|
Yes - OTA Aquatic Therapy Charge
|
Facility
|
IP
|
$246.00
|
|
|
Service Code
|
CPT 97113 GO,CO
|
| Hospital Charge Code |
5571954
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$125.36 |
| Max. Negotiated Rate |
$235.37 |
| Rate for Payer: Aetna Commercial |
$230.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$220.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$135.60
|
| Rate for Payer: Cash Price |
$73.80
|
| Rate for Payer: Cigna Commercial |
$235.37
|
| Rate for Payer: Health EOS Commercial |
$227.70
|
| Rate for Payer: HFN Commercial |
$235.37
|
| Rate for Payer: Multiplan Commercial |
$204.67
|
| Rate for Payer: Preferred Network Access Commercial |
$235.37
|
| Rate for Payer: Quartz Beloit One Network |
$125.36
|
| Rate for Payer: Quartz Commercial |
$153.50
|
| Rate for Payer: WEA Trust Commercial |
$140.71
|
| Rate for Payer: WPS Commercial |
$189.49
|
|
|
Yes - OTA Aquatic Therapy Charge
|
Facility
|
OP
|
$246.00
|
|
|
Service Code
|
CPT 97113 GO,CO
|
| Hospital Charge Code |
5571954
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$71.64 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$230.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$220.02
|
| Rate for Payer: Aetna Managed Medicare |
$71.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$362.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$298.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$282.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$135.60
|
| Rate for Payer: Cash Price |
$73.80
|
| Rate for Payer: Cash Price |
$73.80
|
| Rate for Payer: Cigna Commercial |
$235.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$143.17
|
| Rate for Payer: Health EOS Commercial |
$227.70
|
| Rate for Payer: HFN Commercial |
$235.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$204.67
|
| Rate for Payer: NAPHCARE Commercial |
$153.50
|
| Rate for Payer: Preferred Network Access Commercial |
$235.37
|
| Rate for Payer: Quartz Beloit One Network |
$125.36
|
| Rate for Payer: Quartz Commercial |
$166.30
|
| Rate for Payer: Quartz Medicare Advantage |
$153.50
|
| Rate for Payer: The Alliance Commercial |
$127.92
|
| Rate for Payer: United Healthcare PPO |
$191.88
|
| Rate for Payer: WEA Trust Commercial |
$140.71
|
| Rate for Payer: WPS Commercial |
$189.49
|
|
|
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 |
$80.52 |
| Max. Negotiated Rate |
$151.17 |
| Rate for Payer: Aetna Commercial |
$147.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$141.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$87.09
|
| Rate for Payer: Cash Price |
$47.40
|
| Rate for Payer: Cigna Commercial |
$151.17
|
| Rate for Payer: Health EOS Commercial |
$146.24
|
| Rate for Payer: HFN Commercial |
$151.17
|
| Rate for Payer: Multiplan Commercial |
$131.46
|
| Rate for Payer: Preferred Network Access Commercial |
$151.17
|
| Rate for Payer: Quartz Beloit One Network |
$80.52
|
| Rate for Payer: Quartz Commercial |
$98.59
|
| Rate for Payer: WEA Trust Commercial |
$90.38
|
| Rate for Payer: WPS Commercial |
$121.71
|
|
|
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 |
$46.01 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$147.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$141.32
|
| Rate for Payer: Aetna Managed Medicare |
$46.01
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$362.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$298.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$282.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$87.09
|
| Rate for Payer: Cash Price |
$47.40
|
| Rate for Payer: Cash Price |
$47.40
|
| Rate for Payer: Cigna Commercial |
$151.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$91.96
|
| Rate for Payer: Health EOS Commercial |
$146.24
|
| Rate for Payer: HFN Commercial |
$151.17
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$131.46
|
| Rate for Payer: NAPHCARE Commercial |
$98.59
|
| Rate for Payer: Preferred Network Access Commercial |
$151.17
|
| Rate for Payer: Quartz Beloit One Network |
$80.52
|
| Rate for Payer: Quartz Commercial |
$106.81
|
| Rate for Payer: Quartz Medicare Advantage |
$98.59
|
| Rate for Payer: The Alliance Commercial |
$82.16
|
| Rate for Payer: United Healthcare PPO |
$123.24
|
| Rate for Payer: WEA Trust Commercial |
$90.38
|
| Rate for Payer: WPS Commercial |
$121.71
|
|
|
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 |
$53.58 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$172.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$164.57
|
| Rate for Payer: Aetna Managed Medicare |
$53.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$362.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$298.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$282.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$101.42
|
| Rate for Payer: Cash Price |
$55.20
|
| Rate for Payer: Cash Price |
$55.20
|
| Rate for Payer: Cigna Commercial |
$176.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$107.09
|
| Rate for Payer: Health EOS Commercial |
$170.31
|
| Rate for Payer: HFN Commercial |
$176.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$153.09
|
| Rate for Payer: NAPHCARE Commercial |
$114.82
|
| Rate for Payer: Preferred Network Access Commercial |
$176.05
|
| Rate for Payer: Quartz Beloit One Network |
$93.77
|
| Rate for Payer: Quartz Commercial |
$124.38
|
| Rate for Payer: Quartz Medicare Advantage |
$114.82
|
| Rate for Payer: The Alliance Commercial |
$95.68
|
| Rate for Payer: United Healthcare PPO |
$143.52
|
| Rate for Payer: WEA Trust Commercial |
$105.25
|
| Rate for Payer: WPS Commercial |
$141.74
|
|
|
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 |
$93.77 |
| Max. Negotiated Rate |
$176.05 |
| Rate for Payer: Aetna Commercial |
$172.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$164.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$101.42
|
| Rate for Payer: Cash Price |
$55.20
|
| Rate for Payer: Cigna Commercial |
$176.05
|
| Rate for Payer: Health EOS Commercial |
$170.31
|
| Rate for Payer: HFN Commercial |
$176.05
|
| Rate for Payer: Multiplan Commercial |
$153.09
|
| Rate for Payer: Preferred Network Access Commercial |
$176.05
|
| Rate for Payer: Quartz Beloit One Network |
$93.77
|
| Rate for Payer: Quartz Commercial |
$114.82
|
| Rate for Payer: WEA Trust Commercial |
$105.25
|
| Rate for Payer: WPS Commercial |
$141.74
|
|
|
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 |
$66.39 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$213.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$203.92
|
| Rate for Payer: Aetna Managed Medicare |
$66.39
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$362.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$298.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$282.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$125.67
|
| Rate for Payer: Cash Price |
$68.40
|
| Rate for Payer: Cash Price |
$68.40
|
| Rate for Payer: Cigna Commercial |
$218.15
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$132.70
|
| Rate for Payer: Health EOS Commercial |
$211.04
|
| Rate for Payer: HFN Commercial |
$218.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$189.70
|
| Rate for Payer: NAPHCARE Commercial |
$142.27
|
| Rate for Payer: Preferred Network Access Commercial |
$218.15
|
| Rate for Payer: Quartz Beloit One Network |
$116.19
|
| Rate for Payer: Quartz Commercial |
$154.13
|
| Rate for Payer: Quartz Medicare Advantage |
$142.27
|
| Rate for Payer: The Alliance Commercial |
$118.56
|
| Rate for Payer: United Healthcare PPO |
$177.84
|
| Rate for Payer: WEA Trust Commercial |
$130.42
|
| Rate for Payer: WPS Commercial |
$175.63
|
|
|
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 |
$116.19 |
| Max. Negotiated Rate |
$218.15 |
| Rate for Payer: Aetna Commercial |
$213.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$203.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$125.67
|
| Rate for Payer: Cash Price |
$68.40
|
| Rate for Payer: Cigna Commercial |
$218.15
|
| Rate for Payer: Health EOS Commercial |
$211.04
|
| Rate for Payer: HFN Commercial |
$218.15
|
| Rate for Payer: Multiplan Commercial |
$189.70
|
| Rate for Payer: Preferred Network Access Commercial |
$218.15
|
| Rate for Payer: Quartz Beloit One Network |
$116.19
|
| Rate for Payer: Quartz Commercial |
$142.27
|
| Rate for Payer: WEA Trust Commercial |
$130.42
|
| Rate for Payer: WPS Commercial |
$175.63
|
|
|
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 |
$86.63 |
| Max. Negotiated Rate |
$162.66 |
| Rate for Payer: Aetna Commercial |
$159.12
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$152.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$93.70
|
| Rate for Payer: Cash Price |
$51.00
|
| Rate for Payer: Cigna Commercial |
$162.66
|
| Rate for Payer: Health EOS Commercial |
$157.35
|
| Rate for Payer: HFN Commercial |
$162.66
|
| Rate for Payer: Multiplan Commercial |
$141.44
|
| Rate for Payer: Preferred Network Access Commercial |
$162.66
|
| Rate for Payer: Quartz Beloit One Network |
$86.63
|
| Rate for Payer: Quartz Commercial |
$106.08
|
| Rate for Payer: WEA Trust Commercial |
$97.24
|
| Rate for Payer: WPS Commercial |
$130.95
|
|
|
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 |
$49.50 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$159.12
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$152.05
|
| Rate for Payer: Aetna Managed Medicare |
$49.50
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$362.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$298.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$282.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$93.70
|
| Rate for Payer: Cash Price |
$51.00
|
| Rate for Payer: Cash Price |
$51.00
|
| Rate for Payer: Cigna Commercial |
$162.66
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$98.94
|
| Rate for Payer: Health EOS Commercial |
$157.35
|
| Rate for Payer: HFN Commercial |
$162.66
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$141.44
|
| Rate for Payer: NAPHCARE Commercial |
$106.08
|
| Rate for Payer: Preferred Network Access Commercial |
$162.66
|
| Rate for Payer: Quartz Beloit One Network |
$86.63
|
| Rate for Payer: Quartz Commercial |
$114.92
|
| Rate for Payer: Quartz Medicare Advantage |
$106.08
|
| Rate for Payer: The Alliance Commercial |
$88.40
|
| Rate for Payer: United Healthcare PPO |
$132.60
|
| Rate for Payer: WEA Trust Commercial |
$97.24
|
| Rate for Payer: WPS Commercial |
$130.95
|
|
|
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 |
$125.36 |
| Max. Negotiated Rate |
$235.37 |
| Rate for Payer: Aetna Commercial |
$230.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$220.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$135.60
|
| Rate for Payer: Cash Price |
$73.80
|
| Rate for Payer: Cigna Commercial |
$235.37
|
| Rate for Payer: Health EOS Commercial |
$227.70
|
| Rate for Payer: HFN Commercial |
$235.37
|
| Rate for Payer: Multiplan Commercial |
$204.67
|
| Rate for Payer: Preferred Network Access Commercial |
$235.37
|
| Rate for Payer: Quartz Beloit One Network |
$125.36
|
| Rate for Payer: Quartz Commercial |
$153.50
|
| Rate for Payer: WEA Trust Commercial |
$140.71
|
| Rate for Payer: WPS Commercial |
$189.49
|
|
|
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 |
$71.64 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$230.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$220.02
|
| Rate for Payer: Aetna Managed Medicare |
$71.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$362.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$298.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$282.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$135.60
|
| Rate for Payer: Cash Price |
$73.80
|
| Rate for Payer: Cash Price |
$73.80
|
| Rate for Payer: Cigna Commercial |
$235.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$143.17
|
| Rate for Payer: Health EOS Commercial |
$227.70
|
| Rate for Payer: HFN Commercial |
$235.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$204.67
|
| Rate for Payer: NAPHCARE Commercial |
$153.50
|
| Rate for Payer: Preferred Network Access Commercial |
$235.37
|
| Rate for Payer: Quartz Beloit One Network |
$125.36
|
| Rate for Payer: Quartz Commercial |
$166.30
|
| Rate for Payer: Quartz Medicare Advantage |
$153.50
|
| Rate for Payer: The Alliance Commercial |
$127.92
|
| Rate for Payer: United Healthcare PPO |
$191.88
|
| Rate for Payer: WEA Trust Commercial |
$140.71
|
| Rate for Payer: WPS Commercial |
$189.49
|
|
|
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 |
$98.35 |
| Max. Negotiated Rate |
$184.66 |
| Rate for Payer: Aetna Commercial |
$180.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$172.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$106.38
|
| Rate for Payer: Cash Price |
$57.90
|
| Rate for Payer: Cigna Commercial |
$184.66
|
| Rate for Payer: Health EOS Commercial |
$178.64
|
| Rate for Payer: HFN Commercial |
$184.66
|
| Rate for Payer: Multiplan Commercial |
$160.58
|
| Rate for Payer: Preferred Network Access Commercial |
$184.66
|
| Rate for Payer: Quartz Beloit One Network |
$98.35
|
| Rate for Payer: Quartz Commercial |
$120.43
|
| Rate for Payer: WEA Trust Commercial |
$110.40
|
| Rate for Payer: WPS Commercial |
$148.67
|
|
|
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 |
$56.20 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$180.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$172.62
|
| Rate for Payer: Aetna Managed Medicare |
$56.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$362.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$298.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$282.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$106.38
|
| Rate for Payer: Cash Price |
$57.90
|
| Rate for Payer: Cash Price |
$57.90
|
| Rate for Payer: Cigna Commercial |
$184.66
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$112.33
|
| Rate for Payer: Health EOS Commercial |
$178.64
|
| Rate for Payer: HFN Commercial |
$184.66
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$160.58
|
| Rate for Payer: NAPHCARE Commercial |
$120.43
|
| Rate for Payer: Preferred Network Access Commercial |
$184.66
|
| Rate for Payer: Quartz Beloit One Network |
$98.35
|
| Rate for Payer: Quartz Commercial |
$130.47
|
| Rate for Payer: Quartz Medicare Advantage |
$120.43
|
| Rate for Payer: The Alliance Commercial |
$100.36
|
| Rate for Payer: United Healthcare PPO |
$150.54
|
| Rate for Payer: WEA Trust Commercial |
$110.40
|
| Rate for Payer: WPS Commercial |
$148.67
|
|
|
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 |
$86.20 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$277.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$264.74
|
| Rate for Payer: Aetna Managed Medicare |
$86.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$362.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$298.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$282.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$163.16
|
| Rate for Payer: Cash Price |
$88.80
|
| Rate for Payer: Cash Price |
$88.80
|
| Rate for Payer: Cigna Commercial |
$283.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$172.27
|
| Rate for Payer: Health EOS Commercial |
$273.98
|
| Rate for Payer: HFN Commercial |
$283.21
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$246.27
|
| Rate for Payer: NAPHCARE Commercial |
$184.70
|
| Rate for Payer: Preferred Network Access Commercial |
$283.21
|
| Rate for Payer: Quartz Beloit One Network |
$150.84
|
| Rate for Payer: Quartz Commercial |
$200.10
|
| Rate for Payer: Quartz Medicare Advantage |
$184.70
|
| Rate for Payer: The Alliance Commercial |
$153.92
|
| Rate for Payer: United Healthcare PPO |
$230.88
|
| Rate for Payer: WEA Trust Commercial |
$169.31
|
| Rate for Payer: WPS Commercial |
$228.01
|
|
|
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 |
$150.84 |
| Max. Negotiated Rate |
$283.21 |
| Rate for Payer: Aetna Commercial |
$277.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$264.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$163.16
|
| Rate for Payer: Cash Price |
$88.80
|
| Rate for Payer: Cigna Commercial |
$283.21
|
| Rate for Payer: Health EOS Commercial |
$273.98
|
| Rate for Payer: HFN Commercial |
$283.21
|
| Rate for Payer: Multiplan Commercial |
$246.27
|
| Rate for Payer: Preferred Network Access Commercial |
$283.21
|
| Rate for Payer: Quartz Beloit One Network |
$150.84
|
| Rate for Payer: Quartz Commercial |
$184.70
|
| Rate for Payer: WEA Trust Commercial |
$169.31
|
| Rate for Payer: WPS Commercial |
$228.01
|
|
|
Yes - OT Evaluation High Charge
|
Professional
|
Both
|
$817.00
|
|
|
Service Code
|
CPT 97167 GO
|
| Hospital Charge Code |
5148667
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$373.86 |
| Max. Negotiated Rate |
$807.20 |
| Rate for Payer: Aetna Commercial |
$807.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$730.72
|
| Rate for Payer: Cash Price |
$245.10
|
| Rate for Payer: Cash Price |
$245.10
|
| Rate for Payer: Cigna Commercial |
$807.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$424.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$509.81
|
| Rate for Payer: Health EOS Commercial |
$773.21
|
| Rate for Payer: HFN Commercial |
$807.20
|
| Rate for Payer: Multiplan Commercial |
$679.74
|
| Rate for Payer: Preferred Network Access Commercial |
$807.20
|
| Rate for Payer: Quartz Beloit One Network |
$373.86
|
| Rate for Payer: Quartz Commercial |
$484.32
|
| Rate for Payer: The Alliance Commercial |
$424.84
|
| Rate for Payer: WEA Trust Commercial |
$467.32
|
| Rate for Payer: WPS Commercial |
$629.34
|
|
|
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 |
$210.08 |
| Max. Negotiated Rate |
$781.71 |
| Rate for Payer: Aetna Commercial |
$764.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$730.72
|
| Rate for Payer: Aetna Managed Medicare |
$237.91
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$362.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$298.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$282.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$450.33
|
| Rate for Payer: Cash Price |
$245.10
|
| Rate for Payer: Cash Price |
$245.10
|
| Rate for Payer: Cigna Commercial |
$781.71
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$475.49
|
| Rate for Payer: Health EOS Commercial |
$756.22
|
| Rate for Payer: HFN Commercial |
$781.71
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$679.74
|
| Rate for Payer: NAPHCARE Commercial |
$509.81
|
| Rate for Payer: Preferred Network Access Commercial |
$781.71
|
| Rate for Payer: Quartz Beloit One Network |
$416.34
|
| Rate for Payer: Quartz Commercial |
$552.29
|
| Rate for Payer: Quartz Medicare Advantage |
$509.81
|
| Rate for Payer: The Alliance Commercial |
$424.84
|
| Rate for Payer: United Healthcare PPO |
$637.26
|
| Rate for Payer: WEA Trust Commercial |
$467.32
|
| Rate for Payer: WPS Commercial |
$629.34
|
|
|
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 |
$416.34 |
| Max. Negotiated Rate |
$781.71 |
| Rate for Payer: Aetna Commercial |
$764.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$730.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$450.33
|
| Rate for Payer: Cash Price |
$245.10
|
| Rate for Payer: Cigna Commercial |
$781.71
|
| Rate for Payer: Health EOS Commercial |
$756.22
|
| Rate for Payer: HFN Commercial |
$781.71
|
| Rate for Payer: Multiplan Commercial |
$679.74
|
| Rate for Payer: Preferred Network Access Commercial |
$781.71
|
| Rate for Payer: Quartz Beloit One Network |
$416.34
|
| Rate for Payer: Quartz Commercial |
$509.81
|
| Rate for Payer: WEA Trust Commercial |
$467.32
|
| Rate for Payer: WPS Commercial |
$629.34
|
|
|
Yes - OT Evaluation Low Charge
|
Professional
|
Both
|
$415.00
|
|
|
Service Code
|
CPT 97165 GO
|
| Hospital Charge Code |
5148666
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$189.90 |
| Max. Negotiated Rate |
$410.02 |
| Rate for Payer: Aetna Commercial |
$410.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$371.18
|
| Rate for Payer: Cash Price |
$124.50
|
| Rate for Payer: Cash Price |
$124.50
|
| Rate for Payer: Cigna Commercial |
$410.02
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$215.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$258.96
|
| Rate for Payer: Health EOS Commercial |
$392.76
|
| Rate for Payer: HFN Commercial |
$410.02
|
| Rate for Payer: Multiplan Commercial |
$345.28
|
| Rate for Payer: Preferred Network Access Commercial |
$410.02
|
| Rate for Payer: Quartz Beloit One Network |
$189.90
|
| Rate for Payer: Quartz Commercial |
$246.01
|
| Rate for Payer: The Alliance Commercial |
$215.80
|
| Rate for Payer: WEA Trust Commercial |
$237.38
|
| Rate for Payer: WPS Commercial |
$319.67
|
|
|
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 |
$211.48 |
| Max. Negotiated Rate |
$397.07 |
| Rate for Payer: Aetna Commercial |
$388.44
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$371.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$228.75
|
| Rate for Payer: Cash Price |
$124.50
|
| Rate for Payer: Cigna Commercial |
$397.07
|
| Rate for Payer: Health EOS Commercial |
$384.12
|
| Rate for Payer: HFN Commercial |
$397.07
|
| Rate for Payer: Multiplan Commercial |
$345.28
|
| Rate for Payer: Preferred Network Access Commercial |
$397.07
|
| Rate for Payer: Quartz Beloit One Network |
$211.48
|
| Rate for Payer: Quartz Commercial |
$258.96
|
| Rate for Payer: WEA Trust Commercial |
$237.38
|
| Rate for Payer: WPS Commercial |
$319.67
|
|
|
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 |
$120.85 |
| Max. Negotiated Rate |
$397.07 |
| Rate for Payer: Aetna Commercial |
$388.44
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$371.18
|
| Rate for Payer: Aetna Managed Medicare |
$120.85
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$362.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$298.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$282.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$228.75
|
| Rate for Payer: Cash Price |
$124.50
|
| Rate for Payer: Cash Price |
$124.50
|
| Rate for Payer: Cigna Commercial |
$397.07
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$241.53
|
| Rate for Payer: Health EOS Commercial |
$384.12
|
| Rate for Payer: HFN Commercial |
$397.07
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$345.28
|
| Rate for Payer: NAPHCARE Commercial |
$258.96
|
| Rate for Payer: Preferred Network Access Commercial |
$397.07
|
| Rate for Payer: Quartz Beloit One Network |
$211.48
|
| Rate for Payer: Quartz Commercial |
$280.54
|
| Rate for Payer: Quartz Medicare Advantage |
$258.96
|
| Rate for Payer: The Alliance Commercial |
$215.80
|
| Rate for Payer: United Healthcare PPO |
$323.70
|
| Rate for Payer: WEA Trust Commercial |
$237.38
|
| Rate for Payer: WPS Commercial |
$319.67
|
|
|
Yes - OT Evaluation Moderate Charge
|
Professional
|
Both
|
$655.00
|
|
|
Service Code
|
CPT 97166 GO
|
| Hospital Charge Code |
5148665
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$299.73 |
| Max. Negotiated Rate |
$647.14 |
| Rate for Payer: Aetna Commercial |
$647.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$585.83
|
| Rate for Payer: Cash Price |
$196.50
|
| Rate for Payer: Cash Price |
$196.50
|
| Rate for Payer: Cigna Commercial |
$647.14
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$340.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$408.72
|
| Rate for Payer: Health EOS Commercial |
$619.89
|
| Rate for Payer: HFN Commercial |
$647.14
|
| Rate for Payer: Multiplan Commercial |
$544.96
|
| Rate for Payer: Preferred Network Access Commercial |
$647.14
|
| Rate for Payer: Quartz Beloit One Network |
$299.73
|
| Rate for Payer: Quartz Commercial |
$388.28
|
| Rate for Payer: The Alliance Commercial |
$340.60
|
| Rate for Payer: WEA Trust Commercial |
$374.66
|
| Rate for Payer: WPS Commercial |
$504.55
|
|
|
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 |
$190.74 |
| Max. Negotiated Rate |
$626.70 |
| Rate for Payer: Aetna Commercial |
$613.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$585.83
|
| Rate for Payer: Aetna Managed Medicare |
$190.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$362.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$298.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$282.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$361.04
|
| Rate for Payer: Cash Price |
$196.50
|
| Rate for Payer: Cash Price |
$196.50
|
| Rate for Payer: Cigna Commercial |
$626.70
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$381.21
|
| Rate for Payer: Health EOS Commercial |
$606.27
|
| Rate for Payer: HFN Commercial |
$626.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$544.96
|
| Rate for Payer: NAPHCARE Commercial |
$408.72
|
| Rate for Payer: Preferred Network Access Commercial |
$626.70
|
| Rate for Payer: Quartz Beloit One Network |
$333.79
|
| Rate for Payer: Quartz Commercial |
$442.78
|
| Rate for Payer: Quartz Medicare Advantage |
$408.72
|
| Rate for Payer: The Alliance Commercial |
$340.60
|
| Rate for Payer: United Healthcare PPO |
$510.90
|
| Rate for Payer: WEA Trust Commercial |
$374.66
|
| Rate for Payer: WPS Commercial |
$504.55
|
|
|
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 |
$333.79 |
| Max. Negotiated Rate |
$626.70 |
| Rate for Payer: Aetna Commercial |
$613.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$585.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$361.04
|
| Rate for Payer: Cash Price |
$196.50
|
| Rate for Payer: Cigna Commercial |
$626.70
|
| Rate for Payer: Health EOS Commercial |
$606.27
|
| Rate for Payer: HFN Commercial |
$626.70
|
| Rate for Payer: Multiplan Commercial |
$544.96
|
| Rate for Payer: Preferred Network Access Commercial |
$626.70
|
| Rate for Payer: Quartz Beloit One Network |
$333.79
|
| Rate for Payer: Quartz Commercial |
$408.72
|
| Rate for Payer: WEA Trust Commercial |
$374.66
|
| Rate for Payer: WPS Commercial |
$504.55
|
|
