|
Omniscan 20 ml
|
Professional
|
Both
|
$482.00
|
|
| Hospital Charge Code |
1486804
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$212.08 |
| Max. Negotiated Rate |
$457.90 |
| Rate for Payer: Aetna Commercial |
$457.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$414.52
|
| Rate for Payer: Cash Price |
$144.60
|
| Rate for Payer: Cigna Commercial |
$457.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$241.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$289.20
|
| Rate for Payer: Health EOS Commercial |
$438.62
|
| Rate for Payer: HFN Commercial |
$457.90
|
| Rate for Payer: Multiplan Commercial |
$385.60
|
| Rate for Payer: Preferred Network Access Commercial |
$457.90
|
| Rate for Payer: Quartz Beloit One Network |
$212.08
|
| Rate for Payer: Quartz Commercial |
$274.74
|
| Rate for Payer: The Alliance Commercial |
$241.00
|
| Rate for Payer: WEA Trust Commercial |
$265.10
|
| Rate for Payer: WPS Commercial |
$357.02
|
|
|
Omniscan 20 ml
|
Facility
|
OP
|
$482.00
|
|
| Hospital Charge Code |
1486804
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$134.96 |
| Max. Negotiated Rate |
$1,928.00 |
| Rate for Payer: Aetna Commercial |
$433.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$414.52
|
| Rate for Payer: Aetna Managed Medicare |
$134.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$313.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$241.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$231.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$255.46
|
| Rate for Payer: Cash Price |
$144.60
|
| Rate for Payer: Cigna Commercial |
$443.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$269.73
|
| Rate for Payer: Health EOS Commercial |
$428.98
|
| Rate for Payer: HFN Commercial |
$443.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$361.50
|
| Rate for Payer: Multiplan Commercial |
$385.60
|
| Rate for Payer: NAPHCARE Commercial |
$289.20
|
| Rate for Payer: Preferred Network Access Commercial |
$443.44
|
| Rate for Payer: Quartz Beloit One Network |
$236.18
|
| Rate for Payer: Quartz Commercial |
$313.30
|
| Rate for Payer: Quartz Medicare Advantage |
$289.20
|
| Rate for Payer: The Alliance Commercial |
$1,928.00
|
| Rate for Payer: WEA Trust Commercial |
$265.10
|
| Rate for Payer: WPS Commercial |
$357.02
|
|
|
OMNI SURGICAL SYSTEM 1-108
|
Facility
|
OP
|
$9,452.00
|
|
|
Service Code
|
HCPCS C1889
|
| Hospital Charge Code |
6181743
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,646.56 |
| Max. Negotiated Rate |
$37,808.00 |
| Rate for Payer: Aetna Commercial |
$8,506.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,128.72
|
| Rate for Payer: Aetna Managed Medicare |
$2,646.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,143.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,726.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,536.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,009.56
|
| Rate for Payer: Cash Price |
$2,835.60
|
| Rate for Payer: Cigna Commercial |
$8,695.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,289.34
|
| Rate for Payer: Health EOS Commercial |
$8,412.28
|
| Rate for Payer: HFN Commercial |
$8,695.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,089.00
|
| Rate for Payer: Multiplan Commercial |
$7,561.60
|
| Rate for Payer: NAPHCARE Commercial |
$5,671.20
|
| Rate for Payer: Preferred Network Access Commercial |
$8,695.84
|
| Rate for Payer: Quartz Beloit One Network |
$4,631.48
|
| Rate for Payer: Quartz Commercial |
$6,143.80
|
| Rate for Payer: Quartz Medicare Advantage |
$5,671.20
|
| Rate for Payer: The Alliance Commercial |
$37,808.00
|
| Rate for Payer: WEA Trust Commercial |
$5,198.60
|
| Rate for Payer: WPS Commercial |
$7,001.10
|
|
|
OMNI SURGICAL SYSTEM 1-108
|
Facility
|
IP
|
$9,452.00
|
|
|
Service Code
|
HCPCS C1889
|
| Hospital Charge Code |
6181743
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,631.48 |
| Max. Negotiated Rate |
$8,695.84 |
| Rate for Payer: Aetna Commercial |
$8,506.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,128.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,009.56
|
| Rate for Payer: Cash Price |
$2,835.60
|
| Rate for Payer: Cigna Commercial |
$8,695.84
|
| Rate for Payer: Health EOS Commercial |
$8,412.28
|
| Rate for Payer: HFN Commercial |
$8,695.84
|
| Rate for Payer: Multiplan Commercial |
$7,561.60
|
| Rate for Payer: NAPHCARE Commercial |
$5,671.20
|
| Rate for Payer: Preferred Network Access Commercial |
$8,695.84
|
| Rate for Payer: Quartz Beloit One Network |
$4,631.48
|
| Rate for Payer: Quartz Commercial |
$5,671.20
|
| Rate for Payer: WEA Trust Commercial |
$5,198.60
|
| Rate for Payer: WPS Commercial |
$7,001.10
|
|
|
onabotulinumtoxinA 100 units vial Medical [MED]
|
Facility
|
IP
|
$1,585.00
|
|
|
Service Code
|
HCPCS J0585
|
| Hospital Charge Code |
3393517
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$776.65 |
| Max. Negotiated Rate |
$1,458.20 |
| Rate for Payer: Aetna Commercial |
$1,426.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,363.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$840.05
|
| Rate for Payer: Cash Price |
$475.50
|
| Rate for Payer: Cigna Commercial |
$1,458.20
|
| Rate for Payer: Health EOS Commercial |
$1,410.65
|
| Rate for Payer: HFN Commercial |
$1,458.20
|
| Rate for Payer: Multiplan Commercial |
$1,268.00
|
| Rate for Payer: NAPHCARE Commercial |
$951.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,458.20
|
| Rate for Payer: Quartz Beloit One Network |
$776.65
|
| Rate for Payer: Quartz Commercial |
$951.00
|
| Rate for Payer: WEA Trust Commercial |
$871.75
|
| Rate for Payer: WPS Commercial |
$1,174.01
|
|
|
onabotulinumtoxinA 100 units vial Medical [MED]
|
Facility
|
OP
|
$1,585.00
|
|
|
Service Code
|
HCPCS J0585
|
| Hospital Charge Code |
3393517
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.33 |
| Max. Negotiated Rate |
$1,458.20 |
| Rate for Payer: Aetna Commercial |
$1,426.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,363.10
|
| Rate for Payer: Aetna Managed Medicare |
$6.33
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,030.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$792.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$760.80
|
| Rate for Payer: Anthem Medicare Advantage |
$6.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$840.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$6.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$6.33
|
| Rate for Payer: Cash Price |
$475.50
|
| Rate for Payer: Cash Price |
$475.50
|
| Rate for Payer: Cigna Commercial |
$1,458.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$6.33
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8.36
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$6.33
|
| Rate for Payer: Health EOS Commercial |
$1,410.65
|
| Rate for Payer: HFN Commercial |
$1,458.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$23.54
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$6.33
|
| Rate for Payer: Independent Care Health Plan Medicare |
$6.33
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$6.33
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$6.33
|
| Rate for Payer: Multiplan Commercial |
$1,268.00
|
| Rate for Payer: NAPHCARE Commercial |
$9.49
|
| Rate for Payer: Preferred Network Access Commercial |
$1,458.20
|
| Rate for Payer: Quartz Beloit One Network |
$776.65
|
| Rate for Payer: Quartz Commercial |
$1,030.25
|
| Rate for Payer: Quartz Medicare Advantage |
$6.33
|
| Rate for Payer: The Alliance Commercial |
$25.31
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6.33
|
| Rate for Payer: WEA Trust Commercial |
$871.75
|
| Rate for Payer: Wellcare Medicare |
$6.33
|
| Rate for Payer: WPS Commercial |
$15.80
|
|
|
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
|
|
|
Oncovin 1 mg Charge
|
Professional
|
Both
|
$59.00
|
|
|
Service Code
|
HCPCS J9370
|
| Hospital Charge Code |
2958927
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.29 |
| Max. Negotiated Rate |
$56.05 |
| Rate for Payer: Aetna Commercial |
$56.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$50.74
|
| Rate for Payer: Cash Price |
$17.70
|
| Rate for Payer: Cash Price |
$17.70
|
| Rate for Payer: Cigna Commercial |
$56.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$7.73
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7.91
|
| Rate for Payer: Health EOS Commercial |
$53.69
|
| Rate for Payer: HFN Commercial |
$56.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7.29
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$7.29
|
| Rate for Payer: Multiplan Commercial |
$47.20
|
| Rate for Payer: Preferred Network Access Commercial |
$56.05
|
| Rate for Payer: Quartz Beloit One Network |
$25.96
|
| Rate for Payer: Quartz Commercial |
$33.63
|
| Rate for Payer: The Alliance Commercial |
$29.50
|
| Rate for Payer: United Healthcare Medicaid |
$7.73
|
| Rate for Payer: WEA Trust Commercial |
$32.45
|
| Rate for Payer: WPS Commercial |
$19.78
|
|
|
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
|
|
|
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
|
|
|
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
|
|
|
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 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
|
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 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
|
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 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 JW Waste Charge
|
Professional
|
Both
|
$2.00
|
|
|
Service Code
|
HCPCS J2405 JW
|
| Hospital Charge Code |
5246653
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.88 |
| 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: Cigna Commercial |
$1.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.20
|
| Rate for Payer: Health EOS Commercial |
$1.82
|
| Rate for Payer: HFN Commercial |
$1.90
|
| 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: WEA Trust Commercial |
$1.10
|
| Rate for Payer: WPS Commercial |
$1.48
|
|
|
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
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
HCPCS J2405 JW
|
| Hospital Charge Code |
5246653
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.56 |
| 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: Cigna Commercial |
$1.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.12
|
| 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 |
$1.48
|
|
|
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
|
|
