|
OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$36,124.00
|
|
|
Service Code
|
MSDRG 581
|
| Min. Negotiated Rate |
$12,994.16 |
| Max. Negotiated Rate |
$36,124.00 |
| Rate for Payer: Aetna Managed Medicare |
$12,994.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$28,323.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21,709.35
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$20,625.30
|
| Rate for Payer: Anthem Medicare Advantage |
$12,994.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12,994.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12,994.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12,994.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$22,895.97
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12,994.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$26,260.65
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12,994.16
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12,994.16
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12,994.16
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12,994.16
|
| Rate for Payer: NAPHCARE Commercial |
$19,491.24
|
| Rate for Payer: Quartz Medicare Advantage |
$12,994.16
|
| Rate for Payer: The Alliance Commercial |
$36,124.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12,994.16
|
| Rate for Payer: United Healthcare PPO |
$20,444.25
|
| Rate for Payer: Wellcare Medicare |
$12,994.16
|
|
|
OTHER VASCULAR PROCEDURES WITH CC
|
Facility
|
IP
|
$68,144.00
|
|
|
Service Code
|
MSDRG 253
|
| Min. Negotiated Rate |
$24,512.18 |
| Max. Negotiated Rate |
$68,144.00 |
| Rate for Payer: Aetna Managed Medicare |
$24,512.18
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$53,499.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$41,006.55
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$38,958.90
|
| Rate for Payer: Anthem Medicare Advantage |
$24,512.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$24,512.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$24,512.18
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$24,512.18
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$43,247.95
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$24,512.18
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$49,746.45
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$24,512.18
|
| Rate for Payer: Independent Care Health Plan Medicare |
$24,512.18
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$24,512.18
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$24,512.18
|
| Rate for Payer: NAPHCARE Commercial |
$36,768.27
|
| Rate for Payer: Quartz Medicare Advantage |
$24,512.18
|
| Rate for Payer: The Alliance Commercial |
$68,144.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$24,512.18
|
| Rate for Payer: United Healthcare PPO |
$38,728.25
|
| Rate for Payer: Wellcare Medicare |
$24,512.18
|
|
|
OTHER VASCULAR PROCEDURES WITH MCC
|
Facility
|
IP
|
$89,484.00
|
|
|
Service Code
|
MSDRG 252
|
| Min. Negotiated Rate |
$32,188.64 |
| Max. Negotiated Rate |
$89,484.00 |
| Rate for Payer: Aetna Managed Medicare |
$32,188.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$70,283.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$53,871.35
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$51,181.30
|
| Rate for Payer: Anthem Medicare Advantage |
$32,188.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$32,188.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$32,188.64
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$32,188.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$56,815.93
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$32,188.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$65,399.10
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$32,188.64
|
| Rate for Payer: Independent Care Health Plan Medicare |
$32,188.64
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$32,188.64
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$32,188.64
|
| Rate for Payer: NAPHCARE Commercial |
$48,282.96
|
| Rate for Payer: Quartz Medicare Advantage |
$32,188.64
|
| Rate for Payer: The Alliance Commercial |
$89,484.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$32,188.64
|
| Rate for Payer: United Healthcare PPO |
$50,914.04
|
| Rate for Payer: Wellcare Medicare |
$32,188.64
|
|
|
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$46,450.00
|
|
|
Service Code
|
MSDRG 254
|
| Min. Negotiated Rate |
$16,708.54 |
| Max. Negotiated Rate |
$46,450.00 |
| Rate for Payer: Aetna Managed Medicare |
$16,708.54
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$36,505.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$27,980.94
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$26,583.72
|
| Rate for Payer: Anthem Medicare Advantage |
$16,708.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$16,708.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$16,708.54
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$16,708.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$29,510.37
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$16,708.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$33,834.45
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$16,708.54
|
| Rate for Payer: Independent Care Health Plan Medicare |
$16,708.54
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$16,708.54
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$16,708.54
|
| Rate for Payer: NAPHCARE Commercial |
$25,062.81
|
| Rate for Payer: Quartz Medicare Advantage |
$16,708.54
|
| Rate for Payer: The Alliance Commercial |
$46,450.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16,708.54
|
| Rate for Payer: United Healthcare PPO |
$26,340.55
|
| Rate for Payer: Wellcare Medicare |
$16,708.54
|
|
|
OT Iontophoresis Charges
|
Facility
|
IP
|
$307.00
|
|
|
Service Code
|
CPT 97033 GO
|
| Hospital Charge Code |
2468806
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$150.43 |
| Max. Negotiated Rate |
$282.44 |
| Rate for Payer: Aetna Commercial |
$276.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$264.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$162.71
|
| Rate for Payer: Cash Price |
$92.10
|
| Rate for Payer: Cigna Commercial |
$282.44
|
| Rate for Payer: Health EOS Commercial |
$273.23
|
| Rate for Payer: HFN Commercial |
$282.44
|
| Rate for Payer: Multiplan Commercial |
$245.60
|
| Rate for Payer: NAPHCARE Commercial |
$184.20
|
| Rate for Payer: Preferred Network Access Commercial |
$282.44
|
| Rate for Payer: Quartz Beloit One Network |
$150.43
|
| Rate for Payer: Quartz Commercial |
$184.20
|
| Rate for Payer: WEA Trust Commercial |
$168.85
|
| Rate for Payer: WPS Commercial |
$227.39
|
|
|
OT Iontophoresis Charges
|
Facility
|
OP
|
$307.00
|
|
|
Service Code
|
CPT 97033 GO
|
| Hospital Charge Code |
2468806
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$85.96 |
| Max. Negotiated Rate |
$1,228.00 |
| Rate for Payer: Aetna Commercial |
$276.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$264.02
|
| Rate for Payer: Aetna Managed Medicare |
$85.96
|
| 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 |
$162.71
|
| Rate for Payer: Cash Price |
$92.10
|
| Rate for Payer: Cash Price |
$92.10
|
| Rate for Payer: Cigna Commercial |
$282.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$171.80
|
| Rate for Payer: Health EOS Commercial |
$273.23
|
| Rate for Payer: HFN Commercial |
$282.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$245.60
|
| Rate for Payer: NAPHCARE Commercial |
$184.20
|
| Rate for Payer: Preferred Network Access Commercial |
$282.44
|
| Rate for Payer: Quartz Beloit One Network |
$150.43
|
| Rate for Payer: Quartz Commercial |
$199.55
|
| Rate for Payer: Quartz Medicare Advantage |
$184.20
|
| Rate for Payer: The Alliance Commercial |
$1,228.00
|
| Rate for Payer: United Healthcare PPO |
$230.25
|
| Rate for Payer: WEA Trust Commercial |
$168.85
|
| Rate for Payer: WPS Commercial |
$227.39
|
|
|
OTITIS MEDIA AND URI WITH MCC
|
Facility
|
IP
|
$31,910.00
|
|
|
Service Code
|
MSDRG 152
|
| Min. Negotiated Rate |
$11,478.37 |
| Max. Negotiated Rate |
$31,910.00 |
| Rate for Payer: Aetna Managed Medicare |
$11,478.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$24,966.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$19,136.39
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$18,180.82
|
| Rate for Payer: Anthem Medicare Advantage |
$11,478.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$11,478.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$11,478.37
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$11,478.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$20,182.38
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$11,478.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$23,169.90
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$11,478.37
|
| Rate for Payer: Independent Care Health Plan Medicare |
$11,478.37
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$11,478.37
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$11,478.37
|
| Rate for Payer: NAPHCARE Commercial |
$17,217.56
|
| Rate for Payer: Quartz Medicare Advantage |
$11,478.37
|
| Rate for Payer: The Alliance Commercial |
$31,910.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11,478.37
|
| Rate for Payer: United Healthcare PPO |
$18,038.06
|
| Rate for Payer: Wellcare Medicare |
$11,478.37
|
|
|
OTITIS MEDIA AND URI WITHOUT MCC
|
Facility
|
IP
|
$19,856.00
|
|
|
Service Code
|
MSDRG 153
|
| Min. Negotiated Rate |
$7,142.36 |
| Max. Negotiated Rate |
$19,856.00 |
| Rate for Payer: Aetna Managed Medicare |
$7,142.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$15,315.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11,739.13
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$11,152.94
|
| Rate for Payer: Anthem Medicare Advantage |
$7,142.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7,142.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7,142.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$7,142.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,380.79
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$7,142.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14,328.60
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$7,142.36
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7,142.36
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$7,142.36
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$7,142.36
|
| Rate for Payer: NAPHCARE Commercial |
$10,713.54
|
| Rate for Payer: Quartz Medicare Advantage |
$7,142.36
|
| Rate for Payer: The Alliance Commercial |
$19,856.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7,142.36
|
| Rate for Payer: United Healthcare PPO |
$11,155.00
|
| Rate for Payer: Wellcare Medicare |
$7,142.36
|
|
|
OT Manual Therapy Charge Units
|
Facility
|
IP
|
$234.00
|
|
|
Service Code
|
CPT 97140 GO
|
| Hospital Charge Code |
750909
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$114.66 |
| Max. Negotiated Rate |
$215.28 |
| Rate for Payer: Aetna Commercial |
$210.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$201.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$124.02
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cigna Commercial |
$215.28
|
| Rate for Payer: Health EOS Commercial |
$208.26
|
| Rate for Payer: HFN Commercial |
$215.28
|
| Rate for Payer: Multiplan Commercial |
$187.20
|
| Rate for Payer: NAPHCARE Commercial |
$140.40
|
| Rate for Payer: Preferred Network Access Commercial |
$215.28
|
| Rate for Payer: Quartz Beloit One Network |
$114.66
|
| Rate for Payer: Quartz Commercial |
$140.40
|
| Rate for Payer: WEA Trust Commercial |
$128.70
|
| Rate for Payer: WPS Commercial |
$173.32
|
|
|
OT Manual Therapy Charge Units
|
Facility
|
OP
|
$234.00
|
|
|
Service Code
|
CPT 97140
|
| Hospital Charge Code |
5247099
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$65.52 |
| Max. Negotiated Rate |
$936.00 |
| Rate for Payer: Aetna Commercial |
$210.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$201.24
|
| Rate for Payer: Aetna Managed Medicare |
$65.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$349.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$287.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$272.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$124.02
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cigna Commercial |
$215.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$130.95
|
| Rate for Payer: Health EOS Commercial |
$208.26
|
| Rate for Payer: HFN Commercial |
$215.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$187.20
|
| Rate for Payer: NAPHCARE Commercial |
$140.40
|
| Rate for Payer: Preferred Network Access Commercial |
$215.28
|
| Rate for Payer: Quartz Beloit One Network |
$114.66
|
| Rate for Payer: Quartz Commercial |
$152.10
|
| Rate for Payer: Quartz Medicare Advantage |
$140.40
|
| Rate for Payer: The Alliance Commercial |
$936.00
|
| Rate for Payer: United Healthcare PPO |
$175.50
|
| Rate for Payer: WEA Trust Commercial |
$128.70
|
| Rate for Payer: WPS Commercial |
$173.32
|
|
|
OT Manual Therapy Charge Units
|
Facility
|
IP
|
$234.00
|
|
|
Service Code
|
CPT 97140
|
| Hospital Charge Code |
5247099
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$114.66 |
| Max. Negotiated Rate |
$215.28 |
| Rate for Payer: Aetna Commercial |
$210.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$201.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$124.02
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cigna Commercial |
$215.28
|
| Rate for Payer: Health EOS Commercial |
$208.26
|
| Rate for Payer: HFN Commercial |
$215.28
|
| Rate for Payer: Multiplan Commercial |
$187.20
|
| Rate for Payer: NAPHCARE Commercial |
$140.40
|
| Rate for Payer: Preferred Network Access Commercial |
$215.28
|
| Rate for Payer: Quartz Beloit One Network |
$114.66
|
| Rate for Payer: Quartz Commercial |
$140.40
|
| Rate for Payer: WEA Trust Commercial |
$128.70
|
| Rate for Payer: WPS Commercial |
$173.32
|
|
|
OT Manual Therapy Charge Units
|
Professional
|
Both
|
$234.00
|
|
|
Service Code
|
CPT 97140 GO
|
| Hospital Charge Code |
750909
|
|
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 |
$70.20
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cigna Commercial |
$222.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$117.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$140.40
|
| Rate for Payer: Health EOS Commercial |
$212.94
|
| Rate for Payer: HFN Commercial |
$222.30
|
| Rate for Payer: 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 Manual Therapy Charge Units
|
Facility
|
OP
|
$234.00
|
|
|
Service Code
|
CPT 97140 GO
|
| Hospital Charge Code |
750909
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$65.52 |
| Max. Negotiated Rate |
$936.00 |
| Rate for Payer: Aetna Commercial |
$210.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$201.24
|
| Rate for Payer: Aetna Managed Medicare |
$65.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$349.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$287.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$272.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$124.02
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cigna Commercial |
$215.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$130.95
|
| Rate for Payer: Health EOS Commercial |
$208.26
|
| Rate for Payer: HFN Commercial |
$215.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$187.20
|
| Rate for Payer: NAPHCARE Commercial |
$140.40
|
| Rate for Payer: Preferred Network Access Commercial |
$215.28
|
| Rate for Payer: Quartz Beloit One Network |
$114.66
|
| Rate for Payer: Quartz Commercial |
$152.10
|
| Rate for Payer: Quartz Medicare Advantage |
$140.40
|
| Rate for Payer: The Alliance Commercial |
$936.00
|
| Rate for Payer: United Healthcare PPO |
$175.50
|
| Rate for Payer: WEA Trust Commercial |
$128.70
|
| Rate for Payer: WPS Commercial |
$173.32
|
|
|
OT Massage Charge Units
|
Facility
|
IP
|
$90.00
|
|
|
Service Code
|
CPT 97124 GO
|
| Hospital Charge Code |
2468807
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$44.10 |
| Max. Negotiated Rate |
$82.80 |
| Rate for Payer: Aetna Commercial |
$81.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$77.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$47.70
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$82.80
|
| Rate for Payer: Health EOS Commercial |
$80.10
|
| Rate for Payer: HFN Commercial |
$82.80
|
| Rate for Payer: Multiplan Commercial |
$72.00
|
| Rate for Payer: NAPHCARE Commercial |
$54.00
|
| Rate for Payer: Preferred Network Access Commercial |
$82.80
|
| Rate for Payer: Quartz Beloit One Network |
$44.10
|
| Rate for Payer: Quartz Commercial |
$54.00
|
| Rate for Payer: WEA Trust Commercial |
$49.50
|
| Rate for Payer: WPS Commercial |
$66.66
|
|
|
OT Massage Charge Units
|
Facility
|
OP
|
$90.00
|
|
|
Service Code
|
CPT 97124 GO
|
| Hospital Charge Code |
2468807
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$25.20 |
| Max. Negotiated Rate |
$360.00 |
| Rate for Payer: Aetna Commercial |
$81.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$77.40
|
| Rate for Payer: Aetna Managed Medicare |
$25.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$349.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$287.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$272.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$47.70
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$82.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$50.36
|
| Rate for Payer: Health EOS Commercial |
$80.10
|
| Rate for Payer: HFN Commercial |
$82.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$72.00
|
| Rate for Payer: NAPHCARE Commercial |
$54.00
|
| Rate for Payer: Preferred Network Access Commercial |
$82.80
|
| Rate for Payer: Quartz Beloit One Network |
$44.10
|
| Rate for Payer: Quartz Commercial |
$58.50
|
| Rate for Payer: Quartz Medicare Advantage |
$54.00
|
| Rate for Payer: The Alliance Commercial |
$360.00
|
| Rate for Payer: United Healthcare PPO |
$67.50
|
| Rate for Payer: WEA Trust Commercial |
$49.50
|
| Rate for Payer: WPS Commercial |
$66.66
|
|
|
OT Neuromuscular Reeducation Charges
|
Facility
|
OP
|
$228.00
|
|
|
Service Code
|
CPT 97112 GO
|
| Hospital Charge Code |
750905
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$63.84 |
| Max. Negotiated Rate |
$912.00 |
| Rate for Payer: Aetna Commercial |
$205.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$196.08
|
| Rate for Payer: Aetna Managed Medicare |
$63.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$349.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$287.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$272.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$120.84
|
| Rate for Payer: Cash Price |
$68.40
|
| Rate for Payer: Cash Price |
$68.40
|
| Rate for Payer: Cigna Commercial |
$209.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$127.59
|
| Rate for Payer: Health EOS Commercial |
$202.92
|
| Rate for Payer: HFN Commercial |
$209.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$182.40
|
| Rate for Payer: NAPHCARE Commercial |
$136.80
|
| Rate for Payer: Preferred Network Access Commercial |
$209.76
|
| Rate for Payer: Quartz Beloit One Network |
$111.72
|
| Rate for Payer: Quartz Commercial |
$148.20
|
| Rate for Payer: Quartz Medicare Advantage |
$136.80
|
| Rate for Payer: The Alliance Commercial |
$912.00
|
| Rate for Payer: United Healthcare PPO |
$171.00
|
| Rate for Payer: WEA Trust Commercial |
$125.40
|
| Rate for Payer: WPS Commercial |
$168.88
|
|
|
OT Neuromuscular Reeducation Charges
|
Facility
|
IP
|
$228.00
|
|
|
Service Code
|
CPT 97112 GO
|
| Hospital Charge Code |
750905
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$111.72 |
| Max. Negotiated Rate |
$209.76 |
| Rate for Payer: Aetna Commercial |
$205.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$196.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$120.84
|
| Rate for Payer: Cash Price |
$68.40
|
| Rate for Payer: Cigna Commercial |
$209.76
|
| Rate for Payer: Health EOS Commercial |
$202.92
|
| Rate for Payer: HFN Commercial |
$209.76
|
| Rate for Payer: Multiplan Commercial |
$182.40
|
| Rate for Payer: NAPHCARE Commercial |
$136.80
|
| Rate for Payer: Preferred Network Access Commercial |
$209.76
|
| Rate for Payer: Quartz Beloit One Network |
$111.72
|
| Rate for Payer: Quartz Commercial |
$136.80
|
| Rate for Payer: WEA Trust Commercial |
$125.40
|
| Rate for Payer: WPS Commercial |
$168.88
|
|
|
OTOPLASTY
|
Facility
|
IP
|
$7,602.00
|
|
| Hospital Charge Code |
2960298
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,724.98 |
| Max. Negotiated Rate |
$6,993.84 |
| Rate for Payer: Aetna Commercial |
$6,841.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,537.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,029.06
|
| Rate for Payer: Cash Price |
$2,280.60
|
| Rate for Payer: Cigna Commercial |
$6,993.84
|
| Rate for Payer: Health EOS Commercial |
$6,765.78
|
| Rate for Payer: HFN Commercial |
$6,993.84
|
| Rate for Payer: Multiplan Commercial |
$6,081.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,561.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6,993.84
|
| Rate for Payer: Quartz Beloit One Network |
$3,724.98
|
| Rate for Payer: Quartz Commercial |
$4,561.20
|
| Rate for Payer: WEA Trust Commercial |
$4,181.10
|
| Rate for Payer: WPS Commercial |
$5,630.80
|
|
|
OTOPLASTY
|
Facility
|
OP
|
$7,602.00
|
|
| Hospital Charge Code |
2960298
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,128.56 |
| Max. Negotiated Rate |
$30,408.00 |
| Rate for Payer: Aetna Commercial |
$6,841.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,537.72
|
| Rate for Payer: Aetna Managed Medicare |
$2,128.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,941.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,801.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,648.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,029.06
|
| Rate for Payer: Cash Price |
$2,280.60
|
| Rate for Payer: Cigna Commercial |
$6,993.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,254.08
|
| Rate for Payer: Health EOS Commercial |
$6,765.78
|
| Rate for Payer: HFN Commercial |
$6,993.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,701.50
|
| Rate for Payer: Multiplan Commercial |
$6,081.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,561.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6,993.84
|
| Rate for Payer: Quartz Beloit One Network |
$3,724.98
|
| Rate for Payer: Quartz Commercial |
$4,941.30
|
| Rate for Payer: Quartz Medicare Advantage |
$4,561.20
|
| Rate for Payer: The Alliance Commercial |
$30,408.00
|
| Rate for Payer: WEA Trust Commercial |
$4,181.10
|
| Rate for Payer: WPS Commercial |
$5,630.80
|
|
|
OT Orthotic Training Charges
|
Professional
|
Both
|
$225.00
|
|
|
Service Code
|
CPT 97760 GO
|
| Hospital Charge Code |
2989842
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$99.00 |
| Max. Negotiated Rate |
$213.75 |
| Rate for Payer: Aetna Commercial |
$213.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$193.50
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cigna Commercial |
$213.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$112.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$135.00
|
| Rate for Payer: Health EOS Commercial |
$204.75
|
| Rate for Payer: HFN Commercial |
$213.75
|
| Rate for Payer: Multiplan Commercial |
$180.00
|
| Rate for Payer: Preferred Network Access Commercial |
$213.75
|
| Rate for Payer: Quartz Beloit One Network |
$99.00
|
| Rate for Payer: Quartz Commercial |
$128.25
|
| Rate for Payer: The Alliance Commercial |
$112.50
|
| Rate for Payer: WEA Trust Commercial |
$123.75
|
| Rate for Payer: WPS Commercial |
$166.66
|
|
|
OT Orthotic Training Charges
|
Facility
|
OP
|
$225.00
|
|
|
Service Code
|
CPT 97760 GO
|
| Hospital Charge Code |
2989842
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$63.00 |
| Max. Negotiated Rate |
$900.00 |
| Rate for Payer: Aetna Commercial |
$202.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$193.50
|
| Rate for Payer: Aetna Managed Medicare |
$63.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$349.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$287.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$272.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$119.25
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cigna Commercial |
$207.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$125.91
|
| Rate for Payer: Health EOS Commercial |
$200.25
|
| Rate for Payer: HFN Commercial |
$207.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$180.00
|
| Rate for Payer: NAPHCARE Commercial |
$135.00
|
| Rate for Payer: Preferred Network Access Commercial |
$207.00
|
| Rate for Payer: Quartz Beloit One Network |
$110.25
|
| Rate for Payer: Quartz Commercial |
$146.25
|
| Rate for Payer: Quartz Medicare Advantage |
$135.00
|
| Rate for Payer: The Alliance Commercial |
$900.00
|
| Rate for Payer: United Healthcare PPO |
$168.75
|
| Rate for Payer: WEA Trust Commercial |
$123.75
|
| Rate for Payer: WPS Commercial |
$166.66
|
|
|
OT Orthotic Training Charges
|
Facility
|
IP
|
$225.00
|
|
|
Service Code
|
CPT 97760 GO
|
| Hospital Charge Code |
2989842
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$110.25 |
| Max. Negotiated Rate |
$207.00 |
| Rate for Payer: Aetna Commercial |
$202.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$193.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$119.25
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cigna Commercial |
$207.00
|
| Rate for Payer: Health EOS Commercial |
$200.25
|
| Rate for Payer: HFN Commercial |
$207.00
|
| Rate for Payer: Multiplan Commercial |
$180.00
|
| Rate for Payer: NAPHCARE Commercial |
$135.00
|
| Rate for Payer: Preferred Network Access Commercial |
$207.00
|
| Rate for Payer: Quartz Beloit One Network |
$110.25
|
| Rate for Payer: Quartz Commercial |
$135.00
|
| Rate for Payer: WEA Trust Commercial |
$123.75
|
| Rate for Payer: WPS Commercial |
$166.66
|
|
|
OT Prosthetic Training Charges
|
Facility
|
OP
|
$223.00
|
|
|
Service Code
|
CPT 97761 GO
|
| Hospital Charge Code |
750930
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$62.44 |
| Max. Negotiated Rate |
$892.00 |
| Rate for Payer: Aetna Commercial |
$200.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$191.78
|
| Rate for Payer: Aetna Managed Medicare |
$62.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$349.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$287.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$272.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$118.19
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cigna Commercial |
$205.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$124.79
|
| Rate for Payer: Health EOS Commercial |
$198.47
|
| Rate for Payer: HFN Commercial |
$205.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$178.40
|
| Rate for Payer: NAPHCARE Commercial |
$133.80
|
| Rate for Payer: Preferred Network Access Commercial |
$205.16
|
| Rate for Payer: Quartz Beloit One Network |
$109.27
|
| Rate for Payer: Quartz Commercial |
$144.95
|
| Rate for Payer: Quartz Medicare Advantage |
$133.80
|
| Rate for Payer: The Alliance Commercial |
$892.00
|
| Rate for Payer: United Healthcare PPO |
$167.25
|
| Rate for Payer: WEA Trust Commercial |
$122.65
|
| Rate for Payer: WPS Commercial |
$165.18
|
|
|
OT Prosthetic Training Charges
|
Facility
|
IP
|
$223.00
|
|
|
Service Code
|
CPT 97761 GO
|
| Hospital Charge Code |
750930
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$109.27 |
| Max. Negotiated Rate |
$205.16 |
| Rate for Payer: Aetna Commercial |
$200.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$191.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$118.19
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cigna Commercial |
$205.16
|
| Rate for Payer: Health EOS Commercial |
$198.47
|
| Rate for Payer: HFN Commercial |
$205.16
|
| Rate for Payer: Multiplan Commercial |
$178.40
|
| Rate for Payer: NAPHCARE Commercial |
$133.80
|
| Rate for Payer: Preferred Network Access Commercial |
$205.16
|
| Rate for Payer: Quartz Beloit One Network |
$109.27
|
| Rate for Payer: Quartz Commercial |
$133.80
|
| Rate for Payer: WEA Trust Commercial |
$122.65
|
| Rate for Payer: WPS Commercial |
$165.18
|
|
|
OT Reevaluation
|
Facility
|
IP
|
$693.00
|
|
|
Service Code
|
CPT 97168
|
| Hospital Charge Code |
5250707
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$339.57 |
| Max. Negotiated Rate |
$637.56 |
| Rate for Payer: Aetna Commercial |
$623.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$595.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$367.29
|
| Rate for Payer: Cash Price |
$207.90
|
| Rate for Payer: Cigna Commercial |
$637.56
|
| Rate for Payer: Health EOS Commercial |
$616.77
|
| Rate for Payer: HFN Commercial |
$637.56
|
| Rate for Payer: Multiplan Commercial |
$554.40
|
| Rate for Payer: NAPHCARE Commercial |
$415.80
|
| Rate for Payer: Preferred Network Access Commercial |
$637.56
|
| Rate for Payer: Quartz Beloit One Network |
$339.57
|
| Rate for Payer: Quartz Commercial |
$415.80
|
| Rate for Payer: WEA Trust Commercial |
$381.15
|
| Rate for Payer: WPS Commercial |
$513.31
|
|
