|
Renin Activity
|
Facility
|
OP
|
$471.00
|
|
|
Service Code
|
CPT 84244
|
| Hospital Charge Code |
978054
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$21.99 |
| Max. Negotiated Rate |
$433.32 |
| Rate for Payer: Aetna Commercial |
$423.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$405.06
|
| Rate for Payer: Aetna Managed Medicare |
$21.99
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$82.46
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$38.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$36.50
|
| Rate for Payer: Anthem Medicaid |
$22.72
|
| Rate for Payer: Anthem Medicare Advantage |
$21.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$249.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$21.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$21.99
|
| Rate for Payer: Cash Price |
$141.30
|
| Rate for Payer: Cash Price |
$141.30
|
| Rate for Payer: Cigna Commercial |
$433.32
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$21.99
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$22.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$263.57
|
| Rate for Payer: Dean Health Medicaid |
$22.72
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$21.99
|
| Rate for Payer: Health EOS Commercial |
$419.19
|
| Rate for Payer: HFN Commercial |
$433.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$81.80
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$21.99
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$22.72
|
| Rate for Payer: Independent Care Health Plan Medicare |
$21.99
|
| Rate for Payer: Managed Health Services Medicaid |
$23.63
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$21.99
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$21.99
|
| Rate for Payer: Multiplan Commercial |
$376.80
|
| Rate for Payer: NAPHCARE Commercial |
$32.98
|
| Rate for Payer: Preferred Network Access Commercial |
$433.32
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$22.72
|
| Rate for Payer: Quartz Beloit One Network |
$230.79
|
| Rate for Payer: Quartz Commercial |
$306.15
|
| Rate for Payer: Quartz Medicare Advantage |
$21.99
|
| Rate for Payer: The Alliance Commercial |
$87.96
|
| Rate for Payer: United Healthcare Medicaid |
$22.72
|
| Rate for Payer: United Healthcare Medicare Advantage |
$21.99
|
| Rate for Payer: United Healthcare PPO |
$353.25
|
| Rate for Payer: WEA Trust Commercial |
$259.05
|
| Rate for Payer: Wellcare Medicare |
$21.99
|
| Rate for Payer: WMAP Medicaid |
$22.72
|
| Rate for Payer: WPS Commercial |
$348.87
|
|
|
Renin Activity
|
Professional
|
Both
|
$471.00
|
|
|
Service Code
|
CPT 84244
|
| Hospital Charge Code |
978054
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$77.62 |
| Max. Negotiated Rate |
$447.45 |
| Rate for Payer: Aetna Commercial |
$447.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$405.06
|
| Rate for Payer: Cash Price |
$141.30
|
| Rate for Payer: Cash Price |
$141.30
|
| Rate for Payer: Cigna Commercial |
$447.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$235.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$282.60
|
| Rate for Payer: Health EOS Commercial |
$428.61
|
| Rate for Payer: HFN Commercial |
$447.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$77.62
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$77.62
|
| Rate for Payer: Multiplan Commercial |
$376.80
|
| Rate for Payer: Preferred Network Access Commercial |
$447.45
|
| Rate for Payer: Quartz Beloit One Network |
$207.24
|
| Rate for Payer: Quartz Commercial |
$268.47
|
| Rate for Payer: The Alliance Commercial |
$235.50
|
| Rate for Payer: WEA Trust Commercial |
$259.05
|
| Rate for Payer: WPS Commercial |
$348.87
|
|
|
REOPEN FALLOPIAN TUBE 58350
|
Professional
|
Both
|
$755.00
|
|
|
Service Code
|
CPT 58350
|
| Hospital Charge Code |
3015109
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$311.59 |
| Max. Negotiated Rate |
$717.25 |
| Rate for Payer: Aetna Commercial |
$717.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$649.30
|
| Rate for Payer: Cash Price |
$226.50
|
| Rate for Payer: Cash Price |
$226.50
|
| Rate for Payer: Cigna Commercial |
$717.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$377.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$453.00
|
| Rate for Payer: Health EOS Commercial |
$687.05
|
| Rate for Payer: HFN Commercial |
$717.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$311.59
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$311.59
|
| Rate for Payer: Multiplan Commercial |
$604.00
|
| Rate for Payer: Preferred Network Access Commercial |
$717.25
|
| Rate for Payer: Quartz Beloit One Network |
$332.20
|
| Rate for Payer: Quartz Commercial |
$430.35
|
| Rate for Payer: The Alliance Commercial |
$377.50
|
| Rate for Payer: WEA Trust Commercial |
$415.25
|
| Rate for Payer: WPS Commercial |
$559.23
|
|
|
Repair (Cheiloplasty) over One-Half Vertical Height or Complex
|
Professional
|
Both
|
$2,019.00
|
|
|
Service Code
|
CPT 40654
|
| Hospital Charge Code |
1190862
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$529.29 |
| Max. Negotiated Rate |
$1,918.05 |
| Rate for Payer: Aetna Commercial |
$1,918.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,736.34
|
| Rate for Payer: Cash Price |
$605.70
|
| Rate for Payer: Cash Price |
$605.70
|
| Rate for Payer: Cigna Commercial |
$1,918.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$529.29
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,211.40
|
| Rate for Payer: Health EOS Commercial |
$1,837.29
|
| Rate for Payer: HFN Commercial |
$1,918.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,411.19
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,411.19
|
| Rate for Payer: Multiplan Commercial |
$1,615.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,918.05
|
| Rate for Payer: Quartz Beloit One Network |
$888.36
|
| Rate for Payer: Quartz Commercial |
$1,150.83
|
| Rate for Payer: The Alliance Commercial |
$1,009.50
|
| Rate for Payer: United Healthcare Medicaid |
$529.29
|
| Rate for Payer: WEA Trust Commercial |
$1,110.45
|
| Rate for Payer: WPS Commercial |
$1,495.47
|
|
|
Repair, complex (eyelids, nose, ears, lips) 1.1-2.5cm 13151
|
Professional
|
Both
|
$1,063.00
|
|
|
Service Code
|
CPT 13151
|
| Hospital Charge Code |
3013616
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$206.86 |
| Max. Negotiated Rate |
$1,009.85 |
| Rate for Payer: Aetna Commercial |
$1,009.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$914.18
|
| Rate for Payer: Cash Price |
$318.90
|
| Rate for Payer: Cash Price |
$318.90
|
| Rate for Payer: Cigna Commercial |
$1,009.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$206.86
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$637.80
|
| Rate for Payer: Health EOS Commercial |
$967.33
|
| Rate for Payer: HFN Commercial |
$1,009.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$931.43
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$931.43
|
| Rate for Payer: Multiplan Commercial |
$850.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,009.85
|
| Rate for Payer: Quartz Beloit One Network |
$467.72
|
| Rate for Payer: Quartz Commercial |
$605.91
|
| Rate for Payer: The Alliance Commercial |
$531.50
|
| Rate for Payer: United Healthcare Medicaid |
$206.86
|
| Rate for Payer: WEA Trust Commercial |
$584.65
|
| Rate for Payer: WPS Commercial |
$787.36
|
|
|
Repair, complex (eyelids, nose, ears, lips) 2.6-7.5cm 13152
|
Professional
|
Both
|
$2,232.00
|
|
|
Service Code
|
CPT 13152
|
| Hospital Charge Code |
3013617
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$277.06 |
| Max. Negotiated Rate |
$2,120.40 |
| Rate for Payer: Aetna Commercial |
$2,120.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,919.52
|
| Rate for Payer: Cash Price |
$669.60
|
| Rate for Payer: Cash Price |
$669.60
|
| Rate for Payer: Cigna Commercial |
$2,120.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$277.06
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,339.20
|
| Rate for Payer: Health EOS Commercial |
$2,031.12
|
| Rate for Payer: HFN Commercial |
$2,120.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,124.38
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,124.38
|
| Rate for Payer: Multiplan Commercial |
$1,785.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,120.40
|
| Rate for Payer: Quartz Beloit One Network |
$982.08
|
| Rate for Payer: Quartz Commercial |
$1,272.24
|
| Rate for Payer: The Alliance Commercial |
$1,116.00
|
| Rate for Payer: United Healthcare Medicaid |
$277.06
|
| Rate for Payer: WEA Trust Commercial |
$1,227.60
|
| Rate for Payer: WPS Commercial |
$1,653.24
|
|
|
Repair, complex (eyelids, nose, ears, lips) each additional <= 5cm 13153
|
Professional
|
Both
|
$1,200.00
|
|
|
Service Code
|
CPT 13153
|
| Hospital Charge Code |
4017970
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$140.55 |
| Max. Negotiated Rate |
$1,140.00 |
| Rate for Payer: Aetna Commercial |
$1,140.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,032.00
|
| Rate for Payer: Cash Price |
$360.00
|
| Rate for Payer: Cash Price |
$360.00
|
| Rate for Payer: Cigna Commercial |
$1,140.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$140.55
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$720.00
|
| Rate for Payer: Health EOS Commercial |
$1,092.00
|
| Rate for Payer: HFN Commercial |
$1,140.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$454.06
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$454.06
|
| Rate for Payer: Multiplan Commercial |
$960.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,140.00
|
| Rate for Payer: Quartz Beloit One Network |
$528.00
|
| Rate for Payer: Quartz Commercial |
$684.00
|
| Rate for Payer: The Alliance Commercial |
$600.00
|
| Rate for Payer: United Healthcare Medicaid |
$140.55
|
| Rate for Payer: WEA Trust Commercial |
$660.00
|
| Rate for Payer: WPS Commercial |
$888.84
|
|
|
Repair, complex (forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands, feet)†1.1-2.5cm 131
|
Professional
|
Both
|
$589.00
|
|
|
Service Code
|
CPT 13131
|
| Hospital Charge Code |
3013612
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$172.87 |
| Max. Negotiated Rate |
$811.58 |
| Rate for Payer: Aetna Commercial |
$559.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$506.54
|
| Rate for Payer: Cash Price |
$176.70
|
| Rate for Payer: Cash Price |
$176.70
|
| Rate for Payer: Cigna Commercial |
$559.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$172.87
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$353.40
|
| Rate for Payer: Health EOS Commercial |
$535.99
|
| Rate for Payer: HFN Commercial |
$559.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$811.58
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$811.58
|
| Rate for Payer: Multiplan Commercial |
$471.20
|
| Rate for Payer: Preferred Network Access Commercial |
$559.55
|
| Rate for Payer: Quartz Beloit One Network |
$259.16
|
| Rate for Payer: Quartz Commercial |
$335.73
|
| Rate for Payer: The Alliance Commercial |
$294.50
|
| Rate for Payer: United Healthcare Medicaid |
$172.87
|
| Rate for Payer: WEA Trust Commercial |
$323.95
|
| Rate for Payer: WPS Commercial |
$436.27
|
|
|
Repair, complex (forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands, feet)†2.6-7.5cm 131
|
Professional
|
Both
|
$1,360.00
|
|
|
Service Code
|
CPT 13132
|
| Hospital Charge Code |
3013613
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$263.37 |
| Max. Negotiated Rate |
$1,292.00 |
| Rate for Payer: Aetna Commercial |
$1,292.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,169.60
|
| Rate for Payer: Cash Price |
$408.00
|
| Rate for Payer: Cash Price |
$408.00
|
| Rate for Payer: Cigna Commercial |
$1,292.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$263.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$816.00
|
| Rate for Payer: Health EOS Commercial |
$1,237.60
|
| Rate for Payer: HFN Commercial |
$1,292.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,015.05
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,015.05
|
| Rate for Payer: Multiplan Commercial |
$1,088.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,292.00
|
| Rate for Payer: Quartz Beloit One Network |
$598.40
|
| Rate for Payer: Quartz Commercial |
$775.20
|
| Rate for Payer: The Alliance Commercial |
$680.00
|
| Rate for Payer: United Healthcare Medicaid |
$263.37
|
| Rate for Payer: WEA Trust Commercial |
$748.00
|
| Rate for Payer: WPS Commercial |
$1,007.35
|
|
|
Repair, complex (forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands, feet) each addition
|
Professional
|
Both
|
$662.00
|
|
|
Service Code
|
CPT 13133
|
| Hospital Charge Code |
3013614
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$127.86 |
| Max. Negotiated Rate |
$628.90 |
| Rate for Payer: Aetna Commercial |
$628.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$569.32
|
| Rate for Payer: Cash Price |
$198.60
|
| Rate for Payer: Cash Price |
$198.60
|
| Rate for Payer: Cigna Commercial |
$628.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$127.86
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$397.20
|
| Rate for Payer: Health EOS Commercial |
$602.42
|
| Rate for Payer: HFN Commercial |
$628.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$420.78
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$420.78
|
| Rate for Payer: Multiplan Commercial |
$529.60
|
| Rate for Payer: Preferred Network Access Commercial |
$628.90
|
| Rate for Payer: Quartz Beloit One Network |
$291.28
|
| Rate for Payer: Quartz Commercial |
$377.34
|
| Rate for Payer: The Alliance Commercial |
$331.00
|
| Rate for Payer: United Healthcare Medicaid |
$127.86
|
| Rate for Payer: WEA Trust Commercial |
$364.10
|
| Rate for Payer: WPS Commercial |
$490.34
|
|
|
REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 1.1 CM TO 2.5 CM
|
Facility
|
OP
|
$4,757.59
|
|
|
Service Code
|
CPT 13120
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$620.77 |
| Max. Negotiated Rate |
$4,757.59 |
| Rate for Payer: Aetna Managed Medicare |
$620.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,914.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,297.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,183.00
|
| Rate for Payer: Anthem Medicare Advantage |
$620.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$620.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$620.77
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$620.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,757.59
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$620.77
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,309.26
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$620.77
|
| Rate for Payer: Independent Care Health Plan Medicare |
$620.77
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$620.77
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$620.77
|
| Rate for Payer: NAPHCARE Commercial |
$931.16
|
| Rate for Payer: Quartz Medicare Advantage |
$620.77
|
| Rate for Payer: The Alliance Commercial |
$2,483.08
|
| Rate for Payer: United Healthcare Medicare Advantage |
$620.77
|
| Rate for Payer: United Healthcare PPO |
$2,257.00
|
| Rate for Payer: Wellcare Medicare |
$620.77
|
|
|
Repair, complex (scalp, arms, legs) 1.1-2.5cm 13120
|
Professional
|
Both
|
$809.00
|
|
|
Service Code
|
CPT 13120
|
| Hospital Charge Code |
3013609
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$129.28 |
| Max. Negotiated Rate |
$784.97 |
| Rate for Payer: Aetna Commercial |
$768.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$695.74
|
| Rate for Payer: Cash Price |
$242.70
|
| Rate for Payer: Cash Price |
$242.70
|
| Rate for Payer: Cigna Commercial |
$768.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$129.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$485.40
|
| Rate for Payer: Health EOS Commercial |
$736.19
|
| Rate for Payer: HFN Commercial |
$768.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$784.97
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$784.97
|
| Rate for Payer: Multiplan Commercial |
$647.20
|
| Rate for Payer: Preferred Network Access Commercial |
$768.55
|
| Rate for Payer: Quartz Beloit One Network |
$355.96
|
| Rate for Payer: Quartz Commercial |
$461.13
|
| Rate for Payer: The Alliance Commercial |
$404.50
|
| Rate for Payer: United Healthcare Medicaid |
$129.28
|
| Rate for Payer: WEA Trust Commercial |
$444.95
|
| Rate for Payer: WPS Commercial |
$599.23
|
|
|
Repair, complex (scalp, arms, legs) 2.6-7.5cm 13121
|
Professional
|
Both
|
$882.00
|
|
|
Service Code
|
CPT 13121
|
| Hospital Charge Code |
3013610
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$214.36 |
| Max. Negotiated Rate |
$865.73 |
| Rate for Payer: Aetna Commercial |
$837.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$758.52
|
| Rate for Payer: Cash Price |
$264.60
|
| Rate for Payer: Cash Price |
$264.60
|
| Rate for Payer: Cigna Commercial |
$837.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$214.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$529.20
|
| Rate for Payer: Health EOS Commercial |
$802.62
|
| Rate for Payer: HFN Commercial |
$837.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$865.73
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$865.73
|
| Rate for Payer: Multiplan Commercial |
$705.60
|
| Rate for Payer: Preferred Network Access Commercial |
$837.90
|
| Rate for Payer: Quartz Beloit One Network |
$388.08
|
| Rate for Payer: Quartz Commercial |
$502.74
|
| Rate for Payer: The Alliance Commercial |
$441.00
|
| Rate for Payer: United Healthcare Medicaid |
$214.36
|
| Rate for Payer: WEA Trust Commercial |
$485.10
|
| Rate for Payer: WPS Commercial |
$653.30
|
|
|
Repair, complex (scalp, arms, legs) each additional <=5cm 13122
|
Professional
|
Both
|
$375.00
|
|
|
Service Code
|
CPT 13122
|
| Hospital Charge Code |
3013611
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$86.36 |
| Max. Negotiated Rate |
$356.25 |
| Rate for Payer: Aetna Commercial |
$356.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$322.50
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cigna Commercial |
$356.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$86.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$225.00
|
| Rate for Payer: Health EOS Commercial |
$341.25
|
| Rate for Payer: HFN Commercial |
$356.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$275.16
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$275.16
|
| Rate for Payer: Multiplan Commercial |
$300.00
|
| Rate for Payer: Preferred Network Access Commercial |
$356.25
|
| Rate for Payer: Quartz Beloit One Network |
$165.00
|
| Rate for Payer: Quartz Commercial |
$213.75
|
| Rate for Payer: The Alliance Commercial |
$187.50
|
| Rate for Payer: United Healthcare Medicaid |
$86.36
|
| Rate for Payer: WEA Trust Commercial |
$206.25
|
| Rate for Payer: WPS Commercial |
$277.76
|
|
|
Repair, complex (trunk) 1.1-2.5cm 13100
|
Professional
|
Both
|
$473.00
|
|
|
Service Code
|
CPT 13100
|
| Hospital Charge Code |
3013606
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$103.40 |
| Max. Negotiated Rate |
$671.55 |
| Rate for Payer: Aetna Commercial |
$449.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$406.78
|
| Rate for Payer: Cash Price |
$141.90
|
| Rate for Payer: Cash Price |
$141.90
|
| Rate for Payer: Cigna Commercial |
$449.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$103.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$283.80
|
| Rate for Payer: Health EOS Commercial |
$430.43
|
| Rate for Payer: HFN Commercial |
$449.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$671.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$671.55
|
| Rate for Payer: Multiplan Commercial |
$378.40
|
| Rate for Payer: Preferred Network Access Commercial |
$449.35
|
| Rate for Payer: Quartz Beloit One Network |
$208.12
|
| Rate for Payer: Quartz Commercial |
$269.61
|
| Rate for Payer: The Alliance Commercial |
$236.50
|
| Rate for Payer: United Healthcare Medicaid |
$103.40
|
| Rate for Payer: WEA Trust Commercial |
$260.15
|
| Rate for Payer: WPS Commercial |
$350.35
|
|
|
Repair, complex (trunk) 2.6-7.5cm 13101
|
Professional
|
Both
|
$491.00
|
|
|
Service Code
|
CPT 13101
|
| Hospital Charge Code |
3013607
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$171.75 |
| Max. Negotiated Rate |
$837.49 |
| Rate for Payer: Aetna Commercial |
$466.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$422.26
|
| Rate for Payer: Cash Price |
$147.30
|
| Rate for Payer: Cash Price |
$147.30
|
| Rate for Payer: Cigna Commercial |
$466.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$171.75
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$294.60
|
| Rate for Payer: Health EOS Commercial |
$446.81
|
| Rate for Payer: HFN Commercial |
$466.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$837.49
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$837.49
|
| Rate for Payer: Multiplan Commercial |
$392.80
|
| Rate for Payer: Preferred Network Access Commercial |
$466.45
|
| Rate for Payer: Quartz Beloit One Network |
$216.04
|
| Rate for Payer: Quartz Commercial |
$279.87
|
| Rate for Payer: The Alliance Commercial |
$245.50
|
| Rate for Payer: United Healthcare Medicaid |
$171.75
|
| Rate for Payer: WEA Trust Commercial |
$270.05
|
| Rate for Payer: WPS Commercial |
$363.68
|
|
|
REPAIR, COMPLEX, TRUNK; 2.6 CM TO 7.5 CM
|
Facility
|
OP
|
$6,546.14
|
|
|
Service Code
|
CPT 13101
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$620.77 |
| Max. Negotiated Rate |
$6,546.14 |
| Rate for Payer: Aetna Managed Medicare |
$620.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,914.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,297.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,183.00
|
| Rate for Payer: Anthem Medicare Advantage |
$620.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$620.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$620.77
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$620.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,546.14
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$620.77
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,309.26
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$620.77
|
| Rate for Payer: Independent Care Health Plan Medicare |
$620.77
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$620.77
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$620.77
|
| Rate for Payer: NAPHCARE Commercial |
$931.16
|
| Rate for Payer: Quartz Medicare Advantage |
$620.77
|
| Rate for Payer: The Alliance Commercial |
$2,483.08
|
| Rate for Payer: United Healthcare Medicare Advantage |
$620.77
|
| Rate for Payer: United Healthcare PPO |
$2,257.00
|
| Rate for Payer: Wellcare Medicare |
$620.77
|
|
|
Repair, complex (trunk) each additional <= 5cm 13102
|
Professional
|
Both
|
$285.00
|
|
|
Service Code
|
CPT 13102
|
| Hospital Charge Code |
3013608
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$74.28 |
| Max. Negotiated Rate |
$270.75 |
| Rate for Payer: Aetna Commercial |
$270.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$245.10
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cigna Commercial |
$270.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$74.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$171.00
|
| Rate for Payer: Health EOS Commercial |
$259.35
|
| Rate for Payer: HFN Commercial |
$270.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$238.56
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$238.56
|
| Rate for Payer: Multiplan Commercial |
$228.00
|
| Rate for Payer: Preferred Network Access Commercial |
$270.75
|
| Rate for Payer: Quartz Beloit One Network |
$125.40
|
| Rate for Payer: Quartz Commercial |
$162.45
|
| Rate for Payer: The Alliance Commercial |
$142.50
|
| Rate for Payer: United Healthcare Medicaid |
$74.28
|
| Rate for Payer: WEA Trust Commercial |
$156.75
|
| Rate for Payer: WPS Commercial |
$211.10
|
|
|
REPAIR, COMPLEX, TRUNK; EACH ADDITIONAL 5 CM OR LESS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$6,546.14
|
|
|
Service Code
|
CPT 13102
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$6,546.14 |
| Max. Negotiated Rate |
$6,546.14 |
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,546.14
|
|
|
REPAIR, EXTENSOR TENDON, FINGER, PRIMARY OR SECONDARY; WITHOUT FREE GRAFT, EACH TENDON
|
Facility
|
OP
|
$7,795.33
|
|
|
Service Code
|
CPT 26418
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,588.57 |
| Max. Negotiated Rate |
$7,795.33 |
| Rate for Payer: Aetna Managed Medicare |
$1,588.57
|
| 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 |
$1,588.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,588.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,588.57
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$1,588.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,795.33
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1,588.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,909.48
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,588.57
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,588.57
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$1,588.57
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$1,588.57
|
| Rate for Payer: NAPHCARE Commercial |
$2,382.86
|
| Rate for Payer: Quartz Medicare Advantage |
$1,588.57
|
| Rate for Payer: The Alliance Commercial |
$6,354.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,588.57
|
| Rate for Payer: United Healthcare PPO |
$3,583.00
|
| Rate for Payer: Wellcare Medicare |
$1,588.57
|
|
|
REPAIR EYELID DEFECT 67914
|
Professional
|
Both
|
$1,265.00
|
|
|
Service Code
|
CPT 67914
|
| Hospital Charge Code |
3015247
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$139.23 |
| Max. Negotiated Rate |
$1,201.75 |
| Rate for Payer: Aetna Commercial |
$1,201.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,087.90
|
| Rate for Payer: Cash Price |
$379.50
|
| Rate for Payer: Cash Price |
$379.50
|
| Rate for Payer: Cigna Commercial |
$1,201.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$139.23
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$759.00
|
| Rate for Payer: Health EOS Commercial |
$1,151.15
|
| Rate for Payer: HFN Commercial |
$1,201.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,099.38
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,099.38
|
| Rate for Payer: Multiplan Commercial |
$1,012.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,201.75
|
| Rate for Payer: Quartz Beloit One Network |
$556.60
|
| Rate for Payer: Quartz Commercial |
$721.05
|
| Rate for Payer: The Alliance Commercial |
$632.50
|
| Rate for Payer: United Healthcare Medicaid |
$139.23
|
| Rate for Payer: WEA Trust Commercial |
$695.75
|
| Rate for Payer: WPS Commercial |
$936.99
|
|
|
REPAIR EYELID DEFECT 67923
|
Professional
|
Both
|
$3,561.00
|
|
|
Service Code
|
CPT 67923
|
| Hospital Charge Code |
3015249
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$452.00 |
| Max. Negotiated Rate |
$3,382.95 |
| Rate for Payer: Aetna Commercial |
$3,382.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,062.46
|
| Rate for Payer: Cash Price |
$1,068.30
|
| Rate for Payer: Cash Price |
$1,068.30
|
| Rate for Payer: Cigna Commercial |
$3,382.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$452.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,136.60
|
| Rate for Payer: Health EOS Commercial |
$3,240.51
|
| Rate for Payer: HFN Commercial |
$3,382.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,442.53
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,442.53
|
| Rate for Payer: Multiplan Commercial |
$2,848.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,382.95
|
| Rate for Payer: Quartz Beloit One Network |
$1,566.84
|
| Rate for Payer: Quartz Commercial |
$2,029.77
|
| Rate for Payer: The Alliance Commercial |
$1,780.50
|
| Rate for Payer: United Healthcare Medicaid |
$452.00
|
| Rate for Payer: WEA Trust Commercial |
$1,958.55
|
| Rate for Payer: WPS Commercial |
$2,637.63
|
|
|
REPAIR EYELID WOUND 67935
|
Professional
|
Both
|
$1,687.00
|
|
|
Service Code
|
CPT 67935
|
| Hospital Charge Code |
3015250
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$622.68 |
| Max. Negotiated Rate |
$1,602.65 |
| Rate for Payer: Aetna Commercial |
$1,602.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,450.82
|
| Rate for Payer: Cash Price |
$506.10
|
| Rate for Payer: Cash Price |
$506.10
|
| Rate for Payer: Cigna Commercial |
$1,602.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$622.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,012.20
|
| Rate for Payer: Health EOS Commercial |
$1,535.17
|
| Rate for Payer: HFN Commercial |
$1,602.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,477.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,477.20
|
| Rate for Payer: Multiplan Commercial |
$1,349.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,602.65
|
| Rate for Payer: Quartz Beloit One Network |
$742.28
|
| Rate for Payer: Quartz Commercial |
$961.59
|
| Rate for Payer: The Alliance Commercial |
$843.50
|
| Rate for Payer: United Healthcare Medicaid |
$622.68
|
| Rate for Payer: WEA Trust Commercial |
$927.85
|
| Rate for Payer: WPS Commercial |
$1,249.56
|
|
|
REPAIR HALLUX RIGIDUS 28289
|
Professional
|
Both
|
$1,815.00
|
|
|
Service Code
|
CPT 28289
|
| Hospital Charge Code |
3014232
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$321.01 |
| Max. Negotiated Rate |
$1,724.25 |
| Rate for Payer: Aetna Commercial |
$1,724.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,560.90
|
| Rate for Payer: Cash Price |
$544.50
|
| Rate for Payer: Cash Price |
$544.50
|
| Rate for Payer: Cigna Commercial |
$1,724.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$321.01
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,089.00
|
| Rate for Payer: Health EOS Commercial |
$1,651.65
|
| Rate for Payer: HFN Commercial |
$1,724.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,540.92
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,540.92
|
| Rate for Payer: Multiplan Commercial |
$1,452.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,724.25
|
| Rate for Payer: Quartz Beloit One Network |
$798.60
|
| Rate for Payer: Quartz Commercial |
$1,034.55
|
| Rate for Payer: The Alliance Commercial |
$907.50
|
| Rate for Payer: United Healthcare Medicaid |
$321.01
|
| Rate for Payer: WEA Trust Commercial |
$998.25
|
| Rate for Payer: WPS Commercial |
$1,344.37
|
|
|
REPAIR INCOMPLETE CIRCUMCISION
|
Facility
|
OP
|
$8,052.80
|
|
|
Service Code
|
CPT 54163
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,013.20 |
| Max. Negotiated Rate |
$8,052.80 |
| Rate for Payer: Aetna Managed Medicare |
$2,013.20
|
| 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 |
$2,013.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$2,013.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$2,013.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$2,013.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,757.59
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$2,013.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,489.10
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2,013.20
|
| Rate for Payer: Independent Care Health Plan Medicare |
$2,013.20
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$2,013.20
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$2,013.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,019.80
|
| Rate for Payer: Quartz Medicare Advantage |
$2,013.20
|
| Rate for Payer: The Alliance Commercial |
$8,052.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2,013.20
|
| Rate for Payer: United Healthcare PPO |
$3,583.00
|
| Rate for Payer: Wellcare Medicare |
$2,013.20
|
|
