|
APPENDIX PROCEDURES WITH CC
|
Facility
|
IP
|
$40,553.00
|
|
|
Service Code
|
MSDRG 398
|
| Min. Negotiated Rate |
$14,587.41 |
| Max. Negotiated Rate |
$40,553.00 |
| Rate for Payer: Aetna Managed Medicare |
$14,587.41
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$31,679.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$24,282.31
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$23,069.78
|
| Rate for Payer: Anthem Medicare Advantage |
$14,587.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$14,587.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$14,587.41
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$14,587.41
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$25,609.57
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$14,587.41
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$29,509.35
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$14,587.41
|
| Rate for Payer: Independent Care Health Plan Medicare |
$14,587.41
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$14,587.41
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$14,587.41
|
| Rate for Payer: NAPHCARE Commercial |
$21,881.12
|
| Rate for Payer: Quartz Medicare Advantage |
$14,587.41
|
| Rate for Payer: The Alliance Commercial |
$40,553.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14,587.41
|
| Rate for Payer: United Healthcare PPO |
$22,973.41
|
| Rate for Payer: Wellcare Medicare |
$14,587.41
|
|
|
APPENDIX PROCEDURES WITH MCC
|
Facility
|
IP
|
$60,048.00
|
|
|
Service Code
|
MSDRG 397
|
| Min. Negotiated Rate |
$21,600.15 |
| Max. Negotiated Rate |
$60,048.00 |
| Rate for Payer: Aetna Managed Medicare |
$21,600.15
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$47,205.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$36,182.25
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$34,375.50
|
| Rate for Payer: Anthem Medicare Advantage |
$21,600.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$21,600.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$21,600.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$21,600.15
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$38,159.96
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$21,600.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$43,808.70
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$21,600.15
|
| Rate for Payer: Independent Care Health Plan Medicare |
$21,600.15
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$21,600.15
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$21,600.15
|
| Rate for Payer: NAPHCARE Commercial |
$32,400.22
|
| Rate for Payer: Quartz Medicare Advantage |
$21,600.15
|
| Rate for Payer: The Alliance Commercial |
$60,048.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$21,600.15
|
| Rate for Payer: United Healthcare PPO |
$34,105.63
|
| Rate for Payer: Wellcare Medicare |
$21,600.15
|
|
|
APPENDIX PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$29,913.00
|
|
|
Service Code
|
MSDRG 399
|
| Min. Negotiated Rate |
$10,760.17 |
| Max. Negotiated Rate |
$29,913.00 |
| Rate for Payer: Aetna Managed Medicare |
$10,760.17
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$23,287.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$17,849.91
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$16,958.58
|
| Rate for Payer: Anthem Medicare Advantage |
$10,760.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$10,760.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$10,760.17
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$10,760.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$18,825.58
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$10,760.17
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$21,705.45
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$10,760.17
|
| Rate for Payer: Independent Care Health Plan Medicare |
$10,760.17
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$10,760.17
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$10,760.17
|
| Rate for Payer: NAPHCARE Commercial |
$16,140.26
|
| Rate for Payer: Quartz Medicare Advantage |
$10,760.17
|
| Rate for Payer: The Alliance Commercial |
$29,913.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$10,760.17
|
| Rate for Payer: United Healthcare PPO |
$16,897.97
|
| Rate for Payer: Wellcare Medicare |
$10,760.17
|
|
|
APPLICATION OF FINGER SPLINT 29130
|
Professional
|
Both
|
$154.00
|
|
|
Service Code
|
CPT 29130
|
| Hospital Charge Code |
3014295
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$10.11 |
| Max. Negotiated Rate |
$146.30 |
| Rate for Payer: Aetna Commercial |
$146.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$132.44
|
| Rate for Payer: Cash Price |
$46.20
|
| Rate for Payer: Cash Price |
$46.20
|
| Rate for Payer: Cigna Commercial |
$146.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$10.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$92.40
|
| Rate for Payer: Health EOS Commercial |
$140.14
|
| Rate for Payer: HFN Commercial |
$146.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$95.03
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$95.03
|
| Rate for Payer: Multiplan Commercial |
$123.20
|
| Rate for Payer: Preferred Network Access Commercial |
$146.30
|
| Rate for Payer: Quartz Beloit One Network |
$67.76
|
| Rate for Payer: Quartz Commercial |
$87.78
|
| Rate for Payer: The Alliance Commercial |
$77.00
|
| Rate for Payer: United Healthcare Medicaid |
$10.11
|
| Rate for Payer: WEA Trust Commercial |
$84.70
|
| Rate for Payer: WPS Commercial |
$114.07
|
|
|
APPLICATION OF FINGER SPLINT 29131
|
Professional
|
Both
|
$248.00
|
|
|
Service Code
|
CPT 29131
|
| Hospital Charge Code |
3014296
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$22.59 |
| Max. Negotiated Rate |
$235.60 |
| Rate for Payer: Aetna Commercial |
$235.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$213.28
|
| Rate for Payer: Cash Price |
$74.40
|
| Rate for Payer: Cash Price |
$74.40
|
| Rate for Payer: Cigna Commercial |
$235.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$22.59
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$148.80
|
| Rate for Payer: Health EOS Commercial |
$225.68
|
| Rate for Payer: HFN Commercial |
$235.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$112.78
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$112.78
|
| Rate for Payer: Multiplan Commercial |
$198.40
|
| Rate for Payer: Preferred Network Access Commercial |
$235.60
|
| Rate for Payer: Quartz Beloit One Network |
$109.12
|
| Rate for Payer: Quartz Commercial |
$141.36
|
| Rate for Payer: The Alliance Commercial |
$124.00
|
| Rate for Payer: United Healthcare Medicaid |
$22.59
|
| Rate for Payer: WEA Trust Commercial |
$136.40
|
| Rate for Payer: WPS Commercial |
$183.69
|
|
|
APPLICATION OF FOREARM CAST 29075
|
Professional
|
Both
|
$242.00
|
|
|
Service Code
|
CPT 29075
|
| Hospital Charge Code |
3014290
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$56.33 |
| Max. Negotiated Rate |
$229.90 |
| Rate for Payer: Aetna Commercial |
$229.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$208.12
|
| Rate for Payer: Cash Price |
$72.60
|
| Rate for Payer: Cash Price |
$72.60
|
| Rate for Payer: Cigna Commercial |
$229.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$56.33
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$145.20
|
| Rate for Payer: Health EOS Commercial |
$220.22
|
| Rate for Payer: HFN Commercial |
$229.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$204.74
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$204.74
|
| Rate for Payer: Multiplan Commercial |
$193.60
|
| Rate for Payer: Preferred Network Access Commercial |
$229.90
|
| Rate for Payer: Quartz Beloit One Network |
$106.48
|
| Rate for Payer: Quartz Commercial |
$137.94
|
| Rate for Payer: The Alliance Commercial |
$121.00
|
| Rate for Payer: United Healthcare Medicaid |
$56.33
|
| Rate for Payer: WEA Trust Commercial |
$133.10
|
| Rate for Payer: WPS Commercial |
$179.25
|
|
|
APPLICATION OF HIP CASTS 29325
|
Professional
|
Both
|
$855.00
|
|
|
Service Code
|
CPT 29325
|
| Hospital Charge Code |
3014298
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$285.82 |
| Max. Negotiated Rate |
$812.25 |
| Rate for Payer: Aetna Commercial |
$812.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$735.30
|
| Rate for Payer: Cash Price |
$256.50
|
| Rate for Payer: Cash Price |
$256.50
|
| Rate for Payer: Cigna Commercial |
$812.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$285.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$513.00
|
| Rate for Payer: Health EOS Commercial |
$778.05
|
| Rate for Payer: HFN Commercial |
$812.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$578.67
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$578.67
|
| Rate for Payer: Multiplan Commercial |
$684.00
|
| Rate for Payer: Preferred Network Access Commercial |
$812.25
|
| Rate for Payer: Quartz Beloit One Network |
$376.20
|
| Rate for Payer: Quartz Commercial |
$487.35
|
| Rate for Payer: The Alliance Commercial |
$427.50
|
| Rate for Payer: United Healthcare Medicaid |
$285.82
|
| Rate for Payer: WEA Trust Commercial |
$470.25
|
| Rate for Payer: WPS Commercial |
$633.30
|
|
|
APPLICATION OF LEG CAST 29450
|
Professional
|
Both
|
$331.00
|
|
|
Service Code
|
CPT 29450
|
| Hospital Charge Code |
3014302
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$55.24 |
| Max. Negotiated Rate |
$377.15 |
| Rate for Payer: Aetna Commercial |
$314.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$284.66
|
| Rate for Payer: Cash Price |
$99.30
|
| Rate for Payer: Cash Price |
$99.30
|
| Rate for Payer: Cigna Commercial |
$314.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$55.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$198.60
|
| Rate for Payer: Health EOS Commercial |
$301.21
|
| Rate for Payer: HFN Commercial |
$314.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$377.15
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$377.15
|
| Rate for Payer: Multiplan Commercial |
$264.80
|
| Rate for Payer: Preferred Network Access Commercial |
$314.45
|
| Rate for Payer: Quartz Beloit One Network |
$145.64
|
| Rate for Payer: Quartz Commercial |
$188.67
|
| Rate for Payer: The Alliance Commercial |
$165.50
|
| Rate for Payer: United Healthcare Medicaid |
$55.24
|
| Rate for Payer: WEA Trust Commercial |
$182.05
|
| Rate for Payer: WPS Commercial |
$245.17
|
|
|
Application of Long Arm Cast 29065
|
Professional
|
Both
|
$245.00
|
|
|
Service Code
|
CPT 29065
|
| Hospital Charge Code |
3014289
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$80.86 |
| Max. Negotiated Rate |
$232.75 |
| Rate for Payer: Aetna Commercial |
$232.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$210.70
|
| Rate for Payer: Cash Price |
$73.50
|
| Rate for Payer: Cash Price |
$73.50
|
| Rate for Payer: Cigna Commercial |
$232.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$80.86
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$147.00
|
| Rate for Payer: Health EOS Commercial |
$222.95
|
| Rate for Payer: HFN Commercial |
$232.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$223.24
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$223.24
|
| Rate for Payer: Multiplan Commercial |
$196.00
|
| Rate for Payer: Preferred Network Access Commercial |
$232.75
|
| Rate for Payer: Quartz Beloit One Network |
$107.80
|
| Rate for Payer: Quartz Commercial |
$139.65
|
| Rate for Payer: The Alliance Commercial |
$122.50
|
| Rate for Payer: United Healthcare Medicaid |
$80.86
|
| Rate for Payer: WEA Trust Commercial |
$134.75
|
| Rate for Payer: WPS Commercial |
$181.47
|
|
|
APPLICATION OF LONG LEG CAST 29345
|
Professional
|
Both
|
$364.00
|
|
|
Service Code
|
CPT 29345
|
| Hospital Charge Code |
3014299
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$114.34 |
| Max. Negotiated Rate |
$345.80 |
| Rate for Payer: Aetna Commercial |
$345.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$313.04
|
| Rate for Payer: Cash Price |
$109.20
|
| Rate for Payer: Cash Price |
$109.20
|
| Rate for Payer: Cigna Commercial |
$345.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$114.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$218.40
|
| Rate for Payer: Health EOS Commercial |
$331.24
|
| Rate for Payer: HFN Commercial |
$345.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$326.95
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$326.95
|
| Rate for Payer: Multiplan Commercial |
$291.20
|
| Rate for Payer: Preferred Network Access Commercial |
$345.80
|
| Rate for Payer: Quartz Beloit One Network |
$160.16
|
| Rate for Payer: Quartz Commercial |
$207.48
|
| Rate for Payer: The Alliance Commercial |
$182.00
|
| Rate for Payer: United Healthcare Medicaid |
$114.34
|
| Rate for Payer: WEA Trust Commercial |
$200.20
|
| Rate for Payer: WPS Commercial |
$269.61
|
|
|
Application of Long Leg Cast /Walking 29355
|
Professional
|
Both
|
$410.00
|
|
|
Service Code
|
CPT 29355
|
| Hospital Charge Code |
4125292
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$91.33 |
| Max. Negotiated Rate |
$389.50 |
| Rate for Payer: Aetna Commercial |
$389.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$352.60
|
| Rate for Payer: Cash Price |
$123.00
|
| Rate for Payer: Cash Price |
$123.00
|
| Rate for Payer: Cigna Commercial |
$389.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$91.33
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$246.00
|
| Rate for Payer: Health EOS Commercial |
$373.10
|
| Rate for Payer: HFN Commercial |
$389.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$351.38
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$351.38
|
| Rate for Payer: Multiplan Commercial |
$328.00
|
| Rate for Payer: Preferred Network Access Commercial |
$389.50
|
| Rate for Payer: Quartz Beloit One Network |
$180.40
|
| Rate for Payer: Quartz Commercial |
$233.70
|
| Rate for Payer: The Alliance Commercial |
$205.00
|
| Rate for Payer: United Healthcare Medicaid |
$91.33
|
| Rate for Payer: WEA Trust Commercial |
$225.50
|
| Rate for Payer: WPS Commercial |
$303.69
|
|
|
Application of Long Leg Splint 29505
|
Professional
|
Both
|
$207.00
|
|
|
Service Code
|
CPT 29505
|
| Hospital Charge Code |
3014303
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$45.18 |
| Max. Negotiated Rate |
$196.65 |
| Rate for Payer: Aetna Commercial |
$196.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$178.02
|
| Rate for Payer: Cash Price |
$62.10
|
| Rate for Payer: Cash Price |
$62.10
|
| Rate for Payer: Cigna Commercial |
$196.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$45.18
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$124.20
|
| Rate for Payer: Health EOS Commercial |
$188.37
|
| Rate for Payer: HFN Commercial |
$196.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$169.79
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$169.79
|
| Rate for Payer: Multiplan Commercial |
$165.60
|
| Rate for Payer: Preferred Network Access Commercial |
$196.65
|
| Rate for Payer: Quartz Beloit One Network |
$91.08
|
| Rate for Payer: Quartz Commercial |
$117.99
|
| Rate for Payer: The Alliance Commercial |
$103.50
|
| Rate for Payer: United Healthcare Medicaid |
$45.18
|
| Rate for Payer: WEA Trust Commercial |
$113.85
|
| Rate for Payer: WPS Commercial |
$153.32
|
|
|
Application Of Modality, Mechanical Traction
|
Professional
|
Both
|
$57.00
|
|
|
Service Code
|
CPT 97012
|
| Hospital Charge Code |
1188843
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$25.08 |
| Max. Negotiated Rate |
$54.15 |
| Rate for Payer: Aetna Commercial |
$54.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$49.02
|
| Rate for Payer: Cash Price |
$17.10
|
| Rate for Payer: Cash Price |
$17.10
|
| Rate for Payer: Cigna Commercial |
$54.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$28.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$34.20
|
| Rate for Payer: Health EOS Commercial |
$51.87
|
| Rate for Payer: HFN Commercial |
$54.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$50.87
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$50.87
|
| Rate for Payer: Multiplan Commercial |
$45.60
|
| Rate for Payer: Preferred Network Access Commercial |
$54.15
|
| Rate for Payer: Quartz Beloit One Network |
$25.08
|
| Rate for Payer: Quartz Commercial |
$32.49
|
| Rate for Payer: The Alliance Commercial |
$28.50
|
| Rate for Payer: WEA Trust Commercial |
$31.35
|
| Rate for Payer: WPS Commercial |
$42.22
|
|
|
Application of multi-layer venous wound compression system, below knee 29581
|
Professional
|
Both
|
$209.00
|
|
|
Service Code
|
CPT 29581
|
| Hospital Charge Code |
3014306
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$72.06 |
| Max. Negotiated Rate |
$198.55 |
| Rate for Payer: Aetna Commercial |
$198.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$179.74
|
| Rate for Payer: Cash Price |
$62.70
|
| Rate for Payer: Cash Price |
$62.70
|
| Rate for Payer: Cigna Commercial |
$198.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$72.06
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$125.40
|
| Rate for Payer: Health EOS Commercial |
$190.19
|
| Rate for Payer: HFN Commercial |
$198.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$95.52
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$95.52
|
| Rate for Payer: Multiplan Commercial |
$167.20
|
| Rate for Payer: Preferred Network Access Commercial |
$198.55
|
| Rate for Payer: Quartz Beloit One Network |
$91.96
|
| Rate for Payer: Quartz Commercial |
$119.13
|
| Rate for Payer: The Alliance Commercial |
$104.50
|
| Rate for Payer: United Healthcare Medicaid |
$72.06
|
| Rate for Payer: WEA Trust Commercial |
$114.95
|
| Rate for Payer: WPS Commercial |
$154.81
|
|
|
Application of multi-layer venous wound compression system, below knee 2958150
|
Professional
|
Both
|
$418.00
|
|
|
Service Code
|
CPT 29581 50
|
| Hospital Charge Code |
5494772
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$72.06 |
| Max. Negotiated Rate |
$397.10 |
| Rate for Payer: Aetna Commercial |
$397.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$359.48
|
| Rate for Payer: Cash Price |
$125.40
|
| Rate for Payer: Cash Price |
$125.40
|
| Rate for Payer: Cigna Commercial |
$397.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$72.06
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$250.80
|
| Rate for Payer: Health EOS Commercial |
$380.38
|
| Rate for Payer: HFN Commercial |
$397.10
|
| Rate for Payer: Multiplan Commercial |
$334.40
|
| Rate for Payer: Preferred Network Access Commercial |
$397.10
|
| Rate for Payer: Quartz Beloit One Network |
$183.92
|
| Rate for Payer: Quartz Commercial |
$238.26
|
| Rate for Payer: The Alliance Commercial |
$209.00
|
| Rate for Payer: United Healthcare Medicaid |
$72.06
|
| Rate for Payer: WEA Trust Commercial |
$229.90
|
| Rate for Payer: WPS Commercial |
$309.61
|
|
|
Application of Paste Boot 29580
|
Professional
|
Both
|
$209.00
|
|
|
Service Code
|
CPT 29580
|
| Hospital Charge Code |
3595525
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$20.21 |
| Max. Negotiated Rate |
$198.55 |
| Rate for Payer: Aetna Commercial |
$198.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$179.74
|
| Rate for Payer: Cash Price |
$62.70
|
| Rate for Payer: Cash Price |
$62.70
|
| Rate for Payer: Cigna Commercial |
$198.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$20.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$125.40
|
| Rate for Payer: Health EOS Commercial |
$190.19
|
| Rate for Payer: HFN Commercial |
$198.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$88.50
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$88.50
|
| Rate for Payer: Multiplan Commercial |
$167.20
|
| Rate for Payer: Preferred Network Access Commercial |
$198.55
|
| Rate for Payer: Quartz Beloit One Network |
$91.96
|
| Rate for Payer: Quartz Commercial |
$119.13
|
| Rate for Payer: The Alliance Commercial |
$104.50
|
| Rate for Payer: United Healthcare Medicaid |
$20.21
|
| Rate for Payer: WEA Trust Commercial |
$114.95
|
| Rate for Payer: WPS Commercial |
$154.81
|
|
|
Application of Paste Boot 2958050
|
Professional
|
Both
|
$362.00
|
|
|
Service Code
|
CPT 29580 50
|
| Hospital Charge Code |
3165544
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$159.28 |
| Max. Negotiated Rate |
$343.90 |
| Rate for Payer: Aetna Commercial |
$343.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$311.32
|
| Rate for Payer: Cash Price |
$108.60
|
| Rate for Payer: Cash Price |
$108.60
|
| Rate for Payer: Cigna Commercial |
$343.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$181.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$217.20
|
| Rate for Payer: Health EOS Commercial |
$329.42
|
| Rate for Payer: HFN Commercial |
$343.90
|
| Rate for Payer: Multiplan Commercial |
$289.60
|
| Rate for Payer: Preferred Network Access Commercial |
$343.90
|
| Rate for Payer: Quartz Beloit One Network |
$159.28
|
| Rate for Payer: Quartz Commercial |
$206.34
|
| Rate for Payer: The Alliance Commercial |
$181.00
|
| Rate for Payer: WEA Trust Commercial |
$199.10
|
| Rate for Payer: WPS Commercial |
$268.13
|
|
|
Application of Rigid Total Contact Leg Cast
|
Professional
|
Both
|
$702.00
|
|
|
Service Code
|
CPT 29445
|
| Hospital Charge Code |
2572818
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$151.57 |
| Max. Negotiated Rate |
$666.90 |
| Rate for Payer: Aetna Commercial |
$666.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$603.72
|
| Rate for Payer: Cash Price |
$210.60
|
| Rate for Payer: Cash Price |
$210.60
|
| Rate for Payer: Cigna Commercial |
$666.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$151.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$421.20
|
| Rate for Payer: Health EOS Commercial |
$638.82
|
| Rate for Payer: HFN Commercial |
$666.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$335.99
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$335.99
|
| Rate for Payer: Multiplan Commercial |
$561.60
|
| Rate for Payer: Preferred Network Access Commercial |
$666.90
|
| Rate for Payer: Quartz Beloit One Network |
$308.88
|
| Rate for Payer: Quartz Commercial |
$400.14
|
| Rate for Payer: The Alliance Commercial |
$351.00
|
| Rate for Payer: United Healthcare Medicaid |
$151.57
|
| Rate for Payer: WEA Trust Commercial |
$386.10
|
| Rate for Payer: WPS Commercial |
$519.97
|
|
|
Application of Short Leg Cast 29405
|
Professional
|
Both
|
$422.00
|
|
|
Service Code
|
CPT 29405
|
| Hospital Charge Code |
2572816
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$72.61 |
| Max. Negotiated Rate |
$400.90 |
| Rate for Payer: Aetna Commercial |
$400.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$362.92
|
| Rate for Payer: Cash Price |
$126.60
|
| Rate for Payer: Cash Price |
$126.60
|
| Rate for Payer: Cigna Commercial |
$400.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$72.61
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$253.20
|
| Rate for Payer: Health EOS Commercial |
$384.02
|
| Rate for Payer: HFN Commercial |
$400.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$193.80
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$193.80
|
| Rate for Payer: Multiplan Commercial |
$337.60
|
| Rate for Payer: Preferred Network Access Commercial |
$400.90
|
| Rate for Payer: Quartz Beloit One Network |
$185.68
|
| Rate for Payer: Quartz Commercial |
$240.54
|
| Rate for Payer: The Alliance Commercial |
$211.00
|
| Rate for Payer: United Healthcare Medicaid |
$72.61
|
| Rate for Payer: WEA Trust Commercial |
$232.10
|
| Rate for Payer: WPS Commercial |
$312.58
|
|
|
Application of Short Leg Splint 29515
|
Professional
|
Both
|
$199.00
|
|
|
Service Code
|
CPT 29515
|
| Hospital Charge Code |
3014304
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$30.42 |
| Max. Negotiated Rate |
$189.05 |
| Rate for Payer: Aetna Commercial |
$189.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$171.14
|
| Rate for Payer: Cash Price |
$59.70
|
| Rate for Payer: Cash Price |
$59.70
|
| Rate for Payer: Cigna Commercial |
$189.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$30.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$119.40
|
| Rate for Payer: Health EOS Commercial |
$181.09
|
| Rate for Payer: HFN Commercial |
$189.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$162.38
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$162.38
|
| Rate for Payer: Multiplan Commercial |
$159.20
|
| Rate for Payer: Preferred Network Access Commercial |
$189.05
|
| Rate for Payer: Quartz Beloit One Network |
$87.56
|
| Rate for Payer: Quartz Commercial |
$113.43
|
| Rate for Payer: The Alliance Commercial |
$99.50
|
| Rate for Payer: United Healthcare Medicaid |
$30.42
|
| Rate for Payer: WEA Trust Commercial |
$109.45
|
| Rate for Payer: WPS Commercial |
$147.40
|
|
|
APPLICATION OF SHOULDER CAST 29058
|
Professional
|
Both
|
$388.00
|
|
|
Service Code
|
CPT 29058
|
| Hospital Charge Code |
3014288
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$45.18 |
| Max. Negotiated Rate |
$368.60 |
| Rate for Payer: Aetna Commercial |
$368.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$333.68
|
| Rate for Payer: Cash Price |
$116.40
|
| Rate for Payer: Cash Price |
$116.40
|
| Rate for Payer: Cigna Commercial |
$368.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$45.18
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$232.80
|
| Rate for Payer: Health EOS Commercial |
$353.08
|
| Rate for Payer: HFN Commercial |
$368.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$307.75
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$307.75
|
| Rate for Payer: Multiplan Commercial |
$310.40
|
| Rate for Payer: Preferred Network Access Commercial |
$368.60
|
| Rate for Payer: Quartz Beloit One Network |
$170.72
|
| Rate for Payer: Quartz Commercial |
$221.16
|
| Rate for Payer: The Alliance Commercial |
$194.00
|
| Rate for Payer: United Healthcare Medicaid |
$45.18
|
| Rate for Payer: WEA Trust Commercial |
$213.40
|
| Rate for Payer: WPS Commercial |
$287.39
|
|
|
APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA GREATER THAN OR EQUAL TO 100 SQ CM; FIRST 100 SQ CM WOUND SURFACE AREA, OR 1% OF BODY AREA OF INFANTS AND CHILDREN
|
Facility
|
OP
|
$7,209.92
|
|
|
Service Code
|
CPT 15277
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,802.48 |
| Max. Negotiated Rate |
$7,209.92 |
| Rate for Payer: Aetna Managed Medicare |
$1,802.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,496.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,871.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,726.00
|
| Rate for Payer: Anthem Medicare Advantage |
$1,802.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,802.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,802.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$1,802.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,757.59
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1,802.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,705.23
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,802.48
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,802.48
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$1,802.48
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$1,802.48
|
| Rate for Payer: NAPHCARE Commercial |
$2,703.72
|
| Rate for Payer: Quartz Medicare Advantage |
$1,802.48
|
| Rate for Payer: The Alliance Commercial |
$7,209.92
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,802.48
|
| Rate for Payer: United Healthcare PPO |
$3,583.00
|
| Rate for Payer: Wellcare Medicare |
$1,802.48
|
|
|
APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; EACH ADDITIONAL 25 SQ CM WOUND SURFACE AREA, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$4,757.59
|
|
|
Service Code
|
CPT 15276
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,757.59 |
| Max. Negotiated Rate |
$4,757.59 |
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,757.59
|
|
|
APPLICATION OF SKIN SUBSTITUTE GRAFT TO FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA
|
Facility
|
OP
|
$7,209.92
|
|
|
Service Code
|
CPT 15275
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,802.48 |
| Max. Negotiated Rate |
$7,209.92 |
| Rate for Payer: Aetna Managed Medicare |
$1,802.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,496.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,871.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,726.00
|
| Rate for Payer: Anthem Medicare Advantage |
$1,802.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,802.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,802.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$1,802.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,757.59
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1,802.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,705.23
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,802.48
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,802.48
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$1,802.48
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$1,802.48
|
| Rate for Payer: NAPHCARE Commercial |
$2,703.72
|
| Rate for Payer: Quartz Medicare Advantage |
$1,802.48
|
| Rate for Payer: The Alliance Commercial |
$7,209.92
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,802.48
|
| Rate for Payer: United Healthcare PPO |
$3,583.00
|
| Rate for Payer: Wellcare Medicare |
$1,802.48
|
|
|
APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA
|
Facility
|
OP
|
$7,209.92
|
|
|
Service Code
|
CPT 15271
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,802.48 |
| Max. Negotiated Rate |
$7,209.92 |
| Rate for Payer: Aetna Managed Medicare |
$1,802.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,496.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,871.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,726.00
|
| Rate for Payer: Anthem Medicare Advantage |
$1,802.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,802.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,802.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$1,802.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,757.59
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1,802.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,705.23
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,802.48
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,802.48
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$1,802.48
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$1,802.48
|
| Rate for Payer: NAPHCARE Commercial |
$2,703.72
|
| Rate for Payer: Quartz Medicare Advantage |
$1,802.48
|
| Rate for Payer: The Alliance Commercial |
$7,209.92
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,802.48
|
| Rate for Payer: United Healthcare PPO |
$3,583.00
|
| Rate for Payer: Wellcare Medicare |
$1,802.48
|
|
