|
OSTOMY CLAMPS DUOLOCK 8770
|
Facility
|
OP
|
$40.00
|
|
| Hospital Charge Code |
2963858
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$11.65 |
| Max. Negotiated Rate |
$38.27 |
| Rate for Payer: Aetna Commercial |
$37.44
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$35.78
|
| Rate for Payer: Aetna Managed Medicare |
$11.65
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$27.04
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$20.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$19.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$22.05
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cigna Commercial |
$38.27
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$23.28
|
| Rate for Payer: Health EOS Commercial |
$37.02
|
| Rate for Payer: HFN Commercial |
$38.27
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$31.20
|
| Rate for Payer: Multiplan Commercial |
$33.28
|
| Rate for Payer: NAPHCARE Commercial |
$24.96
|
| Rate for Payer: Preferred Network Access Commercial |
$38.27
|
| Rate for Payer: Quartz Beloit One Network |
$20.38
|
| Rate for Payer: Quartz Commercial |
$27.04
|
| Rate for Payer: Quartz Medicare Advantage |
$24.96
|
| Rate for Payer: The Alliance Commercial |
$20.80
|
| Rate for Payer: WEA Trust Commercial |
$22.88
|
| Rate for Payer: WPS Commercial |
$30.81
|
|
|
OSTOMY CLAMPS DUOLOCK 8770
|
Facility
|
IP
|
$40.00
|
|
| Hospital Charge Code |
2963858
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$20.38 |
| Max. Negotiated Rate |
$38.27 |
| Rate for Payer: Aetna Commercial |
$37.44
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$35.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$22.05
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cigna Commercial |
$38.27
|
| Rate for Payer: Health EOS Commercial |
$37.02
|
| Rate for Payer: HFN Commercial |
$38.27
|
| Rate for Payer: Multiplan Commercial |
$33.28
|
| Rate for Payer: Preferred Network Access Commercial |
$38.27
|
| Rate for Payer: Quartz Beloit One Network |
$20.38
|
| Rate for Payer: Quartz Commercial |
$24.96
|
| Rate for Payer: WEA Trust Commercial |
$22.88
|
| Rate for Payer: WPS Commercial |
$30.81
|
|
|
OSTOMY POUCH DEODERANT 8 OZ
|
Facility
|
IP
|
$367.00
|
|
| Hospital Charge Code |
2963465
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$187.02 |
| Max. Negotiated Rate |
$351.15 |
| Rate for Payer: Aetna Commercial |
$343.51
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$328.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$202.29
|
| Rate for Payer: Cash Price |
$110.10
|
| Rate for Payer: Cigna Commercial |
$351.15
|
| Rate for Payer: Health EOS Commercial |
$339.70
|
| Rate for Payer: HFN Commercial |
$351.15
|
| Rate for Payer: Multiplan Commercial |
$305.34
|
| Rate for Payer: Preferred Network Access Commercial |
$351.15
|
| Rate for Payer: Quartz Beloit One Network |
$187.02
|
| Rate for Payer: Quartz Commercial |
$229.01
|
| Rate for Payer: WEA Trust Commercial |
$209.92
|
| Rate for Payer: WPS Commercial |
$282.70
|
|
|
OSTOMY POUCH DEODERANT 8 OZ
|
Facility
|
OP
|
$367.00
|
|
| Hospital Charge Code |
2963465
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$106.87 |
| Max. Negotiated Rate |
$351.15 |
| Rate for Payer: Aetna Commercial |
$343.51
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$328.24
|
| Rate for Payer: Aetna Managed Medicare |
$106.87
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$248.09
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$190.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$183.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$202.29
|
| Rate for Payer: Cash Price |
$110.10
|
| Rate for Payer: Cigna Commercial |
$351.15
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$213.59
|
| Rate for Payer: Health EOS Commercial |
$339.70
|
| Rate for Payer: HFN Commercial |
$351.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$286.26
|
| Rate for Payer: Multiplan Commercial |
$305.34
|
| Rate for Payer: NAPHCARE Commercial |
$229.01
|
| Rate for Payer: Preferred Network Access Commercial |
$351.15
|
| Rate for Payer: Quartz Beloit One Network |
$187.02
|
| Rate for Payer: Quartz Commercial |
$248.09
|
| Rate for Payer: Quartz Medicare Advantage |
$229.01
|
| Rate for Payer: The Alliance Commercial |
$190.84
|
| Rate for Payer: WEA Trust Commercial |
$209.92
|
| Rate for Payer: WPS Commercial |
$282.70
|
|
|
OSTOMY SKIN BARRIER FLEX-WEAR
|
Facility
|
IP
|
$88.00
|
|
| Hospital Charge Code |
2970765
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$44.84 |
| Max. Negotiated Rate |
$84.20 |
| Rate for Payer: Aetna Commercial |
$82.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$78.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$48.51
|
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Cigna Commercial |
$84.20
|
| Rate for Payer: Health EOS Commercial |
$81.45
|
| Rate for Payer: HFN Commercial |
$84.20
|
| Rate for Payer: Multiplan Commercial |
$73.22
|
| Rate for Payer: Preferred Network Access Commercial |
$84.20
|
| Rate for Payer: Quartz Beloit One Network |
$44.84
|
| Rate for Payer: Quartz Commercial |
$54.91
|
| Rate for Payer: WEA Trust Commercial |
$50.34
|
| Rate for Payer: WPS Commercial |
$67.79
|
|
|
OSTOMY SKIN BARRIER FLEX-WEAR
|
Facility
|
OP
|
$88.00
|
|
| Hospital Charge Code |
2970765
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$25.63 |
| Max. Negotiated Rate |
$84.20 |
| Rate for Payer: The Alliance Commercial |
$45.76
|
| Rate for Payer: Aetna Commercial |
$82.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$78.71
|
| Rate for Payer: Aetna Managed Medicare |
$25.63
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$59.49
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$45.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$43.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$48.51
|
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Cigna Commercial |
$84.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$51.22
|
| Rate for Payer: Health EOS Commercial |
$81.45
|
| Rate for Payer: HFN Commercial |
$84.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$68.64
|
| Rate for Payer: Multiplan Commercial |
$73.22
|
| Rate for Payer: NAPHCARE Commercial |
$54.91
|
| Rate for Payer: Preferred Network Access Commercial |
$84.20
|
| Rate for Payer: Quartz Beloit One Network |
$44.84
|
| Rate for Payer: Quartz Commercial |
$59.49
|
| Rate for Payer: Quartz Medicare Advantage |
$54.91
|
| Rate for Payer: WEA Trust Commercial |
$50.34
|
| Rate for Payer: WPS Commercial |
$67.79
|
|
|
OTA ADL/Training 15 min Charge
|
Facility
|
OP
|
$244.00
|
|
|
Service Code
|
CPT 97535 GO,CO
|
| Hospital Charge Code |
5571778
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$71.05 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$228.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$218.23
|
| Rate for Payer: Aetna Managed Medicare |
$71.05
|
| 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 |
$134.49
|
| Rate for Payer: Cash Price |
$73.20
|
| Rate for Payer: Cash Price |
$73.20
|
| Rate for Payer: Cigna Commercial |
$233.46
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$142.01
|
| Rate for Payer: Health EOS Commercial |
$225.85
|
| Rate for Payer: HFN Commercial |
$233.46
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$203.01
|
| Rate for Payer: NAPHCARE Commercial |
$152.26
|
| Rate for Payer: Preferred Network Access Commercial |
$233.46
|
| Rate for Payer: Quartz Beloit One Network |
$124.34
|
| Rate for Payer: Quartz Commercial |
$164.94
|
| Rate for Payer: Quartz Medicare Advantage |
$152.26
|
| Rate for Payer: The Alliance Commercial |
$126.88
|
| Rate for Payer: United Healthcare PPO |
$190.32
|
| Rate for Payer: WEA Trust Commercial |
$139.57
|
| Rate for Payer: WPS Commercial |
$187.95
|
|
|
OTA ADL/Training 15 min Charge
|
Facility
|
IP
|
$244.00
|
|
|
Service Code
|
CPT 97535 GO,CO
|
| Hospital Charge Code |
5571778
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$124.34 |
| Max. Negotiated Rate |
$233.46 |
| Rate for Payer: Aetna Commercial |
$228.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$218.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$134.49
|
| Rate for Payer: Cash Price |
$73.20
|
| Rate for Payer: Cigna Commercial |
$233.46
|
| Rate for Payer: Health EOS Commercial |
$225.85
|
| Rate for Payer: HFN Commercial |
$233.46
|
| Rate for Payer: Multiplan Commercial |
$203.01
|
| Rate for Payer: Preferred Network Access Commercial |
$233.46
|
| Rate for Payer: Quartz Beloit One Network |
$124.34
|
| Rate for Payer: Quartz Commercial |
$152.26
|
| Rate for Payer: WEA Trust Commercial |
$139.57
|
| Rate for Payer: WPS Commercial |
$187.95
|
|
|
OTA Community/Work Reintegration Charge
|
Facility
|
IP
|
$223.00
|
|
|
Service Code
|
CPT 97022 GO,CO
|
| Hospital Charge Code |
5571782
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$113.64 |
| Max. Negotiated Rate |
$213.37 |
| Rate for Payer: Aetna Commercial |
$208.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$199.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$122.92
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cigna Commercial |
$213.37
|
| Rate for Payer: Health EOS Commercial |
$206.41
|
| Rate for Payer: HFN Commercial |
$213.37
|
| Rate for Payer: Multiplan Commercial |
$185.54
|
| Rate for Payer: Preferred Network Access Commercial |
$213.37
|
| Rate for Payer: Quartz Beloit One Network |
$113.64
|
| Rate for Payer: Quartz Commercial |
$139.15
|
| Rate for Payer: WEA Trust Commercial |
$127.56
|
| Rate for Payer: WPS Commercial |
$171.78
|
|
|
OTA Community/Work Reintegration Charge
|
Facility
|
OP
|
$223.00
|
|
|
Service Code
|
CPT 97022 GO,CO
|
| Hospital Charge Code |
5571782
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$64.94 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$208.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$199.45
|
| Rate for Payer: Aetna Managed Medicare |
$64.94
|
| 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 |
$122.92
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cigna Commercial |
$213.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$129.79
|
| Rate for Payer: Health EOS Commercial |
$206.41
|
| Rate for Payer: HFN Commercial |
$213.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$185.54
|
| Rate for Payer: NAPHCARE Commercial |
$139.15
|
| Rate for Payer: Preferred Network Access Commercial |
$213.37
|
| Rate for Payer: Quartz Beloit One Network |
$113.64
|
| Rate for Payer: Quartz Commercial |
$150.75
|
| Rate for Payer: Quartz Medicare Advantage |
$139.15
|
| Rate for Payer: The Alliance Commercial |
$115.96
|
| Rate for Payer: United Healthcare PPO |
$173.94
|
| Rate for Payer: WEA Trust Commercial |
$127.56
|
| Rate for Payer: WPS Commercial |
$171.78
|
|
|
OT ADL Training/15 min charge
|
Facility
|
IP
|
$244.00
|
|
|
Service Code
|
CPT 97535
|
| Hospital Charge Code |
5247101
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$124.34 |
| Max. Negotiated Rate |
$233.46 |
| Rate for Payer: Aetna Commercial |
$228.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$218.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$134.49
|
| Rate for Payer: Cash Price |
$73.20
|
| Rate for Payer: Cigna Commercial |
$233.46
|
| Rate for Payer: Health EOS Commercial |
$225.85
|
| Rate for Payer: HFN Commercial |
$233.46
|
| Rate for Payer: Multiplan Commercial |
$203.01
|
| Rate for Payer: Preferred Network Access Commercial |
$233.46
|
| Rate for Payer: Quartz Beloit One Network |
$124.34
|
| Rate for Payer: Quartz Commercial |
$152.26
|
| Rate for Payer: WEA Trust Commercial |
$139.57
|
| Rate for Payer: WPS Commercial |
$187.95
|
|
|
OT ADL Training/15 min charge
|
Facility
|
OP
|
$244.00
|
|
|
Service Code
|
CPT 97535
|
| Hospital Charge Code |
5247101
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$71.05 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$228.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$218.23
|
| Rate for Payer: Aetna Managed Medicare |
$71.05
|
| 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 |
$134.49
|
| Rate for Payer: Cash Price |
$73.20
|
| Rate for Payer: Cash Price |
$73.20
|
| Rate for Payer: Cash Price |
$73.20
|
| Rate for Payer: Cigna Commercial |
$233.46
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$142.01
|
| Rate for Payer: Health EOS Commercial |
$225.85
|
| Rate for Payer: HFN Commercial |
$233.46
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$203.01
|
| Rate for Payer: NAPHCARE Commercial |
$152.26
|
| Rate for Payer: Preferred Network Access Commercial |
$233.46
|
| Rate for Payer: Quartz Beloit One Network |
$124.34
|
| Rate for Payer: Quartz Commercial |
$164.94
|
| Rate for Payer: Quartz Medicare Advantage |
$152.26
|
| Rate for Payer: The Alliance Commercial |
$130.83
|
| Rate for Payer: United Healthcare PPO |
$190.32
|
| Rate for Payer: WEA Trust Commercial |
$139.57
|
| Rate for Payer: WPS Commercial |
$187.95
|
|
|
OT ADL Training/15 Min Charges
|
Facility
|
OP
|
$228.00
|
|
|
Service Code
|
CPT 97535 GO
|
| Hospital Charge Code |
2472555
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$66.39 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$213.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$203.92
|
| Rate for Payer: Aetna Managed Medicare |
$66.39
|
| 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 |
$125.67
|
| Rate for Payer: Cash Price |
$68.40
|
| Rate for Payer: Cash Price |
$68.40
|
| Rate for Payer: Cigna Commercial |
$218.15
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$132.70
|
| Rate for Payer: Health EOS Commercial |
$211.04
|
| Rate for Payer: HFN Commercial |
$218.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$189.70
|
| Rate for Payer: NAPHCARE Commercial |
$142.27
|
| Rate for Payer: Preferred Network Access Commercial |
$218.15
|
| Rate for Payer: Quartz Beloit One Network |
$116.19
|
| Rate for Payer: Quartz Commercial |
$154.13
|
| Rate for Payer: Quartz Medicare Advantage |
$142.27
|
| Rate for Payer: The Alliance Commercial |
$118.56
|
| Rate for Payer: United Healthcare PPO |
$177.84
|
| Rate for Payer: WEA Trust Commercial |
$130.42
|
| Rate for Payer: WPS Commercial |
$175.63
|
|
|
OT ADL Training/15 Min Charges
|
Facility
|
IP
|
$228.00
|
|
|
Service Code
|
CPT 97535 GO
|
| Hospital Charge Code |
2472555
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$116.19 |
| Max. Negotiated Rate |
$218.15 |
| Rate for Payer: Aetna Commercial |
$213.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$203.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$125.67
|
| Rate for Payer: Cash Price |
$68.40
|
| Rate for Payer: Cigna Commercial |
$218.15
|
| Rate for Payer: Health EOS Commercial |
$211.04
|
| Rate for Payer: HFN Commercial |
$218.15
|
| Rate for Payer: Multiplan Commercial |
$189.70
|
| Rate for Payer: Preferred Network Access Commercial |
$218.15
|
| Rate for Payer: Quartz Beloit One Network |
$116.19
|
| Rate for Payer: Quartz Commercial |
$142.27
|
| Rate for Payer: WEA Trust Commercial |
$130.42
|
| Rate for Payer: WPS Commercial |
$175.63
|
|
|
OTA E-Stim Attended Charges
|
Facility
|
IP
|
$251.00
|
|
|
Service Code
|
CPT 97032 GO,CO
|
| Hospital Charge Code |
5571734
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$127.91 |
| Max. Negotiated Rate |
$240.16 |
| Rate for Payer: Aetna Commercial |
$234.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$224.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$138.35
|
| Rate for Payer: Cash Price |
$75.30
|
| Rate for Payer: Cigna Commercial |
$240.16
|
| Rate for Payer: Health EOS Commercial |
$232.33
|
| Rate for Payer: HFN Commercial |
$240.16
|
| Rate for Payer: Multiplan Commercial |
$208.83
|
| Rate for Payer: Preferred Network Access Commercial |
$240.16
|
| Rate for Payer: Quartz Beloit One Network |
$127.91
|
| Rate for Payer: Quartz Commercial |
$156.62
|
| Rate for Payer: WEA Trust Commercial |
$143.57
|
| Rate for Payer: WPS Commercial |
$193.35
|
|
|
OTA E-Stim Attended Charges
|
Facility
|
OP
|
$251.00
|
|
|
Service Code
|
CPT 97032 GO,CO
|
| Hospital Charge Code |
5571734
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$73.09 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$234.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$224.49
|
| Rate for Payer: Aetna Managed Medicare |
$73.09
|
| 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 |
$138.35
|
| Rate for Payer: Cash Price |
$75.30
|
| Rate for Payer: Cash Price |
$75.30
|
| Rate for Payer: Cigna Commercial |
$240.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$146.08
|
| Rate for Payer: Health EOS Commercial |
$232.33
|
| Rate for Payer: HFN Commercial |
$240.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$208.83
|
| Rate for Payer: NAPHCARE Commercial |
$156.62
|
| Rate for Payer: Preferred Network Access Commercial |
$240.16
|
| Rate for Payer: Quartz Beloit One Network |
$127.91
|
| Rate for Payer: Quartz Commercial |
$169.68
|
| Rate for Payer: Quartz Medicare Advantage |
$156.62
|
| Rate for Payer: The Alliance Commercial |
$130.52
|
| Rate for Payer: United Healthcare PPO |
$195.78
|
| Rate for Payer: WEA Trust Commercial |
$143.57
|
| Rate for Payer: WPS Commercial |
$193.35
|
|
|
OTA Iontophoresis Charge
|
Facility
|
OP
|
$224.00
|
|
|
Service Code
|
CPT 97033 GO,CO
|
| Hospital Charge Code |
5571730
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$65.23 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$209.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$200.35
|
| Rate for Payer: Aetna Managed Medicare |
$65.23
|
| 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 |
$123.47
|
| Rate for Payer: Cash Price |
$67.20
|
| Rate for Payer: Cash Price |
$67.20
|
| Rate for Payer: Cigna Commercial |
$214.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$130.37
|
| Rate for Payer: Health EOS Commercial |
$207.33
|
| Rate for Payer: HFN Commercial |
$214.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$186.37
|
| Rate for Payer: NAPHCARE Commercial |
$139.78
|
| Rate for Payer: Preferred Network Access Commercial |
$214.32
|
| Rate for Payer: Quartz Beloit One Network |
$114.15
|
| Rate for Payer: Quartz Commercial |
$151.42
|
| Rate for Payer: Quartz Medicare Advantage |
$139.78
|
| Rate for Payer: The Alliance Commercial |
$116.48
|
| Rate for Payer: United Healthcare PPO |
$174.72
|
| Rate for Payer: WEA Trust Commercial |
$128.13
|
| Rate for Payer: WPS Commercial |
$172.55
|
|
|
OTA Iontophoresis Charge
|
Facility
|
IP
|
$224.00
|
|
|
Service Code
|
CPT 97033 GO,CO
|
| Hospital Charge Code |
5571730
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$114.15 |
| Max. Negotiated Rate |
$214.32 |
| Rate for Payer: Aetna Commercial |
$209.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$200.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$123.47
|
| Rate for Payer: Cash Price |
$67.20
|
| Rate for Payer: Cigna Commercial |
$214.32
|
| Rate for Payer: Health EOS Commercial |
$207.33
|
| Rate for Payer: HFN Commercial |
$214.32
|
| Rate for Payer: Multiplan Commercial |
$186.37
|
| Rate for Payer: Preferred Network Access Commercial |
$214.32
|
| Rate for Payer: Quartz Beloit One Network |
$114.15
|
| Rate for Payer: Quartz Commercial |
$139.78
|
| Rate for Payer: WEA Trust Commercial |
$128.13
|
| Rate for Payer: WPS Commercial |
$172.55
|
|
|
OTA Manual Therapy Charges
|
Facility
|
OP
|
$251.00
|
|
|
Service Code
|
CPT 97140 GO,CO
|
| Hospital Charge Code |
5571710
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$73.09 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$234.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$224.49
|
| Rate for Payer: Aetna Managed Medicare |
$73.09
|
| 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 |
$138.35
|
| Rate for Payer: Cash Price |
$75.30
|
| Rate for Payer: Cash Price |
$75.30
|
| Rate for Payer: Cigna Commercial |
$240.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$146.08
|
| Rate for Payer: Health EOS Commercial |
$232.33
|
| Rate for Payer: HFN Commercial |
$240.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$208.83
|
| Rate for Payer: NAPHCARE Commercial |
$156.62
|
| Rate for Payer: Preferred Network Access Commercial |
$240.16
|
| Rate for Payer: Quartz Beloit One Network |
$127.91
|
| Rate for Payer: Quartz Commercial |
$169.68
|
| Rate for Payer: Quartz Medicare Advantage |
$156.62
|
| Rate for Payer: The Alliance Commercial |
$130.52
|
| Rate for Payer: United Healthcare PPO |
$195.78
|
| Rate for Payer: WEA Trust Commercial |
$143.57
|
| Rate for Payer: WPS Commercial |
$193.35
|
|
|
OTA Manual Therapy Charges
|
Facility
|
IP
|
$251.00
|
|
|
Service Code
|
CPT 97140 GO,CO
|
| Hospital Charge Code |
5571710
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$127.91 |
| Max. Negotiated Rate |
$240.16 |
| Rate for Payer: Aetna Commercial |
$234.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$224.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$138.35
|
| Rate for Payer: Cash Price |
$75.30
|
| Rate for Payer: Cigna Commercial |
$240.16
|
| Rate for Payer: Health EOS Commercial |
$232.33
|
| Rate for Payer: HFN Commercial |
$240.16
|
| Rate for Payer: Multiplan Commercial |
$208.83
|
| Rate for Payer: Preferred Network Access Commercial |
$240.16
|
| Rate for Payer: Quartz Beloit One Network |
$127.91
|
| Rate for Payer: Quartz Commercial |
$156.62
|
| Rate for Payer: WEA Trust Commercial |
$143.57
|
| Rate for Payer: WPS Commercial |
$193.35
|
|
|
OTA Massage Charge
|
Facility
|
OP
|
$73.00
|
|
|
Service Code
|
CPT 97124 GO,CO
|
| Hospital Charge Code |
5571714
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$21.26 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$68.33
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$65.29
|
| Rate for Payer: Aetna Managed Medicare |
$21.26
|
| 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 |
$40.24
|
| Rate for Payer: Cash Price |
$21.90
|
| Rate for Payer: Cash Price |
$21.90
|
| Rate for Payer: Cigna Commercial |
$69.85
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$42.49
|
| Rate for Payer: Health EOS Commercial |
$67.57
|
| Rate for Payer: HFN Commercial |
$69.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$60.74
|
| Rate for Payer: NAPHCARE Commercial |
$45.55
|
| Rate for Payer: Preferred Network Access Commercial |
$69.85
|
| Rate for Payer: Quartz Beloit One Network |
$37.20
|
| Rate for Payer: Quartz Commercial |
$49.35
|
| Rate for Payer: Quartz Medicare Advantage |
$45.55
|
| Rate for Payer: The Alliance Commercial |
$37.96
|
| Rate for Payer: United Healthcare PPO |
$56.94
|
| Rate for Payer: WEA Trust Commercial |
$41.76
|
| Rate for Payer: WPS Commercial |
$56.23
|
|
|
OTA Massage Charge
|
Facility
|
IP
|
$73.00
|
|
|
Service Code
|
CPT 97124 GO,CO
|
| Hospital Charge Code |
5571714
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$37.20 |
| Max. Negotiated Rate |
$69.85 |
| Rate for Payer: Aetna Commercial |
$68.33
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$65.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$40.24
|
| Rate for Payer: Cash Price |
$21.90
|
| Rate for Payer: Cigna Commercial |
$69.85
|
| Rate for Payer: Health EOS Commercial |
$67.57
|
| Rate for Payer: HFN Commercial |
$69.85
|
| Rate for Payer: Multiplan Commercial |
$60.74
|
| Rate for Payer: Preferred Network Access Commercial |
$69.85
|
| Rate for Payer: Quartz Beloit One Network |
$37.20
|
| Rate for Payer: Quartz Commercial |
$45.55
|
| Rate for Payer: WEA Trust Commercial |
$41.76
|
| Rate for Payer: WPS Commercial |
$56.23
|
|
|
OTA Neuromuscular Reeducation Charges
|
Facility
|
IP
|
$251.00
|
|
|
Service Code
|
CPT 97112 GO,CO
|
| Hospital Charge Code |
5571700
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$127.91 |
| Max. Negotiated Rate |
$240.16 |
| Rate for Payer: Aetna Commercial |
$234.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$224.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$138.35
|
| Rate for Payer: Cash Price |
$75.30
|
| Rate for Payer: Cigna Commercial |
$240.16
|
| Rate for Payer: Health EOS Commercial |
$232.33
|
| Rate for Payer: HFN Commercial |
$240.16
|
| Rate for Payer: Multiplan Commercial |
$208.83
|
| Rate for Payer: Preferred Network Access Commercial |
$240.16
|
| Rate for Payer: Quartz Beloit One Network |
$127.91
|
| Rate for Payer: Quartz Commercial |
$156.62
|
| Rate for Payer: WEA Trust Commercial |
$143.57
|
| Rate for Payer: WPS Commercial |
$193.35
|
|
|
OTA Neuromuscular Reeducation Charges
|
Facility
|
OP
|
$251.00
|
|
|
Service Code
|
CPT 97112 GO,CO
|
| Hospital Charge Code |
5571700
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$73.09 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$234.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$224.49
|
| Rate for Payer: Aetna Managed Medicare |
$73.09
|
| 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 |
$138.35
|
| Rate for Payer: Cash Price |
$75.30
|
| Rate for Payer: Cash Price |
$75.30
|
| Rate for Payer: Cigna Commercial |
$240.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$146.08
|
| Rate for Payer: Health EOS Commercial |
$232.33
|
| Rate for Payer: HFN Commercial |
$240.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$208.83
|
| Rate for Payer: NAPHCARE Commercial |
$156.62
|
| Rate for Payer: Preferred Network Access Commercial |
$240.16
|
| Rate for Payer: Quartz Beloit One Network |
$127.91
|
| Rate for Payer: Quartz Commercial |
$169.68
|
| Rate for Payer: Quartz Medicare Advantage |
$156.62
|
| Rate for Payer: The Alliance Commercial |
$130.52
|
| Rate for Payer: United Healthcare PPO |
$195.78
|
| Rate for Payer: WEA Trust Commercial |
$143.57
|
| Rate for Payer: WPS Commercial |
$193.35
|
|
|
OTA Orthotic Training Charge
|
Facility
|
OP
|
$264.00
|
|
|
Service Code
|
CPT 97760 GO,CO
|
| Hospital Charge Code |
5571704
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$76.88 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$247.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$236.12
|
| Rate for Payer: Aetna Managed Medicare |
$76.88
|
| 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 |
$145.52
|
| Rate for Payer: Cash Price |
$79.20
|
| Rate for Payer: Cash Price |
$79.20
|
| Rate for Payer: Cigna Commercial |
$252.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$153.65
|
| Rate for Payer: Health EOS Commercial |
$244.36
|
| Rate for Payer: HFN Commercial |
$252.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$219.65
|
| Rate for Payer: NAPHCARE Commercial |
$164.74
|
| Rate for Payer: Preferred Network Access Commercial |
$252.60
|
| Rate for Payer: Quartz Beloit One Network |
$134.53
|
| Rate for Payer: Quartz Commercial |
$178.46
|
| Rate for Payer: Quartz Medicare Advantage |
$164.74
|
| Rate for Payer: The Alliance Commercial |
$137.28
|
| Rate for Payer: United Healthcare PPO |
$205.92
|
| Rate for Payer: WEA Trust Commercial |
$151.01
|
| Rate for Payer: WPS Commercial |
$203.36
|
|
