|
SKIN BARRIER TAPE NEW IMAGE SZ 4 #14206
|
Facility
|
IP
|
$98.00
|
|
| Hospital Charge Code |
2969905
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$48.02 |
| Max. Negotiated Rate |
$90.16 |
| Rate for Payer: Aetna Commercial |
$88.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$84.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$51.94
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cigna Commercial |
$90.16
|
| Rate for Payer: Health EOS Commercial |
$87.22
|
| Rate for Payer: HFN Commercial |
$90.16
|
| Rate for Payer: Multiplan Commercial |
$78.40
|
| Rate for Payer: NAPHCARE Commercial |
$58.80
|
| Rate for Payer: Preferred Network Access Commercial |
$90.16
|
| Rate for Payer: Quartz Beloit One Network |
$48.02
|
| Rate for Payer: Quartz Commercial |
$58.80
|
| Rate for Payer: WEA Trust Commercial |
$53.90
|
| Rate for Payer: WPS Commercial |
$72.59
|
|
|
SKIN BARRIER TAPE NEW IMAGE SZ 4 #14206
|
Facility
|
OP
|
$98.00
|
|
| Hospital Charge Code |
2969905
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$27.44 |
| Max. Negotiated Rate |
$392.00 |
| Rate for Payer: Aetna Commercial |
$88.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$84.28
|
| Rate for Payer: Aetna Managed Medicare |
$27.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$63.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$49.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$47.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$51.94
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cigna Commercial |
$90.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$54.84
|
| Rate for Payer: Health EOS Commercial |
$87.22
|
| Rate for Payer: HFN Commercial |
$90.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$73.50
|
| Rate for Payer: Multiplan Commercial |
$78.40
|
| Rate for Payer: NAPHCARE Commercial |
$58.80
|
| Rate for Payer: Preferred Network Access Commercial |
$90.16
|
| Rate for Payer: Quartz Beloit One Network |
$48.02
|
| Rate for Payer: Quartz Commercial |
$63.70
|
| Rate for Payer: Quartz Medicare Advantage |
$58.80
|
| Rate for Payer: The Alliance Commercial |
$392.00
|
| Rate for Payer: WEA Trust Commercial |
$53.90
|
| Rate for Payer: WPS Commercial |
$72.59
|
|
|
Skin Care Management
|
Facility
|
OP
|
$137.00
|
|
|
Service Code
|
CPT 99211
|
| Hospital Charge Code |
3005551
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$38.36 |
| Max. Negotiated Rate |
$548.00 |
| Rate for Payer: Aetna Commercial |
$123.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$117.82
|
| Rate for Payer: Aetna Managed Medicare |
$38.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$89.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$68.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$65.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$72.61
|
| Rate for Payer: Cash Price |
$41.10
|
| Rate for Payer: Cigna Commercial |
$126.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$76.67
|
| Rate for Payer: Health EOS Commercial |
$121.93
|
| Rate for Payer: HFN Commercial |
$126.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$102.75
|
| Rate for Payer: Multiplan Commercial |
$109.60
|
| Rate for Payer: NAPHCARE Commercial |
$82.20
|
| Rate for Payer: Preferred Network Access Commercial |
$126.04
|
| Rate for Payer: Quartz Beloit One Network |
$67.13
|
| Rate for Payer: Quartz Commercial |
$89.05
|
| Rate for Payer: Quartz Medicare Advantage |
$82.20
|
| Rate for Payer: The Alliance Commercial |
$548.00
|
| Rate for Payer: WEA Trust Commercial |
$75.35
|
| Rate for Payer: WPS Commercial |
$101.48
|
|
|
Skin Care Management
|
Facility
|
IP
|
$137.00
|
|
|
Service Code
|
CPT 99211
|
| Hospital Charge Code |
3005551
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$67.13 |
| Max. Negotiated Rate |
$126.04 |
| Rate for Payer: Aetna Commercial |
$123.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$117.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$72.61
|
| Rate for Payer: Cash Price |
$41.10
|
| Rate for Payer: Cigna Commercial |
$126.04
|
| Rate for Payer: Health EOS Commercial |
$121.93
|
| Rate for Payer: HFN Commercial |
$126.04
|
| Rate for Payer: Multiplan Commercial |
$109.60
|
| Rate for Payer: NAPHCARE Commercial |
$82.20
|
| Rate for Payer: Preferred Network Access Commercial |
$126.04
|
| Rate for Payer: Quartz Beloit One Network |
$67.13
|
| Rate for Payer: Quartz Commercial |
$82.20
|
| Rate for Payer: WEA Trust Commercial |
$75.35
|
| Rate for Payer: WPS Commercial |
$101.48
|
|
|
SKIN CLOSURE DEVICE ZIPLINE ZIP16 PS1160
|
Facility
|
OP
|
$691.00
|
|
| Hospital Charge Code |
4493817
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$193.48 |
| Max. Negotiated Rate |
$2,764.00 |
| Rate for Payer: Aetna Commercial |
$621.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$594.26
|
| Rate for Payer: Aetna Managed Medicare |
$193.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$449.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$345.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$331.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$366.23
|
| Rate for Payer: Cash Price |
$207.30
|
| Rate for Payer: Cigna Commercial |
$635.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$386.68
|
| Rate for Payer: Health EOS Commercial |
$614.99
|
| Rate for Payer: HFN Commercial |
$635.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$518.25
|
| Rate for Payer: Multiplan Commercial |
$552.80
|
| Rate for Payer: NAPHCARE Commercial |
$414.60
|
| Rate for Payer: Preferred Network Access Commercial |
$635.72
|
| Rate for Payer: Quartz Beloit One Network |
$338.59
|
| Rate for Payer: Quartz Commercial |
$449.15
|
| Rate for Payer: Quartz Medicare Advantage |
$414.60
|
| Rate for Payer: The Alliance Commercial |
$2,764.00
|
| Rate for Payer: WEA Trust Commercial |
$380.05
|
| Rate for Payer: WPS Commercial |
$511.82
|
|
|
SKIN CLOSURE DEVICE ZIPLINE ZIP16 PS1160
|
Facility
|
IP
|
$691.00
|
|
| Hospital Charge Code |
4493817
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$338.59 |
| Max. Negotiated Rate |
$635.72 |
| Rate for Payer: Aetna Commercial |
$621.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$594.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$366.23
|
| Rate for Payer: Cash Price |
$207.30
|
| Rate for Payer: Cigna Commercial |
$635.72
|
| Rate for Payer: Health EOS Commercial |
$614.99
|
| Rate for Payer: HFN Commercial |
$635.72
|
| Rate for Payer: Multiplan Commercial |
$552.80
|
| Rate for Payer: NAPHCARE Commercial |
$414.60
|
| Rate for Payer: Preferred Network Access Commercial |
$635.72
|
| Rate for Payer: Quartz Beloit One Network |
$338.59
|
| Rate for Payer: Quartz Commercial |
$414.60
|
| Rate for Payer: WEA Trust Commercial |
$380.05
|
| Rate for Payer: WPS Commercial |
$511.82
|
|
|
SKIN CLOSURE DEVICE ZIPLINE ZIP4 PS2040
|
Facility
|
IP
|
$339.00
|
|
| Hospital Charge Code |
5106665
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$166.11 |
| Max. Negotiated Rate |
$311.88 |
| Rate for Payer: Aetna Commercial |
$305.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$291.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$179.67
|
| Rate for Payer: Cash Price |
$101.70
|
| Rate for Payer: Cigna Commercial |
$311.88
|
| Rate for Payer: Health EOS Commercial |
$301.71
|
| Rate for Payer: HFN Commercial |
$311.88
|
| Rate for Payer: Multiplan Commercial |
$271.20
|
| Rate for Payer: NAPHCARE Commercial |
$203.40
|
| Rate for Payer: Preferred Network Access Commercial |
$311.88
|
| Rate for Payer: Quartz Beloit One Network |
$166.11
|
| Rate for Payer: Quartz Commercial |
$203.40
|
| Rate for Payer: WEA Trust Commercial |
$186.45
|
| Rate for Payer: WPS Commercial |
$251.10
|
|
|
SKIN CLOSURE DEVICE ZIPLINE ZIP4 PS2040
|
Facility
|
OP
|
$339.00
|
|
| Hospital Charge Code |
5106665
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$94.92 |
| Max. Negotiated Rate |
$1,356.00 |
| Rate for Payer: Aetna Commercial |
$305.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$291.54
|
| Rate for Payer: Aetna Managed Medicare |
$94.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$220.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$169.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$162.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$179.67
|
| Rate for Payer: Cash Price |
$101.70
|
| Rate for Payer: Cigna Commercial |
$311.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$189.70
|
| Rate for Payer: Health EOS Commercial |
$301.71
|
| Rate for Payer: HFN Commercial |
$311.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$254.25
|
| Rate for Payer: Multiplan Commercial |
$271.20
|
| Rate for Payer: NAPHCARE Commercial |
$203.40
|
| Rate for Payer: Preferred Network Access Commercial |
$311.88
|
| Rate for Payer: Quartz Beloit One Network |
$166.11
|
| Rate for Payer: Quartz Commercial |
$220.35
|
| Rate for Payer: Quartz Medicare Advantage |
$203.40
|
| Rate for Payer: The Alliance Commercial |
$1,356.00
|
| Rate for Payer: WEA Trust Commercial |
$186.45
|
| Rate for Payer: WPS Commercial |
$251.10
|
|
|
SKIN CLOSURE DEVICE ZIPLINE ZIP8 PS2080
|
Facility
|
IP
|
$678.00
|
|
| Hospital Charge Code |
4493818
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$332.22 |
| Max. Negotiated Rate |
$623.76 |
| Rate for Payer: Aetna Commercial |
$610.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$583.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$359.34
|
| Rate for Payer: Cash Price |
$203.40
|
| Rate for Payer: Cigna Commercial |
$623.76
|
| Rate for Payer: Health EOS Commercial |
$603.42
|
| Rate for Payer: HFN Commercial |
$623.76
|
| Rate for Payer: Multiplan Commercial |
$542.40
|
| Rate for Payer: NAPHCARE Commercial |
$406.80
|
| Rate for Payer: Preferred Network Access Commercial |
$623.76
|
| Rate for Payer: Quartz Beloit One Network |
$332.22
|
| Rate for Payer: Quartz Commercial |
$406.80
|
| Rate for Payer: WEA Trust Commercial |
$372.90
|
| Rate for Payer: WPS Commercial |
$502.19
|
|
|
SKIN CLOSURE DEVICE ZIPLINE ZIP8 PS2080
|
Facility
|
OP
|
$678.00
|
|
| Hospital Charge Code |
4493818
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$189.84 |
| Max. Negotiated Rate |
$2,712.00 |
| Rate for Payer: Aetna Commercial |
$610.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$583.08
|
| Rate for Payer: Aetna Managed Medicare |
$189.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$440.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$339.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$325.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$359.34
|
| Rate for Payer: Cash Price |
$203.40
|
| Rate for Payer: Cigna Commercial |
$623.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$379.41
|
| Rate for Payer: Health EOS Commercial |
$603.42
|
| Rate for Payer: HFN Commercial |
$623.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$508.50
|
| Rate for Payer: Multiplan Commercial |
$542.40
|
| Rate for Payer: NAPHCARE Commercial |
$406.80
|
| Rate for Payer: Preferred Network Access Commercial |
$623.76
|
| Rate for Payer: Quartz Beloit One Network |
$332.22
|
| Rate for Payer: Quartz Commercial |
$440.70
|
| Rate for Payer: Quartz Medicare Advantage |
$406.80
|
| Rate for Payer: The Alliance Commercial |
$2,712.00
|
| Rate for Payer: WEA Trust Commercial |
$372.90
|
| Rate for Payer: WPS Commercial |
$502.19
|
|
|
SKIN DEBRIDEMENT WITH CC
|
Facility
|
IP
|
$45,301.00
|
|
|
Service Code
|
MSDRG 571
|
| Min. Negotiated Rate |
$16,295.40 |
| Max. Negotiated Rate |
$45,301.00 |
| Rate for Payer: Aetna Managed Medicare |
$16,295.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$35,456.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$27,176.89
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$25,819.82
|
| Rate for Payer: Anthem Medicare Advantage |
$16,295.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$16,295.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$16,295.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$16,295.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$28,662.37
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$16,295.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$32,992.05
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$16,295.40
|
| Rate for Payer: Independent Care Health Plan Medicare |
$16,295.40
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$16,295.40
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$16,295.40
|
| Rate for Payer: NAPHCARE Commercial |
$24,443.10
|
| Rate for Payer: Quartz Medicare Advantage |
$16,295.40
|
| Rate for Payer: The Alliance Commercial |
$45,301.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16,295.40
|
| Rate for Payer: United Healthcare PPO |
$25,684.73
|
| Rate for Payer: Wellcare Medicare |
$16,295.40
|
|
|
SKIN DEBRIDEMENT WITH MCC
|
Facility
|
IP
|
$78,010.00
|
|
|
Service Code
|
MSDRG 570
|
| Min. Negotiated Rate |
$28,061.13 |
| Max. Negotiated Rate |
$78,010.00 |
| Rate for Payer: Aetna Managed Medicare |
$28,061.13
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$61,261.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$46,956.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$44,611.76
|
| Rate for Payer: Anthem Medicare Advantage |
$28,061.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$28,061.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$28,061.13
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$28,061.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$49,523.14
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$28,061.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$56,982.90
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$28,061.13
|
| Rate for Payer: Independent Care Health Plan Medicare |
$28,061.13
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$28,061.13
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$28,061.13
|
| Rate for Payer: NAPHCARE Commercial |
$42,091.70
|
| Rate for Payer: Quartz Medicare Advantage |
$28,061.13
|
| Rate for Payer: The Alliance Commercial |
$78,010.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$28,061.13
|
| Rate for Payer: United Healthcare PPO |
$44,361.92
|
| Rate for Payer: Wellcare Medicare |
$28,061.13
|
|
|
SKIN DEBRIDEMENT WITHOUT CC/MCC
|
Facility
|
IP
|
$30,618.00
|
|
|
Service Code
|
MSDRG 572
|
| Min. Negotiated Rate |
$11,013.59 |
| Max. Negotiated Rate |
$30,618.00 |
| Rate for Payer: Aetna Managed Medicare |
$11,013.59
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$23,917.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$18,332.34
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$17,416.92
|
| Rate for Payer: Anthem Medicare Advantage |
$11,013.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$11,013.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$11,013.59
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$11,013.59
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19,334.38
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$11,013.59
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$22,222.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$11,013.59
|
| Rate for Payer: Independent Care Health Plan Medicare |
$11,013.59
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$11,013.59
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$11,013.59
|
| Rate for Payer: NAPHCARE Commercial |
$16,520.38
|
| Rate for Payer: Quartz Medicare Advantage |
$11,013.59
|
| Rate for Payer: The Alliance Commercial |
$30,618.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11,013.59
|
| Rate for Payer: United Healthcare PPO |
$17,300.27
|
| Rate for Payer: Wellcare Medicare |
$11,013.59
|
|
|
SKIN FULL GRAFT ADD-ON 15221
|
Professional
|
Both
|
$854.00
|
|
|
Service Code
|
CPT 15221
|
| Hospital Charge Code |
3013642
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$212.92 |
| Max. Negotiated Rate |
$811.30 |
| Rate for Payer: Aetna Commercial |
$811.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$734.44
|
| Rate for Payer: Cash Price |
$256.20
|
| Rate for Payer: Cash Price |
$256.20
|
| Rate for Payer: Cigna Commercial |
$811.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$212.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$512.40
|
| Rate for Payer: Health EOS Commercial |
$777.14
|
| Rate for Payer: HFN Commercial |
$811.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$228.50
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$228.50
|
| Rate for Payer: Multiplan Commercial |
$683.20
|
| Rate for Payer: Preferred Network Access Commercial |
$811.30
|
| Rate for Payer: Quartz Beloit One Network |
$375.76
|
| Rate for Payer: Quartz Commercial |
$486.78
|
| Rate for Payer: The Alliance Commercial |
$427.00
|
| Rate for Payer: United Healthcare Medicaid |
$212.92
|
| Rate for Payer: WEA Trust Commercial |
$469.70
|
| Rate for Payer: WPS Commercial |
$632.56
|
|
|
SKIN FULL GRAFT EEN AND LIPS 15260
|
Professional
|
Both
|
$3,308.00
|
|
|
Service Code
|
CPT 15260
|
| Hospital Charge Code |
3013644
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$753.31 |
| Max. Negotiated Rate |
$3,142.60 |
| Rate for Payer: Aetna Commercial |
$3,142.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,844.88
|
| Rate for Payer: Cash Price |
$992.40
|
| Rate for Payer: Cash Price |
$992.40
|
| Rate for Payer: Cigna Commercial |
$3,142.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$753.31
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,984.80
|
| Rate for Payer: Health EOS Commercial |
$3,010.28
|
| Rate for Payer: HFN Commercial |
$3,142.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,819.38
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2,819.38
|
| Rate for Payer: Multiplan Commercial |
$2,646.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,142.60
|
| Rate for Payer: Quartz Beloit One Network |
$1,455.52
|
| Rate for Payer: Quartz Commercial |
$1,885.56
|
| Rate for Payer: The Alliance Commercial |
$1,654.00
|
| Rate for Payer: United Healthcare Medicaid |
$753.31
|
| Rate for Payer: WEA Trust Commercial |
$1,819.40
|
| Rate for Payer: WPS Commercial |
$2,450.24
|
|
|
SKIN FULL GRAFT SCLP/ARM/LEG 15220
|
Professional
|
Both
|
$3,097.00
|
|
|
Service Code
|
CPT 15220
|
| Hospital Charge Code |
3013641
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$452.00 |
| Max. Negotiated Rate |
$2,942.15 |
| Rate for Payer: Aetna Commercial |
$2,942.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,663.42
|
| Rate for Payer: Cash Price |
$929.10
|
| Rate for Payer: Cash Price |
$929.10
|
| Rate for Payer: Cigna Commercial |
$2,942.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$452.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,858.20
|
| Rate for Payer: Health EOS Commercial |
$2,818.27
|
| Rate for Payer: HFN Commercial |
$2,942.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,026.29
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2,026.29
|
| Rate for Payer: Multiplan Commercial |
$2,477.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,942.15
|
| Rate for Payer: Quartz Beloit One Network |
$1,362.68
|
| Rate for Payer: Quartz Commercial |
$1,765.29
|
| Rate for Payer: The Alliance Commercial |
$1,548.50
|
| Rate for Payer: United Healthcare Medicaid |
$452.00
|
| Rate for Payer: WEA Trust Commercial |
$1,703.35
|
| Rate for Payer: WPS Commercial |
$2,293.95
|
|
|
SKIN FULL GRAFT, TRUNK 15200
|
Professional
|
Both
|
$3,459.00
|
|
|
Service Code
|
CPT 15200
|
| Hospital Charge Code |
3013640
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$363.86 |
| Max. Negotiated Rate |
$3,286.05 |
| Rate for Payer: Aetna Commercial |
$3,286.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,974.74
|
| Rate for Payer: Cash Price |
$1,037.70
|
| Rate for Payer: Cash Price |
$1,037.70
|
| Rate for Payer: Cigna Commercial |
$3,286.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$363.86
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,075.40
|
| Rate for Payer: Health EOS Commercial |
$3,147.69
|
| Rate for Payer: HFN Commercial |
$3,286.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,217.44
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2,217.44
|
| Rate for Payer: Multiplan Commercial |
$2,767.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,286.05
|
| Rate for Payer: Quartz Beloit One Network |
$1,521.96
|
| Rate for Payer: Quartz Commercial |
$1,971.63
|
| Rate for Payer: The Alliance Commercial |
$1,729.50
|
| Rate for Payer: United Healthcare Medicaid |
$363.86
|
| Rate for Payer: WEA Trust Commercial |
$1,902.45
|
| Rate for Payer: WPS Commercial |
$2,562.08
|
|
|
SKIN FULL GRFT ADD-ON =EA ADDL 20CM -FACE/GENIT/HF 15241
|
Professional
|
Both
|
$573.00
|
|
|
Service Code
|
CPT 15241
|
| Hospital Charge Code |
5837662
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$252.12 |
| Max. Negotiated Rate |
$544.35 |
| Rate for Payer: Aetna Commercial |
$544.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$492.78
|
| Rate for Payer: Cash Price |
$171.90
|
| Rate for Payer: Cash Price |
$171.90
|
| Rate for Payer: Cigna Commercial |
$544.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$309.94
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$343.80
|
| Rate for Payer: Health EOS Commercial |
$521.43
|
| Rate for Payer: HFN Commercial |
$544.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$350.32
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$350.32
|
| Rate for Payer: Multiplan Commercial |
$458.40
|
| Rate for Payer: Preferred Network Access Commercial |
$544.35
|
| Rate for Payer: Quartz Beloit One Network |
$252.12
|
| Rate for Payer: Quartz Commercial |
$326.61
|
| Rate for Payer: The Alliance Commercial |
$286.50
|
| Rate for Payer: United Healthcare Medicaid |
$309.94
|
| Rate for Payer: WEA Trust Commercial |
$315.15
|
| Rate for Payer: WPS Commercial |
$424.42
|
|
|
SKIN FULL GRFT ADD-ON = EA ADDL 20 SQ CM -EEN & LIPS 15261
|
Professional
|
Both
|
$661.00
|
|
|
Service Code
|
CPT 15261
|
| Hospital Charge Code |
5837663
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$290.84 |
| Max. Negotiated Rate |
$627.95 |
| Rate for Payer: Aetna Commercial |
$627.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$568.46
|
| Rate for Payer: Cash Price |
$198.30
|
| Rate for Payer: Cash Price |
$198.30
|
| Rate for Payer: Cigna Commercial |
$627.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$361.18
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$396.60
|
| Rate for Payer: Health EOS Commercial |
$601.51
|
| Rate for Payer: HFN Commercial |
$627.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$455.02
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$455.02
|
| Rate for Payer: Multiplan Commercial |
$528.80
|
| Rate for Payer: Preferred Network Access Commercial |
$627.95
|
| Rate for Payer: Quartz Beloit One Network |
$290.84
|
| Rate for Payer: Quartz Commercial |
$376.77
|
| Rate for Payer: The Alliance Commercial |
$330.50
|
| Rate for Payer: United Healthcare Medicaid |
$361.18
|
| Rate for Payer: WEA Trust Commercial |
$363.55
|
| Rate for Payer: WPS Commercial |
$489.60
|
|
|
SKIN FULL GRFT FACE/GENIT/HF 15240
|
Professional
|
Both
|
$2,628.00
|
|
|
Service Code
|
CPT 15240
|
| Hospital Charge Code |
3013643
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$835.27 |
| Max. Negotiated Rate |
$2,642.56 |
| Rate for Payer: Aetna Commercial |
$2,496.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,260.08
|
| Rate for Payer: Cash Price |
$788.40
|
| Rate for Payer: Cash Price |
$788.40
|
| Rate for Payer: Cigna Commercial |
$2,496.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$835.27
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,576.80
|
| Rate for Payer: Health EOS Commercial |
$2,391.48
|
| Rate for Payer: HFN Commercial |
$2,496.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,642.56
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2,642.56
|
| Rate for Payer: Multiplan Commercial |
$2,102.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,496.60
|
| Rate for Payer: Quartz Beloit One Network |
$1,156.32
|
| Rate for Payer: Quartz Commercial |
$1,497.96
|
| Rate for Payer: The Alliance Commercial |
$1,314.00
|
| Rate for Payer: United Healthcare Medicaid |
$835.27
|
| Rate for Payer: WEA Trust Commercial |
$1,445.40
|
| Rate for Payer: WPS Commercial |
$1,946.56
|
|
|
Skin Fungi Culture 87101PP
|
Professional
|
Both
|
$264.00
|
|
|
Service Code
|
CPT 87101
|
| Hospital Charge Code |
3137591
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$27.22 |
| Max. Negotiated Rate |
$250.80 |
| Rate for Payer: Aetna Commercial |
$250.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$227.04
|
| Rate for Payer: Cash Price |
$79.20
|
| Rate for Payer: Cash Price |
$79.20
|
| Rate for Payer: Cigna Commercial |
$250.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$132.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$158.40
|
| Rate for Payer: Health EOS Commercial |
$240.24
|
| Rate for Payer: HFN Commercial |
$250.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$27.22
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$27.22
|
| Rate for Payer: Multiplan Commercial |
$211.20
|
| Rate for Payer: Preferred Network Access Commercial |
$250.80
|
| Rate for Payer: Quartz Beloit One Network |
$116.16
|
| Rate for Payer: Quartz Commercial |
$150.48
|
| Rate for Payer: The Alliance Commercial |
$132.00
|
| Rate for Payer: WEA Trust Commercial |
$145.20
|
| Rate for Payer: WPS Commercial |
$195.54
|
|
|
SKIN GRAFT 15620
|
Professional
|
Both
|
$2,625.00
|
|
|
Service Code
|
CPT 15620
|
| Hospital Charge Code |
3013645
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$319.14 |
| Max. Negotiated Rate |
$2,493.75 |
| Rate for Payer: Aetna Commercial |
$2,493.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,257.50
|
| Rate for Payer: Cash Price |
$787.50
|
| Rate for Payer: Cash Price |
$787.50
|
| Rate for Payer: Cigna Commercial |
$2,493.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$319.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,575.00
|
| Rate for Payer: Health EOS Commercial |
$2,388.75
|
| Rate for Payer: HFN Commercial |
$2,493.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,080.60
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,080.60
|
| Rate for Payer: Multiplan Commercial |
$2,100.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,493.75
|
| Rate for Payer: Quartz Beloit One Network |
$1,155.00
|
| Rate for Payer: Quartz Commercial |
$1,496.25
|
| Rate for Payer: The Alliance Commercial |
$1,312.50
|
| Rate for Payer: United Healthcare Medicaid |
$319.14
|
| Rate for Payer: WEA Trust Commercial |
$1,443.75
|
| Rate for Payer: WPS Commercial |
$1,944.34
|
|
|
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC
|
Facility
|
IP
|
$70,749.00
|
|
|
Service Code
|
MSDRG 577
|
| Min. Negotiated Rate |
$25,449.40 |
| Max. Negotiated Rate |
$70,749.00 |
| Rate for Payer: Aetna Managed Medicare |
$25,449.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$55,597.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$42,614.65
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$40,486.70
|
| Rate for Payer: Anthem Medicare Advantage |
$25,449.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$25,449.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$25,449.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$25,449.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$44,943.95
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$25,449.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$51,657.45
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$25,449.40
|
| Rate for Payer: Independent Care Health Plan Medicare |
$25,449.40
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$25,449.40
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$25,449.40
|
| Rate for Payer: NAPHCARE Commercial |
$38,174.10
|
| Rate for Payer: Quartz Medicare Advantage |
$25,449.40
|
| Rate for Payer: The Alliance Commercial |
$70,749.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$25,449.40
|
| Rate for Payer: United Healthcare PPO |
$40,215.99
|
| Rate for Payer: Wellcare Medicare |
$25,449.40
|
|
|
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC
|
Facility
|
IP
|
$151,411.00
|
|
|
Service Code
|
MSDRG 576
|
| Min. Negotiated Rate |
$54,464.42 |
| Max. Negotiated Rate |
$151,411.00 |
| Rate for Payer: Aetna Managed Medicare |
$54,464.42
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$119,166.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$91,340.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$86,779.04
|
| Rate for Payer: Anthem Medicare Advantage |
$54,464.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$54,464.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$54,464.42
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$54,464.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$96,332.69
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$54,464.42
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$110,820.50
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$54,464.42
|
| Rate for Payer: Independent Care Health Plan Medicare |
$54,464.42
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$54,464.42
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$54,464.42
|
| Rate for Payer: NAPHCARE Commercial |
$81,696.63
|
| Rate for Payer: Quartz Medicare Advantage |
$54,464.42
|
| Rate for Payer: The Alliance Commercial |
$151,411.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$54,464.42
|
| Rate for Payer: United Healthcare PPO |
$86,275.14
|
| Rate for Payer: Wellcare Medicare |
$54,464.42
|
|
|
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC
|
Facility
|
IP
|
$43,137.00
|
|
|
Service Code
|
MSDRG 578
|
| Min. Negotiated Rate |
$15,516.95 |
| Max. Negotiated Rate |
$43,137.00 |
| Rate for Payer: Aetna Managed Medicare |
$15,516.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$33,777.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$25,890.41
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$24,597.58
|
| Rate for Payer: Anthem Medicare Advantage |
$15,516.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15,516.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15,516.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$15,516.95
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$27,305.57
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$15,516.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$31,404.75
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$15,516.95
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15,516.95
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$15,516.95
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$15,516.95
|
| Rate for Payer: NAPHCARE Commercial |
$23,275.42
|
| Rate for Payer: Quartz Medicare Advantage |
$15,516.95
|
| Rate for Payer: The Alliance Commercial |
$43,137.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15,516.95
|
| Rate for Payer: United Healthcare PPO |
$24,449.00
|
| Rate for Payer: Wellcare Medicare |
$15,516.95
|
|
