|
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
|
|
|
Yes - OT Telemed Est Patient 21>min Chg
|
Facility
|
OP
|
$147.00
|
|
|
Service Code
|
CPT 98972 GO,95
|
| Hospital Charge Code |
5583129
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$42.81 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$137.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$131.48
|
| Rate for Payer: Aetna Managed Medicare |
$42.81
|
| 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 |
$81.03
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: Cigna Commercial |
$140.65
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$85.55
|
| Rate for Payer: Health EOS Commercial |
$136.06
|
| Rate for Payer: HFN Commercial |
$140.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$122.30
|
| Rate for Payer: NAPHCARE Commercial |
$91.73
|
| Rate for Payer: Preferred Network Access Commercial |
$140.65
|
| Rate for Payer: Quartz Beloit One Network |
$74.91
|
| Rate for Payer: Quartz Commercial |
$99.37
|
| Rate for Payer: Quartz Medicare Advantage |
$91.73
|
| Rate for Payer: The Alliance Commercial |
$76.44
|
| Rate for Payer: United Healthcare PPO |
$114.66
|
| Rate for Payer: WEA Trust Commercial |
$84.08
|
| Rate for Payer: WPS Commercial |
$113.23
|
|
|
Yes - OT Telemed Est Patient 21>min Chg
|
Facility
|
IP
|
$147.00
|
|
|
Service Code
|
CPT 98972 GO,95
|
| Hospital Charge Code |
5583129
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$74.91 |
| Max. Negotiated Rate |
$140.65 |
| Rate for Payer: Aetna Commercial |
$137.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$131.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$81.03
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: Cigna Commercial |
$140.65
|
| Rate for Payer: Health EOS Commercial |
$136.06
|
| Rate for Payer: HFN Commercial |
$140.65
|
| Rate for Payer: Multiplan Commercial |
$122.30
|
| Rate for Payer: Preferred Network Access Commercial |
$140.65
|
| Rate for Payer: Quartz Beloit One Network |
$74.91
|
| Rate for Payer: Quartz Commercial |
$91.73
|
| Rate for Payer: WEA Trust Commercial |
$84.08
|
| Rate for Payer: WPS Commercial |
$113.23
|
|
|
Yes - OT Telemed Est Patient 5-10 min Chg
|
Facility
|
OP
|
$61.00
|
|
|
Service Code
|
CPT 98970 GO,95
|
| Hospital Charge Code |
5583130
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$17.76 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$57.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$54.56
|
| Rate for Payer: Aetna Managed Medicare |
$17.76
|
| 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 |
$33.62
|
| Rate for Payer: Cash Price |
$18.30
|
| Rate for Payer: Cash Price |
$18.30
|
| Rate for Payer: Cigna Commercial |
$58.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$35.50
|
| Rate for Payer: Health EOS Commercial |
$56.46
|
| Rate for Payer: HFN Commercial |
$58.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$50.75
|
| Rate for Payer: NAPHCARE Commercial |
$38.06
|
| Rate for Payer: Preferred Network Access Commercial |
$58.36
|
| Rate for Payer: Quartz Beloit One Network |
$31.09
|
| Rate for Payer: Quartz Commercial |
$41.24
|
| Rate for Payer: Quartz Medicare Advantage |
$38.06
|
| Rate for Payer: The Alliance Commercial |
$31.72
|
| Rate for Payer: United Healthcare PPO |
$47.58
|
| Rate for Payer: WEA Trust Commercial |
$34.89
|
| Rate for Payer: WPS Commercial |
$46.99
|
|
|
Yes - OT Telemed Est Patient 5-10 min Chg
|
Facility
|
IP
|
$61.00
|
|
|
Service Code
|
CPT 98970 GO,95
|
| Hospital Charge Code |
5583130
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$31.09 |
| Max. Negotiated Rate |
$58.36 |
| Rate for Payer: Aetna Commercial |
$57.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$54.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$33.62
|
| Rate for Payer: Cash Price |
$18.30
|
| Rate for Payer: Cigna Commercial |
$58.36
|
| Rate for Payer: Health EOS Commercial |
$56.46
|
| Rate for Payer: HFN Commercial |
$58.36
|
| Rate for Payer: Multiplan Commercial |
$50.75
|
| Rate for Payer: Preferred Network Access Commercial |
$58.36
|
| Rate for Payer: Quartz Beloit One Network |
$31.09
|
| Rate for Payer: Quartz Commercial |
$38.06
|
| Rate for Payer: WEA Trust Commercial |
$34.89
|
| Rate for Payer: WPS Commercial |
$46.99
|
|
|
Yes - OT Telephone call 11-20 min Charge
|
Facility
|
OP
|
$164.00
|
|
|
Service Code
|
CPT 98967 GO,95
|
| Hospital Charge Code |
5583193
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$47.76 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$153.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$146.68
|
| Rate for Payer: Aetna Managed Medicare |
$47.76
|
| 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 |
$90.40
|
| Rate for Payer: Cash Price |
$49.20
|
| Rate for Payer: Cash Price |
$49.20
|
| Rate for Payer: Cigna Commercial |
$156.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$95.45
|
| Rate for Payer: Health EOS Commercial |
$151.80
|
| Rate for Payer: HFN Commercial |
$156.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$136.45
|
| Rate for Payer: NAPHCARE Commercial |
$102.34
|
| Rate for Payer: Preferred Network Access Commercial |
$156.92
|
| Rate for Payer: Quartz Beloit One Network |
$83.57
|
| Rate for Payer: Quartz Commercial |
$110.86
|
| Rate for Payer: Quartz Medicare Advantage |
$102.34
|
| Rate for Payer: The Alliance Commercial |
$85.28
|
| Rate for Payer: United Healthcare PPO |
$127.92
|
| Rate for Payer: WEA Trust Commercial |
$93.81
|
| Rate for Payer: WPS Commercial |
$126.33
|
|
|
Yes - OT Telephone call 11-20 min Charge
|
Facility
|
IP
|
$164.00
|
|
|
Service Code
|
CPT 98967 GO,95
|
| Hospital Charge Code |
5583193
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$83.57 |
| Max. Negotiated Rate |
$156.92 |
| Rate for Payer: Aetna Commercial |
$153.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$146.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$90.40
|
| Rate for Payer: Cash Price |
$49.20
|
| Rate for Payer: Cigna Commercial |
$156.92
|
| Rate for Payer: Health EOS Commercial |
$151.80
|
| Rate for Payer: HFN Commercial |
$156.92
|
| Rate for Payer: Multiplan Commercial |
$136.45
|
| Rate for Payer: Preferred Network Access Commercial |
$156.92
|
| Rate for Payer: Quartz Beloit One Network |
$83.57
|
| Rate for Payer: Quartz Commercial |
$102.34
|
| Rate for Payer: WEA Trust Commercial |
$93.81
|
| Rate for Payer: WPS Commercial |
$126.33
|
|
|
Yes - OT Telephone call 21> min Charge
|
Facility
|
IP
|
$245.00
|
|
|
Service Code
|
CPT 98968 GO,95
|
| Hospital Charge Code |
5583194
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$124.85 |
| Max. Negotiated Rate |
$234.42 |
| Rate for Payer: Aetna Commercial |
$229.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$219.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$135.04
|
| Rate for Payer: Cash Price |
$73.50
|
| Rate for Payer: Cigna Commercial |
$234.42
|
| Rate for Payer: Health EOS Commercial |
$226.77
|
| Rate for Payer: HFN Commercial |
$234.42
|
| Rate for Payer: Multiplan Commercial |
$203.84
|
| Rate for Payer: Preferred Network Access Commercial |
$234.42
|
| Rate for Payer: Quartz Beloit One Network |
$124.85
|
| Rate for Payer: Quartz Commercial |
$152.88
|
| Rate for Payer: WEA Trust Commercial |
$140.14
|
| Rate for Payer: WPS Commercial |
$188.72
|
|
|
Yes - OT Telephone call 21> min Charge
|
Facility
|
OP
|
$245.00
|
|
|
Service Code
|
CPT 98968 GO,95
|
| Hospital Charge Code |
5583194
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$71.34 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$229.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$219.13
|
| Rate for Payer: Aetna Managed Medicare |
$71.34
|
| 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 |
$135.04
|
| Rate for Payer: Cash Price |
$73.50
|
| Rate for Payer: Cash Price |
$73.50
|
| Rate for Payer: Cigna Commercial |
$234.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$142.59
|
| Rate for Payer: Health EOS Commercial |
$226.77
|
| Rate for Payer: HFN Commercial |
$234.42
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$203.84
|
| Rate for Payer: NAPHCARE Commercial |
$152.88
|
| Rate for Payer: Preferred Network Access Commercial |
$234.42
|
| Rate for Payer: Quartz Beloit One Network |
$124.85
|
| Rate for Payer: Quartz Commercial |
$165.62
|
| Rate for Payer: Quartz Medicare Advantage |
$152.88
|
| Rate for Payer: The Alliance Commercial |
$127.40
|
| Rate for Payer: United Healthcare PPO |
$191.10
|
| Rate for Payer: WEA Trust Commercial |
$140.14
|
| Rate for Payer: WPS Commercial |
$188.72
|
|
|
Yes - OT Telephone call 5-10 min Charge
|
Facility
|
OP
|
$82.00
|
|
|
Service Code
|
CPT 98966 GO,95
|
| Hospital Charge Code |
5583195
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$23.88 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$76.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$73.34
|
| Rate for Payer: Aetna Managed Medicare |
$23.88
|
| 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 |
$45.20
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cigna Commercial |
$78.46
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$47.72
|
| Rate for Payer: Health EOS Commercial |
$75.90
|
| Rate for Payer: HFN Commercial |
$78.46
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$68.22
|
| Rate for Payer: NAPHCARE Commercial |
$51.17
|
| Rate for Payer: Preferred Network Access Commercial |
$78.46
|
| Rate for Payer: Quartz Beloit One Network |
$41.79
|
| Rate for Payer: Quartz Commercial |
$55.43
|
| Rate for Payer: Quartz Medicare Advantage |
$51.17
|
| Rate for Payer: The Alliance Commercial |
$42.64
|
| Rate for Payer: United Healthcare PPO |
$63.96
|
| Rate for Payer: WEA Trust Commercial |
$46.90
|
| Rate for Payer: WPS Commercial |
$63.16
|
|
|
Yes - OT Telephone call 5-10 min Charge
|
Facility
|
IP
|
$82.00
|
|
|
Service Code
|
CPT 98966 GO,95
|
| Hospital Charge Code |
5583195
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$41.79 |
| Max. Negotiated Rate |
$78.46 |
| Rate for Payer: Aetna Commercial |
$76.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$73.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$45.20
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cigna Commercial |
$78.46
|
| Rate for Payer: Health EOS Commercial |
$75.90
|
| Rate for Payer: HFN Commercial |
$78.46
|
| Rate for Payer: Multiplan Commercial |
$68.22
|
| Rate for Payer: Preferred Network Access Commercial |
$78.46
|
| Rate for Payer: Quartz Beloit One Network |
$41.79
|
| Rate for Payer: Quartz Commercial |
$51.17
|
| Rate for Payer: WEA Trust Commercial |
$46.90
|
| Rate for Payer: WPS Commercial |
$63.16
|
|
|
Yes - OT TH Evaluation High Complexity Chg
|
Facility
|
OP
|
$1,044.00
|
|
|
Service Code
|
CPT 97167 GO,95
|
| Hospital Charge Code |
5585263
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$210.08 |
| Max. Negotiated Rate |
$998.90 |
| Rate for Payer: Aetna Commercial |
$977.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$933.75
|
| Rate for Payer: Aetna Managed Medicare |
$304.01
|
| 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 |
$575.45
|
| Rate for Payer: Cash Price |
$313.20
|
| Rate for Payer: Cash Price |
$313.20
|
| Rate for Payer: Cigna Commercial |
$998.90
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$607.61
|
| Rate for Payer: Health EOS Commercial |
$966.33
|
| Rate for Payer: HFN Commercial |
$998.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$868.61
|
| Rate for Payer: NAPHCARE Commercial |
$651.46
|
| Rate for Payer: Preferred Network Access Commercial |
$998.90
|
| Rate for Payer: Quartz Beloit One Network |
$532.02
|
| Rate for Payer: Quartz Commercial |
$705.74
|
| Rate for Payer: Quartz Medicare Advantage |
$651.46
|
| Rate for Payer: The Alliance Commercial |
$542.88
|
| Rate for Payer: United Healthcare PPO |
$814.32
|
| Rate for Payer: WEA Trust Commercial |
$597.17
|
| Rate for Payer: WPS Commercial |
$804.19
|
|
|
Yes - OT TH Evaluation High Complexity Chg
|
Facility
|
IP
|
$1,044.00
|
|
|
Service Code
|
CPT 97167 GO,95
|
| Hospital Charge Code |
5585263
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$532.02 |
| Max. Negotiated Rate |
$998.90 |
| Rate for Payer: Aetna Commercial |
$977.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$933.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$575.45
|
| Rate for Payer: Cash Price |
$313.20
|
| Rate for Payer: Cigna Commercial |
$998.90
|
| Rate for Payer: Health EOS Commercial |
$966.33
|
| Rate for Payer: HFN Commercial |
$998.90
|
| Rate for Payer: Multiplan Commercial |
$868.61
|
| Rate for Payer: Preferred Network Access Commercial |
$998.90
|
| Rate for Payer: Quartz Beloit One Network |
$532.02
|
| Rate for Payer: Quartz Commercial |
$651.46
|
| Rate for Payer: WEA Trust Commercial |
$597.17
|
| Rate for Payer: WPS Commercial |
$804.19
|
|
|
Yes - OT TH Evaluation Low Complexity Chg
|
Facility
|
OP
|
$332.00
|
|
|
Service Code
|
CPT 97165 GO,95
|
| Hospital Charge Code |
5585274
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$96.68 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$310.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$296.94
|
| Rate for Payer: Aetna Managed Medicare |
$96.68
|
| 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 |
$183.00
|
| Rate for Payer: Cash Price |
$99.60
|
| Rate for Payer: Cash Price |
$99.60
|
| Rate for Payer: Cigna Commercial |
$317.66
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$193.22
|
| Rate for Payer: Health EOS Commercial |
$307.30
|
| Rate for Payer: HFN Commercial |
$317.66
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$276.22
|
| Rate for Payer: NAPHCARE Commercial |
$207.17
|
| Rate for Payer: Preferred Network Access Commercial |
$317.66
|
| Rate for Payer: Quartz Beloit One Network |
$169.19
|
| Rate for Payer: Quartz Commercial |
$224.43
|
| Rate for Payer: Quartz Medicare Advantage |
$207.17
|
| Rate for Payer: The Alliance Commercial |
$172.64
|
| Rate for Payer: United Healthcare PPO |
$258.96
|
| Rate for Payer: WEA Trust Commercial |
$189.90
|
| Rate for Payer: WPS Commercial |
$255.74
|
|
|
Yes - OT TH Evaluation Low Complexity Chg
|
Facility
|
IP
|
$332.00
|
|
|
Service Code
|
CPT 97165 GO,95
|
| Hospital Charge Code |
5585274
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$169.19 |
| Max. Negotiated Rate |
$317.66 |
| Rate for Payer: Aetna Commercial |
$310.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$296.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$183.00
|
| Rate for Payer: Cash Price |
$99.60
|
| Rate for Payer: Cigna Commercial |
$317.66
|
| Rate for Payer: Health EOS Commercial |
$307.30
|
| Rate for Payer: HFN Commercial |
$317.66
|
| Rate for Payer: Multiplan Commercial |
$276.22
|
| Rate for Payer: Preferred Network Access Commercial |
$317.66
|
| Rate for Payer: Quartz Beloit One Network |
$169.19
|
| Rate for Payer: Quartz Commercial |
$207.17
|
| Rate for Payer: WEA Trust Commercial |
$189.90
|
| Rate for Payer: WPS Commercial |
$255.74
|
|
|
Yes - OT TH Evaluation Moderate Complexity Chg
|
Facility
|
OP
|
$667.00
|
|
|
Service Code
|
CPT 97166 95,GO
|
| Hospital Charge Code |
5585290
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$194.23 |
| Max. Negotiated Rate |
$638.19 |
| Rate for Payer: Aetna Commercial |
$624.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$596.56
|
| Rate for Payer: Aetna Managed Medicare |
$194.23
|
| 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 |
$367.65
|
| Rate for Payer: Cash Price |
$200.10
|
| Rate for Payer: Cash Price |
$200.10
|
| Rate for Payer: Cigna Commercial |
$638.19
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$388.19
|
| Rate for Payer: Health EOS Commercial |
$617.38
|
| Rate for Payer: HFN Commercial |
$638.19
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$554.94
|
| Rate for Payer: NAPHCARE Commercial |
$416.21
|
| Rate for Payer: Preferred Network Access Commercial |
$638.19
|
| Rate for Payer: Quartz Beloit One Network |
$339.90
|
| Rate for Payer: Quartz Commercial |
$450.89
|
| Rate for Payer: Quartz Medicare Advantage |
$416.21
|
| Rate for Payer: The Alliance Commercial |
$346.84
|
| Rate for Payer: United Healthcare PPO |
$520.26
|
| Rate for Payer: WEA Trust Commercial |
$381.52
|
| Rate for Payer: WPS Commercial |
$513.79
|
|
|
Yes - OT TH Evaluation Moderate Complexity Chg
|
Facility
|
IP
|
$667.00
|
|
|
Service Code
|
CPT 97166 95,GO
|
| Hospital Charge Code |
5585290
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$339.90 |
| Max. Negotiated Rate |
$638.19 |
| Rate for Payer: Aetna Commercial |
$624.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$596.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$367.65
|
| Rate for Payer: Cash Price |
$200.10
|
| Rate for Payer: Cigna Commercial |
$638.19
|
| Rate for Payer: Health EOS Commercial |
$617.38
|
| Rate for Payer: HFN Commercial |
$638.19
|
| Rate for Payer: Multiplan Commercial |
$554.94
|
| Rate for Payer: Preferred Network Access Commercial |
$638.19
|
| Rate for Payer: Quartz Beloit One Network |
$339.90
|
| Rate for Payer: Quartz Commercial |
$416.21
|
| Rate for Payer: WEA Trust Commercial |
$381.52
|
| Rate for Payer: WPS Commercial |
$513.79
|
|
|
Yes - OT TH Reevaluation Chg
|
Facility
|
OP
|
$693.00
|
|
|
Service Code
|
CPT 97168 GO,95
|
| Hospital Charge Code |
5585302
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$201.80 |
| Max. Negotiated Rate |
$663.06 |
| Rate for Payer: Aetna Commercial |
$648.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$619.82
|
| Rate for Payer: Aetna Managed Medicare |
$201.80
|
| 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 |
$381.98
|
| Rate for Payer: Cash Price |
$207.90
|
| Rate for Payer: Cash Price |
$207.90
|
| Rate for Payer: Cigna Commercial |
$663.06
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$403.33
|
| Rate for Payer: Health EOS Commercial |
$641.44
|
| Rate for Payer: HFN Commercial |
$663.06
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$576.58
|
| Rate for Payer: NAPHCARE Commercial |
$432.43
|
| Rate for Payer: Preferred Network Access Commercial |
$663.06
|
| Rate for Payer: Quartz Beloit One Network |
$353.15
|
| Rate for Payer: Quartz Commercial |
$468.47
|
| Rate for Payer: Quartz Medicare Advantage |
$432.43
|
| Rate for Payer: The Alliance Commercial |
$360.36
|
| Rate for Payer: United Healthcare PPO |
$540.54
|
| Rate for Payer: WEA Trust Commercial |
$396.40
|
| Rate for Payer: WPS Commercial |
$533.82
|
|
|
Yes - OT TH Reevaluation Chg
|
Facility
|
IP
|
$693.00
|
|
|
Service Code
|
CPT 97168 GO,95
|
| Hospital Charge Code |
5585302
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$353.15 |
| Max. Negotiated Rate |
$663.06 |
| Rate for Payer: Aetna Commercial |
$648.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$619.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$381.98
|
| Rate for Payer: Cash Price |
$207.90
|
| Rate for Payer: Cigna Commercial |
$663.06
|
| Rate for Payer: Health EOS Commercial |
$641.44
|
| Rate for Payer: HFN Commercial |
$663.06
|
| Rate for Payer: Multiplan Commercial |
$576.58
|
| Rate for Payer: Preferred Network Access Commercial |
$663.06
|
| Rate for Payer: Quartz Beloit One Network |
$353.15
|
| Rate for Payer: Quartz Commercial |
$432.43
|
| Rate for Payer: WEA Trust Commercial |
$396.40
|
| Rate for Payer: WPS Commercial |
$533.82
|
|
|
Yes - OT Unattended Electrical Therapy Charge
|
Facility
|
IP
|
$158.00
|
|
|
Service Code
|
CPT 97014 GO
|
| Hospital Charge Code |
2989792
|
|
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 - OT Unattended Electrical Therapy Charge
|
Facility
|
OP
|
$158.00
|
|
|
Service Code
|
CPT 97014 GO
|
| Hospital Charge Code |
2989792
|
|
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 - OT Vasopneumatic Charge
|
Facility
|
IP
|
$193.00
|
|
|
Service Code
|
CPT 97016 GO
|
| Hospital Charge Code |
2989879
|
|
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 - OT Vasopneumatic Charge
|
Facility
|
OP
|
$193.00
|
|
|
Service Code
|
CPT 97016 GO
|
| Hospital Charge Code |
2989879
|
|
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 - OT Whirlpool Charge
|
Facility
|
OP
|
$296.00
|
|
|
Service Code
|
CPT 97022 GO
|
| Hospital Charge Code |
2987961
|
|
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 - OT Whirlpool Charge
|
Facility
|
IP
|
$296.00
|
|
|
Service Code
|
CPT 97022 GO
|
| Hospital Charge Code |
2987961
|
|
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
|
|
