|
Yes - Nasal Cannula Holder Charge
|
Facility
|
IP
|
$29.00
|
|
| Hospital Charge Code |
2990208
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$14.78 |
| Max. Negotiated Rate |
$27.75 |
| Rate for Payer: Aetna Commercial |
$27.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$25.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$15.98
|
| Rate for Payer: Cash Price |
$8.70
|
| Rate for Payer: Cigna Commercial |
$27.75
|
| Rate for Payer: Health EOS Commercial |
$26.84
|
| Rate for Payer: HFN Commercial |
$27.75
|
| Rate for Payer: Multiplan Commercial |
$24.13
|
| Rate for Payer: Preferred Network Access Commercial |
$27.75
|
| Rate for Payer: Quartz Beloit One Network |
$14.78
|
| Rate for Payer: Quartz Commercial |
$18.10
|
| Rate for Payer: WEA Trust Commercial |
$16.59
|
| Rate for Payer: WPS Commercial |
$22.34
|
|
|
Yes - Nasal Cannula(std) Charge
|
Facility
|
OP
|
$49.00
|
|
| Hospital Charge Code |
3006964
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$14.27 |
| Max. Negotiated Rate |
$46.88 |
| Rate for Payer: Aetna Commercial |
$45.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$43.83
|
| Rate for Payer: Aetna Managed Medicare |
$14.27
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$33.12
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$25.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$24.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$27.01
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cigna Commercial |
$46.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$28.52
|
| Rate for Payer: Health EOS Commercial |
$45.35
|
| Rate for Payer: HFN Commercial |
$46.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$38.22
|
| Rate for Payer: Multiplan Commercial |
$40.77
|
| Rate for Payer: NAPHCARE Commercial |
$30.58
|
| Rate for Payer: Preferred Network Access Commercial |
$46.88
|
| Rate for Payer: Quartz Beloit One Network |
$24.97
|
| Rate for Payer: Quartz Commercial |
$33.12
|
| Rate for Payer: Quartz Medicare Advantage |
$30.58
|
| Rate for Payer: The Alliance Commercial |
$25.48
|
| Rate for Payer: WEA Trust Commercial |
$28.03
|
| Rate for Payer: WPS Commercial |
$37.74
|
|
|
Yes - Nasal Cannula(std) Charge
|
Facility
|
IP
|
$49.00
|
|
| Hospital Charge Code |
3006964
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$24.97 |
| Max. Negotiated Rate |
$46.88 |
| Rate for Payer: Aetna Commercial |
$45.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$43.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$27.01
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cigna Commercial |
$46.88
|
| Rate for Payer: Health EOS Commercial |
$45.35
|
| Rate for Payer: HFN Commercial |
$46.88
|
| Rate for Payer: Multiplan Commercial |
$40.77
|
| Rate for Payer: Preferred Network Access Commercial |
$46.88
|
| Rate for Payer: Quartz Beloit One Network |
$24.97
|
| Rate for Payer: Quartz Commercial |
$30.58
|
| Rate for Payer: WEA Trust Commercial |
$28.03
|
| Rate for Payer: WPS Commercial |
$37.74
|
|
|
Yes - Nebulizer Setup Charge
|
Facility
|
IP
|
$453.00
|
|
| Hospital Charge Code |
3006961
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$230.85 |
| Max. Negotiated Rate |
$433.43 |
| Rate for Payer: Aetna Commercial |
$424.01
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$405.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$249.69
|
| Rate for Payer: Cash Price |
$135.90
|
| Rate for Payer: Cigna Commercial |
$433.43
|
| Rate for Payer: Health EOS Commercial |
$419.30
|
| Rate for Payer: HFN Commercial |
$433.43
|
| Rate for Payer: Multiplan Commercial |
$376.90
|
| Rate for Payer: Preferred Network Access Commercial |
$433.43
|
| Rate for Payer: Quartz Beloit One Network |
$230.85
|
| Rate for Payer: Quartz Commercial |
$282.67
|
| Rate for Payer: WEA Trust Commercial |
$259.12
|
| Rate for Payer: WPS Commercial |
$348.95
|
|
|
Yes - Nebulizer Setup Charge
|
Facility
|
OP
|
$453.00
|
|
| Hospital Charge Code |
3006961
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$131.91 |
| Max. Negotiated Rate |
$433.43 |
| Rate for Payer: Aetna Commercial |
$424.01
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$405.16
|
| Rate for Payer: Aetna Managed Medicare |
$131.91
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$306.23
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$235.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$226.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$249.69
|
| Rate for Payer: Cash Price |
$135.90
|
| Rate for Payer: Cigna Commercial |
$433.43
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$263.65
|
| Rate for Payer: Health EOS Commercial |
$419.30
|
| Rate for Payer: HFN Commercial |
$433.43
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$353.34
|
| Rate for Payer: Multiplan Commercial |
$376.90
|
| Rate for Payer: NAPHCARE Commercial |
$282.67
|
| Rate for Payer: Preferred Network Access Commercial |
$433.43
|
| Rate for Payer: Quartz Beloit One Network |
$230.85
|
| Rate for Payer: Quartz Commercial |
$306.23
|
| Rate for Payer: Quartz Medicare Advantage |
$282.67
|
| Rate for Payer: The Alliance Commercial |
$235.56
|
| Rate for Payer: WEA Trust Commercial |
$259.12
|
| Rate for Payer: WPS Commercial |
$348.95
|
|
|
Yes - Nebulizer T-Adapter Charge
|
Facility
|
IP
|
$11.00
|
|
| Hospital Charge Code |
3006962
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$5.61 |
| Max. Negotiated Rate |
$10.52 |
| Rate for Payer: Aetna Commercial |
$10.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6.06
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cigna Commercial |
$10.52
|
| Rate for Payer: Health EOS Commercial |
$10.18
|
| Rate for Payer: HFN Commercial |
$10.52
|
| Rate for Payer: Multiplan Commercial |
$9.15
|
| Rate for Payer: Preferred Network Access Commercial |
$10.52
|
| Rate for Payer: Quartz Beloit One Network |
$5.61
|
| Rate for Payer: Quartz Commercial |
$6.86
|
| Rate for Payer: WEA Trust Commercial |
$6.29
|
| Rate for Payer: WPS Commercial |
$8.47
|
|
|
Yes - Nebulizer T-Adapter Charge
|
Facility
|
OP
|
$11.00
|
|
| Hospital Charge Code |
3006962
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$3.20 |
| Max. Negotiated Rate |
$10.52 |
| Rate for Payer: Aetna Commercial |
$10.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9.84
|
| Rate for Payer: Aetna Managed Medicare |
$3.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6.06
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cigna Commercial |
$10.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6.40
|
| Rate for Payer: Health EOS Commercial |
$10.18
|
| Rate for Payer: HFN Commercial |
$10.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8.58
|
| Rate for Payer: Multiplan Commercial |
$9.15
|
| Rate for Payer: NAPHCARE Commercial |
$6.86
|
| Rate for Payer: Preferred Network Access Commercial |
$10.52
|
| Rate for Payer: Quartz Beloit One Network |
$5.61
|
| Rate for Payer: Quartz Commercial |
$7.44
|
| Rate for Payer: Quartz Medicare Advantage |
$6.86
|
| Rate for Payer: The Alliance Commercial |
$5.72
|
| Rate for Payer: WEA Trust Commercial |
$6.29
|
| Rate for Payer: WPS Commercial |
$8.47
|
|
|
Yes - Nocturnal Oximetry Study Charge
|
Facility
|
IP
|
$444.00
|
|
|
Service Code
|
CPT 94762
|
| Hospital Charge Code |
3026389
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$226.26 |
| Max. Negotiated Rate |
$424.82 |
| Rate for Payer: Aetna Commercial |
$415.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$397.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$244.73
|
| Rate for Payer: Cash Price |
$133.20
|
| Rate for Payer: Cigna Commercial |
$424.82
|
| Rate for Payer: Health EOS Commercial |
$410.97
|
| Rate for Payer: HFN Commercial |
$424.82
|
| Rate for Payer: Multiplan Commercial |
$369.41
|
| Rate for Payer: Preferred Network Access Commercial |
$424.82
|
| Rate for Payer: Quartz Beloit One Network |
$226.26
|
| Rate for Payer: Quartz Commercial |
$277.06
|
| Rate for Payer: WEA Trust Commercial |
$253.97
|
| Rate for Payer: WPS Commercial |
$342.01
|
|
|
Yes - Nocturnal Oximetry Study Charge
|
Facility
|
OP
|
$444.00
|
|
|
Service Code
|
CPT 94762
|
| Hospital Charge Code |
3026389
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$43.42 |
| Max. Negotiated Rate |
$541.67 |
| Rate for Payer: Aetna Commercial |
$415.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$397.11
|
| Rate for Payer: Aetna Managed Medicare |
$135.42
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$43.42
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$43.42
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$43.42
|
| Rate for Payer: Anthem Medicare Advantage |
$135.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$244.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$135.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$135.42
|
| Rate for Payer: Cash Price |
$133.20
|
| Rate for Payer: Cash Price |
$133.20
|
| Rate for Payer: Cigna Commercial |
$424.82
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$135.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$258.41
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$135.42
|
| Rate for Payer: Health EOS Commercial |
$410.97
|
| Rate for Payer: HFN Commercial |
$424.82
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$503.76
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$135.42
|
| Rate for Payer: Independent Care Health Plan Medicare |
$135.42
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$135.42
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$135.42
|
| Rate for Payer: Multiplan Commercial |
$369.41
|
| Rate for Payer: NAPHCARE Commercial |
$203.13
|
| Rate for Payer: Preferred Network Access Commercial |
$424.82
|
| Rate for Payer: Quartz Beloit One Network |
$226.26
|
| Rate for Payer: Quartz Commercial |
$300.14
|
| Rate for Payer: Quartz Medicare Advantage |
$135.42
|
| Rate for Payer: The Alliance Commercial |
$541.67
|
| Rate for Payer: United Healthcare Medicare Advantage |
$135.42
|
| Rate for Payer: United Healthcare PPO |
$346.32
|
| Rate for Payer: WEA Trust Commercial |
$253.97
|
| Rate for Payer: Wellcare Medicare |
$135.42
|
| Rate for Payer: WPS Commercial |
$342.01
|
|
|
Yes - Non-Rebeather Mask Charge
|
Facility
|
IP
|
$77.00
|
|
| Hospital Charge Code |
3006963
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$39.24 |
| Max. Negotiated Rate |
$73.67 |
| Rate for Payer: Aetna Commercial |
$72.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$68.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$42.44
|
| Rate for Payer: Cash Price |
$23.10
|
| Rate for Payer: Cigna Commercial |
$73.67
|
| Rate for Payer: Health EOS Commercial |
$71.27
|
| Rate for Payer: HFN Commercial |
$73.67
|
| Rate for Payer: Multiplan Commercial |
$64.06
|
| Rate for Payer: Preferred Network Access Commercial |
$73.67
|
| Rate for Payer: Quartz Beloit One Network |
$39.24
|
| Rate for Payer: Quartz Commercial |
$48.05
|
| Rate for Payer: WEA Trust Commercial |
$44.04
|
| Rate for Payer: WPS Commercial |
$59.31
|
|
|
Yes - Non-Rebeather Mask Charge
|
Facility
|
OP
|
$77.00
|
|
| Hospital Charge Code |
3006963
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$22.42 |
| Max. Negotiated Rate |
$73.67 |
| Rate for Payer: Aetna Commercial |
$72.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$68.87
|
| Rate for Payer: Aetna Managed Medicare |
$22.42
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$52.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$40.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$38.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$42.44
|
| Rate for Payer: Cash Price |
$23.10
|
| Rate for Payer: Cigna Commercial |
$73.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$44.81
|
| Rate for Payer: Health EOS Commercial |
$71.27
|
| Rate for Payer: HFN Commercial |
$73.67
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$60.06
|
| Rate for Payer: Multiplan Commercial |
$64.06
|
| Rate for Payer: NAPHCARE Commercial |
$48.05
|
| Rate for Payer: Preferred Network Access Commercial |
$73.67
|
| Rate for Payer: Quartz Beloit One Network |
$39.24
|
| Rate for Payer: Quartz Commercial |
$52.05
|
| Rate for Payer: Quartz Medicare Advantage |
$48.05
|
| Rate for Payer: The Alliance Commercial |
$40.04
|
| Rate for Payer: WEA Trust Commercial |
$44.04
|
| Rate for Payer: WPS Commercial |
$59.31
|
|
|
Yes - Noturnal Oximetry Charge
|
Facility
|
IP
|
$356.00
|
|
|
Service Code
|
CPT 94762
|
| Hospital Charge Code |
2990180
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$181.42 |
| Max. Negotiated Rate |
$340.62 |
| Rate for Payer: Aetna Commercial |
$333.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$318.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$196.23
|
| Rate for Payer: Cash Price |
$106.80
|
| Rate for Payer: Cigna Commercial |
$340.62
|
| Rate for Payer: Health EOS Commercial |
$329.51
|
| Rate for Payer: HFN Commercial |
$340.62
|
| Rate for Payer: Multiplan Commercial |
$296.19
|
| Rate for Payer: Preferred Network Access Commercial |
$340.62
|
| Rate for Payer: Quartz Beloit One Network |
$181.42
|
| Rate for Payer: Quartz Commercial |
$222.14
|
| Rate for Payer: WEA Trust Commercial |
$203.63
|
| Rate for Payer: WPS Commercial |
$274.23
|
|
|
Yes - Noturnal Oximetry Charge
|
Facility
|
OP
|
$356.00
|
|
|
Service Code
|
CPT 94762
|
| Hospital Charge Code |
2990180
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$43.42 |
| Max. Negotiated Rate |
$541.67 |
| Rate for Payer: Aetna Commercial |
$333.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$318.41
|
| Rate for Payer: Aetna Managed Medicare |
$135.42
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$43.42
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$43.42
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$43.42
|
| Rate for Payer: Anthem Medicare Advantage |
$135.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$196.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$135.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$135.42
|
| Rate for Payer: Cash Price |
$106.80
|
| Rate for Payer: Cash Price |
$106.80
|
| Rate for Payer: Cigna Commercial |
$340.62
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$135.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$207.19
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$135.42
|
| Rate for Payer: Health EOS Commercial |
$329.51
|
| Rate for Payer: HFN Commercial |
$340.62
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$503.76
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$135.42
|
| Rate for Payer: Independent Care Health Plan Medicare |
$135.42
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$135.42
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$135.42
|
| Rate for Payer: Multiplan Commercial |
$296.19
|
| Rate for Payer: NAPHCARE Commercial |
$203.13
|
| Rate for Payer: Preferred Network Access Commercial |
$340.62
|
| Rate for Payer: Quartz Beloit One Network |
$181.42
|
| Rate for Payer: Quartz Commercial |
$240.66
|
| Rate for Payer: Quartz Medicare Advantage |
$135.42
|
| Rate for Payer: The Alliance Commercial |
$541.67
|
| Rate for Payer: United Healthcare Medicare Advantage |
$135.42
|
| Rate for Payer: United Healthcare PPO |
$277.68
|
| Rate for Payer: WEA Trust Commercial |
$203.63
|
| Rate for Payer: Wellcare Medicare |
$135.42
|
| Rate for Payer: WPS Commercial |
$274.23
|
|
|
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 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 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 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 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 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 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
|
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 - 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 - 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
|
|
