|
CDS T & A BOX DYNJ900890
|
Facility
IP
|
$2,356.00
|
|
| Hospital Charge Code |
4115513
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,154.44 |
| Max. Negotiated Rate |
$2,167.52 |
| Rate for Payer: Aetna Commercial |
$2,120.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,248.68
|
| Rate for Payer: Cash Price |
$706.80
|
| Rate for Payer: Cigna Commercial |
$2,167.52
|
| Rate for Payer: Health EOS Commercial |
$2,096.84
|
| Rate for Payer: HFN Commercial |
$2,167.52
|
| Rate for Payer: Multiplan Commercial |
$1,884.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,413.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,167.52
|
| Rate for Payer: Quartz Beloit One Network |
$1,154.44
|
| Rate for Payer: Quartz Commercial |
$1,413.60
|
| Rate for Payer: WEA Trust Commercial |
$1,295.80
|
| Rate for Payer: WPS Commercial |
$1,745.09
|
|
|
CDS TOTAL HIP BOX DYNJ900882
|
Facility
IP
|
$4,298.00
|
|
| Hospital Charge Code |
4124767
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,106.02 |
| Max. Negotiated Rate |
$3,954.16 |
| Rate for Payer: Aetna Commercial |
$3,868.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,277.94
|
| Rate for Payer: Cash Price |
$1,289.40
|
| Rate for Payer: Cigna Commercial |
$3,954.16
|
| Rate for Payer: Health EOS Commercial |
$3,825.22
|
| Rate for Payer: HFN Commercial |
$3,954.16
|
| Rate for Payer: Multiplan Commercial |
$3,438.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,578.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,954.16
|
| Rate for Payer: Quartz Beloit One Network |
$2,106.02
|
| Rate for Payer: Quartz Commercial |
$2,578.80
|
| Rate for Payer: WEA Trust Commercial |
$2,363.90
|
| Rate for Payer: WPS Commercial |
$3,183.53
|
|
|
CDS TOTAL HIP BOX DYNJ900882
|
Facility
OP
|
$4,298.00
|
|
| Hospital Charge Code |
4124767
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,203.44 |
| Max. Negotiated Rate |
$17,192.00 |
| Rate for Payer: Aetna Commercial |
$3,868.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,696.28
|
| Rate for Payer: Aetna Managed Medicare |
$1,203.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,793.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,149.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,063.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,277.94
|
| Rate for Payer: Cash Price |
$1,289.40
|
| Rate for Payer: Cigna Commercial |
$3,954.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,405.16
|
| Rate for Payer: Health EOS Commercial |
$3,825.22
|
| Rate for Payer: HFN Commercial |
$3,954.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,223.50
|
| Rate for Payer: Multiplan Commercial |
$3,438.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,578.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,954.16
|
| Rate for Payer: Quartz Beloit One Network |
$2,106.02
|
| Rate for Payer: Quartz Commercial |
$2,793.70
|
| Rate for Payer: Quartz Medicare Advantage |
$2,578.80
|
| Rate for Payer: The Alliance Commercial |
$17,192.00
|
| Rate for Payer: WEA Trust Commercial |
$2,363.90
|
| Rate for Payer: WPS Commercial |
$3,183.53
|
|
|
CDS TOTAL KNEE BOX DYNJ900881
|
Facility
IP
|
$5,755.00
|
|
| Hospital Charge Code |
4124766
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,819.95 |
| Max. Negotiated Rate |
$5,294.60 |
| Rate for Payer: Aetna Commercial |
$5,179.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,050.15
|
| Rate for Payer: Cash Price |
$1,726.50
|
| Rate for Payer: Cigna Commercial |
$5,294.60
|
| Rate for Payer: Health EOS Commercial |
$5,121.95
|
| Rate for Payer: HFN Commercial |
$5,294.60
|
| Rate for Payer: Multiplan Commercial |
$4,604.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,453.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,294.60
|
| Rate for Payer: Quartz Beloit One Network |
$2,819.95
|
| Rate for Payer: Quartz Commercial |
$3,453.00
|
| Rate for Payer: WEA Trust Commercial |
$3,165.25
|
| Rate for Payer: WPS Commercial |
$4,262.73
|
|
|
CDS TOTAL KNEE BOX DYNJ900881
|
Facility
OP
|
$5,755.00
|
|
| Hospital Charge Code |
4124766
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,611.40 |
| Max. Negotiated Rate |
$23,020.00 |
| Rate for Payer: Aetna Commercial |
$5,179.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,949.30
|
| Rate for Payer: Aetna Managed Medicare |
$1,611.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,740.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,877.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,762.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,050.15
|
| Rate for Payer: Cash Price |
$1,726.50
|
| Rate for Payer: Cigna Commercial |
$5,294.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,220.50
|
| Rate for Payer: Health EOS Commercial |
$5,121.95
|
| Rate for Payer: HFN Commercial |
$5,294.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,316.25
|
| Rate for Payer: Multiplan Commercial |
$4,604.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,453.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,294.60
|
| Rate for Payer: Quartz Beloit One Network |
$2,819.95
|
| Rate for Payer: Quartz Commercial |
$3,740.75
|
| Rate for Payer: Quartz Medicare Advantage |
$3,453.00
|
| Rate for Payer: The Alliance Commercial |
$23,020.00
|
| Rate for Payer: WEA Trust Commercial |
$3,165.25
|
| Rate for Payer: WPS Commercial |
$4,262.73
|
|
|
CDS UPPER EXTREMITY BOX DYNJ900880
|
Facility
IP
|
$1,904.00
|
|
| Hospital Charge Code |
4124776
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$932.96 |
| Max. Negotiated Rate |
$1,751.68 |
| Rate for Payer: Aetna Commercial |
$1,713.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,009.12
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,751.68
|
| Rate for Payer: Health EOS Commercial |
$1,694.56
|
| Rate for Payer: HFN Commercial |
$1,751.68
|
| Rate for Payer: Multiplan Commercial |
$1,523.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,142.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,751.68
|
| Rate for Payer: Quartz Beloit One Network |
$932.96
|
| Rate for Payer: Quartz Commercial |
$1,142.40
|
| Rate for Payer: WEA Trust Commercial |
$1,047.20
|
| Rate for Payer: WPS Commercial |
$1,410.29
|
|
|
CDS UPPER EXTREMITY BOX DYNJ900880
|
Facility
OP
|
$1,904.00
|
|
| Hospital Charge Code |
4124776
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$533.12 |
| Max. Negotiated Rate |
$7,616.00 |
| Rate for Payer: Aetna Commercial |
$1,713.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,637.44
|
| Rate for Payer: Aetna Managed Medicare |
$533.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,237.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$952.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$913.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,009.12
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,751.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,065.48
|
| Rate for Payer: Health EOS Commercial |
$1,694.56
|
| Rate for Payer: HFN Commercial |
$1,751.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,428.00
|
| Rate for Payer: Multiplan Commercial |
$1,523.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,142.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,751.68
|
| Rate for Payer: Quartz Beloit One Network |
$932.96
|
| Rate for Payer: Quartz Commercial |
$1,237.60
|
| Rate for Payer: Quartz Medicare Advantage |
$1,142.40
|
| Rate for Payer: The Alliance Commercial |
$7,616.00
|
| Rate for Payer: WEA Trust Commercial |
$1,047.20
|
| Rate for Payer: WPS Commercial |
$1,410.29
|
|
|
CEA, Peritoneal Fluid
|
Facility
IP
|
$111.00
|
|
|
Service Code
|
CPT 82378
|
| Hospital Charge Code |
5791656
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$54.39 |
| Max. Negotiated Rate |
$102.12 |
| Rate for Payer: Aetna Commercial |
$99.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$58.83
|
| Rate for Payer: Cash Price |
$33.30
|
| Rate for Payer: Cigna Commercial |
$102.12
|
| Rate for Payer: Health EOS Commercial |
$98.79
|
| Rate for Payer: HFN Commercial |
$102.12
|
| Rate for Payer: Multiplan Commercial |
$88.80
|
| Rate for Payer: NAPHCARE Commercial |
$66.60
|
| Rate for Payer: Preferred Network Access Commercial |
$102.12
|
| Rate for Payer: Quartz Beloit One Network |
$54.39
|
| Rate for Payer: Quartz Commercial |
$66.60
|
| Rate for Payer: WEA Trust Commercial |
$61.05
|
| Rate for Payer: WPS Commercial |
$82.22
|
|
|
CEA, Peritoneal Fluid
|
Facility
OP
|
$111.00
|
|
|
Service Code
|
CPT 82378
|
| Hospital Charge Code |
5791656
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.96 |
| Max. Negotiated Rate |
$444.00 |
| Rate for Payer: Aetna Commercial |
$99.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$95.46
|
| Rate for Payer: Aetna Managed Medicare |
$18.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$71.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$33.18
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$31.47
|
| Rate for Payer: Anthem Medicaid |
$19.59
|
| Rate for Payer: Anthem Medicare Advantage |
$18.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$58.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$18.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$18.96
|
| Rate for Payer: Cash Price |
$33.30
|
| Rate for Payer: Cash Price |
$33.30
|
| Rate for Payer: Cigna Commercial |
$102.12
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$18.96
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$19.59
|
| Rate for Payer: Dean Health Medicaid |
$19.59
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$18.96
|
| Rate for Payer: Health EOS Commercial |
$98.79
|
| Rate for Payer: HFN Commercial |
$102.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$70.53
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$18.96
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$19.59
|
| Rate for Payer: Independent Care Health Plan Medicare |
$18.96
|
| Rate for Payer: Managed Health Services Medicaid |
$20.37
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$18.96
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$18.96
|
| Rate for Payer: Multiplan Commercial |
$88.80
|
| Rate for Payer: NAPHCARE Commercial |
$28.44
|
| Rate for Payer: Preferred Network Access Commercial |
$102.12
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$19.59
|
| Rate for Payer: Quartz Beloit One Network |
$54.39
|
| Rate for Payer: Quartz Commercial |
$72.15
|
| Rate for Payer: Quartz Medicare Advantage |
$18.96
|
| Rate for Payer: The Alliance Commercial |
$444.00
|
| Rate for Payer: United Healthcare Medicaid |
$19.59
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.96
|
| Rate for Payer: United Healthcare PPO |
$83.25
|
| Rate for Payer: WEA Trust Commercial |
$61.05
|
| Rate for Payer: Wellcare Medicare |
$18.96
|
| Rate for Payer: WMAP Medicaid |
$19.59
|
| Rate for Payer: WPS Commercial |
$82.22
|
|
|
CEA, Peritoneal Fluid
|
Professional
|
$111.00
|
|
|
Service Code
|
CPT 82378
|
| Hospital Charge Code |
5791656
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.96 |
| Max. Negotiated Rate |
$105.45 |
| Rate for Payer: Aetna Commercial |
$105.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$95.46
|
| Rate for Payer: Aetna Managed Medicare |
$18.96
|
| Rate for Payer: Anthem Medicare Advantage |
$18.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$18.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$18.96
|
| Rate for Payer: Cash Price |
$33.30
|
| Rate for Payer: Cash Price |
$33.30
|
| Rate for Payer: Cigna Commercial |
$105.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$55.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$18.96
|
| Rate for Payer: Health EOS Commercial |
$101.01
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$66.93
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$66.93
|
| Rate for Payer: Independent Care Health Plan Medicare |
$18.96
|
| Rate for Payer: Multiplan Commercial |
$88.80
|
| Rate for Payer: Preferred Network Access Commercial |
$105.45
|
| Rate for Payer: Quartz Beloit One Network |
$48.84
|
| Rate for Payer: Quartz Commercial |
$63.27
|
| Rate for Payer: Quartz Medicare Advantage |
$18.96
|
| Rate for Payer: The Alliance Commercial |
$74.89
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.96
|
| Rate for Payer: WEA Trust Commercial |
$61.05
|
| Rate for Payer: WPS Commercial |
$83.42
|
|
|
Cefazolin 1gm vial [Med]
|
Facility
OP
|
$17.00
|
|
|
Service Code
|
HCPCS J0690
|
| Hospital Charge Code |
2974907
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.08 |
| Max. Negotiated Rate |
$933.88 |
| Rate for Payer: Aetna Commercial |
$15.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14.62
|
| Rate for Payer: Aetna Managed Medicare |
$4.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9.01
|
| Rate for Payer: Cash Price |
$5.10
|
| Rate for Payer: Cash Price |
$5.10
|
| Rate for Payer: Cigna Commercial |
$15.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.08
|
| Rate for Payer: Health EOS Commercial |
$15.13
|
| Rate for Payer: HFN Commercial |
$15.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12.75
|
| Rate for Payer: Multiplan Commercial |
$13.60
|
| Rate for Payer: NAPHCARE Commercial |
$10.20
|
| Rate for Payer: Preferred Network Access Commercial |
$15.64
|
| Rate for Payer: Quartz Beloit One Network |
$8.33
|
| Rate for Payer: Quartz Commercial |
$11.05
|
| Rate for Payer: Quartz Medicare Advantage |
$10.20
|
| Rate for Payer: The Alliance Commercial |
$933.88
|
| Rate for Payer: WEA Trust Commercial |
$9.35
|
| Rate for Payer: WPS Commercial |
$2.04
|
|
|
Cefazolin 1gm vial [Med]
|
Facility
IP
|
$17.00
|
|
|
Service Code
|
HCPCS J0690
|
| Hospital Charge Code |
2974907
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.33 |
| Max. Negotiated Rate |
$15.64 |
| Rate for Payer: Aetna Commercial |
$15.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9.01
|
| Rate for Payer: Cash Price |
$5.10
|
| Rate for Payer: Cigna Commercial |
$15.64
|
| Rate for Payer: Health EOS Commercial |
$15.13
|
| Rate for Payer: HFN Commercial |
$15.64
|
| Rate for Payer: Multiplan Commercial |
$13.60
|
| Rate for Payer: NAPHCARE Commercial |
$10.20
|
| Rate for Payer: Preferred Network Access Commercial |
$15.64
|
| Rate for Payer: Quartz Beloit One Network |
$8.33
|
| Rate for Payer: Quartz Commercial |
$10.20
|
| Rate for Payer: WEA Trust Commercial |
$9.35
|
| Rate for Payer: WPS Commercial |
$12.59
|
|
|
Cefazolin 2gm Vial (Med)
|
Facility
OP
|
$61.00
|
|
|
Service Code
|
HCPCS J0690
|
| Hospital Charge Code |
6226125
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.08 |
| Max. Negotiated Rate |
$933.88 |
| Rate for Payer: Aetna Commercial |
$54.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$52.46
|
| Rate for Payer: Aetna Managed Medicare |
$17.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$39.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$30.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$29.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$32.33
|
| Rate for Payer: Cash Price |
$18.30
|
| Rate for Payer: Cash Price |
$18.30
|
| Rate for Payer: Cigna Commercial |
$56.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.08
|
| Rate for Payer: Health EOS Commercial |
$54.29
|
| Rate for Payer: HFN Commercial |
$56.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$45.75
|
| Rate for Payer: Multiplan Commercial |
$48.80
|
| Rate for Payer: NAPHCARE Commercial |
$36.60
|
| Rate for Payer: Preferred Network Access Commercial |
$56.12
|
| Rate for Payer: Quartz Beloit One Network |
$29.89
|
| Rate for Payer: Quartz Commercial |
$39.65
|
| Rate for Payer: Quartz Medicare Advantage |
$36.60
|
| Rate for Payer: The Alliance Commercial |
$933.88
|
| Rate for Payer: WEA Trust Commercial |
$33.55
|
| Rate for Payer: WPS Commercial |
$2.04
|
|
|
Cefazolin 2gm Vial (Med)
|
Facility
IP
|
$61.00
|
|
|
Service Code
|
HCPCS J0690
|
| Hospital Charge Code |
6226125
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$29.89 |
| Max. Negotiated Rate |
$56.12 |
| Rate for Payer: Aetna Commercial |
$54.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$32.33
|
| Rate for Payer: Cash Price |
$18.30
|
| Rate for Payer: Cigna Commercial |
$56.12
|
| Rate for Payer: Health EOS Commercial |
$54.29
|
| Rate for Payer: HFN Commercial |
$56.12
|
| Rate for Payer: Multiplan Commercial |
$48.80
|
| Rate for Payer: NAPHCARE Commercial |
$36.60
|
| Rate for Payer: Preferred Network Access Commercial |
$56.12
|
| Rate for Payer: Quartz Beloit One Network |
$29.89
|
| Rate for Payer: Quartz Commercial |
$36.60
|
| Rate for Payer: WEA Trust Commercial |
$33.55
|
| Rate for Payer: WPS Commercial |
$45.18
|
|
|
Cefazolin (Ancef)
|
Facility
IP
|
$31.00
|
|
|
Service Code
|
HCPCS J0690
|
| Hospital Charge Code |
4075399
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.19 |
| Max. Negotiated Rate |
$28.52 |
| Rate for Payer: Aetna Commercial |
$27.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$16.43
|
| Rate for Payer: Cash Price |
$9.30
|
| Rate for Payer: Cigna Commercial |
$28.52
|
| Rate for Payer: Health EOS Commercial |
$27.59
|
| Rate for Payer: HFN Commercial |
$28.52
|
| Rate for Payer: Multiplan Commercial |
$24.80
|
| Rate for Payer: NAPHCARE Commercial |
$18.60
|
| Rate for Payer: Preferred Network Access Commercial |
$28.52
|
| Rate for Payer: Quartz Beloit One Network |
$15.19
|
| Rate for Payer: Quartz Commercial |
$18.60
|
| Rate for Payer: WEA Trust Commercial |
$17.05
|
| Rate for Payer: WPS Commercial |
$22.96
|
|
|
Cefazolin (Ancef)
|
Facility
OP
|
$31.00
|
|
|
Service Code
|
HCPCS J0690
|
| Hospital Charge Code |
4075399
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.08 |
| Max. Negotiated Rate |
$933.88 |
| Rate for Payer: Aetna Commercial |
$27.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$26.66
|
| Rate for Payer: Aetna Managed Medicare |
$8.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$20.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$15.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$14.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$16.43
|
| Rate for Payer: Cash Price |
$9.30
|
| Rate for Payer: Cash Price |
$9.30
|
| Rate for Payer: Cigna Commercial |
$28.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.08
|
| Rate for Payer: Health EOS Commercial |
$27.59
|
| Rate for Payer: HFN Commercial |
$28.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$23.25
|
| Rate for Payer: Multiplan Commercial |
$24.80
|
| Rate for Payer: NAPHCARE Commercial |
$18.60
|
| Rate for Payer: Preferred Network Access Commercial |
$28.52
|
| Rate for Payer: Quartz Beloit One Network |
$15.19
|
| Rate for Payer: Quartz Commercial |
$20.15
|
| Rate for Payer: Quartz Medicare Advantage |
$18.60
|
| Rate for Payer: The Alliance Commercial |
$933.88
|
| Rate for Payer: WEA Trust Commercial |
$17.05
|
| Rate for Payer: WPS Commercial |
$2.04
|
|
|
Cefazolin JW Waste Charge per 500 mg
|
Facility
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J0690 JW
|
| Hospital Charge Code |
5266692
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.24 |
| Max. Negotiated Rate |
$32.00 |
| Rate for Payer: Aetna Commercial |
$7.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.88
|
| Rate for Payer: Aetna Managed Medicare |
$2.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4.24
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$7.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4.48
|
| Rate for Payer: Health EOS Commercial |
$7.12
|
| Rate for Payer: HFN Commercial |
$7.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6.00
|
| Rate for Payer: Multiplan Commercial |
$6.40
|
| Rate for Payer: NAPHCARE Commercial |
$4.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7.36
|
| Rate for Payer: Quartz Beloit One Network |
$3.92
|
| Rate for Payer: Quartz Commercial |
$5.20
|
| Rate for Payer: Quartz Medicare Advantage |
$4.80
|
| Rate for Payer: The Alliance Commercial |
$32.00
|
| Rate for Payer: WEA Trust Commercial |
$4.40
|
| Rate for Payer: WPS Commercial |
$5.93
|
|
|
Cefazolin JW Waste Charge per 500 mg
|
Facility
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J0690 JW
|
| Hospital Charge Code |
5266692
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.92 |
| Max. Negotiated Rate |
$7.36 |
| Rate for Payer: Aetna Commercial |
$7.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4.24
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$7.36
|
| Rate for Payer: Health EOS Commercial |
$7.12
|
| Rate for Payer: HFN Commercial |
$7.36
|
| Rate for Payer: Multiplan Commercial |
$6.40
|
| Rate for Payer: NAPHCARE Commercial |
$4.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7.36
|
| Rate for Payer: Quartz Beloit One Network |
$3.92
|
| Rate for Payer: Quartz Commercial |
$4.80
|
| Rate for Payer: WEA Trust Commercial |
$4.40
|
| Rate for Payer: WPS Commercial |
$5.93
|
|
|
Cefazolin JW Waste Charge per 500 mg
|
Professional
|
$8.00
|
|
|
Service Code
|
HCPCS J0690 JW
|
| Hospital Charge Code |
5266692
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.52 |
| Max. Negotiated Rate |
$7.60 |
| Rate for Payer: Aetna Commercial |
$7.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.88
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$7.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4.80
|
| Rate for Payer: Health EOS Commercial |
$7.28
|
| Rate for Payer: Multiplan Commercial |
$6.40
|
| Rate for Payer: Preferred Network Access Commercial |
$7.60
|
| Rate for Payer: Quartz Beloit One Network |
$3.52
|
| Rate for Payer: Quartz Commercial |
$4.56
|
| Rate for Payer: The Alliance Commercial |
$4.00
|
| Rate for Payer: WEA Trust Commercial |
$4.40
|
| Rate for Payer: WPS Commercial |
$5.93
|
|
|
Cefoxitin 1gm vial [Med]
|
Facility
IP
|
$96.00
|
|
|
Service Code
|
HCPCS J0694
|
| Hospital Charge Code |
2974918
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.04 |
| Max. Negotiated Rate |
$88.32 |
| Rate for Payer: Aetna Commercial |
$86.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$50.88
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cigna Commercial |
$88.32
|
| Rate for Payer: Health EOS Commercial |
$85.44
|
| Rate for Payer: HFN Commercial |
$88.32
|
| Rate for Payer: Multiplan Commercial |
$76.80
|
| Rate for Payer: NAPHCARE Commercial |
$57.60
|
| Rate for Payer: Preferred Network Access Commercial |
$88.32
|
| Rate for Payer: Quartz Beloit One Network |
$47.04
|
| Rate for Payer: Quartz Commercial |
$57.60
|
| Rate for Payer: WEA Trust Commercial |
$52.80
|
| Rate for Payer: WPS Commercial |
$71.11
|
|
|
Cefoxitin 1gm vial [Med]
|
Facility
OP
|
$96.00
|
|
|
Service Code
|
HCPCS J0694
|
| Hospital Charge Code |
2974918
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.48 |
| Max. Negotiated Rate |
$419.00 |
| Rate for Payer: Aetna Commercial |
$86.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$82.56
|
| Rate for Payer: Aetna Managed Medicare |
$26.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$62.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$48.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$46.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$50.88
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cigna Commercial |
$88.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6.48
|
| Rate for Payer: Health EOS Commercial |
$85.44
|
| Rate for Payer: HFN Commercial |
$88.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$72.00
|
| Rate for Payer: Multiplan Commercial |
$76.80
|
| Rate for Payer: NAPHCARE Commercial |
$57.60
|
| Rate for Payer: Preferred Network Access Commercial |
$88.32
|
| Rate for Payer: Quartz Beloit One Network |
$47.04
|
| Rate for Payer: Quartz Commercial |
$62.40
|
| Rate for Payer: Quartz Medicare Advantage |
$57.60
|
| Rate for Payer: The Alliance Commercial |
$419.00
|
| Rate for Payer: WEA Trust Commercial |
$52.80
|
| Rate for Payer: WPS Commercial |
$12.24
|
|
|
Cefoxitin 2gm vial [Med]
|
Facility
OP
|
$135.00
|
|
|
Service Code
|
HCPCS J0694
|
| Hospital Charge Code |
2974919
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.48 |
| Max. Negotiated Rate |
$419.00 |
| Rate for Payer: Aetna Commercial |
$121.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$116.10
|
| Rate for Payer: Aetna Managed Medicare |
$37.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$87.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$67.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$64.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$71.55
|
| Rate for Payer: Cash Price |
$40.50
|
| Rate for Payer: Cash Price |
$40.50
|
| Rate for Payer: Cigna Commercial |
$124.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6.48
|
| Rate for Payer: Health EOS Commercial |
$120.15
|
| Rate for Payer: HFN Commercial |
$124.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$101.25
|
| Rate for Payer: Multiplan Commercial |
$108.00
|
| Rate for Payer: NAPHCARE Commercial |
$81.00
|
| Rate for Payer: Preferred Network Access Commercial |
$124.20
|
| Rate for Payer: Quartz Beloit One Network |
$66.15
|
| Rate for Payer: Quartz Commercial |
$87.75
|
| Rate for Payer: Quartz Medicare Advantage |
$81.00
|
| Rate for Payer: The Alliance Commercial |
$419.00
|
| Rate for Payer: WEA Trust Commercial |
$74.25
|
| Rate for Payer: WPS Commercial |
$12.24
|
|
|
Cefoxitin 2gm vial [Med]
|
Facility
IP
|
$135.00
|
|
|
Service Code
|
HCPCS J0694
|
| Hospital Charge Code |
2974919
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$66.15 |
| Max. Negotiated Rate |
$124.20 |
| Rate for Payer: Aetna Commercial |
$121.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$71.55
|
| Rate for Payer: Cash Price |
$40.50
|
| Rate for Payer: Cigna Commercial |
$124.20
|
| Rate for Payer: Health EOS Commercial |
$120.15
|
| Rate for Payer: HFN Commercial |
$124.20
|
| Rate for Payer: Multiplan Commercial |
$108.00
|
| Rate for Payer: NAPHCARE Commercial |
$81.00
|
| Rate for Payer: Preferred Network Access Commercial |
$124.20
|
| Rate for Payer: Quartz Beloit One Network |
$66.15
|
| Rate for Payer: Quartz Commercial |
$81.00
|
| Rate for Payer: WEA Trust Commercial |
$74.25
|
| Rate for Payer: WPS Commercial |
$99.99
|
|
|
Ceftriaxone 1gm vial [Med]
|
Facility
OP
|
$34.00
|
|
|
Service Code
|
HCPCS J0696
|
| Hospital Charge Code |
2974920
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$700.24 |
| Rate for Payer: Aetna Commercial |
$30.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$29.24
|
| Rate for Payer: Aetna Managed Medicare |
$9.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$22.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$17.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$16.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$18.02
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Cigna Commercial |
$31.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.60
|
| Rate for Payer: Health EOS Commercial |
$30.26
|
| Rate for Payer: HFN Commercial |
$31.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$25.50
|
| Rate for Payer: Multiplan Commercial |
$27.20
|
| Rate for Payer: NAPHCARE Commercial |
$20.40
|
| Rate for Payer: Preferred Network Access Commercial |
$31.28
|
| Rate for Payer: Quartz Beloit One Network |
$16.66
|
| Rate for Payer: Quartz Commercial |
$22.10
|
| Rate for Payer: Quartz Medicare Advantage |
$20.40
|
| Rate for Payer: The Alliance Commercial |
$700.24
|
| Rate for Payer: WEA Trust Commercial |
$18.70
|
| Rate for Payer: WPS Commercial |
$1.14
|
|
|
Ceftriaxone 1gm vial [Med]
|
Facility
IP
|
$34.00
|
|
|
Service Code
|
HCPCS J0696
|
| Hospital Charge Code |
2974920
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.66 |
| Max. Negotiated Rate |
$31.28 |
| Rate for Payer: Aetna Commercial |
$30.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$18.02
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Cigna Commercial |
$31.28
|
| Rate for Payer: Health EOS Commercial |
$30.26
|
| Rate for Payer: HFN Commercial |
$31.28
|
| Rate for Payer: Multiplan Commercial |
$27.20
|
| Rate for Payer: NAPHCARE Commercial |
$20.40
|
| Rate for Payer: Preferred Network Access Commercial |
$31.28
|
| Rate for Payer: Quartz Beloit One Network |
$16.66
|
| Rate for Payer: Quartz Commercial |
$20.40
|
| Rate for Payer: WEA Trust Commercial |
$18.70
|
| Rate for Payer: WPS Commercial |
$25.18
|
|
