|
Therapeutic Injection sub or Intra 96372
|
Facility
|
OP
|
$118.00
|
|
|
Service Code
|
CPT 96372
|
| Hospital Charge Code |
3382926
|
|
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
|
Professional
|
Both
|
$118.00
|
|
|
Service Code
|
CPT 96372
|
| Hospital Charge Code |
3382926
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$3.31 |
| Max. Negotiated Rate |
$112.10 |
| Rate for Payer: Aetna Commercial |
$112.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$101.48
|
| Rate for Payer: Cash Price |
$35.40
|
| Rate for Payer: Cash Price |
$35.40
|
| Rate for Payer: Cigna Commercial |
$112.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3.31
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$70.80
|
| Rate for Payer: Health EOS Commercial |
$107.38
|
| Rate for Payer: HFN Commercial |
$112.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$48.01
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$48.01
|
| Rate for Payer: Multiplan Commercial |
$94.40
|
| Rate for Payer: Preferred Network Access Commercial |
$112.10
|
| Rate for Payer: Quartz Beloit One Network |
$51.92
|
| Rate for Payer: Quartz Commercial |
$67.26
|
| Rate for Payer: The Alliance Commercial |
$59.00
|
| Rate for Payer: United Healthcare Medicaid |
$3.31
|
| Rate for Payer: WEA Trust Commercial |
$64.90
|
| Rate for Payer: WPS Commercial |
$87.40
|
|
|
therapeutic Inj Sub or Intra 96372
|
Facility
|
IP
|
$118.00
|
|
|
Service Code
|
CPT 96372
|
| Hospital Charge Code |
3157541
|
|
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 Sub or Intra 96372
|
Facility
|
OP
|
$118.00
|
|
|
Service Code
|
CPT 96372
|
| Hospital Charge Code |
3157541
|
|
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 Procedures; Low Vision Evaluation, 15 minutes
|
Professional
|
Both
|
$80.00
|
|
|
Service Code
|
CPT 97530
|
| Hospital Charge Code |
1188938
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$35.20 |
| Max. Negotiated Rate |
$132.66 |
| Rate for Payer: Aetna Commercial |
$76.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$68.80
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cigna Commercial |
$76.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$40.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$48.00
|
| Rate for Payer: Health EOS Commercial |
$72.80
|
| Rate for Payer: HFN Commercial |
$76.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$132.66
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$132.66
|
| Rate for Payer: Multiplan Commercial |
$64.00
|
| Rate for Payer: Preferred Network Access Commercial |
$76.00
|
| Rate for Payer: Quartz Beloit One Network |
$35.20
|
| Rate for Payer: Quartz Commercial |
$45.60
|
| Rate for Payer: The Alliance Commercial |
$40.00
|
| Rate for Payer: WEA Trust Commercial |
$44.00
|
| Rate for Payer: WPS Commercial |
$59.26
|
|
|
Therapeutic Rad-Complete 7729026
|
Professional
|
Both
|
$927.00
|
|
|
Service Code
|
CPT 77290 26
|
| Hospital Charge Code |
5258626
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$280.99 |
| Max. Negotiated Rate |
$880.65 |
| Rate for Payer: Aetna Commercial |
$880.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$797.22
|
| Rate for Payer: Cash Price |
$278.10
|
| Rate for Payer: Cash Price |
$278.10
|
| Rate for Payer: Cash Price |
$278.10
|
| Rate for Payer: Cigna Commercial |
$880.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$463.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$556.20
|
| Rate for Payer: Health EOS Commercial |
$843.57
|
| Rate for Payer: HFN Commercial |
$880.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$280.99
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$280.99
|
| Rate for Payer: Multiplan Commercial |
$741.60
|
| Rate for Payer: Preferred Network Access Commercial |
$880.65
|
| Rate for Payer: Quartz Beloit One Network |
$407.88
|
| Rate for Payer: Quartz Commercial |
$528.39
|
| Rate for Payer: The Alliance Commercial |
$463.50
|
| Rate for Payer: WEA Trust Commercial |
$509.85
|
| Rate for Payer: WPS Commercial |
$686.63
|
|
|
Therapeutic Rad-Intermediate 7728526
|
Professional
|
Both
|
$926.00
|
|
|
Service Code
|
CPT 77285 26
|
| Hospital Charge Code |
5258625
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$195.77 |
| Max. Negotiated Rate |
$879.70 |
| Rate for Payer: Aetna Commercial |
$879.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$796.36
|
| Rate for Payer: Cash Price |
$277.80
|
| Rate for Payer: Cash Price |
$277.80
|
| Rate for Payer: Cash Price |
$277.80
|
| Rate for Payer: Cigna Commercial |
$879.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$463.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$555.60
|
| Rate for Payer: Health EOS Commercial |
$842.66
|
| Rate for Payer: HFN Commercial |
$879.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$195.77
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$195.77
|
| Rate for Payer: Multiplan Commercial |
$740.80
|
| Rate for Payer: Preferred Network Access Commercial |
$879.70
|
| Rate for Payer: Quartz Beloit One Network |
$407.44
|
| Rate for Payer: Quartz Commercial |
$527.82
|
| Rate for Payer: The Alliance Commercial |
$463.00
|
| Rate for Payer: WEA Trust Commercial |
$509.30
|
| Rate for Payer: WPS Commercial |
$685.89
|
|
|
Therapeutic Rad-Simple 7728026
|
Professional
|
Both
|
$391.00
|
|
|
Service Code
|
CPT 77280 26
|
| Hospital Charge Code |
5258624
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$129.45 |
| Max. Negotiated Rate |
$371.45 |
| Rate for Payer: Aetna Commercial |
$371.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$336.26
|
| Rate for Payer: Cash Price |
$117.30
|
| Rate for Payer: Cash Price |
$117.30
|
| Rate for Payer: Cash Price |
$117.30
|
| Rate for Payer: Cigna Commercial |
$371.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$195.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$234.60
|
| Rate for Payer: Health EOS Commercial |
$355.81
|
| Rate for Payer: HFN Commercial |
$371.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$129.45
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$129.45
|
| Rate for Payer: Multiplan Commercial |
$312.80
|
| Rate for Payer: Preferred Network Access Commercial |
$371.45
|
| Rate for Payer: Quartz Beloit One Network |
$172.04
|
| Rate for Payer: Quartz Commercial |
$222.87
|
| Rate for Payer: The Alliance Commercial |
$195.50
|
| Rate for Payer: WEA Trust Commercial |
$215.05
|
| Rate for Payer: WPS Commercial |
$289.61
|
|
|
THERAPLUS TA HAND SIZE:MED (L)
|
Facility
|
OP
|
$952.00
|
|
| Hospital Charge Code |
2971878
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$266.56 |
| Max. Negotiated Rate |
$3,808.00 |
| Rate for Payer: Aetna Commercial |
$856.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$818.72
|
| Rate for Payer: Aetna Managed Medicare |
$266.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$618.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$476.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$456.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$504.56
|
| Rate for Payer: Cash Price |
$285.60
|
| Rate for Payer: Cigna Commercial |
$875.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$532.74
|
| Rate for Payer: Health EOS Commercial |
$847.28
|
| Rate for Payer: HFN Commercial |
$875.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$714.00
|
| Rate for Payer: Multiplan Commercial |
$761.60
|
| Rate for Payer: NAPHCARE Commercial |
$571.20
|
| Rate for Payer: Preferred Network Access Commercial |
$875.84
|
| Rate for Payer: Quartz Beloit One Network |
$466.48
|
| Rate for Payer: Quartz Commercial |
$618.80
|
| Rate for Payer: Quartz Medicare Advantage |
$571.20
|
| Rate for Payer: The Alliance Commercial |
$3,808.00
|
| Rate for Payer: WEA Trust Commercial |
$523.60
|
| Rate for Payer: WPS Commercial |
$705.15
|
|
|
THERAPLUS TA HAND SIZE:MED (L)
|
Facility
|
IP
|
$952.00
|
|
| Hospital Charge Code |
2971878
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$466.48 |
| Max. Negotiated Rate |
$875.84 |
| Rate for Payer: Aetna Commercial |
$856.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$818.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$504.56
|
| Rate for Payer: Cash Price |
$285.60
|
| Rate for Payer: Cigna Commercial |
$875.84
|
| Rate for Payer: Health EOS Commercial |
$847.28
|
| Rate for Payer: HFN Commercial |
$875.84
|
| Rate for Payer: Multiplan Commercial |
$761.60
|
| Rate for Payer: NAPHCARE Commercial |
$571.20
|
| Rate for Payer: Preferred Network Access Commercial |
$875.84
|
| Rate for Payer: Quartz Beloit One Network |
$466.48
|
| Rate for Payer: Quartz Commercial |
$571.20
|
| Rate for Payer: WEA Trust Commercial |
$523.60
|
| Rate for Payer: WPS Commercial |
$705.15
|
|
|
THERAPUTTY MEDIUM GREEN 5 LBS #5072-05
|
Facility
|
IP
|
$888.00
|
|
| Hospital Charge Code |
2971727
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$435.12 |
| Max. Negotiated Rate |
$816.96 |
| Rate for Payer: Aetna Commercial |
$799.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$763.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$470.64
|
| Rate for Payer: Cash Price |
$266.40
|
| Rate for Payer: Cigna Commercial |
$816.96
|
| Rate for Payer: Health EOS Commercial |
$790.32
|
| Rate for Payer: HFN Commercial |
$816.96
|
| Rate for Payer: Multiplan Commercial |
$710.40
|
| Rate for Payer: NAPHCARE Commercial |
$532.80
|
| Rate for Payer: Preferred Network Access Commercial |
$816.96
|
| Rate for Payer: Quartz Beloit One Network |
$435.12
|
| Rate for Payer: Quartz Commercial |
$532.80
|
| Rate for Payer: WEA Trust Commercial |
$488.40
|
| Rate for Payer: WPS Commercial |
$657.74
|
|
|
THERAPUTTY MEDIUM GREEN 5 LBS #5072-05
|
Facility
|
OP
|
$888.00
|
|
| Hospital Charge Code |
2971727
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$248.64 |
| Max. Negotiated Rate |
$3,552.00 |
| Rate for Payer: Aetna Commercial |
$799.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$763.68
|
| Rate for Payer: Aetna Managed Medicare |
$248.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$577.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$444.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$426.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$470.64
|
| Rate for Payer: Cash Price |
$266.40
|
| Rate for Payer: Cigna Commercial |
$816.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$496.92
|
| Rate for Payer: Health EOS Commercial |
$790.32
|
| Rate for Payer: HFN Commercial |
$816.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$666.00
|
| Rate for Payer: Multiplan Commercial |
$710.40
|
| Rate for Payer: NAPHCARE Commercial |
$532.80
|
| Rate for Payer: Preferred Network Access Commercial |
$816.96
|
| Rate for Payer: Quartz Beloit One Network |
$435.12
|
| Rate for Payer: Quartz Commercial |
$577.20
|
| Rate for Payer: Quartz Medicare Advantage |
$532.80
|
| Rate for Payer: The Alliance Commercial |
$3,552.00
|
| Rate for Payer: WEA Trust Commercial |
$488.40
|
| Rate for Payer: WPS Commercial |
$657.74
|
|
|
THERAPY SYSTEM V.A.C.VIA WOUND VAC VIAKIT077D01/US
|
Facility
|
IP
|
$4,806.00
|
|
| Hospital Charge Code |
5415563
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,354.94 |
| Max. Negotiated Rate |
$4,421.52 |
| Rate for Payer: Aetna Commercial |
$4,325.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,133.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,547.18
|
| Rate for Payer: Cash Price |
$1,441.80
|
| Rate for Payer: Cigna Commercial |
$4,421.52
|
| Rate for Payer: Health EOS Commercial |
$4,277.34
|
| Rate for Payer: HFN Commercial |
$4,421.52
|
| Rate for Payer: Multiplan Commercial |
$3,844.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,883.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,421.52
|
| Rate for Payer: Quartz Beloit One Network |
$2,354.94
|
| Rate for Payer: Quartz Commercial |
$2,883.60
|
| Rate for Payer: WEA Trust Commercial |
$2,643.30
|
| Rate for Payer: WPS Commercial |
$3,559.80
|
|
|
THERAPY SYSTEM V.A.C.VIA WOUND VAC VIAKIT077D01/US
|
Facility
|
OP
|
$4,806.00
|
|
| Hospital Charge Code |
5415563
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,345.68 |
| Max. Negotiated Rate |
$19,224.00 |
| Rate for Payer: Aetna Commercial |
$4,325.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,133.16
|
| Rate for Payer: Aetna Managed Medicare |
$1,345.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,123.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,403.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,306.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,547.18
|
| Rate for Payer: Cash Price |
$1,441.80
|
| Rate for Payer: Cigna Commercial |
$4,421.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,689.44
|
| Rate for Payer: Health EOS Commercial |
$4,277.34
|
| Rate for Payer: HFN Commercial |
$4,421.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,604.50
|
| Rate for Payer: Multiplan Commercial |
$3,844.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,883.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,421.52
|
| Rate for Payer: Quartz Beloit One Network |
$2,354.94
|
| Rate for Payer: Quartz Commercial |
$3,123.90
|
| Rate for Payer: Quartz Medicare Advantage |
$2,883.60
|
| Rate for Payer: The Alliance Commercial |
$19,224.00
|
| Rate for Payer: WEA Trust Commercial |
$2,643.30
|
| Rate for Payer: WPS Commercial |
$3,559.80
|
|
|
Therapy vest
|
Facility
|
OP
|
$134.00
|
|
|
Service Code
|
CPT 94667
|
| Hospital Charge Code |
2989709
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$64.32 |
| Max. Negotiated Rate |
$505.04 |
| Rate for Payer: Aetna Commercial |
$120.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$115.24
|
| Rate for Payer: Aetna Managed Medicare |
$126.26
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$87.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$67.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$64.32
|
| Rate for Payer: Anthem Medicare Advantage |
$126.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$71.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$126.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$126.26
|
| Rate for Payer: Cash Price |
$40.20
|
| Rate for Payer: Cash Price |
$40.20
|
| Rate for Payer: Cigna Commercial |
$123.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$126.26
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$74.99
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$126.26
|
| Rate for Payer: Health EOS Commercial |
$119.26
|
| Rate for Payer: HFN Commercial |
$123.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$469.69
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$126.26
|
| Rate for Payer: Independent Care Health Plan Medicare |
$126.26
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$126.26
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$126.26
|
| Rate for Payer: Multiplan Commercial |
$107.20
|
| Rate for Payer: NAPHCARE Commercial |
$189.39
|
| Rate for Payer: Preferred Network Access Commercial |
$123.28
|
| Rate for Payer: Quartz Beloit One Network |
$65.66
|
| Rate for Payer: Quartz Commercial |
$87.10
|
| Rate for Payer: Quartz Medicare Advantage |
$126.26
|
| Rate for Payer: The Alliance Commercial |
$505.04
|
| Rate for Payer: United Healthcare Medicare Advantage |
$126.26
|
| Rate for Payer: United Healthcare PPO |
$100.50
|
| Rate for Payer: WEA Trust Commercial |
$73.70
|
| Rate for Payer: Wellcare Medicare |
$126.26
|
| Rate for Payer: WPS Commercial |
$99.25
|
|
|
Therapy vest
|
Facility
|
IP
|
$134.00
|
|
|
Service Code
|
CPT 94667
|
| Hospital Charge Code |
2989709
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$65.66 |
| Max. Negotiated Rate |
$123.28 |
| Rate for Payer: Aetna Commercial |
$120.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$115.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$71.02
|
| Rate for Payer: Cash Price |
$40.20
|
| Rate for Payer: Cigna Commercial |
$123.28
|
| Rate for Payer: Health EOS Commercial |
$119.26
|
| Rate for Payer: HFN Commercial |
$123.28
|
| Rate for Payer: Multiplan Commercial |
$107.20
|
| Rate for Payer: NAPHCARE Commercial |
$80.40
|
| Rate for Payer: Preferred Network Access Commercial |
$123.28
|
| Rate for Payer: Quartz Beloit One Network |
$65.66
|
| Rate for Payer: Quartz Commercial |
$80.40
|
| Rate for Payer: WEA Trust Commercial |
$73.70
|
| Rate for Payer: WPS Commercial |
$99.25
|
|
|
Ther Injection, Carp Tunnel 2052650
|
Professional
|
Both
|
$509.00
|
|
|
Service Code
|
CPT 20526 50
|
| Hospital Charge Code |
3190198
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$25.89 |
| Max. Negotiated Rate |
$483.55 |
| Rate for Payer: Aetna Commercial |
$483.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$437.74
|
| Rate for Payer: Cash Price |
$152.70
|
| Rate for Payer: Cash Price |
$152.70
|
| Rate for Payer: Cash Price |
$152.70
|
| Rate for Payer: Cigna Commercial |
$483.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$25.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$305.40
|
| Rate for Payer: Health EOS Commercial |
$463.19
|
| Rate for Payer: HFN Commercial |
$483.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$187.76
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$187.76
|
| Rate for Payer: Multiplan Commercial |
$407.20
|
| Rate for Payer: Preferred Network Access Commercial |
$483.55
|
| Rate for Payer: Quartz Beloit One Network |
$223.96
|
| Rate for Payer: Quartz Commercial |
$290.13
|
| Rate for Payer: The Alliance Commercial |
$254.50
|
| Rate for Payer: United Healthcare Medicaid |
$25.89
|
| Rate for Payer: WEA Trust Commercial |
$279.95
|
| Rate for Payer: WPS Commercial |
$377.02
|
|
|
THERMASHELL CHARGE REFILL PACK
|
Facility
|
OP
|
$1,099.00
|
|
| Hospital Charge Code |
2972013
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$307.72 |
| Max. Negotiated Rate |
$4,396.00 |
| Rate for Payer: Aetna Commercial |
$989.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$945.14
|
| Rate for Payer: Aetna Managed Medicare |
$307.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$714.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$549.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$527.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$582.47
|
| Rate for Payer: Cash Price |
$329.70
|
| Rate for Payer: Cigna Commercial |
$1,011.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$615.00
|
| Rate for Payer: Health EOS Commercial |
$978.11
|
| Rate for Payer: HFN Commercial |
$1,011.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$824.25
|
| Rate for Payer: Multiplan Commercial |
$879.20
|
| Rate for Payer: NAPHCARE Commercial |
$659.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,011.08
|
| Rate for Payer: Quartz Beloit One Network |
$538.51
|
| Rate for Payer: Quartz Commercial |
$714.35
|
| Rate for Payer: Quartz Medicare Advantage |
$659.40
|
| Rate for Payer: The Alliance Commercial |
$4,396.00
|
| Rate for Payer: WEA Trust Commercial |
$604.45
|
| Rate for Payer: WPS Commercial |
$814.03
|
|
|
THERMASHELL CHARGE REFILL PACK
|
Facility
|
IP
|
$1,099.00
|
|
| Hospital Charge Code |
2972013
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$538.51 |
| Max. Negotiated Rate |
$1,011.08 |
| Rate for Payer: Aetna Commercial |
$989.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$945.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$582.47
|
| Rate for Payer: Cash Price |
$329.70
|
| Rate for Payer: Cigna Commercial |
$1,011.08
|
| Rate for Payer: Health EOS Commercial |
$978.11
|
| Rate for Payer: HFN Commercial |
$1,011.08
|
| Rate for Payer: Multiplan Commercial |
$879.20
|
| Rate for Payer: NAPHCARE Commercial |
$659.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,011.08
|
| Rate for Payer: Quartz Beloit One Network |
$538.51
|
| Rate for Payer: Quartz Commercial |
$659.40
|
| Rate for Payer: WEA Trust Commercial |
$604.45
|
| Rate for Payer: WPS Commercial |
$814.03
|
|
|
THERMOMETER RECTAL & ESOPH 9FR
|
Facility
|
IP
|
$94.00
|
|
| Hospital Charge Code |
2964052
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$46.06 |
| Max. Negotiated Rate |
$86.48 |
| Rate for Payer: Aetna Commercial |
$84.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$80.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$49.82
|
| Rate for Payer: Cash Price |
$28.20
|
| Rate for Payer: Cigna Commercial |
$86.48
|
| Rate for Payer: Health EOS Commercial |
$83.66
|
| Rate for Payer: HFN Commercial |
$86.48
|
| Rate for Payer: Multiplan Commercial |
$75.20
|
| Rate for Payer: NAPHCARE Commercial |
$56.40
|
| Rate for Payer: Preferred Network Access Commercial |
$86.48
|
| Rate for Payer: Quartz Beloit One Network |
$46.06
|
| Rate for Payer: Quartz Commercial |
$56.40
|
| Rate for Payer: WEA Trust Commercial |
$51.70
|
| Rate for Payer: WPS Commercial |
$69.63
|
|
|
THERMOMETER RECTAL & ESOPH 9FR
|
Facility
|
OP
|
$94.00
|
|
| Hospital Charge Code |
2964052
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$26.32 |
| Max. Negotiated Rate |
$376.00 |
| Rate for Payer: Aetna Commercial |
$84.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$80.84
|
| Rate for Payer: Aetna Managed Medicare |
$26.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$61.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$47.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$45.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$49.82
|
| Rate for Payer: Cash Price |
$28.20
|
| Rate for Payer: Cigna Commercial |
$86.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$52.60
|
| Rate for Payer: Health EOS Commercial |
$83.66
|
| Rate for Payer: HFN Commercial |
$86.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$70.50
|
| Rate for Payer: Multiplan Commercial |
$75.20
|
| Rate for Payer: NAPHCARE Commercial |
$56.40
|
| Rate for Payer: Preferred Network Access Commercial |
$86.48
|
| Rate for Payer: Quartz Beloit One Network |
$46.06
|
| Rate for Payer: Quartz Commercial |
$61.10
|
| Rate for Payer: Quartz Medicare Advantage |
$56.40
|
| Rate for Payer: The Alliance Commercial |
$376.00
|
| Rate for Payer: WEA Trust Commercial |
$51.70
|
| Rate for Payer: WPS Commercial |
$69.63
|
|
|
THERMOSET #414240403
|
Facility
|
IP
|
$344.00
|
|
| Hospital Charge Code |
2963892
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$168.56 |
| Max. Negotiated Rate |
$316.48 |
| Rate for Payer: Aetna Commercial |
$309.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$295.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$182.32
|
| Rate for Payer: Cash Price |
$103.20
|
| Rate for Payer: Cigna Commercial |
$316.48
|
| Rate for Payer: Health EOS Commercial |
$306.16
|
| Rate for Payer: HFN Commercial |
$316.48
|
| Rate for Payer: Multiplan Commercial |
$275.20
|
| Rate for Payer: NAPHCARE Commercial |
$206.40
|
| Rate for Payer: Preferred Network Access Commercial |
$316.48
|
| Rate for Payer: Quartz Beloit One Network |
$168.56
|
| Rate for Payer: Quartz Commercial |
$206.40
|
| Rate for Payer: WEA Trust Commercial |
$189.20
|
| Rate for Payer: WPS Commercial |
$254.80
|
|
|
THERMOSET #414240403
|
Facility
|
OP
|
$344.00
|
|
| Hospital Charge Code |
2963892
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$96.32 |
| Max. Negotiated Rate |
$1,376.00 |
| Rate for Payer: Aetna Commercial |
$309.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$295.84
|
| Rate for Payer: Aetna Managed Medicare |
$96.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$223.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$172.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$165.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$182.32
|
| Rate for Payer: Cash Price |
$103.20
|
| Rate for Payer: Cigna Commercial |
$316.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$192.50
|
| Rate for Payer: Health EOS Commercial |
$306.16
|
| Rate for Payer: HFN Commercial |
$316.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$258.00
|
| Rate for Payer: Multiplan Commercial |
$275.20
|
| Rate for Payer: NAPHCARE Commercial |
$206.40
|
| Rate for Payer: Preferred Network Access Commercial |
$316.48
|
| Rate for Payer: Quartz Beloit One Network |
$168.56
|
| Rate for Payer: Quartz Commercial |
$223.60
|
| Rate for Payer: Quartz Medicare Advantage |
$206.40
|
| Rate for Payer: The Alliance Commercial |
$1,376.00
|
| Rate for Payer: WEA Trust Commercial |
$189.20
|
| Rate for Payer: WPS Commercial |
$254.80
|
|
|
Ther spi pnxr drg csf 62272
|
Professional
|
Both
|
$1,030.00
|
|
|
Service Code
|
CPT 62272
|
| Hospital Charge Code |
6178533
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$87.46 |
| Max. Negotiated Rate |
$978.50 |
| Rate for Payer: Aetna Commercial |
$978.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$885.80
|
| Rate for Payer: Cash Price |
$309.00
|
| Rate for Payer: Cash Price |
$309.00
|
| Rate for Payer: Cash Price |
$309.00
|
| Rate for Payer: Cigna Commercial |
$978.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$87.46
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$618.00
|
| Rate for Payer: Health EOS Commercial |
$937.30
|
| Rate for Payer: HFN Commercial |
$978.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$282.44
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$282.44
|
| Rate for Payer: Multiplan Commercial |
$824.00
|
| Rate for Payer: Preferred Network Access Commercial |
$978.50
|
| Rate for Payer: Quartz Beloit One Network |
$453.20
|
| Rate for Payer: Quartz Commercial |
$587.10
|
| Rate for Payer: The Alliance Commercial |
$515.00
|
| Rate for Payer: United Healthcare Medicaid |
$87.46
|
| Rate for Payer: WEA Trust Commercial |
$566.50
|
| Rate for Payer: WPS Commercial |
$762.92
|
|
|
Thiamine hcl 100 MG J3411
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
HCPCS J3411
|
| Hospital Charge Code |
3407537
|
|
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
|
|
