|
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 |
$3.44 |
| Max. Negotiated Rate |
$116.58 |
| Rate for Payer: Aetna Commercial |
$116.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$105.54
|
| Rate for Payer: Aetna Managed Medicare |
$15.33
|
| Rate for Payer: Anthem Medicare Advantage |
$15.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15.33
|
| Rate for Payer: Cash Price |
$35.40
|
| Rate for Payer: Cash Price |
$35.40
|
| Rate for Payer: Cigna Commercial |
$116.58
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15.33
|
| Rate for Payer: Health EOS Commercial |
$111.68
|
| Rate for Payer: HFN Commercial |
$116.58
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$49.93
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$49.93
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15.33
|
| Rate for Payer: Multiplan Commercial |
$98.18
|
| Rate for Payer: NAPHCARE Commercial |
$22.99
|
| Rate for Payer: Preferred Network Access Commercial |
$116.58
|
| Rate for Payer: Quartz Beloit One Network |
$54.00
|
| Rate for Payer: Quartz Commercial |
$69.95
|
| Rate for Payer: Quartz Medicare Advantage |
$15.33
|
| Rate for Payer: The Alliance Commercial |
$38.32
|
| Rate for Payer: United Healthcare Medicaid |
$3.44
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.33
|
| Rate for Payer: WEA Trust Commercial |
$67.50
|
| Rate for Payer: WPS Commercial |
$61.32
|
|
|
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 |
$60.13 |
| Max. Negotiated Rate |
$112.90 |
| Rate for Payer: Aetna Commercial |
$110.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$105.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$65.04
|
| Rate for Payer: Cash Price |
$35.40
|
| Rate for Payer: Cigna Commercial |
$112.90
|
| Rate for Payer: Health EOS Commercial |
$109.22
|
| Rate for Payer: HFN Commercial |
$112.90
|
| Rate for Payer: Multiplan Commercial |
$98.18
|
| Rate for Payer: Preferred Network Access Commercial |
$112.90
|
| Rate for Payer: Quartz Beloit One Network |
$60.13
|
| Rate for Payer: Quartz Commercial |
$73.63
|
| Rate for Payer: WEA Trust Commercial |
$67.50
|
| Rate for Payer: WPS Commercial |
$90.90
|
|
|
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 |
$58.91 |
| Max. Negotiated Rate |
$303.10 |
| Rate for Payer: Aetna Commercial |
$110.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$105.54
|
| Rate for Payer: Aetna Managed Medicare |
$75.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$79.77
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$61.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$58.91
|
| Rate for Payer: Anthem Medicare Advantage |
$75.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$65.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$75.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$75.77
|
| Rate for Payer: Cash Price |
$35.40
|
| Rate for Payer: Cash Price |
$35.40
|
| Rate for Payer: Cigna Commercial |
$112.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$75.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$68.68
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$75.77
|
| Rate for Payer: Health EOS Commercial |
$109.22
|
| Rate for Payer: HFN Commercial |
$112.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$281.88
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$75.77
|
| Rate for Payer: Independent Care Health Plan Medicare |
$75.77
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$75.77
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$75.77
|
| Rate for Payer: Multiplan Commercial |
$98.18
|
| Rate for Payer: NAPHCARE Commercial |
$113.66
|
| Rate for Payer: Preferred Network Access Commercial |
$112.90
|
| Rate for Payer: Quartz Beloit One Network |
$60.13
|
| Rate for Payer: Quartz Commercial |
$79.77
|
| Rate for Payer: Quartz Medicare Advantage |
$75.77
|
| Rate for Payer: The Alliance Commercial |
$303.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$75.77
|
| Rate for Payer: United Healthcare PPO |
$92.04
|
| Rate for Payer: WEA Trust Commercial |
$67.50
|
| Rate for Payer: Wellcare Medicare |
$75.77
|
| Rate for Payer: WPS Commercial |
$90.90
|
|
|
THERAPEUTIC NUCLEAR MEDICINE
|
Facility
|
OP
|
$277.78
|
|
|
Service Code
|
EAPG 00340
|
| Min. Negotiated Rate |
$267.10 |
| Max. Negotiated Rate |
$277.78 |
| Rate for Payer: Anthem Medicaid |
$267.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$267.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$267.10
|
| Rate for Payer: Dean Health Medicaid |
$267.10
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$267.10
|
| Rate for Payer: Managed Health Services Medicaid |
$277.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$267.10
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$267.10
|
| Rate for Payer: United Healthcare Medicaid |
$267.10
|
|
|
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 |
$35.36 |
| Max. Negotiated Rate |
$141.44 |
| Rate for Payer: Aetna Commercial |
$79.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$71.55
|
| Rate for Payer: Aetna Managed Medicare |
$35.36
|
| Rate for Payer: Anthem Medicare Advantage |
$35.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$35.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$35.36
|
| 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 |
$79.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$41.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$35.36
|
| Rate for Payer: Health EOS Commercial |
$75.71
|
| Rate for Payer: HFN Commercial |
$79.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$137.97
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$137.97
|
| Rate for Payer: Independent Care Health Plan Medicare |
$35.36
|
| Rate for Payer: Multiplan Commercial |
$66.56
|
| Rate for Payer: NAPHCARE Commercial |
$53.04
|
| Rate for Payer: Preferred Network Access Commercial |
$79.04
|
| Rate for Payer: Quartz Beloit One Network |
$36.61
|
| Rate for Payer: Quartz Commercial |
$47.42
|
| Rate for Payer: Quartz Medicare Advantage |
$35.36
|
| Rate for Payer: The Alliance Commercial |
$88.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$35.36
|
| Rate for Payer: WEA Trust Commercial |
$45.76
|
| Rate for Payer: WPS Commercial |
$141.44
|
|
|
Therapeutic Rad-Complete 7729026
|
Professional
|
Both
|
$927.00
|
|
|
Service Code
|
CPT 77290 26
|
| Hospital Charge Code |
5258626
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$82.17 |
| Max. Negotiated Rate |
$915.88 |
| Rate for Payer: Aetna Commercial |
$915.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$829.11
|
| Rate for Payer: Aetna Managed Medicare |
$82.17
|
| Rate for Payer: Anthem Medicare Advantage |
$82.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$82.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$82.17
|
| 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 |
$915.88
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$482.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$82.17
|
| Rate for Payer: Health EOS Commercial |
$877.31
|
| Rate for Payer: HFN Commercial |
$915.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$292.23
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$292.23
|
| Rate for Payer: Independent Care Health Plan Medicare |
$82.17
|
| Rate for Payer: Multiplan Commercial |
$771.26
|
| Rate for Payer: NAPHCARE Commercial |
$123.26
|
| Rate for Payer: Preferred Network Access Commercial |
$915.88
|
| Rate for Payer: Quartz Beloit One Network |
$424.20
|
| Rate for Payer: Quartz Commercial |
$549.53
|
| Rate for Payer: Quartz Medicare Advantage |
$82.17
|
| Rate for Payer: The Alliance Commercial |
$312.25
|
| Rate for Payer: United Healthcare Medicare Advantage |
$82.17
|
| Rate for Payer: WEA Trust Commercial |
$530.24
|
| Rate for Payer: WPS Commercial |
$410.85
|
|
|
Therapeutic Rad-Intermediate 7728526
|
Professional
|
Both
|
$926.00
|
|
|
Service Code
|
CPT 77285 26
|
| Hospital Charge Code |
5258625
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$56.16 |
| Max. Negotiated Rate |
$914.89 |
| Rate for Payer: Aetna Commercial |
$914.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$828.21
|
| Rate for Payer: Aetna Managed Medicare |
$56.16
|
| Rate for Payer: Anthem Medicare Advantage |
$56.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$56.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$56.16
|
| 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 |
$914.89
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$481.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$56.16
|
| Rate for Payer: Health EOS Commercial |
$876.37
|
| Rate for Payer: HFN Commercial |
$914.89
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$203.60
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$203.60
|
| Rate for Payer: Independent Care Health Plan Medicare |
$56.16
|
| Rate for Payer: Multiplan Commercial |
$770.43
|
| Rate for Payer: NAPHCARE Commercial |
$84.24
|
| Rate for Payer: Preferred Network Access Commercial |
$914.89
|
| Rate for Payer: Quartz Beloit One Network |
$423.74
|
| Rate for Payer: Quartz Commercial |
$548.93
|
| Rate for Payer: Quartz Medicare Advantage |
$56.16
|
| Rate for Payer: The Alliance Commercial |
$213.41
|
| Rate for Payer: United Healthcare Medicare Advantage |
$56.16
|
| Rate for Payer: WEA Trust Commercial |
$529.67
|
| Rate for Payer: WPS Commercial |
$280.80
|
|
|
Therapeutic Rad-Simple 7728026
|
Professional
|
Both
|
$391.00
|
|
|
Service Code
|
CPT 77280 26
|
| Hospital Charge Code |
5258624
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$37.25 |
| Max. Negotiated Rate |
$386.31 |
| Rate for Payer: Aetna Commercial |
$386.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$349.71
|
| Rate for Payer: Aetna Managed Medicare |
$37.25
|
| Rate for Payer: Anthem Medicare Advantage |
$37.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$37.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$37.25
|
| 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 |
$386.31
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$203.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$37.25
|
| Rate for Payer: Health EOS Commercial |
$370.04
|
| Rate for Payer: HFN Commercial |
$386.31
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$134.63
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$134.63
|
| Rate for Payer: Independent Care Health Plan Medicare |
$37.25
|
| Rate for Payer: Multiplan Commercial |
$325.31
|
| Rate for Payer: NAPHCARE Commercial |
$55.88
|
| Rate for Payer: Preferred Network Access Commercial |
$386.31
|
| Rate for Payer: Quartz Beloit One Network |
$178.92
|
| Rate for Payer: Quartz Commercial |
$231.78
|
| Rate for Payer: Quartz Medicare Advantage |
$37.25
|
| Rate for Payer: The Alliance Commercial |
$141.56
|
| Rate for Payer: United Healthcare Medicare Advantage |
$37.25
|
| Rate for Payer: WEA Trust Commercial |
$223.65
|
| Rate for Payer: WPS Commercial |
$186.26
|
|
|
THERAPLUS TA HAND SIZE:MED (L)
|
Facility
|
IP
|
$952.00
|
|
| Hospital Charge Code |
2971878
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$485.14 |
| Max. Negotiated Rate |
$910.87 |
| Rate for Payer: Aetna Commercial |
$891.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$851.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$524.74
|
| Rate for Payer: Cash Price |
$285.60
|
| Rate for Payer: Cigna Commercial |
$910.87
|
| Rate for Payer: Health EOS Commercial |
$881.17
|
| Rate for Payer: HFN Commercial |
$910.87
|
| Rate for Payer: Multiplan Commercial |
$792.06
|
| Rate for Payer: Preferred Network Access Commercial |
$910.87
|
| Rate for Payer: Quartz Beloit One Network |
$485.14
|
| Rate for Payer: Quartz Commercial |
$594.05
|
| Rate for Payer: WEA Trust Commercial |
$544.54
|
| Rate for Payer: WPS Commercial |
$733.33
|
|
|
THERAPLUS TA HAND SIZE:MED (L)
|
Facility
|
OP
|
$952.00
|
|
| Hospital Charge Code |
2971878
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$277.22 |
| Max. Negotiated Rate |
$910.87 |
| Rate for Payer: Aetna Commercial |
$891.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$851.47
|
| Rate for Payer: Aetna Managed Medicare |
$277.22
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$643.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$495.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$475.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$524.74
|
| Rate for Payer: Cash Price |
$285.60
|
| Rate for Payer: Cigna Commercial |
$910.87
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$554.06
|
| Rate for Payer: Health EOS Commercial |
$881.17
|
| Rate for Payer: HFN Commercial |
$910.87
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$742.56
|
| Rate for Payer: Multiplan Commercial |
$792.06
|
| Rate for Payer: NAPHCARE Commercial |
$594.05
|
| Rate for Payer: Preferred Network Access Commercial |
$910.87
|
| Rate for Payer: Quartz Beloit One Network |
$485.14
|
| Rate for Payer: Quartz Commercial |
$643.55
|
| Rate for Payer: Quartz Medicare Advantage |
$594.05
|
| Rate for Payer: The Alliance Commercial |
$495.04
|
| Rate for Payer: WEA Trust Commercial |
$544.54
|
| Rate for Payer: WPS Commercial |
$733.33
|
|
|
THERAPUTTY MEDIUM GREEN 5 LBS #5072-05
|
Facility
|
OP
|
$888.00
|
|
| Hospital Charge Code |
2971727
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$258.59 |
| Max. Negotiated Rate |
$849.64 |
| Rate for Payer: Aetna Commercial |
$831.17
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$794.23
|
| Rate for Payer: Aetna Managed Medicare |
$258.59
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$600.29
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$461.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$443.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$489.47
|
| Rate for Payer: Cash Price |
$266.40
|
| Rate for Payer: Cigna Commercial |
$849.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$516.82
|
| Rate for Payer: Health EOS Commercial |
$821.93
|
| Rate for Payer: HFN Commercial |
$849.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$692.64
|
| Rate for Payer: Multiplan Commercial |
$738.82
|
| Rate for Payer: NAPHCARE Commercial |
$554.11
|
| Rate for Payer: Preferred Network Access Commercial |
$849.64
|
| Rate for Payer: Quartz Beloit One Network |
$452.52
|
| Rate for Payer: Quartz Commercial |
$600.29
|
| Rate for Payer: Quartz Medicare Advantage |
$554.11
|
| Rate for Payer: The Alliance Commercial |
$461.76
|
| Rate for Payer: WEA Trust Commercial |
$507.94
|
| Rate for Payer: WPS Commercial |
$684.03
|
|
|
THERAPUTTY MEDIUM GREEN 5 LBS #5072-05
|
Facility
|
IP
|
$888.00
|
|
| Hospital Charge Code |
2971727
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$452.52 |
| Max. Negotiated Rate |
$849.64 |
| Rate for Payer: Aetna Commercial |
$831.17
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$794.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$489.47
|
| Rate for Payer: Cash Price |
$266.40
|
| Rate for Payer: Cigna Commercial |
$849.64
|
| Rate for Payer: Health EOS Commercial |
$821.93
|
| Rate for Payer: HFN Commercial |
$849.64
|
| Rate for Payer: Multiplan Commercial |
$738.82
|
| Rate for Payer: Preferred Network Access Commercial |
$849.64
|
| Rate for Payer: Quartz Beloit One Network |
$452.52
|
| Rate for Payer: Quartz Commercial |
$554.11
|
| Rate for Payer: WEA Trust Commercial |
$507.94
|
| Rate for Payer: WPS Commercial |
$684.03
|
|
|
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 |
$1,399.51 |
| Max. Negotiated Rate |
$4,598.38 |
| Rate for Payer: Aetna Commercial |
$4,498.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,298.49
|
| Rate for Payer: Aetna Managed Medicare |
$1,399.51
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,248.86
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,499.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,399.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,649.07
|
| Rate for Payer: Cash Price |
$1,441.80
|
| Rate for Payer: Cigna Commercial |
$4,598.38
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,797.09
|
| Rate for Payer: Health EOS Commercial |
$4,448.43
|
| Rate for Payer: HFN Commercial |
$4,598.38
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,748.68
|
| Rate for Payer: Multiplan Commercial |
$3,998.59
|
| Rate for Payer: NAPHCARE Commercial |
$2,998.94
|
| Rate for Payer: Preferred Network Access Commercial |
$4,598.38
|
| Rate for Payer: Quartz Beloit One Network |
$2,449.14
|
| Rate for Payer: Quartz Commercial |
$3,248.86
|
| Rate for Payer: Quartz Medicare Advantage |
$2,998.94
|
| Rate for Payer: The Alliance Commercial |
$2,499.12
|
| Rate for Payer: WEA Trust Commercial |
$2,749.03
|
| Rate for Payer: WPS Commercial |
$3,702.06
|
|
|
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 |
$2,449.14 |
| Max. Negotiated Rate |
$4,598.38 |
| Rate for Payer: Aetna Commercial |
$4,498.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,298.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,649.07
|
| Rate for Payer: Cash Price |
$1,441.80
|
| Rate for Payer: Cigna Commercial |
$4,598.38
|
| Rate for Payer: Health EOS Commercial |
$4,448.43
|
| Rate for Payer: HFN Commercial |
$4,598.38
|
| Rate for Payer: Multiplan Commercial |
$3,998.59
|
| Rate for Payer: Preferred Network Access Commercial |
$4,598.38
|
| Rate for Payer: Quartz Beloit One Network |
$2,449.14
|
| Rate for Payer: Quartz Commercial |
$2,998.94
|
| Rate for Payer: WEA Trust Commercial |
$2,749.03
|
| Rate for Payer: WPS Commercial |
$3,702.06
|
|
|
Therapy vest
|
Facility
|
IP
|
$134.00
|
|
|
Service Code
|
CPT 94667
|
| Hospital Charge Code |
2989709
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$68.29 |
| Max. Negotiated Rate |
$128.21 |
| Rate for Payer: Aetna Commercial |
$125.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$119.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$73.86
|
| Rate for Payer: Cash Price |
$40.20
|
| Rate for Payer: Cigna Commercial |
$128.21
|
| Rate for Payer: Health EOS Commercial |
$124.03
|
| Rate for Payer: HFN Commercial |
$128.21
|
| Rate for Payer: Multiplan Commercial |
$111.49
|
| Rate for Payer: Preferred Network Access Commercial |
$128.21
|
| Rate for Payer: Quartz Beloit One Network |
$68.29
|
| Rate for Payer: Quartz Commercial |
$83.62
|
| Rate for Payer: WEA Trust Commercial |
$76.65
|
| Rate for Payer: WPS Commercial |
$103.22
|
|
|
Therapy vest
|
Facility
|
OP
|
$134.00
|
|
|
Service Code
|
CPT 94667
|
| Hospital Charge Code |
2989709
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$66.89 |
| Max. Negotiated Rate |
$560.06 |
| Rate for Payer: Aetna Commercial |
$125.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$119.85
|
| Rate for Payer: Aetna Managed Medicare |
$140.02
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$90.58
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$69.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$66.89
|
| Rate for Payer: Anthem Medicare Advantage |
$140.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$73.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$140.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$140.02
|
| Rate for Payer: Cash Price |
$40.20
|
| Rate for Payer: Cash Price |
$40.20
|
| Rate for Payer: Cigna Commercial |
$128.21
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$140.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$77.99
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$140.02
|
| Rate for Payer: Health EOS Commercial |
$124.03
|
| Rate for Payer: HFN Commercial |
$128.21
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$520.86
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$140.02
|
| Rate for Payer: Independent Care Health Plan Medicare |
$140.02
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$140.02
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$140.02
|
| Rate for Payer: Multiplan Commercial |
$111.49
|
| Rate for Payer: NAPHCARE Commercial |
$210.02
|
| Rate for Payer: Preferred Network Access Commercial |
$128.21
|
| Rate for Payer: Quartz Beloit One Network |
$68.29
|
| Rate for Payer: Quartz Commercial |
$90.58
|
| Rate for Payer: Quartz Medicare Advantage |
$140.02
|
| Rate for Payer: The Alliance Commercial |
$560.06
|
| Rate for Payer: United Healthcare Medicare Advantage |
$140.02
|
| Rate for Payer: United Healthcare PPO |
$104.52
|
| Rate for Payer: WEA Trust Commercial |
$76.65
|
| Rate for Payer: Wellcare Medicare |
$140.02
|
| Rate for Payer: WPS Commercial |
$103.22
|
|
|
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 |
$26.93 |
| Max. Negotiated Rate |
$502.89 |
| Rate for Payer: Aetna Commercial |
$502.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$455.25
|
| 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 |
$502.89
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$26.93
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$317.62
|
| Rate for Payer: Health EOS Commercial |
$481.72
|
| Rate for Payer: HFN Commercial |
$502.89
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$195.27
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$195.27
|
| Rate for Payer: Multiplan Commercial |
$423.49
|
| Rate for Payer: Preferred Network Access Commercial |
$502.89
|
| Rate for Payer: Quartz Beloit One Network |
$232.92
|
| Rate for Payer: Quartz Commercial |
$301.74
|
| Rate for Payer: The Alliance Commercial |
$264.68
|
| Rate for Payer: United Healthcare Medicaid |
$26.93
|
| Rate for Payer: WEA Trust Commercial |
$291.15
|
| Rate for Payer: WPS Commercial |
$392.08
|
|
|
THERMASHELL CHARGE REFILL PACK
|
Facility
|
OP
|
$1,099.00
|
|
| Hospital Charge Code |
2972013
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$320.03 |
| Max. Negotiated Rate |
$1,051.52 |
| Rate for Payer: Aetna Commercial |
$1,028.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$982.95
|
| Rate for Payer: Aetna Managed Medicare |
$320.03
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$742.92
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$571.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$548.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$605.77
|
| Rate for Payer: Cash Price |
$329.70
|
| Rate for Payer: Cigna Commercial |
$1,051.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$639.62
|
| Rate for Payer: Health EOS Commercial |
$1,017.23
|
| Rate for Payer: HFN Commercial |
$1,051.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$857.22
|
| Rate for Payer: Multiplan Commercial |
$914.37
|
| Rate for Payer: NAPHCARE Commercial |
$685.78
|
| Rate for Payer: Preferred Network Access Commercial |
$1,051.52
|
| Rate for Payer: Quartz Beloit One Network |
$560.05
|
| Rate for Payer: Quartz Commercial |
$742.92
|
| Rate for Payer: Quartz Medicare Advantage |
$685.78
|
| Rate for Payer: The Alliance Commercial |
$571.48
|
| Rate for Payer: WEA Trust Commercial |
$628.63
|
| Rate for Payer: WPS Commercial |
$846.56
|
|
|
THERMASHELL CHARGE REFILL PACK
|
Facility
|
IP
|
$1,099.00
|
|
| Hospital Charge Code |
2972013
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$560.05 |
| Max. Negotiated Rate |
$1,051.52 |
| Rate for Payer: Aetna Commercial |
$1,028.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$982.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$605.77
|
| Rate for Payer: Cash Price |
$329.70
|
| Rate for Payer: Cigna Commercial |
$1,051.52
|
| Rate for Payer: Health EOS Commercial |
$1,017.23
|
| Rate for Payer: HFN Commercial |
$1,051.52
|
| Rate for Payer: Multiplan Commercial |
$914.37
|
| Rate for Payer: Preferred Network Access Commercial |
$1,051.52
|
| Rate for Payer: Quartz Beloit One Network |
$560.05
|
| Rate for Payer: Quartz Commercial |
$685.78
|
| Rate for Payer: WEA Trust Commercial |
$628.63
|
| Rate for Payer: WPS Commercial |
$846.56
|
|
|
THERMOMETER RECTAL & ESOPH 9FR
|
Facility
|
OP
|
$94.00
|
|
| Hospital Charge Code |
2964052
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$27.37 |
| Max. Negotiated Rate |
$89.94 |
| Rate for Payer: Aetna Commercial |
$87.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$84.07
|
| Rate for Payer: Aetna Managed Medicare |
$27.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$63.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$48.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$46.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$51.81
|
| Rate for Payer: Cash Price |
$28.20
|
| Rate for Payer: Cigna Commercial |
$89.94
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$54.71
|
| Rate for Payer: Health EOS Commercial |
$87.01
|
| Rate for Payer: HFN Commercial |
$89.94
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$73.32
|
| Rate for Payer: Multiplan Commercial |
$78.21
|
| Rate for Payer: NAPHCARE Commercial |
$58.66
|
| Rate for Payer: Preferred Network Access Commercial |
$89.94
|
| Rate for Payer: Quartz Beloit One Network |
$47.90
|
| Rate for Payer: Quartz Commercial |
$63.54
|
| Rate for Payer: Quartz Medicare Advantage |
$58.66
|
| Rate for Payer: The Alliance Commercial |
$48.88
|
| Rate for Payer: WEA Trust Commercial |
$53.77
|
| Rate for Payer: WPS Commercial |
$72.41
|
|
|
THERMOMETER RECTAL & ESOPH 9FR
|
Facility
|
IP
|
$94.00
|
|
| Hospital Charge Code |
2964052
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$47.90 |
| Max. Negotiated Rate |
$89.94 |
| Rate for Payer: Aetna Commercial |
$87.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$84.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$51.81
|
| Rate for Payer: Cash Price |
$28.20
|
| Rate for Payer: Cigna Commercial |
$89.94
|
| Rate for Payer: Health EOS Commercial |
$87.01
|
| Rate for Payer: HFN Commercial |
$89.94
|
| Rate for Payer: Multiplan Commercial |
$78.21
|
| Rate for Payer: Preferred Network Access Commercial |
$89.94
|
| Rate for Payer: Quartz Beloit One Network |
$47.90
|
| Rate for Payer: Quartz Commercial |
$58.66
|
| Rate for Payer: WEA Trust Commercial |
$53.77
|
| Rate for Payer: WPS Commercial |
$72.41
|
|
|
THERMOSET #414240403
|
Facility
|
OP
|
$344.00
|
|
| Hospital Charge Code |
2963892
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$100.17 |
| Max. Negotiated Rate |
$329.14 |
| Rate for Payer: Aetna Commercial |
$321.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$307.67
|
| Rate for Payer: Aetna Managed Medicare |
$100.17
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$232.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$178.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$171.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$189.61
|
| Rate for Payer: Cash Price |
$103.20
|
| Rate for Payer: Cigna Commercial |
$329.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$200.21
|
| Rate for Payer: Health EOS Commercial |
$318.41
|
| Rate for Payer: HFN Commercial |
$329.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$268.32
|
| Rate for Payer: Multiplan Commercial |
$286.21
|
| Rate for Payer: NAPHCARE Commercial |
$214.66
|
| Rate for Payer: Preferred Network Access Commercial |
$329.14
|
| Rate for Payer: Quartz Beloit One Network |
$175.30
|
| Rate for Payer: Quartz Commercial |
$232.54
|
| Rate for Payer: Quartz Medicare Advantage |
$214.66
|
| Rate for Payer: The Alliance Commercial |
$178.88
|
| Rate for Payer: WEA Trust Commercial |
$196.77
|
| Rate for Payer: WPS Commercial |
$264.98
|
|
|
THERMOSET #414240403
|
Facility
|
IP
|
$344.00
|
|
| Hospital Charge Code |
2963892
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$175.30 |
| Max. Negotiated Rate |
$329.14 |
| Rate for Payer: Aetna Commercial |
$321.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$307.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$189.61
|
| Rate for Payer: Cash Price |
$103.20
|
| Rate for Payer: Cigna Commercial |
$329.14
|
| Rate for Payer: Health EOS Commercial |
$318.41
|
| Rate for Payer: HFN Commercial |
$329.14
|
| Rate for Payer: Multiplan Commercial |
$286.21
|
| Rate for Payer: Preferred Network Access Commercial |
$329.14
|
| Rate for Payer: Quartz Beloit One Network |
$175.30
|
| Rate for Payer: Quartz Commercial |
$214.66
|
| Rate for Payer: WEA Trust Commercial |
$196.77
|
| Rate for Payer: WPS Commercial |
$264.98
|
|
|
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 |
$76.16 |
| Max. Negotiated Rate |
$1,017.64 |
| Rate for Payer: Aetna Commercial |
$1,017.64
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$921.23
|
| Rate for Payer: Aetna Managed Medicare |
$76.16
|
| Rate for Payer: Anthem Medicare Advantage |
$76.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$76.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$76.16
|
| 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 |
$1,017.64
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$90.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$76.16
|
| Rate for Payer: Health EOS Commercial |
$974.79
|
| Rate for Payer: HFN Commercial |
$1,017.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$293.74
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$293.74
|
| Rate for Payer: Independent Care Health Plan Medicare |
$76.16
|
| Rate for Payer: Multiplan Commercial |
$856.96
|
| Rate for Payer: NAPHCARE Commercial |
$114.24
|
| Rate for Payer: Preferred Network Access Commercial |
$1,017.64
|
| Rate for Payer: Quartz Beloit One Network |
$471.33
|
| Rate for Payer: Quartz Commercial |
$610.58
|
| Rate for Payer: Quartz Medicare Advantage |
$76.16
|
| Rate for Payer: The Alliance Commercial |
$323.68
|
| Rate for Payer: United Healthcare Medicaid |
$90.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$76.16
|
| Rate for Payer: WEA Trust Commercial |
$589.16
|
| Rate for Payer: WPS Commercial |
$342.72
|
|
|
Thiamine hcl 100 MG J3411
|
Professional
|
Both
|
$7.00
|
|
|
Service Code
|
HCPCS J3411
|
| Hospital Charge Code |
3407537
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.88 |
| Max. Negotiated Rate |
$6.92 |
| Rate for Payer: Aetna Commercial |
$6.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.26
|
| Rate for Payer: Aetna Managed Medicare |
$1.88
|
| Rate for Payer: Anthem Medicare Advantage |
$1.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1.88
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2.35
|
| Rate for Payer: Health EOS Commercial |
$6.62
|
| Rate for Payer: HFN Commercial |
$6.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4.52
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$4.52
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1.88
|
| Rate for Payer: Multiplan Commercial |
$5.82
|
| Rate for Payer: NAPHCARE Commercial |
$2.82
|
| Rate for Payer: Preferred Network Access Commercial |
$6.92
|
| Rate for Payer: Quartz Beloit One Network |
$3.20
|
| Rate for Payer: Quartz Commercial |
$4.15
|
| Rate for Payer: Quartz Medicare Advantage |
$1.88
|
| Rate for Payer: The Alliance Commercial |
$5.18
|
| Rate for Payer: United Healthcare Medicaid |
$1.88
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1.88
|
| Rate for Payer: WEA Trust Commercial |
$4.00
|
| Rate for Payer: WPS Commercial |
$5.88
|
|
