|
Phenylephrine 10% Ophth solution 5ml (refrigerator) [Med]
|
Facility
|
OP
|
$150.00
|
|
| Hospital Charge Code |
2974969
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$43.68 |
| Max. Negotiated Rate |
$143.52 |
| Rate for Payer: Aetna Commercial |
$140.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$134.16
|
| Rate for Payer: Aetna Managed Medicare |
$43.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$101.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$78.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$74.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$82.68
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cigna Commercial |
$143.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$87.30
|
| Rate for Payer: Health EOS Commercial |
$138.84
|
| Rate for Payer: HFN Commercial |
$143.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$117.00
|
| Rate for Payer: Multiplan Commercial |
$124.80
|
| Rate for Payer: NAPHCARE Commercial |
$93.60
|
| Rate for Payer: Preferred Network Access Commercial |
$143.52
|
| Rate for Payer: Quartz Beloit One Network |
$76.44
|
| Rate for Payer: Quartz Commercial |
$101.40
|
| Rate for Payer: Quartz Medicare Advantage |
$93.60
|
| Rate for Payer: The Alliance Commercial |
$78.00
|
| Rate for Payer: WEA Trust Commercial |
$85.80
|
| Rate for Payer: WPS Commercial |
$115.55
|
|
|
Phenylephrine 10% Ophth solution 5ml (refrigerator) [Med]
|
Facility
|
IP
|
$150.00
|
|
| Hospital Charge Code |
2974969
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$76.44 |
| Max. Negotiated Rate |
$143.52 |
| Rate for Payer: Aetna Commercial |
$140.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$134.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$82.68
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cigna Commercial |
$143.52
|
| Rate for Payer: Health EOS Commercial |
$138.84
|
| Rate for Payer: HFN Commercial |
$143.52
|
| Rate for Payer: Multiplan Commercial |
$124.80
|
| Rate for Payer: Preferred Network Access Commercial |
$143.52
|
| Rate for Payer: Quartz Beloit One Network |
$76.44
|
| Rate for Payer: Quartz Commercial |
$93.60
|
| Rate for Payer: WEA Trust Commercial |
$85.80
|
| Rate for Payer: WPS Commercial |
$115.55
|
|
|
Phenylephrine 2.5% Ophth Solution 2.5ml [Med]
|
Facility
|
IP
|
$125.00
|
|
| Hospital Charge Code |
2974904
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$63.70 |
| Max. Negotiated Rate |
$119.60 |
| Rate for Payer: Aetna Commercial |
$117.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$111.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$68.90
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cigna Commercial |
$119.60
|
| Rate for Payer: Health EOS Commercial |
$115.70
|
| Rate for Payer: HFN Commercial |
$119.60
|
| Rate for Payer: Multiplan Commercial |
$104.00
|
| Rate for Payer: Preferred Network Access Commercial |
$119.60
|
| Rate for Payer: Quartz Beloit One Network |
$63.70
|
| Rate for Payer: Quartz Commercial |
$78.00
|
| Rate for Payer: WEA Trust Commercial |
$71.50
|
| Rate for Payer: WPS Commercial |
$96.29
|
|
|
Phenylephrine 2.5% Ophth Solution 2.5ml [Med]
|
Facility
|
OP
|
$125.00
|
|
| Hospital Charge Code |
2974904
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.40 |
| Max. Negotiated Rate |
$119.60 |
| Rate for Payer: Aetna Commercial |
$117.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$111.80
|
| Rate for Payer: Aetna Managed Medicare |
$36.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$84.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$65.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$62.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$68.90
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cigna Commercial |
$119.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$72.75
|
| Rate for Payer: Health EOS Commercial |
$115.70
|
| Rate for Payer: HFN Commercial |
$119.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$97.50
|
| Rate for Payer: Multiplan Commercial |
$104.00
|
| Rate for Payer: NAPHCARE Commercial |
$78.00
|
| Rate for Payer: Preferred Network Access Commercial |
$119.60
|
| Rate for Payer: Quartz Beloit One Network |
$63.70
|
| Rate for Payer: Quartz Commercial |
$84.50
|
| Rate for Payer: Quartz Medicare Advantage |
$78.00
|
| Rate for Payer: The Alliance Commercial |
$65.00
|
| Rate for Payer: WEA Trust Commercial |
$71.50
|
| Rate for Payer: WPS Commercial |
$96.29
|
|
|
Phenylephrine JW Waste Charge per 1 ml
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
HCPCS J2370 JW
|
| Hospital Charge Code |
5266688
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.61 |
| Max. Negotiated Rate |
$10.52 |
| Rate for Payer: Aetna Commercial |
$10.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6.06
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cigna Commercial |
$10.52
|
| Rate for Payer: Health EOS Commercial |
$10.18
|
| Rate for Payer: HFN Commercial |
$10.52
|
| Rate for Payer: Multiplan Commercial |
$9.15
|
| Rate for Payer: Preferred Network Access Commercial |
$10.52
|
| Rate for Payer: Quartz Beloit One Network |
$5.61
|
| Rate for Payer: Quartz Commercial |
$6.86
|
| Rate for Payer: WEA Trust Commercial |
$6.29
|
| Rate for Payer: WPS Commercial |
$8.47
|
|
|
Phenylephrine JW Waste Charge per 1 ml
|
Professional
|
Both
|
$11.00
|
|
|
Service Code
|
HCPCS J2370 JW
|
| Hospital Charge Code |
5266688
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.68 |
| Max. Negotiated Rate |
$10.87 |
| Rate for Payer: Aetna Commercial |
$10.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9.84
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cigna Commercial |
$10.87
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6.86
|
| Rate for Payer: Health EOS Commercial |
$10.41
|
| Rate for Payer: HFN Commercial |
$10.87
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4.68
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$4.68
|
| Rate for Payer: Multiplan Commercial |
$9.15
|
| Rate for Payer: Preferred Network Access Commercial |
$10.87
|
| Rate for Payer: Quartz Beloit One Network |
$5.03
|
| Rate for Payer: Quartz Commercial |
$6.52
|
| Rate for Payer: The Alliance Commercial |
$5.72
|
| Rate for Payer: WEA Trust Commercial |
$6.29
|
| Rate for Payer: WPS Commercial |
$8.47
|
|
|
Phenylephrine JW Waste Charge per 1 ml
|
Facility
|
OP
|
$11.00
|
|
|
Service Code
|
HCPCS J2370 JW
|
| Hospital Charge Code |
5266688
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.20 |
| Max. Negotiated Rate |
$10.52 |
| Rate for Payer: Aetna Commercial |
$10.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9.84
|
| Rate for Payer: Aetna Managed Medicare |
$3.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6.06
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cigna Commercial |
$10.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6.40
|
| Rate for Payer: Health EOS Commercial |
$10.18
|
| Rate for Payer: HFN Commercial |
$10.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8.58
|
| Rate for Payer: Multiplan Commercial |
$9.15
|
| Rate for Payer: NAPHCARE Commercial |
$6.86
|
| Rate for Payer: Preferred Network Access Commercial |
$10.52
|
| Rate for Payer: Quartz Beloit One Network |
$5.61
|
| Rate for Payer: Quartz Commercial |
$7.44
|
| Rate for Payer: Quartz Medicare Advantage |
$6.86
|
| Rate for Payer: The Alliance Commercial |
$5.72
|
| Rate for Payer: WEA Trust Commercial |
$6.29
|
| Rate for Payer: WPS Commercial |
$8.47
|
|
|
Phenytoin JW Waste Charge per 50 mg
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
HCPCS J1165 JW
|
| Hospital Charge Code |
5266720
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$4.78 |
| Rate for Payer: Aetna Commercial |
$4.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2.76
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cigna Commercial |
$4.78
|
| Rate for Payer: Health EOS Commercial |
$4.63
|
| Rate for Payer: HFN Commercial |
$4.78
|
| Rate for Payer: Multiplan Commercial |
$4.16
|
| Rate for Payer: Preferred Network Access Commercial |
$4.78
|
| Rate for Payer: Quartz Beloit One Network |
$2.55
|
| Rate for Payer: Quartz Commercial |
$3.12
|
| Rate for Payer: WEA Trust Commercial |
$2.86
|
| Rate for Payer: WPS Commercial |
$3.85
|
|
|
Phenytoin JW Waste Charge per 50 mg
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
HCPCS J1165 JW
|
| Hospital Charge Code |
5266720
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$4.78 |
| Rate for Payer: Aetna Commercial |
$4.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4.47
|
| Rate for Payer: Aetna Managed Medicare |
$1.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3.38
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2.76
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cigna Commercial |
$4.78
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.88
|
| Rate for Payer: Health EOS Commercial |
$4.63
|
| Rate for Payer: HFN Commercial |
$4.78
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3.90
|
| Rate for Payer: Multiplan Commercial |
$4.16
|
| Rate for Payer: NAPHCARE Commercial |
$3.12
|
| Rate for Payer: Preferred Network Access Commercial |
$4.78
|
| Rate for Payer: Quartz Beloit One Network |
$2.55
|
| Rate for Payer: Quartz Commercial |
$3.38
|
| Rate for Payer: Quartz Medicare Advantage |
$3.12
|
| Rate for Payer: The Alliance Commercial |
$2.60
|
| Rate for Payer: WEA Trust Commercial |
$2.86
|
| Rate for Payer: WPS Commercial |
$1.66
|
|
|
Phenytoin JW Waste Charge per 50 mg
|
Professional
|
Both
|
$5.00
|
|
|
Service Code
|
HCPCS J1165 JW
|
| Hospital Charge Code |
5266720
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$4.94 |
| Rate for Payer: Aetna Commercial |
$4.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4.47
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cigna Commercial |
$4.94
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$0.62
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.67
|
| Rate for Payer: Health EOS Commercial |
$4.73
|
| Rate for Payer: HFN Commercial |
$4.94
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$0.63
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$0.63
|
| Rate for Payer: Multiplan Commercial |
$4.16
|
| Rate for Payer: Preferred Network Access Commercial |
$4.94
|
| Rate for Payer: Quartz Beloit One Network |
$2.29
|
| Rate for Payer: Quartz Commercial |
$2.96
|
| Rate for Payer: The Alliance Commercial |
$2.60
|
| Rate for Payer: United Healthcare Medicaid |
$0.62
|
| Rate for Payer: WEA Trust Commercial |
$2.86
|
| Rate for Payer: WPS Commercial |
$1.66
|
|
|
Phenytoin Level Free
|
Professional
|
Both
|
$210.00
|
|
|
Service Code
|
CPT 80186
|
| Hospital Charge Code |
633802
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.31 |
| Max. Negotiated Rate |
$207.48 |
| Rate for Payer: Aetna Commercial |
$207.48
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$187.82
|
| Rate for Payer: Aetna Managed Medicare |
$14.31
|
| Rate for Payer: Anthem Medicare Advantage |
$14.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$14.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$14.31
|
| Rate for Payer: Cash Price |
$63.00
|
| Rate for Payer: Cash Price |
$63.00
|
| Rate for Payer: Cigna Commercial |
$207.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$109.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$14.31
|
| Rate for Payer: Health EOS Commercial |
$198.74
|
| Rate for Payer: HFN Commercial |
$207.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$50.51
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$50.51
|
| Rate for Payer: Independent Care Health Plan Medicare |
$14.31
|
| Rate for Payer: Multiplan Commercial |
$174.72
|
| Rate for Payer: NAPHCARE Commercial |
$21.47
|
| Rate for Payer: Preferred Network Access Commercial |
$207.48
|
| Rate for Payer: Quartz Beloit One Network |
$96.10
|
| Rate for Payer: Quartz Commercial |
$124.49
|
| Rate for Payer: Quartz Medicare Advantage |
$14.31
|
| Rate for Payer: The Alliance Commercial |
$56.53
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.31
|
| Rate for Payer: WEA Trust Commercial |
$120.12
|
| Rate for Payer: WPS Commercial |
$62.97
|
|
|
Phenytoin Level Free
|
Facility
|
OP
|
$210.00
|
|
|
Service Code
|
CPT 80186
|
| Hospital Charge Code |
633802
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.31 |
| Max. Negotiated Rate |
$200.93 |
| Rate for Payer: Aetna Commercial |
$196.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$187.82
|
| Rate for Payer: Aetna Managed Medicare |
$14.31
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$53.66
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$25.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$23.76
|
| Rate for Payer: Anthem Medicare Advantage |
$14.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$115.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$14.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$14.31
|
| Rate for Payer: Cash Price |
$63.00
|
| Rate for Payer: Cash Price |
$63.00
|
| Rate for Payer: Cigna Commercial |
$200.93
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$14.31
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$122.22
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$14.31
|
| Rate for Payer: Health EOS Commercial |
$194.38
|
| Rate for Payer: HFN Commercial |
$200.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$53.23
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$14.31
|
| Rate for Payer: Independent Care Health Plan Medicare |
$14.31
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$14.31
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$14.31
|
| Rate for Payer: Multiplan Commercial |
$174.72
|
| Rate for Payer: NAPHCARE Commercial |
$21.47
|
| Rate for Payer: Preferred Network Access Commercial |
$200.93
|
| Rate for Payer: Quartz Beloit One Network |
$107.02
|
| Rate for Payer: Quartz Commercial |
$141.96
|
| Rate for Payer: Quartz Medicare Advantage |
$14.31
|
| Rate for Payer: The Alliance Commercial |
$57.24
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.31
|
| Rate for Payer: United Healthcare PPO |
$163.80
|
| Rate for Payer: WEA Trust Commercial |
$120.12
|
| Rate for Payer: Wellcare Medicare |
$14.31
|
| Rate for Payer: WPS Commercial |
$161.76
|
|
|
Phenytoin Level Free
|
Facility
|
IP
|
$210.00
|
|
|
Service Code
|
CPT 80186
|
| Hospital Charge Code |
633802
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$107.02 |
| Max. Negotiated Rate |
$200.93 |
| Rate for Payer: Aetna Commercial |
$196.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$187.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$115.75
|
| Rate for Payer: Cash Price |
$63.00
|
| Rate for Payer: Cigna Commercial |
$200.93
|
| Rate for Payer: Health EOS Commercial |
$194.38
|
| Rate for Payer: HFN Commercial |
$200.93
|
| Rate for Payer: Multiplan Commercial |
$174.72
|
| Rate for Payer: Preferred Network Access Commercial |
$200.93
|
| Rate for Payer: Quartz Beloit One Network |
$107.02
|
| Rate for Payer: Quartz Commercial |
$131.04
|
| Rate for Payer: WEA Trust Commercial |
$120.12
|
| Rate for Payer: WPS Commercial |
$161.76
|
|
|
Phenytoin Level Total
|
Facility
|
IP
|
$241.00
|
|
|
Service Code
|
CPT 80185
|
| Hospital Charge Code |
633801
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$122.81 |
| Max. Negotiated Rate |
$230.59 |
| Rate for Payer: Aetna Commercial |
$225.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$215.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$132.84
|
| Rate for Payer: Cash Price |
$72.30
|
| Rate for Payer: Cigna Commercial |
$230.59
|
| Rate for Payer: Health EOS Commercial |
$223.07
|
| Rate for Payer: HFN Commercial |
$230.59
|
| Rate for Payer: Multiplan Commercial |
$200.51
|
| Rate for Payer: Preferred Network Access Commercial |
$230.59
|
| Rate for Payer: Quartz Beloit One Network |
$122.81
|
| Rate for Payer: Quartz Commercial |
$150.38
|
| Rate for Payer: WEA Trust Commercial |
$137.85
|
| Rate for Payer: WPS Commercial |
$185.64
|
|
|
Phenytoin Level Total
|
Professional
|
Both
|
$241.00
|
|
|
Service Code
|
CPT 80185
|
| Hospital Charge Code |
633801
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.78 |
| Max. Negotiated Rate |
$238.11 |
| Rate for Payer: Aetna Commercial |
$238.11
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$215.55
|
| Rate for Payer: Aetna Managed Medicare |
$13.78
|
| Rate for Payer: Anthem Medicare Advantage |
$13.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$13.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$13.78
|
| Rate for Payer: Cash Price |
$72.30
|
| Rate for Payer: Cash Price |
$72.30
|
| Rate for Payer: Cigna Commercial |
$238.11
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$125.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.78
|
| Rate for Payer: Health EOS Commercial |
$228.08
|
| Rate for Payer: HFN Commercial |
$238.11
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$48.64
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$48.64
|
| Rate for Payer: Independent Care Health Plan Medicare |
$13.78
|
| Rate for Payer: Multiplan Commercial |
$200.51
|
| Rate for Payer: NAPHCARE Commercial |
$20.67
|
| Rate for Payer: Preferred Network Access Commercial |
$238.11
|
| Rate for Payer: Quartz Beloit One Network |
$110.28
|
| Rate for Payer: Quartz Commercial |
$142.86
|
| Rate for Payer: Quartz Medicare Advantage |
$13.78
|
| Rate for Payer: The Alliance Commercial |
$54.43
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.78
|
| Rate for Payer: WEA Trust Commercial |
$137.85
|
| Rate for Payer: WPS Commercial |
$60.63
|
|
|
Phenytoin Level Total
|
Facility
|
OP
|
$241.00
|
|
|
Service Code
|
CPT 80185
|
| Hospital Charge Code |
633801
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.78 |
| Max. Negotiated Rate |
$230.59 |
| Rate for Payer: Aetna Commercial |
$225.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$215.55
|
| Rate for Payer: Aetna Managed Medicare |
$13.78
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$51.67
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$24.11
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$22.87
|
| Rate for Payer: Anthem Medicare Advantage |
$13.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$132.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$13.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$13.78
|
| Rate for Payer: Cash Price |
$72.30
|
| Rate for Payer: Cash Price |
$72.30
|
| Rate for Payer: Cigna Commercial |
$230.59
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$13.78
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$140.26
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$13.78
|
| Rate for Payer: Health EOS Commercial |
$223.07
|
| Rate for Payer: HFN Commercial |
$230.59
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$51.26
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$13.78
|
| Rate for Payer: Independent Care Health Plan Medicare |
$13.78
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$13.78
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$13.78
|
| Rate for Payer: Multiplan Commercial |
$200.51
|
| Rate for Payer: NAPHCARE Commercial |
$20.67
|
| Rate for Payer: Preferred Network Access Commercial |
$230.59
|
| Rate for Payer: Quartz Beloit One Network |
$122.81
|
| Rate for Payer: Quartz Commercial |
$162.92
|
| Rate for Payer: Quartz Medicare Advantage |
$13.78
|
| Rate for Payer: The Alliance Commercial |
$55.12
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.78
|
| Rate for Payer: United Healthcare PPO |
$187.98
|
| Rate for Payer: WEA Trust Commercial |
$137.85
|
| Rate for Payer: Wellcare Medicare |
$13.78
|
| Rate for Payer: WPS Commercial |
$185.64
|
|
|
pH, Feces
|
Professional
|
Both
|
$55.00
|
|
|
Service Code
|
CPT 83986
|
| Hospital Charge Code |
3167486
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$3.72 |
| Max. Negotiated Rate |
$54.34 |
| Rate for Payer: Aetna Commercial |
$54.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$49.19
|
| Rate for Payer: Aetna Managed Medicare |
$3.72
|
| Rate for Payer: Anthem Medicare Advantage |
$3.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3.72
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Cigna Commercial |
$54.34
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$28.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3.72
|
| Rate for Payer: Health EOS Commercial |
$52.05
|
| Rate for Payer: HFN Commercial |
$54.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13.15
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$13.15
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3.72
|
| Rate for Payer: Multiplan Commercial |
$45.76
|
| Rate for Payer: NAPHCARE Commercial |
$5.58
|
| Rate for Payer: Preferred Network Access Commercial |
$54.34
|
| Rate for Payer: Quartz Beloit One Network |
$25.17
|
| Rate for Payer: Quartz Commercial |
$32.60
|
| Rate for Payer: Quartz Medicare Advantage |
$3.72
|
| Rate for Payer: The Alliance Commercial |
$14.71
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3.72
|
| Rate for Payer: WEA Trust Commercial |
$31.46
|
| Rate for Payer: WPS Commercial |
$16.38
|
|
|
pH, Feces
|
Facility
|
IP
|
$55.00
|
|
|
Service Code
|
CPT 83986
|
| Hospital Charge Code |
3167486
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$28.03 |
| Max. Negotiated Rate |
$52.62 |
| Rate for Payer: Aetna Commercial |
$51.48
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$49.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$30.32
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Cigna Commercial |
$52.62
|
| Rate for Payer: Health EOS Commercial |
$50.91
|
| Rate for Payer: HFN Commercial |
$52.62
|
| Rate for Payer: Multiplan Commercial |
$45.76
|
| Rate for Payer: Preferred Network Access Commercial |
$52.62
|
| Rate for Payer: Quartz Beloit One Network |
$28.03
|
| Rate for Payer: Quartz Commercial |
$34.32
|
| Rate for Payer: WEA Trust Commercial |
$31.46
|
| Rate for Payer: WPS Commercial |
$42.37
|
|
|
pH, Feces
|
Facility
|
OP
|
$55.00
|
|
|
Service Code
|
CPT 83986
|
| Hospital Charge Code |
3167486
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$3.72 |
| Max. Negotiated Rate |
$52.62 |
| Rate for Payer: Aetna Commercial |
$51.48
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$49.19
|
| Rate for Payer: Aetna Managed Medicare |
$3.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6.18
|
| Rate for Payer: Anthem Medicare Advantage |
$3.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$30.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3.72
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Cigna Commercial |
$52.62
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$3.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$32.01
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$3.72
|
| Rate for Payer: Health EOS Commercial |
$50.91
|
| Rate for Payer: HFN Commercial |
$52.62
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13.85
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3.72
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3.72
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$3.72
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$3.72
|
| Rate for Payer: Multiplan Commercial |
$45.76
|
| Rate for Payer: NAPHCARE Commercial |
$5.58
|
| Rate for Payer: Preferred Network Access Commercial |
$52.62
|
| Rate for Payer: Quartz Beloit One Network |
$28.03
|
| Rate for Payer: Quartz Commercial |
$37.18
|
| Rate for Payer: Quartz Medicare Advantage |
$3.72
|
| Rate for Payer: The Alliance Commercial |
$14.89
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3.72
|
| Rate for Payer: United Healthcare PPO |
$42.90
|
| Rate for Payer: WEA Trust Commercial |
$31.46
|
| Rate for Payer: Wellcare Medicare |
$3.72
|
| Rate for Payer: WPS Commercial |
$42.37
|
|
|
pH, Fluid
|
Professional
|
Both
|
$55.00
|
|
|
Service Code
|
CPT 83986
|
| Hospital Charge Code |
3154876
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$3.72 |
| Max. Negotiated Rate |
$54.34 |
| Rate for Payer: Aetna Commercial |
$54.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$49.19
|
| Rate for Payer: Aetna Managed Medicare |
$3.72
|
| Rate for Payer: Anthem Medicare Advantage |
$3.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3.72
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Cigna Commercial |
$54.34
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$28.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3.72
|
| Rate for Payer: Health EOS Commercial |
$52.05
|
| Rate for Payer: HFN Commercial |
$54.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13.15
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$13.15
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3.72
|
| Rate for Payer: Multiplan Commercial |
$45.76
|
| Rate for Payer: NAPHCARE Commercial |
$5.58
|
| Rate for Payer: Preferred Network Access Commercial |
$54.34
|
| Rate for Payer: Quartz Beloit One Network |
$25.17
|
| Rate for Payer: Quartz Commercial |
$32.60
|
| Rate for Payer: Quartz Medicare Advantage |
$3.72
|
| Rate for Payer: The Alliance Commercial |
$14.71
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3.72
|
| Rate for Payer: WEA Trust Commercial |
$31.46
|
| Rate for Payer: WPS Commercial |
$16.38
|
|
|
pH, Fluid
|
Facility
|
IP
|
$55.00
|
|
|
Service Code
|
CPT 83986
|
| Hospital Charge Code |
3154876
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$28.03 |
| Max. Negotiated Rate |
$52.62 |
| Rate for Payer: Aetna Commercial |
$51.48
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$49.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$30.32
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Cigna Commercial |
$52.62
|
| Rate for Payer: Health EOS Commercial |
$50.91
|
| Rate for Payer: HFN Commercial |
$52.62
|
| Rate for Payer: Multiplan Commercial |
$45.76
|
| Rate for Payer: Preferred Network Access Commercial |
$52.62
|
| Rate for Payer: Quartz Beloit One Network |
$28.03
|
| Rate for Payer: Quartz Commercial |
$34.32
|
| Rate for Payer: WEA Trust Commercial |
$31.46
|
| Rate for Payer: WPS Commercial |
$42.37
|
|
|
pH, Fluid
|
Facility
|
OP
|
$55.00
|
|
|
Service Code
|
CPT 83986
|
| Hospital Charge Code |
3154876
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$3.72 |
| Max. Negotiated Rate |
$52.62 |
| Rate for Payer: Aetna Commercial |
$51.48
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$49.19
|
| Rate for Payer: Aetna Managed Medicare |
$3.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6.18
|
| Rate for Payer: Anthem Medicare Advantage |
$3.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$30.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3.72
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Cigna Commercial |
$52.62
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$3.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$32.01
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$3.72
|
| Rate for Payer: Health EOS Commercial |
$50.91
|
| Rate for Payer: HFN Commercial |
$52.62
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13.85
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3.72
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3.72
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$3.72
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$3.72
|
| Rate for Payer: Multiplan Commercial |
$45.76
|
| Rate for Payer: NAPHCARE Commercial |
$5.58
|
| Rate for Payer: Preferred Network Access Commercial |
$52.62
|
| Rate for Payer: Quartz Beloit One Network |
$28.03
|
| Rate for Payer: Quartz Commercial |
$37.18
|
| Rate for Payer: Quartz Medicare Advantage |
$3.72
|
| Rate for Payer: The Alliance Commercial |
$14.89
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3.72
|
| Rate for Payer: United Healthcare PPO |
$42.90
|
| Rate for Payer: WEA Trust Commercial |
$31.46
|
| Rate for Payer: Wellcare Medicare |
$3.72
|
| Rate for Payer: WPS Commercial |
$42.37
|
|
|
PHLEBECTOMY/VARICOSE VEIN LIGATION AND STRIPPING
|
Facility
|
IP
|
$1,084.00
|
|
| Hospital Charge Code |
2960315
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$552.41 |
| Max. Negotiated Rate |
$1,037.17 |
| Rate for Payer: Aetna Commercial |
$1,014.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$969.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$597.50
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$1,037.17
|
| Rate for Payer: Health EOS Commercial |
$1,003.35
|
| Rate for Payer: HFN Commercial |
$1,037.17
|
| Rate for Payer: Multiplan Commercial |
$901.89
|
| Rate for Payer: Preferred Network Access Commercial |
$1,037.17
|
| Rate for Payer: Quartz Beloit One Network |
$552.41
|
| Rate for Payer: Quartz Commercial |
$676.42
|
| Rate for Payer: WEA Trust Commercial |
$620.05
|
| Rate for Payer: WPS Commercial |
$835.01
|
|
|
PHLEBECTOMY/VARICOSE VEIN LIGATION AND STRIPPING
|
Facility
|
OP
|
$1,084.00
|
|
| Hospital Charge Code |
2960315
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$315.66 |
| Max. Negotiated Rate |
$1,037.17 |
| Rate for Payer: Aetna Commercial |
$1,014.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$969.53
|
| Rate for Payer: Aetna Managed Medicare |
$315.66
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$732.78
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$563.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$541.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$597.50
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$1,037.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$630.89
|
| Rate for Payer: Health EOS Commercial |
$1,003.35
|
| Rate for Payer: HFN Commercial |
$1,037.17
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$845.52
|
| Rate for Payer: Multiplan Commercial |
$901.89
|
| Rate for Payer: NAPHCARE Commercial |
$676.42
|
| Rate for Payer: Preferred Network Access Commercial |
$1,037.17
|
| Rate for Payer: Quartz Beloit One Network |
$552.41
|
| Rate for Payer: Quartz Commercial |
$732.78
|
| Rate for Payer: Quartz Medicare Advantage |
$676.42
|
| Rate for Payer: The Alliance Commercial |
$563.68
|
| Rate for Payer: WEA Trust Commercial |
$620.05
|
| Rate for Payer: WPS Commercial |
$835.01
|
|
|
PHLEBITIS
|
Facility
|
OP
|
$86.48
|
|
|
Service Code
|
EAPG 00597
|
| Min. Negotiated Rate |
$83.15 |
| Max. Negotiated Rate |
$86.48 |
| Rate for Payer: Anthem Medicaid |
$83.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$83.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$83.15
|
| Rate for Payer: Dean Health Medicaid |
$83.15
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$83.15
|
| Rate for Payer: Managed Health Services Medicaid |
$86.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$83.15
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$83.15
|
| Rate for Payer: United Healthcare Medicaid |
$83.15
|
|
