|
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 |
$85.10 |
| Max. Negotiated Rate |
$159.79 |
| Rate for Payer: Aetna Commercial |
$156.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$149.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$92.05
|
| Rate for Payer: Cash Price |
$50.10
|
| Rate for Payer: Cigna Commercial |
$159.79
|
| Rate for Payer: Health EOS Commercial |
$154.58
|
| Rate for Payer: HFN Commercial |
$159.79
|
| Rate for Payer: Multiplan Commercial |
$138.94
|
| Rate for Payer: Preferred Network Access Commercial |
$159.79
|
| Rate for Payer: Quartz Beloit One Network |
$85.10
|
| Rate for Payer: Quartz Commercial |
$104.21
|
| Rate for Payer: WEA Trust Commercial |
$95.52
|
| Rate for Payer: WPS Commercial |
$128.64
|
|
|
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 |
$60.28 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$193.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$185.14
|
| Rate for Payer: Aetna Managed Medicare |
$60.28
|
| 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 |
$114.10
|
| Rate for Payer: Cash Price |
$62.10
|
| Rate for Payer: Cash Price |
$62.10
|
| Rate for Payer: Cigna Commercial |
$198.06
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$120.47
|
| Rate for Payer: Health EOS Commercial |
$191.60
|
| Rate for Payer: HFN Commercial |
$198.06
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$172.22
|
| Rate for Payer: NAPHCARE Commercial |
$129.17
|
| Rate for Payer: Preferred Network Access Commercial |
$198.06
|
| Rate for Payer: Quartz Beloit One Network |
$105.49
|
| Rate for Payer: Quartz Commercial |
$139.93
|
| Rate for Payer: Quartz Medicare Advantage |
$129.17
|
| Rate for Payer: The Alliance Commercial |
$107.64
|
| Rate for Payer: United Healthcare PPO |
$161.46
|
| Rate for Payer: WEA Trust Commercial |
$118.40
|
| Rate for Payer: WPS Commercial |
$159.45
|
|
|
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 |
$105.49 |
| Max. Negotiated Rate |
$198.06 |
| Rate for Payer: Aetna Commercial |
$193.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$185.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$114.10
|
| Rate for Payer: Cash Price |
$62.10
|
| Rate for Payer: Cigna Commercial |
$198.06
|
| Rate for Payer: Health EOS Commercial |
$191.60
|
| Rate for Payer: HFN Commercial |
$198.06
|
| Rate for Payer: Multiplan Commercial |
$172.22
|
| Rate for Payer: Preferred Network Access Commercial |
$198.06
|
| Rate for Payer: Quartz Beloit One Network |
$105.49
|
| Rate for Payer: Quartz Commercial |
$129.17
|
| Rate for Payer: WEA Trust Commercial |
$118.40
|
| Rate for Payer: WPS Commercial |
$159.45
|
|
|
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 |
$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 - PTA Whirlpool Charge
|
Facility
|
OP
|
$186.00
|
|
|
Service Code
|
CPT 97022 GP,CQ
|
| Hospital Charge Code |
5565378
|
|
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 - PTA Whirlpool Charge
|
Professional
|
Both
|
$186.00
|
|
|
Service Code
|
CPT 97022 GP,CQ
|
| Hospital Charge Code |
5565378
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$63.18 |
| 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: 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: Humana Commercial/EPO/HMO/POS/PPO |
$63.18
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$63.18
|
| 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 - 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 |
$92.31 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$296.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$283.52
|
| Rate for Payer: Aetna Managed Medicare |
$92.31
|
| 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 |
$174.73
|
| Rate for Payer: Cash Price |
$95.10
|
| Rate for Payer: Cash Price |
$95.10
|
| Rate for Payer: Cigna Commercial |
$303.31
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$184.49
|
| Rate for Payer: Health EOS Commercial |
$293.42
|
| Rate for Payer: HFN Commercial |
$303.31
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$263.74
|
| Rate for Payer: NAPHCARE Commercial |
$197.81
|
| Rate for Payer: Preferred Network Access Commercial |
$303.31
|
| Rate for Payer: Quartz Beloit One Network |
$161.54
|
| Rate for Payer: Quartz Commercial |
$214.29
|
| Rate for Payer: Quartz Medicare Advantage |
$197.81
|
| Rate for Payer: The Alliance Commercial |
$164.84
|
| Rate for Payer: United Healthcare PPO |
$247.26
|
| Rate for Payer: WEA Trust Commercial |
$181.32
|
| Rate for Payer: WPS Commercial |
$244.19
|
|
|
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 |
$161.54 |
| Max. Negotiated Rate |
$303.31 |
| Rate for Payer: Aetna Commercial |
$296.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$283.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$174.73
|
| Rate for Payer: Cash Price |
$95.10
|
| Rate for Payer: Cigna Commercial |
$303.31
|
| Rate for Payer: Health EOS Commercial |
$293.42
|
| Rate for Payer: HFN Commercial |
$303.31
|
| Rate for Payer: Multiplan Commercial |
$263.74
|
| Rate for Payer: Preferred Network Access Commercial |
$303.31
|
| Rate for Payer: Quartz Beloit One Network |
$161.54
|
| Rate for Payer: Quartz Commercial |
$197.81
|
| Rate for Payer: WEA Trust Commercial |
$181.32
|
| Rate for Payer: WPS Commercial |
$244.19
|
|
|
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 |
$73.96 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$237.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$227.18
|
| Rate for Payer: Aetna Managed Medicare |
$73.96
|
| 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 |
$140.00
|
| Rate for Payer: Cash Price |
$76.20
|
| Rate for Payer: Cash Price |
$76.20
|
| Rate for Payer: Cigna Commercial |
$243.03
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$147.83
|
| Rate for Payer: Health EOS Commercial |
$235.10
|
| Rate for Payer: HFN Commercial |
$243.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$211.33
|
| Rate for Payer: NAPHCARE Commercial |
$158.50
|
| Rate for Payer: Preferred Network Access Commercial |
$243.03
|
| Rate for Payer: Quartz Beloit One Network |
$129.44
|
| Rate for Payer: Quartz Commercial |
$171.70
|
| Rate for Payer: Quartz Medicare Advantage |
$158.50
|
| Rate for Payer: The Alliance Commercial |
$132.08
|
| Rate for Payer: United Healthcare PPO |
$198.12
|
| Rate for Payer: WEA Trust Commercial |
$145.29
|
| Rate for Payer: WPS Commercial |
$195.66
|
|
|
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 |
$129.44 |
| Max. Negotiated Rate |
$243.03 |
| Rate for Payer: Aetna Commercial |
$237.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$227.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$140.00
|
| Rate for Payer: Cash Price |
$76.20
|
| Rate for Payer: Cigna Commercial |
$243.03
|
| Rate for Payer: Health EOS Commercial |
$235.10
|
| Rate for Payer: HFN Commercial |
$243.03
|
| Rate for Payer: Multiplan Commercial |
$211.33
|
| Rate for Payer: Preferred Network Access Commercial |
$243.03
|
| Rate for Payer: Quartz Beloit One Network |
$129.44
|
| Rate for Payer: Quartz Commercial |
$158.50
|
| Rate for Payer: WEA Trust Commercial |
$145.29
|
| Rate for Payer: WPS Commercial |
$195.66
|
|
|
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 |
$133.08 |
| Max. Negotiated Rate |
$437.26 |
| Rate for Payer: Aetna Commercial |
$427.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$408.74
|
| Rate for Payer: Aetna Managed Medicare |
$133.08
|
| 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 |
$251.90
|
| Rate for Payer: Cash Price |
$137.10
|
| Rate for Payer: Cash Price |
$137.10
|
| Rate for Payer: Cigna Commercial |
$437.26
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$265.97
|
| Rate for Payer: Health EOS Commercial |
$423.00
|
| Rate for Payer: HFN Commercial |
$437.26
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$380.22
|
| Rate for Payer: NAPHCARE Commercial |
$285.17
|
| Rate for Payer: Preferred Network Access Commercial |
$437.26
|
| Rate for Payer: Quartz Beloit One Network |
$232.89
|
| Rate for Payer: Quartz Commercial |
$308.93
|
| Rate for Payer: Quartz Medicare Advantage |
$285.17
|
| Rate for Payer: The Alliance Commercial |
$237.64
|
| Rate for Payer: United Healthcare PPO |
$356.46
|
| Rate for Payer: WEA Trust Commercial |
$261.40
|
| Rate for Payer: WPS Commercial |
$352.03
|
|
|
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 |
$232.89 |
| Max. Negotiated Rate |
$437.26 |
| Rate for Payer: Aetna Commercial |
$427.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$408.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$251.90
|
| Rate for Payer: Cash Price |
$137.10
|
| Rate for Payer: Cigna Commercial |
$437.26
|
| Rate for Payer: Health EOS Commercial |
$423.00
|
| Rate for Payer: HFN Commercial |
$437.26
|
| Rate for Payer: Multiplan Commercial |
$380.22
|
| Rate for Payer: Preferred Network Access Commercial |
$437.26
|
| Rate for Payer: Quartz Beloit One Network |
$232.89
|
| Rate for Payer: Quartz Commercial |
$285.17
|
| Rate for Payer: WEA Trust Commercial |
$261.40
|
| Rate for Payer: WPS Commercial |
$352.03
|
|
|
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 - 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 |
$106.00 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$340.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$325.56
|
| Rate for Payer: Aetna Managed Medicare |
$106.00
|
| 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 |
$200.64
|
| Rate for Payer: Cash Price |
$109.20
|
| Rate for Payer: Cash Price |
$109.20
|
| Rate for Payer: Cigna Commercial |
$348.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$211.85
|
| Rate for Payer: Health EOS Commercial |
$336.92
|
| Rate for Payer: HFN Commercial |
$348.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$302.85
|
| Rate for Payer: NAPHCARE Commercial |
$227.14
|
| Rate for Payer: Preferred Network Access Commercial |
$348.28
|
| Rate for Payer: Quartz Beloit One Network |
$185.49
|
| Rate for Payer: Quartz Commercial |
$246.06
|
| Rate for Payer: Quartz Medicare Advantage |
$227.14
|
| Rate for Payer: The Alliance Commercial |
$189.28
|
| Rate for Payer: United Healthcare PPO |
$283.92
|
| Rate for Payer: WEA Trust Commercial |
$208.21
|
| Rate for Payer: WPS Commercial |
$280.39
|
|
|
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 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 |
$52.90 |
| 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: 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: Humana Commercial/EPO/HMO/POS/PPO |
$52.90
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$52.90
|
| 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
|
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: Humana Commercial/EPO/HMO/POS/PPO |
$47.58
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$47.58
|
| 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
|
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 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: 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: Humana Commercial/EPO/HMO/POS/PPO |
$359.66
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$359.66
|
| 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 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: 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: Humana Commercial/EPO/HMO/POS/PPO |
$359.66
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$359.66
|
| 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
|
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
|
|
