Aetna Commercial |
$1.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1.72
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna Commercial |
$1.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$0.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.10
|
| Rate for Payer: Health EOS Commercial |
$1.82
|
| Rate for Payer: HFN Commercial |
$1.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$0.15
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$0.15
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1.90
|
| Rate for Payer: Quartz Beloit One Network |
$0.88
|
| Rate for Payer: Quartz Commercial |
$1.14
|
| Rate for Payer: The Alliance Commercial |
$1.00
|
| Rate for Payer: United Healthcare Medicaid |
$0.10
|
| Rate for Payer: WEA Trust Commercial |
$1.10
|
| Rate for Payer: WPS Commercial |
$0.24
|
|
|
Ondansetron JW Waste Charge
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
HCPCS J2405 JW
|
| Hospital Charge Code |
5246653
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$8.00 |
| Rate for Payer: Aetna Commercial |
$1.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1.72
|
| Rate for Payer: Aetna Managed Medicare |
$0.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$0.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1.06
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna Commercial |
$1.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.13
|
| Rate for Payer: Health EOS Commercial |
$1.78
|
| Rate for Payer: HFN Commercial |
$1.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1.50
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
| Rate for Payer: NAPHCARE Commercial |
$1.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1.84
|
| Rate for Payer: Quartz Beloit One Network |
$0.98
|
| Rate for Payer: Quartz Commercial |
$1.30
|
| Rate for Payer: Quartz Medicare Advantage |
$1.20
|
| Rate for Payer: The Alliance Commercial |
$8.00
|
| Rate for Payer: WEA Trust Commercial |
$1.10
|
| Rate for Payer: WPS Commercial |
$0.24
|
|
|
ONYX DES STENT
|
Facility
|
OP
|
$4,357.00
|
|
| Hospital Charge Code |
6175142
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,219.96 |
| Max. Negotiated Rate |
$17,428.00 |
| Rate for Payer: Aetna Commercial |
$3,921.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,747.02
|
| Rate for Payer: Aetna Managed Medicare |
$1,219.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,832.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,178.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,091.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,309.21
|
| Rate for Payer: Cash Price |
$1,307.10
|
| Rate for Payer: Cigna Commercial |
$4,008.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,438.18
|
| Rate for Payer: Health EOS Commercial |
$3,877.73
|
| Rate for Payer: HFN Commercial |
$4,008.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,267.75
|
| Rate for Payer: Multiplan Commercial |
$3,485.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,614.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,008.44
|
| Rate for Payer: Quartz Beloit One Network |
$2,134.93
|
| Rate for Payer: Quartz Commercial |
$2,832.05
|
| Rate for Payer: Quartz Medicare Advantage |
$2,614.20
|
| Rate for Payer: The Alliance Commercial |
$17,428.00
|
| Rate for Payer: WEA Trust Commercial |
$2,396.35
|
| Rate for Payer: WPS Commercial |
$3,227.23
|
|
|
ONYX DES STENT
|
Facility
|
IP
|
$4,357.00
|
|
| Hospital Charge Code |
6175142
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,134.93 |
| Max. Negotiated Rate |
$4,008.44 |
| Rate for Payer: Aetna Commercial |
$3,921.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,747.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,309.21
|
| Rate for Payer: Cash Price |
$1,307.10
|
| Rate for Payer: Cigna Commercial |
$4,008.44
|
| Rate for Payer: Health EOS Commercial |
$3,877.73
|
| Rate for Payer: HFN Commercial |
$4,008.44
|
| Rate for Payer: Multiplan Commercial |
$3,485.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,614.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,008.44
|
| Rate for Payer: Quartz Beloit One Network |
$2,134.93
|
| Rate for Payer: Quartz Commercial |
$2,614.20
|
| Rate for Payer: WEA Trust Commercial |
$2,396.35
|
| Rate for Payer: WPS Commercial |
$3,227.23
|
|
|
OP Cardiac Rehab w/Monitoring
|
Facility
|
OP
|
$371.00
|
|
|
Service Code
|
CPT 93798
|
| Hospital Charge Code |
3052595
|
|
Hospital Revenue Code
|
943
|
| Min. Negotiated Rate |
$130.61 |
| Max. Negotiated Rate |
$522.44 |
| Rate for Payer: Aetna Commercial |
$333.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$319.06
|
| Rate for Payer: Aetna Managed Medicare |
$130.61
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$349.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$287.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$272.00
|
| Rate for Payer: Anthem Medicare Advantage |
$130.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$196.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$130.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$130.61
|
| Rate for Payer: Cash Price |
$111.30
|
| Rate for Payer: Cash Price |
$111.30
|
| Rate for Payer: Cash Price |
$111.30
|
| Rate for Payer: Cigna Commercial |
$341.32
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$130.61
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$207.61
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$130.61
|
| Rate for Payer: Health EOS Commercial |
$330.19
|
| Rate for Payer: HFN Commercial |
$341.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$485.87
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$130.61
|
| Rate for Payer: Independent Care Health Plan Medicare |
$130.61
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$130.61
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$130.61
|
| Rate for Payer: Multiplan Commercial |
$296.80
|
| Rate for Payer: NAPHCARE Commercial |
$195.92
|
| Rate for Payer: Preferred Network Access Commercial |
$341.32
|
| Rate for Payer: Quartz Beloit One Network |
$181.79
|
| Rate for Payer: Quartz Commercial |
$241.15
|
| Rate for Payer: Quartz Medicare Advantage |
$130.61
|
| Rate for Payer: The Alliance Commercial |
$522.44
|
| Rate for Payer: United Healthcare Medicare Advantage |
$130.61
|
| Rate for Payer: United Healthcare PPO |
$278.25
|
| Rate for Payer: WEA Trust Commercial |
$204.05
|
| Rate for Payer: Wellcare Medicare |
$130.61
|
| Rate for Payer: WPS Commercial |
$274.80
|
|
|
OP Cardiac Rehab w/Monitoring
|
Facility
|
IP
|
$371.00
|
|
|
Service Code
|
CPT 93798
|
| Hospital Charge Code |
3052595
|
|
Hospital Revenue Code
|
943
|
| Min. Negotiated Rate |
$181.79 |
| Max. Negotiated Rate |
$341.32 |
| Rate for Payer: Aetna Commercial |
$333.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$319.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$196.63
|
| Rate for Payer: Cash Price |
$111.30
|
| Rate for Payer: Cigna Commercial |
$341.32
|
| Rate for Payer: Health EOS Commercial |
$330.19
|
| Rate for Payer: HFN Commercial |
$341.32
|
| Rate for Payer: Multiplan Commercial |
$296.80
|
| Rate for Payer: NAPHCARE Commercial |
$222.60
|
| Rate for Payer: Preferred Network Access Commercial |
$341.32
|
| Rate for Payer: Quartz Beloit One Network |
$181.79
|
| Rate for Payer: Quartz Commercial |
$222.60
|
| Rate for Payer: WEA Trust Commercial |
$204.05
|
| Rate for Payer: WPS Commercial |
$274.80
|
|
|
OP Dialysis
|
Facility
|
OP
|
$1,151.00
|
|
|
Service Code
|
CPT 90999
|
| Hospital Charge Code |
3005571
|
|
Hospital Revenue Code
|
821
|
| Min. Negotiated Rate |
$322.28 |
| Max. Negotiated Rate |
$4,604.00 |
| Rate for Payer: Aetna Commercial |
$1,035.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$989.86
|
| Rate for Payer: Aetna Managed Medicare |
$322.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,281.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,149.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,091.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$610.03
|
| Rate for Payer: Cash Price |
$345.30
|
| Rate for Payer: Cash Price |
$345.30
|
| Rate for Payer: Cigna Commercial |
$1,058.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$644.10
|
| Rate for Payer: Health EOS Commercial |
$1,024.39
|
| Rate for Payer: HFN Commercial |
$1,058.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$863.25
|
| Rate for Payer: Multiplan Commercial |
$920.80
|
| Rate for Payer: NAPHCARE Commercial |
$690.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,058.92
|
| Rate for Payer: Quartz Beloit One Network |
$563.99
|
| Rate for Payer: Quartz Commercial |
$748.15
|
| Rate for Payer: Quartz Medicare Advantage |
$690.60
|
| Rate for Payer: The Alliance Commercial |
$4,604.00
|
| Rate for Payer: United Healthcare PPO |
$863.25
|
| Rate for Payer: WEA Trust Commercial |
$633.05
|
| Rate for Payer: WPS Commercial |
$852.55
|
|
|
OP Dialysis
|
Facility
|
IP
|
$1,151.00
|
|
|
Service Code
|
CPT 90999
|
| Hospital Charge Code |
3005571
|
|
Hospital Revenue Code
|
821
|
| Min. Negotiated Rate |
$563.99 |
| Max. Negotiated Rate |
$1,058.92 |
| Rate for Payer: Aetna Commercial |
$1,035.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$989.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$610.03
|
| Rate for Payer: Cash Price |
$345.30
|
| Rate for Payer: Cigna Commercial |
$1,058.92
|
| Rate for Payer: Health EOS Commercial |
$1,024.39
|
| Rate for Payer: HFN Commercial |
$1,058.92
|
| Rate for Payer: Multiplan Commercial |
$920.80
|
| Rate for Payer: NAPHCARE Commercial |
$690.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,058.92
|
| Rate for Payer: Quartz Beloit One Network |
$563.99
|
| Rate for Payer: Quartz Commercial |
$690.60
|
| Rate for Payer: WEA Trust Commercial |
$633.05
|
| Rate for Payer: WPS Commercial |
$852.55
|
|
|
O.P.Dressing Change Major (includes nursing care, irrigate, - Daily Charges
|
Facility
|
IP
|
$146.00
|
|
|
Service Code
|
CPT 99212
|
| Hospital Charge Code |
3003961
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$71.54 |
| Max. Negotiated Rate |
$134.32 |
| Rate for Payer: Aetna Commercial |
$131.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$125.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$77.38
|
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Cigna Commercial |
$134.32
|
| Rate for Payer: Health EOS Commercial |
$129.94
|
| Rate for Payer: HFN Commercial |
$134.32
|
| Rate for Payer: Multiplan Commercial |
$116.80
|
| Rate for Payer: NAPHCARE Commercial |
$87.60
|
| Rate for Payer: Preferred Network Access Commercial |
$134.32
|
| Rate for Payer: Quartz Beloit One Network |
$71.54
|
| Rate for Payer: Quartz Commercial |
$87.60
|
| Rate for Payer: WEA Trust Commercial |
$80.30
|
| Rate for Payer: WPS Commercial |
$108.14
|
|
|
O.P.Dressing Change Major (includes nursing care, irrigate, - Daily Charges
|
Facility
|
OP
|
$146.00
|
|
|
Service Code
|
CPT 99212
|
| Hospital Charge Code |
3003961
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$40.88 |
| Max. Negotiated Rate |
$584.00 |
| Rate for Payer: Aetna Commercial |
$131.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$125.56
|
| Rate for Payer: Aetna Managed Medicare |
$40.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$94.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$73.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$70.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$77.38
|
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Cigna Commercial |
$134.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$81.70
|
| Rate for Payer: Health EOS Commercial |
$129.94
|
| Rate for Payer: HFN Commercial |
$134.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$109.50
|
| Rate for Payer: Multiplan Commercial |
$116.80
|
| Rate for Payer: NAPHCARE Commercial |
$87.60
|
| Rate for Payer: Preferred Network Access Commercial |
$134.32
|
| Rate for Payer: Quartz Beloit One Network |
$71.54
|
| Rate for Payer: Quartz Commercial |
$94.90
|
| Rate for Payer: Quartz Medicare Advantage |
$87.60
|
| Rate for Payer: The Alliance Commercial |
$584.00
|
| Rate for Payer: WEA Trust Commercial |
$80.30
|
| Rate for Payer: WPS Commercial |
$108.14
|
|
|
O.P Dressing Change Minor (includes nursing care) - Daily Charges
|
Facility
|
IP
|
$88.00
|
|
|
Service Code
|
CPT 99211
|
| Hospital Charge Code |
3003966
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$43.12 |
| Max. Negotiated Rate |
$80.96 |
| Rate for Payer: Aetna Commercial |
$79.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$75.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$46.64
|
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Cigna Commercial |
$80.96
|
| Rate for Payer: Health EOS Commercial |
$78.32
|
| Rate for Payer: HFN Commercial |
$80.96
|
| Rate for Payer: Multiplan Commercial |
$70.40
|
| Rate for Payer: NAPHCARE Commercial |
$52.80
|
| Rate for Payer: Preferred Network Access Commercial |
$80.96
|
| Rate for Payer: Quartz Beloit One Network |
$43.12
|
| Rate for Payer: Quartz Commercial |
$52.80
|
| Rate for Payer: WEA Trust Commercial |
$48.40
|
| Rate for Payer: WPS Commercial |
$65.18
|
|
