|
Yes - OTA E-Stim Unattended Charge
|
Facility
IP
|
$158.00
|
|
|
Service Code
|
CPT 97014 GO,CO
|
| Hospital Charge Code |
5572105
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$77.42 |
| Max. Negotiated Rate |
$145.36 |
| Rate for Payer: Aetna Commercial |
$142.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$83.74
|
| Rate for Payer: Cash Price |
$47.40
|
| Rate for Payer: Cigna Commercial |
$145.36
|
| Rate for Payer: Health EOS Commercial |
$140.62
|
| Rate for Payer: HFN Commercial |
$145.36
|
| Rate for Payer: Multiplan Commercial |
$126.40
|
| Rate for Payer: NAPHCARE Commercial |
$94.80
|
| Rate for Payer: Preferred Network Access Commercial |
$145.36
|
| Rate for Payer: Quartz Beloit One Network |
$77.42
|
| Rate for Payer: Quartz Commercial |
$94.80
|
| Rate for Payer: WEA Trust Commercial |
$86.90
|
| Rate for Payer: WPS Commercial |
$117.03
|
|
|
Yes - OTA E-Stim Unattended Charge
|
Facility
OP
|
$158.00
|
|
|
Service Code
|
CPT 97014 GO,CO
|
| Hospital Charge Code |
5572105
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$44.24 |
| Max. Negotiated Rate |
$632.00 |
| Rate for Payer: Aetna Commercial |
$142.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$135.88
|
| Rate for Payer: Aetna Managed Medicare |
$44.24
|
| 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 |
$83.74
|
| Rate for Payer: Cash Price |
$47.40
|
| Rate for Payer: Cash Price |
$47.40
|
| Rate for Payer: Cigna Commercial |
$145.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$88.42
|
| Rate for Payer: Health EOS Commercial |
$140.62
|
| Rate for Payer: HFN Commercial |
$145.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$126.40
|
| Rate for Payer: NAPHCARE Commercial |
$94.80
|
| Rate for Payer: Preferred Network Access Commercial |
$145.36
|
| Rate for Payer: Quartz Beloit One Network |
$77.42
|
| Rate for Payer: Quartz Commercial |
$102.70
|
| Rate for Payer: Quartz Medicare Advantage |
$94.80
|
| Rate for Payer: The Alliance Commercial |
$632.00
|
| Rate for Payer: United Healthcare PPO |
$118.50
|
| Rate for Payer: WEA Trust Commercial |
$86.90
|
| Rate for Payer: WPS Commercial |
$117.03
|
|
|
Yes - OTA Fluidotherapy Charge
|
Facility
IP
|
$184.00
|
|
|
Service Code
|
CPT 97022 GO,CO
|
| Hospital Charge Code |
5572061
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$90.16 |
| Max. Negotiated Rate |
$169.28 |
| Rate for Payer: Aetna Commercial |
$165.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$97.52
|
| Rate for Payer: Cash Price |
$55.20
|
| Rate for Payer: Cigna Commercial |
$169.28
|
| Rate for Payer: Health EOS Commercial |
$163.76
|
| Rate for Payer: HFN Commercial |
$169.28
|
| Rate for Payer: Multiplan Commercial |
$147.20
|
| Rate for Payer: NAPHCARE Commercial |
$110.40
|
| Rate for Payer: Preferred Network Access Commercial |
$169.28
|
| Rate for Payer: Quartz Beloit One Network |
$90.16
|
| Rate for Payer: Quartz Commercial |
$110.40
|
| Rate for Payer: WEA Trust Commercial |
$101.20
|
| Rate for Payer: WPS Commercial |
$136.29
|
|
|
Yes - OTA Fluidotherapy Charge
|
Facility
OP
|
$184.00
|
|
|
Service Code
|
CPT 97022 GO,CO
|
| Hospital Charge Code |
5572061
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$51.52 |
| Max. Negotiated Rate |
$736.00 |
| Rate for Payer: Aetna Commercial |
$165.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$158.24
|
| Rate for Payer: Aetna Managed Medicare |
$51.52
|
| 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 |
$97.52
|
| Rate for Payer: Cash Price |
$55.20
|
| Rate for Payer: Cash Price |
$55.20
|
| Rate for Payer: Cigna Commercial |
$169.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$102.97
|
| Rate for Payer: Health EOS Commercial |
$163.76
|
| Rate for Payer: HFN Commercial |
$169.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$147.20
|
| Rate for Payer: NAPHCARE Commercial |
$110.40
|
| Rate for Payer: Preferred Network Access Commercial |
$169.28
|
| Rate for Payer: Quartz Beloit One Network |
$90.16
|
| Rate for Payer: Quartz Commercial |
$119.60
|
| Rate for Payer: Quartz Medicare Advantage |
$110.40
|
| Rate for Payer: The Alliance Commercial |
$736.00
|
| Rate for Payer: United Healthcare PPO |
$138.00
|
| Rate for Payer: WEA Trust Commercial |
$101.20
|
| Rate for Payer: WPS Commercial |
$136.29
|
|
|
Yes - OTA Group Therapy Charge
|
Facility
OP
|
$228.00
|
|
|
Service Code
|
CPT 97150 GO,CO
|
| Hospital Charge Code |
5571934
|
|
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
|
|
|
Yes - OTA Group Therapy Charge
|
Facility
IP
|
$228.00
|
|
|
Service Code
|
CPT 97150 GO,CO
|
| Hospital Charge Code |
5571934
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$111.72 |
| Max. Negotiated Rate |
$209.76 |
| Rate for Payer: Aetna Commercial |
$205.20
|
| 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
|
|
|
Yes - OTA Paraffin Bath Charge
|
Facility
OP
|
$170.00
|
|
|
Service Code
|
CPT 97018 GO,CO
|
| Hospital Charge Code |
5571944
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$47.60 |
| Max. Negotiated Rate |
$680.00 |
| Rate for Payer: Aetna Commercial |
$153.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$146.20
|
| Rate for Payer: Aetna Managed Medicare |
$47.60
|
| 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 |
$90.10
|
| Rate for Payer: Cash Price |
$51.00
|
| Rate for Payer: Cash Price |
$51.00
|
| Rate for Payer: Cigna Commercial |
$156.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$95.13
|
| Rate for Payer: Health EOS Commercial |
$151.30
|
| Rate for Payer: HFN Commercial |
$156.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$136.00
|
| Rate for Payer: NAPHCARE Commercial |
$102.00
|
| Rate for Payer: Preferred Network Access Commercial |
$156.40
|
| Rate for Payer: Quartz Beloit One Network |
$83.30
|
| Rate for Payer: Quartz Commercial |
$110.50
|
| Rate for Payer: Quartz Medicare Advantage |
$102.00
|
| Rate for Payer: The Alliance Commercial |
$680.00
|
| Rate for Payer: United Healthcare PPO |
$127.50
|
| Rate for Payer: WEA Trust Commercial |
$93.50
|
| Rate for Payer: WPS Commercial |
$125.92
|
|
|
Yes - OTA Paraffin Bath Charge
|
Facility
IP
|
$170.00
|
|
|
Service Code
|
CPT 97018 GO,CO
|
| Hospital Charge Code |
5571944
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$83.30 |
| Max. Negotiated Rate |
$156.40 |
| Rate for Payer: Aetna Commercial |
$153.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$90.10
|
| Rate for Payer: Cash Price |
$51.00
|
| Rate for Payer: Cigna Commercial |
$156.40
|
| Rate for Payer: Health EOS Commercial |
$151.30
|
| Rate for Payer: HFN Commercial |
$156.40
|
| Rate for Payer: Multiplan Commercial |
$136.00
|
| Rate for Payer: NAPHCARE Commercial |
$102.00
|
| Rate for Payer: Preferred Network Access Commercial |
$156.40
|
| Rate for Payer: Quartz Beloit One Network |
$83.30
|
| Rate for Payer: Quartz Commercial |
$102.00
|
| Rate for Payer: WEA Trust Commercial |
$93.50
|
| Rate for Payer: WPS Commercial |
$125.92
|
|
|
Yes - OT Aquatic Therapy Charges
|
Facility
OP
|
$246.00
|
|
|
Service Code
|
CPT 97113 GO
|
| Hospital Charge Code |
3007181
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$68.88 |
| Max. Negotiated Rate |
$984.00 |
| Rate for Payer: Aetna Commercial |
$221.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$211.56
|
| Rate for Payer: Aetna Managed Medicare |
$68.88
|
| 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 |
$130.38
|
| Rate for Payer: Cash Price |
$73.80
|
| Rate for Payer: Cash Price |
$73.80
|
| Rate for Payer: Cigna Commercial |
$226.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$137.66
|
| Rate for Payer: Health EOS Commercial |
$218.94
|
| Rate for Payer: HFN Commercial |
$226.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$196.80
|
| Rate for Payer: NAPHCARE Commercial |
$147.60
|
| Rate for Payer: Preferred Network Access Commercial |
$226.32
|
| Rate for Payer: Quartz Beloit One Network |
$120.54
|
| Rate for Payer: Quartz Commercial |
$159.90
|
| Rate for Payer: Quartz Medicare Advantage |
$147.60
|
| Rate for Payer: The Alliance Commercial |
$984.00
|
| Rate for Payer: United Healthcare PPO |
$184.50
|
| Rate for Payer: WEA Trust Commercial |
$135.30
|
| Rate for Payer: WPS Commercial |
$182.21
|
|
|
Yes - OT Aquatic Therapy Charges
|
Facility
IP
|
$246.00
|
|
|
Service Code
|
CPT 97113 GO
|
| Hospital Charge Code |
3007181
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$120.54 |
| Max. Negotiated Rate |
$226.32 |
| Rate for Payer: Aetna Commercial |
$221.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$130.38
|
| Rate for Payer: Cash Price |
$73.80
|
| Rate for Payer: Cigna Commercial |
$226.32
|
| Rate for Payer: Health EOS Commercial |
$218.94
|
| Rate for Payer: HFN Commercial |
$226.32
|
| Rate for Payer: Multiplan Commercial |
$196.80
|
| Rate for Payer: NAPHCARE Commercial |
$147.60
|
| Rate for Payer: Preferred Network Access Commercial |
$226.32
|
| Rate for Payer: Quartz Beloit One Network |
$120.54
|
| Rate for Payer: Quartz Commercial |
$147.60
|
| Rate for Payer: WEA Trust Commercial |
$135.30
|
| Rate for Payer: WPS Commercial |
$182.21
|
|
|
Yes - OTA Vasopnuematic Device Charge
|
Facility
IP
|
$193.00
|
|
|
Service Code
|
CPT 97016 GO,CO
|
| Hospital Charge Code |
5572017
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$94.57 |
| Max. Negotiated Rate |
$177.56 |
| Rate for Payer: Aetna Commercial |
$173.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$102.29
|
| Rate for Payer: Cash Price |
$57.90
|
| Rate for Payer: Cigna Commercial |
$177.56
|
| Rate for Payer: Health EOS Commercial |
$171.77
|
| Rate for Payer: HFN Commercial |
$177.56
|
| Rate for Payer: Multiplan Commercial |
$154.40
|
| Rate for Payer: NAPHCARE Commercial |
$115.80
|
| Rate for Payer: Preferred Network Access Commercial |
$177.56
|
| Rate for Payer: Quartz Beloit One Network |
$94.57
|
| Rate for Payer: Quartz Commercial |
$115.80
|
| Rate for Payer: WEA Trust Commercial |
$106.15
|
| Rate for Payer: WPS Commercial |
$142.96
|
|
|
Yes - OTA Vasopnuematic Device Charge
|
Facility
OP
|
$193.00
|
|
|
Service Code
|
CPT 97016 GO,CO
|
| Hospital Charge Code |
5572017
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$54.04 |
| Max. Negotiated Rate |
$772.00 |
| Rate for Payer: Aetna Commercial |
$173.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$165.98
|
| Rate for Payer: Aetna Managed Medicare |
$54.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$349.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$287.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$272.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$102.29
|
| Rate for Payer: Cash Price |
$57.90
|
| Rate for Payer: Cash Price |
$57.90
|
| Rate for Payer: Cigna Commercial |
$177.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$108.00
|
| Rate for Payer: Health EOS Commercial |
$171.77
|
| Rate for Payer: HFN Commercial |
$177.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$154.40
|
| Rate for Payer: NAPHCARE Commercial |
$115.80
|
| Rate for Payer: Preferred Network Access Commercial |
$177.56
|
| Rate for Payer: Quartz Beloit One Network |
$94.57
|
| Rate for Payer: Quartz Commercial |
$125.45
|
| Rate for Payer: Quartz Medicare Advantage |
$115.80
|
| Rate for Payer: The Alliance Commercial |
$772.00
|
| Rate for Payer: United Healthcare PPO |
$144.75
|
| Rate for Payer: WEA Trust Commercial |
$106.15
|
| Rate for Payer: WPS Commercial |
$142.96
|
|
|
Yes - OTA Whirlpool Charge
|
Facility
IP
|
$296.00
|
|
|
Service Code
|
CPT 97022 GO,CO
|
| Hospital Charge Code |
5572095
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$145.04 |
| Max. Negotiated Rate |
$272.32 |
| Rate for Payer: Aetna Commercial |
$266.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$156.88
|
| Rate for Payer: Cash Price |
$88.80
|
| Rate for Payer: Cigna Commercial |
$272.32
|
| Rate for Payer: Health EOS Commercial |
$263.44
|
| Rate for Payer: HFN Commercial |
$272.32
|
| Rate for Payer: Multiplan Commercial |
$236.80
|
| Rate for Payer: NAPHCARE Commercial |
$177.60
|
| Rate for Payer: Preferred Network Access Commercial |
$272.32
|
| Rate for Payer: Quartz Beloit One Network |
$145.04
|
| Rate for Payer: Quartz Commercial |
$177.60
|
| Rate for Payer: WEA Trust Commercial |
$162.80
|
| Rate for Payer: WPS Commercial |
$219.25
|
|
|
Yes - OTA Whirlpool Charge
|
Facility
OP
|
$296.00
|
|
|
Service Code
|
CPT 97022 GO,CO
|
| Hospital Charge Code |
5572095
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$82.88 |
| Max. Negotiated Rate |
$1,184.00 |
| Rate for Payer: Aetna Commercial |
$266.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$254.56
|
| Rate for Payer: Aetna Managed Medicare |
$82.88
|
| 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 |
$156.88
|
| Rate for Payer: Cash Price |
$88.80
|
| Rate for Payer: Cash Price |
$88.80
|
| Rate for Payer: Cigna Commercial |
$272.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$165.64
|
| Rate for Payer: Health EOS Commercial |
$263.44
|
| Rate for Payer: HFN Commercial |
$272.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$236.80
|
| Rate for Payer: NAPHCARE Commercial |
$177.60
|
| Rate for Payer: Preferred Network Access Commercial |
$272.32
|
| Rate for Payer: Quartz Beloit One Network |
$145.04
|
| Rate for Payer: Quartz Commercial |
$192.40
|
| Rate for Payer: Quartz Medicare Advantage |
$177.60
|
| Rate for Payer: The Alliance Commercial |
$1,184.00
|
| Rate for Payer: United Healthcare PPO |
$222.00
|
| Rate for Payer: WEA Trust Commercial |
$162.80
|
| Rate for Payer: WPS Commercial |
$219.25
|
|
|
Yes - OT Evaluation High Charge
|
Facility
OP
|
$817.00
|
|
|
Service Code
|
CPT 97167 GO
|
| Hospital Charge Code |
5148667
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$202.00 |
| Max. Negotiated Rate |
$3,268.00 |
| Rate for Payer: Aetna Commercial |
$735.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$702.62
|
| Rate for Payer: Aetna Managed Medicare |
$228.76
|
| 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 |
$433.01
|
| Rate for Payer: Cash Price |
$245.10
|
| Rate for Payer: Cash Price |
$245.10
|
| Rate for Payer: Cigna Commercial |
$751.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$457.19
|
| Rate for Payer: Health EOS Commercial |
$727.13
|
| Rate for Payer: HFN Commercial |
$751.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$653.60
|
| Rate for Payer: NAPHCARE Commercial |
$490.20
|
| Rate for Payer: Preferred Network Access Commercial |
$751.64
|
| Rate for Payer: Quartz Beloit One Network |
$400.33
|
| Rate for Payer: Quartz Commercial |
$531.05
|
| Rate for Payer: Quartz Medicare Advantage |
$490.20
|
| Rate for Payer: The Alliance Commercial |
$3,268.00
|
| Rate for Payer: United Healthcare PPO |
$612.75
|
| Rate for Payer: WEA Trust Commercial |
$449.35
|
| Rate for Payer: WPS Commercial |
$605.15
|
|
|
Yes - OT Evaluation High Charge
|
Professional
|
$817.00
|
|
|
Service Code
|
CPT 97167 GO
|
| Hospital Charge Code |
5148667
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$359.48 |
| Max. Negotiated Rate |
$776.15 |
| Rate for Payer: Aetna Commercial |
$776.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$702.62
|
| Rate for Payer: Cash Price |
$245.10
|
| Rate for Payer: Cash Price |
$245.10
|
| Rate for Payer: Cigna Commercial |
$776.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$408.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$490.20
|
| Rate for Payer: Health EOS Commercial |
$743.47
|
| Rate for Payer: Multiplan Commercial |
$653.60
|
| Rate for Payer: Preferred Network Access Commercial |
$776.15
|
| Rate for Payer: Quartz Beloit One Network |
$359.48
|
| Rate for Payer: Quartz Commercial |
$465.69
|
| Rate for Payer: The Alliance Commercial |
$408.50
|
| Rate for Payer: WEA Trust Commercial |
$449.35
|
| Rate for Payer: WPS Commercial |
$605.15
|
|
|
Yes - OT Evaluation High Charge
|
Facility
IP
|
$817.00
|
|
|
Service Code
|
CPT 97167 GO
|
| Hospital Charge Code |
5148667
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$400.33 |
| Max. Negotiated Rate |
$751.64 |
| Rate for Payer: Aetna Commercial |
$735.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$433.01
|
| Rate for Payer: Cash Price |
$245.10
|
| Rate for Payer: Cigna Commercial |
$751.64
|
| Rate for Payer: Health EOS Commercial |
$727.13
|
| Rate for Payer: HFN Commercial |
$751.64
|
| Rate for Payer: Multiplan Commercial |
$653.60
|
| Rate for Payer: NAPHCARE Commercial |
$490.20
|
| Rate for Payer: Preferred Network Access Commercial |
$751.64
|
| Rate for Payer: Quartz Beloit One Network |
$400.33
|
| Rate for Payer: Quartz Commercial |
$490.20
|
| Rate for Payer: WEA Trust Commercial |
$449.35
|
| Rate for Payer: WPS Commercial |
$605.15
|
|
|
Yes - OT Evaluation Low Charge
|
Professional
|
$415.00
|
|
|
Service Code
|
CPT 97165 GO
|
| Hospital Charge Code |
5148666
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$182.60 |
| Max. Negotiated Rate |
$394.25 |
| Rate for Payer: Aetna Commercial |
$394.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$356.90
|
| Rate for Payer: Cash Price |
$124.50
|
| Rate for Payer: Cash Price |
$124.50
|
| Rate for Payer: Cigna Commercial |
$394.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$207.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$249.00
|
| Rate for Payer: Health EOS Commercial |
$377.65
|
| Rate for Payer: Multiplan Commercial |
$332.00
|
| Rate for Payer: Preferred Network Access Commercial |
$394.25
|
| Rate for Payer: Quartz Beloit One Network |
$182.60
|
| Rate for Payer: Quartz Commercial |
$236.55
|
| Rate for Payer: The Alliance Commercial |
$207.50
|
| Rate for Payer: WEA Trust Commercial |
$228.25
|
| Rate for Payer: WPS Commercial |
$307.39
|
|
|
Yes - OT Evaluation Low Charge
|
Facility
IP
|
$415.00
|
|
|
Service Code
|
CPT 97165 GO
|
| Hospital Charge Code |
5148666
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$203.35 |
| Max. Negotiated Rate |
$381.80 |
| Rate for Payer: Aetna Commercial |
$373.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$219.95
|
| Rate for Payer: Cash Price |
$124.50
|
| Rate for Payer: Cigna Commercial |
$381.80
|
| Rate for Payer: Health EOS Commercial |
$369.35
|
| Rate for Payer: HFN Commercial |
$381.80
|
| Rate for Payer: Multiplan Commercial |
$332.00
|
| Rate for Payer: NAPHCARE Commercial |
$249.00
|
| Rate for Payer: Preferred Network Access Commercial |
$381.80
|
| Rate for Payer: Quartz Beloit One Network |
$203.35
|
| Rate for Payer: Quartz Commercial |
$249.00
|
| Rate for Payer: WEA Trust Commercial |
$228.25
|
| Rate for Payer: WPS Commercial |
$307.39
|
|
|
Yes - OT Evaluation Low Charge
|
Facility
OP
|
$415.00
|
|
|
Service Code
|
CPT 97165 GO
|
| Hospital Charge Code |
5148666
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$116.20 |
| Max. Negotiated Rate |
$1,660.00 |
| Rate for Payer: Aetna Commercial |
$373.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$356.90
|
| Rate for Payer: Aetna Managed Medicare |
$116.20
|
| 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 |
$219.95
|
| Rate for Payer: Cash Price |
$124.50
|
| Rate for Payer: Cash Price |
$124.50
|
| Rate for Payer: Cigna Commercial |
$381.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$232.23
|
| Rate for Payer: Health EOS Commercial |
$369.35
|
| Rate for Payer: HFN Commercial |
$381.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$332.00
|
| Rate for Payer: NAPHCARE Commercial |
$249.00
|
| Rate for Payer: Preferred Network Access Commercial |
$381.80
|
| Rate for Payer: Quartz Beloit One Network |
$203.35
|
| Rate for Payer: Quartz Commercial |
$269.75
|
| Rate for Payer: Quartz Medicare Advantage |
$249.00
|
| Rate for Payer: The Alliance Commercial |
$1,660.00
|
| Rate for Payer: United Healthcare PPO |
$311.25
|
| Rate for Payer: WEA Trust Commercial |
$228.25
|
| Rate for Payer: WPS Commercial |
$307.39
|
|
|
Yes - OT Evaluation Moderate Charge
|
Facility
OP
|
$655.00
|
|
|
Service Code
|
CPT 97166 GO
|
| Hospital Charge Code |
5148665
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$183.40 |
| Max. Negotiated Rate |
$2,620.00 |
| Rate for Payer: Aetna Commercial |
$589.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$563.30
|
| Rate for Payer: Aetna Managed Medicare |
$183.40
|
| 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 |
$347.15
|
| Rate for Payer: Cash Price |
$196.50
|
| Rate for Payer: Cash Price |
$196.50
|
| Rate for Payer: Cigna Commercial |
$602.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$366.54
|
| Rate for Payer: Health EOS Commercial |
$582.95
|
| Rate for Payer: HFN Commercial |
$602.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$524.00
|
| Rate for Payer: NAPHCARE Commercial |
$393.00
|
| Rate for Payer: Preferred Network Access Commercial |
$602.60
|
| Rate for Payer: Quartz Beloit One Network |
$320.95
|
| Rate for Payer: Quartz Commercial |
$425.75
|
| Rate for Payer: Quartz Medicare Advantage |
$393.00
|
| Rate for Payer: The Alliance Commercial |
$2,620.00
|
| Rate for Payer: United Healthcare PPO |
$491.25
|
| Rate for Payer: WEA Trust Commercial |
$360.25
|
| Rate for Payer: WPS Commercial |
$485.16
|
|
|
Yes - OT Evaluation Moderate Charge
|
Facility
IP
|
$655.00
|
|
|
Service Code
|
CPT 97166 GO
|
| Hospital Charge Code |
5148665
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$320.95 |
| Max. Negotiated Rate |
$602.60 |
| Rate for Payer: Aetna Commercial |
$589.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$347.15
|
| Rate for Payer: Cash Price |
$196.50
|
| Rate for Payer: Cigna Commercial |
$602.60
|
| Rate for Payer: Health EOS Commercial |
$582.95
|
| Rate for Payer: HFN Commercial |
$602.60
|
| Rate for Payer: Multiplan Commercial |
$524.00
|
| Rate for Payer: NAPHCARE Commercial |
$393.00
|
| Rate for Payer: Preferred Network Access Commercial |
$602.60
|
| Rate for Payer: Quartz Beloit One Network |
$320.95
|
| Rate for Payer: Quartz Commercial |
$393.00
|
| Rate for Payer: WEA Trust Commercial |
$360.25
|
| Rate for Payer: WPS Commercial |
$485.16
|
|
|
Yes - OT Evaluation Moderate Charge
|
Professional
|
$655.00
|
|
|
Service Code
|
CPT 97166 GO
|
| Hospital Charge Code |
5148665
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$288.20 |
| Max. Negotiated Rate |
$622.25 |
| Rate for Payer: Aetna Commercial |
$622.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$563.30
|
| Rate for Payer: Cash Price |
$196.50
|
| Rate for Payer: Cash Price |
$196.50
|
| Rate for Payer: Cigna Commercial |
$622.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$327.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$393.00
|
| Rate for Payer: Health EOS Commercial |
$596.05
|
| Rate for Payer: Multiplan Commercial |
$524.00
|
| Rate for Payer: Preferred Network Access Commercial |
$622.25
|
| Rate for Payer: Quartz Beloit One Network |
$288.20
|
| Rate for Payer: Quartz Commercial |
$373.35
|
| Rate for Payer: The Alliance Commercial |
$327.50
|
| Rate for Payer: WEA Trust Commercial |
$360.25
|
| Rate for Payer: WPS Commercial |
$485.16
|
|
|
Yes - OT Fluidotherapy Charge
|
Professional
|
$186.00
|
|
|
Service Code
|
CPT 97022 GO
|
| Hospital Charge Code |
2989696
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$81.84 |
| Max. Negotiated Rate |
$176.70 |
| Rate for Payer: Aetna Commercial |
$176.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$159.96
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cigna Commercial |
$176.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$93.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$111.60
|
| Rate for Payer: Health EOS Commercial |
$169.26
|
| Rate for Payer: Multiplan Commercial |
$148.80
|
| Rate for Payer: Preferred Network Access Commercial |
$176.70
|
| Rate for Payer: Quartz Beloit One Network |
$81.84
|
| Rate for Payer: Quartz Commercial |
$106.02
|
| Rate for Payer: The Alliance Commercial |
$93.00
|
| Rate for Payer: WEA Trust Commercial |
$102.30
|
| Rate for Payer: WPS Commercial |
$137.77
|
|
|
Yes - OT Fluidotherapy Charge
|
Facility
OP
|
$186.00
|
|
|
Service Code
|
CPT 97022 GO
|
| Hospital Charge Code |
2989696
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$52.08 |
| Max. Negotiated Rate |
$744.00 |
| Rate for Payer: Aetna Commercial |
$167.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$159.96
|
| Rate for Payer: Aetna Managed Medicare |
$52.08
|
| 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 |
$98.58
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cigna Commercial |
$171.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$104.09
|
| Rate for Payer: Health EOS Commercial |
$165.54
|
| Rate for Payer: HFN Commercial |
$171.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$148.80
|
| Rate for Payer: NAPHCARE Commercial |
$111.60
|
| Rate for Payer: Preferred Network Access Commercial |
$171.12
|
| Rate for Payer: Quartz Beloit One Network |
$91.14
|
| Rate for Payer: Quartz Commercial |
$120.90
|
| Rate for Payer: Quartz Medicare Advantage |
$111.60
|
| Rate for Payer: The Alliance Commercial |
$744.00
|
| Rate for Payer: United Healthcare PPO |
$139.50
|
| Rate for Payer: WEA Trust Commercial |
$102.30
|
| Rate for Payer: WPS Commercial |
$137.77
|
|
