|
OTITIS MEDIA AND URI WITHOUT MCC
|
Facility
|
IP
|
$19,856.00
|
|
|
Service Code
|
MSDRG 153
|
| Min. Negotiated Rate |
$7,142.36 |
| Max. Negotiated Rate |
$19,856.00 |
| Rate for Payer: Aetna Managed Medicare |
$7,142.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$15,315.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11,739.13
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$11,152.94
|
| Rate for Payer: Anthem Medicare Advantage |
$7,142.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7,142.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7,142.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$7,142.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,380.79
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$7,142.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14,328.60
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$7,142.36
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7,142.36
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$7,142.36
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$7,142.36
|
| Rate for Payer: NAPHCARE Commercial |
$10,713.54
|
| Rate for Payer: Quartz Medicare Advantage |
$7,142.36
|
| Rate for Payer: The Alliance Commercial |
$19,856.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7,142.36
|
| Rate for Payer: United Healthcare PPO |
$11,155.00
|
| Rate for Payer: Wellcare Medicare |
$7,142.36
|
|
|
OT Manual Therapy Charge Units
|
Facility
|
IP
|
$234.00
|
|
|
Service Code
|
CPT 97140
|
| Hospital Charge Code |
5247099
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$114.66 |
| Max. Negotiated Rate |
$215.28 |
| Rate for Payer: Aetna Commercial |
$210.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$201.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$124.02
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cigna Commercial |
$215.28
|
| Rate for Payer: Health EOS Commercial |
$208.26
|
| Rate for Payer: HFN Commercial |
$215.28
|
| Rate for Payer: Multiplan Commercial |
$187.20
|
| Rate for Payer: NAPHCARE Commercial |
$140.40
|
| Rate for Payer: Preferred Network Access Commercial |
$215.28
|
| Rate for Payer: Quartz Beloit One Network |
$114.66
|
| Rate for Payer: Quartz Commercial |
$140.40
|
| Rate for Payer: WEA Trust Commercial |
$128.70
|
| Rate for Payer: WPS Commercial |
$173.32
|
|
|
OT Manual Therapy Charge Units
|
Facility
|
OP
|
$234.00
|
|
|
Service Code
|
CPT 97140
|
| Hospital Charge Code |
5247099
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$65.52 |
| Max. Negotiated Rate |
$936.00 |
| Rate for Payer: Aetna Commercial |
$210.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$201.24
|
| Rate for Payer: Aetna Managed Medicare |
$65.52
|
| 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 |
$124.02
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cigna Commercial |
$215.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$130.95
|
| Rate for Payer: Health EOS Commercial |
$208.26
|
| Rate for Payer: HFN Commercial |
$215.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$187.20
|
| Rate for Payer: NAPHCARE Commercial |
$140.40
|
| Rate for Payer: Preferred Network Access Commercial |
$215.28
|
| Rate for Payer: Quartz Beloit One Network |
$114.66
|
| Rate for Payer: Quartz Commercial |
$152.10
|
| Rate for Payer: Quartz Medicare Advantage |
$140.40
|
| Rate for Payer: The Alliance Commercial |
$936.00
|
| Rate for Payer: United Healthcare PPO |
$175.50
|
| Rate for Payer: WEA Trust Commercial |
$128.70
|
| Rate for Payer: WPS Commercial |
$173.32
|
|
|
OT Manual Therapy Charge Units
|
Facility
|
OP
|
$234.00
|
|
|
Service Code
|
CPT 97140 GO
|
| Hospital Charge Code |
750909
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$65.52 |
| Max. Negotiated Rate |
$936.00 |
| Rate for Payer: Aetna Commercial |
$210.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$201.24
|
| Rate for Payer: Aetna Managed Medicare |
$65.52
|
| 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 |
$124.02
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cigna Commercial |
$215.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$130.95
|
| Rate for Payer: Health EOS Commercial |
$208.26
|
| Rate for Payer: HFN Commercial |
$215.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$187.20
|
| Rate for Payer: NAPHCARE Commercial |
$140.40
|
| Rate for Payer: Preferred Network Access Commercial |
$215.28
|
| Rate for Payer: Quartz Beloit One Network |
$114.66
|
| Rate for Payer: Quartz Commercial |
$152.10
|
| Rate for Payer: Quartz Medicare Advantage |
$140.40
|
| Rate for Payer: The Alliance Commercial |
$936.00
|
| Rate for Payer: United Healthcare PPO |
$175.50
|
| Rate for Payer: WEA Trust Commercial |
$128.70
|
| Rate for Payer: WPS Commercial |
$173.32
|
|
|
OT Manual Therapy Charge Units
|
Facility
|
IP
|
$234.00
|
|
|
Service Code
|
CPT 97140 GO
|
| Hospital Charge Code |
750909
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$114.66 |
| Max. Negotiated Rate |
$215.28 |
| Rate for Payer: Aetna Commercial |
$210.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$201.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$124.02
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cigna Commercial |
$215.28
|
| Rate for Payer: Health EOS Commercial |
$208.26
|
| Rate for Payer: HFN Commercial |
$215.28
|
| Rate for Payer: Multiplan Commercial |
$187.20
|
| Rate for Payer: NAPHCARE Commercial |
$140.40
|
| Rate for Payer: Preferred Network Access Commercial |
$215.28
|
| Rate for Payer: Quartz Beloit One Network |
$114.66
|
| Rate for Payer: Quartz Commercial |
$140.40
|
| Rate for Payer: WEA Trust Commercial |
$128.70
|
| Rate for Payer: WPS Commercial |
$173.32
|
|
|
OT Manual Therapy Charge Units
|
Professional
|
Both
|
$234.00
|
|
|
Service Code
|
CPT 97140 GO
|
| Hospital Charge Code |
750909
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$94.29 |
| Max. Negotiated Rate |
$222.30 |
| Rate for Payer: Aetna Commercial |
$222.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$201.24
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cigna Commercial |
$222.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$117.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$140.40
|
| Rate for Payer: Health EOS Commercial |
$212.94
|
| Rate for Payer: HFN Commercial |
$222.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$94.29
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$94.29
|
| Rate for Payer: Multiplan Commercial |
$187.20
|
| Rate for Payer: Preferred Network Access Commercial |
$222.30
|
| Rate for Payer: Quartz Beloit One Network |
$102.96
|
| Rate for Payer: Quartz Commercial |
$133.38
|
| Rate for Payer: The Alliance Commercial |
$117.00
|
| Rate for Payer: WEA Trust Commercial |
$128.70
|
| Rate for Payer: WPS Commercial |
$173.32
|
|
|
OT Massage Charge Units
|
Facility
|
OP
|
$90.00
|
|
|
Service Code
|
CPT 97124 GO
|
| Hospital Charge Code |
2468807
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$25.20 |
| Max. Negotiated Rate |
$360.00 |
| Rate for Payer: Aetna Commercial |
$81.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$77.40
|
| Rate for Payer: Aetna Managed Medicare |
$25.20
|
| 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 |
$47.70
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$82.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$50.36
|
| Rate for Payer: Health EOS Commercial |
$80.10
|
| Rate for Payer: HFN Commercial |
$82.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$72.00
|
| Rate for Payer: NAPHCARE Commercial |
$54.00
|
| Rate for Payer: Preferred Network Access Commercial |
$82.80
|
| Rate for Payer: Quartz Beloit One Network |
$44.10
|
| Rate for Payer: Quartz Commercial |
$58.50
|
| Rate for Payer: Quartz Medicare Advantage |
$54.00
|
| Rate for Payer: The Alliance Commercial |
$360.00
|
| Rate for Payer: United Healthcare PPO |
$67.50
|
| Rate for Payer: WEA Trust Commercial |
$49.50
|
| Rate for Payer: WPS Commercial |
$66.66
|
|
|
OT Massage Charge Units
|
Facility
|
IP
|
$90.00
|
|
|
Service Code
|
CPT 97124 GO
|
| Hospital Charge Code |
2468807
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$44.10 |
| Max. Negotiated Rate |
$82.80 |
| Rate for Payer: Aetna Commercial |
$81.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$77.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$47.70
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$82.80
|
| Rate for Payer: Health EOS Commercial |
$80.10
|
| Rate for Payer: HFN Commercial |
$82.80
|
| Rate for Payer: Multiplan Commercial |
$72.00
|
| Rate for Payer: NAPHCARE Commercial |
$54.00
|
| Rate for Payer: Preferred Network Access Commercial |
$82.80
|
| Rate for Payer: Quartz Beloit One Network |
$44.10
|
| Rate for Payer: Quartz Commercial |
$54.00
|
| Rate for Payer: WEA Trust Commercial |
$49.50
|
| Rate for Payer: WPS Commercial |
$66.66
|
|
|
OT Neuromuscular Reeducation Charges
|
Facility
|
OP
|
$228.00
|
|
|
Service Code
|
CPT 97112 GO
|
| Hospital Charge Code |
750905
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$63.84 |
| Max. Negotiated Rate |
$912.00 |
| Rate for Payer: Aetna Commercial |
$205.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$196.08
|
| Rate for Payer: Aetna Managed Medicare |
$63.84
|
| 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 |
$120.84
|
| Rate for Payer: Cash Price |
$68.40
|
| Rate for Payer: Cash Price |
$68.40
|
| Rate for Payer: Cigna Commercial |
$209.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$127.59
|
| Rate for Payer: Health EOS Commercial |
$202.92
|
| Rate for Payer: HFN Commercial |
$209.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$182.40
|
| Rate for Payer: NAPHCARE Commercial |
$136.80
|
| Rate for Payer: Preferred Network Access Commercial |
$209.76
|
| Rate for Payer: Quartz Beloit One Network |
$111.72
|
| Rate for Payer: Quartz Commercial |
$148.20
|
| Rate for Payer: Quartz Medicare Advantage |
$136.80
|
| Rate for Payer: The Alliance Commercial |
$912.00
|
| Rate for Payer: United Healthcare PPO |
$171.00
|
| Rate for Payer: WEA Trust Commercial |
$125.40
|
| Rate for Payer: WPS Commercial |
$168.88
|
|
|
OT Neuromuscular Reeducation Charges
|
Facility
|
IP
|
$228.00
|
|
|
Service Code
|
CPT 97112 GO
|
| Hospital Charge Code |
750905
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$111.72 |
| Max. Negotiated Rate |
$209.76 |
| Rate for Payer: Aetna Commercial |
$205.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$196.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$120.84
|
| Rate for Payer: Cash Price |
$68.40
|
| Rate for Payer: Cigna Commercial |
$209.76
|
| Rate for Payer: Health EOS Commercial |
$202.92
|
| Rate for Payer: HFN Commercial |
$209.76
|
| Rate for Payer: Multiplan Commercial |
$182.40
|
| Rate for Payer: NAPHCARE Commercial |
$136.80
|
| Rate for Payer: Preferred Network Access Commercial |
$209.76
|
| Rate for Payer: Quartz Beloit One Network |
$111.72
|
| Rate for Payer: Quartz Commercial |
$136.80
|
| Rate for Payer: WEA Trust Commercial |
$125.40
|
| Rate for Payer: WPS Commercial |
$168.88
|
|
|
OTOPLASTY
|
Facility
|
OP
|
$7,602.00
|
|
| Hospital Charge Code |
2960298
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,128.56 |
| Max. Negotiated Rate |
$30,408.00 |
| Rate for Payer: Aetna Commercial |
$6,841.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,537.72
|
| Rate for Payer: Aetna Managed Medicare |
$2,128.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,941.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,801.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,648.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,029.06
|
| Rate for Payer: Cash Price |
$2,280.60
|
| Rate for Payer: Cigna Commercial |
$6,993.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,254.08
|
| Rate for Payer: Health EOS Commercial |
$6,765.78
|
| Rate for Payer: HFN Commercial |
$6,993.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,701.50
|
| Rate for Payer: Multiplan Commercial |
$6,081.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,561.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6,993.84
|
| Rate for Payer: Quartz Beloit One Network |
$3,724.98
|
| Rate for Payer: Quartz Commercial |
$4,941.30
|
| Rate for Payer: Quartz Medicare Advantage |
$4,561.20
|
| Rate for Payer: The Alliance Commercial |
$30,408.00
|
| Rate for Payer: WEA Trust Commercial |
$4,181.10
|
| Rate for Payer: WPS Commercial |
$5,630.80
|
|
|
OTOPLASTY
|
Facility
|
IP
|
$7,602.00
|
|
| Hospital Charge Code |
2960298
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,724.98 |
| Max. Negotiated Rate |
$6,993.84 |
| Rate for Payer: Aetna Commercial |
$6,841.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,537.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,029.06
|
| Rate for Payer: Cash Price |
$2,280.60
|
| Rate for Payer: Cigna Commercial |
$6,993.84
|
| Rate for Payer: Health EOS Commercial |
$6,765.78
|
| Rate for Payer: HFN Commercial |
$6,993.84
|
| Rate for Payer: Multiplan Commercial |
$6,081.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,561.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6,993.84
|
| Rate for Payer: Quartz Beloit One Network |
$3,724.98
|
| Rate for Payer: Quartz Commercial |
$4,561.20
|
| Rate for Payer: WEA Trust Commercial |
$4,181.10
|
| Rate for Payer: WPS Commercial |
$5,630.80
|
|
|
OT Orthotic Training Charges
|
Facility
|
IP
|
$225.00
|
|
|
Service Code
|
CPT 97760 GO
|
| Hospital Charge Code |
2989842
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$110.25 |
| Max. Negotiated Rate |
$207.00 |
| Rate for Payer: Aetna Commercial |
$202.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$193.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$119.25
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cigna Commercial |
$207.00
|
| Rate for Payer: Health EOS Commercial |
$200.25
|
| Rate for Payer: HFN Commercial |
$207.00
|
| Rate for Payer: Multiplan Commercial |
$180.00
|
| Rate for Payer: NAPHCARE Commercial |
$135.00
|
| Rate for Payer: Preferred Network Access Commercial |
$207.00
|
| Rate for Payer: Quartz Beloit One Network |
$110.25
|
| Rate for Payer: Quartz Commercial |
$135.00
|
| Rate for Payer: WEA Trust Commercial |
$123.75
|
| Rate for Payer: WPS Commercial |
$166.66
|
|
|
OT Orthotic Training Charges
|
Facility
|
OP
|
$225.00
|
|
|
Service Code
|
CPT 97760 GO
|
| Hospital Charge Code |
2989842
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$63.00 |
| Max. Negotiated Rate |
$900.00 |
| Rate for Payer: Aetna Commercial |
$202.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$193.50
|
| Rate for Payer: Aetna Managed Medicare |
$63.00
|
| 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 |
$119.25
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cigna Commercial |
$207.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$125.91
|
| Rate for Payer: Health EOS Commercial |
$200.25
|
| Rate for Payer: HFN Commercial |
$207.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$180.00
|
| Rate for Payer: NAPHCARE Commercial |
$135.00
|
| Rate for Payer: Preferred Network Access Commercial |
$207.00
|
| Rate for Payer: Quartz Beloit One Network |
$110.25
|
| Rate for Payer: Quartz Commercial |
$146.25
|
| Rate for Payer: Quartz Medicare Advantage |
$135.00
|
| Rate for Payer: The Alliance Commercial |
$900.00
|
| Rate for Payer: United Healthcare PPO |
$168.75
|
| Rate for Payer: WEA Trust Commercial |
$123.75
|
| Rate for Payer: WPS Commercial |
$166.66
|
|
|
OT Orthotic Training Charges
|
Professional
|
Both
|
$225.00
|
|
|
Service Code
|
CPT 97760 GO
|
| Hospital Charge Code |
2989842
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$99.00 |
| Max. Negotiated Rate |
$213.75 |
| Rate for Payer: Aetna Commercial |
$213.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$193.50
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cigna Commercial |
$213.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$112.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$135.00
|
| Rate for Payer: Health EOS Commercial |
$204.75
|
| Rate for Payer: HFN Commercial |
$213.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$169.05
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$169.05
|
| Rate for Payer: Multiplan Commercial |
$180.00
|
| Rate for Payer: Preferred Network Access Commercial |
$213.75
|
| Rate for Payer: Quartz Beloit One Network |
$99.00
|
| Rate for Payer: Quartz Commercial |
$128.25
|
| Rate for Payer: The Alliance Commercial |
$112.50
|
| Rate for Payer: WEA Trust Commercial |
$123.75
|
| Rate for Payer: WPS Commercial |
$166.66
|
|
|
OT Prosthetic Training Charges
|
Facility
|
OP
|
$223.00
|
|
|
Service Code
|
CPT 97761 GO
|
| Hospital Charge Code |
750930
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$62.44 |
| Max. Negotiated Rate |
$892.00 |
| Rate for Payer: Aetna Commercial |
$200.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$191.78
|
| Rate for Payer: Aetna Managed Medicare |
$62.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$349.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$287.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$272.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$118.19
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cigna Commercial |
$205.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$124.79
|
| Rate for Payer: Health EOS Commercial |
$198.47
|
| Rate for Payer: HFN Commercial |
$205.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$178.40
|
| Rate for Payer: NAPHCARE Commercial |
$133.80
|
| Rate for Payer: Preferred Network Access Commercial |
$205.16
|
| Rate for Payer: Quartz Beloit One Network |
$109.27
|
| Rate for Payer: Quartz Commercial |
$144.95
|
| Rate for Payer: Quartz Medicare Advantage |
$133.80
|
| Rate for Payer: The Alliance Commercial |
$892.00
|
| Rate for Payer: United Healthcare PPO |
$167.25
|
| Rate for Payer: WEA Trust Commercial |
$122.65
|
| Rate for Payer: WPS Commercial |
$165.18
|
|
|
OT Prosthetic Training Charges
|
Facility
|
IP
|
$223.00
|
|
|
Service Code
|
CPT 97761 GO
|
| Hospital Charge Code |
750930
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$109.27 |
| Max. Negotiated Rate |
$205.16 |
| Rate for Payer: Aetna Commercial |
$200.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$191.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$118.19
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cigna Commercial |
$205.16
|
| Rate for Payer: Health EOS Commercial |
$198.47
|
| Rate for Payer: HFN Commercial |
$205.16
|
| Rate for Payer: Multiplan Commercial |
$178.40
|
| Rate for Payer: NAPHCARE Commercial |
$133.80
|
| Rate for Payer: Preferred Network Access Commercial |
$205.16
|
| Rate for Payer: Quartz Beloit One Network |
$109.27
|
| Rate for Payer: Quartz Commercial |
$133.80
|
| Rate for Payer: WEA Trust Commercial |
$122.65
|
| Rate for Payer: WPS Commercial |
$165.18
|
|
|
OT Reevaluation
|
Facility
|
OP
|
$693.00
|
|
|
Service Code
|
CPT 97168
|
| Hospital Charge Code |
5250707
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$194.04 |
| Max. Negotiated Rate |
$2,772.00 |
| Rate for Payer: Aetna Commercial |
$623.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$595.98
|
| Rate for Payer: Aetna Managed Medicare |
$194.04
|
| 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 |
$367.29
|
| Rate for Payer: Cash Price |
$207.90
|
| Rate for Payer: Cash Price |
$207.90
|
| Rate for Payer: Cigna Commercial |
$637.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$387.80
|
| Rate for Payer: Health EOS Commercial |
$616.77
|
| Rate for Payer: HFN Commercial |
$637.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$554.40
|
| Rate for Payer: NAPHCARE Commercial |
$415.80
|
| Rate for Payer: Preferred Network Access Commercial |
$637.56
|
| Rate for Payer: Quartz Beloit One Network |
$339.57
|
| Rate for Payer: Quartz Commercial |
$450.45
|
| Rate for Payer: Quartz Medicare Advantage |
$415.80
|
| Rate for Payer: The Alliance Commercial |
$2,772.00
|
| Rate for Payer: United Healthcare PPO |
$519.75
|
| Rate for Payer: WEA Trust Commercial |
$381.15
|
| Rate for Payer: WPS Commercial |
$513.31
|
|
|
OT Reevaluation
|
Facility
|
IP
|
$693.00
|
|
|
Service Code
|
CPT 97168
|
| Hospital Charge Code |
5250707
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$339.57 |
| Max. Negotiated Rate |
$637.56 |
| Rate for Payer: Aetna Commercial |
$623.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$595.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$367.29
|
| Rate for Payer: Cash Price |
$207.90
|
| Rate for Payer: Cigna Commercial |
$637.56
|
| Rate for Payer: Health EOS Commercial |
$616.77
|
| Rate for Payer: HFN Commercial |
$637.56
|
| Rate for Payer: Multiplan Commercial |
$554.40
|
| Rate for Payer: NAPHCARE Commercial |
$415.80
|
| Rate for Payer: Preferred Network Access Commercial |
$637.56
|
| Rate for Payer: Quartz Beloit One Network |
$339.57
|
| Rate for Payer: Quartz Commercial |
$415.80
|
| Rate for Payer: WEA Trust Commercial |
$381.15
|
| Rate for Payer: WPS Commercial |
$513.31
|
|
|
OT Strapping/Unna Boot Charges
|
Facility
|
OP
|
$174.00
|
|
|
Service Code
|
CPT 29581 GO
|
| Hospital Charge Code |
2472556
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$85.26 |
| Max. Negotiated Rate |
$4,218.22 |
| Rate for Payer: Aetna Commercial |
$156.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$149.64
|
| Rate for Payer: Aetna Managed Medicare |
$155.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$349.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$287.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$272.00
|
| Rate for Payer: Anthem Medicare Advantage |
$155.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$92.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$155.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$155.74
|
| Rate for Payer: Cash Price |
$52.20
|
| Rate for Payer: Cash Price |
$52.20
|
| Rate for Payer: Cash Price |
$52.20
|
| Rate for Payer: Cigna Commercial |
$160.08
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$155.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,218.22
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$155.74
|
| Rate for Payer: Health EOS Commercial |
$154.86
|
| Rate for Payer: HFN Commercial |
$160.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$155.74
|
| Rate for Payer: Independent Care Health Plan Medicare |
$155.74
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$155.74
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$155.74
|
| Rate for Payer: Multiplan Commercial |
$139.20
|
| Rate for Payer: NAPHCARE Commercial |
$233.61
|
| Rate for Payer: Preferred Network Access Commercial |
$160.08
|
| Rate for Payer: Quartz Beloit One Network |
$85.26
|
| Rate for Payer: Quartz Commercial |
$113.10
|
| Rate for Payer: Quartz Medicare Advantage |
$155.74
|
| Rate for Payer: The Alliance Commercial |
$622.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$155.74
|
| Rate for Payer: United Healthcare PPO |
$130.50
|
| Rate for Payer: WEA Trust Commercial |
$95.70
|
| Rate for Payer: Wellcare Medicare |
$155.74
|
| Rate for Payer: WPS Commercial |
$128.88
|
|
|
OT Strapping/Unna Boot Charges
|
Facility
|
IP
|
$174.00
|
|
|
Service Code
|
CPT 29581 GO
|
| Hospital Charge Code |
2472556
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$85.26 |
| Max. Negotiated Rate |
$160.08 |
| Rate for Payer: Aetna Commercial |
$156.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$149.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$92.22
|
| Rate for Payer: Cash Price |
$52.20
|
| Rate for Payer: Cigna Commercial |
$160.08
|
| Rate for Payer: Health EOS Commercial |
$154.86
|
| Rate for Payer: HFN Commercial |
$160.08
|
| Rate for Payer: Multiplan Commercial |
$139.20
|
| Rate for Payer: NAPHCARE Commercial |
$104.40
|
| Rate for Payer: Preferred Network Access Commercial |
$160.08
|
| Rate for Payer: Quartz Beloit One Network |
$85.26
|
| Rate for Payer: Quartz Commercial |
$104.40
|
| Rate for Payer: WEA Trust Commercial |
$95.70
|
| Rate for Payer: WPS Commercial |
$128.88
|
|
|
OT Therapeutic Activities Charges
|
Facility
|
OP
|
$231.00
|
|
|
Service Code
|
CPT 97530 GO
|
| Hospital Charge Code |
750903
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$64.68 |
| Max. Negotiated Rate |
$924.00 |
| Rate for Payer: Aetna Commercial |
$207.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$198.66
|
| Rate for Payer: Aetna Managed Medicare |
$64.68
|
| 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 |
$122.43
|
| Rate for Payer: Cash Price |
$69.30
|
| Rate for Payer: Cash Price |
$69.30
|
| Rate for Payer: Cigna Commercial |
$212.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$129.27
|
| Rate for Payer: Health EOS Commercial |
$205.59
|
| Rate for Payer: HFN Commercial |
$212.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$184.80
|
| Rate for Payer: NAPHCARE Commercial |
$138.60
|
| Rate for Payer: Preferred Network Access Commercial |
$212.52
|
| Rate for Payer: Quartz Beloit One Network |
$113.19
|
| Rate for Payer: Quartz Commercial |
$150.15
|
| Rate for Payer: Quartz Medicare Advantage |
$138.60
|
| Rate for Payer: The Alliance Commercial |
$924.00
|
| Rate for Payer: United Healthcare PPO |
$173.25
|
| Rate for Payer: WEA Trust Commercial |
$127.05
|
| Rate for Payer: WPS Commercial |
$171.10
|
|
|
OT Therapeutic Activities Charges
|
Facility
|
IP
|
$231.00
|
|
|
Service Code
|
CPT 97530 GO
|
| Hospital Charge Code |
750903
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$113.19 |
| Max. Negotiated Rate |
$212.52 |
| Rate for Payer: Aetna Commercial |
$207.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$198.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$122.43
|
| Rate for Payer: Cash Price |
$69.30
|
| Rate for Payer: Cigna Commercial |
$212.52
|
| Rate for Payer: Health EOS Commercial |
$205.59
|
| Rate for Payer: HFN Commercial |
$212.52
|
| Rate for Payer: Multiplan Commercial |
$184.80
|
| Rate for Payer: NAPHCARE Commercial |
$138.60
|
| Rate for Payer: Preferred Network Access Commercial |
$212.52
|
| Rate for Payer: Quartz Beloit One Network |
$113.19
|
| Rate for Payer: Quartz Commercial |
$138.60
|
| Rate for Payer: WEA Trust Commercial |
$127.05
|
| Rate for Payer: WPS Commercial |
$171.10
|
|
|
OT Therapeutic Exercise Charge
|
Facility
|
IP
|
$194.00
|
|
|
Service Code
|
CPT 97110
|
| Hospital Charge Code |
5247098
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$95.06 |
| Max. Negotiated Rate |
$178.48 |
| Rate for Payer: Aetna Commercial |
$174.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$166.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$102.82
|
| Rate for Payer: Cash Price |
$58.20
|
| Rate for Payer: Cigna Commercial |
$178.48
|
| Rate for Payer: Health EOS Commercial |
$172.66
|
| Rate for Payer: HFN Commercial |
$178.48
|
| Rate for Payer: Multiplan Commercial |
$155.20
|
| Rate for Payer: NAPHCARE Commercial |
$116.40
|
| Rate for Payer: Preferred Network Access Commercial |
$178.48
|
| Rate for Payer: Quartz Beloit One Network |
$95.06
|
| Rate for Payer: Quartz Commercial |
$116.40
|
| Rate for Payer: WEA Trust Commercial |
$106.70
|
| Rate for Payer: WPS Commercial |
$143.70
|
|
|
OT Therapeutic Exercise Charge
|
Facility
|
OP
|
$194.00
|
|
|
Service Code
|
CPT 97110
|
| Hospital Charge Code |
5247098
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$54.32 |
| Max. Negotiated Rate |
$776.00 |
| Rate for Payer: Aetna Commercial |
$174.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$166.84
|
| Rate for Payer: Aetna Managed Medicare |
$54.32
|
| 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 |
$102.82
|
| Rate for Payer: Cash Price |
$58.20
|
| Rate for Payer: Cash Price |
$58.20
|
| Rate for Payer: Cigna Commercial |
$178.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$108.56
|
| Rate for Payer: Health EOS Commercial |
$172.66
|
| Rate for Payer: HFN Commercial |
$178.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$155.20
|
| Rate for Payer: NAPHCARE Commercial |
$116.40
|
| Rate for Payer: Preferred Network Access Commercial |
$178.48
|
| Rate for Payer: Quartz Beloit One Network |
$95.06
|
| Rate for Payer: Quartz Commercial |
$126.10
|
| Rate for Payer: Quartz Medicare Advantage |
$116.40
|
| Rate for Payer: The Alliance Commercial |
$776.00
|
| Rate for Payer: United Healthcare PPO |
$145.50
|
| Rate for Payer: WEA Trust Commercial |
$106.70
|
| Rate for Payer: WPS Commercial |
$143.70
|
|
