|
Yes - PT Reevaluation Charge
|
Facility
OP
|
$287.00
|
|
|
Service Code
|
CPT 97164 GP
|
| Hospital Charge Code |
2989812
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$80.36 |
| Max. Negotiated Rate |
$1,148.00 |
| Rate for Payer: Aetna Commercial |
$258.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$246.82
|
| Rate for Payer: Aetna Managed Medicare |
$80.36
|
| 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 |
$152.11
|
| Rate for Payer: Cash Price |
$86.10
|
| Rate for Payer: Cash Price |
$86.10
|
| Rate for Payer: Cigna Commercial |
$264.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$160.61
|
| Rate for Payer: Health EOS Commercial |
$255.43
|
| Rate for Payer: HFN Commercial |
$264.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$229.60
|
| Rate for Payer: NAPHCARE Commercial |
$172.20
|
| Rate for Payer: Preferred Network Access Commercial |
$264.04
|
| Rate for Payer: Quartz Beloit One Network |
$140.63
|
| Rate for Payer: Quartz Commercial |
$186.55
|
| Rate for Payer: Quartz Medicare Advantage |
$172.20
|
| Rate for Payer: The Alliance Commercial |
$1,148.00
|
| Rate for Payer: United Healthcare PPO |
$215.25
|
| Rate for Payer: WEA Trust Commercial |
$157.85
|
| Rate for Payer: WPS Commercial |
$212.58
|
|
|
Yes - PT Reevaluation Charge
|
Professional
|
$287.00
|
|
|
Service Code
|
CPT 97164 GP
|
| Hospital Charge Code |
2989812
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$126.28 |
| Max. Negotiated Rate |
$272.65 |
| Rate for Payer: Aetna Commercial |
$272.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$246.82
|
| Rate for Payer: Cash Price |
$86.10
|
| Rate for Payer: Cash Price |
$86.10
|
| Rate for Payer: Cigna Commercial |
$272.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$143.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$172.20
|
| Rate for Payer: Health EOS Commercial |
$261.17
|
| Rate for Payer: Multiplan Commercial |
$229.60
|
| Rate for Payer: Preferred Network Access Commercial |
$272.65
|
| Rate for Payer: Quartz Beloit One Network |
$126.28
|
| Rate for Payer: Quartz Commercial |
$163.59
|
| Rate for Payer: The Alliance Commercial |
$143.50
|
| Rate for Payer: WEA Trust Commercial |
$157.85
|
| Rate for Payer: WPS Commercial |
$212.58
|
|
|
Yes - PT Reevaluation Charge
|
Facility
IP
|
$287.00
|
|
|
Service Code
|
CPT 97164 GP
|
| Hospital Charge Code |
2989812
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$140.63 |
| Max. Negotiated Rate |
$264.04 |
| Rate for Payer: Aetna Commercial |
$258.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$152.11
|
| Rate for Payer: Cash Price |
$86.10
|
| Rate for Payer: Cigna Commercial |
$264.04
|
| Rate for Payer: Health EOS Commercial |
$255.43
|
| Rate for Payer: HFN Commercial |
$264.04
|
| Rate for Payer: Multiplan Commercial |
$229.60
|
| Rate for Payer: NAPHCARE Commercial |
$172.20
|
| Rate for Payer: Preferred Network Access Commercial |
$264.04
|
| Rate for Payer: Quartz Beloit One Network |
$140.63
|
| Rate for Payer: Quartz Commercial |
$172.20
|
| Rate for Payer: WEA Trust Commercial |
$157.85
|
| Rate for Payer: WPS Commercial |
$212.58
|
|
|
Yes - PT Telemed Est Patient 11-20 min Chg
|
Facility
IP
|
$147.00
|
|
|
Service Code
|
CPT 98971 GP,95
|
| Hospital Charge Code |
5583145
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$72.03 |
| Max. Negotiated Rate |
$135.24 |
| Rate for Payer: Aetna Commercial |
$132.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$77.91
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: Cigna Commercial |
$135.24
|
| Rate for Payer: Health EOS Commercial |
$130.83
|
| Rate for Payer: HFN Commercial |
$135.24
|
| Rate for Payer: Multiplan Commercial |
$117.60
|
| Rate for Payer: NAPHCARE Commercial |
$88.20
|
| Rate for Payer: Preferred Network Access Commercial |
$135.24
|
| Rate for Payer: Quartz Beloit One Network |
$72.03
|
| Rate for Payer: Quartz Commercial |
$88.20
|
| Rate for Payer: WEA Trust Commercial |
$80.85
|
| Rate for Payer: WPS Commercial |
$108.88
|
|
|
Yes - PT Telemed Est Patient 11-20 min Chg
|
Facility
OP
|
$147.00
|
|
|
Service Code
|
CPT 98971 GP,95
|
| Hospital Charge Code |
5583145
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$41.16 |
| Max. Negotiated Rate |
$588.00 |
| Rate for Payer: Aetna Commercial |
$132.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$126.42
|
| Rate for Payer: Aetna Managed Medicare |
$41.16
|
| 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 |
$77.91
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: Cigna Commercial |
$135.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$82.26
|
| Rate for Payer: Health EOS Commercial |
$130.83
|
| Rate for Payer: HFN Commercial |
$135.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$117.60
|
| Rate for Payer: NAPHCARE Commercial |
$88.20
|
| Rate for Payer: Preferred Network Access Commercial |
$135.24
|
| Rate for Payer: Quartz Beloit One Network |
$72.03
|
| Rate for Payer: Quartz Commercial |
$95.55
|
| Rate for Payer: Quartz Medicare Advantage |
$88.20
|
| Rate for Payer: The Alliance Commercial |
$588.00
|
| Rate for Payer: United Healthcare PPO |
$110.25
|
| Rate for Payer: WEA Trust Commercial |
$80.85
|
| Rate for Payer: WPS Commercial |
$108.88
|
|
|
Yes - PT Telemed Est Patient 21>min Chg
|
Facility
OP
|
$147.00
|
|
|
Service Code
|
CPT 98972 GP,95
|
| Hospital Charge Code |
5583146
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$41.16 |
| Max. Negotiated Rate |
$588.00 |
| Rate for Payer: Aetna Commercial |
$132.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$126.42
|
| Rate for Payer: Aetna Managed Medicare |
$41.16
|
| 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 |
$77.91
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: Cigna Commercial |
$135.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$82.26
|
| Rate for Payer: Health EOS Commercial |
$130.83
|
| Rate for Payer: HFN Commercial |
$135.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$117.60
|
| Rate for Payer: NAPHCARE Commercial |
$88.20
|
| Rate for Payer: Preferred Network Access Commercial |
$135.24
|
| Rate for Payer: Quartz Beloit One Network |
$72.03
|
| Rate for Payer: Quartz Commercial |
$95.55
|
| Rate for Payer: Quartz Medicare Advantage |
$88.20
|
| Rate for Payer: The Alliance Commercial |
$588.00
|
| Rate for Payer: United Healthcare PPO |
$110.25
|
| Rate for Payer: WEA Trust Commercial |
$80.85
|
| Rate for Payer: WPS Commercial |
$108.88
|
|
|
Yes - PT Telemed Est Patient 21>min Chg
|
Facility
IP
|
$147.00
|
|
|
Service Code
|
CPT 98972 GP,95
|
| Hospital Charge Code |
5583146
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$72.03 |
| Max. Negotiated Rate |
$135.24 |
| Rate for Payer: Aetna Commercial |
$132.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$77.91
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: Cigna Commercial |
$135.24
|
| Rate for Payer: Health EOS Commercial |
$130.83
|
| Rate for Payer: HFN Commercial |
$135.24
|
| Rate for Payer: Multiplan Commercial |
$117.60
|
| Rate for Payer: NAPHCARE Commercial |
$88.20
|
| Rate for Payer: Preferred Network Access Commercial |
$135.24
|
| Rate for Payer: Quartz Beloit One Network |
$72.03
|
| Rate for Payer: Quartz Commercial |
$88.20
|
| Rate for Payer: WEA Trust Commercial |
$80.85
|
| Rate for Payer: WPS Commercial |
$108.88
|
|
|
Yes - PT Telemed Est Patient 5-10 min Chg
|
Facility
IP
|
$61.00
|
|
|
Service Code
|
CPT 98970 GP,95
|
| Hospital Charge Code |
5583147
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$29.89 |
| Max. Negotiated Rate |
$56.12 |
| Rate for Payer: Aetna Commercial |
$54.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$32.33
|
| Rate for Payer: Cash Price |
$18.30
|
| Rate for Payer: Cigna Commercial |
$56.12
|
| Rate for Payer: Health EOS Commercial |
$54.29
|
| Rate for Payer: HFN Commercial |
$56.12
|
| Rate for Payer: Multiplan Commercial |
$48.80
|
| Rate for Payer: NAPHCARE Commercial |
$36.60
|
| Rate for Payer: Preferred Network Access Commercial |
$56.12
|
| Rate for Payer: Quartz Beloit One Network |
$29.89
|
| Rate for Payer: Quartz Commercial |
$36.60
|
| Rate for Payer: WEA Trust Commercial |
$33.55
|
| Rate for Payer: WPS Commercial |
$45.18
|
|
|
Yes - PT Telemed Est Patient 5-10 min Chg
|
Facility
OP
|
$61.00
|
|
|
Service Code
|
CPT 98970 GP,95
|
| Hospital Charge Code |
5583147
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$17.08 |
| Max. Negotiated Rate |
$349.00 |
| Rate for Payer: Aetna Commercial |
$54.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$52.46
|
| Rate for Payer: Aetna Managed Medicare |
$17.08
|
| 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 |
$32.33
|
| Rate for Payer: Cash Price |
$18.30
|
| Rate for Payer: Cash Price |
$18.30
|
| Rate for Payer: Cigna Commercial |
$56.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$34.14
|
| Rate for Payer: Health EOS Commercial |
$54.29
|
| Rate for Payer: HFN Commercial |
$56.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$48.80
|
| Rate for Payer: NAPHCARE Commercial |
$36.60
|
| Rate for Payer: Preferred Network Access Commercial |
$56.12
|
| Rate for Payer: Quartz Beloit One Network |
$29.89
|
| Rate for Payer: Quartz Commercial |
$39.65
|
| Rate for Payer: Quartz Medicare Advantage |
$36.60
|
| Rate for Payer: The Alliance Commercial |
$244.00
|
| Rate for Payer: United Healthcare PPO |
$45.75
|
| Rate for Payer: WEA Trust Commercial |
$33.55
|
| Rate for Payer: WPS Commercial |
$45.18
|
|
|
Yes - PT Telephone call 11-20 min Charge
|
Facility
IP
|
$164.00
|
|
|
Service Code
|
CPT 98967 GP,95
|
| Hospital Charge Code |
5585217
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$80.36 |
| Max. Negotiated Rate |
$150.88 |
| Rate for Payer: Aetna Commercial |
$147.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$86.92
|
| Rate for Payer: Cash Price |
$49.20
|
| Rate for Payer: Cigna Commercial |
$150.88
|
| Rate for Payer: Health EOS Commercial |
$145.96
|
| Rate for Payer: HFN Commercial |
$150.88
|
| Rate for Payer: Multiplan Commercial |
$131.20
|
| Rate for Payer: NAPHCARE Commercial |
$98.40
|
| Rate for Payer: Preferred Network Access Commercial |
$150.88
|
| Rate for Payer: Quartz Beloit One Network |
$80.36
|
| Rate for Payer: Quartz Commercial |
$98.40
|
| Rate for Payer: WEA Trust Commercial |
$90.20
|
| Rate for Payer: WPS Commercial |
$121.47
|
|
|
Yes - PT Telephone call 11-20 min Charge
|
Facility
OP
|
$164.00
|
|
|
Service Code
|
CPT 98967 GP,95
|
| Hospital Charge Code |
5585217
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$45.92 |
| Max. Negotiated Rate |
$656.00 |
| Rate for Payer: Aetna Commercial |
$147.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$141.04
|
| Rate for Payer: Aetna Managed Medicare |
$45.92
|
| 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 |
$86.92
|
| Rate for Payer: Cash Price |
$49.20
|
| Rate for Payer: Cash Price |
$49.20
|
| Rate for Payer: Cigna Commercial |
$150.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$91.77
|
| Rate for Payer: Health EOS Commercial |
$145.96
|
| Rate for Payer: HFN Commercial |
$150.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$131.20
|
| Rate for Payer: NAPHCARE Commercial |
$98.40
|
| Rate for Payer: Preferred Network Access Commercial |
$150.88
|
| Rate for Payer: Quartz Beloit One Network |
$80.36
|
| Rate for Payer: Quartz Commercial |
$106.60
|
| Rate for Payer: Quartz Medicare Advantage |
$98.40
|
| Rate for Payer: The Alliance Commercial |
$656.00
|
| Rate for Payer: United Healthcare PPO |
$123.00
|
| Rate for Payer: WEA Trust Commercial |
$90.20
|
| Rate for Payer: WPS Commercial |
$121.47
|
|
|
Yes - PT Telephone call 21> min Charge
|
Facility
OP
|
$245.00
|
|
|
Service Code
|
CPT 98968 GP,95
|
| Hospital Charge Code |
5585218
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$68.60 |
| Max. Negotiated Rate |
$980.00 |
| Rate for Payer: Aetna Commercial |
$220.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$210.70
|
| Rate for Payer: Aetna Managed Medicare |
$68.60
|
| 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 |
$129.85
|
| Rate for Payer: Cash Price |
$73.50
|
| Rate for Payer: Cash Price |
$73.50
|
| Rate for Payer: Cigna Commercial |
$225.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$137.10
|
| Rate for Payer: Health EOS Commercial |
$218.05
|
| Rate for Payer: HFN Commercial |
$225.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$196.00
|
| Rate for Payer: NAPHCARE Commercial |
$147.00
|
| Rate for Payer: Preferred Network Access Commercial |
$225.40
|
| Rate for Payer: Quartz Beloit One Network |
$120.05
|
| Rate for Payer: Quartz Commercial |
$159.25
|
| Rate for Payer: Quartz Medicare Advantage |
$147.00
|
| Rate for Payer: The Alliance Commercial |
$980.00
|
| Rate for Payer: United Healthcare PPO |
$183.75
|
| Rate for Payer: WEA Trust Commercial |
$134.75
|
| Rate for Payer: WPS Commercial |
$181.47
|
|
|
Yes - PT Telephone call 21> min Charge
|
Facility
IP
|
$245.00
|
|
|
Service Code
|
CPT 98968 GP,95
|
| Hospital Charge Code |
5585218
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$120.05 |
| Max. Negotiated Rate |
$225.40 |
| Rate for Payer: Aetna Commercial |
$220.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$129.85
|
| Rate for Payer: Cash Price |
$73.50
|
| Rate for Payer: Cigna Commercial |
$225.40
|
| Rate for Payer: Health EOS Commercial |
$218.05
|
| Rate for Payer: HFN Commercial |
$225.40
|
| Rate for Payer: Multiplan Commercial |
$196.00
|
| Rate for Payer: NAPHCARE Commercial |
$147.00
|
| Rate for Payer: Preferred Network Access Commercial |
$225.40
|
| Rate for Payer: Quartz Beloit One Network |
$120.05
|
| Rate for Payer: Quartz Commercial |
$147.00
|
| Rate for Payer: WEA Trust Commercial |
$134.75
|
| Rate for Payer: WPS Commercial |
$181.47
|
|
|
Yes - PT Telephone call 5-10 min Charge
|
Facility
OP
|
$82.00
|
|
|
Service Code
|
CPT 98966 GP,95
|
| Hospital Charge Code |
5585219
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$22.96 |
| Max. Negotiated Rate |
$349.00 |
| Rate for Payer: Aetna Commercial |
$73.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$70.52
|
| Rate for Payer: Aetna Managed Medicare |
$22.96
|
| 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 |
$43.46
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cigna Commercial |
$75.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$45.89
|
| Rate for Payer: Health EOS Commercial |
$72.98
|
| Rate for Payer: HFN Commercial |
$75.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$65.60
|
| Rate for Payer: NAPHCARE Commercial |
$49.20
|
| Rate for Payer: Preferred Network Access Commercial |
$75.44
|
| Rate for Payer: Quartz Beloit One Network |
$40.18
|
| Rate for Payer: Quartz Commercial |
$53.30
|
| Rate for Payer: Quartz Medicare Advantage |
$49.20
|
| Rate for Payer: The Alliance Commercial |
$328.00
|
| Rate for Payer: United Healthcare PPO |
$61.50
|
| Rate for Payer: WEA Trust Commercial |
$45.10
|
| Rate for Payer: WPS Commercial |
$60.74
|
|
|
Yes - PT Telephone call 5-10 min Charge
|
Facility
IP
|
$82.00
|
|
|
Service Code
|
CPT 98966 GP,95
|
| Hospital Charge Code |
5585219
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$40.18 |
| Max. Negotiated Rate |
$75.44 |
| Rate for Payer: Aetna Commercial |
$73.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$43.46
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cigna Commercial |
$75.44
|
| Rate for Payer: Health EOS Commercial |
$72.98
|
| Rate for Payer: HFN Commercial |
$75.44
|
| Rate for Payer: Multiplan Commercial |
$65.60
|
| Rate for Payer: NAPHCARE Commercial |
$49.20
|
| Rate for Payer: Preferred Network Access Commercial |
$75.44
|
| Rate for Payer: Quartz Beloit One Network |
$40.18
|
| Rate for Payer: Quartz Commercial |
$49.20
|
| Rate for Payer: WEA Trust Commercial |
$45.10
|
| Rate for Payer: WPS Commercial |
$60.74
|
|
|
Yes - PT TH Evaluation High Complexity Chg
|
Facility
IP
|
$1,044.00
|
|
|
Service Code
|
CPT 97163 GP,95
|
| Hospital Charge Code |
5585345
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$511.56 |
| Max. Negotiated Rate |
$960.48 |
| Rate for Payer: Aetna Commercial |
$939.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$553.32
|
| Rate for Payer: Cash Price |
$313.20
|
| Rate for Payer: Cigna Commercial |
$960.48
|
| Rate for Payer: Health EOS Commercial |
$929.16
|
| Rate for Payer: HFN Commercial |
$960.48
|
| Rate for Payer: Multiplan Commercial |
$835.20
|
| Rate for Payer: NAPHCARE Commercial |
$626.40
|
| Rate for Payer: Preferred Network Access Commercial |
$960.48
|
| Rate for Payer: Quartz Beloit One Network |
$511.56
|
| Rate for Payer: Quartz Commercial |
$626.40
|
| Rate for Payer: WEA Trust Commercial |
$574.20
|
| Rate for Payer: WPS Commercial |
$773.29
|
|
|
Yes - PT TH Evaluation High Complexity Chg
|
Facility
OP
|
$1,044.00
|
|
|
Service Code
|
CPT 97163 GP,95
|
| Hospital Charge Code |
5585345
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$202.00 |
| Max. Negotiated Rate |
$4,176.00 |
| Rate for Payer: Aetna Commercial |
$939.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$897.84
|
| Rate for Payer: Aetna Managed Medicare |
$292.32
|
| 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 |
$553.32
|
| Rate for Payer: Cash Price |
$313.20
|
| Rate for Payer: Cash Price |
$313.20
|
| Rate for Payer: Cigna Commercial |
$960.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$584.22
|
| Rate for Payer: Health EOS Commercial |
$929.16
|
| Rate for Payer: HFN Commercial |
$960.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$835.20
|
| Rate for Payer: NAPHCARE Commercial |
$626.40
|
| Rate for Payer: Preferred Network Access Commercial |
$960.48
|
| Rate for Payer: Quartz Beloit One Network |
$511.56
|
| Rate for Payer: Quartz Commercial |
$678.60
|
| Rate for Payer: Quartz Medicare Advantage |
$626.40
|
| Rate for Payer: The Alliance Commercial |
$4,176.00
|
| Rate for Payer: United Healthcare PPO |
$783.00
|
| Rate for Payer: WEA Trust Commercial |
$574.20
|
| Rate for Payer: WPS Commercial |
$773.29
|
|
|
Yes - PT TH Evaluation Low Complexity Chg
|
Facility
IP
|
$332.00
|
|
|
Service Code
|
CPT 97161 GP,95
|
| Hospital Charge Code |
5585354
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$162.68 |
| Max. Negotiated Rate |
$305.44 |
| Rate for Payer: Aetna Commercial |
$298.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$175.96
|
| Rate for Payer: Cash Price |
$99.60
|
| Rate for Payer: Cigna Commercial |
$305.44
|
| Rate for Payer: Health EOS Commercial |
$295.48
|
| Rate for Payer: HFN Commercial |
$305.44
|
| Rate for Payer: Multiplan Commercial |
$265.60
|
| Rate for Payer: NAPHCARE Commercial |
$199.20
|
| Rate for Payer: Preferred Network Access Commercial |
$305.44
|
| Rate for Payer: Quartz Beloit One Network |
$162.68
|
| Rate for Payer: Quartz Commercial |
$199.20
|
| Rate for Payer: WEA Trust Commercial |
$182.60
|
| Rate for Payer: WPS Commercial |
$245.91
|
|
|
Yes - PT TH Evaluation Low Complexity Chg
|
Facility
OP
|
$332.00
|
|
|
Service Code
|
CPT 97161 GP,95
|
| Hospital Charge Code |
5585354
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$92.96 |
| Max. Negotiated Rate |
$1,328.00 |
| Rate for Payer: Aetna Commercial |
$298.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$285.52
|
| Rate for Payer: Aetna Managed Medicare |
$92.96
|
| 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 |
$175.96
|
| Rate for Payer: Cash Price |
$99.60
|
| Rate for Payer: Cash Price |
$99.60
|
| Rate for Payer: Cigna Commercial |
$305.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$185.79
|
| Rate for Payer: Health EOS Commercial |
$295.48
|
| Rate for Payer: HFN Commercial |
$305.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$265.60
|
| Rate for Payer: NAPHCARE Commercial |
$199.20
|
| Rate for Payer: Preferred Network Access Commercial |
$305.44
|
| Rate for Payer: Quartz Beloit One Network |
$162.68
|
| Rate for Payer: Quartz Commercial |
$215.80
|
| Rate for Payer: Quartz Medicare Advantage |
$199.20
|
| Rate for Payer: The Alliance Commercial |
$1,328.00
|
| Rate for Payer: United Healthcare PPO |
$249.00
|
| Rate for Payer: WEA Trust Commercial |
$182.60
|
| Rate for Payer: WPS Commercial |
$245.91
|
|
|
Yes - PT TH Evaluation Moderate Complexity Chg
|
Facility
OP
|
$666.00
|
|
|
Service Code
|
CPT 97162 GP,95
|
| Hospital Charge Code |
5585382
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$186.48 |
| Max. Negotiated Rate |
$2,664.00 |
| Rate for Payer: Aetna Commercial |
$599.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$572.76
|
| Rate for Payer: Aetna Managed Medicare |
$186.48
|
| 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 |
$352.98
|
| Rate for Payer: Cash Price |
$199.80
|
| Rate for Payer: Cash Price |
$199.80
|
| Rate for Payer: Cigna Commercial |
$612.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$372.69
|
| Rate for Payer: Health EOS Commercial |
$592.74
|
| Rate for Payer: HFN Commercial |
$612.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$532.80
|
| Rate for Payer: NAPHCARE Commercial |
$399.60
|
| Rate for Payer: Preferred Network Access Commercial |
$612.72
|
| Rate for Payer: Quartz Beloit One Network |
$326.34
|
| Rate for Payer: Quartz Commercial |
$432.90
|
| Rate for Payer: Quartz Medicare Advantage |
$399.60
|
| Rate for Payer: The Alliance Commercial |
$2,664.00
|
| Rate for Payer: United Healthcare PPO |
$499.50
|
| Rate for Payer: WEA Trust Commercial |
$366.30
|
| Rate for Payer: WPS Commercial |
$493.31
|
|
|
Yes - PT TH Evaluation Moderate Complexity Chg
|
Facility
IP
|
$666.00
|
|
|
Service Code
|
CPT 97162 GP,95
|
| Hospital Charge Code |
5585382
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$326.34 |
| Max. Negotiated Rate |
$612.72 |
| Rate for Payer: Aetna Commercial |
$599.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$352.98
|
| Rate for Payer: Cash Price |
$199.80
|
| Rate for Payer: Cigna Commercial |
$612.72
|
| Rate for Payer: Health EOS Commercial |
$592.74
|
| Rate for Payer: HFN Commercial |
$612.72
|
| Rate for Payer: Multiplan Commercial |
$532.80
|
| Rate for Payer: NAPHCARE Commercial |
$399.60
|
| Rate for Payer: Preferred Network Access Commercial |
$612.72
|
| Rate for Payer: Quartz Beloit One Network |
$326.34
|
| Rate for Payer: Quartz Commercial |
$399.60
|
| Rate for Payer: WEA Trust Commercial |
$366.30
|
| Rate for Payer: WPS Commercial |
$493.31
|
|
|
Yes - PT TH Reevaluation Chg
|
Facility
OP
|
$251.00
|
|
|
Service Code
|
CPT 97164 GP,95
|
| Hospital Charge Code |
5585407
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$70.28 |
| Max. Negotiated Rate |
$1,004.00 |
| Rate for Payer: Aetna Commercial |
$225.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$215.86
|
| Rate for Payer: Aetna Managed Medicare |
$70.28
|
| 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 |
$133.03
|
| Rate for Payer: Cash Price |
$75.30
|
| Rate for Payer: Cash Price |
$75.30
|
| Rate for Payer: Cigna Commercial |
$230.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$140.46
|
| Rate for Payer: Health EOS Commercial |
$223.39
|
| Rate for Payer: HFN Commercial |
$230.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$200.80
|
| Rate for Payer: NAPHCARE Commercial |
$150.60
|
| Rate for Payer: Preferred Network Access Commercial |
$230.92
|
| Rate for Payer: Quartz Beloit One Network |
$122.99
|
| Rate for Payer: Quartz Commercial |
$163.15
|
| Rate for Payer: Quartz Medicare Advantage |
$150.60
|
| Rate for Payer: The Alliance Commercial |
$1,004.00
|
| Rate for Payer: United Healthcare PPO |
$188.25
|
| Rate for Payer: WEA Trust Commercial |
$138.05
|
| Rate for Payer: WPS Commercial |
$185.92
|
|
|
Yes - PT TH Reevaluation Chg
|
Facility
IP
|
$251.00
|
|
|
Service Code
|
CPT 97164 GP,95
|
| Hospital Charge Code |
5585407
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$122.99 |
| Max. Negotiated Rate |
$230.92 |
| Rate for Payer: Aetna Commercial |
$225.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$133.03
|
| Rate for Payer: Cash Price |
$75.30
|
| Rate for Payer: Cigna Commercial |
$230.92
|
| Rate for Payer: Health EOS Commercial |
$223.39
|
| Rate for Payer: HFN Commercial |
$230.92
|
| Rate for Payer: Multiplan Commercial |
$200.80
|
| Rate for Payer: NAPHCARE Commercial |
$150.60
|
| Rate for Payer: Preferred Network Access Commercial |
$230.92
|
| Rate for Payer: Quartz Beloit One Network |
$122.99
|
| Rate for Payer: Quartz Commercial |
$150.60
|
| Rate for Payer: WEA Trust Commercial |
$138.05
|
| Rate for Payer: WPS Commercial |
$185.92
|
|
|
Yes - PT Ultrasound Charges
|
Professional
|
$159.00
|
|
|
Service Code
|
CPT 97035 GP
|
| Hospital Charge Code |
2989859
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$69.96 |
| Max. Negotiated Rate |
$151.05 |
| Rate for Payer: Aetna Commercial |
$151.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$136.74
|
| Rate for Payer: Cash Price |
$47.70
|
| Rate for Payer: Cash Price |
$47.70
|
| Rate for Payer: Cigna Commercial |
$151.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$79.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$95.40
|
| Rate for Payer: Health EOS Commercial |
$144.69
|
| Rate for Payer: Multiplan Commercial |
$127.20
|
| Rate for Payer: Preferred Network Access Commercial |
$151.05
|
| Rate for Payer: Quartz Beloit One Network |
$69.96
|
| Rate for Payer: Quartz Commercial |
$90.63
|
| Rate for Payer: The Alliance Commercial |
$79.50
|
| Rate for Payer: WEA Trust Commercial |
$87.45
|
| Rate for Payer: WPS Commercial |
$117.77
|
|
|
Yes - PT Ultrasound Charges
|
Facility
OP
|
$159.00
|
|
|
Service Code
|
CPT 97035 GP
|
| Hospital Charge Code |
2989859
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$44.52 |
| Max. Negotiated Rate |
$636.00 |
| Rate for Payer: Aetna Commercial |
$143.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$136.74
|
| Rate for Payer: Aetna Managed Medicare |
$44.52
|
| 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 |
$84.27
|
| Rate for Payer: Cash Price |
$47.70
|
| Rate for Payer: Cash Price |
$47.70
|
| Rate for Payer: Cigna Commercial |
$146.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$88.98
|
| Rate for Payer: Health EOS Commercial |
$141.51
|
| Rate for Payer: HFN Commercial |
$146.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$127.20
|
| Rate for Payer: NAPHCARE Commercial |
$95.40
|
| Rate for Payer: Preferred Network Access Commercial |
$146.28
|
| Rate for Payer: Quartz Beloit One Network |
$77.91
|
| Rate for Payer: Quartz Commercial |
$103.35
|
| Rate for Payer: Quartz Medicare Advantage |
$95.40
|
| Rate for Payer: The Alliance Commercial |
$636.00
|
| Rate for Payer: United Healthcare PPO |
$119.25
|
| Rate for Payer: WEA Trust Commercial |
$87.45
|
| Rate for Payer: WPS Commercial |
$117.77
|
|
