|
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
|
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 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
|
Professional
|
Both
|
$817.00
|
|
|
Service Code
|
CPT 97167 GO
|
| Hospital Charge Code |
5148667
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$348.81 |
| 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: 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: Humana Commercial/EPO/HMO/POS/PPO |
$348.81
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$348.81
|
| 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 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
|
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: 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: Humana Commercial/EPO/HMO/POS/PPO |
$348.81
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$348.81
|
| 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
|
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
|
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
|
|
|
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
|
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: 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: Humana Commercial/EPO/HMO/POS/PPO |
$348.81
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$348.81
|
| 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 Fluidotherapy Charge
|
Professional
|
Both
|
$186.00
|
|
|
Service Code
|
CPT 97022 GO
|
| Hospital Charge Code |
2989696
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$63.18 |
| Max. Negotiated Rate |
$183.77 |
| Rate for Payer: Aetna Commercial |
$183.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$166.36
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cigna Commercial |
$183.77
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$96.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$116.06
|
| Rate for Payer: Health EOS Commercial |
$176.03
|
| Rate for Payer: HFN Commercial |
$183.77
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$63.18
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$63.18
|
| Rate for Payer: Multiplan Commercial |
$154.75
|
| Rate for Payer: Preferred Network Access Commercial |
$183.77
|
| Rate for Payer: Quartz Beloit One Network |
$85.11
|
| Rate for Payer: Quartz Commercial |
$110.26
|
| Rate for Payer: The Alliance Commercial |
$96.72
|
| Rate for Payer: WEA Trust Commercial |
$106.39
|
| Rate for Payer: WPS Commercial |
$143.28
|
|
|
Yes - OT Fluidotherapy Charge
|
Facility
|
OP
|
$186.00
|
|
|
Service Code
|
CPT 97022 GO
|
| Hospital Charge Code |
2989696
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$54.16 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$174.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$166.36
|
| Rate for Payer: Aetna Managed Medicare |
$54.16
|
| 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 |
$102.52
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cigna Commercial |
$177.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$108.25
|
| Rate for Payer: Health EOS Commercial |
$172.16
|
| Rate for Payer: HFN Commercial |
$177.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$154.75
|
| Rate for Payer: NAPHCARE Commercial |
$116.06
|
| Rate for Payer: Preferred Network Access Commercial |
$177.96
|
| Rate for Payer: Quartz Beloit One Network |
$94.79
|
| Rate for Payer: Quartz Commercial |
$125.74
|
| Rate for Payer: Quartz Medicare Advantage |
$116.06
|
| Rate for Payer: The Alliance Commercial |
$96.72
|
| Rate for Payer: United Healthcare PPO |
$145.08
|
| Rate for Payer: WEA Trust Commercial |
$106.39
|
| Rate for Payer: WPS Commercial |
$143.28
|
|
|
Yes - OT Fluidotherapy Charge
|
Facility
|
IP
|
$186.00
|
|
|
Service Code
|
CPT 97022 GO
|
| Hospital Charge Code |
2989696
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$94.79 |
| Max. Negotiated Rate |
$177.96 |
| Rate for Payer: Aetna Commercial |
$174.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$166.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$102.52
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cigna Commercial |
$177.96
|
| Rate for Payer: Health EOS Commercial |
$172.16
|
| Rate for Payer: HFN Commercial |
$177.96
|
| Rate for Payer: Multiplan Commercial |
$154.75
|
| Rate for Payer: Preferred Network Access Commercial |
$177.96
|
| Rate for Payer: Quartz Beloit One Network |
$94.79
|
| Rate for Payer: Quartz Commercial |
$116.06
|
| Rate for Payer: WEA Trust Commercial |
$106.39
|
| Rate for Payer: WPS Commercial |
$143.28
|
|
|
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 |
$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 - OT Group Therapy Charge
|
Facility
|
IP
|
$228.00
|
|
|
Service Code
|
CPT 97150 GO
|
| Hospital Charge Code |
2987943
|
|
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 - OT Paraffin Bath Charge
|
Professional
|
Both
|
$114.00
|
|
|
Service Code
|
CPT 97018 GO
|
| Hospital Charge Code |
2989791
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$20.11 |
| Max. Negotiated Rate |
$112.63 |
| Rate for Payer: Aetna Commercial |
$112.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$101.96
|
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Cigna Commercial |
$112.63
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$59.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$71.14
|
| Rate for Payer: Health EOS Commercial |
$107.89
|
| Rate for Payer: HFN Commercial |
$112.63
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$20.11
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$20.11
|
| Rate for Payer: Multiplan Commercial |
$94.85
|
| Rate for Payer: Preferred Network Access Commercial |
$112.63
|
| Rate for Payer: Quartz Beloit One Network |
$52.17
|
| Rate for Payer: Quartz Commercial |
$67.58
|
| Rate for Payer: The Alliance Commercial |
$59.28
|
| Rate for Payer: WEA Trust Commercial |
$65.21
|
| Rate for Payer: WPS Commercial |
$87.81
|
|
|
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 |
$58.09 |
| Max. Negotiated Rate |
$109.08 |
| Rate for Payer: Aetna Commercial |
$106.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$101.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$62.84
|
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Cigna Commercial |
$109.08
|
| Rate for Payer: Health EOS Commercial |
$105.52
|
| Rate for Payer: HFN Commercial |
$109.08
|
| Rate for Payer: Multiplan Commercial |
$94.85
|
| Rate for Payer: Preferred Network Access Commercial |
$109.08
|
| Rate for Payer: Quartz Beloit One Network |
$58.09
|
| Rate for Payer: Quartz Commercial |
$71.14
|
| Rate for Payer: WEA Trust Commercial |
$65.21
|
| Rate for Payer: WPS Commercial |
$87.81
|
|
|
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 |
$33.20 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$106.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$101.96
|
| Rate for Payer: Aetna Managed Medicare |
$33.20
|
| 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 |
$62.84
|
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Cigna Commercial |
$109.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$66.35
|
| Rate for Payer: Health EOS Commercial |
$105.52
|
| Rate for Payer: HFN Commercial |
$109.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$94.85
|
| Rate for Payer: NAPHCARE Commercial |
$71.14
|
| Rate for Payer: Preferred Network Access Commercial |
$109.08
|
| Rate for Payer: Quartz Beloit One Network |
$58.09
|
| Rate for Payer: Quartz Commercial |
$77.06
|
| Rate for Payer: Quartz Medicare Advantage |
$71.14
|
| Rate for Payer: The Alliance Commercial |
$59.28
|
| Rate for Payer: United Healthcare PPO |
$88.92
|
| Rate for Payer: WEA Trust Commercial |
$65.21
|
| Rate for Payer: WPS Commercial |
$87.81
|
|
|
Yes - OT Reevaluation Charge
|
Facility
|
IP
|
$466.00
|
|
|
Service Code
|
CPT 97168 GO
|
| Hospital Charge Code |
2987953
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$237.47 |
| Max. Negotiated Rate |
$445.87 |
| Rate for Payer: Aetna Commercial |
$436.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$416.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$256.86
|
| Rate for Payer: Cash Price |
$139.80
|
| Rate for Payer: Cigna Commercial |
$445.87
|
| Rate for Payer: Health EOS Commercial |
$431.33
|
| Rate for Payer: HFN Commercial |
$445.87
|
| Rate for Payer: Multiplan Commercial |
$387.71
|
| Rate for Payer: Preferred Network Access Commercial |
$445.87
|
| Rate for Payer: Quartz Beloit One Network |
$237.47
|
| Rate for Payer: Quartz Commercial |
$290.78
|
| Rate for Payer: WEA Trust Commercial |
$266.55
|
| Rate for Payer: WPS Commercial |
$358.96
|
|
|
Yes - OT Reevaluation Charge
|
Professional
|
Both
|
$466.00
|
|
|
Service Code
|
CPT 97168 GO
|
| Hospital Charge Code |
2987953
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$213.24 |
| Max. Negotiated Rate |
$460.41 |
| Rate for Payer: Aetna Commercial |
$460.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$416.79
|
| Rate for Payer: Cash Price |
$139.80
|
| Rate for Payer: Cash Price |
$139.80
|
| Rate for Payer: Cash Price |
$139.80
|
| Rate for Payer: Cigna Commercial |
$460.41
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$242.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$290.78
|
| Rate for Payer: Health EOS Commercial |
$441.02
|
| Rate for Payer: HFN Commercial |
$460.41
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$234.29
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$234.29
|
| Rate for Payer: Multiplan Commercial |
$387.71
|
| Rate for Payer: Preferred Network Access Commercial |
$460.41
|
| Rate for Payer: Quartz Beloit One Network |
$213.24
|
| Rate for Payer: Quartz Commercial |
$276.24
|
| Rate for Payer: The Alliance Commercial |
$242.32
|
| Rate for Payer: WEA Trust Commercial |
$266.55
|
| Rate for Payer: WPS Commercial |
$358.96
|
|
|
Yes - OT Reevaluation Charge
|
Facility
|
OP
|
$466.00
|
|
|
Service Code
|
CPT 97168 GO
|
| Hospital Charge Code |
2987953
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$135.70 |
| Max. Negotiated Rate |
$445.87 |
| Rate for Payer: Aetna Commercial |
$436.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$416.79
|
| Rate for Payer: Aetna Managed Medicare |
$135.70
|
| 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 |
$256.86
|
| Rate for Payer: Cash Price |
$139.80
|
| Rate for Payer: Cash Price |
$139.80
|
| Rate for Payer: Cigna Commercial |
$445.87
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$271.21
|
| Rate for Payer: Health EOS Commercial |
$431.33
|
| Rate for Payer: HFN Commercial |
$445.87
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$387.71
|
| Rate for Payer: NAPHCARE Commercial |
$290.78
|
| Rate for Payer: Preferred Network Access Commercial |
$445.87
|
| Rate for Payer: Quartz Beloit One Network |
$237.47
|
| Rate for Payer: Quartz Commercial |
$315.02
|
| Rate for Payer: Quartz Medicare Advantage |
$290.78
|
| Rate for Payer: The Alliance Commercial |
$242.32
|
| Rate for Payer: United Healthcare PPO |
$363.48
|
| Rate for Payer: WEA Trust Commercial |
$266.55
|
| Rate for Payer: WPS Commercial |
$358.96
|
|
|
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 |
$30.28 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$97.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$93.02
|
| Rate for Payer: Aetna Managed Medicare |
$30.28
|
| 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 |
$57.32
|
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Cigna Commercial |
$99.51
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$60.53
|
| Rate for Payer: Health EOS Commercial |
$96.26
|
| Rate for Payer: HFN Commercial |
$99.51
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$86.53
|
| Rate for Payer: NAPHCARE Commercial |
$64.90
|
| Rate for Payer: Preferred Network Access Commercial |
$99.51
|
| Rate for Payer: Quartz Beloit One Network |
$53.00
|
| Rate for Payer: Quartz Commercial |
$70.30
|
| Rate for Payer: Quartz Medicare Advantage |
$64.90
|
| Rate for Payer: The Alliance Commercial |
$54.08
|
| Rate for Payer: United Healthcare PPO |
$81.12
|
| Rate for Payer: WEA Trust Commercial |
$59.49
|
| Rate for Payer: WPS Commercial |
$80.11
|
|
