|
Yes - OT Fluidotherapy Charge
|
Facility
IP
|
$186.00
|
|
|
Service Code
|
CPT 97022 GO
|
| Hospital Charge Code |
2989696
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$91.14 |
| Max. Negotiated Rate |
$171.12 |
| Rate for Payer: Aetna Commercial |
$167.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$98.58
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cigna Commercial |
$171.12
|
| Rate for Payer: Health EOS Commercial |
$165.54
|
| Rate for Payer: HFN Commercial |
$171.12
|
| 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 |
$111.60
|
| Rate for Payer: WEA Trust Commercial |
$102.30
|
| Rate for Payer: WPS Commercial |
$137.77
|
|
|
Yes - OT Group Therapy Charge
|
Facility
OP
|
$228.00
|
|
|
Service Code
|
CPT 97150 GO
|
| Hospital Charge Code |
2987943
|
|
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 - OT Group Therapy Charge
|
Facility
IP
|
$228.00
|
|
|
Service Code
|
CPT 97150 GO
|
| Hospital Charge Code |
2987943
|
|
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 - OT Paraffin Bath Charge
|
Professional
|
$114.00
|
|
|
Service Code
|
CPT 97018 GO
|
| Hospital Charge Code |
2989791
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$50.16 |
| Max. Negotiated Rate |
$108.30 |
| Rate for Payer: Aetna Commercial |
$108.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$98.04
|
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Cigna Commercial |
$108.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$57.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$68.40
|
| Rate for Payer: Health EOS Commercial |
$103.74
|
| Rate for Payer: Multiplan Commercial |
$91.20
|
| Rate for Payer: Preferred Network Access Commercial |
$108.30
|
| Rate for Payer: Quartz Beloit One Network |
$50.16
|
| Rate for Payer: Quartz Commercial |
$64.98
|
| Rate for Payer: The Alliance Commercial |
$57.00
|
| Rate for Payer: WEA Trust Commercial |
$62.70
|
| Rate for Payer: WPS Commercial |
$84.44
|
|
|
Yes - OT Paraffin Bath Charge
|
Facility
IP
|
$114.00
|
|
|
Service Code
|
CPT 97018 GO
|
| Hospital Charge Code |
2989791
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$55.86 |
| Max. Negotiated Rate |
$104.88 |
| Rate for Payer: Aetna Commercial |
$102.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$60.42
|
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Cigna Commercial |
$104.88
|
| Rate for Payer: Health EOS Commercial |
$101.46
|
| Rate for Payer: HFN Commercial |
$104.88
|
| Rate for Payer: Multiplan Commercial |
$91.20
|
| Rate for Payer: NAPHCARE Commercial |
$68.40
|
| Rate for Payer: Preferred Network Access Commercial |
$104.88
|
| Rate for Payer: Quartz Beloit One Network |
$55.86
|
| Rate for Payer: Quartz Commercial |
$68.40
|
| Rate for Payer: WEA Trust Commercial |
$62.70
|
| Rate for Payer: WPS Commercial |
$84.44
|
|
|
Yes - OT Paraffin Bath Charge
|
Facility
OP
|
$114.00
|
|
|
Service Code
|
CPT 97018 GO
|
| Hospital Charge Code |
2989791
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$31.92 |
| Max. Negotiated Rate |
$456.00 |
| Rate for Payer: Aetna Commercial |
$102.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$98.04
|
| Rate for Payer: Aetna Managed Medicare |
$31.92
|
| 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 |
$60.42
|
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Cigna Commercial |
$104.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$63.79
|
| Rate for Payer: Health EOS Commercial |
$101.46
|
| Rate for Payer: HFN Commercial |
$104.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$91.20
|
| Rate for Payer: NAPHCARE Commercial |
$68.40
|
| Rate for Payer: Preferred Network Access Commercial |
$104.88
|
| Rate for Payer: Quartz Beloit One Network |
$55.86
|
| Rate for Payer: Quartz Commercial |
$74.10
|
| Rate for Payer: Quartz Medicare Advantage |
$68.40
|
| Rate for Payer: The Alliance Commercial |
$456.00
|
| Rate for Payer: United Healthcare PPO |
$85.50
|
| Rate for Payer: WEA Trust Commercial |
$62.70
|
| Rate for Payer: WPS Commercial |
$84.44
|
|
|
Yes - OT Reevaluation Charge
|
Professional
|
$466.00
|
|
|
Service Code
|
CPT 97168 GO
|
| Hospital Charge Code |
2987953
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$205.04 |
| Max. Negotiated Rate |
$442.70 |
| Rate for Payer: Aetna Commercial |
$442.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$400.76
|
| Rate for Payer: Cash Price |
$139.80
|
| Rate for Payer: Cash Price |
$139.80
|
| Rate for Payer: Cigna Commercial |
$442.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$233.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$279.60
|
| Rate for Payer: Health EOS Commercial |
$424.06
|
| Rate for Payer: Multiplan Commercial |
$372.80
|
| Rate for Payer: Preferred Network Access Commercial |
$442.70
|
| Rate for Payer: Quartz Beloit One Network |
$205.04
|
| Rate for Payer: Quartz Commercial |
$265.62
|
| Rate for Payer: The Alliance Commercial |
$233.00
|
| Rate for Payer: WEA Trust Commercial |
$256.30
|
| Rate for Payer: WPS Commercial |
$345.17
|
|
|
Yes - OT Reevaluation Charge
|
Facility
IP
|
$466.00
|
|
|
Service Code
|
CPT 97168 GO
|
| Hospital Charge Code |
2987953
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$228.34 |
| Max. Negotiated Rate |
$428.72 |
| Rate for Payer: Aetna Commercial |
$419.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$246.98
|
| Rate for Payer: Cash Price |
$139.80
|
| Rate for Payer: Cigna Commercial |
$428.72
|
| Rate for Payer: Health EOS Commercial |
$414.74
|
| Rate for Payer: HFN Commercial |
$428.72
|
| Rate for Payer: Multiplan Commercial |
$372.80
|
| Rate for Payer: NAPHCARE Commercial |
$279.60
|
| Rate for Payer: Preferred Network Access Commercial |
$428.72
|
| Rate for Payer: Quartz Beloit One Network |
$228.34
|
| Rate for Payer: Quartz Commercial |
$279.60
|
| Rate for Payer: WEA Trust Commercial |
$256.30
|
| Rate for Payer: WPS Commercial |
$345.17
|
|
|
Yes - OT Reevaluation Charge
|
Facility
OP
|
$466.00
|
|
|
Service Code
|
CPT 97168 GO
|
| Hospital Charge Code |
2987953
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$130.48 |
| Max. Negotiated Rate |
$1,864.00 |
| Rate for Payer: Aetna Commercial |
$419.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$400.76
|
| Rate for Payer: Aetna Managed Medicare |
$130.48
|
| 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 |
$246.98
|
| Rate for Payer: Cash Price |
$139.80
|
| Rate for Payer: Cash Price |
$139.80
|
| Rate for Payer: Cigna Commercial |
$428.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$260.77
|
| Rate for Payer: Health EOS Commercial |
$414.74
|
| Rate for Payer: HFN Commercial |
$428.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$372.80
|
| Rate for Payer: NAPHCARE Commercial |
$279.60
|
| Rate for Payer: Preferred Network Access Commercial |
$428.72
|
| Rate for Payer: Quartz Beloit One Network |
$228.34
|
| Rate for Payer: Quartz Commercial |
$302.90
|
| Rate for Payer: Quartz Medicare Advantage |
$279.60
|
| Rate for Payer: The Alliance Commercial |
$1,864.00
|
| Rate for Payer: United Healthcare PPO |
$349.50
|
| Rate for Payer: WEA Trust Commercial |
$256.30
|
| Rate for Payer: WPS Commercial |
$345.17
|
|
|
Yes - OT Telemed Est Patient 11-20 min Chg
|
Facility
OP
|
$104.00
|
|
|
Service Code
|
CPT 98971 GO,95
|
| Hospital Charge Code |
5583121
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$29.12 |
| Max. Negotiated Rate |
$416.00 |
| Rate for Payer: Aetna Commercial |
$93.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$89.44
|
| Rate for Payer: Aetna Managed Medicare |
$29.12
|
| 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 |
$55.12
|
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Cigna Commercial |
$95.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$58.20
|
| Rate for Payer: Health EOS Commercial |
$92.56
|
| Rate for Payer: HFN Commercial |
$95.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$83.20
|
| Rate for Payer: NAPHCARE Commercial |
$62.40
|
| Rate for Payer: Preferred Network Access Commercial |
$95.68
|
| Rate for Payer: Quartz Beloit One Network |
$50.96
|
| Rate for Payer: Quartz Commercial |
$67.60
|
| Rate for Payer: Quartz Medicare Advantage |
$62.40
|
| Rate for Payer: The Alliance Commercial |
$416.00
|
| Rate for Payer: United Healthcare PPO |
$78.00
|
| Rate for Payer: WEA Trust Commercial |
$57.20
|
| Rate for Payer: WPS Commercial |
$77.03
|
|
|
Yes - OT Telemed Est Patient 11-20 min Chg
|
Facility
IP
|
$104.00
|
|
|
Service Code
|
CPT 98971 GO,95
|
| Hospital Charge Code |
5583121
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$50.96 |
| Max. Negotiated Rate |
$95.68 |
| Rate for Payer: Aetna Commercial |
$93.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$55.12
|
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Cigna Commercial |
$95.68
|
| Rate for Payer: Health EOS Commercial |
$92.56
|
| Rate for Payer: HFN Commercial |
$95.68
|
| Rate for Payer: Multiplan Commercial |
$83.20
|
| Rate for Payer: NAPHCARE Commercial |
$62.40
|
| Rate for Payer: Preferred Network Access Commercial |
$95.68
|
| Rate for Payer: Quartz Beloit One Network |
$50.96
|
| Rate for Payer: Quartz Commercial |
$62.40
|
| Rate for Payer: WEA Trust Commercial |
$57.20
|
| Rate for Payer: WPS Commercial |
$77.03
|
|
|
Yes - OT Telemed Est Patient 21>min Chg
|
Facility
OP
|
$147.00
|
|
|
Service Code
|
CPT 98972 GO,95
|
| Hospital Charge Code |
5583129
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$41.16 |
| Max. Negotiated Rate |
$588.00 |
| Rate for Payer: Aetna Commercial |
$132.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$126.42
|
| Rate for Payer: Aetna Managed Medicare |
$41.16
|
| 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 |
$77.91
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: Cigna Commercial |
$135.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$82.26
|
| Rate for Payer: Health EOS Commercial |
$130.83
|
| Rate for Payer: HFN Commercial |
$135.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$117.60
|
| Rate for Payer: NAPHCARE Commercial |
$88.20
|
| Rate for Payer: Preferred Network Access Commercial |
$135.24
|
| Rate for Payer: Quartz Beloit One Network |
$72.03
|
| Rate for Payer: Quartz Commercial |
$95.55
|
| Rate for Payer: Quartz Medicare Advantage |
$88.20
|
| Rate for Payer: The Alliance Commercial |
$588.00
|
| Rate for Payer: United Healthcare PPO |
$110.25
|
| Rate for Payer: WEA Trust Commercial |
$80.85
|
| Rate for Payer: WPS Commercial |
$108.88
|
|
|
Yes - OT Telemed Est Patient 21>min Chg
|
Facility
IP
|
$147.00
|
|
|
Service Code
|
CPT 98972 GO,95
|
| Hospital Charge Code |
5583129
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$72.03 |
| Max. Negotiated Rate |
$135.24 |
| Rate for Payer: Aetna Commercial |
$132.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$77.91
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: Cigna Commercial |
$135.24
|
| Rate for Payer: Health EOS Commercial |
$130.83
|
| Rate for Payer: HFN Commercial |
$135.24
|
| Rate for Payer: Multiplan Commercial |
$117.60
|
| Rate for Payer: NAPHCARE Commercial |
$88.20
|
| Rate for Payer: Preferred Network Access Commercial |
$135.24
|
| Rate for Payer: Quartz Beloit One Network |
$72.03
|
| Rate for Payer: Quartz Commercial |
$88.20
|
| Rate for Payer: WEA Trust Commercial |
$80.85
|
| Rate for Payer: WPS Commercial |
$108.88
|
|
|
Yes - OT Telemed Est Patient 5-10 min Chg
|
Facility
IP
|
$61.00
|
|
|
Service Code
|
CPT 98970 GO,95
|
| Hospital Charge Code |
5583130
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$29.89 |
| Max. Negotiated Rate |
$56.12 |
| Rate for Payer: Aetna Commercial |
$54.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$32.33
|
| Rate for Payer: Cash Price |
$18.30
|
| Rate for Payer: Cigna Commercial |
$56.12
|
| Rate for Payer: Health EOS Commercial |
$54.29
|
| Rate for Payer: HFN Commercial |
$56.12
|
| Rate for Payer: Multiplan Commercial |
$48.80
|
| Rate for Payer: NAPHCARE Commercial |
$36.60
|
| Rate for Payer: Preferred Network Access Commercial |
$56.12
|
| Rate for Payer: Quartz Beloit One Network |
$29.89
|
| Rate for Payer: Quartz Commercial |
$36.60
|
| Rate for Payer: WEA Trust Commercial |
$33.55
|
| Rate for Payer: WPS Commercial |
$45.18
|
|
|
Yes - OT Telemed Est Patient 5-10 min Chg
|
Facility
OP
|
$61.00
|
|
|
Service Code
|
CPT 98970 GO,95
|
| Hospital Charge Code |
5583130
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$17.08 |
| Max. Negotiated Rate |
$349.00 |
| Rate for Payer: Dean Health DHI/DHP/ASO |
$34.14
|
| Rate for Payer: Aetna Commercial |
$54.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$52.46
|
| Rate for Payer: Aetna Managed Medicare |
$17.08
|
| 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 |
$32.33
|
| Rate for Payer: Cash Price |
$18.30
|
| Rate for Payer: Cash Price |
$18.30
|
| Rate for Payer: Cigna Commercial |
$56.12
|
| Rate for Payer: Health EOS Commercial |
$54.29
|
| Rate for Payer: HFN Commercial |
$56.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$48.80
|
| Rate for Payer: NAPHCARE Commercial |
$36.60
|
| Rate for Payer: Preferred Network Access Commercial |
$56.12
|
| Rate for Payer: Quartz Beloit One Network |
$29.89
|
| Rate for Payer: Quartz Commercial |
$39.65
|
| Rate for Payer: Quartz Medicare Advantage |
$36.60
|
| Rate for Payer: The Alliance Commercial |
$244.00
|
| Rate for Payer: United Healthcare PPO |
$45.75
|
| Rate for Payer: WEA Trust Commercial |
$33.55
|
| Rate for Payer: WPS Commercial |
$45.18
|
|
|
Yes - OT Telephone call 11-20 min Charge
|
Facility
OP
|
$164.00
|
|
|
Service Code
|
CPT 98967 GO,95
|
| Hospital Charge Code |
5583193
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$45.92 |
| Max. Negotiated Rate |
$656.00 |
| Rate for Payer: Aetna Commercial |
$147.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$141.04
|
| Rate for Payer: Aetna Managed Medicare |
$45.92
|
| 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 |
$86.92
|
| Rate for Payer: Cash Price |
$49.20
|
| Rate for Payer: Cash Price |
$49.20
|
| Rate for Payer: Cigna Commercial |
$150.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$91.77
|
| Rate for Payer: Health EOS Commercial |
$145.96
|
| Rate for Payer: HFN Commercial |
$150.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$131.20
|
| Rate for Payer: NAPHCARE Commercial |
$98.40
|
| Rate for Payer: Preferred Network Access Commercial |
$150.88
|
| Rate for Payer: Quartz Beloit One Network |
$80.36
|
| Rate for Payer: Quartz Commercial |
$106.60
|
| Rate for Payer: Quartz Medicare Advantage |
$98.40
|
| Rate for Payer: The Alliance Commercial |
$656.00
|
| Rate for Payer: United Healthcare PPO |
$123.00
|
| Rate for Payer: WEA Trust Commercial |
$90.20
|
| Rate for Payer: WPS Commercial |
$121.47
|
|
|
Yes - OT Telephone call 11-20 min Charge
|
Facility
IP
|
$164.00
|
|
|
Service Code
|
CPT 98967 GO,95
|
| Hospital Charge Code |
5583193
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$80.36 |
| Max. Negotiated Rate |
$150.88 |
| Rate for Payer: Aetna Commercial |
$147.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$86.92
|
| Rate for Payer: Cash Price |
$49.20
|
| Rate for Payer: Cigna Commercial |
$150.88
|
| Rate for Payer: Health EOS Commercial |
$145.96
|
| Rate for Payer: HFN Commercial |
$150.88
|
| Rate for Payer: Multiplan Commercial |
$131.20
|
| Rate for Payer: NAPHCARE Commercial |
$98.40
|
| Rate for Payer: Preferred Network Access Commercial |
$150.88
|
| Rate for Payer: Quartz Beloit One Network |
$80.36
|
| Rate for Payer: Quartz Commercial |
$98.40
|
| Rate for Payer: WEA Trust Commercial |
$90.20
|
| Rate for Payer: WPS Commercial |
$121.47
|
|
|
Yes - OT Telephone call 21> min Charge
|
Facility
IP
|
$245.00
|
|
|
Service Code
|
CPT 98968 GO,95
|
| Hospital Charge Code |
5583194
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$120.05 |
| Max. Negotiated Rate |
$225.40 |
| Rate for Payer: Aetna Commercial |
$220.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$129.85
|
| Rate for Payer: Cash Price |
$73.50
|
| Rate for Payer: Cigna Commercial |
$225.40
|
| Rate for Payer: Health EOS Commercial |
$218.05
|
| Rate for Payer: HFN Commercial |
$225.40
|
| Rate for Payer: Multiplan Commercial |
$196.00
|
| Rate for Payer: NAPHCARE Commercial |
$147.00
|
| Rate for Payer: Preferred Network Access Commercial |
$225.40
|
| Rate for Payer: Quartz Beloit One Network |
$120.05
|
| Rate for Payer: Quartz Commercial |
$147.00
|
| Rate for Payer: WEA Trust Commercial |
$134.75
|
| Rate for Payer: WPS Commercial |
$181.47
|
|
|
Yes - OT Telephone call 21> min Charge
|
Facility
OP
|
$245.00
|
|
|
Service Code
|
CPT 98968 GO,95
|
| Hospital Charge Code |
5583194
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$68.60 |
| Max. Negotiated Rate |
$980.00 |
| Rate for Payer: Aetna Commercial |
$220.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$210.70
|
| Rate for Payer: Aetna Managed Medicare |
$68.60
|
| 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 |
$129.85
|
| Rate for Payer: Cash Price |
$73.50
|
| Rate for Payer: Cash Price |
$73.50
|
| Rate for Payer: Cigna Commercial |
$225.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$137.10
|
| Rate for Payer: Health EOS Commercial |
$218.05
|
| Rate for Payer: HFN Commercial |
$225.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$196.00
|
| Rate for Payer: NAPHCARE Commercial |
$147.00
|
| Rate for Payer: Preferred Network Access Commercial |
$225.40
|
| Rate for Payer: Quartz Beloit One Network |
$120.05
|
| Rate for Payer: Quartz Commercial |
$159.25
|
| Rate for Payer: Quartz Medicare Advantage |
$147.00
|
| Rate for Payer: The Alliance Commercial |
$980.00
|
| Rate for Payer: United Healthcare PPO |
$183.75
|
| Rate for Payer: WEA Trust Commercial |
$134.75
|
| Rate for Payer: WPS Commercial |
$181.47
|
|
|
Yes - OT Telephone call 5-10 min Charge
|
Facility
OP
|
$82.00
|
|
|
Service Code
|
CPT 98966 GO,95
|
| Hospital Charge Code |
5583195
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$22.96 |
| Max. Negotiated Rate |
$349.00 |
| Rate for Payer: Aetna Commercial |
$73.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$70.52
|
| Rate for Payer: Aetna Managed Medicare |
$22.96
|
| 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 |
$43.46
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cigna Commercial |
$75.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$45.89
|
| Rate for Payer: Health EOS Commercial |
$72.98
|
| Rate for Payer: HFN Commercial |
$75.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$65.60
|
| Rate for Payer: NAPHCARE Commercial |
$49.20
|
| Rate for Payer: Preferred Network Access Commercial |
$75.44
|
| Rate for Payer: Quartz Beloit One Network |
$40.18
|
| Rate for Payer: Quartz Commercial |
$53.30
|
| Rate for Payer: Quartz Medicare Advantage |
$49.20
|
| Rate for Payer: The Alliance Commercial |
$328.00
|
| Rate for Payer: United Healthcare PPO |
$61.50
|
| Rate for Payer: WEA Trust Commercial |
$45.10
|
| Rate for Payer: WPS Commercial |
$60.74
|
|
|
Yes - OT Telephone call 5-10 min Charge
|
Facility
IP
|
$82.00
|
|
|
Service Code
|
CPT 98966 GO,95
|
| Hospital Charge Code |
5583195
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$40.18 |
| Max. Negotiated Rate |
$75.44 |
| Rate for Payer: Aetna Commercial |
$73.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$43.46
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cigna Commercial |
$75.44
|
| Rate for Payer: Health EOS Commercial |
$72.98
|
| Rate for Payer: HFN Commercial |
$75.44
|
| Rate for Payer: Multiplan Commercial |
$65.60
|
| Rate for Payer: NAPHCARE Commercial |
$49.20
|
| Rate for Payer: Preferred Network Access Commercial |
$75.44
|
| Rate for Payer: Quartz Beloit One Network |
$40.18
|
| Rate for Payer: Quartz Commercial |
$49.20
|
| Rate for Payer: WEA Trust Commercial |
$45.10
|
| Rate for Payer: WPS Commercial |
$60.74
|
|
|
Yes - OT TH Evaluation High Complexity Chg
|
Facility
IP
|
$1,044.00
|
|
|
Service Code
|
CPT 97167 GO,95
|
| Hospital Charge Code |
5585263
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$511.56 |
| Max. Negotiated Rate |
$960.48 |
| Rate for Payer: Aetna Commercial |
$939.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$553.32
|
| Rate for Payer: Cash Price |
$313.20
|
| Rate for Payer: Cigna Commercial |
$960.48
|
| Rate for Payer: Health EOS Commercial |
$929.16
|
| Rate for Payer: HFN Commercial |
$960.48
|
| Rate for Payer: Multiplan Commercial |
$835.20
|
| Rate for Payer: NAPHCARE Commercial |
$626.40
|
| Rate for Payer: Preferred Network Access Commercial |
$960.48
|
| Rate for Payer: Quartz Beloit One Network |
$511.56
|
| Rate for Payer: Quartz Commercial |
$626.40
|
| Rate for Payer: WEA Trust Commercial |
$574.20
|
| Rate for Payer: WPS Commercial |
$773.29
|
|
|
Yes - OT TH Evaluation High Complexity Chg
|
Facility
OP
|
$1,044.00
|
|
|
Service Code
|
CPT 97167 GO,95
|
| Hospital Charge Code |
5585263
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$202.00 |
| Max. Negotiated Rate |
$4,176.00 |
| Rate for Payer: Aetna Commercial |
$939.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$897.84
|
| Rate for Payer: Aetna Managed Medicare |
$292.32
|
| 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 |
$553.32
|
| Rate for Payer: Cash Price |
$313.20
|
| Rate for Payer: Cash Price |
$313.20
|
| Rate for Payer: Cigna Commercial |
$960.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$584.22
|
| Rate for Payer: Health EOS Commercial |
$929.16
|
| Rate for Payer: HFN Commercial |
$960.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$835.20
|
| Rate for Payer: NAPHCARE Commercial |
$626.40
|
| Rate for Payer: Preferred Network Access Commercial |
$960.48
|
| Rate for Payer: Quartz Beloit One Network |
$511.56
|
| Rate for Payer: Quartz Commercial |
$678.60
|
| Rate for Payer: Quartz Medicare Advantage |
$626.40
|
| Rate for Payer: The Alliance Commercial |
$4,176.00
|
| Rate for Payer: United Healthcare PPO |
$783.00
|
| Rate for Payer: WEA Trust Commercial |
$574.20
|
| Rate for Payer: WPS Commercial |
$773.29
|
|
|
Yes - OT TH Evaluation Low Complexity Chg
|
Facility
IP
|
$332.00
|
|
|
Service Code
|
CPT 97165 GO,95
|
| Hospital Charge Code |
5585274
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$162.68 |
| Max. Negotiated Rate |
$305.44 |
| Rate for Payer: Aetna Commercial |
$298.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$175.96
|
| Rate for Payer: Cash Price |
$99.60
|
| Rate for Payer: Cigna Commercial |
$305.44
|
| Rate for Payer: Health EOS Commercial |
$295.48
|
| Rate for Payer: HFN Commercial |
$305.44
|
| Rate for Payer: Multiplan Commercial |
$265.60
|
| Rate for Payer: NAPHCARE Commercial |
$199.20
|
| Rate for Payer: Preferred Network Access Commercial |
$305.44
|
| Rate for Payer: Quartz Beloit One Network |
$162.68
|
| Rate for Payer: Quartz Commercial |
$199.20
|
| Rate for Payer: WEA Trust Commercial |
$182.60
|
| Rate for Payer: WPS Commercial |
$245.91
|
|
|
Yes - OT TH Evaluation Low Complexity Chg
|
Facility
OP
|
$332.00
|
|
|
Service Code
|
CPT 97165 GO,95
|
| Hospital Charge Code |
5585274
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$92.96 |
| Max. Negotiated Rate |
$1,328.00 |
| Rate for Payer: Aetna Commercial |
$298.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$285.52
|
| Rate for Payer: Aetna Managed Medicare |
$92.96
|
| 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 |
$175.96
|
| Rate for Payer: Cash Price |
$99.60
|
| Rate for Payer: Cash Price |
$99.60
|
| Rate for Payer: Cigna Commercial |
$305.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$185.79
|
| Rate for Payer: Health EOS Commercial |
$295.48
|
| Rate for Payer: HFN Commercial |
$305.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$265.60
|
| Rate for Payer: NAPHCARE Commercial |
$199.20
|
| Rate for Payer: Preferred Network Access Commercial |
$305.44
|
| Rate for Payer: Quartz Beloit One Network |
$162.68
|
| Rate for Payer: Quartz Commercial |
$215.80
|
| Rate for Payer: Quartz Medicare Advantage |
$199.20
|
| Rate for Payer: The Alliance Commercial |
$1,328.00
|
| Rate for Payer: United Healthcare PPO |
$249.00
|
| Rate for Payer: WEA Trust Commercial |
$182.60
|
| Rate for Payer: WPS Commercial |
$245.91
|
|
