|
Phenobarbital
|
Facility
|
IP
|
$21.00
|
|
|
Service Code
|
CPT 80184
|
| Hospital Charge Code |
2942975
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.70 |
| Max. Negotiated Rate |
$20.09 |
| Rate for Payer: Aetna Commercial |
$19.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.58
|
| Rate for Payer: Cash Price |
$6.30
|
| Rate for Payer: Cigna Commercial |
$20.09
|
| Rate for Payer: Health EOS Commercial |
$19.44
|
| Rate for Payer: HFN Commercial |
$20.09
|
| Rate for Payer: Multiplan Commercial |
$17.47
|
| Rate for Payer: Preferred Network Access Commercial |
$20.09
|
| Rate for Payer: Quartz Beloit One Network |
$10.70
|
| Rate for Payer: Quartz Commercial |
$13.10
|
| Rate for Payer: WEA Trust Commercial |
$12.01
|
| Rate for Payer: WPS Commercial |
$16.18
|
|
|
Phenobarbital
|
Professional
|
Both
|
$21.00
|
|
|
Service Code
|
CPT 80184
|
| Hospital Charge Code |
2942975
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$9.61 |
| Max. Negotiated Rate |
$70.01 |
| Rate for Payer: Aetna Commercial |
$20.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.78
|
| Rate for Payer: Aetna Managed Medicare |
$15.91
|
| Rate for Payer: Anthem Medicare Advantage |
$15.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15.91
|
| Rate for Payer: Cash Price |
$6.30
|
| Rate for Payer: Cash Price |
$6.30
|
| Rate for Payer: Cigna Commercial |
$20.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$10.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15.91
|
| Rate for Payer: Health EOS Commercial |
$19.87
|
| Rate for Payer: HFN Commercial |
$20.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$56.17
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$56.17
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15.91
|
| Rate for Payer: Multiplan Commercial |
$17.47
|
| Rate for Payer: NAPHCARE Commercial |
$23.87
|
| Rate for Payer: Preferred Network Access Commercial |
$20.75
|
| Rate for Payer: Quartz Beloit One Network |
$9.61
|
| Rate for Payer: Quartz Commercial |
$12.45
|
| Rate for Payer: Quartz Medicare Advantage |
$15.91
|
| Rate for Payer: The Alliance Commercial |
$62.85
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.91
|
| Rate for Payer: WEA Trust Commercial |
$12.01
|
| Rate for Payer: WPS Commercial |
$70.01
|
|
|
Phenobarbital
|
Facility
|
OP
|
$21.00
|
|
|
Service Code
|
CPT 80184
|
| Hospital Charge Code |
2942975
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.70 |
| Max. Negotiated Rate |
$63.65 |
| Rate for Payer: Aetna Commercial |
$19.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.78
|
| Rate for Payer: Aetna Managed Medicare |
$15.91
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$59.67
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$27.85
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$26.41
|
| Rate for Payer: Anthem Medicare Advantage |
$15.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15.91
|
| Rate for Payer: Cash Price |
$6.30
|
| Rate for Payer: Cash Price |
$6.30
|
| Rate for Payer: Cigna Commercial |
$20.09
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$15.91
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.22
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$15.91
|
| Rate for Payer: Health EOS Commercial |
$19.44
|
| Rate for Payer: HFN Commercial |
$20.09
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$59.19
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$15.91
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15.91
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$15.91
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$15.91
|
| Rate for Payer: Multiplan Commercial |
$17.47
|
| Rate for Payer: NAPHCARE Commercial |
$23.87
|
| Rate for Payer: Preferred Network Access Commercial |
$20.09
|
| Rate for Payer: Quartz Beloit One Network |
$10.70
|
| Rate for Payer: Quartz Commercial |
$14.20
|
| Rate for Payer: Quartz Medicare Advantage |
$15.91
|
| Rate for Payer: The Alliance Commercial |
$63.65
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.91
|
| Rate for Payer: United Healthcare PPO |
$16.38
|
| Rate for Payer: WEA Trust Commercial |
$12.01
|
| Rate for Payer: Wellcare Medicare |
$15.91
|
| Rate for Payer: WPS Commercial |
$16.18
|
|
|
Phenobarbital JW Waste Charge per 120 mg
|
Professional
|
Both
|
$368.00
|
|
|
Service Code
|
HCPCS J2560 JW
|
| Hospital Charge Code |
5266679
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.24 |
| Max. Negotiated Rate |
$363.58 |
| Rate for Payer: Aetna Commercial |
$363.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$329.14
|
| Rate for Payer: Cash Price |
$110.40
|
| Rate for Payer: Cash Price |
$110.40
|
| Rate for Payer: Cigna Commercial |
$363.58
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$30.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$34.11
|
| Rate for Payer: Health EOS Commercial |
$348.28
|
| Rate for Payer: HFN Commercial |
$363.58
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$69.10
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$69.10
|
| Rate for Payer: Multiplan Commercial |
$306.18
|
| Rate for Payer: Preferred Network Access Commercial |
$363.58
|
| Rate for Payer: Quartz Beloit One Network |
$168.40
|
| Rate for Payer: Quartz Commercial |
$218.15
|
| Rate for Payer: The Alliance Commercial |
$191.36
|
| Rate for Payer: United Healthcare Medicaid |
$30.24
|
| Rate for Payer: WEA Trust Commercial |
$210.50
|
| Rate for Payer: WPS Commercial |
$85.28
|
|
|
Phenobarbital JW Waste Charge per 120 mg
|
Facility
|
IP
|
$368.00
|
|
|
Service Code
|
HCPCS J2560 JW
|
| Hospital Charge Code |
5266679
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$187.53 |
| Max. Negotiated Rate |
$352.10 |
| Rate for Payer: Aetna Commercial |
$344.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$329.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$202.84
|
| Rate for Payer: Cash Price |
$110.40
|
| Rate for Payer: Cigna Commercial |
$352.10
|
| Rate for Payer: Health EOS Commercial |
$340.62
|
| Rate for Payer: HFN Commercial |
$352.10
|
| Rate for Payer: Multiplan Commercial |
$306.18
|
| Rate for Payer: Preferred Network Access Commercial |
$352.10
|
| Rate for Payer: Quartz Beloit One Network |
$187.53
|
| Rate for Payer: Quartz Commercial |
$229.63
|
| Rate for Payer: WEA Trust Commercial |
$210.50
|
| Rate for Payer: WPS Commercial |
$283.47
|
|
|
Phenobarbital JW Waste Charge per 120 mg
|
Facility
|
OP
|
$368.00
|
|
|
Service Code
|
HCPCS J2560 JW
|
| Hospital Charge Code |
5266679
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$45.13 |
| Max. Negotiated Rate |
$352.10 |
| Rate for Payer: Aetna Commercial |
$344.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$329.14
|
| Rate for Payer: Aetna Managed Medicare |
$107.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$248.77
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$191.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$183.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$202.84
|
| Rate for Payer: Cash Price |
$110.40
|
| Rate for Payer: Cash Price |
$110.40
|
| Rate for Payer: Cigna Commercial |
$352.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$45.13
|
| Rate for Payer: Health EOS Commercial |
$340.62
|
| Rate for Payer: HFN Commercial |
$352.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$287.04
|
| Rate for Payer: Multiplan Commercial |
$306.18
|
| Rate for Payer: NAPHCARE Commercial |
$229.63
|
| Rate for Payer: Preferred Network Access Commercial |
$352.10
|
| Rate for Payer: Quartz Beloit One Network |
$187.53
|
| Rate for Payer: Quartz Commercial |
$248.77
|
| Rate for Payer: Quartz Medicare Advantage |
$229.63
|
| Rate for Payer: The Alliance Commercial |
$191.36
|
| Rate for Payer: WEA Trust Commercial |
$210.50
|
| Rate for Payer: WPS Commercial |
$85.28
|
|
|
Phenobarbital Level
|
Facility
|
IP
|
$269.00
|
|
|
Service Code
|
CPT 80184
|
| Hospital Charge Code |
633800
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$137.08 |
| Max. Negotiated Rate |
$257.38 |
| Rate for Payer: Aetna Commercial |
$251.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$240.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$148.27
|
| Rate for Payer: Cash Price |
$80.70
|
| Rate for Payer: Cigna Commercial |
$257.38
|
| Rate for Payer: Health EOS Commercial |
$248.99
|
| Rate for Payer: HFN Commercial |
$257.38
|
| Rate for Payer: Multiplan Commercial |
$223.81
|
| Rate for Payer: Preferred Network Access Commercial |
$257.38
|
| Rate for Payer: Quartz Beloit One Network |
$137.08
|
| Rate for Payer: Quartz Commercial |
$167.86
|
| Rate for Payer: WEA Trust Commercial |
$153.87
|
| Rate for Payer: WPS Commercial |
$207.21
|
|
|
Phenobarbital Level
|
Professional
|
Both
|
$269.00
|
|
|
Service Code
|
CPT 80184
|
| Hospital Charge Code |
633800
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.91 |
| Max. Negotiated Rate |
$265.77 |
| Rate for Payer: Aetna Commercial |
$265.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$240.59
|
| Rate for Payer: Aetna Managed Medicare |
$15.91
|
| Rate for Payer: Anthem Medicare Advantage |
$15.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15.91
|
| Rate for Payer: Cash Price |
$80.70
|
| Rate for Payer: Cash Price |
$80.70
|
| Rate for Payer: Cigna Commercial |
$265.77
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$139.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15.91
|
| Rate for Payer: Health EOS Commercial |
$254.58
|
| Rate for Payer: HFN Commercial |
$265.77
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$56.17
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$56.17
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15.91
|
| Rate for Payer: Multiplan Commercial |
$223.81
|
| Rate for Payer: NAPHCARE Commercial |
$23.87
|
| Rate for Payer: Preferred Network Access Commercial |
$265.77
|
| Rate for Payer: Quartz Beloit One Network |
$123.09
|
| Rate for Payer: Quartz Commercial |
$159.46
|
| Rate for Payer: Quartz Medicare Advantage |
$15.91
|
| Rate for Payer: The Alliance Commercial |
$62.85
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.91
|
| Rate for Payer: WEA Trust Commercial |
$153.87
|
| Rate for Payer: WPS Commercial |
$70.01
|
|
|
Phenobarbital Level
|
Facility
|
OP
|
$269.00
|
|
|
Service Code
|
CPT 80184
|
| Hospital Charge Code |
633800
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.91 |
| Max. Negotiated Rate |
$257.38 |
| Rate for Payer: Aetna Commercial |
$251.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$240.59
|
| Rate for Payer: Aetna Managed Medicare |
$15.91
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$59.67
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$27.85
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$26.41
|
| Rate for Payer: Anthem Medicare Advantage |
$15.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$148.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15.91
|
| Rate for Payer: Cash Price |
$80.70
|
| Rate for Payer: Cash Price |
$80.70
|
| Rate for Payer: Cigna Commercial |
$257.38
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$15.91
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$156.56
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$15.91
|
| Rate for Payer: Health EOS Commercial |
$248.99
|
| Rate for Payer: HFN Commercial |
$257.38
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$59.19
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$15.91
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15.91
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$15.91
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$15.91
|
| Rate for Payer: Multiplan Commercial |
$223.81
|
| Rate for Payer: NAPHCARE Commercial |
$23.87
|
| Rate for Payer: Preferred Network Access Commercial |
$257.38
|
| Rate for Payer: Quartz Beloit One Network |
$137.08
|
| Rate for Payer: Quartz Commercial |
$181.84
|
| Rate for Payer: Quartz Medicare Advantage |
$15.91
|
| Rate for Payer: The Alliance Commercial |
$63.65
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.91
|
| Rate for Payer: United Healthcare PPO |
$209.82
|
| Rate for Payer: WEA Trust Commercial |
$153.87
|
| Rate for Payer: Wellcare Medicare |
$15.91
|
| Rate for Payer: WPS Commercial |
$207.21
|
|
|
PhenoSense
|
Professional
|
Both
|
$2,081.00
|
|
|
Service Code
|
CPT 87903
|
| Hospital Charge Code |
5502672
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$508.21 |
| Max. Negotiated Rate |
$2,236.11 |
| Rate for Payer: Aetna Commercial |
$2,056.03
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,861.25
|
| Rate for Payer: Aetna Managed Medicare |
$508.21
|
| Rate for Payer: Anthem Medicare Advantage |
$508.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$508.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$508.21
|
| Rate for Payer: Cash Price |
$624.30
|
| Rate for Payer: Cash Price |
$624.30
|
| Rate for Payer: Cigna Commercial |
$2,056.03
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,082.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$508.21
|
| Rate for Payer: Health EOS Commercial |
$1,969.46
|
| Rate for Payer: HFN Commercial |
$2,056.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,793.97
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,793.97
|
| Rate for Payer: Independent Care Health Plan Medicare |
$508.21
|
| Rate for Payer: Multiplan Commercial |
$1,731.39
|
| Rate for Payer: NAPHCARE Commercial |
$762.31
|
| Rate for Payer: Preferred Network Access Commercial |
$2,056.03
|
| Rate for Payer: Quartz Beloit One Network |
$952.27
|
| Rate for Payer: Quartz Commercial |
$1,233.62
|
| Rate for Payer: Quartz Medicare Advantage |
$508.21
|
| Rate for Payer: The Alliance Commercial |
$2,007.42
|
| Rate for Payer: United Healthcare Medicare Advantage |
$508.21
|
| Rate for Payer: WEA Trust Commercial |
$1,190.33
|
| Rate for Payer: WPS Commercial |
$2,236.11
|
|
|
PhenoSense
|
Facility
|
OP
|
$2,081.00
|
|
|
Service Code
|
CPT 87903
|
| Hospital Charge Code |
5502672
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$508.21 |
| Max. Negotiated Rate |
$2,032.83 |
| Rate for Payer: Aetna Commercial |
$1,947.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,861.25
|
| Rate for Payer: Aetna Managed Medicare |
$508.21
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,905.77
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$889.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$843.62
|
| Rate for Payer: Anthem Medicare Advantage |
$508.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,147.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$508.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$508.21
|
| Rate for Payer: Cash Price |
$624.30
|
| Rate for Payer: Cash Price |
$624.30
|
| Rate for Payer: Cigna Commercial |
$1,991.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$508.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,211.14
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$508.21
|
| Rate for Payer: Health EOS Commercial |
$1,926.17
|
| Rate for Payer: HFN Commercial |
$1,991.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,890.53
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$508.21
|
| Rate for Payer: Independent Care Health Plan Medicare |
$508.21
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$508.21
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$508.21
|
| Rate for Payer: Multiplan Commercial |
$1,731.39
|
| Rate for Payer: NAPHCARE Commercial |
$762.31
|
| Rate for Payer: Preferred Network Access Commercial |
$1,991.10
|
| Rate for Payer: Quartz Beloit One Network |
$1,060.48
|
| Rate for Payer: Quartz Commercial |
$1,406.76
|
| Rate for Payer: Quartz Medicare Advantage |
$508.21
|
| Rate for Payer: The Alliance Commercial |
$2,032.83
|
| Rate for Payer: United Healthcare Medicare Advantage |
$508.21
|
| Rate for Payer: United Healthcare PPO |
$1,623.18
|
| Rate for Payer: WEA Trust Commercial |
$1,190.33
|
| Rate for Payer: Wellcare Medicare |
$508.21
|
| Rate for Payer: WPS Commercial |
$1,602.99
|
|
|
PhenoSense
|
Facility
|
IP
|
$2,081.00
|
|
|
Service Code
|
CPT 87903
|
| Hospital Charge Code |
5502672
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$1,060.48 |
| Max. Negotiated Rate |
$1,991.10 |
| Rate for Payer: Aetna Commercial |
$1,947.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,861.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,147.05
|
| Rate for Payer: Cash Price |
$624.30
|
| Rate for Payer: Cigna Commercial |
$1,991.10
|
| Rate for Payer: Health EOS Commercial |
$1,926.17
|
| Rate for Payer: HFN Commercial |
$1,991.10
|
| Rate for Payer: Multiplan Commercial |
$1,731.39
|
| Rate for Payer: Preferred Network Access Commercial |
$1,991.10
|
| Rate for Payer: Quartz Beloit One Network |
$1,060.48
|
| Rate for Payer: Quartz Commercial |
$1,298.54
|
| Rate for Payer: WEA Trust Commercial |
$1,190.33
|
| Rate for Payer: WPS Commercial |
$1,602.99
|
|
|
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
|
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
|
|
|
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
|
|
|
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 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
|
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 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: Dean Health DHI/DHP/ASO |
$122.22
|
| 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 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
|
|
