|
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 |
$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 ADL Training/15 min charge
|
Facility
|
OP
|
$244.00
|
|
|
Service Code
|
CPT 97535
|
| Hospital Charge Code |
5247101
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$68.32 |
| Max. Negotiated Rate |
$976.00 |
| Rate for Payer: Aetna Commercial |
$219.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$209.84
|
| Rate for Payer: Aetna Managed Medicare |
$68.32
|
| 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 |
$129.32
|
| Rate for Payer: Cash Price |
$73.20
|
| Rate for Payer: Cash Price |
$73.20
|
| Rate for Payer: Cigna Commercial |
$224.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$136.54
|
| Rate for Payer: Health EOS Commercial |
$217.16
|
| Rate for Payer: HFN Commercial |
$224.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$195.20
|
| Rate for Payer: NAPHCARE Commercial |
$146.40
|
| Rate for Payer: Preferred Network Access Commercial |
$224.48
|
| Rate for Payer: Quartz Beloit One Network |
$119.56
|
| Rate for Payer: Quartz Commercial |
$158.60
|
| Rate for Payer: Quartz Medicare Advantage |
$146.40
|
| Rate for Payer: The Alliance Commercial |
$976.00
|
| Rate for Payer: United Healthcare PPO |
$183.00
|
| Rate for Payer: WEA Trust Commercial |
$134.20
|
| Rate for Payer: WPS Commercial |
$180.73
|
|
|
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 |
$119.56 |
| Max. Negotiated Rate |
$224.48 |
| Rate for Payer: Aetna Commercial |
$219.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$209.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$129.32
|
| Rate for Payer: Cash Price |
$73.20
|
| Rate for Payer: Cigna Commercial |
$224.48
|
| Rate for Payer: Health EOS Commercial |
$217.16
|
| Rate for Payer: HFN Commercial |
$224.48
|
| Rate for Payer: Multiplan Commercial |
$195.20
|
| Rate for Payer: NAPHCARE Commercial |
$146.40
|
| Rate for Payer: Preferred Network Access Commercial |
$224.48
|
| Rate for Payer: Quartz Beloit One Network |
$119.56
|
| Rate for Payer: Quartz Commercial |
$146.40
|
| Rate for Payer: WEA Trust Commercial |
$134.20
|
| Rate for Payer: WPS Commercial |
$180.73
|
|
|
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 |
$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 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 |
$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
|
|
|
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 |
$122.99 |
| Max. Negotiated Rate |
$230.92 |
| Rate for Payer: Aetna Commercial |
$225.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$215.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$133.03
|
| Rate for Payer: Cash Price |
$75.30
|
| Rate for Payer: Cigna Commercial |
$230.92
|
| Rate for Payer: Health EOS Commercial |
$223.39
|
| Rate for Payer: HFN Commercial |
$230.92
|
| Rate for Payer: Multiplan Commercial |
$200.80
|
| Rate for Payer: NAPHCARE Commercial |
$150.60
|
| Rate for Payer: Preferred Network Access Commercial |
$230.92
|
| Rate for Payer: Quartz Beloit One Network |
$122.99
|
| Rate for Payer: Quartz Commercial |
$150.60
|
| Rate for Payer: WEA Trust Commercial |
$138.05
|
| Rate for Payer: WPS Commercial |
$185.92
|
|
|
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 |
$70.28 |
| Max. Negotiated Rate |
$1,004.00 |
| Rate for Payer: Aetna Commercial |
$225.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$215.86
|
| Rate for Payer: Aetna Managed Medicare |
$70.28
|
| 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 |
$133.03
|
| Rate for Payer: Cash Price |
$75.30
|
| Rate for Payer: Cash Price |
$75.30
|
| Rate for Payer: Cigna Commercial |
$230.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$140.46
|
| Rate for Payer: Health EOS Commercial |
$223.39
|
| Rate for Payer: HFN Commercial |
$230.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$200.80
|
| Rate for Payer: NAPHCARE Commercial |
$150.60
|
| Rate for Payer: Preferred Network Access Commercial |
$230.92
|
| Rate for Payer: Quartz Beloit One Network |
$122.99
|
| Rate for Payer: Quartz Commercial |
$163.15
|
| Rate for Payer: Quartz Medicare Advantage |
$150.60
|
| Rate for Payer: The Alliance Commercial |
$1,004.00
|
| Rate for Payer: United Healthcare PPO |
$188.25
|
| Rate for Payer: WEA Trust Commercial |
$138.05
|
| Rate for Payer: WPS Commercial |
$185.92
|
|
|
OTA Iontophoresis Charge
|
Facility
|
IP
|
$224.00
|
|
|
Service Code
|
CPT 97033 GO,CO
|
| Hospital Charge Code |
5571730
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$109.76 |
| Max. Negotiated Rate |
$206.08 |
| Rate for Payer: Aetna Commercial |
$201.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$192.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$118.72
|
| Rate for Payer: Cash Price |
$67.20
|
| Rate for Payer: Cigna Commercial |
$206.08
|
| Rate for Payer: Health EOS Commercial |
$199.36
|
| Rate for Payer: HFN Commercial |
$206.08
|
| Rate for Payer: Multiplan Commercial |
$179.20
|
| Rate for Payer: NAPHCARE Commercial |
$134.40
|
| Rate for Payer: Preferred Network Access Commercial |
$206.08
|
| Rate for Payer: Quartz Beloit One Network |
$109.76
|
| Rate for Payer: Quartz Commercial |
$134.40
|
| Rate for Payer: WEA Trust Commercial |
$123.20
|
| Rate for Payer: WPS Commercial |
$165.92
|
|
|
OTA Iontophoresis Charge
|
Facility
|
OP
|
$224.00
|
|
|
Service Code
|
CPT 97033 GO,CO
|
| Hospital Charge Code |
5571730
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$62.72 |
| Max. Negotiated Rate |
$896.00 |
| Rate for Payer: Aetna Commercial |
$201.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$192.64
|
| Rate for Payer: Aetna Managed Medicare |
$62.72
|
| 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 |
$118.72
|
| Rate for Payer: Cash Price |
$67.20
|
| Rate for Payer: Cash Price |
$67.20
|
| Rate for Payer: Cigna Commercial |
$206.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$125.35
|
| Rate for Payer: Health EOS Commercial |
$199.36
|
| Rate for Payer: HFN Commercial |
$206.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$179.20
|
| Rate for Payer: NAPHCARE Commercial |
$134.40
|
| Rate for Payer: Preferred Network Access Commercial |
$206.08
|
| Rate for Payer: Quartz Beloit One Network |
$109.76
|
| Rate for Payer: Quartz Commercial |
$145.60
|
| Rate for Payer: Quartz Medicare Advantage |
$134.40
|
| Rate for Payer: The Alliance Commercial |
$896.00
|
| Rate for Payer: United Healthcare PPO |
$168.00
|
| Rate for Payer: WEA Trust Commercial |
$123.20
|
| Rate for Payer: WPS Commercial |
$165.92
|
|
|
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 |
$70.28 |
| Max. Negotiated Rate |
$1,004.00 |
| Rate for Payer: Aetna Commercial |
$225.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$215.86
|
| Rate for Payer: Aetna Managed Medicare |
$70.28
|
| 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 |
$133.03
|
| Rate for Payer: Cash Price |
$75.30
|
| Rate for Payer: Cash Price |
$75.30
|
| Rate for Payer: Cigna Commercial |
$230.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$140.46
|
| Rate for Payer: Health EOS Commercial |
$223.39
|
| Rate for Payer: HFN Commercial |
$230.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$200.80
|
| Rate for Payer: NAPHCARE Commercial |
$150.60
|
| Rate for Payer: Preferred Network Access Commercial |
$230.92
|
| Rate for Payer: Quartz Beloit One Network |
$122.99
|
| Rate for Payer: Quartz Commercial |
$163.15
|
| Rate for Payer: Quartz Medicare Advantage |
$150.60
|
| Rate for Payer: The Alliance Commercial |
$1,004.00
|
| Rate for Payer: United Healthcare PPO |
$188.25
|
| Rate for Payer: WEA Trust Commercial |
$138.05
|
| Rate for Payer: WPS Commercial |
$185.92
|
|
|
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 |
$122.99 |
| Max. Negotiated Rate |
$230.92 |
| Rate for Payer: Aetna Commercial |
$225.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$215.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$133.03
|
| Rate for Payer: Cash Price |
$75.30
|
| Rate for Payer: Cigna Commercial |
$230.92
|
| Rate for Payer: Health EOS Commercial |
$223.39
|
| Rate for Payer: HFN Commercial |
$230.92
|
| Rate for Payer: Multiplan Commercial |
$200.80
|
| Rate for Payer: NAPHCARE Commercial |
$150.60
|
| Rate for Payer: Preferred Network Access Commercial |
$230.92
|
| Rate for Payer: Quartz Beloit One Network |
$122.99
|
| Rate for Payer: Quartz Commercial |
$150.60
|
| Rate for Payer: WEA Trust Commercial |
$138.05
|
| Rate for Payer: WPS Commercial |
$185.92
|
|
|
OTA Massage Charge
|
Facility
|
IP
|
$73.00
|
|
|
Service Code
|
CPT 97124 GO,CO
|
| Hospital Charge Code |
5571714
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$35.77 |
| Max. Negotiated Rate |
$67.16 |
| Rate for Payer: Aetna Commercial |
$65.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$62.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$38.69
|
| Rate for Payer: Cash Price |
$21.90
|
| Rate for Payer: Cigna Commercial |
$67.16
|
| Rate for Payer: Health EOS Commercial |
$64.97
|
| Rate for Payer: HFN Commercial |
$67.16
|
| Rate for Payer: Multiplan Commercial |
$58.40
|
| Rate for Payer: NAPHCARE Commercial |
$43.80
|
| Rate for Payer: Preferred Network Access Commercial |
$67.16
|
| Rate for Payer: Quartz Beloit One Network |
$35.77
|
| Rate for Payer: Quartz Commercial |
$43.80
|
| Rate for Payer: WEA Trust Commercial |
$40.15
|
| Rate for Payer: WPS Commercial |
$54.07
|
|
|
OTA Massage Charge
|
Facility
|
OP
|
$73.00
|
|
|
Service Code
|
CPT 97124 GO,CO
|
| Hospital Charge Code |
5571714
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$20.44 |
| Max. Negotiated Rate |
$349.00 |
| Rate for Payer: Aetna Commercial |
$65.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$62.78
|
| Rate for Payer: Aetna Managed Medicare |
$20.44
|
| 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 |
$38.69
|
| Rate for Payer: Cash Price |
$21.90
|
| Rate for Payer: Cash Price |
$21.90
|
| Rate for Payer: Cigna Commercial |
$67.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$40.85
|
| Rate for Payer: Health EOS Commercial |
$64.97
|
| Rate for Payer: HFN Commercial |
$67.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$58.40
|
| Rate for Payer: NAPHCARE Commercial |
$43.80
|
| Rate for Payer: Preferred Network Access Commercial |
$67.16
|
| Rate for Payer: Quartz Beloit One Network |
$35.77
|
| Rate for Payer: Quartz Commercial |
$47.45
|
| Rate for Payer: Quartz Medicare Advantage |
$43.80
|
| Rate for Payer: The Alliance Commercial |
$292.00
|
| Rate for Payer: United Healthcare PPO |
$54.75
|
| Rate for Payer: WEA Trust Commercial |
$40.15
|
| Rate for Payer: WPS Commercial |
$54.07
|
|
|
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 |
$122.99 |
| Max. Negotiated Rate |
$230.92 |
| Rate for Payer: Aetna Commercial |
$225.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$215.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$133.03
|
| Rate for Payer: Cash Price |
$75.30
|
| Rate for Payer: Cigna Commercial |
$230.92
|
| Rate for Payer: Health EOS Commercial |
$223.39
|
| Rate for Payer: HFN Commercial |
$230.92
|
| Rate for Payer: Multiplan Commercial |
$200.80
|
| Rate for Payer: NAPHCARE Commercial |
$150.60
|
| Rate for Payer: Preferred Network Access Commercial |
$230.92
|
| Rate for Payer: Quartz Beloit One Network |
$122.99
|
| Rate for Payer: Quartz Commercial |
$150.60
|
| Rate for Payer: WEA Trust Commercial |
$138.05
|
| Rate for Payer: WPS Commercial |
$185.92
|
|
|
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 |
$70.28 |
| Max. Negotiated Rate |
$1,004.00 |
| Rate for Payer: Aetna Commercial |
$225.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$215.86
|
| Rate for Payer: Aetna Managed Medicare |
$70.28
|
| 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 |
$133.03
|
| Rate for Payer: Cash Price |
$75.30
|
| Rate for Payer: Cash Price |
$75.30
|
| Rate for Payer: Cigna Commercial |
$230.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$140.46
|
| Rate for Payer: Health EOS Commercial |
$223.39
|
| Rate for Payer: HFN Commercial |
$230.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$200.80
|
| Rate for Payer: NAPHCARE Commercial |
$150.60
|
| Rate for Payer: Preferred Network Access Commercial |
$230.92
|
| Rate for Payer: Quartz Beloit One Network |
$122.99
|
| Rate for Payer: Quartz Commercial |
$163.15
|
| Rate for Payer: Quartz Medicare Advantage |
$150.60
|
| Rate for Payer: The Alliance Commercial |
$1,004.00
|
| Rate for Payer: United Healthcare PPO |
$188.25
|
| Rate for Payer: WEA Trust Commercial |
$138.05
|
| Rate for Payer: WPS Commercial |
$185.92
|
|
|
OTA Orthotic Training Charge
|
Facility
|
IP
|
$264.00
|
|
|
Service Code
|
CPT 97760 GO,CO
|
| Hospital Charge Code |
5571704
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$129.36 |
| Max. Negotiated Rate |
$242.88 |
| Rate for Payer: Aetna Commercial |
$237.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$227.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$139.92
|
| Rate for Payer: Cash Price |
$79.20
|
| Rate for Payer: Cigna Commercial |
$242.88
|
| Rate for Payer: Health EOS Commercial |
$234.96
|
| Rate for Payer: HFN Commercial |
$242.88
|
| Rate for Payer: Multiplan Commercial |
$211.20
|
| Rate for Payer: NAPHCARE Commercial |
$158.40
|
| Rate for Payer: Preferred Network Access Commercial |
$242.88
|
| Rate for Payer: Quartz Beloit One Network |
$129.36
|
| Rate for Payer: Quartz Commercial |
$158.40
|
| Rate for Payer: WEA Trust Commercial |
$145.20
|
| Rate for Payer: WPS Commercial |
$195.54
|
|
|
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 |
$73.92 |
| Max. Negotiated Rate |
$1,056.00 |
| Rate for Payer: Aetna Commercial |
$237.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$227.04
|
| Rate for Payer: Aetna Managed Medicare |
$73.92
|
| 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 |
$139.92
|
| Rate for Payer: Cash Price |
$79.20
|
| Rate for Payer: Cash Price |
$79.20
|
| Rate for Payer: Cigna Commercial |
$242.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$147.73
|
| Rate for Payer: Health EOS Commercial |
$234.96
|
| Rate for Payer: HFN Commercial |
$242.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$211.20
|
| Rate for Payer: NAPHCARE Commercial |
$158.40
|
| Rate for Payer: Preferred Network Access Commercial |
$242.88
|
| Rate for Payer: Quartz Beloit One Network |
$129.36
|
| Rate for Payer: Quartz Commercial |
$171.60
|
| Rate for Payer: Quartz Medicare Advantage |
$158.40
|
| Rate for Payer: The Alliance Commercial |
$1,056.00
|
| Rate for Payer: United Healthcare PPO |
$198.00
|
| Rate for Payer: WEA Trust Commercial |
$145.20
|
| Rate for Payer: WPS Commercial |
$195.54
|
|
|
OTA Physical Perf Test WH Eval Charge
|
Facility
|
OP
|
$173.00
|
|
|
Service Code
|
CPT 97750 GO,CO
|
| Hospital Charge Code |
5572121
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$48.44 |
| Max. Negotiated Rate |
$692.00 |
| Rate for Payer: Aetna Commercial |
$155.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$148.78
|
| Rate for Payer: Aetna Managed Medicare |
$48.44
|
| 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 |
$91.69
|
| Rate for Payer: Cash Price |
$51.90
|
| Rate for Payer: Cash Price |
$51.90
|
| Rate for Payer: Cigna Commercial |
$159.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$96.81
|
| Rate for Payer: Health EOS Commercial |
$153.97
|
| Rate for Payer: HFN Commercial |
$159.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$138.40
|
| Rate for Payer: NAPHCARE Commercial |
$103.80
|
| Rate for Payer: Preferred Network Access Commercial |
$159.16
|
| Rate for Payer: Quartz Beloit One Network |
$84.77
|
| Rate for Payer: Quartz Commercial |
$112.45
|
| Rate for Payer: Quartz Medicare Advantage |
$103.80
|
| Rate for Payer: The Alliance Commercial |
$692.00
|
| Rate for Payer: United Healthcare PPO |
$129.75
|
| Rate for Payer: WEA Trust Commercial |
$95.15
|
| Rate for Payer: WPS Commercial |
$128.14
|
|
|
OTA Physical Perf Test WH Eval Charge
|
Facility
|
IP
|
$173.00
|
|
|
Service Code
|
CPT 97750 GO,CO
|
| Hospital Charge Code |
5572121
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$84.77 |
| Max. Negotiated Rate |
$159.16 |
| Rate for Payer: Aetna Commercial |
$155.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$148.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$91.69
|
| Rate for Payer: Cash Price |
$51.90
|
| Rate for Payer: Cigna Commercial |
$159.16
|
| Rate for Payer: Health EOS Commercial |
$153.97
|
| Rate for Payer: HFN Commercial |
$159.16
|
| Rate for Payer: Multiplan Commercial |
$138.40
|
| Rate for Payer: NAPHCARE Commercial |
$103.80
|
| Rate for Payer: Preferred Network Access Commercial |
$159.16
|
| Rate for Payer: Quartz Beloit One Network |
$84.77
|
| Rate for Payer: Quartz Commercial |
$103.80
|
| Rate for Payer: WEA Trust Commercial |
$95.15
|
| Rate for Payer: WPS Commercial |
$128.14
|
|
|
OTA Physical Pert Test - FAC Charge
|
Facility
|
IP
|
$123.00
|
|
|
Service Code
|
CPT 97750 CO,GO
|
| Hospital Charge Code |
5572119
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$60.27 |
| Max. Negotiated Rate |
$113.16 |
| Rate for Payer: Aetna Commercial |
$110.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$105.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$65.19
|
| Rate for Payer: Cash Price |
$36.90
|
| Rate for Payer: Cigna Commercial |
$113.16
|
| Rate for Payer: Health EOS Commercial |
$109.47
|
| Rate for Payer: HFN Commercial |
$113.16
|
| Rate for Payer: Multiplan Commercial |
$98.40
|
| Rate for Payer: NAPHCARE Commercial |
$73.80
|
| Rate for Payer: Preferred Network Access Commercial |
$113.16
|
| Rate for Payer: Quartz Beloit One Network |
$60.27
|
| Rate for Payer: Quartz Commercial |
$73.80
|
| Rate for Payer: WEA Trust Commercial |
$67.65
|
| Rate for Payer: WPS Commercial |
$91.11
|
|
|
OTA Physical Pert Test - FAC Charge
|
Facility
|
OP
|
$123.00
|
|
|
Service Code
|
CPT 97750 CO,GO
|
| Hospital Charge Code |
5572119
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$34.44 |
| Max. Negotiated Rate |
$492.00 |
| Rate for Payer: Aetna Commercial |
$110.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$105.78
|
| Rate for Payer: Aetna Managed Medicare |
$34.44
|
| 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 |
$65.19
|
| Rate for Payer: Cash Price |
$36.90
|
| Rate for Payer: Cash Price |
$36.90
|
| Rate for Payer: Cigna Commercial |
$113.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$68.83
|
| Rate for Payer: Health EOS Commercial |
$109.47
|
| Rate for Payer: HFN Commercial |
$113.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$98.40
|
| Rate for Payer: NAPHCARE Commercial |
$73.80
|
| Rate for Payer: Preferred Network Access Commercial |
$113.16
|
| Rate for Payer: Quartz Beloit One Network |
$60.27
|
| Rate for Payer: Quartz Commercial |
$79.95
|
| Rate for Payer: Quartz Medicare Advantage |
$73.80
|
| Rate for Payer: The Alliance Commercial |
$492.00
|
| Rate for Payer: United Healthcare PPO |
$92.25
|
| Rate for Payer: WEA Trust Commercial |
$67.65
|
| Rate for Payer: WPS Commercial |
$91.11
|
|
|
OTA Physical Pert Test Miss FCA Charge
|
Facility
|
IP
|
$587.00
|
|
|
Service Code
|
CPT 97750 GO,CO
|
| Hospital Charge Code |
5572125
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$287.63 |
| Max. Negotiated Rate |
$540.04 |
| Rate for Payer: Aetna Commercial |
$528.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$504.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$311.11
|
| Rate for Payer: Cash Price |
$176.10
|
| Rate for Payer: Cigna Commercial |
$540.04
|
| Rate for Payer: Health EOS Commercial |
$522.43
|
| Rate for Payer: HFN Commercial |
$540.04
|
| Rate for Payer: Multiplan Commercial |
$469.60
|
| Rate for Payer: NAPHCARE Commercial |
$352.20
|
| Rate for Payer: Preferred Network Access Commercial |
$540.04
|
| Rate for Payer: Quartz Beloit One Network |
$287.63
|
| Rate for Payer: Quartz Commercial |
$352.20
|
| Rate for Payer: WEA Trust Commercial |
$322.85
|
| Rate for Payer: WPS Commercial |
$434.79
|
|
|
OTA Physical Pert Test Miss FCA Charge
|
Facility
|
OP
|
$587.00
|
|
|
Service Code
|
CPT 97750 GO,CO
|
| Hospital Charge Code |
5572125
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$164.36 |
| Max. Negotiated Rate |
$2,348.00 |
| Rate for Payer: Aetna Commercial |
$528.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$504.82
|
| Rate for Payer: Aetna Managed Medicare |
$164.36
|
| 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 |
$311.11
|
| Rate for Payer: Cash Price |
$176.10
|
| Rate for Payer: Cash Price |
$176.10
|
| Rate for Payer: Cigna Commercial |
$540.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$328.49
|
| Rate for Payer: Health EOS Commercial |
$522.43
|
| Rate for Payer: HFN Commercial |
$540.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$469.60
|
| Rate for Payer: NAPHCARE Commercial |
$352.20
|
| Rate for Payer: Preferred Network Access Commercial |
$540.04
|
| Rate for Payer: Quartz Beloit One Network |
$287.63
|
| Rate for Payer: Quartz Commercial |
$381.55
|
| Rate for Payer: Quartz Medicare Advantage |
$352.20
|
| Rate for Payer: The Alliance Commercial |
$2,348.00
|
| Rate for Payer: United Healthcare PPO |
$440.25
|
| Rate for Payer: WEA Trust Commercial |
$322.85
|
| Rate for Payer: WPS Commercial |
$434.79
|
|
|
OTA Physical Pert Test Mod FCA Charge
|
Facility
|
IP
|
$163.00
|
|
|
Service Code
|
CPT 97750 GO,CO
|
| Hospital Charge Code |
5572123
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$79.87 |
| Max. Negotiated Rate |
$149.96 |
| Rate for Payer: Aetna Commercial |
$146.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$140.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$86.39
|
| Rate for Payer: Cash Price |
$48.90
|
| Rate for Payer: Cigna Commercial |
$149.96
|
| Rate for Payer: Health EOS Commercial |
$145.07
|
| Rate for Payer: HFN Commercial |
$149.96
|
| Rate for Payer: Multiplan Commercial |
$130.40
|
| Rate for Payer: NAPHCARE Commercial |
$97.80
|
| Rate for Payer: Preferred Network Access Commercial |
$149.96
|
| Rate for Payer: Quartz Beloit One Network |
$79.87
|
| Rate for Payer: Quartz Commercial |
$97.80
|
| Rate for Payer: WEA Trust Commercial |
$89.65
|
| Rate for Payer: WPS Commercial |
$120.73
|
|
|
OTA Physical Pert Test Mod FCA Charge
|
Facility
|
OP
|
$163.00
|
|
|
Service Code
|
CPT 97750 GO,CO
|
| Hospital Charge Code |
5572123
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$45.64 |
| Max. Negotiated Rate |
$652.00 |
| Rate for Payer: Aetna Commercial |
$146.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$140.18
|
| Rate for Payer: Aetna Managed Medicare |
$45.64
|
| 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 |
$86.39
|
| Rate for Payer: Cash Price |
$48.90
|
| Rate for Payer: Cash Price |
$48.90
|
| Rate for Payer: Cigna Commercial |
$149.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$91.21
|
| Rate for Payer: Health EOS Commercial |
$145.07
|
| Rate for Payer: HFN Commercial |
$149.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$130.40
|
| Rate for Payer: NAPHCARE Commercial |
$97.80
|
| Rate for Payer: Preferred Network Access Commercial |
$149.96
|
| Rate for Payer: Quartz Beloit One Network |
$79.87
|
| Rate for Payer: Quartz Commercial |
$105.95
|
| Rate for Payer: Quartz Medicare Advantage |
$97.80
|
| Rate for Payer: The Alliance Commercial |
$652.00
|
| Rate for Payer: United Healthcare PPO |
$122.25
|
| Rate for Payer: WEA Trust Commercial |
$89.65
|
| Rate for Payer: WPS Commercial |
$120.73
|
|
