|
Simple repair of wounds (scalp, neck, axillae, external genitalia, trunk) 12.6-20.0cm 12005
|
Professional
|
Both
|
$791.00
|
|
|
Service Code
|
CPT 12005
|
| Hospital Charge Code |
3013585
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$82.61 |
| Max. Negotiated Rate |
$781.51 |
| Rate for Payer: Aetna Commercial |
$781.51
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$707.47
|
| Rate for Payer: Aetna Managed Medicare |
$82.61
|
| Rate for Payer: Anthem Medicare Advantage |
$82.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$82.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$82.61
|
| Rate for Payer: Cash Price |
$237.30
|
| Rate for Payer: Cash Price |
$237.30
|
| Rate for Payer: Cash Price |
$237.30
|
| Rate for Payer: Cigna Commercial |
$781.51
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$145.30
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$82.61
|
| Rate for Payer: Health EOS Commercial |
$748.60
|
| Rate for Payer: HFN Commercial |
$781.51
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$322.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$322.25
|
| Rate for Payer: Independent Care Health Plan Medicare |
$82.61
|
| Rate for Payer: Multiplan Commercial |
$658.11
|
| Rate for Payer: NAPHCARE Commercial |
$123.91
|
| Rate for Payer: Preferred Network Access Commercial |
$781.51
|
| Rate for Payer: Quartz Beloit One Network |
$361.96
|
| Rate for Payer: Quartz Commercial |
$468.90
|
| Rate for Payer: Quartz Medicare Advantage |
$82.61
|
| Rate for Payer: The Alliance Commercial |
$351.08
|
| Rate for Payer: United Healthcare Medicaid |
$145.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$82.61
|
| Rate for Payer: WEA Trust Commercial |
$452.45
|
| Rate for Payer: WPS Commercial |
$371.73
|
|
|
Simple repair of wounds (scalp, neck, axillae, external genitalia, trunk) 20.1-30.0cm 12006
|
Professional
|
Both
|
$974.00
|
|
|
Service Code
|
CPT 12006
|
| Hospital Charge Code |
3013586
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$100.70 |
| Max. Negotiated Rate |
$962.31 |
| Rate for Payer: Aetna Commercial |
$962.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$871.15
|
| Rate for Payer: Aetna Managed Medicare |
$100.70
|
| Rate for Payer: Anthem Medicare Advantage |
$100.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$100.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$100.70
|
| Rate for Payer: Cash Price |
$292.20
|
| Rate for Payer: Cash Price |
$292.20
|
| Rate for Payer: Cash Price |
$292.20
|
| Rate for Payer: Cigna Commercial |
$962.31
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$192.35
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$100.70
|
| Rate for Payer: Health EOS Commercial |
$921.79
|
| Rate for Payer: HFN Commercial |
$962.31
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$394.43
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$394.43
|
| Rate for Payer: Independent Care Health Plan Medicare |
$100.70
|
| Rate for Payer: Multiplan Commercial |
$810.37
|
| Rate for Payer: NAPHCARE Commercial |
$151.05
|
| Rate for Payer: Preferred Network Access Commercial |
$962.31
|
| Rate for Payer: Quartz Beloit One Network |
$445.70
|
| Rate for Payer: Quartz Commercial |
$577.39
|
| Rate for Payer: Quartz Medicare Advantage |
$100.70
|
| Rate for Payer: The Alliance Commercial |
$427.99
|
| Rate for Payer: United Healthcare Medicaid |
$192.35
|
| Rate for Payer: United Healthcare Medicare Advantage |
$100.70
|
| Rate for Payer: WEA Trust Commercial |
$557.13
|
| Rate for Payer: WPS Commercial |
$453.16
|
|
|
Simple repair of wounds (scalp, neck, axillae, external genitalia, trunk) <=2.5cm 12001
|
Professional
|
Both
|
$491.00
|
|
|
Service Code
|
CPT 12001
|
| Hospital Charge Code |
2957667
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$41.06 |
| Max. Negotiated Rate |
$485.11 |
| Rate for Payer: Aetna Commercial |
$485.11
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$439.15
|
| Rate for Payer: Aetna Managed Medicare |
$41.06
|
| Rate for Payer: Anthem Medicare Advantage |
$41.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$41.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$41.06
|
| Rate for Payer: Cash Price |
$147.30
|
| Rate for Payer: Cash Price |
$147.30
|
| Rate for Payer: Cash Price |
$147.30
|
| Rate for Payer: Cigna Commercial |
$485.11
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$53.41
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$41.06
|
| Rate for Payer: Health EOS Commercial |
$464.68
|
| Rate for Payer: HFN Commercial |
$485.11
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$150.71
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$150.71
|
| Rate for Payer: Independent Care Health Plan Medicare |
$41.06
|
| Rate for Payer: Multiplan Commercial |
$408.51
|
| Rate for Payer: NAPHCARE Commercial |
$61.59
|
| Rate for Payer: Preferred Network Access Commercial |
$485.11
|
| Rate for Payer: Quartz Beloit One Network |
$224.68
|
| Rate for Payer: Quartz Commercial |
$291.06
|
| Rate for Payer: Quartz Medicare Advantage |
$41.06
|
| Rate for Payer: The Alliance Commercial |
$174.50
|
| Rate for Payer: United Healthcare Medicaid |
$53.41
|
| Rate for Payer: United Healthcare Medicare Advantage |
$41.06
|
| Rate for Payer: WEA Trust Commercial |
$280.85
|
| Rate for Payer: WPS Commercial |
$184.77
|
|
|
Simple repair of wounds (scalp, neck, axillae, external genitalia, trunk) 2.6-7.5cm 12002
|
Professional
|
Both
|
$495.00
|
|
|
Service Code
|
CPT 12002
|
| Hospital Charge Code |
3013583
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$53.44 |
| Max. Negotiated Rate |
$489.06 |
| Rate for Payer: Aetna Commercial |
$489.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$442.73
|
| Rate for Payer: Aetna Managed Medicare |
$53.44
|
| Rate for Payer: Anthem Medicare Advantage |
$53.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$53.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$53.44
|
| Rate for Payer: Cash Price |
$148.50
|
| Rate for Payer: Cash Price |
$148.50
|
| Rate for Payer: Cash Price |
$148.50
|
| Rate for Payer: Cigna Commercial |
$489.06
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$68.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$53.44
|
| Rate for Payer: Health EOS Commercial |
$468.47
|
| Rate for Payer: HFN Commercial |
$489.06
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$198.65
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$198.65
|
| Rate for Payer: Independent Care Health Plan Medicare |
$53.44
|
| Rate for Payer: Multiplan Commercial |
$411.84
|
| Rate for Payer: NAPHCARE Commercial |
$80.15
|
| Rate for Payer: Preferred Network Access Commercial |
$489.06
|
| Rate for Payer: Quartz Beloit One Network |
$226.51
|
| Rate for Payer: Quartz Commercial |
$293.44
|
| Rate for Payer: Quartz Medicare Advantage |
$53.44
|
| Rate for Payer: The Alliance Commercial |
$227.10
|
| Rate for Payer: United Healthcare Medicaid |
$68.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$53.44
|
| Rate for Payer: WEA Trust Commercial |
$283.14
|
| Rate for Payer: WPS Commercial |
$240.46
|
|
|
Simple repair of wounds (scalp, neck, axillae, external genitalia, trunk) 7.6-12.5cm 12004
|
Professional
|
Both
|
$614.00
|
|
|
Service Code
|
CPT 12004
|
| Hospital Charge Code |
3013584
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$66.48 |
| Max. Negotiated Rate |
$606.63 |
| Rate for Payer: Aetna Commercial |
$606.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$549.16
|
| Rate for Payer: Aetna Managed Medicare |
$66.48
|
| Rate for Payer: Anthem Medicare Advantage |
$66.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$66.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$66.48
|
| Rate for Payer: Cash Price |
$184.20
|
| Rate for Payer: Cash Price |
$184.20
|
| Rate for Payer: Cash Price |
$184.20
|
| Rate for Payer: Cigna Commercial |
$606.63
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$91.07
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$66.48
|
| Rate for Payer: Health EOS Commercial |
$581.09
|
| Rate for Payer: HFN Commercial |
$606.63
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$247.41
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$247.41
|
| Rate for Payer: Independent Care Health Plan Medicare |
$66.48
|
| Rate for Payer: Multiplan Commercial |
$510.85
|
| Rate for Payer: NAPHCARE Commercial |
$99.72
|
| Rate for Payer: Preferred Network Access Commercial |
$606.63
|
| Rate for Payer: Quartz Beloit One Network |
$280.97
|
| Rate for Payer: Quartz Commercial |
$363.98
|
| Rate for Payer: Quartz Medicare Advantage |
$66.48
|
| Rate for Payer: The Alliance Commercial |
$282.53
|
| Rate for Payer: United Healthcare Medicaid |
$91.07
|
| Rate for Payer: United Healthcare Medicare Advantage |
$66.48
|
| Rate for Payer: WEA Trust Commercial |
$351.21
|
| Rate for Payer: WPS Commercial |
$299.15
|
|
|
SIMPLE WOUND REPAIR AND TREATMENT
|
Facility
|
OP
|
$327.57
|
|
|
Service Code
|
EAPG 00016
|
| Min. Negotiated Rate |
$314.98 |
| Max. Negotiated Rate |
$327.57 |
| Rate for Payer: Anthem Medicaid |
$314.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$314.98
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$314.98
|
| Rate for Payer: Dean Health Medicaid |
$314.98
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$314.98
|
| Rate for Payer: Managed Health Services Medicaid |
$327.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$314.98
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$314.98
|
| Rate for Payer: United Healthcare Medicaid |
$314.98
|
|
|
SIMS RESPONSE FORM
|
Facility
|
IP
|
$89.00
|
|
| Hospital Charge Code |
2972199
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$45.35 |
| Max. Negotiated Rate |
$85.16 |
| Rate for Payer: Aetna Commercial |
$83.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$79.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$49.06
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cigna Commercial |
$85.16
|
| Rate for Payer: Health EOS Commercial |
$82.38
|
| Rate for Payer: HFN Commercial |
$85.16
|
| Rate for Payer: Multiplan Commercial |
$74.05
|
| Rate for Payer: Preferred Network Access Commercial |
$85.16
|
| Rate for Payer: Quartz Beloit One Network |
$45.35
|
| Rate for Payer: Quartz Commercial |
$55.54
|
| Rate for Payer: WEA Trust Commercial |
$50.91
|
| Rate for Payer: WPS Commercial |
$68.56
|
|
|
SIMS RESPONSE FORM
|
Facility
|
OP
|
$89.00
|
|
| Hospital Charge Code |
2972199
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$25.92 |
| Max. Negotiated Rate |
$85.16 |
| Rate for Payer: Aetna Commercial |
$83.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$79.60
|
| Rate for Payer: Aetna Managed Medicare |
$25.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$60.16
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$46.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$44.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$49.06
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cigna Commercial |
$85.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$51.80
|
| Rate for Payer: Health EOS Commercial |
$82.38
|
| Rate for Payer: HFN Commercial |
$85.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$69.42
|
| Rate for Payer: Multiplan Commercial |
$74.05
|
| Rate for Payer: NAPHCARE Commercial |
$55.54
|
| Rate for Payer: Preferred Network Access Commercial |
$85.16
|
| Rate for Payer: Quartz Beloit One Network |
$45.35
|
| Rate for Payer: Quartz Commercial |
$60.16
|
| Rate for Payer: Quartz Medicare Advantage |
$55.54
|
| Rate for Payer: The Alliance Commercial |
$46.28
|
| Rate for Payer: WEA Trust Commercial |
$50.91
|
| Rate for Payer: WPS Commercial |
$68.56
|
|
|
Simulation Complex
|
Facility
|
IP
|
$4,761.00
|
|
|
Service Code
|
CPT 77290
|
| Hospital Charge Code |
3040376
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$2,426.21 |
| Max. Negotiated Rate |
$4,555.32 |
| Rate for Payer: Aetna Commercial |
$4,456.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,258.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,624.26
|
| Rate for Payer: Cash Price |
$1,428.30
|
| Rate for Payer: Cigna Commercial |
$4,555.32
|
| Rate for Payer: Health EOS Commercial |
$4,406.78
|
| Rate for Payer: HFN Commercial |
$4,555.32
|
| Rate for Payer: Multiplan Commercial |
$3,961.15
|
| Rate for Payer: Preferred Network Access Commercial |
$4,555.32
|
| Rate for Payer: Quartz Beloit One Network |
$2,426.21
|
| Rate for Payer: Quartz Commercial |
$2,970.86
|
| Rate for Payer: WEA Trust Commercial |
$2,723.29
|
| Rate for Payer: WPS Commercial |
$3,667.40
|
|
|
Simulation Complex
|
Facility
|
OP
|
$4,761.00
|
|
|
Service Code
|
CPT 77290
|
| Hospital Charge Code |
3040376
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$394.05 |
| Max. Negotiated Rate |
$4,555.32 |
| Rate for Payer: Aetna Commercial |
$4,456.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,258.24
|
| Rate for Payer: Aetna Managed Medicare |
$394.05
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,424.32
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,139.46
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,082.48
|
| Rate for Payer: Anthem Medicare Advantage |
$394.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,624.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$394.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$394.05
|
| Rate for Payer: Cash Price |
$1,428.30
|
| Rate for Payer: Cash Price |
$1,428.30
|
| Rate for Payer: Cigna Commercial |
$4,555.32
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$394.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,770.90
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$394.05
|
| Rate for Payer: Health EOS Commercial |
$4,406.78
|
| Rate for Payer: HFN Commercial |
$4,555.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,465.85
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$394.05
|
| Rate for Payer: Independent Care Health Plan Medicare |
$394.05
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$394.05
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$394.05
|
| Rate for Payer: Multiplan Commercial |
$3,961.15
|
| Rate for Payer: NAPHCARE Commercial |
$591.07
|
| Rate for Payer: Preferred Network Access Commercial |
$4,555.32
|
| Rate for Payer: Quartz Beloit One Network |
$2,426.21
|
| Rate for Payer: Quartz Commercial |
$3,218.44
|
| Rate for Payer: Quartz Medicare Advantage |
$394.05
|
| Rate for Payer: The Alliance Commercial |
$1,576.18
|
| Rate for Payer: United Healthcare Medicare Advantage |
$394.05
|
| Rate for Payer: United Healthcare PPO |
$3,713.58
|
| Rate for Payer: WEA Trust Commercial |
$2,723.29
|
| Rate for Payer: Wellcare Medicare |
$394.05
|
| Rate for Payer: WPS Commercial |
$3,667.40
|
|
|
Simulation Intermediate
|
Facility
|
IP
|
$5,953.00
|
|
|
Service Code
|
CPT 77285
|
| Hospital Charge Code |
3040375
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$3,033.65 |
| Max. Negotiated Rate |
$5,695.83 |
| Rate for Payer: Aetna Commercial |
$5,572.01
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,324.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,281.29
|
| Rate for Payer: Cash Price |
$1,785.90
|
| Rate for Payer: Cigna Commercial |
$5,695.83
|
| Rate for Payer: Health EOS Commercial |
$5,510.10
|
| Rate for Payer: HFN Commercial |
$5,695.83
|
| Rate for Payer: Multiplan Commercial |
$4,952.90
|
| Rate for Payer: Preferred Network Access Commercial |
$5,695.83
|
| Rate for Payer: Quartz Beloit One Network |
$3,033.65
|
| Rate for Payer: Quartz Commercial |
$3,714.67
|
| Rate for Payer: WEA Trust Commercial |
$3,405.12
|
| Rate for Payer: WPS Commercial |
$4,585.60
|
|
|
Simulation Intermediate
|
Facility
|
OP
|
$5,953.00
|
|
|
Service Code
|
CPT 77285
|
| Hospital Charge Code |
3040375
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$394.05 |
| Max. Negotiated Rate |
$5,695.83 |
| Rate for Payer: Aetna Commercial |
$5,572.01
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,324.36
|
| Rate for Payer: Aetna Managed Medicare |
$394.05
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,424.32
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,139.46
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,082.48
|
| Rate for Payer: Anthem Medicare Advantage |
$394.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,281.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$394.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$394.05
|
| Rate for Payer: Cash Price |
$1,785.90
|
| Rate for Payer: Cash Price |
$1,785.90
|
| Rate for Payer: Cigna Commercial |
$5,695.83
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$394.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,464.65
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$394.05
|
| Rate for Payer: Health EOS Commercial |
$5,510.10
|
| Rate for Payer: HFN Commercial |
$5,695.83
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,465.85
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$394.05
|
| Rate for Payer: Independent Care Health Plan Medicare |
$394.05
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$394.05
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$394.05
|
| Rate for Payer: Multiplan Commercial |
$4,952.90
|
| Rate for Payer: NAPHCARE Commercial |
$591.07
|
| Rate for Payer: Preferred Network Access Commercial |
$5,695.83
|
| Rate for Payer: Quartz Beloit One Network |
$3,033.65
|
| Rate for Payer: Quartz Commercial |
$4,024.23
|
| Rate for Payer: Quartz Medicare Advantage |
$394.05
|
| Rate for Payer: The Alliance Commercial |
$1,576.18
|
| Rate for Payer: United Healthcare Medicare Advantage |
$394.05
|
| Rate for Payer: United Healthcare PPO |
$4,643.34
|
| Rate for Payer: WEA Trust Commercial |
$3,405.12
|
| Rate for Payer: Wellcare Medicare |
$394.05
|
| Rate for Payer: WPS Commercial |
$4,585.60
|
|
|
Simulation Simple
|
Facility
|
IP
|
$2,036.00
|
|
|
Service Code
|
CPT 77280
|
| Hospital Charge Code |
3040374
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$1,037.55 |
| Max. Negotiated Rate |
$1,948.04 |
| Rate for Payer: Aetna Commercial |
$1,905.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,821.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,122.24
|
| Rate for Payer: Cash Price |
$610.80
|
| Rate for Payer: Cigna Commercial |
$1,948.04
|
| Rate for Payer: Health EOS Commercial |
$1,884.52
|
| Rate for Payer: HFN Commercial |
$1,948.04
|
| Rate for Payer: Multiplan Commercial |
$1,693.95
|
| Rate for Payer: Preferred Network Access Commercial |
$1,948.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,037.55
|
| Rate for Payer: Quartz Commercial |
$1,270.46
|
| Rate for Payer: WEA Trust Commercial |
$1,164.59
|
| Rate for Payer: WPS Commercial |
$1,568.33
|
|
|
Simulation Simple
|
Facility
|
OP
|
$2,036.00
|
|
|
Service Code
|
CPT 77280
|
| Hospital Charge Code |
3040374
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$141.45 |
| Max. Negotiated Rate |
$1,948.04 |
| Rate for Payer: Aetna Commercial |
$1,905.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,821.00
|
| Rate for Payer: Aetna Managed Medicare |
$141.45
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$523.03
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$418.42
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$397.50
|
| Rate for Payer: Anthem Medicare Advantage |
$141.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,122.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$141.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$141.45
|
| Rate for Payer: Cash Price |
$610.80
|
| Rate for Payer: Cash Price |
$610.80
|
| Rate for Payer: Cigna Commercial |
$1,948.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$141.45
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,184.95
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$141.45
|
| Rate for Payer: Health EOS Commercial |
$1,884.52
|
| Rate for Payer: HFN Commercial |
$1,948.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$526.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$141.45
|
| Rate for Payer: Independent Care Health Plan Medicare |
$141.45
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$141.45
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$141.45
|
| Rate for Payer: Multiplan Commercial |
$1,693.95
|
| Rate for Payer: NAPHCARE Commercial |
$212.18
|
| Rate for Payer: Preferred Network Access Commercial |
$1,948.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,037.55
|
| Rate for Payer: Quartz Commercial |
$1,376.34
|
| Rate for Payer: Quartz Medicare Advantage |
$141.45
|
| Rate for Payer: The Alliance Commercial |
$565.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$141.45
|
| Rate for Payer: United Healthcare PPO |
$1,588.08
|
| Rate for Payer: WEA Trust Commercial |
$1,164.59
|
| Rate for Payer: Wellcare Medicare |
$141.45
|
| Rate for Payer: WPS Commercial |
$1,568.33
|
|
|
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT
|
Facility
|
IP
|
$145,816.32
|
|
|
Service Code
|
MSDRG 008
|
| Min. Negotiated Rate |
$43,427.91 |
| Max. Negotiated Rate |
$145,816.32 |
| Rate for Payer: Aetna Managed Medicare |
$43,427.91
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$122,287.89
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$93,732.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$89,052.16
|
| Rate for Payer: Anthem Medicare Advantage |
$43,427.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$43,427.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$43,427.91
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$43,427.91
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$98,856.06
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$43,427.91
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$43,427.91
|
| Rate for Payer: Independent Care Health Plan Medicare |
$43,427.91
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$43,427.91
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$43,427.91
|
| Rate for Payer: NAPHCARE Commercial |
$65,141.87
|
| Rate for Payer: Quartz Medicare Advantage |
$43,427.91
|
| Rate for Payer: The Alliance Commercial |
$145,816.32
|
| Rate for Payer: United Healthcare Medicare Advantage |
$43,427.91
|
| Rate for Payer: Wellcare Medicare |
$43,427.91
|
|
|
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS
|
Facility
|
IP
|
$221,348.40
|
|
|
Service Code
|
MSDRG 019
|
| Min. Negotiated Rate |
$55,144.95 |
| Max. Negotiated Rate |
$221,348.40 |
| Rate for Payer: Aetna Managed Medicare |
$55,144.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$144,600.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$110,834.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$105,300.38
|
| Rate for Payer: Anthem Medicare Advantage |
$55,144.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$55,144.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$55,144.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$55,144.95
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$116,893.07
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$55,144.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$162,108.23
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$55,144.95
|
| Rate for Payer: Independent Care Health Plan Medicare |
$55,144.95
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$55,144.95
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$55,144.95
|
| Rate for Payer: NAPHCARE Commercial |
$82,717.42
|
| Rate for Payer: Quartz Medicare Advantage |
$55,144.95
|
| Rate for Payer: The Alliance Commercial |
$221,348.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$55,144.95
|
| Rate for Payer: United Healthcare PPO |
$126,203.29
|
| Rate for Payer: Wellcare Medicare |
$55,144.95
|
|
|
Sincalide
|
Facility
|
IP
|
$310.00
|
|
|
Service Code
|
HCPCS J2805
|
| Hospital Charge Code |
5593282
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$157.98 |
| Max. Negotiated Rate |
$296.61 |
| Rate for Payer: Aetna Commercial |
$290.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$277.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$170.87
|
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Cigna Commercial |
$296.61
|
| Rate for Payer: Health EOS Commercial |
$286.94
|
| Rate for Payer: HFN Commercial |
$296.61
|
| Rate for Payer: Multiplan Commercial |
$257.92
|
| Rate for Payer: Preferred Network Access Commercial |
$296.61
|
| Rate for Payer: Quartz Beloit One Network |
$157.98
|
| Rate for Payer: Quartz Commercial |
$193.44
|
| Rate for Payer: WEA Trust Commercial |
$177.32
|
| Rate for Payer: WPS Commercial |
$238.79
|
|
|
Sincalide
|
Professional
|
Both
|
$310.00
|
|
|
Service Code
|
HCPCS J2805
|
| Hospital Charge Code |
5593282
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$114.54 |
| Max. Negotiated Rate |
$337.33 |
| Rate for Payer: Aetna Commercial |
$306.28
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$277.26
|
| Rate for Payer: Aetna Managed Medicare |
$114.54
|
| Rate for Payer: Anthem Medicare Advantage |
$114.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$114.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$114.54
|
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Cigna Commercial |
$306.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$114.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$134.93
|
| Rate for Payer: Health EOS Commercial |
$293.38
|
| Rate for Payer: HFN Commercial |
$306.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$174.86
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$174.86
|
| Rate for Payer: Independent Care Health Plan Medicare |
$114.54
|
| Rate for Payer: Multiplan Commercial |
$257.92
|
| Rate for Payer: NAPHCARE Commercial |
$171.80
|
| Rate for Payer: Preferred Network Access Commercial |
$306.28
|
| Rate for Payer: Quartz Beloit One Network |
$141.86
|
| Rate for Payer: Quartz Commercial |
$183.77
|
| Rate for Payer: Quartz Medicare Advantage |
$114.54
|
| Rate for Payer: The Alliance Commercial |
$314.97
|
| Rate for Payer: United Healthcare Medicaid |
$114.54
|
| Rate for Payer: United Healthcare Medicare Advantage |
$114.54
|
| Rate for Payer: WEA Trust Commercial |
$177.32
|
| Rate for Payer: WPS Commercial |
$337.33
|
|
|
Sincalide
|
Facility
|
OP
|
$310.00
|
|
|
Service Code
|
HCPCS J2805
|
| Hospital Charge Code |
5593282
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$90.27 |
| Max. Negotiated Rate |
$458.14 |
| Rate for Payer: Aetna Commercial |
$290.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$277.26
|
| Rate for Payer: Aetna Managed Medicare |
$90.27
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$209.56
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$161.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$154.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$170.87
|
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Cigna Commercial |
$296.61
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$178.51
|
| Rate for Payer: Health EOS Commercial |
$286.94
|
| Rate for Payer: HFN Commercial |
$296.61
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$241.80
|
| Rate for Payer: Multiplan Commercial |
$257.92
|
| Rate for Payer: NAPHCARE Commercial |
$193.44
|
| Rate for Payer: Preferred Network Access Commercial |
$296.61
|
| Rate for Payer: Quartz Beloit One Network |
$157.98
|
| Rate for Payer: Quartz Commercial |
$209.56
|
| Rate for Payer: Quartz Medicare Advantage |
$193.44
|
| Rate for Payer: The Alliance Commercial |
$458.14
|
| Rate for Payer: WEA Trust Commercial |
$177.32
|
| Rate for Payer: WPS Commercial |
$337.33
|
|
|
Single Biopatch used - Arterial Line Dressing:
|
Facility
|
OP
|
$196.00
|
|
| Hospital Charge Code |
3025894
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$57.08 |
| Max. Negotiated Rate |
$187.53 |
| Rate for Payer: Aetna Commercial |
$183.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$175.30
|
| Rate for Payer: Aetna Managed Medicare |
$57.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$132.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$101.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$97.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$108.04
|
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: Cigna Commercial |
$187.53
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$114.07
|
| Rate for Payer: Health EOS Commercial |
$181.42
|
| Rate for Payer: HFN Commercial |
$187.53
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$152.88
|
| Rate for Payer: Multiplan Commercial |
$163.07
|
| Rate for Payer: NAPHCARE Commercial |
$122.30
|
| Rate for Payer: Preferred Network Access Commercial |
$187.53
|
| Rate for Payer: Quartz Beloit One Network |
$99.88
|
| Rate for Payer: Quartz Commercial |
$132.50
|
| Rate for Payer: Quartz Medicare Advantage |
$122.30
|
| Rate for Payer: The Alliance Commercial |
$101.92
|
| Rate for Payer: WEA Trust Commercial |
$112.11
|
| Rate for Payer: WPS Commercial |
$150.98
|
|
|
Single Biopatch used - Arterial Line Dressing:
|
Facility
|
IP
|
$196.00
|
|
| Hospital Charge Code |
3025894
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$99.88 |
| Max. Negotiated Rate |
$187.53 |
| Rate for Payer: Aetna Commercial |
$183.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$175.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$108.04
|
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: Cigna Commercial |
$187.53
|
| Rate for Payer: Health EOS Commercial |
$181.42
|
| Rate for Payer: HFN Commercial |
$187.53
|
| Rate for Payer: Multiplan Commercial |
$163.07
|
| Rate for Payer: Preferred Network Access Commercial |
$187.53
|
| Rate for Payer: Quartz Beloit One Network |
$99.88
|
| Rate for Payer: Quartz Commercial |
$122.30
|
| Rate for Payer: WEA Trust Commercial |
$112.11
|
| Rate for Payer: WPS Commercial |
$150.98
|
|
|
Single Biopatch used - Central IV Dressing:
|
Facility
|
IP
|
$188.00
|
|
| Hospital Charge Code |
3025904
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$95.80 |
| Max. Negotiated Rate |
$179.88 |
| Rate for Payer: Aetna Commercial |
$175.97
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$168.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$103.63
|
| Rate for Payer: Cash Price |
$56.40
|
| Rate for Payer: Cigna Commercial |
$179.88
|
| Rate for Payer: Health EOS Commercial |
$174.01
|
| Rate for Payer: HFN Commercial |
$179.88
|
| Rate for Payer: Multiplan Commercial |
$156.42
|
| Rate for Payer: Preferred Network Access Commercial |
$179.88
|
| Rate for Payer: Quartz Beloit One Network |
$95.80
|
| Rate for Payer: Quartz Commercial |
$117.31
|
| Rate for Payer: WEA Trust Commercial |
$107.54
|
| Rate for Payer: WPS Commercial |
$144.82
|
|
|
Single Biopatch used - Central IV Dressing:
|
Facility
|
OP
|
$188.00
|
|
| Hospital Charge Code |
3025904
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$54.75 |
| Max. Negotiated Rate |
$179.88 |
| Rate for Payer: Aetna Commercial |
$175.97
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$168.15
|
| Rate for Payer: Aetna Managed Medicare |
$54.75
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$127.09
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$97.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$93.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$103.63
|
| Rate for Payer: Cash Price |
$56.40
|
| Rate for Payer: Cigna Commercial |
$179.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$109.42
|
| Rate for Payer: Health EOS Commercial |
$174.01
|
| Rate for Payer: HFN Commercial |
$179.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$146.64
|
| Rate for Payer: Multiplan Commercial |
$156.42
|
| Rate for Payer: NAPHCARE Commercial |
$117.31
|
| Rate for Payer: Preferred Network Access Commercial |
$179.88
|
| Rate for Payer: Quartz Beloit One Network |
$95.80
|
| Rate for Payer: Quartz Commercial |
$127.09
|
| Rate for Payer: Quartz Medicare Advantage |
$117.31
|
| Rate for Payer: The Alliance Commercial |
$97.76
|
| Rate for Payer: WEA Trust Commercial |
$107.54
|
| Rate for Payer: WPS Commercial |
$144.82
|
|
|
Single Biopatch used - IABP Dressing/Activity
|
Facility
|
OP
|
$196.00
|
|
| Hospital Charge Code |
3025921
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$57.08 |
| Max. Negotiated Rate |
$187.53 |
| Rate for Payer: Aetna Commercial |
$183.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$175.30
|
| Rate for Payer: Aetna Managed Medicare |
$57.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$132.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$101.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$97.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$108.04
|
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: Cigna Commercial |
$187.53
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$114.07
|
| Rate for Payer: Health EOS Commercial |
$181.42
|
| Rate for Payer: HFN Commercial |
$187.53
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$152.88
|
| Rate for Payer: Multiplan Commercial |
$163.07
|
| Rate for Payer: NAPHCARE Commercial |
$122.30
|
| Rate for Payer: Preferred Network Access Commercial |
$187.53
|
| Rate for Payer: Quartz Beloit One Network |
$99.88
|
| Rate for Payer: Quartz Commercial |
$132.50
|
| Rate for Payer: Quartz Medicare Advantage |
$122.30
|
| Rate for Payer: The Alliance Commercial |
$101.92
|
| Rate for Payer: WEA Trust Commercial |
$112.11
|
| Rate for Payer: WPS Commercial |
$150.98
|
|
|
Single Biopatch used - IABP Dressing/Activity
|
Facility
|
IP
|
$196.00
|
|
| Hospital Charge Code |
3025921
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$99.88 |
| Max. Negotiated Rate |
$187.53 |
| Rate for Payer: Aetna Commercial |
$183.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$175.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$108.04
|
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: Cigna Commercial |
$187.53
|
| Rate for Payer: Health EOS Commercial |
$181.42
|
| Rate for Payer: HFN Commercial |
$187.53
|
| Rate for Payer: Multiplan Commercial |
$163.07
|
| Rate for Payer: Preferred Network Access Commercial |
$187.53
|
| Rate for Payer: Quartz Beloit One Network |
$99.88
|
| Rate for Payer: Quartz Commercial |
$122.30
|
| Rate for Payer: WEA Trust Commercial |
$112.11
|
| Rate for Payer: WPS Commercial |
$150.98
|
|
