|
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: 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: 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 |
$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
|
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 Fluidotherapy Charge
|
Professional
|
Both
|
$186.00
|
|
|
Service Code
|
CPT 97022 GP
|
| Hospital Charge Code |
2987956
|
|
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 - 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 Group Therapy Charge
|
Professional
|
Both
|
$249.00
|
|
|
Service Code
|
CPT 97150 GP
|
| Hospital Charge Code |
2989695
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$64.06 |
| 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: 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: Humana Commercial/EPO/HMO/POS/PPO |
$64.06
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$64.06
|
| 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
|
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
|
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
|
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
|
|
|
Yes - PT Iontophoresis Charges
|
Professional
|
Both
|
$307.00
|
|
|
Service Code
|
CPT 97033 GP
|
| Hospital Charge Code |
2989866
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$72.29 |
| 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: 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: Humana Commercial/EPO/HMO/POS/PPO |
$72.29
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$72.29
|
| 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
|
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 Paraffin Bath Charge
|
Facility
|
OP
|
$170.00
|
|
|
Service Code
|
CPT 97018 GP
|
| Hospital Charge Code |
2959232
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$49.50 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$159.12
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$152.05
|
| Rate for Payer: Aetna Managed Medicare |
$49.50
|
| 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 |
$93.70
|
| Rate for Payer: Cash Price |
$51.00
|
| Rate for Payer: Cash Price |
$51.00
|
| Rate for Payer: Cigna Commercial |
$162.66
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$98.94
|
| Rate for Payer: Health EOS Commercial |
$157.35
|
| Rate for Payer: HFN Commercial |
$162.66
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$141.44
|
| Rate for Payer: NAPHCARE Commercial |
$106.08
|
| Rate for Payer: Preferred Network Access Commercial |
$162.66
|
| Rate for Payer: Quartz Beloit One Network |
$86.63
|
| Rate for Payer: Quartz Commercial |
$114.92
|
| Rate for Payer: Quartz Medicare Advantage |
$106.08
|
| Rate for Payer: The Alliance Commercial |
$88.40
|
| Rate for Payer: United Healthcare PPO |
$132.60
|
| Rate for Payer: WEA Trust Commercial |
$97.24
|
| Rate for Payer: WPS Commercial |
$130.95
|
|
|
Yes - PT Paraffin Bath Charge
|
Facility
|
IP
|
$170.00
|
|
|
Service Code
|
CPT 97018 GP
|
| Hospital Charge Code |
2959232
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$86.63 |
| Max. Negotiated Rate |
$162.66 |
| Rate for Payer: Aetna Commercial |
$159.12
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$152.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$93.70
|
| Rate for Payer: Cash Price |
$51.00
|
| Rate for Payer: Cigna Commercial |
$162.66
|
| Rate for Payer: Health EOS Commercial |
$157.35
|
| Rate for Payer: HFN Commercial |
$162.66
|
| Rate for Payer: Multiplan Commercial |
$141.44
|
| Rate for Payer: Preferred Network Access Commercial |
$162.66
|
| Rate for Payer: Quartz Beloit One Network |
$86.63
|
| Rate for Payer: Quartz Commercial |
$106.08
|
| Rate for Payer: WEA Trust Commercial |
$97.24
|
| Rate for Payer: WPS Commercial |
$130.95
|
|
|
Yes - PT Reevaluation Charge
|
Professional
|
Both
|
$287.00
|
|
|
Service Code
|
CPT 97164 GP
|
| Hospital Charge Code |
2989812
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$131.33 |
| Max. Negotiated Rate |
$283.56 |
| Rate for Payer: Aetna Commercial |
$283.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$256.69
|
| Rate for Payer: Cash Price |
$86.10
|
| Rate for Payer: Cash Price |
$86.10
|
| Rate for Payer: Cash Price |
$86.10
|
| Rate for Payer: Cigna Commercial |
$283.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$149.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$179.09
|
| Rate for Payer: Health EOS Commercial |
$271.62
|
| Rate for Payer: HFN Commercial |
$283.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$245.16
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$245.16
|
| Rate for Payer: Multiplan Commercial |
$238.78
|
| Rate for Payer: Preferred Network Access Commercial |
$283.56
|
| Rate for Payer: Quartz Beloit One Network |
$131.33
|
| Rate for Payer: Quartz Commercial |
$170.13
|
| Rate for Payer: The Alliance Commercial |
$149.24
|
| Rate for Payer: WEA Trust Commercial |
$164.16
|
| Rate for Payer: WPS Commercial |
$221.08
|
|
|
Yes - PT Reevaluation Charge
|
Facility
|
IP
|
$287.00
|
|
|
Service Code
|
CPT 97164 GP
|
| Hospital Charge Code |
2989812
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$146.26 |
| Max. Negotiated Rate |
$274.60 |
| Rate for Payer: Aetna Commercial |
$268.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$256.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$158.19
|
| Rate for Payer: Cash Price |
$86.10
|
| Rate for Payer: Cigna Commercial |
$274.60
|
| Rate for Payer: Health EOS Commercial |
$265.65
|
| Rate for Payer: HFN Commercial |
$274.60
|
| Rate for Payer: Multiplan Commercial |
$238.78
|
| Rate for Payer: Preferred Network Access Commercial |
$274.60
|
| Rate for Payer: Quartz Beloit One Network |
$146.26
|
| Rate for Payer: Quartz Commercial |
$179.09
|
| Rate for Payer: WEA Trust Commercial |
$164.16
|
| Rate for Payer: WPS Commercial |
$221.08
|
|
|
Yes - PT Reevaluation Charge
|
Facility
|
OP
|
$287.00
|
|
|
Service Code
|
CPT 97164 GP
|
| Hospital Charge Code |
2989812
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$83.57 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$268.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$256.69
|
| Rate for Payer: Aetna Managed Medicare |
$83.57
|
| 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 |
$158.19
|
| Rate for Payer: Cash Price |
$86.10
|
| Rate for Payer: Cash Price |
$86.10
|
| Rate for Payer: Cigna Commercial |
$274.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$167.03
|
| Rate for Payer: Health EOS Commercial |
$265.65
|
| Rate for Payer: HFN Commercial |
$274.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$238.78
|
| Rate for Payer: NAPHCARE Commercial |
$179.09
|
| Rate for Payer: Preferred Network Access Commercial |
$274.60
|
| Rate for Payer: Quartz Beloit One Network |
$146.26
|
| Rate for Payer: Quartz Commercial |
$194.01
|
| Rate for Payer: Quartz Medicare Advantage |
$179.09
|
| Rate for Payer: The Alliance Commercial |
$149.24
|
| Rate for Payer: United Healthcare PPO |
$223.86
|
| Rate for Payer: WEA Trust Commercial |
$164.16
|
| Rate for Payer: WPS Commercial |
$221.08
|
|
|
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 |
$74.91 |
| Max. Negotiated Rate |
$140.65 |
| Rate for Payer: Aetna Commercial |
$137.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$131.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$81.03
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: Cigna Commercial |
$140.65
|
| Rate for Payer: Health EOS Commercial |
$136.06
|
| Rate for Payer: HFN Commercial |
$140.65
|
| Rate for Payer: Multiplan Commercial |
$122.30
|
| Rate for Payer: Preferred Network Access Commercial |
$140.65
|
| Rate for Payer: Quartz Beloit One Network |
$74.91
|
| Rate for Payer: Quartz Commercial |
$91.73
|
| Rate for Payer: WEA Trust Commercial |
$84.08
|
| Rate for Payer: WPS Commercial |
$113.23
|
|
|
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 |
$42.81 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$137.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$131.48
|
| Rate for Payer: Aetna Managed Medicare |
$42.81
|
| 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 |
$81.03
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: Cigna Commercial |
$140.65
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$85.55
|
| Rate for Payer: Health EOS Commercial |
$136.06
|
| Rate for Payer: HFN Commercial |
$140.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$122.30
|
| Rate for Payer: NAPHCARE Commercial |
$91.73
|
| Rate for Payer: Preferred Network Access Commercial |
$140.65
|
| Rate for Payer: Quartz Beloit One Network |
$74.91
|
| Rate for Payer: Quartz Commercial |
$99.37
|
| Rate for Payer: Quartz Medicare Advantage |
$91.73
|
| Rate for Payer: The Alliance Commercial |
$76.44
|
| Rate for Payer: United Healthcare PPO |
$114.66
|
| Rate for Payer: WEA Trust Commercial |
$84.08
|
| Rate for Payer: WPS Commercial |
$113.23
|
|
|
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 |
$42.81 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$137.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$131.48
|
| Rate for Payer: Aetna Managed Medicare |
$42.81
|
| 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 |
$81.03
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: Cigna Commercial |
$140.65
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$85.55
|
| Rate for Payer: Health EOS Commercial |
$136.06
|
| Rate for Payer: HFN Commercial |
$140.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$122.30
|
| Rate for Payer: NAPHCARE Commercial |
$91.73
|
| Rate for Payer: Preferred Network Access Commercial |
$140.65
|
| Rate for Payer: Quartz Beloit One Network |
$74.91
|
| Rate for Payer: Quartz Commercial |
$99.37
|
| Rate for Payer: Quartz Medicare Advantage |
$91.73
|
| Rate for Payer: The Alliance Commercial |
$76.44
|
| Rate for Payer: United Healthcare PPO |
$114.66
|
| Rate for Payer: WEA Trust Commercial |
$84.08
|
| Rate for Payer: WPS Commercial |
$113.23
|
|
|
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 |
$74.91 |
| Max. Negotiated Rate |
$140.65 |
| Rate for Payer: Aetna Commercial |
$137.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$131.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$81.03
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: Cigna Commercial |
$140.65
|
| Rate for Payer: Health EOS Commercial |
$136.06
|
| Rate for Payer: HFN Commercial |
$140.65
|
| Rate for Payer: Multiplan Commercial |
$122.30
|
| Rate for Payer: Preferred Network Access Commercial |
$140.65
|
| Rate for Payer: Quartz Beloit One Network |
$74.91
|
| Rate for Payer: Quartz Commercial |
$91.73
|
| Rate for Payer: WEA Trust Commercial |
$84.08
|
| Rate for Payer: WPS Commercial |
$113.23
|
|
|
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 |
$17.76 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$57.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$54.56
|
| Rate for Payer: Aetna Managed Medicare |
$17.76
|
| 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 |
$33.62
|
| Rate for Payer: Cash Price |
$18.30
|
| Rate for Payer: Cash Price |
$18.30
|
| Rate for Payer: Cigna Commercial |
$58.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$35.50
|
| Rate for Payer: Health EOS Commercial |
$56.46
|
| Rate for Payer: HFN Commercial |
$58.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$50.75
|
| Rate for Payer: NAPHCARE Commercial |
$38.06
|
| Rate for Payer: Preferred Network Access Commercial |
$58.36
|
| Rate for Payer: Quartz Beloit One Network |
$31.09
|
| Rate for Payer: Quartz Commercial |
$41.24
|
| Rate for Payer: Quartz Medicare Advantage |
$38.06
|
| Rate for Payer: The Alliance Commercial |
$31.72
|
| Rate for Payer: United Healthcare PPO |
$47.58
|
| Rate for Payer: WEA Trust Commercial |
$34.89
|
| Rate for Payer: WPS Commercial |
$46.99
|
|
|
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 |
$31.09 |
| Max. Negotiated Rate |
$58.36 |
| Rate for Payer: Aetna Commercial |
$57.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$54.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$33.62
|
| Rate for Payer: Cash Price |
$18.30
|
| Rate for Payer: Cigna Commercial |
$58.36
|
| Rate for Payer: Health EOS Commercial |
$56.46
|
| Rate for Payer: HFN Commercial |
$58.36
|
| Rate for Payer: Multiplan Commercial |
$50.75
|
| Rate for Payer: Preferred Network Access Commercial |
$58.36
|
| Rate for Payer: Quartz Beloit One Network |
$31.09
|
| Rate for Payer: Quartz Commercial |
$38.06
|
| Rate for Payer: WEA Trust Commercial |
$34.89
|
| Rate for Payer: WPS Commercial |
$46.99
|
|
|
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 |
$47.76 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Quartz Medicare Advantage |
$102.34
|
| Rate for Payer: Aetna Commercial |
$153.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$146.68
|
| Rate for Payer: Aetna Managed Medicare |
$47.76
|
| 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 |
$90.40
|
| Rate for Payer: Cash Price |
$49.20
|
| Rate for Payer: Cash Price |
$49.20
|
| Rate for Payer: Cigna Commercial |
$156.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$95.45
|
| Rate for Payer: Health EOS Commercial |
$151.80
|
| Rate for Payer: HFN Commercial |
$156.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$136.45
|
| Rate for Payer: NAPHCARE Commercial |
$102.34
|
| Rate for Payer: Preferred Network Access Commercial |
$156.92
|
| Rate for Payer: Quartz Beloit One Network |
$83.57
|
| Rate for Payer: Quartz Commercial |
$110.86
|
| Rate for Payer: The Alliance Commercial |
$85.28
|
| Rate for Payer: United Healthcare PPO |
$127.92
|
| Rate for Payer: WEA Trust Commercial |
$93.81
|
| Rate for Payer: WPS Commercial |
$126.33
|
|
