|
Thalassemia & Hemoglobinopathy Comprehensive
|
Facility
|
IP
|
$99.27
|
|
|
Service Code
|
CPT 82728
|
| Hospital Charge Code |
4254047
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$48.64 |
| Max. Negotiated Rate |
$91.33 |
| Rate for Payer: Aetna Commercial |
$89.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$85.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$52.61
|
| Rate for Payer: Cash Price |
$29.78
|
| Rate for Payer: Cigna Commercial |
$91.33
|
| Rate for Payer: Health EOS Commercial |
$88.35
|
| Rate for Payer: HFN Commercial |
$91.33
|
| Rate for Payer: Multiplan Commercial |
$79.42
|
| Rate for Payer: NAPHCARE Commercial |
$59.56
|
| Rate for Payer: Preferred Network Access Commercial |
$91.33
|
| Rate for Payer: Quartz Beloit One Network |
$48.64
|
| Rate for Payer: Quartz Commercial |
$59.56
|
| Rate for Payer: WEA Trust Commercial |
$54.60
|
| Rate for Payer: WPS Commercial |
$73.53
|
|
|
Thalassemia & Hemoglobinopathy Comprehensive
|
Facility
|
OP
|
$99.27
|
|
|
Service Code
|
CPT 82728
|
| Hospital Charge Code |
4254047
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.63 |
| Max. Negotiated Rate |
$91.33 |
| Rate for Payer: Aetna Commercial |
$89.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$85.37
|
| Rate for Payer: Aetna Managed Medicare |
$13.63
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$51.11
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$23.85
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$22.63
|
| Rate for Payer: Anthem Medicaid |
$14.08
|
| Rate for Payer: Anthem Medicare Advantage |
$13.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$52.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$13.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$13.63
|
| Rate for Payer: Cash Price |
$29.78
|
| Rate for Payer: Cash Price |
$29.78
|
| Rate for Payer: Cigna Commercial |
$91.33
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$13.63
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$14.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$55.55
|
| Rate for Payer: Dean Health Medicaid |
$14.08
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$13.63
|
| Rate for Payer: Health EOS Commercial |
$88.35
|
| Rate for Payer: HFN Commercial |
$91.33
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$50.70
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$13.63
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$14.08
|
| Rate for Payer: Independent Care Health Plan Medicare |
$13.63
|
| Rate for Payer: Managed Health Services Medicaid |
$14.64
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$13.63
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$13.63
|
| Rate for Payer: Multiplan Commercial |
$79.42
|
| Rate for Payer: NAPHCARE Commercial |
$20.44
|
| Rate for Payer: Preferred Network Access Commercial |
$91.33
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$14.08
|
| Rate for Payer: Quartz Beloit One Network |
$48.64
|
| Rate for Payer: Quartz Commercial |
$64.53
|
| Rate for Payer: Quartz Medicare Advantage |
$13.63
|
| Rate for Payer: The Alliance Commercial |
$54.52
|
| Rate for Payer: United Healthcare Medicaid |
$14.08
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.63
|
| Rate for Payer: United Healthcare PPO |
$74.45
|
| Rate for Payer: WEA Trust Commercial |
$54.60
|
| Rate for Payer: Wellcare Medicare |
$13.63
|
| Rate for Payer: WMAP Medicaid |
$14.08
|
| Rate for Payer: WPS Commercial |
$73.53
|
|
|
Thalassemia & Hemoglobinopathy Comprehensive
|
Professional
|
Both
|
$99.27
|
|
|
Service Code
|
CPT 82728
|
| Hospital Charge Code |
4254047
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$43.68 |
| Max. Negotiated Rate |
$94.31 |
| Rate for Payer: Aetna Commercial |
$94.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$85.37
|
| Rate for Payer: Cash Price |
$29.78
|
| Rate for Payer: Cash Price |
$29.78
|
| Rate for Payer: Cigna Commercial |
$94.31
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$49.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$59.56
|
| Rate for Payer: Health EOS Commercial |
$90.34
|
| Rate for Payer: HFN Commercial |
$94.31
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$48.11
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$48.11
|
| Rate for Payer: Multiplan Commercial |
$79.42
|
| Rate for Payer: Preferred Network Access Commercial |
$94.31
|
| Rate for Payer: Quartz Beloit One Network |
$43.68
|
| Rate for Payer: Quartz Commercial |
$56.58
|
| Rate for Payer: The Alliance Commercial |
$49.64
|
| Rate for Payer: WEA Trust Commercial |
$54.60
|
| Rate for Payer: WPS Commercial |
$73.53
|
|
|
Thalass Interp
|
Facility
|
IP
|
$129.00
|
|
|
Service Code
|
CPT 83021
|
| Hospital Charge Code |
4254086
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$63.21 |
| Max. Negotiated Rate |
$118.68 |
| Rate for Payer: Aetna Commercial |
$116.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$110.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$68.37
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cigna Commercial |
$118.68
|
| Rate for Payer: Health EOS Commercial |
$114.81
|
| Rate for Payer: HFN Commercial |
$118.68
|
| Rate for Payer: Multiplan Commercial |
$103.20
|
| Rate for Payer: NAPHCARE Commercial |
$77.40
|
| Rate for Payer: Preferred Network Access Commercial |
$118.68
|
| Rate for Payer: Quartz Beloit One Network |
$63.21
|
| Rate for Payer: Quartz Commercial |
$77.40
|
| Rate for Payer: WEA Trust Commercial |
$70.95
|
| Rate for Payer: WPS Commercial |
$95.55
|
|
|
Thalass Interp
|
Facility
|
OP
|
$129.00
|
|
|
Service Code
|
CPT 83021
|
| Hospital Charge Code |
4254086
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.06 |
| Max. Negotiated Rate |
$118.68 |
| Rate for Payer: Aetna Commercial |
$116.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$110.94
|
| Rate for Payer: Aetna Managed Medicare |
$18.06
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$67.72
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$31.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$29.98
|
| Rate for Payer: Anthem Medicaid |
$18.66
|
| Rate for Payer: Anthem Medicare Advantage |
$18.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$68.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$18.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$18.06
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cigna Commercial |
$118.68
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$18.06
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$18.66
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$72.19
|
| Rate for Payer: Dean Health Medicaid |
$18.66
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$18.06
|
| Rate for Payer: Health EOS Commercial |
$114.81
|
| Rate for Payer: HFN Commercial |
$118.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$67.18
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$18.06
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$18.66
|
| Rate for Payer: Independent Care Health Plan Medicare |
$18.06
|
| Rate for Payer: Managed Health Services Medicaid |
$19.41
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$18.06
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$18.06
|
| Rate for Payer: Multiplan Commercial |
$103.20
|
| Rate for Payer: NAPHCARE Commercial |
$27.09
|
| Rate for Payer: Preferred Network Access Commercial |
$118.68
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$18.66
|
| Rate for Payer: Quartz Beloit One Network |
$63.21
|
| Rate for Payer: Quartz Commercial |
$83.85
|
| Rate for Payer: Quartz Medicare Advantage |
$18.06
|
| Rate for Payer: The Alliance Commercial |
$72.24
|
| Rate for Payer: United Healthcare Medicaid |
$18.66
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.06
|
| Rate for Payer: United Healthcare PPO |
$96.75
|
| Rate for Payer: WEA Trust Commercial |
$70.95
|
| Rate for Payer: Wellcare Medicare |
$18.06
|
| Rate for Payer: WMAP Medicaid |
$18.66
|
| Rate for Payer: WPS Commercial |
$95.55
|
|
|
Thalass Interp
|
Professional
|
Both
|
$129.00
|
|
|
Service Code
|
CPT 83021
|
| Hospital Charge Code |
4254086
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$56.76 |
| Max. Negotiated Rate |
$122.55 |
| Rate for Payer: Aetna Commercial |
$122.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$110.94
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cigna Commercial |
$122.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$64.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$77.40
|
| Rate for Payer: Health EOS Commercial |
$117.39
|
| Rate for Payer: HFN Commercial |
$122.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$63.75
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$63.75
|
| Rate for Payer: Multiplan Commercial |
$103.20
|
| Rate for Payer: Preferred Network Access Commercial |
$122.55
|
| Rate for Payer: Quartz Beloit One Network |
$56.76
|
| Rate for Payer: Quartz Commercial |
$73.53
|
| Rate for Payer: The Alliance Commercial |
$64.50
|
| Rate for Payer: WEA Trust Commercial |
$70.95
|
| Rate for Payer: WPS Commercial |
$95.55
|
|
|
Thallium-201(per mCi)
|
Facility
|
OP
|
$128.00
|
|
|
Service Code
|
HCPCS A9505
|
| Hospital Charge Code |
1486854
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.84 |
| Max. Negotiated Rate |
$512.00 |
| Rate for Payer: Aetna Commercial |
$115.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$110.08
|
| Rate for Payer: Aetna Managed Medicare |
$35.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$83.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$64.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$61.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$67.84
|
| Rate for Payer: Cash Price |
$38.40
|
| Rate for Payer: Cigna Commercial |
$117.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$71.63
|
| Rate for Payer: Health EOS Commercial |
$113.92
|
| Rate for Payer: HFN Commercial |
$117.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$96.00
|
| Rate for Payer: Multiplan Commercial |
$102.40
|
| Rate for Payer: NAPHCARE Commercial |
$76.80
|
| Rate for Payer: Preferred Network Access Commercial |
$117.76
|
| Rate for Payer: Quartz Beloit One Network |
$62.72
|
| Rate for Payer: Quartz Commercial |
$83.20
|
| Rate for Payer: Quartz Medicare Advantage |
$76.80
|
| Rate for Payer: The Alliance Commercial |
$512.00
|
| Rate for Payer: WEA Trust Commercial |
$70.40
|
| Rate for Payer: WPS Commercial |
$94.81
|
|
|
Thallium-201(per mCi)
|
Facility
|
OP
|
$120.00
|
|
|
Service Code
|
HCPCS A9505
|
| Hospital Charge Code |
5381842
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.60 |
| Max. Negotiated Rate |
$480.00 |
| Rate for Payer: Aetna Commercial |
$108.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$103.20
|
| Rate for Payer: Aetna Managed Medicare |
$33.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$78.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$60.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$57.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$63.60
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$110.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$67.15
|
| Rate for Payer: Health EOS Commercial |
$106.80
|
| Rate for Payer: HFN Commercial |
$110.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$90.00
|
| Rate for Payer: Multiplan Commercial |
$96.00
|
| Rate for Payer: NAPHCARE Commercial |
$72.00
|
| Rate for Payer: Preferred Network Access Commercial |
$110.40
|
| Rate for Payer: Quartz Beloit One Network |
$58.80
|
| Rate for Payer: Quartz Commercial |
$78.00
|
| Rate for Payer: Quartz Medicare Advantage |
$72.00
|
| Rate for Payer: The Alliance Commercial |
$480.00
|
| Rate for Payer: WEA Trust Commercial |
$66.00
|
| Rate for Payer: WPS Commercial |
$88.88
|
|
|
Thallium-201(per mCi)
|
Facility
|
IP
|
$128.00
|
|
|
Service Code
|
HCPCS A9505
|
| Hospital Charge Code |
1486854
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$62.72 |
| Max. Negotiated Rate |
$117.76 |
| Rate for Payer: Aetna Commercial |
$115.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$110.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$67.84
|
| Rate for Payer: Cash Price |
$38.40
|
| Rate for Payer: Cigna Commercial |
$117.76
|
| Rate for Payer: Health EOS Commercial |
$113.92
|
| Rate for Payer: HFN Commercial |
$117.76
|
| Rate for Payer: Multiplan Commercial |
$102.40
|
| Rate for Payer: NAPHCARE Commercial |
$76.80
|
| Rate for Payer: Preferred Network Access Commercial |
$117.76
|
| Rate for Payer: Quartz Beloit One Network |
$62.72
|
| Rate for Payer: Quartz Commercial |
$76.80
|
| Rate for Payer: WEA Trust Commercial |
$70.40
|
| Rate for Payer: WPS Commercial |
$94.81
|
|
|
Thallium-201(per mCi)
|
Facility
|
IP
|
$120.00
|
|
|
Service Code
|
HCPCS A9505
|
| Hospital Charge Code |
5381842
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$58.80 |
| Max. Negotiated Rate |
$110.40 |
| Rate for Payer: Aetna Commercial |
$108.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$103.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$63.60
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$110.40
|
| Rate for Payer: Health EOS Commercial |
$106.80
|
| Rate for Payer: HFN Commercial |
$110.40
|
| Rate for Payer: Multiplan Commercial |
$96.00
|
| Rate for Payer: NAPHCARE Commercial |
$72.00
|
| Rate for Payer: Preferred Network Access Commercial |
$110.40
|
| Rate for Payer: Quartz Beloit One Network |
$58.80
|
| Rate for Payer: Quartz Commercial |
$72.00
|
| Rate for Payer: WEA Trust Commercial |
$66.00
|
| Rate for Payer: WPS Commercial |
$88.88
|
|
|
Thallium-201(per mCi)
|
Professional
|
Both
|
$120.00
|
|
|
Service Code
|
HCPCS A9505
|
| Hospital Charge Code |
5381842
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$52.80 |
| Max. Negotiated Rate |
$114.00 |
| Rate for Payer: Aetna Commercial |
$114.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$103.20
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$114.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$60.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$72.00
|
| Rate for Payer: Health EOS Commercial |
$109.20
|
| Rate for Payer: HFN Commercial |
$114.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$53.23
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$53.23
|
| Rate for Payer: Multiplan Commercial |
$96.00
|
| Rate for Payer: Preferred Network Access Commercial |
$114.00
|
| Rate for Payer: Quartz Beloit One Network |
$52.80
|
| Rate for Payer: Quartz Commercial |
$68.40
|
| Rate for Payer: The Alliance Commercial |
$60.00
|
| Rate for Payer: WEA Trust Commercial |
$66.00
|
| Rate for Payer: WPS Commercial |
$88.88
|
|
|
Thallium-201(per mCi)
|
Professional
|
Both
|
$128.00
|
|
|
Service Code
|
HCPCS A9505
|
| Hospital Charge Code |
1486854
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$53.23 |
| Max. Negotiated Rate |
$121.60 |
| Rate for Payer: Aetna Commercial |
$121.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$110.08
|
| Rate for Payer: Cash Price |
$38.40
|
| Rate for Payer: Cash Price |
$38.40
|
| Rate for Payer: Cigna Commercial |
$121.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$64.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$76.80
|
| Rate for Payer: Health EOS Commercial |
$116.48
|
| Rate for Payer: HFN Commercial |
$121.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$53.23
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$53.23
|
| Rate for Payer: Multiplan Commercial |
$102.40
|
| Rate for Payer: Preferred Network Access Commercial |
$121.60
|
| Rate for Payer: Quartz Beloit One Network |
$56.32
|
| Rate for Payer: Quartz Commercial |
$72.96
|
| Rate for Payer: The Alliance Commercial |
$64.00
|
| Rate for Payer: WEA Trust Commercial |
$70.40
|
| Rate for Payer: WPS Commercial |
$94.81
|
|
|
Thawing Fee
|
Facility
|
IP
|
$49.00
|
|
|
Service Code
|
CPT 86927
|
| Hospital Charge Code |
2949311
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$24.01 |
| Max. Negotiated Rate |
$45.08 |
| Rate for Payer: Aetna Commercial |
$44.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$42.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$25.97
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cigna Commercial |
$45.08
|
| Rate for Payer: Health EOS Commercial |
$43.61
|
| Rate for Payer: HFN Commercial |
$45.08
|
| Rate for Payer: Multiplan Commercial |
$39.20
|
| Rate for Payer: NAPHCARE Commercial |
$29.40
|
| Rate for Payer: Preferred Network Access Commercial |
$45.08
|
| Rate for Payer: Quartz Beloit One Network |
$24.01
|
| Rate for Payer: Quartz Commercial |
$29.40
|
| Rate for Payer: WEA Trust Commercial |
$26.95
|
| Rate for Payer: WPS Commercial |
$36.29
|
|
|
Thawing Fee
|
Facility
|
OP
|
$49.00
|
|
|
Service Code
|
CPT 86927
|
| Hospital Charge Code |
2949311
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$23.52 |
| Max. Negotiated Rate |
$675.28 |
| Rate for Payer: Aetna Commercial |
$44.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$42.14
|
| Rate for Payer: Aetna Managed Medicare |
$168.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$31.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$24.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$23.52
|
| Rate for Payer: Anthem Medicare Advantage |
$168.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$25.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$168.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$168.82
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cigna Commercial |
$45.08
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$168.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$27.42
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$168.82
|
| Rate for Payer: Health EOS Commercial |
$43.61
|
| Rate for Payer: HFN Commercial |
$45.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$628.01
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$168.82
|
| Rate for Payer: Independent Care Health Plan Medicare |
$168.82
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$168.82
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$168.82
|
| Rate for Payer: Multiplan Commercial |
$39.20
|
| Rate for Payer: NAPHCARE Commercial |
$253.23
|
| Rate for Payer: Preferred Network Access Commercial |
$45.08
|
| Rate for Payer: Quartz Beloit One Network |
$24.01
|
| Rate for Payer: Quartz Commercial |
$31.85
|
| Rate for Payer: Quartz Medicare Advantage |
$168.82
|
| Rate for Payer: The Alliance Commercial |
$675.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$168.82
|
| Rate for Payer: United Healthcare PPO |
$36.75
|
| Rate for Payer: WEA Trust Commercial |
$26.95
|
| Rate for Payer: Wellcare Medicare |
$168.82
|
| Rate for Payer: WPS Commercial |
$36.29
|
|
|
Thawing Fee
|
Professional
|
Both
|
$49.00
|
|
|
Service Code
|
CPT 86927
|
| Hospital Charge Code |
2949311
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$21.56 |
| Max. Negotiated Rate |
$68.45 |
| Rate for Payer: Aetna Commercial |
$46.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$42.14
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cigna Commercial |
$46.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$24.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$29.40
|
| Rate for Payer: Health EOS Commercial |
$44.59
|
| Rate for Payer: HFN Commercial |
$46.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$68.45
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$68.45
|
| Rate for Payer: Multiplan Commercial |
$39.20
|
| Rate for Payer: Preferred Network Access Commercial |
$46.55
|
| Rate for Payer: Quartz Beloit One Network |
$21.56
|
| Rate for Payer: Quartz Commercial |
$27.93
|
| Rate for Payer: The Alliance Commercial |
$24.50
|
| Rate for Payer: WEA Trust Commercial |
$26.95
|
| Rate for Payer: WPS Commercial |
$36.29
|
|
|
Theophylline Level
|
Facility
|
OP
|
$350.00
|
|
|
Service Code
|
CPT 80198
|
| Hospital Charge Code |
633839
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.14 |
| Max. Negotiated Rate |
$322.00 |
| Rate for Payer: Aetna Commercial |
$315.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$301.00
|
| Rate for Payer: Aetna Managed Medicare |
$14.14
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$53.02
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$24.74
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$23.47
|
| Rate for Payer: Anthem Medicaid |
$14.61
|
| Rate for Payer: Anthem Medicare Advantage |
$14.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$185.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$14.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$14.14
|
| Rate for Payer: Cash Price |
$105.00
|
| Rate for Payer: Cash Price |
$105.00
|
| Rate for Payer: Cigna Commercial |
$322.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$14.14
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$14.61
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$195.86
|
| Rate for Payer: Dean Health Medicaid |
$14.61
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$14.14
|
| Rate for Payer: Health EOS Commercial |
$311.50
|
| Rate for Payer: HFN Commercial |
$322.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$52.60
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$14.14
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$14.61
|
| Rate for Payer: Independent Care Health Plan Medicare |
$14.14
|
| Rate for Payer: Managed Health Services Medicaid |
$15.19
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$14.14
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$14.14
|
| Rate for Payer: Multiplan Commercial |
$280.00
|
| Rate for Payer: NAPHCARE Commercial |
$21.21
|
| Rate for Payer: Preferred Network Access Commercial |
$322.00
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$14.61
|
| Rate for Payer: Quartz Beloit One Network |
$171.50
|
| Rate for Payer: Quartz Commercial |
$227.50
|
| Rate for Payer: Quartz Medicare Advantage |
$14.14
|
| Rate for Payer: The Alliance Commercial |
$56.56
|
| Rate for Payer: United Healthcare Medicaid |
$14.61
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.14
|
| Rate for Payer: United Healthcare PPO |
$262.50
|
| Rate for Payer: WEA Trust Commercial |
$192.50
|
| Rate for Payer: Wellcare Medicare |
$14.14
|
| Rate for Payer: WMAP Medicaid |
$14.61
|
| Rate for Payer: WPS Commercial |
$259.24
|
|
|
Theophylline Level
|
Professional
|
Both
|
$350.00
|
|
|
Service Code
|
CPT 80198
|
| Hospital Charge Code |
633839
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$49.91 |
| Max. Negotiated Rate |
$332.50 |
| Rate for Payer: Aetna Commercial |
$332.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$301.00
|
| Rate for Payer: Cash Price |
$105.00
|
| Rate for Payer: Cash Price |
$105.00
|
| Rate for Payer: Cigna Commercial |
$332.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$175.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$210.00
|
| Rate for Payer: Health EOS Commercial |
$318.50
|
| Rate for Payer: HFN Commercial |
$332.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$49.91
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$49.91
|
| Rate for Payer: Multiplan Commercial |
$280.00
|
| Rate for Payer: Preferred Network Access Commercial |
$332.50
|
| Rate for Payer: Quartz Beloit One Network |
$154.00
|
| Rate for Payer: Quartz Commercial |
$199.50
|
| Rate for Payer: The Alliance Commercial |
$175.00
|
| Rate for Payer: WEA Trust Commercial |
$192.50
|
| Rate for Payer: WPS Commercial |
$259.24
|
|
|
Theophylline Level
|
Facility
|
IP
|
$350.00
|
|
|
Service Code
|
CPT 80198
|
| Hospital Charge Code |
633839
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$171.50 |
| Max. Negotiated Rate |
$322.00 |
| Rate for Payer: Aetna Commercial |
$315.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$301.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$185.50
|
| Rate for Payer: Cash Price |
$105.00
|
| Rate for Payer: Cigna Commercial |
$322.00
|
| Rate for Payer: Health EOS Commercial |
$311.50
|
| Rate for Payer: HFN Commercial |
$322.00
|
| Rate for Payer: Multiplan Commercial |
$280.00
|
| Rate for Payer: NAPHCARE Commercial |
$210.00
|
| Rate for Payer: Preferred Network Access Commercial |
$322.00
|
| Rate for Payer: Quartz Beloit One Network |
$171.50
|
| Rate for Payer: Quartz Commercial |
$210.00
|
| Rate for Payer: WEA Trust Commercial |
$192.50
|
| Rate for Payer: WPS Commercial |
$259.24
|
|
|
THERA BAND SILVER LATEX FREE 50 YARD #9254-23-06
|
Facility
|
OP
|
$1,830.00
|
|
| Hospital Charge Code |
2969904
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$512.40 |
| Max. Negotiated Rate |
$7,320.00 |
| Rate for Payer: Aetna Commercial |
$1,647.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,573.80
|
| Rate for Payer: Aetna Managed Medicare |
$512.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,189.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$915.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$878.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$969.90
|
| Rate for Payer: Cash Price |
$549.00
|
| Rate for Payer: Cigna Commercial |
$1,683.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,024.07
|
| Rate for Payer: Health EOS Commercial |
$1,628.70
|
| Rate for Payer: HFN Commercial |
$1,683.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,372.50
|
| Rate for Payer: Multiplan Commercial |
$1,464.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,098.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,683.60
|
| Rate for Payer: Quartz Beloit One Network |
$896.70
|
| Rate for Payer: Quartz Commercial |
$1,189.50
|
| Rate for Payer: Quartz Medicare Advantage |
$1,098.00
|
| Rate for Payer: The Alliance Commercial |
$7,320.00
|
| Rate for Payer: WEA Trust Commercial |
$1,006.50
|
| Rate for Payer: WPS Commercial |
$1,355.48
|
|
|
THERA BAND SILVER LATEX FREE 50 YARD #9254-23-06
|
Facility
|
IP
|
$1,830.00
|
|
| Hospital Charge Code |
2969904
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$896.70 |
| Max. Negotiated Rate |
$1,683.60 |
| Rate for Payer: Aetna Commercial |
$1,647.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,573.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$969.90
|
| Rate for Payer: Cash Price |
$549.00
|
| Rate for Payer: Cigna Commercial |
$1,683.60
|
| Rate for Payer: Health EOS Commercial |
$1,628.70
|
| Rate for Payer: HFN Commercial |
$1,683.60
|
| Rate for Payer: Multiplan Commercial |
$1,464.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,098.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,683.60
|
| Rate for Payer: Quartz Beloit One Network |
$896.70
|
| Rate for Payer: Quartz Commercial |
$1,098.00
|
| Rate for Payer: WEA Trust Commercial |
$1,006.50
|
| Rate for Payer: WPS Commercial |
$1,355.48
|
|
|
Therapeutic Exercise Charges ST
|
Facility
|
IP
|
$270.00
|
|
|
Service Code
|
CPT 97110 GN
|
| Hospital Charge Code |
753741
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$132.30 |
| Max. Negotiated Rate |
$248.40 |
| Rate for Payer: Aetna Commercial |
$243.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$232.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$143.10
|
| Rate for Payer: Cash Price |
$81.00
|
| Rate for Payer: Cigna Commercial |
$248.40
|
| Rate for Payer: Health EOS Commercial |
$240.30
|
| Rate for Payer: HFN Commercial |
$248.40
|
| Rate for Payer: Multiplan Commercial |
$216.00
|
| Rate for Payer: NAPHCARE Commercial |
$162.00
|
| Rate for Payer: Preferred Network Access Commercial |
$248.40
|
| Rate for Payer: Quartz Beloit One Network |
$132.30
|
| Rate for Payer: Quartz Commercial |
$162.00
|
| Rate for Payer: WEA Trust Commercial |
$148.50
|
| Rate for Payer: WPS Commercial |
$199.99
|
|
|
Therapeutic Exercise Charges ST
|
Facility
|
OP
|
$270.00
|
|
|
Service Code
|
CPT 97110 GN
|
| Hospital Charge Code |
753741
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$75.60 |
| Max. Negotiated Rate |
$1,080.00 |
| Rate for Payer: Aetna Commercial |
$243.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$232.20
|
| Rate for Payer: Aetna Managed Medicare |
$75.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$349.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$287.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$272.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$143.10
|
| Rate for Payer: Cash Price |
$81.00
|
| Rate for Payer: Cash Price |
$81.00
|
| Rate for Payer: Cigna Commercial |
$248.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$151.09
|
| Rate for Payer: Health EOS Commercial |
$240.30
|
| Rate for Payer: HFN Commercial |
$248.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$216.00
|
| Rate for Payer: NAPHCARE Commercial |
$162.00
|
| Rate for Payer: Preferred Network Access Commercial |
$248.40
|
| Rate for Payer: Quartz Beloit One Network |
$132.30
|
| Rate for Payer: Quartz Commercial |
$175.50
|
| Rate for Payer: Quartz Medicare Advantage |
$162.00
|
| Rate for Payer: The Alliance Commercial |
$1,080.00
|
| Rate for Payer: United Healthcare PPO |
$202.50
|
| Rate for Payer: WEA Trust Commercial |
$148.50
|
| Rate for Payer: WPS Commercial |
$199.99
|
|
|
Therapeutic Inj
|
Facility
|
IP
|
$118.00
|
|
|
Service Code
|
CPT 96372
|
| Hospital Charge Code |
3970747
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$57.82 |
| Max. Negotiated Rate |
$108.56 |
| Rate for Payer: Aetna Commercial |
$106.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$101.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$62.54
|
| Rate for Payer: Cash Price |
$35.40
|
| Rate for Payer: Cigna Commercial |
$108.56
|
| Rate for Payer: Health EOS Commercial |
$105.02
|
| Rate for Payer: HFN Commercial |
$108.56
|
| Rate for Payer: Multiplan Commercial |
$94.40
|
| Rate for Payer: NAPHCARE Commercial |
$70.80
|
| Rate for Payer: Preferred Network Access Commercial |
$108.56
|
| Rate for Payer: Quartz Beloit One Network |
$57.82
|
| Rate for Payer: Quartz Commercial |
$70.80
|
| Rate for Payer: WEA Trust Commercial |
$64.90
|
| Rate for Payer: WPS Commercial |
$87.40
|
|
|
Therapeutic Inj
|
Facility
|
OP
|
$118.00
|
|
|
Service Code
|
CPT 96372
|
| Hospital Charge Code |
3970747
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$56.64 |
| Max. Negotiated Rate |
$278.52 |
| Rate for Payer: Aetna Commercial |
$106.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$101.48
|
| Rate for Payer: Aetna Managed Medicare |
$69.63
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$76.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$59.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$56.64
|
| Rate for Payer: Anthem Medicare Advantage |
$69.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$62.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$69.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$69.63
|
| Rate for Payer: Cash Price |
$35.40
|
| Rate for Payer: Cash Price |
$35.40
|
| Rate for Payer: Cigna Commercial |
$108.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$69.63
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$66.03
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$69.63
|
| Rate for Payer: Health EOS Commercial |
$105.02
|
| Rate for Payer: HFN Commercial |
$108.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$259.02
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$69.63
|
| Rate for Payer: Independent Care Health Plan Medicare |
$69.63
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$69.63
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$69.63
|
| Rate for Payer: Multiplan Commercial |
$94.40
|
| Rate for Payer: NAPHCARE Commercial |
$104.44
|
| Rate for Payer: Preferred Network Access Commercial |
$108.56
|
| Rate for Payer: Quartz Beloit One Network |
$57.82
|
| Rate for Payer: Quartz Commercial |
$76.70
|
| Rate for Payer: Quartz Medicare Advantage |
$69.63
|
| Rate for Payer: The Alliance Commercial |
$278.52
|
| Rate for Payer: United Healthcare Medicare Advantage |
$69.63
|
| Rate for Payer: United Healthcare PPO |
$88.50
|
| Rate for Payer: WEA Trust Commercial |
$64.90
|
| Rate for Payer: Wellcare Medicare |
$69.63
|
| Rate for Payer: WPS Commercial |
$87.40
|
|
|
Therapeutic Injection sub or Intra 96372
|
Facility
|
IP
|
$118.00
|
|
|
Service Code
|
CPT 96372
|
| Hospital Charge Code |
3382926
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$57.82 |
| Max. Negotiated Rate |
$108.56 |
| Rate for Payer: Aetna Commercial |
$106.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$101.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$62.54
|
| Rate for Payer: Cash Price |
$35.40
|
| Rate for Payer: Cigna Commercial |
$108.56
|
| Rate for Payer: Health EOS Commercial |
$105.02
|
| Rate for Payer: HFN Commercial |
$108.56
|
| Rate for Payer: Multiplan Commercial |
$94.40
|
| Rate for Payer: NAPHCARE Commercial |
$70.80
|
| Rate for Payer: Preferred Network Access Commercial |
$108.56
|
| Rate for Payer: Quartz Beloit One Network |
$57.82
|
| Rate for Payer: Quartz Commercial |
$70.80
|
| Rate for Payer: WEA Trust Commercial |
$64.90
|
| Rate for Payer: WPS Commercial |
$87.40
|
|
