|
Yes - PTA Mechanical Traction Charge
|
Facility
OP
|
$224.00
|
|
|
Service Code
|
CPT 97012 GP,CQ
|
| Hospital Charge Code |
5569033
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$62.72 |
| Max. Negotiated Rate |
$896.00 |
| Rate for Payer: Aetna Commercial |
$201.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$192.64
|
| Rate for Payer: Aetna Managed Medicare |
$62.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$349.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$287.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$272.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$118.72
|
| Rate for Payer: Cash Price |
$67.20
|
| Rate for Payer: Cash Price |
$67.20
|
| Rate for Payer: Cigna Commercial |
$206.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$125.35
|
| Rate for Payer: Health EOS Commercial |
$199.36
|
| Rate for Payer: HFN Commercial |
$206.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$179.20
|
| Rate for Payer: NAPHCARE Commercial |
$134.40
|
| Rate for Payer: Preferred Network Access Commercial |
$206.08
|
| Rate for Payer: Quartz Beloit One Network |
$109.76
|
| Rate for Payer: Quartz Commercial |
$145.60
|
| Rate for Payer: Quartz Medicare Advantage |
$134.40
|
| Rate for Payer: The Alliance Commercial |
$896.00
|
| Rate for Payer: United Healthcare PPO |
$168.00
|
| Rate for Payer: WEA Trust Commercial |
$123.20
|
| Rate for Payer: WPS Commercial |
$165.92
|
|
|
Yes - PTA Non-Selective Debridement Charge
|
Facility
OP
|
$85.00
|
|
|
Service Code
|
CPT 97602
|
| Hospital Charge Code |
5569209
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$41.65 |
| Max. Negotiated Rate |
$349.00 |
| Rate for Payer: Aetna Commercial |
$76.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$73.10
|
| Rate for Payer: Aetna Managed Medicare |
$197.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$349.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$287.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$272.00
|
| Rate for Payer: Anthem Medicare Advantage |
$197.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$45.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$197.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$197.88
|
| Rate for Payer: Cash Price |
$25.50
|
| Rate for Payer: Cash Price |
$25.50
|
| Rate for Payer: Cash Price |
$25.50
|
| Rate for Payer: Cigna Commercial |
$78.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$197.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$47.57
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$197.88
|
| Rate for Payer: Health EOS Commercial |
$75.65
|
| Rate for Payer: HFN Commercial |
$78.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$197.88
|
| Rate for Payer: Independent Care Health Plan Medicare |
$197.88
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$197.88
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$197.88
|
| Rate for Payer: Multiplan Commercial |
$68.00
|
| Rate for Payer: NAPHCARE Commercial |
$296.82
|
| Rate for Payer: Preferred Network Access Commercial |
$78.20
|
| Rate for Payer: Quartz Beloit One Network |
$41.65
|
| Rate for Payer: Quartz Commercial |
$55.25
|
| Rate for Payer: Quartz Medicare Advantage |
$197.88
|
| Rate for Payer: United Healthcare Medicare Advantage |
$197.88
|
| Rate for Payer: United Healthcare PPO |
$63.75
|
| Rate for Payer: WEA Trust Commercial |
$46.75
|
| Rate for Payer: Wellcare Medicare |
$197.88
|
| Rate for Payer: WPS Commercial |
$62.96
|
|
|
Yes - PTA Non-Selective Debridement Charge
|
Facility
IP
|
$85.00
|
|
|
Service Code
|
CPT 97602
|
| Hospital Charge Code |
5569209
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$41.65 |
| Max. Negotiated Rate |
$78.20 |
| Rate for Payer: Aetna Commercial |
$76.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$45.05
|
| Rate for Payer: Cash Price |
$25.50
|
| Rate for Payer: Cigna Commercial |
$78.20
|
| Rate for Payer: Health EOS Commercial |
$75.65
|
| Rate for Payer: HFN Commercial |
$78.20
|
| Rate for Payer: Multiplan Commercial |
$68.00
|
| Rate for Payer: NAPHCARE Commercial |
$51.00
|
| Rate for Payer: Preferred Network Access Commercial |
$78.20
|
| Rate for Payer: Quartz Beloit One Network |
$41.65
|
| Rate for Payer: Quartz Commercial |
$51.00
|
| Rate for Payer: WEA Trust Commercial |
$46.75
|
| Rate for Payer: WPS Commercial |
$62.96
|
|
|
Yes - PTA Paraffin Bath Charge
|
Facility
OP
|
$170.00
|
|
|
Service Code
|
CPT 97018 GP,CQ
|
| Hospital Charge Code |
5569187
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$47.60 |
| Max. Negotiated Rate |
$680.00 |
| Rate for Payer: Aetna Commercial |
$153.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$146.20
|
| Rate for Payer: Aetna Managed Medicare |
$47.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$349.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$287.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$272.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$90.10
|
| Rate for Payer: Cash Price |
$51.00
|
| Rate for Payer: Cash Price |
$51.00
|
| Rate for Payer: Cigna Commercial |
$156.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$95.13
|
| Rate for Payer: Health EOS Commercial |
$151.30
|
| Rate for Payer: HFN Commercial |
$156.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$136.00
|
| Rate for Payer: NAPHCARE Commercial |
$102.00
|
| Rate for Payer: Preferred Network Access Commercial |
$156.40
|
| Rate for Payer: Quartz Beloit One Network |
$83.30
|
| Rate for Payer: Quartz Commercial |
$110.50
|
| Rate for Payer: Quartz Medicare Advantage |
$102.00
|
| Rate for Payer: The Alliance Commercial |
$680.00
|
| Rate for Payer: United Healthcare PPO |
$127.50
|
| Rate for Payer: WEA Trust Commercial |
$93.50
|
| Rate for Payer: WPS Commercial |
$125.92
|
|
|
Yes - PTA Paraffin Bath Charge
|
Facility
IP
|
$170.00
|
|
|
Service Code
|
CPT 97018 GP,CQ
|
| Hospital Charge Code |
5569187
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$83.30 |
| Max. Negotiated Rate |
$156.40 |
| Rate for Payer: Aetna Commercial |
$153.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$90.10
|
| Rate for Payer: Cash Price |
$51.00
|
| Rate for Payer: Cigna Commercial |
$156.40
|
| Rate for Payer: Health EOS Commercial |
$151.30
|
| Rate for Payer: HFN Commercial |
$156.40
|
| Rate for Payer: Multiplan Commercial |
$136.00
|
| Rate for Payer: NAPHCARE Commercial |
$102.00
|
| Rate for Payer: Preferred Network Access Commercial |
$156.40
|
| Rate for Payer: Quartz Beloit One Network |
$83.30
|
| Rate for Payer: Quartz Commercial |
$102.00
|
| Rate for Payer: WEA Trust Commercial |
$93.50
|
| Rate for Payer: WPS Commercial |
$125.92
|
|
|
Yes - PTA Selective Debride Charge Add 20sq cm
|
Facility
OP
|
$62.00
|
|
|
Service Code
|
CPT 97598 GP,CQ
|
| Hospital Charge Code |
5568970
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$17.36 |
| Max. Negotiated Rate |
$349.00 |
| Rate for Payer: Aetna Commercial |
$55.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$53.32
|
| Rate for Payer: Aetna Managed Medicare |
$17.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$349.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$287.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$272.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$32.86
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cigna Commercial |
$57.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$34.70
|
| Rate for Payer: Health EOS Commercial |
$55.18
|
| Rate for Payer: HFN Commercial |
$57.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$49.60
|
| Rate for Payer: NAPHCARE Commercial |
$37.20
|
| Rate for Payer: Preferred Network Access Commercial |
$57.04
|
| Rate for Payer: Quartz Beloit One Network |
$30.38
|
| Rate for Payer: Quartz Commercial |
$40.30
|
| Rate for Payer: Quartz Medicare Advantage |
$37.20
|
| Rate for Payer: The Alliance Commercial |
$248.00
|
| Rate for Payer: United Healthcare PPO |
$46.50
|
| Rate for Payer: WEA Trust Commercial |
$34.10
|
| Rate for Payer: WPS Commercial |
$45.92
|
|
|
Yes - PTA Selective Debride Charge Add 20sq cm
|
Facility
IP
|
$62.00
|
|
|
Service Code
|
CPT 97598 GP,CQ
|
| Hospital Charge Code |
5568970
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$30.38 |
| Max. Negotiated Rate |
$57.04 |
| Rate for Payer: Aetna Commercial |
$55.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$32.86
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cigna Commercial |
$57.04
|
| Rate for Payer: Health EOS Commercial |
$55.18
|
| Rate for Payer: HFN Commercial |
$57.04
|
| Rate for Payer: Multiplan Commercial |
$49.60
|
| Rate for Payer: NAPHCARE Commercial |
$37.20
|
| Rate for Payer: Preferred Network Access Commercial |
$57.04
|
| Rate for Payer: Quartz Beloit One Network |
$30.38
|
| Rate for Payer: Quartz Commercial |
$37.20
|
| Rate for Payer: WEA Trust Commercial |
$34.10
|
| Rate for Payer: WPS Commercial |
$45.92
|
|
|
Yes - PTA Selective Debridement Charge 20sq cm
|
Facility
IP
|
$254.00
|
|
|
Service Code
|
CPT 97597 GP,CQ
|
| Hospital Charge Code |
5568959
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$124.46 |
| Max. Negotiated Rate |
$233.68 |
| Rate for Payer: Aetna Commercial |
$228.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$134.62
|
| Rate for Payer: Cash Price |
$76.20
|
| Rate for Payer: Cigna Commercial |
$233.68
|
| Rate for Payer: Health EOS Commercial |
$226.06
|
| Rate for Payer: HFN Commercial |
$233.68
|
| Rate for Payer: Multiplan Commercial |
$203.20
|
| Rate for Payer: NAPHCARE Commercial |
$152.40
|
| Rate for Payer: Preferred Network Access Commercial |
$233.68
|
| Rate for Payer: Quartz Beloit One Network |
$124.46
|
| Rate for Payer: Quartz Commercial |
$152.40
|
| Rate for Payer: WEA Trust Commercial |
$139.70
|
| Rate for Payer: WPS Commercial |
$188.14
|
|
|
Yes - PTA Selective Debridement Charge 20sq cm
|
Facility
OP
|
$254.00
|
|
|
Service Code
|
CPT 97597 GP,CQ
|
| Hospital Charge Code |
5568959
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$71.12 |
| Max. Negotiated Rate |
$1,016.00 |
| Rate for Payer: Aetna Commercial |
$228.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$218.44
|
| Rate for Payer: Aetna Managed Medicare |
$71.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$349.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$287.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$272.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$134.62
|
| Rate for Payer: Cash Price |
$76.20
|
| Rate for Payer: Cash Price |
$76.20
|
| Rate for Payer: Cigna Commercial |
$233.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$142.14
|
| Rate for Payer: Health EOS Commercial |
$226.06
|
| Rate for Payer: HFN Commercial |
$233.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$203.20
|
| Rate for Payer: NAPHCARE Commercial |
$152.40
|
| Rate for Payer: Preferred Network Access Commercial |
$233.68
|
| Rate for Payer: Quartz Beloit One Network |
$124.46
|
| Rate for Payer: Quartz Commercial |
$165.10
|
| Rate for Payer: Quartz Medicare Advantage |
$152.40
|
| Rate for Payer: The Alliance Commercial |
$1,016.00
|
| Rate for Payer: United Healthcare PPO |
$190.50
|
| Rate for Payer: WEA Trust Commercial |
$139.70
|
| Rate for Payer: WPS Commercial |
$188.14
|
|
|
Yes - PTA Ultrasound Charge
|
Facility
IP
|
$167.00
|
|
|
Service Code
|
CPT 97035 GP,CQ
|
| Hospital Charge Code |
5569103
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$81.83 |
| Max. Negotiated Rate |
$153.64 |
| Rate for Payer: Aetna Commercial |
$150.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$88.51
|
| Rate for Payer: Cash Price |
$50.10
|
| Rate for Payer: Cigna Commercial |
$153.64
|
| Rate for Payer: Health EOS Commercial |
$148.63
|
| Rate for Payer: HFN Commercial |
$153.64
|
| Rate for Payer: Multiplan Commercial |
$133.60
|
| Rate for Payer: NAPHCARE Commercial |
$100.20
|
| Rate for Payer: Preferred Network Access Commercial |
$153.64
|
| Rate for Payer: Quartz Beloit One Network |
$81.83
|
| Rate for Payer: Quartz Commercial |
$100.20
|
| Rate for Payer: WEA Trust Commercial |
$91.85
|
| Rate for Payer: WPS Commercial |
$123.70
|
|
|
Yes - PTA Ultrasound Charge
|
Facility
OP
|
$167.00
|
|
|
Service Code
|
CPT 97035 GP,CQ
|
| Hospital Charge Code |
5569103
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$46.76 |
| Max. Negotiated Rate |
$668.00 |
| Rate for Payer: Aetna Commercial |
$150.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$143.62
|
| Rate for Payer: Aetna Managed Medicare |
$46.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$349.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$287.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$272.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$88.51
|
| Rate for Payer: Cash Price |
$50.10
|
| Rate for Payer: Cash Price |
$50.10
|
| Rate for Payer: Cigna Commercial |
$153.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$93.45
|
| Rate for Payer: Health EOS Commercial |
$148.63
|
| Rate for Payer: HFN Commercial |
$153.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$133.60
|
| Rate for Payer: NAPHCARE Commercial |
$100.20
|
| Rate for Payer: Preferred Network Access Commercial |
$153.64
|
| Rate for Payer: Quartz Beloit One Network |
$81.83
|
| Rate for Payer: Quartz Commercial |
$108.55
|
| Rate for Payer: Quartz Medicare Advantage |
$100.20
|
| Rate for Payer: The Alliance Commercial |
$668.00
|
| Rate for Payer: United Healthcare PPO |
$125.25
|
| Rate for Payer: WEA Trust Commercial |
$91.85
|
| Rate for Payer: WPS Commercial |
$123.70
|
|
|
Yes - PTA Vasopnuematic Device Charge
|
Facility
OP
|
$207.00
|
|
|
Service Code
|
CPT 97018 GP,CQ
|
| Hospital Charge Code |
5569168
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$57.96 |
| Max. Negotiated Rate |
$828.00 |
| Rate for Payer: Aetna Commercial |
$186.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$178.02
|
| Rate for Payer: Aetna Managed Medicare |
$57.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$349.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$287.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$272.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$109.71
|
| Rate for Payer: Cash Price |
$62.10
|
| Rate for Payer: Cash Price |
$62.10
|
| Rate for Payer: Cigna Commercial |
$190.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$115.84
|
| Rate for Payer: Health EOS Commercial |
$184.23
|
| Rate for Payer: HFN Commercial |
$190.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$165.60
|
| Rate for Payer: NAPHCARE Commercial |
$124.20
|
| Rate for Payer: Preferred Network Access Commercial |
$190.44
|
| Rate for Payer: Quartz Beloit One Network |
$101.43
|
| Rate for Payer: Quartz Commercial |
$134.55
|
| Rate for Payer: Quartz Medicare Advantage |
$124.20
|
| Rate for Payer: The Alliance Commercial |
$828.00
|
| Rate for Payer: United Healthcare PPO |
$155.25
|
| Rate for Payer: WEA Trust Commercial |
$113.85
|
| Rate for Payer: WPS Commercial |
$153.32
|
|
|
Yes - PTA Vasopnuematic Device Charge
|
Facility
IP
|
$207.00
|
|
|
Service Code
|
CPT 97018 GP,CQ
|
| Hospital Charge Code |
5569168
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$101.43 |
| Max. Negotiated Rate |
$190.44 |
| Rate for Payer: Aetna Commercial |
$186.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$109.71
|
| Rate for Payer: Cash Price |
$62.10
|
| Rate for Payer: Cigna Commercial |
$190.44
|
| Rate for Payer: Health EOS Commercial |
$184.23
|
| Rate for Payer: HFN Commercial |
$190.44
|
| Rate for Payer: Multiplan Commercial |
$165.60
|
| Rate for Payer: NAPHCARE Commercial |
$124.20
|
| Rate for Payer: Preferred Network Access Commercial |
$190.44
|
| Rate for Payer: Quartz Beloit One Network |
$101.43
|
| Rate for Payer: Quartz Commercial |
$124.20
|
| Rate for Payer: WEA Trust Commercial |
$113.85
|
| Rate for Payer: WPS Commercial |
$153.32
|
|
|
Yes - PTA Whirlpool Charge
|
Facility
IP
|
$186.00
|
|
|
Service Code
|
CPT 97022 GP,CQ
|
| Hospital Charge Code |
5565378
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$91.14 |
| Max. Negotiated Rate |
$171.12 |
| Rate for Payer: Aetna Commercial |
$167.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$98.58
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cigna Commercial |
$171.12
|
| Rate for Payer: Health EOS Commercial |
$165.54
|
| Rate for Payer: HFN Commercial |
$171.12
|
| Rate for Payer: Multiplan Commercial |
$148.80
|
| Rate for Payer: NAPHCARE Commercial |
$111.60
|
| Rate for Payer: Preferred Network Access Commercial |
$171.12
|
| Rate for Payer: Quartz Beloit One Network |
$91.14
|
| Rate for Payer: Quartz Commercial |
$111.60
|
| Rate for Payer: WEA Trust Commercial |
$102.30
|
| Rate for Payer: WPS Commercial |
$137.77
|
|
|
Yes - PTA Whirlpool Charge
|
Professional
|
$186.00
|
|
|
Service Code
|
CPT 97022 GP,CQ
|
| Hospital Charge Code |
5565378
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$81.84 |
| Max. Negotiated Rate |
$176.70 |
| Rate for Payer: Aetna Commercial |
$176.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$159.96
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cigna Commercial |
$176.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$93.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$111.60
|
| Rate for Payer: Health EOS Commercial |
$169.26
|
| Rate for Payer: Multiplan Commercial |
$148.80
|
| Rate for Payer: Preferred Network Access Commercial |
$176.70
|
| Rate for Payer: Quartz Beloit One Network |
$81.84
|
| Rate for Payer: Quartz Commercial |
$106.02
|
| Rate for Payer: The Alliance Commercial |
$93.00
|
| Rate for Payer: WEA Trust Commercial |
$102.30
|
| Rate for Payer: WPS Commercial |
$137.77
|
|
|
Yes - PTA Whirlpool Charge
|
Facility
OP
|
$186.00
|
|
|
Service Code
|
CPT 97022 GP,CQ
|
| Hospital Charge Code |
5565378
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$52.08 |
| Max. Negotiated Rate |
$744.00 |
| Rate for Payer: Aetna Commercial |
$167.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$159.96
|
| Rate for Payer: Aetna Managed Medicare |
$52.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$349.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$287.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$272.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$98.58
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cigna Commercial |
$171.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$104.09
|
| Rate for Payer: Health EOS Commercial |
$165.54
|
| Rate for Payer: HFN Commercial |
$171.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$148.80
|
| Rate for Payer: NAPHCARE Commercial |
$111.60
|
| Rate for Payer: Preferred Network Access Commercial |
$171.12
|
| Rate for Payer: Quartz Beloit One Network |
$91.14
|
| Rate for Payer: Quartz Commercial |
$120.90
|
| Rate for Payer: Quartz Medicare Advantage |
$111.60
|
| Rate for Payer: The Alliance Commercial |
$744.00
|
| Rate for Payer: United Healthcare PPO |
$139.50
|
| Rate for Payer: WEA Trust Commercial |
$102.30
|
| Rate for Payer: WPS Commercial |
$137.77
|
|
|
Yes - PTA Wound Vac Charges > 50sq cm
|
Facility
IP
|
$317.00
|
|
|
Service Code
|
CPT 97606 GO,CQ
|
| Hospital Charge Code |
5568992
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$155.33 |
| Max. Negotiated Rate |
$291.64 |
| Rate for Payer: Aetna Commercial |
$285.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$168.01
|
| Rate for Payer: Cash Price |
$95.10
|
| Rate for Payer: Cigna Commercial |
$291.64
|
| Rate for Payer: Health EOS Commercial |
$282.13
|
| Rate for Payer: HFN Commercial |
$291.64
|
| Rate for Payer: Multiplan Commercial |
$253.60
|
| Rate for Payer: NAPHCARE Commercial |
$190.20
|
| Rate for Payer: Preferred Network Access Commercial |
$291.64
|
| Rate for Payer: Quartz Beloit One Network |
$155.33
|
| Rate for Payer: Quartz Commercial |
$190.20
|
| Rate for Payer: WEA Trust Commercial |
$174.35
|
| Rate for Payer: WPS Commercial |
$234.80
|
|
|
Yes - PTA Wound Vac Charges > 50sq cm
|
Facility
OP
|
$317.00
|
|
|
Service Code
|
CPT 97606 GO,CQ
|
| Hospital Charge Code |
5568992
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$88.76 |
| Max. Negotiated Rate |
$1,268.00 |
| Rate for Payer: Aetna Commercial |
$285.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$272.62
|
| Rate for Payer: Aetna Managed Medicare |
$88.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$349.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$287.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$272.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$168.01
|
| Rate for Payer: Cash Price |
$95.10
|
| Rate for Payer: Cash Price |
$95.10
|
| Rate for Payer: Cigna Commercial |
$291.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$177.39
|
| Rate for Payer: Health EOS Commercial |
$282.13
|
| Rate for Payer: HFN Commercial |
$291.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$253.60
|
| Rate for Payer: NAPHCARE Commercial |
$190.20
|
| Rate for Payer: Preferred Network Access Commercial |
$291.64
|
| Rate for Payer: Quartz Beloit One Network |
$155.33
|
| Rate for Payer: Quartz Commercial |
$206.05
|
| Rate for Payer: Quartz Medicare Advantage |
$190.20
|
| Rate for Payer: The Alliance Commercial |
$1,268.00
|
| Rate for Payer: United Healthcare PPO |
$237.75
|
| Rate for Payer: WEA Trust Commercial |
$174.35
|
| Rate for Payer: WPS Commercial |
$234.80
|
|
|
Yes - PTA Wound Vac Charges 50sq cm
|
Facility
IP
|
$254.00
|
|
|
Service Code
|
CPT 97605 GP,CQ
|
| Hospital Charge Code |
5568981
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$124.46 |
| Max. Negotiated Rate |
$233.68 |
| Rate for Payer: Aetna Commercial |
$228.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$134.62
|
| Rate for Payer: Cash Price |
$76.20
|
| Rate for Payer: Cigna Commercial |
$233.68
|
| Rate for Payer: Health EOS Commercial |
$226.06
|
| Rate for Payer: HFN Commercial |
$233.68
|
| Rate for Payer: Multiplan Commercial |
$203.20
|
| Rate for Payer: NAPHCARE Commercial |
$152.40
|
| Rate for Payer: Preferred Network Access Commercial |
$233.68
|
| Rate for Payer: Quartz Beloit One Network |
$124.46
|
| Rate for Payer: Quartz Commercial |
$152.40
|
| Rate for Payer: WEA Trust Commercial |
$139.70
|
| Rate for Payer: WPS Commercial |
$188.14
|
|
|
Yes - PTA Wound Vac Charges 50sq cm
|
Facility
OP
|
$254.00
|
|
|
Service Code
|
CPT 97605 GP,CQ
|
| Hospital Charge Code |
5568981
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$71.12 |
| Max. Negotiated Rate |
$1,016.00 |
| Rate for Payer: Aetna Commercial |
$228.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$218.44
|
| Rate for Payer: Aetna Managed Medicare |
$71.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$349.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$287.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$272.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$134.62
|
| Rate for Payer: Cash Price |
$76.20
|
| Rate for Payer: Cash Price |
$76.20
|
| Rate for Payer: Cigna Commercial |
$233.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$142.14
|
| Rate for Payer: Health EOS Commercial |
$226.06
|
| Rate for Payer: HFN Commercial |
$233.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$203.20
|
| Rate for Payer: NAPHCARE Commercial |
$152.40
|
| Rate for Payer: Preferred Network Access Commercial |
$233.68
|
| Rate for Payer: Quartz Beloit One Network |
$124.46
|
| Rate for Payer: Quartz Commercial |
$165.10
|
| Rate for Payer: Quartz Medicare Advantage |
$152.40
|
| Rate for Payer: The Alliance Commercial |
$1,016.00
|
| Rate for Payer: United Healthcare PPO |
$190.50
|
| Rate for Payer: WEA Trust Commercial |
$139.70
|
| Rate for Payer: WPS Commercial |
$188.14
|
|
|
Yes - PTA Wound Vac Disp Charges > 50sq cm
|
Facility
IP
|
$457.00
|
|
|
Service Code
|
CPT 97608 GP,CQ
|
| Hospital Charge Code |
5569014
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$223.93 |
| Max. Negotiated Rate |
$420.44 |
| Rate for Payer: Aetna Commercial |
$411.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$242.21
|
| Rate for Payer: Cash Price |
$137.10
|
| Rate for Payer: Cigna Commercial |
$420.44
|
| Rate for Payer: Health EOS Commercial |
$406.73
|
| Rate for Payer: HFN Commercial |
$420.44
|
| Rate for Payer: Multiplan Commercial |
$365.60
|
| Rate for Payer: NAPHCARE Commercial |
$274.20
|
| Rate for Payer: Preferred Network Access Commercial |
$420.44
|
| Rate for Payer: Quartz Beloit One Network |
$223.93
|
| Rate for Payer: Quartz Commercial |
$274.20
|
| Rate for Payer: WEA Trust Commercial |
$251.35
|
| Rate for Payer: WPS Commercial |
$338.50
|
|
|
Yes - PTA Wound Vac Disp Charges > 50sq cm
|
Facility
OP
|
$457.00
|
|
|
Service Code
|
CPT 97608 GP,CQ
|
| Hospital Charge Code |
5569014
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$127.96 |
| Max. Negotiated Rate |
$1,828.00 |
| Rate for Payer: Aetna Commercial |
$411.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$393.02
|
| Rate for Payer: Aetna Managed Medicare |
$127.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$349.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$287.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$272.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$242.21
|
| Rate for Payer: Cash Price |
$137.10
|
| Rate for Payer: Cash Price |
$137.10
|
| Rate for Payer: Cigna Commercial |
$420.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$255.74
|
| Rate for Payer: Health EOS Commercial |
$406.73
|
| Rate for Payer: HFN Commercial |
$420.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$365.60
|
| Rate for Payer: NAPHCARE Commercial |
$274.20
|
| Rate for Payer: Preferred Network Access Commercial |
$420.44
|
| Rate for Payer: Quartz Beloit One Network |
$223.93
|
| Rate for Payer: Quartz Commercial |
$297.05
|
| Rate for Payer: Quartz Medicare Advantage |
$274.20
|
| Rate for Payer: The Alliance Commercial |
$1,828.00
|
| Rate for Payer: United Healthcare PPO |
$342.75
|
| Rate for Payer: WEA Trust Commercial |
$251.35
|
| Rate for Payer: WPS Commercial |
$338.50
|
|
|
Yes - PTA Wound Vac Disp Charges 50sq cm
|
Facility
OP
|
$364.00
|
|
|
Service Code
|
CPT 97607 GP,CQ
|
| Hospital Charge Code |
5569003
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$101.92 |
| Max. Negotiated Rate |
$1,456.00 |
| Rate for Payer: Aetna Commercial |
$327.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$313.04
|
| Rate for Payer: Aetna Managed Medicare |
$101.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$349.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$287.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$272.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$192.92
|
| Rate for Payer: Cash Price |
$109.20
|
| Rate for Payer: Cash Price |
$109.20
|
| Rate for Payer: Cigna Commercial |
$334.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$203.69
|
| Rate for Payer: Health EOS Commercial |
$323.96
|
| Rate for Payer: HFN Commercial |
$334.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$291.20
|
| Rate for Payer: NAPHCARE Commercial |
$218.40
|
| 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 |
$218.40
|
| Rate for Payer: The Alliance Commercial |
$1,456.00
|
| Rate for Payer: United Healthcare PPO |
$273.00
|
| Rate for Payer: WEA Trust Commercial |
$200.20
|
| Rate for Payer: WPS Commercial |
$269.61
|
|
|
Yes - PTA Wound Vac Disp Charges 50sq cm
|
Facility
IP
|
$364.00
|
|
|
Service Code
|
CPT 97607 GP,CQ
|
| Hospital Charge Code |
5569003
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$178.36 |
| Max. Negotiated Rate |
$334.88 |
| Rate for Payer: Aetna Commercial |
$327.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$192.92
|
| Rate for Payer: Cash Price |
$109.20
|
| 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: NAPHCARE Commercial |
$218.40
|
| 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
|
|
|
Yes - PT E-Stim Attended Charges
|
Facility
IP
|
$173.00
|
|
|
Service Code
|
CPT 97032 GP
|
| Hospital Charge Code |
2989871
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$84.77 |
| Max. Negotiated Rate |
$159.16 |
| Rate for Payer: Aetna Commercial |
$155.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$91.69
|
| Rate for Payer: Cash Price |
$51.90
|
| Rate for Payer: Cigna Commercial |
$159.16
|
| Rate for Payer: Health EOS Commercial |
$153.97
|
| Rate for Payer: HFN Commercial |
$159.16
|
| Rate for Payer: Multiplan Commercial |
$138.40
|
| Rate for Payer: NAPHCARE Commercial |
$103.80
|
| Rate for Payer: Preferred Network Access Commercial |
$159.16
|
| Rate for Payer: Quartz Beloit One Network |
$84.77
|
| Rate for Payer: Quartz Commercial |
$103.80
|
| Rate for Payer: WEA Trust Commercial |
$95.15
|
| Rate for Payer: WPS Commercial |
$128.14
|
|
