|
Phase III - Pulmonary Rehab
|
Facility
|
OP
|
$90.00
|
|
| Hospital Charge Code |
3004212
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$25.20 |
| Max. Negotiated Rate |
$360.00 |
| Rate for Payer: Aetna Commercial |
$81.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$77.40
|
| Rate for Payer: Aetna Managed Medicare |
$25.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$58.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$45.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$43.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$47.70
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$82.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$50.36
|
| Rate for Payer: Health EOS Commercial |
$80.10
|
| Rate for Payer: HFN Commercial |
$82.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$67.50
|
| Rate for Payer: Multiplan Commercial |
$72.00
|
| Rate for Payer: NAPHCARE Commercial |
$54.00
|
| Rate for Payer: Preferred Network Access Commercial |
$82.80
|
| Rate for Payer: Quartz Beloit One Network |
$44.10
|
| Rate for Payer: Quartz Commercial |
$58.50
|
| Rate for Payer: Quartz Medicare Advantage |
$54.00
|
| Rate for Payer: The Alliance Commercial |
$360.00
|
| Rate for Payer: United Healthcare PPO |
$67.50
|
| Rate for Payer: WEA Trust Commercial |
$49.50
|
| Rate for Payer: WPS Commercial |
$66.66
|
|
|
Phase II Non-COPD - Pulmonary Rehab
|
Facility
|
OP
|
$368.00
|
|
|
Service Code
|
HCPCS G0239
|
| Hospital Charge Code |
2990160
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$39.64 |
| Max. Negotiated Rate |
$338.56 |
| Rate for Payer: Aetna Commercial |
$331.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$316.48
|
| Rate for Payer: Aetna Managed Medicare |
$39.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$239.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$184.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$176.64
|
| Rate for Payer: Anthem Medicare Advantage |
$39.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$195.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$39.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$39.64
|
| Rate for Payer: Cash Price |
$110.40
|
| Rate for Payer: Cash Price |
$110.40
|
| Rate for Payer: Cigna Commercial |
$338.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$39.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$205.93
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$39.64
|
| Rate for Payer: Health EOS Commercial |
$327.52
|
| Rate for Payer: HFN Commercial |
$338.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$147.46
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$39.64
|
| Rate for Payer: Independent Care Health Plan Medicare |
$39.64
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$39.64
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$39.64
|
| Rate for Payer: Multiplan Commercial |
$294.40
|
| Rate for Payer: NAPHCARE Commercial |
$59.46
|
| Rate for Payer: Preferred Network Access Commercial |
$338.56
|
| Rate for Payer: Quartz Beloit One Network |
$180.32
|
| Rate for Payer: Quartz Commercial |
$239.20
|
| Rate for Payer: Quartz Medicare Advantage |
$39.64
|
| Rate for Payer: The Alliance Commercial |
$158.56
|
| Rate for Payer: United Healthcare Medicare Advantage |
$39.64
|
| Rate for Payer: United Healthcare PPO |
$276.00
|
| Rate for Payer: WEA Trust Commercial |
$202.40
|
| Rate for Payer: Wellcare Medicare |
$39.64
|
| Rate for Payer: WPS Commercial |
$272.58
|
|
|
Phase II Non-COPD - Pulmonary Rehab
|
Facility
|
IP
|
$368.00
|
|
|
Service Code
|
HCPCS G0239
|
| Hospital Charge Code |
2990160
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$180.32 |
| Max. Negotiated Rate |
$338.56 |
| Rate for Payer: Aetna Commercial |
$331.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$316.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$195.04
|
| Rate for Payer: Cash Price |
$110.40
|
| Rate for Payer: Cigna Commercial |
$338.56
|
| Rate for Payer: Health EOS Commercial |
$327.52
|
| Rate for Payer: HFN Commercial |
$338.56
|
| Rate for Payer: Multiplan Commercial |
$294.40
|
| Rate for Payer: NAPHCARE Commercial |
$220.80
|
| Rate for Payer: Preferred Network Access Commercial |
$338.56
|
| Rate for Payer: Quartz Beloit One Network |
$180.32
|
| Rate for Payer: Quartz Commercial |
$220.80
|
| Rate for Payer: WEA Trust Commercial |
$202.40
|
| Rate for Payer: WPS Commercial |
$272.58
|
|
|
Phencyclidine Meconium
|
Facility
|
IP
|
$38.00
|
|
| Hospital Charge Code |
2942890
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.62 |
| Max. Negotiated Rate |
$34.96 |
| Rate for Payer: Aetna Commercial |
$34.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$32.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$20.14
|
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Cigna Commercial |
$34.96
|
| Rate for Payer: Health EOS Commercial |
$33.82
|
| Rate for Payer: HFN Commercial |
$34.96
|
| Rate for Payer: Multiplan Commercial |
$30.40
|
| Rate for Payer: NAPHCARE Commercial |
$22.80
|
| Rate for Payer: Preferred Network Access Commercial |
$34.96
|
| Rate for Payer: Quartz Beloit One Network |
$18.62
|
| Rate for Payer: Quartz Commercial |
$22.80
|
| Rate for Payer: WEA Trust Commercial |
$20.90
|
| Rate for Payer: WPS Commercial |
$28.15
|
|
|
Phencyclidine Meconium
|
Professional
|
Both
|
$38.00
|
|
| Hospital Charge Code |
2942890
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.72 |
| Max. Negotiated Rate |
$36.10 |
| Rate for Payer: Aetna Commercial |
$36.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$32.68
|
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Cigna Commercial |
$36.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$19.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$22.80
|
| Rate for Payer: Health EOS Commercial |
$34.58
|
| Rate for Payer: HFN Commercial |
$36.10
|
| Rate for Payer: Multiplan Commercial |
$30.40
|
| Rate for Payer: Preferred Network Access Commercial |
$36.10
|
| Rate for Payer: Quartz Beloit One Network |
$16.72
|
| Rate for Payer: Quartz Commercial |
$21.66
|
| Rate for Payer: The Alliance Commercial |
$19.00
|
| Rate for Payer: WEA Trust Commercial |
$20.90
|
| Rate for Payer: WPS Commercial |
$28.15
|
|
|
Phencyclidine Meconium
|
Facility
|
OP
|
$38.00
|
|
| Hospital Charge Code |
2942890
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.64 |
| Max. Negotiated Rate |
$152.00 |
| Rate for Payer: Aetna Commercial |
$34.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$32.68
|
| Rate for Payer: Aetna Managed Medicare |
$10.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$24.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$19.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$18.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$20.14
|
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Cigna Commercial |
$34.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$21.26
|
| Rate for Payer: Health EOS Commercial |
$33.82
|
| Rate for Payer: HFN Commercial |
$34.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$28.50
|
| Rate for Payer: Multiplan Commercial |
$30.40
|
| Rate for Payer: NAPHCARE Commercial |
$22.80
|
| Rate for Payer: Preferred Network Access Commercial |
$34.96
|
| Rate for Payer: Quartz Beloit One Network |
$18.62
|
| Rate for Payer: Quartz Commercial |
$24.70
|
| Rate for Payer: Quartz Medicare Advantage |
$22.80
|
| Rate for Payer: The Alliance Commercial |
$152.00
|
| Rate for Payer: United Healthcare PPO |
$28.50
|
| Rate for Payer: WEA Trust Commercial |
$20.90
|
| Rate for Payer: WPS Commercial |
$28.15
|
|
|
Phencyclidine, Quant, GC/MS, Urine
|
Facility
|
IP
|
$151.00
|
|
|
Service Code
|
CPT 83992
|
| Hospital Charge Code |
983359
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$73.99 |
| Max. Negotiated Rate |
$138.92 |
| Rate for Payer: Aetna Commercial |
$135.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$129.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$80.03
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cigna Commercial |
$138.92
|
| Rate for Payer: Health EOS Commercial |
$134.39
|
| Rate for Payer: HFN Commercial |
$138.92
|
| Rate for Payer: Multiplan Commercial |
$120.80
|
| Rate for Payer: NAPHCARE Commercial |
$90.60
|
| Rate for Payer: Preferred Network Access Commercial |
$138.92
|
| Rate for Payer: Quartz Beloit One Network |
$73.99
|
| Rate for Payer: Quartz Commercial |
$90.60
|
| Rate for Payer: WEA Trust Commercial |
$83.05
|
| Rate for Payer: WPS Commercial |
$111.85
|
|
|
Phencyclidine, Quant, GC/MS, Urine
|
Professional
|
Both
|
$151.00
|
|
|
Service Code
|
CPT 83992
|
| Hospital Charge Code |
983359
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$66.44 |
| Max. Negotiated Rate |
$143.45 |
| Rate for Payer: Aetna Commercial |
$143.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$129.86
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cigna Commercial |
$143.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$75.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$90.60
|
| Rate for Payer: Health EOS Commercial |
$137.41
|
| Rate for Payer: HFN Commercial |
$143.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$138.06
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$138.06
|
| Rate for Payer: Multiplan Commercial |
$120.80
|
| Rate for Payer: Preferred Network Access Commercial |
$143.45
|
| Rate for Payer: Quartz Beloit One Network |
$66.44
|
| Rate for Payer: Quartz Commercial |
$86.07
|
| Rate for Payer: The Alliance Commercial |
$75.50
|
| Rate for Payer: WEA Trust Commercial |
$83.05
|
| Rate for Payer: WPS Commercial |
$111.85
|
|
|
Phencyclidine, Quant, GC/MS, Urine
|
Facility
|
OP
|
$151.00
|
|
|
Service Code
|
CPT 83992
|
| Hospital Charge Code |
983359
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$20.67 |
| Max. Negotiated Rate |
$604.00 |
| Rate for Payer: Aetna Commercial |
$135.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$129.86
|
| Rate for Payer: Aetna Managed Medicare |
$42.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$98.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$75.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$72.48
|
| Rate for Payer: Anthem Medicaid |
$20.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$80.03
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cigna Commercial |
$138.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$20.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$84.50
|
| Rate for Payer: Dean Health Medicaid |
$20.67
|
| Rate for Payer: Health EOS Commercial |
$134.39
|
| Rate for Payer: HFN Commercial |
$138.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$113.25
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$20.67
|
| Rate for Payer: Managed Health Services Medicaid |
$21.50
|
| Rate for Payer: Multiplan Commercial |
$120.80
|
| Rate for Payer: NAPHCARE Commercial |
$90.60
|
| Rate for Payer: Preferred Network Access Commercial |
$138.92
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$20.67
|
| Rate for Payer: Quartz Beloit One Network |
$73.99
|
| Rate for Payer: Quartz Commercial |
$98.15
|
| Rate for Payer: Quartz Medicare Advantage |
$90.60
|
| Rate for Payer: The Alliance Commercial |
$604.00
|
| Rate for Payer: United Healthcare Medicaid |
$20.67
|
| Rate for Payer: United Healthcare PPO |
$113.25
|
| Rate for Payer: WEA Trust Commercial |
$83.05
|
| Rate for Payer: WMAP Medicaid |
$20.67
|
| Rate for Payer: WPS Commercial |
$111.85
|
|
|
Phenergan 50 mg Charge
|
Professional
|
Both
|
$7.00
|
|
|
Service Code
|
HCPCS J2550
|
| Hospital Charge Code |
2958938
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.08 |
| Max. Negotiated Rate |
$7.75 |
| Rate for Payer: Aetna Commercial |
$6.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.02
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3.10
|
| Rate for Payer: Health EOS Commercial |
$6.37
|
| Rate for Payer: HFN Commercial |
$6.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3.46
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3.46
|
| Rate for Payer: Multiplan Commercial |
$5.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6.65
|
| Rate for Payer: Quartz Beloit One Network |
$3.08
|
| Rate for Payer: Quartz Commercial |
$3.99
|
| Rate for Payer: The Alliance Commercial |
$3.50
|
| Rate for Payer: United Healthcare Medicaid |
$3.10
|
| Rate for Payer: WEA Trust Commercial |
$3.85
|
| Rate for Payer: WPS Commercial |
$7.75
|
|
|
Phenergan 50 mg Charge
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
HCPCS J2550
|
| Hospital Charge Code |
2958938
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.96 |
| Max. Negotiated Rate |
$28.00 |
| Rate for Payer: Aetna Commercial |
$6.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.02
|
| Rate for Payer: Aetna Managed Medicare |
$1.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.71
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4.10
|
| Rate for Payer: Health EOS Commercial |
$6.23
|
| Rate for Payer: HFN Commercial |
$6.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5.25
|
| Rate for Payer: Multiplan Commercial |
$5.60
|
| Rate for Payer: NAPHCARE Commercial |
$4.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6.44
|
| Rate for Payer: Quartz Beloit One Network |
$3.43
|
| Rate for Payer: Quartz Commercial |
$4.55
|
| Rate for Payer: Quartz Medicare Advantage |
$4.20
|
| Rate for Payer: The Alliance Commercial |
$28.00
|
| Rate for Payer: WEA Trust Commercial |
$3.85
|
| Rate for Payer: WPS Commercial |
$7.75
|
|
|
Phenergan 50 mg Charge
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
HCPCS J2550
|
| Hospital Charge Code |
2958938
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.43 |
| Max. Negotiated Rate |
$6.44 |
| Rate for Payer: Aetna Commercial |
$6.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.71
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.44
|
| Rate for Payer: Health EOS Commercial |
$6.23
|
| Rate for Payer: HFN Commercial |
$6.44
|
| Rate for Payer: Multiplan Commercial |
$5.60
|
| Rate for Payer: NAPHCARE Commercial |
$4.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6.44
|
| Rate for Payer: Quartz Beloit One Network |
$3.43
|
| Rate for Payer: Quartz Commercial |
$4.20
|
| Rate for Payer: WEA Trust Commercial |
$3.85
|
| Rate for Payer: WPS Commercial |
$5.18
|
|
|
Phenobarbital
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
CPT 80184
|
| Hospital Charge Code |
1037307
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.70 |
| Max. Negotiated Rate |
$27.60 |
| Rate for Payer: Aetna Commercial |
$27.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$25.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$15.90
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cigna Commercial |
$27.60
|
| Rate for Payer: Health EOS Commercial |
$26.70
|
| Rate for Payer: HFN Commercial |
$27.60
|
| Rate for Payer: Multiplan Commercial |
$24.00
|
| Rate for Payer: NAPHCARE Commercial |
$18.00
|
| Rate for Payer: Preferred Network Access Commercial |
$27.60
|
| Rate for Payer: Quartz Beloit One Network |
$14.70
|
| Rate for Payer: Quartz Commercial |
$18.00
|
| Rate for Payer: WEA Trust Commercial |
$16.50
|
| Rate for Payer: WPS Commercial |
$22.22
|
|
|
Phenobarbital
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
CPT 80184
|
| Hospital Charge Code |
1037307
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.70 |
| Max. Negotiated Rate |
$61.20 |
| Rate for Payer: Aetna Commercial |
$27.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$25.80
|
| Rate for Payer: Aetna Managed Medicare |
$15.30
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$57.38
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26.78
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$25.40
|
| Rate for Payer: Anthem Medicaid |
$15.81
|
| Rate for Payer: Anthem Medicare Advantage |
$15.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$15.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15.30
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cigna Commercial |
$27.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$15.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$15.81
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$16.79
|
| Rate for Payer: Dean Health Medicaid |
$15.81
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$15.30
|
| Rate for Payer: Health EOS Commercial |
$26.70
|
| Rate for Payer: HFN Commercial |
$27.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$56.92
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$15.30
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$15.81
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15.30
|
| Rate for Payer: Managed Health Services Medicaid |
$16.44
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$15.30
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$15.30
|
| Rate for Payer: Multiplan Commercial |
$24.00
|
| Rate for Payer: NAPHCARE Commercial |
$22.95
|
| Rate for Payer: Preferred Network Access Commercial |
$27.60
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$15.81
|
| Rate for Payer: Quartz Beloit One Network |
$14.70
|
| Rate for Payer: Quartz Commercial |
$19.50
|
| Rate for Payer: Quartz Medicare Advantage |
$15.30
|
| Rate for Payer: The Alliance Commercial |
$61.20
|
| Rate for Payer: United Healthcare Medicaid |
$15.81
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.30
|
| Rate for Payer: United Healthcare PPO |
$22.50
|
| Rate for Payer: WEA Trust Commercial |
$16.50
|
| Rate for Payer: Wellcare Medicare |
$15.30
|
| Rate for Payer: WMAP Medicaid |
$15.81
|
| Rate for Payer: WPS Commercial |
$22.22
|
|
|
Phenobarbital
|
Professional
|
Both
|
$30.00
|
|
|
Service Code
|
CPT 80184
|
| Hospital Charge Code |
1037307
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.20 |
| Max. Negotiated Rate |
$54.01 |
| Rate for Payer: Aetna Commercial |
$28.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$25.80
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cigna Commercial |
$28.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$15.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$18.00
|
| Rate for Payer: Health EOS Commercial |
$27.30
|
| Rate for Payer: HFN Commercial |
$28.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$54.01
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$54.01
|
| Rate for Payer: Multiplan Commercial |
$24.00
|
| Rate for Payer: Preferred Network Access Commercial |
$28.50
|
| Rate for Payer: Quartz Beloit One Network |
$13.20
|
| Rate for Payer: Quartz Commercial |
$17.10
|
| Rate for Payer: The Alliance Commercial |
$15.00
|
| Rate for Payer: WEA Trust Commercial |
$16.50
|
| Rate for Payer: WPS Commercial |
$22.22
|
|
|
Phenobarbital
|
Facility
|
OP
|
$21.00
|
|
|
Service Code
|
CPT 80184
|
| Hospital Charge Code |
2942975
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.29 |
| Max. Negotiated Rate |
$61.20 |
| Rate for Payer: Aetna Commercial |
$18.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.06
|
| Rate for Payer: Aetna Managed Medicare |
$15.30
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$57.38
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26.78
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$25.40
|
| Rate for Payer: Anthem Medicaid |
$15.81
|
| Rate for Payer: Anthem Medicare Advantage |
$15.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15.30
|
| Rate for Payer: Cash Price |
$6.30
|
| Rate for Payer: Cash Price |
$6.30
|
| Rate for Payer: Cigna Commercial |
$19.32
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$15.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$15.81
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11.75
|
| Rate for Payer: Dean Health Medicaid |
$15.81
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$15.30
|
| Rate for Payer: Health EOS Commercial |
$18.69
|
| Rate for Payer: HFN Commercial |
$19.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$56.92
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$15.30
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$15.81
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15.30
|
| Rate for Payer: Managed Health Services Medicaid |
$16.44
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$15.30
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$15.30
|
| Rate for Payer: Multiplan Commercial |
$16.80
|
| Rate for Payer: NAPHCARE Commercial |
$22.95
|
| Rate for Payer: Preferred Network Access Commercial |
$19.32
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$15.81
|
| Rate for Payer: Quartz Beloit One Network |
$10.29
|
| Rate for Payer: Quartz Commercial |
$13.65
|
| Rate for Payer: Quartz Medicare Advantage |
$15.30
|
| Rate for Payer: The Alliance Commercial |
$61.20
|
| Rate for Payer: United Healthcare Medicaid |
$15.81
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.30
|
| Rate for Payer: United Healthcare PPO |
$15.75
|
| Rate for Payer: WEA Trust Commercial |
$11.55
|
| Rate for Payer: Wellcare Medicare |
$15.30
|
| Rate for Payer: WMAP Medicaid |
$15.81
|
| Rate for Payer: WPS Commercial |
$15.55
|
|
|
Phenobarbital
|
Professional
|
Both
|
$21.00
|
|
|
Service Code
|
CPT 80184
|
| Hospital Charge Code |
2942975
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$9.24 |
| Max. Negotiated Rate |
$54.01 |
| Rate for Payer: Aetna Commercial |
$19.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.06
|
| Rate for Payer: Cash Price |
$6.30
|
| Rate for Payer: Cash Price |
$6.30
|
| Rate for Payer: Cigna Commercial |
$19.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$10.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.60
|
| Rate for Payer: Health EOS Commercial |
$19.11
|
| Rate for Payer: HFN Commercial |
$19.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$54.01
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$54.01
|
| Rate for Payer: Multiplan Commercial |
$16.80
|
| Rate for Payer: Preferred Network Access Commercial |
$19.95
|
| Rate for Payer: Quartz Beloit One Network |
$9.24
|
| Rate for Payer: Quartz Commercial |
$11.97
|
| Rate for Payer: The Alliance Commercial |
$10.50
|
| Rate for Payer: WEA Trust Commercial |
$11.55
|
| Rate for Payer: WPS Commercial |
$15.55
|
|
|
Phenobarbital
|
Facility
|
IP
|
$21.00
|
|
|
Service Code
|
CPT 80184
|
| Hospital Charge Code |
2942975
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.29 |
| Max. Negotiated Rate |
$19.32 |
| Rate for Payer: Aetna Commercial |
$18.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.13
|
| Rate for Payer: Cash Price |
$6.30
|
| Rate for Payer: Cigna Commercial |
$19.32
|
| Rate for Payer: Health EOS Commercial |
$18.69
|
| Rate for Payer: HFN Commercial |
$19.32
|
| Rate for Payer: Multiplan Commercial |
$16.80
|
| Rate for Payer: NAPHCARE Commercial |
$12.60
|
| Rate for Payer: Preferred Network Access Commercial |
$19.32
|
| Rate for Payer: Quartz Beloit One Network |
$10.29
|
| Rate for Payer: Quartz Commercial |
$12.60
|
| Rate for Payer: WEA Trust Commercial |
$11.55
|
| Rate for Payer: WPS Commercial |
$15.55
|
|
|
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 |
$161.92 |
| Max. Negotiated Rate |
$349.60 |
| Rate for Payer: Aetna Commercial |
$349.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$316.48
|
| Rate for Payer: Cash Price |
$110.40
|
| Rate for Payer: Cigna Commercial |
$349.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$184.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$220.80
|
| Rate for Payer: Health EOS Commercial |
$334.88
|
| Rate for Payer: HFN Commercial |
$349.60
|
| Rate for Payer: Multiplan Commercial |
$294.40
|
| Rate for Payer: Preferred Network Access Commercial |
$349.60
|
| Rate for Payer: Quartz Beloit One Network |
$161.92
|
| Rate for Payer: Quartz Commercial |
$209.76
|
| Rate for Payer: The Alliance Commercial |
$184.00
|
| Rate for Payer: WEA Trust Commercial |
$202.40
|
| Rate for Payer: WPS Commercial |
$272.58
|
|
|
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 |
$180.32 |
| Max. Negotiated Rate |
$338.56 |
| Rate for Payer: Aetna Commercial |
$331.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$316.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$195.04
|
| Rate for Payer: Cash Price |
$110.40
|
| Rate for Payer: Cigna Commercial |
$338.56
|
| Rate for Payer: Health EOS Commercial |
$327.52
|
| Rate for Payer: HFN Commercial |
$338.56
|
| Rate for Payer: Multiplan Commercial |
$294.40
|
| Rate for Payer: NAPHCARE Commercial |
$220.80
|
| Rate for Payer: Preferred Network Access Commercial |
$338.56
|
| Rate for Payer: Quartz Beloit One Network |
$180.32
|
| Rate for Payer: Quartz Commercial |
$220.80
|
| Rate for Payer: WEA Trust Commercial |
$202.40
|
| Rate for Payer: WPS Commercial |
$272.58
|
|
|
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 |
$103.04 |
| Max. Negotiated Rate |
$1,472.00 |
| Rate for Payer: Aetna Commercial |
$331.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$316.48
|
| Rate for Payer: Aetna Managed Medicare |
$103.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$239.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$184.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$176.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$195.04
|
| Rate for Payer: Cash Price |
$110.40
|
| Rate for Payer: Cigna Commercial |
$338.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$205.93
|
| Rate for Payer: Health EOS Commercial |
$327.52
|
| Rate for Payer: HFN Commercial |
$338.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$276.00
|
| Rate for Payer: Multiplan Commercial |
$294.40
|
| Rate for Payer: NAPHCARE Commercial |
$220.80
|
| Rate for Payer: Preferred Network Access Commercial |
$338.56
|
| Rate for Payer: Quartz Beloit One Network |
$180.32
|
| Rate for Payer: Quartz Commercial |
$239.20
|
| Rate for Payer: Quartz Medicare Advantage |
$220.80
|
| Rate for Payer: The Alliance Commercial |
$1,472.00
|
| Rate for Payer: WEA Trust Commercial |
$202.40
|
| Rate for Payer: WPS Commercial |
$272.58
|
|
|
Phenobarbital Level
|
Professional
|
Both
|
$269.00
|
|
|
Service Code
|
CPT 80184
|
| Hospital Charge Code |
633800
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$54.01 |
| Max. Negotiated Rate |
$255.55 |
| Rate for Payer: Aetna Commercial |
$255.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$231.34
|
| Rate for Payer: Cash Price |
$80.70
|
| Rate for Payer: Cash Price |
$80.70
|
| Rate for Payer: Cigna Commercial |
$255.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$134.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$161.40
|
| Rate for Payer: Health EOS Commercial |
$244.79
|
| Rate for Payer: HFN Commercial |
$255.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$54.01
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$54.01
|
| Rate for Payer: Multiplan Commercial |
$215.20
|
| Rate for Payer: Preferred Network Access Commercial |
$255.55
|
| Rate for Payer: Quartz Beloit One Network |
$118.36
|
| Rate for Payer: Quartz Commercial |
$153.33
|
| Rate for Payer: The Alliance Commercial |
$134.50
|
| Rate for Payer: WEA Trust Commercial |
$147.95
|
| Rate for Payer: WPS Commercial |
$199.25
|
|
|
Phenobarbital Level
|
Facility
|
IP
|
$269.00
|
|
|
Service Code
|
CPT 80184
|
| Hospital Charge Code |
633800
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$131.81 |
| Max. Negotiated Rate |
$247.48 |
| Rate for Payer: Aetna Commercial |
$242.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$231.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$142.57
|
| Rate for Payer: Cash Price |
$80.70
|
| Rate for Payer: Cigna Commercial |
$247.48
|
| Rate for Payer: Health EOS Commercial |
$239.41
|
| Rate for Payer: HFN Commercial |
$247.48
|
| Rate for Payer: Multiplan Commercial |
$215.20
|
| Rate for Payer: NAPHCARE Commercial |
$161.40
|
| Rate for Payer: Preferred Network Access Commercial |
$247.48
|
| Rate for Payer: Quartz Beloit One Network |
$131.81
|
| Rate for Payer: Quartz Commercial |
$161.40
|
| Rate for Payer: WEA Trust Commercial |
$147.95
|
| Rate for Payer: WPS Commercial |
$199.25
|
|
|
Phenobarbital Level
|
Facility
|
OP
|
$269.00
|
|
|
Service Code
|
CPT 80184
|
| Hospital Charge Code |
633800
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.30 |
| Max. Negotiated Rate |
$247.48 |
| Rate for Payer: Aetna Commercial |
$242.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$231.34
|
| Rate for Payer: Aetna Managed Medicare |
$15.30
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$57.38
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26.78
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$25.40
|
| Rate for Payer: Anthem Medicaid |
$15.81
|
| Rate for Payer: Anthem Medicare Advantage |
$15.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$142.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15.30
|
| Rate for Payer: Cash Price |
$80.70
|
| Rate for Payer: Cash Price |
$80.70
|
| Rate for Payer: Cigna Commercial |
$247.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$15.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$15.81
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$150.53
|
| Rate for Payer: Dean Health Medicaid |
$15.81
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$15.30
|
| Rate for Payer: Health EOS Commercial |
$239.41
|
| Rate for Payer: HFN Commercial |
$247.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$56.92
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$15.30
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$15.81
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15.30
|
| Rate for Payer: Managed Health Services Medicaid |
$16.44
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$15.30
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$15.30
|
| Rate for Payer: Multiplan Commercial |
$215.20
|
| Rate for Payer: NAPHCARE Commercial |
$22.95
|
| Rate for Payer: Preferred Network Access Commercial |
$247.48
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$15.81
|
| Rate for Payer: Quartz Beloit One Network |
$131.81
|
| Rate for Payer: Quartz Commercial |
$174.85
|
| Rate for Payer: Quartz Medicare Advantage |
$15.30
|
| Rate for Payer: The Alliance Commercial |
$61.20
|
| Rate for Payer: United Healthcare Medicaid |
$15.81
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.30
|
| Rate for Payer: United Healthcare PPO |
$201.75
|
| Rate for Payer: WEA Trust Commercial |
$147.95
|
| Rate for Payer: Wellcare Medicare |
$15.30
|
| Rate for Payer: WMAP Medicaid |
$15.81
|
| Rate for Payer: WPS Commercial |
$199.25
|
|
|
PhenoSense
|
Facility
|
IP
|
$2,081.00
|
|
|
Service Code
|
CPT 87903
|
| Hospital Charge Code |
5502672
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$1,019.69 |
| Max. Negotiated Rate |
$1,914.52 |
| Rate for Payer: Aetna Commercial |
$1,872.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,789.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,102.93
|
| Rate for Payer: Cash Price |
$624.30
|
| Rate for Payer: Cigna Commercial |
$1,914.52
|
| Rate for Payer: Health EOS Commercial |
$1,852.09
|
| Rate for Payer: HFN Commercial |
$1,914.52
|
| Rate for Payer: Multiplan Commercial |
$1,664.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,248.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,914.52
|
| Rate for Payer: Quartz Beloit One Network |
$1,019.69
|
| Rate for Payer: Quartz Commercial |
$1,248.60
|
| Rate for Payer: WEA Trust Commercial |
$1,144.55
|
| Rate for Payer: WPS Commercial |
$1,541.40
|
|
