|
Theophylline Level
|
Facility
|
IP
|
$350.00
|
|
|
Service Code
|
CPT 80198
|
| Hospital Charge Code |
633839
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$178.36 |
| Max. Negotiated Rate |
$334.88 |
| Rate for Payer: Aetna Commercial |
$327.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$313.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$192.92
|
| Rate for Payer: Cash Price |
$105.00
|
| Rate for Payer: Cigna Commercial |
$334.88
|
| Rate for Payer: Health EOS Commercial |
$323.96
|
| Rate for Payer: HFN Commercial |
$334.88
|
| Rate for Payer: Multiplan Commercial |
$291.20
|
| Rate for Payer: Preferred Network Access Commercial |
$334.88
|
| Rate for Payer: Quartz Beloit One Network |
$178.36
|
| Rate for Payer: Quartz Commercial |
$218.40
|
| Rate for Payer: WEA Trust Commercial |
$200.20
|
| Rate for Payer: WPS Commercial |
$269.61
|
|
|
Theophylline Level
|
Facility
|
OP
|
$350.00
|
|
|
Service Code
|
CPT 80198
|
| Hospital Charge Code |
633839
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.71 |
| Max. Negotiated Rate |
$334.88 |
| Rate for Payer: Dean Health DHI/DHP/ASO |
$203.70
|
| Rate for Payer: Aetna Commercial |
$327.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$313.04
|
| Rate for Payer: Aetna Managed Medicare |
$14.71
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$55.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$25.73
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$24.41
|
| Rate for Payer: Anthem Medicare Advantage |
$14.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$192.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$14.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$14.71
|
| Rate for Payer: Cash Price |
$105.00
|
| Rate for Payer: Cash Price |
$105.00
|
| Rate for Payer: Cigna Commercial |
$334.88
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$14.71
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$14.71
|
| Rate for Payer: Health EOS Commercial |
$323.96
|
| Rate for Payer: HFN Commercial |
$334.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$54.70
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$14.71
|
| Rate for Payer: Independent Care Health Plan Medicare |
$14.71
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$14.71
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$14.71
|
| Rate for Payer: Multiplan Commercial |
$291.20
|
| Rate for Payer: NAPHCARE Commercial |
$22.06
|
| Rate for Payer: Preferred Network Access Commercial |
$334.88
|
| Rate for Payer: Quartz Beloit One Network |
$178.36
|
| Rate for Payer: Quartz Commercial |
$236.60
|
| Rate for Payer: Quartz Medicare Advantage |
$14.71
|
| Rate for Payer: The Alliance Commercial |
$58.82
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.71
|
| Rate for Payer: United Healthcare PPO |
$273.00
|
| Rate for Payer: WEA Trust Commercial |
$200.20
|
| Rate for Payer: Wellcare Medicare |
$14.71
|
| Rate for Payer: WPS Commercial |
$269.61
|
|
|
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 |
$532.90 |
| Max. Negotiated Rate |
$1,750.94 |
| Rate for Payer: Aetna Commercial |
$1,712.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,636.75
|
| Rate for Payer: Aetna Managed Medicare |
$532.90
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,237.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$951.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$913.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,008.70
|
| Rate for Payer: Cash Price |
$549.00
|
| Rate for Payer: Cigna Commercial |
$1,750.94
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,065.06
|
| Rate for Payer: Health EOS Commercial |
$1,693.85
|
| Rate for Payer: HFN Commercial |
$1,750.94
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,427.40
|
| Rate for Payer: Multiplan Commercial |
$1,522.56
|
| Rate for Payer: NAPHCARE Commercial |
$1,141.92
|
| Rate for Payer: Preferred Network Access Commercial |
$1,750.94
|
| Rate for Payer: Quartz Beloit One Network |
$932.57
|
| Rate for Payer: Quartz Commercial |
$1,237.08
|
| Rate for Payer: Quartz Medicare Advantage |
$1,141.92
|
| Rate for Payer: The Alliance Commercial |
$951.60
|
| Rate for Payer: WEA Trust Commercial |
$1,046.76
|
| Rate for Payer: WPS Commercial |
$1,409.65
|
|
|
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 |
$932.57 |
| Max. Negotiated Rate |
$1,750.94 |
| Rate for Payer: Aetna Commercial |
$1,712.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,636.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,008.70
|
| Rate for Payer: Cash Price |
$549.00
|
| Rate for Payer: Cigna Commercial |
$1,750.94
|
| Rate for Payer: Health EOS Commercial |
$1,693.85
|
| Rate for Payer: HFN Commercial |
$1,750.94
|
| Rate for Payer: Multiplan Commercial |
$1,522.56
|
| Rate for Payer: Preferred Network Access Commercial |
$1,750.94
|
| Rate for Payer: Quartz Beloit One Network |
$932.57
|
| Rate for Payer: Quartz Commercial |
$1,141.92
|
| Rate for Payer: WEA Trust Commercial |
$1,046.76
|
| Rate for Payer: WPS Commercial |
$1,409.65
|
|
|
THERAPEUTIC DRUG MONITORING
|
Facility
|
OP
|
$2.16
|
|
|
Service Code
|
EAPG 00405
|
| Min. Negotiated Rate |
$2.07 |
| Max. Negotiated Rate |
$2.16 |
| Rate for Payer: Anthem Medicaid |
$2.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$2.07
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2.07
|
| Rate for Payer: Dean Health Medicaid |
$2.07
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$2.07
|
| Rate for Payer: Managed Health Services Medicaid |
$2.16
|
| Rate for Payer: Molina Healthcare Medicaid |
$2.07
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$2.07
|
| Rate for Payer: United Healthcare Medicaid |
$2.07
|
|
|
Therapeutic Exercise Charges ST
|
Facility
|
OP
|
$270.00
|
|
|
Service Code
|
CPT 97110 GN
|
| Hospital Charge Code |
753741
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$78.62 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$252.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$241.49
|
| Rate for Payer: Aetna Managed Medicare |
$78.62
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$362.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$298.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$282.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$148.82
|
| Rate for Payer: Cash Price |
$81.00
|
| Rate for Payer: Cash Price |
$81.00
|
| Rate for Payer: Cigna Commercial |
$258.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$157.14
|
| Rate for Payer: Health EOS Commercial |
$249.91
|
| Rate for Payer: HFN Commercial |
$258.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$224.64
|
| Rate for Payer: NAPHCARE Commercial |
$168.48
|
| Rate for Payer: Preferred Network Access Commercial |
$258.34
|
| Rate for Payer: Quartz Beloit One Network |
$137.59
|
| Rate for Payer: Quartz Commercial |
$182.52
|
| Rate for Payer: Quartz Medicare Advantage |
$168.48
|
| Rate for Payer: The Alliance Commercial |
$140.40
|
| Rate for Payer: United Healthcare PPO |
$210.60
|
| Rate for Payer: WEA Trust Commercial |
$154.44
|
| Rate for Payer: WPS Commercial |
$207.98
|
|
|
Therapeutic Exercise Charges ST
|
Facility
|
IP
|
$270.00
|
|
|
Service Code
|
CPT 97110 GN
|
| Hospital Charge Code |
753741
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$137.59 |
| Max. Negotiated Rate |
$258.34 |
| Rate for Payer: Aetna Commercial |
$252.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$241.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$148.82
|
| Rate for Payer: Cash Price |
$81.00
|
| Rate for Payer: Cigna Commercial |
$258.34
|
| Rate for Payer: Health EOS Commercial |
$249.91
|
| Rate for Payer: HFN Commercial |
$258.34
|
| Rate for Payer: Multiplan Commercial |
$224.64
|
| Rate for Payer: Preferred Network Access Commercial |
$258.34
|
| Rate for Payer: Quartz Beloit One Network |
$137.59
|
| Rate for Payer: Quartz Commercial |
$168.48
|
| Rate for Payer: WEA Trust Commercial |
$154.44
|
| Rate for Payer: WPS Commercial |
$207.98
|
|
|
Therapeutic Inj
|
Facility
|
OP
|
$118.00
|
|
|
Service Code
|
CPT 96372
|
| Hospital Charge Code |
3970747
|
|
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 Inj
|
Facility
|
IP
|
$118.00
|
|
|
Service Code
|
CPT 96372
|
| Hospital Charge Code |
3970747
|
|
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 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 Injection sub or Intra 96372
|
Facility
|
OP
|
$118.00
|
|
|
Service Code
|
CPT 96372
|
| Hospital Charge Code |
3382926
|
|
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 Injection sub or Intra 96372
|
Facility
|
IP
|
$118.00
|
|
|
Service Code
|
CPT 96372
|
| Hospital Charge Code |
3382926
|
|
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
|
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
|
$52.19
|
|
|
Service Code
|
EAPG 00340
|
| Min. Negotiated Rate |
$50.18 |
| Max. Negotiated Rate |
$52.19 |
| Rate for Payer: Anthem Medicaid |
$50.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$50.18
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$50.18
|
| Rate for Payer: Dean Health Medicaid |
$50.18
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$50.18
|
| Rate for Payer: Managed Health Services Medicaid |
$52.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$50.18
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$50.18
|
| Rate for Payer: United Healthcare Medicaid |
$50.18
|
|
|
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, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug
|
Facility
|
OP
|
$895.40
|
|
|
Service Code
|
CPT 96374
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$223.85 |
| Max. Negotiated Rate |
$895.40 |
| Rate for Payer: Aetna Managed Medicare |
$223.85
|
| Rate for Payer: Anthem Medicare Advantage |
$223.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$223.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$223.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$223.85
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$223.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$832.72
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$223.85
|
| Rate for Payer: Independent Care Health Plan Medicare |
$223.85
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$223.85
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$223.85
|
| Rate for Payer: NAPHCARE Commercial |
$335.77
|
| Rate for Payer: Quartz Medicare Advantage |
$223.85
|
| Rate for Payer: The Alliance Commercial |
$895.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$223.85
|
| Rate for Payer: Wellcare Medicare |
$223.85
|
|
|
THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); SUBCUTANEOUS OR INTRAMUSCULAR
|
Facility
|
OP
|
$303.10
|
|
|
Service Code
|
CPT 96372
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$75.77 |
| Max. Negotiated Rate |
$303.10 |
| Rate for Payer: Aetna Managed Medicare |
$75.77
|
| Rate for Payer: Anthem Medicare Advantage |
$75.77
|
| 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: Cook Children's Health Plan (CCHP) Commercial |
$75.77
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$75.77
|
| 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: NAPHCARE Commercial |
$113.66
|
| 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: Wellcare Medicare |
$75.77
|
|
|
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
|
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
|
|
|
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
|
|
