|
OTITIS MEDIA AND URI WITH MCC
|
Facility
|
IP
|
$33,186.40
|
|
|
Service Code
|
MSDRG 152
|
| Min. Negotiated Rate |
$9,560.30 |
| Max. Negotiated Rate |
$33,186.40 |
| Rate for Payer: Aetna Managed Medicare |
$9,560.30
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$25,794.66
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$19,771.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$18,784.12
|
| Rate for Payer: Anthem Medicare Advantage |
$9,560.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$9,560.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$9,560.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$9,560.30
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$20,852.09
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$9,560.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$24,096.70
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$9,560.30
|
| Rate for Payer: Independent Care Health Plan Medicare |
$9,560.30
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$9,560.30
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$9,560.30
|
| Rate for Payer: NAPHCARE Commercial |
$14,340.46
|
| Rate for Payer: Quartz Medicare Advantage |
$9,560.30
|
| Rate for Payer: The Alliance Commercial |
$33,186.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$9,560.30
|
| Rate for Payer: United Healthcare PPO |
$18,759.58
|
| Rate for Payer: Wellcare Medicare |
$9,560.30
|
|
|
OTITIS MEDIA AND URI WITHOUT MCC
|
Facility
|
IP
|
$20,650.24
|
|
|
Service Code
|
MSDRG 153
|
| Min. Negotiated Rate |
$6,160.07 |
| Max. Negotiated Rate |
$20,650.24 |
| Rate for Payer: Aetna Managed Medicare |
$6,160.07
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$16,106.93
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$12,345.83
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$11,729.35
|
| Rate for Payer: Anthem Medicare Advantage |
$6,160.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$6,160.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$6,160.07
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$6,160.07
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13,020.65
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$6,160.07
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14,901.74
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$6,160.07
|
| Rate for Payer: Independent Care Health Plan Medicare |
$6,160.07
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$6,160.07
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$6,160.07
|
| Rate for Payer: NAPHCARE Commercial |
$9,240.10
|
| Rate for Payer: Quartz Medicare Advantage |
$6,160.07
|
| Rate for Payer: The Alliance Commercial |
$20,650.24
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6,160.07
|
| Rate for Payer: United Healthcare PPO |
$11,601.20
|
| Rate for Payer: Wellcare Medicare |
$6,160.07
|
|
|
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 |
$119.25 |
| Max. Negotiated Rate |
$223.89 |
| Rate for Payer: Aetna Commercial |
$219.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$209.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$128.98
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cigna Commercial |
$223.89
|
| Rate for Payer: Health EOS Commercial |
$216.59
|
| Rate for Payer: HFN Commercial |
$223.89
|
| Rate for Payer: Multiplan Commercial |
$194.69
|
| Rate for Payer: Preferred Network Access Commercial |
$223.89
|
| Rate for Payer: Quartz Beloit One Network |
$119.25
|
| Rate for Payer: Quartz Commercial |
$146.02
|
| Rate for Payer: WEA Trust Commercial |
$133.85
|
| Rate for Payer: WPS Commercial |
$180.25
|
|
|
OT Manual Therapy Charge Units
|
Facility
|
IP
|
$234.00
|
|
|
Service Code
|
CPT 97140
|
| Hospital Charge Code |
5247099
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$119.25 |
| Max. Negotiated Rate |
$223.89 |
| Rate for Payer: Aetna Commercial |
$219.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$209.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$128.98
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cigna Commercial |
$223.89
|
| Rate for Payer: Health EOS Commercial |
$216.59
|
| Rate for Payer: HFN Commercial |
$223.89
|
| Rate for Payer: Multiplan Commercial |
$194.69
|
| Rate for Payer: Preferred Network Access Commercial |
$223.89
|
| Rate for Payer: Quartz Beloit One Network |
$119.25
|
| Rate for Payer: Quartz Commercial |
$146.02
|
| Rate for Payer: WEA Trust Commercial |
$133.85
|
| Rate for Payer: WPS Commercial |
$180.25
|
|
|
OT Manual Therapy Charge Units
|
Facility
|
OP
|
$234.00
|
|
|
Service Code
|
CPT 97140
|
| Hospital Charge Code |
5247099
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$68.14 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$219.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$209.29
|
| Rate for Payer: Aetna Managed Medicare |
$68.14
|
| 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 |
$128.98
|
| 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 |
$223.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$136.19
|
| Rate for Payer: Health EOS Commercial |
$216.59
|
| Rate for Payer: HFN Commercial |
$223.89
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$194.69
|
| Rate for Payer: NAPHCARE Commercial |
$146.02
|
| Rate for Payer: Preferred Network Access Commercial |
$223.89
|
| Rate for Payer: Quartz Beloit One Network |
$119.25
|
| Rate for Payer: Quartz Commercial |
$158.18
|
| Rate for Payer: Quartz Medicare Advantage |
$146.02
|
| Rate for Payer: The Alliance Commercial |
$112.07
|
| Rate for Payer: United Healthcare PPO |
$182.52
|
| Rate for Payer: WEA Trust Commercial |
$133.85
|
| Rate for Payer: WPS Commercial |
$180.25
|
|
|
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 |
$68.14 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$219.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$209.29
|
| Rate for Payer: Aetna Managed Medicare |
$68.14
|
| 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 |
$128.98
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cigna Commercial |
$223.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$136.19
|
| Rate for Payer: Health EOS Commercial |
$216.59
|
| Rate for Payer: HFN Commercial |
$223.89
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$194.69
|
| Rate for Payer: NAPHCARE Commercial |
$146.02
|
| Rate for Payer: Preferred Network Access Commercial |
$223.89
|
| Rate for Payer: Quartz Beloit One Network |
$119.25
|
| Rate for Payer: Quartz Commercial |
$158.18
|
| Rate for Payer: Quartz Medicare Advantage |
$146.02
|
| Rate for Payer: The Alliance Commercial |
$121.68
|
| Rate for Payer: United Healthcare PPO |
$182.52
|
| Rate for Payer: WEA Trust Commercial |
$133.85
|
| Rate for Payer: WPS Commercial |
$180.25
|
|
|
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 |
$98.06 |
| Max. Negotiated Rate |
$231.19 |
| Rate for Payer: Aetna Commercial |
$231.19
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$209.29
|
| 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 |
$231.19
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$121.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$146.02
|
| Rate for Payer: Health EOS Commercial |
$221.46
|
| Rate for Payer: HFN Commercial |
$231.19
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$98.06
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$98.06
|
| Rate for Payer: Multiplan Commercial |
$194.69
|
| Rate for Payer: Preferred Network Access Commercial |
$231.19
|
| Rate for Payer: Quartz Beloit One Network |
$107.08
|
| Rate for Payer: Quartz Commercial |
$138.72
|
| Rate for Payer: The Alliance Commercial |
$121.68
|
| Rate for Payer: WEA Trust Commercial |
$133.85
|
| Rate for Payer: WPS Commercial |
$180.25
|
|
|
OT Massage Charge Units
|
Facility
|
IP
|
$90.00
|
|
|
Service Code
|
CPT 97124 GO
|
| Hospital Charge Code |
2468807
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$45.86 |
| Max. Negotiated Rate |
$86.11 |
| Rate for Payer: Aetna Commercial |
$84.24
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$80.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$49.61
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$86.11
|
| Rate for Payer: Health EOS Commercial |
$83.30
|
| Rate for Payer: HFN Commercial |
$86.11
|
| Rate for Payer: Multiplan Commercial |
$74.88
|
| Rate for Payer: Preferred Network Access Commercial |
$86.11
|
| Rate for Payer: Quartz Beloit One Network |
$45.86
|
| Rate for Payer: Quartz Commercial |
$56.16
|
| Rate for Payer: WEA Trust Commercial |
$51.48
|
| Rate for Payer: WPS Commercial |
$69.33
|
|
|
OT Massage Charge Units
|
Facility
|
OP
|
$90.00
|
|
|
Service Code
|
CPT 97124 GO
|
| Hospital Charge Code |
2468807
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$26.21 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$84.24
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$80.50
|
| Rate for Payer: Aetna Managed Medicare |
$26.21
|
| 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 |
$49.61
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$86.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$52.38
|
| Rate for Payer: Health EOS Commercial |
$83.30
|
| Rate for Payer: HFN Commercial |
$86.11
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$74.88
|
| Rate for Payer: NAPHCARE Commercial |
$56.16
|
| Rate for Payer: Preferred Network Access Commercial |
$86.11
|
| Rate for Payer: Quartz Beloit One Network |
$45.86
|
| Rate for Payer: Quartz Commercial |
$60.84
|
| Rate for Payer: Quartz Medicare Advantage |
$56.16
|
| Rate for Payer: The Alliance Commercial |
$46.80
|
| Rate for Payer: United Healthcare PPO |
$70.20
|
| Rate for Payer: WEA Trust Commercial |
$51.48
|
| Rate for Payer: WPS Commercial |
$69.33
|
|
|
OT Neuromuscular Reeducation Charges
|
Facility
|
OP
|
$228.00
|
|
|
Service Code
|
CPT 97112 GO
|
| Hospital Charge Code |
750905
|
|
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 Neuromuscular Reeducation Charges
|
Facility
|
IP
|
$228.00
|
|
|
Service Code
|
CPT 97112 GO
|
| Hospital Charge Code |
750905
|
|
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
|
|
|
OTOPLASTY
|
Facility
|
OP
|
$7,602.00
|
|
| Hospital Charge Code |
2960298
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,213.70 |
| Max. Negotiated Rate |
$7,273.59 |
| Rate for Payer: Aetna Commercial |
$7,115.47
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,799.23
|
| Rate for Payer: Aetna Managed Medicare |
$2,213.70
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,138.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,953.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,794.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,190.22
|
| Rate for Payer: Cash Price |
$2,280.60
|
| Rate for Payer: Cigna Commercial |
$7,273.59
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,424.36
|
| Rate for Payer: Health EOS Commercial |
$7,036.41
|
| Rate for Payer: HFN Commercial |
$7,273.59
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,929.56
|
| Rate for Payer: Multiplan Commercial |
$6,324.86
|
| Rate for Payer: NAPHCARE Commercial |
$4,743.65
|
| Rate for Payer: Preferred Network Access Commercial |
$7,273.59
|
| Rate for Payer: Quartz Beloit One Network |
$3,873.98
|
| Rate for Payer: Quartz Commercial |
$5,138.95
|
| Rate for Payer: Quartz Medicare Advantage |
$4,743.65
|
| Rate for Payer: The Alliance Commercial |
$3,953.04
|
| Rate for Payer: WEA Trust Commercial |
$4,348.34
|
| Rate for Payer: WPS Commercial |
$5,855.82
|
|
|
OTOPLASTY
|
Facility
|
IP
|
$7,602.00
|
|
| Hospital Charge Code |
2960298
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,873.98 |
| Max. Negotiated Rate |
$7,273.59 |
| Rate for Payer: Aetna Commercial |
$7,115.47
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,799.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,190.22
|
| Rate for Payer: Cash Price |
$2,280.60
|
| Rate for Payer: Cigna Commercial |
$7,273.59
|
| Rate for Payer: Health EOS Commercial |
$7,036.41
|
| Rate for Payer: HFN Commercial |
$7,273.59
|
| Rate for Payer: Multiplan Commercial |
$6,324.86
|
| Rate for Payer: Preferred Network Access Commercial |
$7,273.59
|
| Rate for Payer: Quartz Beloit One Network |
$3,873.98
|
| Rate for Payer: Quartz Commercial |
$4,743.65
|
| Rate for Payer: WEA Trust Commercial |
$4,348.34
|
| Rate for Payer: WPS Commercial |
$5,855.82
|
|
|
OTORHINOLARYNGOLOGIC FUNCTION TESTS
|
Facility
|
OP
|
$96.96
|
|
|
Service Code
|
EAPG 00251
|
| Min. Negotiated Rate |
$93.23 |
| Max. Negotiated Rate |
$96.96 |
| Rate for Payer: Anthem Medicaid |
$93.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$93.23
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$93.23
|
| Rate for Payer: Dean Health Medicaid |
$93.23
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$93.23
|
| Rate for Payer: Managed Health Services Medicaid |
$96.96
|
| Rate for Payer: Molina Healthcare Medicaid |
$93.23
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$93.23
|
| Rate for Payer: United Healthcare Medicaid |
$93.23
|
|
|
OT Orthotic Training Charges
|
Professional
|
Both
|
$225.00
|
|
|
Service Code
|
CPT 97760 GO
|
| Hospital Charge Code |
2989842
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$102.96 |
| 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 |
$67.50
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cash Price |
$67.50
|
| 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 |
$175.81
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$175.81
|
| 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 Orthotic Training Charges
|
Facility
|
OP
|
$225.00
|
|
|
Service Code
|
CPT 97760 GO
|
| Hospital Charge Code |
2989842
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$65.52 |
| Max. Negotiated Rate |
$362.96 |
| 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 |
$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 |
$124.02
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cash Price |
$67.50
|
| 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 |
$210.08
|
| 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 |
$117.00
|
| Rate for Payer: United Healthcare PPO |
$175.50
|
| Rate for Payer: WEA Trust Commercial |
$128.70
|
| Rate for Payer: WPS Commercial |
$173.32
|
|
|
OT Orthotic Training Charges
|
Facility
|
IP
|
$225.00
|
|
|
Service Code
|
CPT 97760 GO
|
| Hospital Charge Code |
2989842
|
|
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 |
$67.50
|
| 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: 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 Prosthetic Training Charges
|
Facility
|
IP
|
$223.00
|
|
|
Service Code
|
CPT 97761 GO
|
| Hospital Charge Code |
750930
|
|
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
|
|
|
OT Prosthetic Training Charges
|
Facility
|
OP
|
$223.00
|
|
|
Service Code
|
CPT 97761 GO
|
| Hospital Charge Code |
750930
|
|
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 Reevaluation
|
Facility
|
OP
|
$693.00
|
|
|
Service Code
|
CPT 97168
|
| Hospital Charge Code |
5250707
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$201.80 |
| Max. Negotiated Rate |
$663.06 |
| Rate for Payer: Aetna Commercial |
$648.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$619.82
|
| Rate for Payer: Aetna Managed Medicare |
$201.80
|
| 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 |
$381.98
|
| Rate for Payer: Cash Price |
$207.90
|
| Rate for Payer: Cash Price |
$207.90
|
| Rate for Payer: Cash Price |
$207.90
|
| Rate for Payer: Cigna Commercial |
$663.06
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$403.33
|
| Rate for Payer: Health EOS Commercial |
$641.44
|
| Rate for Payer: HFN Commercial |
$663.06
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$576.58
|
| Rate for Payer: NAPHCARE Commercial |
$432.43
|
| Rate for Payer: Preferred Network Access Commercial |
$663.06
|
| Rate for Payer: Quartz Beloit One Network |
$353.15
|
| Rate for Payer: Quartz Commercial |
$468.47
|
| Rate for Payer: Quartz Medicare Advantage |
$432.43
|
| Rate for Payer: The Alliance Commercial |
$277.60
|
| Rate for Payer: United Healthcare PPO |
$540.54
|
| Rate for Payer: WEA Trust Commercial |
$396.40
|
| Rate for Payer: WPS Commercial |
$533.82
|
|
|
OT Reevaluation
|
Facility
|
IP
|
$693.00
|
|
|
Service Code
|
CPT 97168
|
| Hospital Charge Code |
5250707
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$353.15 |
| Max. Negotiated Rate |
$663.06 |
| Rate for Payer: Aetna Commercial |
$648.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$619.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$381.98
|
| Rate for Payer: Cash Price |
$207.90
|
| Rate for Payer: Cigna Commercial |
$663.06
|
| Rate for Payer: Health EOS Commercial |
$641.44
|
| Rate for Payer: HFN Commercial |
$663.06
|
| Rate for Payer: Multiplan Commercial |
$576.58
|
| Rate for Payer: Preferred Network Access Commercial |
$663.06
|
| Rate for Payer: Quartz Beloit One Network |
$353.15
|
| Rate for Payer: Quartz Commercial |
$432.43
|
| Rate for Payer: WEA Trust Commercial |
$396.40
|
| Rate for Payer: WPS Commercial |
$533.82
|
|
|
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 |
$50.67 |
| Max. Negotiated Rate |
$4,386.95 |
| Rate for Payer: Aetna Commercial |
$162.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$155.63
|
| Rate for Payer: Aetna Managed Medicare |
$50.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$362.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$298.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$282.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$95.91
|
| 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 |
$166.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,386.95
|
| Rate for Payer: Health EOS Commercial |
$161.05
|
| Rate for Payer: HFN Commercial |
$166.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$144.77
|
| Rate for Payer: NAPHCARE Commercial |
$108.58
|
| Rate for Payer: Preferred Network Access Commercial |
$166.48
|
| Rate for Payer: Quartz Beloit One Network |
$88.67
|
| Rate for Payer: Quartz Commercial |
$117.62
|
| Rate for Payer: Quartz Medicare Advantage |
$108.58
|
| Rate for Payer: The Alliance Commercial |
$90.48
|
| Rate for Payer: United Healthcare PPO |
$135.72
|
| Rate for Payer: WEA Trust Commercial |
$99.53
|
| Rate for Payer: WPS Commercial |
$134.03
|
|
|
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 |
$88.67 |
| Max. Negotiated Rate |
$166.48 |
| Rate for Payer: Aetna Commercial |
$162.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$155.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$95.91
|
| Rate for Payer: Cash Price |
$52.20
|
| Rate for Payer: Cigna Commercial |
$166.48
|
| Rate for Payer: Health EOS Commercial |
$161.05
|
| Rate for Payer: HFN Commercial |
$166.48
|
| Rate for Payer: Multiplan Commercial |
$144.77
|
| Rate for Payer: Preferred Network Access Commercial |
$166.48
|
| Rate for Payer: Quartz Beloit One Network |
$88.67
|
| Rate for Payer: Quartz Commercial |
$108.58
|
| Rate for Payer: WEA Trust Commercial |
$99.53
|
| Rate for Payer: WPS Commercial |
$134.03
|
|
|
OT Therapeutic Activities Charges
|
Facility
|
OP
|
$231.00
|
|
|
Service Code
|
CPT 97530 GO
|
| Hospital Charge Code |
750903
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$67.27 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$216.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$206.61
|
| Rate for Payer: Aetna Managed Medicare |
$67.27
|
| 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 |
$127.33
|
| Rate for Payer: Cash Price |
$69.30
|
| Rate for Payer: Cash Price |
$69.30
|
| Rate for Payer: Cigna Commercial |
$221.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$134.44
|
| Rate for Payer: Health EOS Commercial |
$213.81
|
| Rate for Payer: HFN Commercial |
$221.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$192.19
|
| Rate for Payer: NAPHCARE Commercial |
$144.14
|
| Rate for Payer: Preferred Network Access Commercial |
$221.02
|
| Rate for Payer: Quartz Beloit One Network |
$117.72
|
| Rate for Payer: Quartz Commercial |
$156.16
|
| Rate for Payer: Quartz Medicare Advantage |
$144.14
|
| Rate for Payer: The Alliance Commercial |
$120.12
|
| Rate for Payer: United Healthcare PPO |
$180.18
|
| Rate for Payer: WEA Trust Commercial |
$132.13
|
| Rate for Payer: WPS Commercial |
$177.94
|
|
|
OT Therapeutic Activities Charges
|
Facility
|
IP
|
$231.00
|
|
|
Service Code
|
CPT 97530 GO
|
| Hospital Charge Code |
750903
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$117.72 |
| Max. Negotiated Rate |
$221.02 |
| Rate for Payer: Aetna Commercial |
$216.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$206.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$127.33
|
| Rate for Payer: Cash Price |
$69.30
|
| Rate for Payer: Cigna Commercial |
$221.02
|
| Rate for Payer: Health EOS Commercial |
$213.81
|
| Rate for Payer: HFN Commercial |
$221.02
|
| Rate for Payer: Multiplan Commercial |
$192.19
|
| Rate for Payer: Preferred Network Access Commercial |
$221.02
|
| Rate for Payer: Quartz Beloit One Network |
$117.72
|
| Rate for Payer: Quartz Commercial |
$144.14
|
| Rate for Payer: WEA Trust Commercial |
$132.13
|
| Rate for Payer: WPS Commercial |
$177.94
|
|
