|
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC
|
Facility
|
IP
|
$90,867.00
|
|
|
Service Code
|
MSDRG 574
|
| Min. Negotiated Rate |
$32,685.94 |
| Max. Negotiated Rate |
$90,867.00 |
| Rate for Payer: Aetna Managed Medicare |
$32,685.94
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$71,541.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$54,836.21
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$52,097.98
|
| Rate for Payer: Anthem Medicare Advantage |
$32,685.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$32,685.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$32,685.94
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$32,685.94
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$57,833.53
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$32,685.94
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$66,413.10
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$32,685.94
|
| Rate for Payer: Independent Care Health Plan Medicare |
$32,685.94
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$32,685.94
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$32,685.94
|
| Rate for Payer: NAPHCARE Commercial |
$49,028.91
|
| Rate for Payer: Quartz Medicare Advantage |
$32,685.94
|
| Rate for Payer: The Alliance Commercial |
$90,867.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$32,685.94
|
| Rate for Payer: United Healthcare PPO |
$51,703.45
|
| Rate for Payer: Wellcare Medicare |
$32,685.94
|
|
|
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC
|
Facility
|
IP
|
$165,635.00
|
|
|
Service Code
|
MSDRG 573
|
| Min. Negotiated Rate |
$59,580.78 |
| Max. Negotiated Rate |
$165,635.00 |
| Rate for Payer: Aetna Managed Medicare |
$59,580.78
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$130,495.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$100,023.82
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$95,029.16
|
| Rate for Payer: Anthem Medicare Advantage |
$59,580.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$59,580.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$59,580.78
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$59,580.78
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$105,491.08
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$59,580.78
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$121,253.00
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$59,580.78
|
| Rate for Payer: Independent Care Health Plan Medicare |
$59,580.78
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$59,580.78
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$59,580.78
|
| Rate for Payer: NAPHCARE Commercial |
$89,371.17
|
| Rate for Payer: Quartz Medicare Advantage |
$59,580.78
|
| Rate for Payer: The Alliance Commercial |
$165,635.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$59,580.78
|
| Rate for Payer: United Healthcare PPO |
$94,396.98
|
| Rate for Payer: Wellcare Medicare |
$59,580.78
|
|
|
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC
|
Facility
|
IP
|
$54,715.00
|
|
|
Service Code
|
MSDRG 575
|
| Min. Negotiated Rate |
$19,681.76 |
| Max. Negotiated Rate |
$54,715.00 |
| Rate for Payer: Aetna Managed Medicare |
$19,681.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$43,009.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$32,966.05
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$31,319.90
|
| Rate for Payer: Anthem Medicare Advantage |
$19,681.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$19,681.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$19,681.76
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$19,681.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$34,767.96
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$19,681.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$39,897.00
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$19,681.76
|
| Rate for Payer: Independent Care Health Plan Medicare |
$19,681.76
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$19,681.76
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$19,681.76
|
| Rate for Payer: NAPHCARE Commercial |
$29,522.64
|
| Rate for Payer: Quartz Medicare Advantage |
$19,681.76
|
| Rate for Payer: The Alliance Commercial |
$54,715.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19,681.76
|
| Rate for Payer: United Healthcare PPO |
$31,060.33
|
| Rate for Payer: Wellcare Medicare |
$19,681.76
|
|
|
SKIN GRAFT, FULL THICKNESS
|
Facility
|
OP
|
$1,397.00
|
|
| Hospital Charge Code |
2960377
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$391.16 |
| Max. Negotiated Rate |
$5,588.00 |
| Rate for Payer: Aetna Commercial |
$1,257.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,201.42
|
| Rate for Payer: Aetna Managed Medicare |
$391.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$908.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$698.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$670.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$740.41
|
| Rate for Payer: Cash Price |
$419.10
|
| Rate for Payer: Cigna Commercial |
$1,285.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$781.76
|
| Rate for Payer: Health EOS Commercial |
$1,243.33
|
| Rate for Payer: HFN Commercial |
$1,285.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,047.75
|
| Rate for Payer: Multiplan Commercial |
$1,117.60
|
| Rate for Payer: NAPHCARE Commercial |
$838.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,285.24
|
| Rate for Payer: Quartz Beloit One Network |
$684.53
|
| Rate for Payer: Quartz Commercial |
$908.05
|
| Rate for Payer: Quartz Medicare Advantage |
$838.20
|
| Rate for Payer: The Alliance Commercial |
$5,588.00
|
| Rate for Payer: WEA Trust Commercial |
$768.35
|
| Rate for Payer: WPS Commercial |
$1,034.76
|
|
|
SKIN GRAFT, FULL THICKNESS
|
Facility
|
IP
|
$1,397.00
|
|
| Hospital Charge Code |
2960377
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$684.53 |
| Max. Negotiated Rate |
$1,285.24 |
| Rate for Payer: Aetna Commercial |
$1,257.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,201.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$740.41
|
| Rate for Payer: Cash Price |
$419.10
|
| Rate for Payer: Cigna Commercial |
$1,285.24
|
| Rate for Payer: Health EOS Commercial |
$1,243.33
|
| Rate for Payer: HFN Commercial |
$1,285.24
|
| Rate for Payer: Multiplan Commercial |
$1,117.60
|
| Rate for Payer: NAPHCARE Commercial |
$838.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,285.24
|
| Rate for Payer: Quartz Beloit One Network |
$684.53
|
| Rate for Payer: Quartz Commercial |
$838.20
|
| Rate for Payer: WEA Trust Commercial |
$768.35
|
| Rate for Payer: WPS Commercial |
$1,034.76
|
|
|
SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC
|
Facility
|
IP
|
$49,808.00
|
|
|
Service Code
|
MSDRG 623
|
| Min. Negotiated Rate |
$17,916.38 |
| Max. Negotiated Rate |
$49,808.00 |
| Rate for Payer: Aetna Managed Medicare |
$17,916.38
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$39,022.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$29,910.66
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$28,417.08
|
| Rate for Payer: Anthem Medicare Advantage |
$17,916.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17,916.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17,916.38
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$17,916.38
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$31,545.56
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$17,916.38
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$36,297.30
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17,916.38
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17,916.38
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$17,916.38
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$17,916.38
|
| Rate for Payer: NAPHCARE Commercial |
$26,874.57
|
| Rate for Payer: Quartz Medicare Advantage |
$17,916.38
|
| Rate for Payer: The Alliance Commercial |
$49,808.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17,916.38
|
| Rate for Payer: United Healthcare PPO |
$28,257.91
|
| Rate for Payer: Wellcare Medicare |
$17,916.38
|
|
|
SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC
|
Facility
|
IP
|
$102,028.00
|
|
|
Service Code
|
MSDRG 622
|
| Min. Negotiated Rate |
$36,700.61 |
| Max. Negotiated Rate |
$102,028.00 |
| Rate for Payer: Aetna Managed Medicare |
$36,700.61
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$80,353.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$61,590.23
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$58,514.74
|
| Rate for Payer: Anthem Medicare Advantage |
$36,700.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$36,700.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$36,700.61
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$36,700.61
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$64,956.72
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$36,700.61
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$74,599.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$36,700.61
|
| Rate for Payer: Independent Care Health Plan Medicare |
$36,700.61
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$36,700.61
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$36,700.61
|
| Rate for Payer: NAPHCARE Commercial |
$55,050.92
|
| Rate for Payer: Quartz Medicare Advantage |
$36,700.61
|
| Rate for Payer: The Alliance Commercial |
$102,028.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$36,700.61
|
| Rate for Payer: United Healthcare PPO |
$58,076.43
|
| Rate for Payer: Wellcare Medicare |
$36,700.61
|
|
|
SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC
|
Facility
|
IP
|
$29,950.00
|
|
|
Service Code
|
MSDRG 624
|
| Min. Negotiated Rate |
$10,773.56 |
| Max. Negotiated Rate |
$29,950.00 |
| Rate for Payer: Aetna Managed Medicare |
$10,773.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$23,287.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$17,849.91
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$16,958.58
|
| Rate for Payer: Anthem Medicare Advantage |
$10,773.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$10,773.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$10,773.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$10,773.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$18,825.58
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$10,773.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$21,732.75
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$10,773.56
|
| Rate for Payer: Independent Care Health Plan Medicare |
$10,773.56
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$10,773.56
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$10,773.56
|
| Rate for Payer: NAPHCARE Commercial |
$16,160.34
|
| Rate for Payer: Quartz Medicare Advantage |
$10,773.56
|
| Rate for Payer: The Alliance Commercial |
$29,950.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$10,773.56
|
| Rate for Payer: United Healthcare PPO |
$16,919.22
|
| Rate for Payer: Wellcare Medicare |
$10,773.56
|
|
|
SKIN GRAFTS FOR INJURIES WITH CC/MCC
|
Facility
|
IP
|
$86,890.00
|
|
|
Service Code
|
MSDRG 904
|
| Min. Negotiated Rate |
$31,255.26 |
| Max. Negotiated Rate |
$86,890.00 |
| Rate for Payer: Aetna Managed Medicare |
$31,255.26
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$68,394.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$52,424.06
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$49,806.28
|
| Rate for Payer: Anthem Medicare Advantage |
$31,255.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$31,255.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$31,255.26
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$31,255.26
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$55,289.53
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$31,255.26
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$63,495.90
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$31,255.26
|
| Rate for Payer: Independent Care Health Plan Medicare |
$31,255.26
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$31,255.26
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$31,255.26
|
| Rate for Payer: NAPHCARE Commercial |
$46,882.89
|
| Rate for Payer: Quartz Medicare Advantage |
$31,255.26
|
| Rate for Payer: The Alliance Commercial |
$86,890.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$31,255.26
|
| Rate for Payer: United Healthcare PPO |
$49,432.37
|
| Rate for Payer: Wellcare Medicare |
$31,255.26
|
|
|
SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC
|
Facility
|
IP
|
$42,425.00
|
|
|
Service Code
|
MSDRG 905
|
| Min. Negotiated Rate |
$15,260.65 |
| Max. Negotiated Rate |
$42,425.00 |
| Rate for Payer: Aetna Managed Medicare |
$15,260.65
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$33,148.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$25,407.98
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$24,139.24
|
| Rate for Payer: Anthem Medicare Advantage |
$15,260.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15,260.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15,260.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$15,260.65
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$26,796.77
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$15,260.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$30,882.15
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$15,260.65
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15,260.65
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$15,260.65
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$15,260.65
|
| Rate for Payer: NAPHCARE Commercial |
$22,890.98
|
| Rate for Payer: Quartz Medicare Advantage |
$15,260.65
|
| Rate for Payer: The Alliance Commercial |
$42,425.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15,260.65
|
| Rate for Payer: United Healthcare PPO |
$24,042.15
|
| Rate for Payer: Wellcare Medicare |
$15,260.65
|
|
|
SKIN GRAFT, SPLIT THICKNESS
|
Facility
|
IP
|
$1,503.00
|
|
| Hospital Charge Code |
2960538
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$736.47 |
| Max. Negotiated Rate |
$1,382.76 |
| Rate for Payer: Aetna Commercial |
$1,352.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,292.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$796.59
|
| Rate for Payer: Cash Price |
$450.90
|
| Rate for Payer: Cigna Commercial |
$1,382.76
|
| Rate for Payer: Health EOS Commercial |
$1,337.67
|
| Rate for Payer: HFN Commercial |
$1,382.76
|
| Rate for Payer: Multiplan Commercial |
$1,202.40
|
| Rate for Payer: NAPHCARE Commercial |
$901.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,382.76
|
| Rate for Payer: Quartz Beloit One Network |
$736.47
|
| Rate for Payer: Quartz Commercial |
$901.80
|
| Rate for Payer: WEA Trust Commercial |
$826.65
|
| Rate for Payer: WPS Commercial |
$1,113.27
|
|
|
SKIN GRAFT, SPLIT THICKNESS
|
Facility
|
OP
|
$1,503.00
|
|
| Hospital Charge Code |
2960538
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$420.84 |
| Max. Negotiated Rate |
$6,012.00 |
| Rate for Payer: Aetna Commercial |
$1,352.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,292.58
|
| Rate for Payer: Aetna Managed Medicare |
$420.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$976.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$751.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$721.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$796.59
|
| Rate for Payer: Cash Price |
$450.90
|
| Rate for Payer: Cigna Commercial |
$1,382.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$841.08
|
| Rate for Payer: Health EOS Commercial |
$1,337.67
|
| Rate for Payer: HFN Commercial |
$1,382.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,127.25
|
| Rate for Payer: Multiplan Commercial |
$1,202.40
|
| Rate for Payer: NAPHCARE Commercial |
$901.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,382.76
|
| Rate for Payer: Quartz Beloit One Network |
$736.47
|
| Rate for Payer: Quartz Commercial |
$976.95
|
| Rate for Payer: Quartz Medicare Advantage |
$901.80
|
| Rate for Payer: The Alliance Commercial |
$6,012.00
|
| Rate for Payer: WEA Trust Commercial |
$826.65
|
| Rate for Payer: WPS Commercial |
$1,113.27
|
|
|
SKIN MARKER DEVON FINE DUAL TIP WITH RULER CAP & LABEL 31145868
|
Facility
|
IP
|
$51.00
|
|
| Hospital Charge Code |
3065498
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$24.99 |
| Max. Negotiated Rate |
$46.92 |
| Rate for Payer: Aetna Commercial |
$45.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$43.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$27.03
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cigna Commercial |
$46.92
|
| Rate for Payer: Health EOS Commercial |
$45.39
|
| Rate for Payer: HFN Commercial |
$46.92
|
| Rate for Payer: Multiplan Commercial |
$40.80
|
| Rate for Payer: NAPHCARE Commercial |
$30.60
|
| Rate for Payer: Preferred Network Access Commercial |
$46.92
|
| Rate for Payer: Quartz Beloit One Network |
$24.99
|
| Rate for Payer: Quartz Commercial |
$30.60
|
| Rate for Payer: WEA Trust Commercial |
$28.05
|
| Rate for Payer: WPS Commercial |
$37.78
|
|
|
SKIN MARKER DEVON FINE DUAL TIP WITH RULER CAP & LABEL 31145868
|
Facility
|
OP
|
$51.00
|
|
| Hospital Charge Code |
3065498
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$14.28 |
| Max. Negotiated Rate |
$204.00 |
| Rate for Payer: Aetna Commercial |
$45.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$43.86
|
| Rate for Payer: Aetna Managed Medicare |
$14.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$33.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$25.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$24.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$27.03
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cigna Commercial |
$46.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$28.54
|
| Rate for Payer: Health EOS Commercial |
$45.39
|
| Rate for Payer: HFN Commercial |
$46.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$38.25
|
| Rate for Payer: Multiplan Commercial |
$40.80
|
| Rate for Payer: NAPHCARE Commercial |
$30.60
|
| Rate for Payer: Preferred Network Access Commercial |
$46.92
|
| Rate for Payer: Quartz Beloit One Network |
$24.99
|
| Rate for Payer: Quartz Commercial |
$33.15
|
| Rate for Payer: Quartz Medicare Advantage |
$30.60
|
| Rate for Payer: The Alliance Commercial |
$204.00
|
| Rate for Payer: WEA Trust Commercial |
$28.05
|
| Rate for Payer: WPS Commercial |
$37.78
|
|
|
SKIN MARKERS FINE TIP STERILE DYNJSM03
|
Facility
|
OP
|
$19.00
|
|
| Hospital Charge Code |
3231470
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$5.32 |
| Max. Negotiated Rate |
$76.00 |
| Rate for Payer: Aetna Commercial |
$17.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16.34
|
| Rate for Payer: Aetna Managed Medicare |
$5.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10.07
|
| Rate for Payer: Cash Price |
$5.70
|
| Rate for Payer: Cigna Commercial |
$17.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10.63
|
| Rate for Payer: Health EOS Commercial |
$16.91
|
| Rate for Payer: HFN Commercial |
$17.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14.25
|
| Rate for Payer: Multiplan Commercial |
$15.20
|
| Rate for Payer: NAPHCARE Commercial |
$11.40
|
| Rate for Payer: Preferred Network Access Commercial |
$17.48
|
| Rate for Payer: Quartz Beloit One Network |
$9.31
|
| Rate for Payer: Quartz Commercial |
$12.35
|
| Rate for Payer: Quartz Medicare Advantage |
$11.40
|
| Rate for Payer: The Alliance Commercial |
$76.00
|
| Rate for Payer: WEA Trust Commercial |
$10.45
|
| Rate for Payer: WPS Commercial |
$14.07
|
|
|
SKIN MARKERS FINE TIP STERILE DYNJSM03
|
Facility
|
IP
|
$19.00
|
|
| Hospital Charge Code |
3231470
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$9.31 |
| Max. Negotiated Rate |
$17.48 |
| Rate for Payer: Aetna Commercial |
$17.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10.07
|
| Rate for Payer: Cash Price |
$5.70
|
| Rate for Payer: Cigna Commercial |
$17.48
|
| Rate for Payer: Health EOS Commercial |
$16.91
|
| Rate for Payer: HFN Commercial |
$17.48
|
| Rate for Payer: Multiplan Commercial |
$15.20
|
| Rate for Payer: NAPHCARE Commercial |
$11.40
|
| Rate for Payer: Preferred Network Access Commercial |
$17.48
|
| Rate for Payer: Quartz Beloit One Network |
$9.31
|
| Rate for Payer: Quartz Commercial |
$11.40
|
| Rate for Payer: WEA Trust Commercial |
$10.45
|
| Rate for Payer: WPS Commercial |
$14.07
|
|
|
Skin Sensor
|
Facility
|
IP
|
$78.00
|
|
| Hospital Charge Code |
3101744
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$38.22 |
| Max. Negotiated Rate |
$71.76 |
| Rate for Payer: Aetna Commercial |
$70.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$41.34
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cigna Commercial |
$71.76
|
| Rate for Payer: Health EOS Commercial |
$69.42
|
| Rate for Payer: HFN Commercial |
$71.76
|
| Rate for Payer: Multiplan Commercial |
$62.40
|
| Rate for Payer: NAPHCARE Commercial |
$46.80
|
| Rate for Payer: Preferred Network Access Commercial |
$71.76
|
| Rate for Payer: Quartz Beloit One Network |
$38.22
|
| Rate for Payer: Quartz Commercial |
$46.80
|
| Rate for Payer: WEA Trust Commercial |
$42.90
|
| Rate for Payer: WPS Commercial |
$57.77
|
|
|
Skin Sensor
|
Facility
|
OP
|
$78.00
|
|
| Hospital Charge Code |
3101744
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$21.84 |
| Max. Negotiated Rate |
$312.00 |
| Rate for Payer: Aetna Commercial |
$70.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.08
|
| Rate for Payer: Aetna Managed Medicare |
$21.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$50.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$39.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$37.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$41.34
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cigna Commercial |
$71.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$43.65
|
| Rate for Payer: Health EOS Commercial |
$69.42
|
| Rate for Payer: HFN Commercial |
$71.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$58.50
|
| Rate for Payer: Multiplan Commercial |
$62.40
|
| Rate for Payer: NAPHCARE Commercial |
$46.80
|
| Rate for Payer: Preferred Network Access Commercial |
$71.76
|
| Rate for Payer: Quartz Beloit One Network |
$38.22
|
| Rate for Payer: Quartz Commercial |
$50.70
|
| Rate for Payer: Quartz Medicare Advantage |
$46.80
|
| Rate for Payer: The Alliance Commercial |
$312.00
|
| Rate for Payer: WEA Trust Commercial |
$42.90
|
| Rate for Payer: WPS Commercial |
$57.77
|
|
|
SKIN SPLT GRFT T/A/L, ADD-ON 15101
|
Professional
|
Both
|
$795.00
|
|
|
Service Code
|
CPT 15101
|
| Hospital Charge Code |
3013634
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$214.58 |
| Max. Negotiated Rate |
$755.25 |
| Rate for Payer: Aetna Commercial |
$755.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$683.70
|
| Rate for Payer: Cash Price |
$238.50
|
| Rate for Payer: Cash Price |
$238.50
|
| Rate for Payer: Cigna Commercial |
$755.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$214.58
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$477.00
|
| Rate for Payer: Health EOS Commercial |
$723.45
|
| Rate for Payer: HFN Commercial |
$755.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$368.14
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$368.14
|
| Rate for Payer: Multiplan Commercial |
$636.00
|
| Rate for Payer: Preferred Network Access Commercial |
$755.25
|
| Rate for Payer: Quartz Beloit One Network |
$349.80
|
| Rate for Payer: Quartz Commercial |
$453.15
|
| Rate for Payer: The Alliance Commercial |
$397.50
|
| Rate for Payer: United Healthcare Medicaid |
$214.58
|
| Rate for Payer: WEA Trust Commercial |
$437.25
|
| Rate for Payer: WPS Commercial |
$588.86
|
|
|
SKIN SPLT GRFT, TRNK/ARM/LEG 15100
|
Professional
|
Both
|
$2,445.00
|
|
|
Service Code
|
CPT 15100
|
| Hospital Charge Code |
3013633
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$512.11 |
| Max. Negotiated Rate |
$2,350.77 |
| Rate for Payer: Aetna Commercial |
$2,322.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,102.70
|
| Rate for Payer: Cash Price |
$733.50
|
| Rate for Payer: Cash Price |
$733.50
|
| Rate for Payer: Cigna Commercial |
$2,322.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$512.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,467.00
|
| Rate for Payer: Health EOS Commercial |
$2,224.95
|
| Rate for Payer: HFN Commercial |
$2,322.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,350.77
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2,350.77
|
| Rate for Payer: Multiplan Commercial |
$1,956.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,322.75
|
| Rate for Payer: Quartz Beloit One Network |
$1,075.80
|
| Rate for Payer: Quartz Commercial |
$1,393.65
|
| Rate for Payer: The Alliance Commercial |
$1,222.50
|
| Rate for Payer: United Healthcare Medicaid |
$512.11
|
| Rate for Payer: WEA Trust Commercial |
$1,344.75
|
| Rate for Payer: WPS Commercial |
$1,811.01
|
|
|
Skin Substitute Apligraft 1 Sq Cm Q4101
|
Facility
|
OP
|
$173.00
|
|
|
Service Code
|
HCPCS Q4101
|
| Hospital Charge Code |
3542168
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$40.51 |
| Max. Negotiated Rate |
$692.00 |
| Rate for Payer: Aetna Commercial |
$155.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$148.78
|
| Rate for Payer: Aetna Managed Medicare |
$48.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$112.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$86.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$83.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$91.69
|
| Rate for Payer: Cash Price |
$51.90
|
| Rate for Payer: Cash Price |
$51.90
|
| Rate for Payer: Cigna Commercial |
$159.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$40.51
|
| Rate for Payer: Health EOS Commercial |
$153.97
|
| Rate for Payer: HFN Commercial |
$159.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$129.75
|
| Rate for Payer: Multiplan Commercial |
$138.40
|
| Rate for Payer: NAPHCARE Commercial |
$103.80
|
| Rate for Payer: Preferred Network Access Commercial |
$159.16
|
| Rate for Payer: Quartz Beloit One Network |
$84.77
|
| Rate for Payer: Quartz Commercial |
$112.45
|
| Rate for Payer: Quartz Medicare Advantage |
$103.80
|
| Rate for Payer: The Alliance Commercial |
$692.00
|
| Rate for Payer: WEA Trust Commercial |
$95.15
|
| Rate for Payer: WPS Commercial |
$76.55
|
|
|
Skin Substitute Apligraft 1 Sq Cm Q4101
|
Professional
|
Both
|
$173.00
|
|
|
Service Code
|
HCPCS Q4101
|
| Hospital Charge Code |
3542168
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.62 |
| Max. Negotiated Rate |
$164.35 |
| Rate for Payer: Aetna Commercial |
$164.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$148.78
|
| Rate for Payer: Cash Price |
$51.90
|
| Rate for Payer: Cash Price |
$51.90
|
| Rate for Payer: Cigna Commercial |
$164.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$31.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30.62
|
| Rate for Payer: Health EOS Commercial |
$157.43
|
| Rate for Payer: HFN Commercial |
$164.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$107.56
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$107.56
|
| Rate for Payer: Multiplan Commercial |
$138.40
|
| Rate for Payer: Preferred Network Access Commercial |
$164.35
|
| Rate for Payer: Quartz Beloit One Network |
$76.12
|
| Rate for Payer: Quartz Commercial |
$98.61
|
| Rate for Payer: The Alliance Commercial |
$86.50
|
| Rate for Payer: United Healthcare Medicaid |
$31.17
|
| Rate for Payer: WEA Trust Commercial |
$95.15
|
| Rate for Payer: WPS Commercial |
$76.55
|
|
|
Skin Substitute Apligraft 1 Sq Cm Q4101
|
Facility
|
IP
|
$173.00
|
|
|
Service Code
|
HCPCS Q4101
|
| Hospital Charge Code |
3542168
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$84.77 |
| Max. Negotiated Rate |
$159.16 |
| Rate for Payer: Aetna Commercial |
$155.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$148.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$91.69
|
| Rate for Payer: Cash Price |
$51.90
|
| Rate for Payer: Cigna Commercial |
$159.16
|
| Rate for Payer: Health EOS Commercial |
$153.97
|
| Rate for Payer: HFN Commercial |
$159.16
|
| Rate for Payer: Multiplan Commercial |
$138.40
|
| Rate for Payer: NAPHCARE Commercial |
$103.80
|
| Rate for Payer: Preferred Network Access Commercial |
$159.16
|
| Rate for Payer: Quartz Beloit One Network |
$84.77
|
| Rate for Payer: Quartz Commercial |
$103.80
|
| Rate for Payer: WEA Trust Commercial |
$95.15
|
| Rate for Payer: WPS Commercial |
$128.14
|
|
|
SKIN TISSUE REARRANGEMENT 14000
|
Professional
|
Both
|
$2,167.00
|
|
|
Service Code
|
CPT 14000
|
| Hospital Charge Code |
3013619
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$195.73 |
| Max. Negotiated Rate |
$2,058.65 |
| Rate for Payer: Aetna Commercial |
$2,058.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,863.62
|
| Rate for Payer: Cash Price |
$650.10
|
| Rate for Payer: Cash Price |
$650.10
|
| Rate for Payer: Cigna Commercial |
$2,058.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$195.73
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,300.20
|
| Rate for Payer: Health EOS Commercial |
$1,971.97
|
| Rate for Payer: HFN Commercial |
$2,058.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,652.92
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,652.92
|
| Rate for Payer: Multiplan Commercial |
$1,733.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,058.65
|
| Rate for Payer: Quartz Beloit One Network |
$953.48
|
| Rate for Payer: Quartz Commercial |
$1,235.19
|
| Rate for Payer: The Alliance Commercial |
$1,083.50
|
| Rate for Payer: United Healthcare Medicaid |
$195.73
|
| Rate for Payer: WEA Trust Commercial |
$1,191.85
|
| Rate for Payer: WPS Commercial |
$1,605.10
|
|
|
SKIN TISSUE REARRANGEMENT 14001
|
Professional
|
Both
|
$1,966.00
|
|
|
Service Code
|
CPT 14001
|
| Hospital Charge Code |
3013620
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$322.56 |
| Max. Negotiated Rate |
$2,142.92 |
| Rate for Payer: Aetna Commercial |
$1,867.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,690.76
|
| Rate for Payer: Cash Price |
$589.80
|
| Rate for Payer: Cash Price |
$589.80
|
| Rate for Payer: Cigna Commercial |
$1,867.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$322.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,179.60
|
| Rate for Payer: Health EOS Commercial |
$1,789.06
|
| Rate for Payer: HFN Commercial |
$1,867.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,142.92
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2,142.92
|
| Rate for Payer: Multiplan Commercial |
$1,572.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,867.70
|
| Rate for Payer: Quartz Beloit One Network |
$865.04
|
| Rate for Payer: Quartz Commercial |
$1,120.62
|
| Rate for Payer: The Alliance Commercial |
$983.00
|
| Rate for Payer: United Healthcare Medicaid |
$322.56
|
| Rate for Payer: WEA Trust Commercial |
$1,081.30
|
| Rate for Payer: WPS Commercial |
$1,456.22
|
|
