|
PhenoSense
|
Facility
|
OP
|
$2,081.00
|
|
|
Service Code
|
CPT 87903
|
| Hospital Charge Code |
5502672
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$488.66 |
| Max. Negotiated Rate |
$1,954.64 |
| Rate for Payer: Aetna Commercial |
$1,872.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,789.66
|
| Rate for Payer: Aetna Managed Medicare |
$488.66
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,832.48
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$855.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$811.18
|
| Rate for Payer: Anthem Medicaid |
$504.93
|
| Rate for Payer: Anthem Medicare Advantage |
$488.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,102.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$488.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$488.66
|
| Rate for Payer: Cash Price |
$624.30
|
| Rate for Payer: Cash Price |
$624.30
|
| Rate for Payer: Cigna Commercial |
$1,914.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$488.66
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$504.93
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,164.53
|
| Rate for Payer: Dean Health Medicaid |
$504.93
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$488.66
|
| Rate for Payer: Health EOS Commercial |
$1,852.09
|
| Rate for Payer: HFN Commercial |
$1,914.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,817.82
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$488.66
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$504.93
|
| Rate for Payer: Independent Care Health Plan Medicare |
$488.66
|
| Rate for Payer: Managed Health Services Medicaid |
$525.13
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$488.66
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$488.66
|
| Rate for Payer: Multiplan Commercial |
$1,664.80
|
| Rate for Payer: NAPHCARE Commercial |
$732.99
|
| Rate for Payer: Preferred Network Access Commercial |
$1,914.52
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$504.93
|
| Rate for Payer: Quartz Beloit One Network |
$1,019.69
|
| Rate for Payer: Quartz Commercial |
$1,352.65
|
| Rate for Payer: Quartz Medicare Advantage |
$488.66
|
| Rate for Payer: The Alliance Commercial |
$1,954.64
|
| Rate for Payer: United Healthcare Medicaid |
$504.93
|
| Rate for Payer: United Healthcare Medicare Advantage |
$488.66
|
| Rate for Payer: United Healthcare PPO |
$1,560.75
|
| Rate for Payer: WEA Trust Commercial |
$1,144.55
|
| Rate for Payer: Wellcare Medicare |
$488.66
|
| Rate for Payer: WMAP Medicaid |
$504.93
|
| Rate for Payer: WPS Commercial |
$1,541.40
|
|
|
PhenoSense
|
Professional
|
Both
|
$2,081.00
|
|
|
Service Code
|
CPT 87903
|
| Hospital Charge Code |
5502672
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$915.64 |
| Max. Negotiated Rate |
$1,976.95 |
| Rate for Payer: Aetna Commercial |
$1,976.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,789.66
|
| Rate for Payer: Cash Price |
$624.30
|
| Rate for Payer: Cash Price |
$624.30
|
| Rate for Payer: Cigna Commercial |
$1,976.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,040.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,248.60
|
| Rate for Payer: Health EOS Commercial |
$1,893.71
|
| Rate for Payer: HFN Commercial |
$1,976.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,724.97
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,724.97
|
| Rate for Payer: Multiplan Commercial |
$1,664.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,976.95
|
| Rate for Payer: Quartz Beloit One Network |
$915.64
|
| Rate for Payer: Quartz Commercial |
$1,186.17
|
| Rate for Payer: The Alliance Commercial |
$1,040.50
|
| Rate for Payer: WEA Trust Commercial |
$1,144.55
|
| Rate for Payer: WPS Commercial |
$1,541.40
|
|
|
Phenylephrine 10% Ophth solution 5ml (refrigerator) [Med]
|
Facility
|
OP
|
$150.00
|
|
| Hospital Charge Code |
2974969
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$42.00 |
| Max. Negotiated Rate |
$600.00 |
| Rate for Payer: Aetna Commercial |
$135.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$129.00
|
| Rate for Payer: Aetna Managed Medicare |
$42.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$97.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$75.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$72.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$79.50
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cigna Commercial |
$138.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$83.94
|
| Rate for Payer: Health EOS Commercial |
$133.50
|
| Rate for Payer: HFN Commercial |
$138.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$112.50
|
| Rate for Payer: Multiplan Commercial |
$120.00
|
| Rate for Payer: NAPHCARE Commercial |
$90.00
|
| Rate for Payer: Preferred Network Access Commercial |
$138.00
|
| Rate for Payer: Quartz Beloit One Network |
$73.50
|
| Rate for Payer: Quartz Commercial |
$97.50
|
| Rate for Payer: Quartz Medicare Advantage |
$90.00
|
| Rate for Payer: The Alliance Commercial |
$600.00
|
| Rate for Payer: WEA Trust Commercial |
$82.50
|
| Rate for Payer: WPS Commercial |
$111.10
|
|
|
Phenylephrine 10% Ophth solution 5ml (refrigerator) [Med]
|
Facility
|
IP
|
$150.00
|
|
| Hospital Charge Code |
2974969
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$73.50 |
| Max. Negotiated Rate |
$138.00 |
| Rate for Payer: Aetna Commercial |
$135.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$129.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$79.50
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cigna Commercial |
$138.00
|
| Rate for Payer: Health EOS Commercial |
$133.50
|
| Rate for Payer: HFN Commercial |
$138.00
|
| Rate for Payer: Multiplan Commercial |
$120.00
|
| Rate for Payer: NAPHCARE Commercial |
$90.00
|
| Rate for Payer: Preferred Network Access Commercial |
$138.00
|
| Rate for Payer: Quartz Beloit One Network |
$73.50
|
| Rate for Payer: Quartz Commercial |
$90.00
|
| Rate for Payer: WEA Trust Commercial |
$82.50
|
| Rate for Payer: WPS Commercial |
$111.10
|
|
|
Phenylephrine 2.5% Ophth Solution 2.5ml [Med]
|
Facility
|
OP
|
$125.00
|
|
| Hospital Charge Code |
2974904
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.00 |
| Max. Negotiated Rate |
$500.00 |
| Rate for Payer: Aetna Commercial |
$112.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$107.50
|
| Rate for Payer: Aetna Managed Medicare |
$35.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$81.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$62.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$60.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$66.25
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cigna Commercial |
$115.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$69.95
|
| Rate for Payer: Health EOS Commercial |
$111.25
|
| Rate for Payer: HFN Commercial |
$115.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$93.75
|
| Rate for Payer: Multiplan Commercial |
$100.00
|
| Rate for Payer: NAPHCARE Commercial |
$75.00
|
| Rate for Payer: Preferred Network Access Commercial |
$115.00
|
| Rate for Payer: Quartz Beloit One Network |
$61.25
|
| Rate for Payer: Quartz Commercial |
$81.25
|
| Rate for Payer: Quartz Medicare Advantage |
$75.00
|
| Rate for Payer: The Alliance Commercial |
$500.00
|
| Rate for Payer: WEA Trust Commercial |
$68.75
|
| Rate for Payer: WPS Commercial |
$92.59
|
|
|
Phenylephrine 2.5% Ophth Solution 2.5ml [Med]
|
Facility
|
IP
|
$125.00
|
|
| Hospital Charge Code |
2974904
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$61.25 |
| Max. Negotiated Rate |
$115.00 |
| Rate for Payer: Aetna Commercial |
$112.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$107.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$66.25
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cigna Commercial |
$115.00
|
| Rate for Payer: Health EOS Commercial |
$111.25
|
| Rate for Payer: HFN Commercial |
$115.00
|
| Rate for Payer: Multiplan Commercial |
$100.00
|
| Rate for Payer: NAPHCARE Commercial |
$75.00
|
| Rate for Payer: Preferred Network Access Commercial |
$115.00
|
| Rate for Payer: Quartz Beloit One Network |
$61.25
|
| Rate for Payer: Quartz Commercial |
$75.00
|
| Rate for Payer: WEA Trust Commercial |
$68.75
|
| Rate for Payer: WPS Commercial |
$92.59
|
|
|
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 |
$3.08 |
| Max. Negotiated Rate |
$44.00 |
| Rate for Payer: Aetna Commercial |
$9.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9.46
|
| Rate for Payer: Aetna Managed Medicare |
$3.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5.83
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cigna Commercial |
$10.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6.16
|
| Rate for Payer: Health EOS Commercial |
$9.79
|
| Rate for Payer: HFN Commercial |
$10.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8.25
|
| Rate for Payer: Multiplan Commercial |
$8.80
|
| Rate for Payer: NAPHCARE Commercial |
$6.60
|
| Rate for Payer: Preferred Network Access Commercial |
$10.12
|
| Rate for Payer: Quartz Beloit One Network |
$5.39
|
| Rate for Payer: Quartz Commercial |
$7.15
|
| Rate for Payer: Quartz Medicare Advantage |
$6.60
|
| Rate for Payer: The Alliance Commercial |
$44.00
|
| Rate for Payer: WEA Trust Commercial |
$6.05
|
| Rate for Payer: WPS Commercial |
$8.15
|
|
|
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 |
$5.39 |
| Max. Negotiated Rate |
$10.12 |
| Rate for Payer: Aetna Commercial |
$9.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5.83
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cigna Commercial |
$10.12
|
| Rate for Payer: Health EOS Commercial |
$9.79
|
| Rate for Payer: HFN Commercial |
$10.12
|
| Rate for Payer: Multiplan Commercial |
$8.80
|
| Rate for Payer: NAPHCARE Commercial |
$6.60
|
| Rate for Payer: Preferred Network Access Commercial |
$10.12
|
| Rate for Payer: Quartz Beloit One Network |
$5.39
|
| Rate for Payer: Quartz Commercial |
$6.60
|
| Rate for Payer: WEA Trust Commercial |
$6.05
|
| Rate for Payer: WPS Commercial |
$8.15
|
|
|
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 |
$4.84 |
| Max. Negotiated Rate |
$10.45 |
| Rate for Payer: Aetna Commercial |
$10.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9.46
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cigna Commercial |
$10.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6.60
|
| Rate for Payer: Health EOS Commercial |
$10.01
|
| Rate for Payer: HFN Commercial |
$10.45
|
| Rate for Payer: Multiplan Commercial |
$8.80
|
| Rate for Payer: Preferred Network Access Commercial |
$10.45
|
| Rate for Payer: Quartz Beloit One Network |
$4.84
|
| Rate for Payer: Quartz Commercial |
$6.27
|
| Rate for Payer: The Alliance Commercial |
$5.50
|
| Rate for Payer: WEA Trust Commercial |
$6.05
|
| Rate for Payer: WPS Commercial |
$8.15
|
|
|
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 |
$2.45 |
| Max. Negotiated Rate |
$4.60 |
| Rate for Payer: Aetna Commercial |
$4.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2.65
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cigna Commercial |
$4.60
|
| Rate for Payer: Health EOS Commercial |
$4.45
|
| Rate for Payer: HFN Commercial |
$4.60
|
| Rate for Payer: Multiplan Commercial |
$4.00
|
| Rate for Payer: NAPHCARE Commercial |
$3.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4.60
|
| Rate for Payer: Quartz Beloit One Network |
$2.45
|
| Rate for Payer: Quartz Commercial |
$3.00
|
| Rate for Payer: WEA Trust Commercial |
$2.75
|
| Rate for Payer: WPS Commercial |
$3.70
|
|
|
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 |
$2.20 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Aetna Commercial |
$4.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4.30
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cigna Commercial |
$4.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3.00
|
| Rate for Payer: Health EOS Commercial |
$4.55
|
| Rate for Payer: HFN Commercial |
$4.75
|
| Rate for Payer: Multiplan Commercial |
$4.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4.75
|
| Rate for Payer: Quartz Beloit One Network |
$2.20
|
| Rate for Payer: Quartz Commercial |
$2.85
|
| Rate for Payer: The Alliance Commercial |
$2.50
|
| Rate for Payer: WEA Trust Commercial |
$2.75
|
| Rate for Payer: WPS Commercial |
$3.70
|
|
|
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 |
$1.40 |
| Max. Negotiated Rate |
$20.00 |
| Rate for Payer: Aetna Commercial |
$4.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4.30
|
| Rate for Payer: Aetna Managed Medicare |
$1.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2.65
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cigna Commercial |
$4.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2.80
|
| Rate for Payer: Health EOS Commercial |
$4.45
|
| Rate for Payer: HFN Commercial |
$4.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3.75
|
| Rate for Payer: Multiplan Commercial |
$4.00
|
| Rate for Payer: NAPHCARE Commercial |
$3.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4.60
|
| Rate for Payer: Quartz Beloit One Network |
$2.45
|
| Rate for Payer: Quartz Commercial |
$3.25
|
| Rate for Payer: Quartz Medicare Advantage |
$3.00
|
| Rate for Payer: The Alliance Commercial |
$20.00
|
| Rate for Payer: WEA Trust Commercial |
$2.75
|
| Rate for Payer: WPS Commercial |
$3.70
|
|
|
Phenytoin Level Free
|
Facility
|
IP
|
$210.00
|
|
|
Service Code
|
CPT 80186
|
| Hospital Charge Code |
633802
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$102.90 |
| Max. Negotiated Rate |
$193.20 |
| Rate for Payer: Aetna Commercial |
$189.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$180.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$111.30
|
| Rate for Payer: Cash Price |
$63.00
|
| Rate for Payer: Cigna Commercial |
$193.20
|
| Rate for Payer: Health EOS Commercial |
$186.90
|
| Rate for Payer: HFN Commercial |
$193.20
|
| Rate for Payer: Multiplan Commercial |
$168.00
|
| Rate for Payer: NAPHCARE Commercial |
$126.00
|
| Rate for Payer: Preferred Network Access Commercial |
$193.20
|
| Rate for Payer: Quartz Beloit One Network |
$102.90
|
| Rate for Payer: Quartz Commercial |
$126.00
|
| Rate for Payer: WEA Trust Commercial |
$115.50
|
| Rate for Payer: WPS Commercial |
$155.55
|
|
|
Phenytoin Level Free
|
Professional
|
Both
|
$210.00
|
|
|
Service Code
|
CPT 80186
|
| Hospital Charge Code |
633802
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$48.57 |
| Max. Negotiated Rate |
$199.50 |
| Rate for Payer: Aetna Commercial |
$199.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$180.60
|
| Rate for Payer: Cash Price |
$63.00
|
| Rate for Payer: Cash Price |
$63.00
|
| Rate for Payer: Cigna Commercial |
$199.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$105.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$126.00
|
| Rate for Payer: Health EOS Commercial |
$191.10
|
| Rate for Payer: HFN Commercial |
$199.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$48.57
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$48.57
|
| Rate for Payer: Multiplan Commercial |
$168.00
|
| Rate for Payer: Preferred Network Access Commercial |
$199.50
|
| Rate for Payer: Quartz Beloit One Network |
$92.40
|
| Rate for Payer: Quartz Commercial |
$119.70
|
| Rate for Payer: The Alliance Commercial |
$105.00
|
| Rate for Payer: WEA Trust Commercial |
$115.50
|
| Rate for Payer: WPS Commercial |
$155.55
|
|
|
Phenytoin Level Free
|
Facility
|
OP
|
$210.00
|
|
|
Service Code
|
CPT 80186
|
| Hospital Charge Code |
633802
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.76 |
| Max. Negotiated Rate |
$193.20 |
| Rate for Payer: Aetna Commercial |
$189.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$180.60
|
| Rate for Payer: Aetna Managed Medicare |
$13.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$51.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$24.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$22.84
|
| Rate for Payer: Anthem Medicaid |
$14.22
|
| Rate for Payer: Anthem Medicare Advantage |
$13.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$111.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$13.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$13.76
|
| Rate for Payer: Cash Price |
$63.00
|
| Rate for Payer: Cash Price |
$63.00
|
| Rate for Payer: Cigna Commercial |
$193.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$13.76
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$14.22
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$117.52
|
| Rate for Payer: Dean Health Medicaid |
$14.22
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$13.76
|
| Rate for Payer: Health EOS Commercial |
$186.90
|
| Rate for Payer: HFN Commercial |
$193.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$51.19
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$13.76
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$14.22
|
| Rate for Payer: Independent Care Health Plan Medicare |
$13.76
|
| Rate for Payer: Managed Health Services Medicaid |
$14.79
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$13.76
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$13.76
|
| Rate for Payer: Multiplan Commercial |
$168.00
|
| Rate for Payer: NAPHCARE Commercial |
$20.64
|
| Rate for Payer: Preferred Network Access Commercial |
$193.20
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$14.22
|
| Rate for Payer: Quartz Beloit One Network |
$102.90
|
| Rate for Payer: Quartz Commercial |
$136.50
|
| Rate for Payer: Quartz Medicare Advantage |
$13.76
|
| Rate for Payer: The Alliance Commercial |
$55.04
|
| Rate for Payer: United Healthcare Medicaid |
$14.22
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.76
|
| Rate for Payer: United Healthcare PPO |
$157.50
|
| Rate for Payer: WEA Trust Commercial |
$115.50
|
| Rate for Payer: Wellcare Medicare |
$13.76
|
| Rate for Payer: WMAP Medicaid |
$14.22
|
| Rate for Payer: WPS Commercial |
$155.55
|
|
|
Phenytoin Level Total
|
Facility
|
IP
|
$241.00
|
|
|
Service Code
|
CPT 80185
|
| Hospital Charge Code |
633801
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$118.09 |
| Max. Negotiated Rate |
$221.72 |
| Rate for Payer: Aetna Commercial |
$216.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$207.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$127.73
|
| Rate for Payer: Cash Price |
$72.30
|
| Rate for Payer: Cigna Commercial |
$221.72
|
| Rate for Payer: Health EOS Commercial |
$214.49
|
| Rate for Payer: HFN Commercial |
$221.72
|
| Rate for Payer: Multiplan Commercial |
$192.80
|
| Rate for Payer: NAPHCARE Commercial |
$144.60
|
| Rate for Payer: Preferred Network Access Commercial |
$221.72
|
| Rate for Payer: Quartz Beloit One Network |
$118.09
|
| Rate for Payer: Quartz Commercial |
$144.60
|
| Rate for Payer: WEA Trust Commercial |
$132.55
|
| Rate for Payer: WPS Commercial |
$178.51
|
|
|
Phenytoin Level Total
|
Facility
|
OP
|
$241.00
|
|
|
Service Code
|
CPT 80185
|
| Hospital Charge Code |
633801
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.25 |
| Max. Negotiated Rate |
$221.72 |
| Rate for Payer: Aetna Commercial |
$216.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$207.26
|
| Rate for Payer: Aetna Managed Medicare |
$13.25
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$49.69
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$23.19
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$22.00
|
| Rate for Payer: Anthem Medicaid |
$13.69
|
| Rate for Payer: Anthem Medicare Advantage |
$13.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$127.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$13.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$13.25
|
| Rate for Payer: Cash Price |
$72.30
|
| Rate for Payer: Cash Price |
$72.30
|
| Rate for Payer: Cigna Commercial |
$221.72
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$13.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$13.69
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$134.86
|
| Rate for Payer: Dean Health Medicaid |
$13.69
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$13.25
|
| Rate for Payer: Health EOS Commercial |
$214.49
|
| Rate for Payer: HFN Commercial |
$221.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$49.29
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$13.25
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$13.69
|
| Rate for Payer: Independent Care Health Plan Medicare |
$13.25
|
| Rate for Payer: Managed Health Services Medicaid |
$14.24
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$13.25
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$13.25
|
| Rate for Payer: Multiplan Commercial |
$192.80
|
| Rate for Payer: NAPHCARE Commercial |
$19.88
|
| Rate for Payer: Preferred Network Access Commercial |
$221.72
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$13.69
|
| Rate for Payer: Quartz Beloit One Network |
$118.09
|
| Rate for Payer: Quartz Commercial |
$156.65
|
| Rate for Payer: Quartz Medicare Advantage |
$13.25
|
| Rate for Payer: The Alliance Commercial |
$53.00
|
| Rate for Payer: United Healthcare Medicaid |
$13.69
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.25
|
| Rate for Payer: United Healthcare PPO |
$180.75
|
| Rate for Payer: WEA Trust Commercial |
$132.55
|
| Rate for Payer: Wellcare Medicare |
$13.25
|
| Rate for Payer: WMAP Medicaid |
$13.69
|
| Rate for Payer: WPS Commercial |
$178.51
|
|
|
Phenytoin Level Total
|
Professional
|
Both
|
$241.00
|
|
|
Service Code
|
CPT 80185
|
| Hospital Charge Code |
633801
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$46.77 |
| Max. Negotiated Rate |
$228.95 |
| Rate for Payer: Aetna Commercial |
$228.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$207.26
|
| Rate for Payer: Cash Price |
$72.30
|
| Rate for Payer: Cash Price |
$72.30
|
| Rate for Payer: Cigna Commercial |
$228.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$120.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$144.60
|
| Rate for Payer: Health EOS Commercial |
$219.31
|
| Rate for Payer: HFN Commercial |
$228.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$46.77
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$46.77
|
| Rate for Payer: Multiplan Commercial |
$192.80
|
| Rate for Payer: Preferred Network Access Commercial |
$228.95
|
| Rate for Payer: Quartz Beloit One Network |
$106.04
|
| Rate for Payer: Quartz Commercial |
$137.37
|
| Rate for Payer: The Alliance Commercial |
$120.50
|
| Rate for Payer: WEA Trust Commercial |
$132.55
|
| Rate for Payer: WPS Commercial |
$178.51
|
|
|
pH, Feces
|
Professional
|
Both
|
$55.00
|
|
|
Service Code
|
CPT 83986
|
| Hospital Charge Code |
3167486
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.64 |
| Max. Negotiated Rate |
$52.25 |
| Rate for Payer: Aetna Commercial |
$52.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$47.30
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Cigna Commercial |
$52.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$27.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$33.00
|
| Rate for Payer: Health EOS Commercial |
$50.05
|
| Rate for Payer: HFN Commercial |
$52.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12.64
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.64
|
| Rate for Payer: Multiplan Commercial |
$44.00
|
| Rate for Payer: Preferred Network Access Commercial |
$52.25
|
| Rate for Payer: Quartz Beloit One Network |
$24.20
|
| Rate for Payer: Quartz Commercial |
$31.35
|
| Rate for Payer: The Alliance Commercial |
$27.50
|
| Rate for Payer: WEA Trust Commercial |
$30.25
|
| Rate for Payer: WPS Commercial |
$40.74
|
|
|
pH, Feces
|
Facility
|
OP
|
$55.00
|
|
|
Service Code
|
CPT 83986
|
| Hospital Charge Code |
3167486
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$3.58 |
| Max. Negotiated Rate |
$50.60 |
| Rate for Payer: Aetna Commercial |
$49.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$47.30
|
| Rate for Payer: Aetna Managed Medicare |
$3.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13.42
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6.26
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5.94
|
| Rate for Payer: Anthem Medicaid |
$3.70
|
| Rate for Payer: Anthem Medicare Advantage |
$3.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3.58
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Cigna Commercial |
$50.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$3.58
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3.70
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30.78
|
| Rate for Payer: Dean Health Medicaid |
$3.70
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$3.58
|
| Rate for Payer: Health EOS Commercial |
$48.95
|
| Rate for Payer: HFN Commercial |
$50.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13.32
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3.58
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$3.70
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3.58
|
| Rate for Payer: Managed Health Services Medicaid |
$3.85
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$3.58
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$3.58
|
| Rate for Payer: Multiplan Commercial |
$44.00
|
| Rate for Payer: NAPHCARE Commercial |
$5.37
|
| Rate for Payer: Preferred Network Access Commercial |
$50.60
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$3.70
|
| Rate for Payer: Quartz Beloit One Network |
$26.95
|
| Rate for Payer: Quartz Commercial |
$35.75
|
| Rate for Payer: Quartz Medicare Advantage |
$3.58
|
| Rate for Payer: The Alliance Commercial |
$14.32
|
| Rate for Payer: United Healthcare Medicaid |
$3.70
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3.58
|
| Rate for Payer: United Healthcare PPO |
$41.25
|
| Rate for Payer: WEA Trust Commercial |
$30.25
|
| Rate for Payer: Wellcare Medicare |
$3.58
|
| Rate for Payer: WMAP Medicaid |
$3.70
|
| Rate for Payer: WPS Commercial |
$40.74
|
|
|
pH, Feces
|
Facility
|
IP
|
$55.00
|
|
|
Service Code
|
CPT 83986
|
| Hospital Charge Code |
3167486
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$26.95 |
| Max. Negotiated Rate |
$50.60 |
| Rate for Payer: Aetna Commercial |
$49.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$47.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.15
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Cigna Commercial |
$50.60
|
| Rate for Payer: Health EOS Commercial |
$48.95
|
| Rate for Payer: HFN Commercial |
$50.60
|
| Rate for Payer: Multiplan Commercial |
$44.00
|
| Rate for Payer: NAPHCARE Commercial |
$33.00
|
| Rate for Payer: Preferred Network Access Commercial |
$50.60
|
| Rate for Payer: Quartz Beloit One Network |
$26.95
|
| Rate for Payer: Quartz Commercial |
$33.00
|
| Rate for Payer: WEA Trust Commercial |
$30.25
|
| Rate for Payer: WPS Commercial |
$40.74
|
|
|
pH, Fluid
|
Professional
|
Both
|
$55.00
|
|
|
Service Code
|
CPT 83986
|
| Hospital Charge Code |
3154876
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.64 |
| Max. Negotiated Rate |
$52.25 |
| Rate for Payer: Aetna Commercial |
$52.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$47.30
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Cigna Commercial |
$52.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$27.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$33.00
|
| Rate for Payer: Health EOS Commercial |
$50.05
|
| Rate for Payer: HFN Commercial |
$52.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12.64
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.64
|
| Rate for Payer: Multiplan Commercial |
$44.00
|
| Rate for Payer: Preferred Network Access Commercial |
$52.25
|
| Rate for Payer: Quartz Beloit One Network |
$24.20
|
| Rate for Payer: Quartz Commercial |
$31.35
|
| Rate for Payer: The Alliance Commercial |
$27.50
|
| Rate for Payer: WEA Trust Commercial |
$30.25
|
| Rate for Payer: WPS Commercial |
$40.74
|
|
|
pH, Fluid
|
Facility
|
IP
|
$55.00
|
|
|
Service Code
|
CPT 83986
|
| Hospital Charge Code |
3154876
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$26.95 |
| Max. Negotiated Rate |
$50.60 |
| Rate for Payer: Aetna Commercial |
$49.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$47.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.15
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Cigna Commercial |
$50.60
|
| Rate for Payer: Health EOS Commercial |
$48.95
|
| Rate for Payer: HFN Commercial |
$50.60
|
| Rate for Payer: Multiplan Commercial |
$44.00
|
| Rate for Payer: NAPHCARE Commercial |
$33.00
|
| Rate for Payer: Preferred Network Access Commercial |
$50.60
|
| Rate for Payer: Quartz Beloit One Network |
$26.95
|
| Rate for Payer: Quartz Commercial |
$33.00
|
| Rate for Payer: WEA Trust Commercial |
$30.25
|
| Rate for Payer: WPS Commercial |
$40.74
|
|
|
pH, Fluid
|
Facility
|
OP
|
$55.00
|
|
|
Service Code
|
CPT 83986
|
| Hospital Charge Code |
3154876
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$3.58 |
| Max. Negotiated Rate |
$50.60 |
| Rate for Payer: Aetna Commercial |
$49.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$47.30
|
| Rate for Payer: Aetna Managed Medicare |
$3.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13.42
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6.26
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5.94
|
| Rate for Payer: Anthem Medicaid |
$3.70
|
| Rate for Payer: Anthem Medicare Advantage |
$3.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3.58
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Cigna Commercial |
$50.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$3.58
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3.70
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30.78
|
| Rate for Payer: Dean Health Medicaid |
$3.70
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$3.58
|
| Rate for Payer: Health EOS Commercial |
$48.95
|
| Rate for Payer: HFN Commercial |
$50.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13.32
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3.58
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$3.70
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3.58
|
| Rate for Payer: Managed Health Services Medicaid |
$3.85
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$3.58
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$3.58
|
| Rate for Payer: Multiplan Commercial |
$44.00
|
| Rate for Payer: NAPHCARE Commercial |
$5.37
|
| Rate for Payer: Preferred Network Access Commercial |
$50.60
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$3.70
|
| Rate for Payer: Quartz Beloit One Network |
$26.95
|
| Rate for Payer: Quartz Commercial |
$35.75
|
| Rate for Payer: Quartz Medicare Advantage |
$3.58
|
| Rate for Payer: The Alliance Commercial |
$14.32
|
| Rate for Payer: United Healthcare Medicaid |
$3.70
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3.58
|
| Rate for Payer: United Healthcare PPO |
$41.25
|
| Rate for Payer: WEA Trust Commercial |
$30.25
|
| Rate for Payer: Wellcare Medicare |
$3.58
|
| Rate for Payer: WMAP Medicaid |
$3.70
|
| Rate for Payer: WPS Commercial |
$40.74
|
|
|
PHLEBECTOMY/VARICOSE VEIN LIGATION AND STRIPPING
|
Facility
|
IP
|
$1,084.00
|
|
| Hospital Charge Code |
2960315
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$531.16 |
| Max. Negotiated Rate |
$997.28 |
| Rate for Payer: Aetna Commercial |
$975.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$932.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$574.52
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$997.28
|
| Rate for Payer: Health EOS Commercial |
$964.76
|
| Rate for Payer: HFN Commercial |
$997.28
|
| Rate for Payer: Multiplan Commercial |
$867.20
|
| Rate for Payer: NAPHCARE Commercial |
$650.40
|
| Rate for Payer: Preferred Network Access Commercial |
$997.28
|
| Rate for Payer: Quartz Beloit One Network |
$531.16
|
| Rate for Payer: Quartz Commercial |
$650.40
|
| Rate for Payer: WEA Trust Commercial |
$596.20
|
| Rate for Payer: WPS Commercial |
$802.92
|
|
