|
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 |
$185.49 |
| Max. Negotiated Rate |
$348.28 |
| Rate for Payer: Aetna Commercial |
$340.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$325.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$200.64
|
| Rate for Payer: Cash Price |
$109.20
|
| Rate for Payer: Cigna Commercial |
$348.28
|
| Rate for Payer: Health EOS Commercial |
$336.92
|
| Rate for Payer: HFN Commercial |
$348.28
|
| Rate for Payer: Multiplan Commercial |
$302.85
|
| Rate for Payer: Preferred Network Access Commercial |
$348.28
|
| Rate for Payer: Quartz Beloit One Network |
$185.49
|
| Rate for Payer: Quartz Commercial |
$227.14
|
| Rate for Payer: WEA Trust Commercial |
$208.21
|
| Rate for Payer: WPS Commercial |
$280.39
|
|
|
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 |
$88.16 |
| Max. Negotiated Rate |
$165.53 |
| Rate for Payer: Aetna Commercial |
$161.93
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$154.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$95.36
|
| Rate for Payer: Cash Price |
$51.90
|
| Rate for Payer: Cigna Commercial |
$165.53
|
| Rate for Payer: Health EOS Commercial |
$160.13
|
| Rate for Payer: HFN Commercial |
$165.53
|
| Rate for Payer: Multiplan Commercial |
$143.94
|
| Rate for Payer: Preferred Network Access Commercial |
$165.53
|
| Rate for Payer: Quartz Beloit One Network |
$88.16
|
| Rate for Payer: Quartz Commercial |
$107.95
|
| Rate for Payer: WEA Trust Commercial |
$98.96
|
| Rate for Payer: WPS Commercial |
$133.26
|
|
|
Yes - PT E-Stim Attended Charges
|
Professional
|
Both
|
$173.00
|
|
|
Service Code
|
CPT 97032 GP
|
| Hospital Charge Code |
2989871
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$79.16 |
| Max. Negotiated Rate |
$170.92 |
| Rate for Payer: Aetna Commercial |
$170.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$154.73
|
| Rate for Payer: Cash Price |
$51.90
|
| Rate for Payer: Cash Price |
$51.90
|
| Rate for Payer: Cigna Commercial |
$170.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$89.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$107.95
|
| Rate for Payer: Health EOS Commercial |
$163.73
|
| Rate for Payer: HFN Commercial |
$170.92
|
| Rate for Payer: Multiplan Commercial |
$143.94
|
| Rate for Payer: Preferred Network Access Commercial |
$170.92
|
| Rate for Payer: Quartz Beloit One Network |
$79.16
|
| Rate for Payer: Quartz Commercial |
$102.55
|
| Rate for Payer: The Alliance Commercial |
$89.96
|
| Rate for Payer: WEA Trust Commercial |
$98.96
|
| Rate for Payer: WPS Commercial |
$133.26
|
|
|
Yes - PT E-Stim Attended Charges
|
Facility
|
OP
|
$173.00
|
|
|
Service Code
|
CPT 97032 GP
|
| Hospital Charge Code |
2989871
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$50.38 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$161.93
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$154.73
|
| Rate for Payer: Aetna Managed Medicare |
$50.38
|
| 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 |
$95.36
|
| Rate for Payer: Cash Price |
$51.90
|
| Rate for Payer: Cash Price |
$51.90
|
| Rate for Payer: Cigna Commercial |
$165.53
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$100.69
|
| Rate for Payer: Health EOS Commercial |
$160.13
|
| Rate for Payer: HFN Commercial |
$165.53
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$143.94
|
| Rate for Payer: NAPHCARE Commercial |
$107.95
|
| Rate for Payer: Preferred Network Access Commercial |
$165.53
|
| Rate for Payer: Quartz Beloit One Network |
$88.16
|
| Rate for Payer: Quartz Commercial |
$116.95
|
| Rate for Payer: Quartz Medicare Advantage |
$107.95
|
| Rate for Payer: The Alliance Commercial |
$89.96
|
| Rate for Payer: United Healthcare PPO |
$134.94
|
| Rate for Payer: WEA Trust Commercial |
$98.96
|
| Rate for Payer: WPS Commercial |
$133.26
|
|
|
Yes - PT E-Stim Unattended Charges
|
Professional
|
Both
|
$173.00
|
|
|
Service Code
|
CPT 97014 GP
|
| Hospital Charge Code |
3007926
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$5.20 |
| Max. Negotiated Rate |
$170.92 |
| Rate for Payer: Aetna Commercial |
$170.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$154.73
|
| Rate for Payer: Anthem Commercial |
$5.20
|
| Rate for Payer: Cash Price |
$51.90
|
| Rate for Payer: Cash Price |
$51.90
|
| Rate for Payer: Cigna Commercial |
$170.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$89.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$107.95
|
| Rate for Payer: Health EOS Commercial |
$163.73
|
| Rate for Payer: HFN Commercial |
$170.92
|
| Rate for Payer: Multiplan Commercial |
$143.94
|
| Rate for Payer: Preferred Network Access Commercial |
$170.92
|
| Rate for Payer: Quartz Beloit One Network |
$79.16
|
| Rate for Payer: Quartz Commercial |
$102.55
|
| Rate for Payer: The Alliance Commercial |
$89.96
|
| Rate for Payer: WEA Trust Commercial |
$98.96
|
| Rate for Payer: WPS Commercial |
$133.26
|
|
|
Yes - PT E-Stim Unattended Charges
|
Facility
|
IP
|
$173.00
|
|
|
Service Code
|
CPT 97014 GP
|
| Hospital Charge Code |
3007926
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$88.16 |
| Max. Negotiated Rate |
$165.53 |
| Rate for Payer: Aetna Commercial |
$161.93
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$154.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$95.36
|
| Rate for Payer: Cash Price |
$51.90
|
| Rate for Payer: Cigna Commercial |
$165.53
|
| Rate for Payer: Health EOS Commercial |
$160.13
|
| Rate for Payer: HFN Commercial |
$165.53
|
| Rate for Payer: Multiplan Commercial |
$143.94
|
| Rate for Payer: Preferred Network Access Commercial |
$165.53
|
| Rate for Payer: Quartz Beloit One Network |
$88.16
|
| Rate for Payer: Quartz Commercial |
$107.95
|
| Rate for Payer: WEA Trust Commercial |
$98.96
|
| Rate for Payer: WPS Commercial |
$133.26
|
|
|
Yes - PT E-Stim Unattended Charges
|
Facility
|
OP
|
$173.00
|
|
|
Service Code
|
CPT 97014 GP
|
| Hospital Charge Code |
3007926
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$50.38 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$161.93
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$154.73
|
| Rate for Payer: Aetna Managed Medicare |
$50.38
|
| 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 |
$95.36
|
| Rate for Payer: Cash Price |
$51.90
|
| Rate for Payer: Cash Price |
$51.90
|
| Rate for Payer: Cigna Commercial |
$165.53
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$100.69
|
| Rate for Payer: Health EOS Commercial |
$160.13
|
| Rate for Payer: HFN Commercial |
$165.53
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$143.94
|
| Rate for Payer: NAPHCARE Commercial |
$107.95
|
| Rate for Payer: Preferred Network Access Commercial |
$165.53
|
| Rate for Payer: Quartz Beloit One Network |
$88.16
|
| Rate for Payer: Quartz Commercial |
$116.95
|
| Rate for Payer: Quartz Medicare Advantage |
$107.95
|
| Rate for Payer: The Alliance Commercial |
$89.96
|
| Rate for Payer: United Healthcare PPO |
$134.94
|
| Rate for Payer: WEA Trust Commercial |
$98.96
|
| Rate for Payer: WPS Commercial |
$133.26
|
|
|
Yes - PT Evaluation High Charge
|
Facility
|
IP
|
$702.00
|
|
|
Service Code
|
CPT 97163 GP
|
| Hospital Charge Code |
5149521
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$357.74 |
| Max. Negotiated Rate |
$671.67 |
| Rate for Payer: Aetna Commercial |
$657.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$627.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$386.94
|
| Rate for Payer: Cash Price |
$210.60
|
| Rate for Payer: Cigna Commercial |
$671.67
|
| Rate for Payer: Health EOS Commercial |
$649.77
|
| Rate for Payer: HFN Commercial |
$671.67
|
| Rate for Payer: Multiplan Commercial |
$584.06
|
| Rate for Payer: Preferred Network Access Commercial |
$671.67
|
| Rate for Payer: Quartz Beloit One Network |
$357.74
|
| Rate for Payer: Quartz Commercial |
$438.05
|
| Rate for Payer: WEA Trust Commercial |
$401.54
|
| Rate for Payer: WPS Commercial |
$540.75
|
|
|
Yes - PT Evaluation High Charge
|
Professional
|
Both
|
$702.00
|
|
|
Service Code
|
CPT 97163 GP
|
| Hospital Charge Code |
5149521
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$321.24 |
| Max. Negotiated Rate |
$693.58 |
| Rate for Payer: Aetna Commercial |
$693.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$627.87
|
| Rate for Payer: Cash Price |
$210.60
|
| Rate for Payer: Cash Price |
$210.60
|
| Rate for Payer: Cigna Commercial |
$693.58
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$365.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$438.05
|
| Rate for Payer: Health EOS Commercial |
$664.37
|
| Rate for Payer: HFN Commercial |
$693.58
|
| Rate for Payer: Multiplan Commercial |
$584.06
|
| Rate for Payer: Preferred Network Access Commercial |
$693.58
|
| Rate for Payer: Quartz Beloit One Network |
$321.24
|
| Rate for Payer: Quartz Commercial |
$416.15
|
| Rate for Payer: The Alliance Commercial |
$365.04
|
| Rate for Payer: WEA Trust Commercial |
$401.54
|
| Rate for Payer: WPS Commercial |
$540.75
|
|
|
Yes - PT Evaluation High Charge
|
Facility
|
OP
|
$702.00
|
|
|
Service Code
|
CPT 97163 GP
|
| Hospital Charge Code |
5149521
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$204.42 |
| Max. Negotiated Rate |
$671.67 |
| Rate for Payer: Aetna Commercial |
$657.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$627.87
|
| Rate for Payer: Aetna Managed Medicare |
$204.42
|
| 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 |
$386.94
|
| Rate for Payer: Cash Price |
$210.60
|
| Rate for Payer: Cash Price |
$210.60
|
| Rate for Payer: Cigna Commercial |
$671.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$408.56
|
| Rate for Payer: Health EOS Commercial |
$649.77
|
| Rate for Payer: HFN Commercial |
$671.67
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$584.06
|
| Rate for Payer: NAPHCARE Commercial |
$438.05
|
| Rate for Payer: Preferred Network Access Commercial |
$671.67
|
| Rate for Payer: Quartz Beloit One Network |
$357.74
|
| Rate for Payer: Quartz Commercial |
$474.55
|
| Rate for Payer: Quartz Medicare Advantage |
$438.05
|
| Rate for Payer: The Alliance Commercial |
$365.04
|
| Rate for Payer: United Healthcare PPO |
$547.56
|
| Rate for Payer: WEA Trust Commercial |
$401.54
|
| Rate for Payer: WPS Commercial |
$540.75
|
|
|
Yes - PT Evaluation Low Charge
|
Facility
|
IP
|
$415.00
|
|
|
Service Code
|
CPT 97161 GP
|
| Hospital Charge Code |
5149519
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$211.48 |
| Max. Negotiated Rate |
$397.07 |
| Rate for Payer: Aetna Commercial |
$388.44
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$371.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$228.75
|
| Rate for Payer: Cash Price |
$124.50
|
| Rate for Payer: Cigna Commercial |
$397.07
|
| Rate for Payer: Health EOS Commercial |
$384.12
|
| Rate for Payer: HFN Commercial |
$397.07
|
| Rate for Payer: Multiplan Commercial |
$345.28
|
| Rate for Payer: Preferred Network Access Commercial |
$397.07
|
| Rate for Payer: Quartz Beloit One Network |
$211.48
|
| Rate for Payer: Quartz Commercial |
$258.96
|
| Rate for Payer: WEA Trust Commercial |
$237.38
|
| Rate for Payer: WPS Commercial |
$319.67
|
|
|
Yes - PT Evaluation Low Charge
|
Professional
|
Both
|
$415.00
|
|
|
Service Code
|
CPT 97161 GP
|
| Hospital Charge Code |
5149519
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$189.90 |
| Max. Negotiated Rate |
$410.02 |
| Rate for Payer: Aetna Commercial |
$410.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$371.18
|
| Rate for Payer: Cash Price |
$124.50
|
| Rate for Payer: Cash Price |
$124.50
|
| Rate for Payer: Cigna Commercial |
$410.02
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$215.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$258.96
|
| Rate for Payer: Health EOS Commercial |
$392.76
|
| Rate for Payer: HFN Commercial |
$410.02
|
| Rate for Payer: Multiplan Commercial |
$345.28
|
| Rate for Payer: Preferred Network Access Commercial |
$410.02
|
| Rate for Payer: Quartz Beloit One Network |
$189.90
|
| Rate for Payer: Quartz Commercial |
$246.01
|
| Rate for Payer: The Alliance Commercial |
$215.80
|
| Rate for Payer: WEA Trust Commercial |
$237.38
|
| Rate for Payer: WPS Commercial |
$319.67
|
|
|
Yes - PT Evaluation Low Charge
|
Facility
|
OP
|
$415.00
|
|
|
Service Code
|
CPT 97161 GP
|
| Hospital Charge Code |
5149519
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$120.85 |
| Max. Negotiated Rate |
$397.07 |
| Rate for Payer: Aetna Commercial |
$388.44
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$371.18
|
| Rate for Payer: Aetna Managed Medicare |
$120.85
|
| 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 |
$228.75
|
| Rate for Payer: Cash Price |
$124.50
|
| Rate for Payer: Cash Price |
$124.50
|
| Rate for Payer: Cigna Commercial |
$397.07
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$241.53
|
| Rate for Payer: Health EOS Commercial |
$384.12
|
| Rate for Payer: HFN Commercial |
$397.07
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$345.28
|
| Rate for Payer: NAPHCARE Commercial |
$258.96
|
| Rate for Payer: Preferred Network Access Commercial |
$397.07
|
| Rate for Payer: Quartz Beloit One Network |
$211.48
|
| Rate for Payer: Quartz Commercial |
$280.54
|
| Rate for Payer: Quartz Medicare Advantage |
$258.96
|
| Rate for Payer: The Alliance Commercial |
$215.80
|
| Rate for Payer: United Healthcare PPO |
$323.70
|
| Rate for Payer: WEA Trust Commercial |
$237.38
|
| Rate for Payer: WPS Commercial |
$319.67
|
|
|
Yes - PT Evaluation Moderate Charge
|
Professional
|
Both
|
$640.00
|
|
|
Service Code
|
CPT 97162 GP
|
| Hospital Charge Code |
5149520
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$292.86 |
| Max. Negotiated Rate |
$632.32 |
| Rate for Payer: Aetna Commercial |
$632.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$572.42
|
| Rate for Payer: Cash Price |
$192.00
|
| Rate for Payer: Cash Price |
$192.00
|
| Rate for Payer: Cigna Commercial |
$632.32
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$332.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$399.36
|
| Rate for Payer: Health EOS Commercial |
$605.70
|
| Rate for Payer: HFN Commercial |
$632.32
|
| Rate for Payer: Multiplan Commercial |
$532.48
|
| Rate for Payer: Preferred Network Access Commercial |
$632.32
|
| Rate for Payer: Quartz Beloit One Network |
$292.86
|
| Rate for Payer: Quartz Commercial |
$379.39
|
| Rate for Payer: The Alliance Commercial |
$332.80
|
| Rate for Payer: WEA Trust Commercial |
$366.08
|
| Rate for Payer: WPS Commercial |
$492.99
|
|
|
Yes - PT Evaluation Moderate Charge
|
Facility
|
IP
|
$640.00
|
|
|
Service Code
|
CPT 97162 GP
|
| Hospital Charge Code |
5149520
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$326.14 |
| Max. Negotiated Rate |
$612.35 |
| Rate for Payer: Aetna Commercial |
$599.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$572.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$352.77
|
| Rate for Payer: Cash Price |
$192.00
|
| Rate for Payer: Cigna Commercial |
$612.35
|
| Rate for Payer: Health EOS Commercial |
$592.38
|
| Rate for Payer: HFN Commercial |
$612.35
|
| Rate for Payer: Multiplan Commercial |
$532.48
|
| Rate for Payer: Preferred Network Access Commercial |
$612.35
|
| Rate for Payer: Quartz Beloit One Network |
$326.14
|
| Rate for Payer: Quartz Commercial |
$399.36
|
| Rate for Payer: WEA Trust Commercial |
$366.08
|
| Rate for Payer: WPS Commercial |
$492.99
|
|
|
Yes - PT Evaluation Moderate Charge
|
Facility
|
OP
|
$640.00
|
|
|
Service Code
|
CPT 97162 GP
|
| Hospital Charge Code |
5149520
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$186.37 |
| Max. Negotiated Rate |
$612.35 |
| Rate for Payer: Aetna Commercial |
$599.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$572.42
|
| Rate for Payer: Aetna Managed Medicare |
$186.37
|
| 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 |
$352.77
|
| Rate for Payer: Cash Price |
$192.00
|
| Rate for Payer: Cash Price |
$192.00
|
| Rate for Payer: Cigna Commercial |
$612.35
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$372.48
|
| Rate for Payer: Health EOS Commercial |
$592.38
|
| Rate for Payer: HFN Commercial |
$612.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$532.48
|
| Rate for Payer: NAPHCARE Commercial |
$399.36
|
| Rate for Payer: Preferred Network Access Commercial |
$612.35
|
| Rate for Payer: Quartz Beloit One Network |
$326.14
|
| Rate for Payer: Quartz Commercial |
$432.64
|
| Rate for Payer: Quartz Medicare Advantage |
$399.36
|
| Rate for Payer: The Alliance Commercial |
$332.80
|
| Rate for Payer: United Healthcare PPO |
$499.20
|
| Rate for Payer: WEA Trust Commercial |
$366.08
|
| Rate for Payer: WPS Commercial |
$492.99
|
|
|
Yes - PT Fluidotherapy Charge
|
Professional
|
Both
|
$186.00
|
|
|
Service Code
|
CPT 97022 GP
|
| Hospital Charge Code |
2987956
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$85.11 |
| Max. Negotiated Rate |
$183.77 |
| Rate for Payer: Aetna Commercial |
$183.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$166.36
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cigna Commercial |
$183.77
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$96.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$116.06
|
| Rate for Payer: Health EOS Commercial |
$176.03
|
| Rate for Payer: HFN Commercial |
$183.77
|
| Rate for Payer: Multiplan Commercial |
$154.75
|
| Rate for Payer: Preferred Network Access Commercial |
$183.77
|
| Rate for Payer: Quartz Beloit One Network |
$85.11
|
| Rate for Payer: Quartz Commercial |
$110.26
|
| Rate for Payer: The Alliance Commercial |
$96.72
|
| Rate for Payer: WEA Trust Commercial |
$106.39
|
| Rate for Payer: WPS Commercial |
$143.28
|
|
|
Yes - PT Fluidotherapy Charge
|
Facility
|
IP
|
$186.00
|
|
|
Service Code
|
CPT 97022 GP
|
| Hospital Charge Code |
2987956
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$94.79 |
| Max. Negotiated Rate |
$177.96 |
| Rate for Payer: Aetna Commercial |
$174.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$166.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$102.52
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cigna Commercial |
$177.96
|
| Rate for Payer: Health EOS Commercial |
$172.16
|
| Rate for Payer: HFN Commercial |
$177.96
|
| Rate for Payer: Multiplan Commercial |
$154.75
|
| Rate for Payer: Preferred Network Access Commercial |
$177.96
|
| Rate for Payer: Quartz Beloit One Network |
$94.79
|
| Rate for Payer: Quartz Commercial |
$116.06
|
| Rate for Payer: WEA Trust Commercial |
$106.39
|
| Rate for Payer: WPS Commercial |
$143.28
|
|
|
Yes - PT Fluidotherapy Charge
|
Facility
|
OP
|
$186.00
|
|
|
Service Code
|
CPT 97022 GP
|
| Hospital Charge Code |
2987956
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$54.16 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$174.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$166.36
|
| Rate for Payer: Aetna Managed Medicare |
$54.16
|
| 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 |
$102.52
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cigna Commercial |
$177.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$108.25
|
| Rate for Payer: Health EOS Commercial |
$172.16
|
| Rate for Payer: HFN Commercial |
$177.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$154.75
|
| Rate for Payer: NAPHCARE Commercial |
$116.06
|
| Rate for Payer: Preferred Network Access Commercial |
$177.96
|
| Rate for Payer: Quartz Beloit One Network |
$94.79
|
| Rate for Payer: Quartz Commercial |
$125.74
|
| Rate for Payer: Quartz Medicare Advantage |
$116.06
|
| Rate for Payer: The Alliance Commercial |
$96.72
|
| Rate for Payer: United Healthcare PPO |
$145.08
|
| Rate for Payer: WEA Trust Commercial |
$106.39
|
| Rate for Payer: WPS Commercial |
$143.28
|
|
|
Yes - PT Group Therapy Charge
|
Facility
|
IP
|
$249.00
|
|
|
Service Code
|
CPT 97150 GP
|
| Hospital Charge Code |
2989695
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$126.89 |
| Max. Negotiated Rate |
$238.24 |
| Rate for Payer: Aetna Commercial |
$233.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$222.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$137.25
|
| Rate for Payer: Cash Price |
$74.70
|
| Rate for Payer: Cigna Commercial |
$238.24
|
| Rate for Payer: Health EOS Commercial |
$230.47
|
| Rate for Payer: HFN Commercial |
$238.24
|
| Rate for Payer: Multiplan Commercial |
$207.17
|
| Rate for Payer: Preferred Network Access Commercial |
$238.24
|
| Rate for Payer: Quartz Beloit One Network |
$126.89
|
| Rate for Payer: Quartz Commercial |
$155.38
|
| Rate for Payer: WEA Trust Commercial |
$142.43
|
| Rate for Payer: WPS Commercial |
$191.80
|
|
|
Yes - PT Group Therapy Charge
|
Professional
|
Both
|
$249.00
|
|
|
Service Code
|
CPT 97150 GP
|
| Hospital Charge Code |
2989695
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$113.94 |
| Max. Negotiated Rate |
$246.01 |
| Rate for Payer: Aetna Commercial |
$246.01
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$222.71
|
| Rate for Payer: Cash Price |
$74.70
|
| Rate for Payer: Cash Price |
$74.70
|
| Rate for Payer: Cigna Commercial |
$246.01
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$129.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$155.38
|
| Rate for Payer: Health EOS Commercial |
$235.65
|
| Rate for Payer: HFN Commercial |
$246.01
|
| Rate for Payer: Multiplan Commercial |
$207.17
|
| Rate for Payer: Preferred Network Access Commercial |
$246.01
|
| Rate for Payer: Quartz Beloit One Network |
$113.94
|
| Rate for Payer: Quartz Commercial |
$147.61
|
| Rate for Payer: The Alliance Commercial |
$129.48
|
| Rate for Payer: WEA Trust Commercial |
$142.43
|
| Rate for Payer: WPS Commercial |
$191.80
|
|
|
Yes - PT Group Therapy Charge
|
Facility
|
OP
|
$249.00
|
|
|
Service Code
|
CPT 97150 GP
|
| Hospital Charge Code |
2989695
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$72.51 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$233.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$222.71
|
| Rate for Payer: Aetna Managed Medicare |
$72.51
|
| 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 |
$137.25
|
| Rate for Payer: Cash Price |
$74.70
|
| Rate for Payer: Cash Price |
$74.70
|
| Rate for Payer: Cigna Commercial |
$238.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$144.92
|
| Rate for Payer: Health EOS Commercial |
$230.47
|
| Rate for Payer: HFN Commercial |
$238.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$207.17
|
| Rate for Payer: NAPHCARE Commercial |
$155.38
|
| Rate for Payer: Preferred Network Access Commercial |
$238.24
|
| Rate for Payer: Quartz Beloit One Network |
$126.89
|
| Rate for Payer: Quartz Commercial |
$168.32
|
| Rate for Payer: Quartz Medicare Advantage |
$155.38
|
| Rate for Payer: The Alliance Commercial |
$129.48
|
| Rate for Payer: United Healthcare PPO |
$194.22
|
| Rate for Payer: WEA Trust Commercial |
$142.43
|
| Rate for Payer: WPS Commercial |
$191.80
|
|
|
Yes - PT Iontophoresis Charges
|
Facility
|
IP
|
$307.00
|
|
|
Service Code
|
CPT 97033 GP
|
| Hospital Charge Code |
2989866
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$156.45 |
| Max. Negotiated Rate |
$293.74 |
| Rate for Payer: Aetna Commercial |
$287.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$274.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$169.22
|
| Rate for Payer: Cash Price |
$92.10
|
| Rate for Payer: Cigna Commercial |
$293.74
|
| Rate for Payer: Health EOS Commercial |
$284.16
|
| Rate for Payer: HFN Commercial |
$293.74
|
| Rate for Payer: Multiplan Commercial |
$255.42
|
| Rate for Payer: Preferred Network Access Commercial |
$293.74
|
| Rate for Payer: Quartz Beloit One Network |
$156.45
|
| Rate for Payer: Quartz Commercial |
$191.57
|
| Rate for Payer: WEA Trust Commercial |
$175.60
|
| Rate for Payer: WPS Commercial |
$236.48
|
|
|
Yes - PT Iontophoresis Charges
|
Professional
|
Both
|
$307.00
|
|
|
Service Code
|
CPT 97033 GP
|
| Hospital Charge Code |
2989866
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$140.48 |
| Max. Negotiated Rate |
$303.32 |
| Rate for Payer: Aetna Commercial |
$303.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$274.58
|
| Rate for Payer: Cash Price |
$92.10
|
| Rate for Payer: Cash Price |
$92.10
|
| Rate for Payer: Cigna Commercial |
$303.32
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$159.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$191.57
|
| Rate for Payer: Health EOS Commercial |
$290.54
|
| Rate for Payer: HFN Commercial |
$303.32
|
| Rate for Payer: Multiplan Commercial |
$255.42
|
| Rate for Payer: Preferred Network Access Commercial |
$303.32
|
| Rate for Payer: Quartz Beloit One Network |
$140.48
|
| Rate for Payer: Quartz Commercial |
$181.99
|
| Rate for Payer: The Alliance Commercial |
$159.64
|
| Rate for Payer: WEA Trust Commercial |
$175.60
|
| Rate for Payer: WPS Commercial |
$236.48
|
|
|
Yes - PT Iontophoresis Charges
|
Facility
|
OP
|
$307.00
|
|
|
Service Code
|
CPT 97033 GP
|
| Hospital Charge Code |
2989866
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$89.40 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$287.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$274.58
|
| Rate for Payer: Aetna Managed Medicare |
$89.40
|
| 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 |
$169.22
|
| Rate for Payer: Cash Price |
$92.10
|
| Rate for Payer: Cash Price |
$92.10
|
| Rate for Payer: Cigna Commercial |
$293.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$178.67
|
| Rate for Payer: Health EOS Commercial |
$284.16
|
| Rate for Payer: HFN Commercial |
$293.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$255.42
|
| Rate for Payer: NAPHCARE Commercial |
$191.57
|
| Rate for Payer: Preferred Network Access Commercial |
$293.74
|
| Rate for Payer: Quartz Beloit One Network |
$156.45
|
| Rate for Payer: Quartz Commercial |
$207.53
|
| Rate for Payer: Quartz Medicare Advantage |
$191.57
|
| Rate for Payer: The Alliance Commercial |
$159.64
|
| Rate for Payer: United Healthcare PPO |
$239.46
|
| Rate for Payer: WEA Trust Commercial |
$175.60
|
| Rate for Payer: WPS Commercial |
$236.48
|
|
