|
DEB Assay for Fanconi Anemia
|
Facility
|
IP
|
$461.00
|
|
|
Service Code
|
CPT 88249
|
| Hospital Charge Code |
4125590
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$225.89 |
| Max. Negotiated Rate |
$424.12 |
| Rate for Payer: Aetna Commercial |
$414.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$396.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$244.33
|
| Rate for Payer: Cash Price |
$138.30
|
| Rate for Payer: Cigna Commercial |
$424.12
|
| Rate for Payer: Health EOS Commercial |
$410.29
|
| Rate for Payer: HFN Commercial |
$424.12
|
| Rate for Payer: Multiplan Commercial |
$368.80
|
| Rate for Payer: NAPHCARE Commercial |
$276.60
|
| Rate for Payer: Preferred Network Access Commercial |
$424.12
|
| Rate for Payer: Quartz Beloit One Network |
$225.89
|
| Rate for Payer: Quartz Commercial |
$276.60
|
| Rate for Payer: WEA Trust Commercial |
$253.55
|
| Rate for Payer: WPS Commercial |
$341.46
|
|
|
DEB Assay for Fanconi Anemia
|
Facility
|
OP
|
$461.00
|
|
|
Service Code
|
CPT 88249
|
| Hospital Charge Code |
4125590
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$173.17 |
| Max. Negotiated Rate |
$692.68 |
| Rate for Payer: Aetna Commercial |
$414.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$396.46
|
| Rate for Payer: Aetna Managed Medicare |
$173.17
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$649.39
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$303.05
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$287.46
|
| Rate for Payer: Anthem Medicaid |
$178.94
|
| Rate for Payer: Anthem Medicare Advantage |
$173.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$244.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$173.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$173.17
|
| Rate for Payer: Cash Price |
$138.30
|
| Rate for Payer: Cash Price |
$138.30
|
| Rate for Payer: Cigna Commercial |
$424.12
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$173.17
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$178.94
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$257.98
|
| Rate for Payer: Dean Health Medicaid |
$178.94
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$173.17
|
| Rate for Payer: Health EOS Commercial |
$410.29
|
| Rate for Payer: HFN Commercial |
$424.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$644.19
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$173.17
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$178.94
|
| Rate for Payer: Independent Care Health Plan Medicare |
$173.17
|
| Rate for Payer: Managed Health Services Medicaid |
$186.10
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$173.17
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$173.17
|
| Rate for Payer: Multiplan Commercial |
$368.80
|
| Rate for Payer: NAPHCARE Commercial |
$259.76
|
| Rate for Payer: Preferred Network Access Commercial |
$424.12
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$178.94
|
| Rate for Payer: Quartz Beloit One Network |
$225.89
|
| Rate for Payer: Quartz Commercial |
$299.65
|
| Rate for Payer: Quartz Medicare Advantage |
$173.17
|
| Rate for Payer: The Alliance Commercial |
$692.68
|
| Rate for Payer: United Healthcare Medicaid |
$178.94
|
| Rate for Payer: United Healthcare Medicare Advantage |
$173.17
|
| Rate for Payer: United Healthcare PPO |
$345.75
|
| Rate for Payer: WEA Trust Commercial |
$253.55
|
| Rate for Payer: Wellcare Medicare |
$173.17
|
| Rate for Payer: WMAP Medicaid |
$178.94
|
| Rate for Payer: WPS Commercial |
$341.46
|
|
|
DEB Assay for Fanconi Anemia
|
Facility
|
IP
|
$461.00
|
|
|
Service Code
|
CPT 88291
|
| Hospital Charge Code |
4125589
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$225.89 |
| Max. Negotiated Rate |
$424.12 |
| Rate for Payer: Aetna Commercial |
$414.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$396.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$244.33
|
| Rate for Payer: Cash Price |
$138.30
|
| Rate for Payer: Cigna Commercial |
$424.12
|
| Rate for Payer: Health EOS Commercial |
$410.29
|
| Rate for Payer: HFN Commercial |
$424.12
|
| Rate for Payer: Multiplan Commercial |
$368.80
|
| Rate for Payer: NAPHCARE Commercial |
$276.60
|
| Rate for Payer: Preferred Network Access Commercial |
$424.12
|
| Rate for Payer: Quartz Beloit One Network |
$225.89
|
| Rate for Payer: Quartz Commercial |
$276.60
|
| Rate for Payer: WEA Trust Commercial |
$253.55
|
| Rate for Payer: WPS Commercial |
$341.46
|
|
|
DEB Assay for Fanconi Anemia
|
Professional
|
Both
|
$461.00
|
|
|
Service Code
|
CPT 88291
|
| Hospital Charge Code |
4125589
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.66 |
| Max. Negotiated Rate |
$437.95 |
| Rate for Payer: Aetna Commercial |
$437.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$396.46
|
| Rate for Payer: Anthem Commercial |
$5.66
|
| Rate for Payer: Cash Price |
$138.30
|
| Rate for Payer: Cash Price |
$138.30
|
| Rate for Payer: Cigna Commercial |
$437.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$230.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$276.60
|
| Rate for Payer: Health EOS Commercial |
$419.51
|
| Rate for Payer: HFN Commercial |
$437.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$113.07
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$113.07
|
| Rate for Payer: Multiplan Commercial |
$368.80
|
| Rate for Payer: Preferred Network Access Commercial |
$437.95
|
| Rate for Payer: Quartz Beloit One Network |
$202.84
|
| Rate for Payer: Quartz Commercial |
$262.77
|
| Rate for Payer: The Alliance Commercial |
$230.50
|
| Rate for Payer: WEA Trust Commercial |
$253.55
|
| Rate for Payer: WPS Commercial |
$341.46
|
|
|
DEB Assay for Fanconi Anemia
|
Professional
|
Both
|
$461.00
|
|
|
Service Code
|
CPT 88249
|
| Hospital Charge Code |
4125590
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$202.84 |
| Max. Negotiated Rate |
$611.29 |
| Rate for Payer: Aetna Commercial |
$437.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$396.46
|
| Rate for Payer: Cash Price |
$138.30
|
| Rate for Payer: Cash Price |
$138.30
|
| Rate for Payer: Cigna Commercial |
$437.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$230.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$276.60
|
| Rate for Payer: Health EOS Commercial |
$419.51
|
| Rate for Payer: HFN Commercial |
$437.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$611.29
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$611.29
|
| Rate for Payer: Multiplan Commercial |
$368.80
|
| Rate for Payer: Preferred Network Access Commercial |
$437.95
|
| Rate for Payer: Quartz Beloit One Network |
$202.84
|
| Rate for Payer: Quartz Commercial |
$262.77
|
| Rate for Payer: The Alliance Commercial |
$230.50
|
| Rate for Payer: WEA Trust Commercial |
$253.55
|
| Rate for Payer: WPS Commercial |
$341.46
|
|
|
DEB Assay for Fanconi Anemia
|
Facility
|
OP
|
$461.00
|
|
|
Service Code
|
CPT 88291
|
| Hospital Charge Code |
4125589
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$129.08 |
| Max. Negotiated Rate |
$1,844.00 |
| Rate for Payer: Aetna Commercial |
$414.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$396.46
|
| Rate for Payer: Aetna Managed Medicare |
$129.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$299.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$230.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$221.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$244.33
|
| Rate for Payer: Cash Price |
$138.30
|
| Rate for Payer: Cigna Commercial |
$424.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$257.98
|
| Rate for Payer: Health EOS Commercial |
$410.29
|
| Rate for Payer: HFN Commercial |
$424.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$345.75
|
| Rate for Payer: Multiplan Commercial |
$368.80
|
| Rate for Payer: NAPHCARE Commercial |
$276.60
|
| Rate for Payer: Preferred Network Access Commercial |
$424.12
|
| Rate for Payer: Quartz Beloit One Network |
$225.89
|
| Rate for Payer: Quartz Commercial |
$299.65
|
| Rate for Payer: Quartz Medicare Advantage |
$276.60
|
| Rate for Payer: The Alliance Commercial |
$1,844.00
|
| Rate for Payer: United Healthcare PPO |
$345.75
|
| Rate for Payer: WEA Trust Commercial |
$253.55
|
| Rate for Payer: WPS Commercial |
$341.46
|
|
|
DEBRIDE INFECTED SKIN 11000
|
Professional
|
Both
|
$248.00
|
|
|
Service Code
|
CPT 11000
|
| Hospital Charge Code |
3013510
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$32.34 |
| Max. Negotiated Rate |
$235.60 |
| Rate for Payer: Aetna Commercial |
$235.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$213.28
|
| Rate for Payer: Cash Price |
$74.40
|
| Rate for Payer: Cash Price |
$74.40
|
| Rate for Payer: Cigna Commercial |
$235.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$32.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$148.80
|
| Rate for Payer: Health EOS Commercial |
$225.68
|
| Rate for Payer: HFN Commercial |
$235.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$94.29
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$94.29
|
| Rate for Payer: Multiplan Commercial |
$198.40
|
| Rate for Payer: Preferred Network Access Commercial |
$235.60
|
| Rate for Payer: Quartz Beloit One Network |
$109.12
|
| Rate for Payer: Quartz Commercial |
$141.36
|
| Rate for Payer: The Alliance Commercial |
$124.00
|
| Rate for Payer: United Healthcare Medicaid |
$32.34
|
| Rate for Payer: WEA Trust Commercial |
$136.40
|
| Rate for Payer: WPS Commercial |
$183.69
|
|
|
DEBRIDE INFECTED SKIN ADD-ON 11001
|
Professional
|
Both
|
$96.00
|
|
|
Service Code
|
CPT 11001
|
| Hospital Charge Code |
3013511
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$42.24 |
| Max. Negotiated Rate |
$91.20 |
| Rate for Payer: Aetna Commercial |
$91.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$82.56
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cigna Commercial |
$91.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$47.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$57.60
|
| Rate for Payer: Health EOS Commercial |
$87.36
|
| Rate for Payer: HFN Commercial |
$91.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$47.69
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$47.69
|
| Rate for Payer: Multiplan Commercial |
$76.80
|
| Rate for Payer: Preferred Network Access Commercial |
$91.20
|
| Rate for Payer: Quartz Beloit One Network |
$42.24
|
| Rate for Payer: Quartz Commercial |
$54.72
|
| Rate for Payer: The Alliance Commercial |
$48.00
|
| Rate for Payer: United Healthcare Medicaid |
$47.40
|
| Rate for Payer: WEA Trust Commercial |
$52.80
|
| Rate for Payer: WPS Commercial |
$71.11
|
|
|
DEBRIDEMENT, BONE (INCLUDES EPIDERMIS, DERMIS, SUBCUTANEOUS TISSUE, MUSCLE AND/OR FASCIA, IF PERFORMED); EACH ADDITIONAL 20 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$4,757.59
|
|
|
Service Code
|
CPT 11047
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,757.59 |
| Max. Negotiated Rate |
$4,757.59 |
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,757.59
|
|
|
DEBRIDEMENT, BONE (INCLUDES EPIDERMIS, DERMIS, SUBCUTANEOUS TISSUE, MUSCLE AND/OR FASCIA, IF PERFORMED); FIRST 20 SQ CM OR LESS
|
Facility
|
OP
|
$6,409.96
|
|
|
Service Code
|
CPT 11044
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,602.49 |
| Max. Negotiated Rate |
$6,409.96 |
| Rate for Payer: Aetna Managed Medicare |
$1,602.49
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,496.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,871.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,726.00
|
| Rate for Payer: Anthem Medicare Advantage |
$1,602.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,602.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,602.49
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$1,602.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,757.59
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1,602.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,961.26
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,602.49
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,602.49
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$1,602.49
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$1,602.49
|
| Rate for Payer: NAPHCARE Commercial |
$2,403.74
|
| Rate for Payer: Quartz Medicare Advantage |
$1,602.49
|
| Rate for Payer: The Alliance Commercial |
$6,409.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,602.49
|
| Rate for Payer: United Healthcare PPO |
$3,583.00
|
| Rate for Payer: Wellcare Medicare |
$1,602.49
|
|
|
Debridement, bone, includes tissue, muscle, fascia; ea add'l 20 sq cm 11047
|
Professional
|
Both
|
$800.00
|
|
|
Service Code
|
CPT 11047
|
| Hospital Charge Code |
3013523
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$46.24 |
| Max. Negotiated Rate |
$760.00 |
| Rate for Payer: Aetna Commercial |
$760.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$688.00
|
| Rate for Payer: Cash Price |
$240.00
|
| Rate for Payer: Cash Price |
$240.00
|
| Rate for Payer: Cigna Commercial |
$760.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$46.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$480.00
|
| Rate for Payer: Health EOS Commercial |
$728.00
|
| Rate for Payer: HFN Commercial |
$760.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$316.50
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$316.50
|
| Rate for Payer: Multiplan Commercial |
$640.00
|
| Rate for Payer: Preferred Network Access Commercial |
$760.00
|
| Rate for Payer: Quartz Beloit One Network |
$352.00
|
| Rate for Payer: Quartz Commercial |
$456.00
|
| Rate for Payer: The Alliance Commercial |
$400.00
|
| Rate for Payer: United Healthcare Medicaid |
$46.24
|
| Rate for Payer: WEA Trust Commercial |
$440.00
|
| Rate for Payer: WPS Commercial |
$592.56
|
|
|
Debridement, bone, includes tissue, muscle, fascia; first 20 sq cm or less 11044
|
Professional
|
Both
|
$1,154.00
|
|
|
Service Code
|
CPT 11044
|
| Hospital Charge Code |
3013520
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$312.36 |
| Max. Negotiated Rate |
$1,096.30 |
| Rate for Payer: Aetna Commercial |
$1,096.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$992.44
|
| Rate for Payer: Cash Price |
$346.20
|
| Rate for Payer: Cash Price |
$346.20
|
| Rate for Payer: Cigna Commercial |
$1,096.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$312.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$692.40
|
| Rate for Payer: Health EOS Commercial |
$1,050.14
|
| Rate for Payer: HFN Commercial |
$1,096.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$740.66
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$740.66
|
| Rate for Payer: Multiplan Commercial |
$923.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,096.30
|
| Rate for Payer: Quartz Beloit One Network |
$507.76
|
| Rate for Payer: Quartz Commercial |
$657.78
|
| Rate for Payer: The Alliance Commercial |
$577.00
|
| Rate for Payer: United Healthcare Medicaid |
$312.36
|
| Rate for Payer: WEA Trust Commercial |
$634.70
|
| Rate for Payer: WPS Commercial |
$854.77
|
|
|
DEBRIDEMENT (LOWER BODY)
|
Facility
|
OP
|
$1,084.00
|
|
| Hospital Charge Code |
4698606
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$303.52 |
| Max. Negotiated Rate |
$4,336.00 |
| Rate for Payer: Aetna Commercial |
$975.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$932.24
|
| Rate for Payer: Aetna Managed Medicare |
$303.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$704.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$542.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$520.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$574.52
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$997.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$606.61
|
| Rate for Payer: Health EOS Commercial |
$964.76
|
| Rate for Payer: HFN Commercial |
$997.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$813.00
|
| Rate for Payer: Multiplan Commercial |
$867.20
|
| Rate for Payer: NAPHCARE Commercial |
$650.40
|
| Rate for Payer: Preferred Network Access Commercial |
$997.28
|
| Rate for Payer: Quartz Beloit One Network |
$531.16
|
| Rate for Payer: Quartz Commercial |
$704.60
|
| Rate for Payer: Quartz Medicare Advantage |
$650.40
|
| Rate for Payer: The Alliance Commercial |
$4,336.00
|
| Rate for Payer: WEA Trust Commercial |
$596.20
|
| Rate for Payer: WPS Commercial |
$802.92
|
|
|
DEBRIDEMENT (LOWER BODY)
|
Facility
|
IP
|
$1,084.00
|
|
| Hospital Charge Code |
4698606
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$531.16 |
| Max. Negotiated Rate |
$997.28 |
| Rate for Payer: Aetna Commercial |
$975.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$932.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$574.52
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$997.28
|
| Rate for Payer: Health EOS Commercial |
$964.76
|
| Rate for Payer: HFN Commercial |
$997.28
|
| Rate for Payer: Multiplan Commercial |
$867.20
|
| Rate for Payer: NAPHCARE Commercial |
$650.40
|
| Rate for Payer: Preferred Network Access Commercial |
$997.28
|
| Rate for Payer: Quartz Beloit One Network |
$531.16
|
| Rate for Payer: Quartz Commercial |
$650.40
|
| Rate for Payer: WEA Trust Commercial |
$596.20
|
| Rate for Payer: WPS Commercial |
$802.92
|
|
|
Debridement, Masoidectomy Cavity, simple
|
Professional
|
Both
|
$178.00
|
|
|
Service Code
|
CPT 69220
|
| Hospital Charge Code |
1152809
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$43.60 |
| Max. Negotiated Rate |
$169.10 |
| Rate for Payer: Aetna Commercial |
$169.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$153.08
|
| Rate for Payer: Cash Price |
$53.40
|
| Rate for Payer: Cash Price |
$53.40
|
| Rate for Payer: Cigna Commercial |
$169.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$43.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$106.80
|
| Rate for Payer: Health EOS Commercial |
$161.98
|
| Rate for Payer: HFN Commercial |
$169.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$168.45
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$168.45
|
| Rate for Payer: Multiplan Commercial |
$142.40
|
| Rate for Payer: Preferred Network Access Commercial |
$169.10
|
| Rate for Payer: Quartz Beloit One Network |
$78.32
|
| Rate for Payer: Quartz Commercial |
$101.46
|
| Rate for Payer: The Alliance Commercial |
$89.00
|
| Rate for Payer: United Healthcare Medicaid |
$43.60
|
| Rate for Payer: WEA Trust Commercial |
$97.90
|
| Rate for Payer: WPS Commercial |
$131.84
|
|
|
Debridement, muscle and/or fascia; ea add'l 20 sq cm 11046
|
Professional
|
Both
|
$400.00
|
|
|
Service Code
|
CPT 11046
|
| Hospital Charge Code |
3013522
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$26.75 |
| Max. Negotiated Rate |
$380.00 |
| Rate for Payer: Aetna Commercial |
$380.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$344.00
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Cigna Commercial |
$380.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$26.75
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$240.00
|
| Rate for Payer: Health EOS Commercial |
$364.00
|
| Rate for Payer: HFN Commercial |
$380.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$180.56
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$180.56
|
| Rate for Payer: Multiplan Commercial |
$320.00
|
| Rate for Payer: Preferred Network Access Commercial |
$380.00
|
| Rate for Payer: Quartz Beloit One Network |
$176.00
|
| Rate for Payer: Quartz Commercial |
$228.00
|
| Rate for Payer: The Alliance Commercial |
$200.00
|
| Rate for Payer: United Healthcare Medicaid |
$26.75
|
| Rate for Payer: WEA Trust Commercial |
$220.00
|
| Rate for Payer: WPS Commercial |
$296.28
|
|
|
Debridement, muscle and/or fascia; first 20 sq cm or less 11043
|
Professional
|
Both
|
$1,100.00
|
|
|
Service Code
|
CPT 11043
|
| Hospital Charge Code |
3013519
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$228.63 |
| Max. Negotiated Rate |
$1,045.00 |
| Rate for Payer: Aetna Commercial |
$1,045.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$946.00
|
| Rate for Payer: Cash Price |
$330.00
|
| Rate for Payer: Cash Price |
$330.00
|
| Rate for Payer: Cigna Commercial |
$1,045.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$228.63
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$660.00
|
| Rate for Payer: Health EOS Commercial |
$1,001.00
|
| Rate for Payer: HFN Commercial |
$1,045.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$510.33
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$510.33
|
| Rate for Payer: Multiplan Commercial |
$880.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,045.00
|
| Rate for Payer: Quartz Beloit One Network |
$484.00
|
| Rate for Payer: Quartz Commercial |
$627.00
|
| Rate for Payer: The Alliance Commercial |
$550.00
|
| Rate for Payer: United Healthcare Medicaid |
$228.63
|
| Rate for Payer: WEA Trust Commercial |
$605.00
|
| Rate for Payer: WPS Commercial |
$814.77
|
|
|
DEBRIDEMENT, MUSCLE AND/OR FASCIA (INCLUDES EPIDERMIS, DERMIS, AND SUBCUTANEOUS TISSUE, IF PERFORMED); FIRST 20 SQ CM OR LESS
|
Facility
|
OP
|
$4,757.59
|
|
|
Service Code
|
CPT 11043
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$620.77 |
| Max. Negotiated Rate |
$4,757.59 |
| Rate for Payer: Aetna Managed Medicare |
$620.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,914.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,297.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,183.00
|
| Rate for Payer: Anthem Medicare Advantage |
$620.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$620.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$620.77
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$620.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,757.59
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$620.77
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,309.26
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$620.77
|
| Rate for Payer: Independent Care Health Plan Medicare |
$620.77
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$620.77
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$620.77
|
| Rate for Payer: NAPHCARE Commercial |
$931.16
|
| Rate for Payer: Quartz Medicare Advantage |
$620.77
|
| Rate for Payer: The Alliance Commercial |
$2,483.08
|
| Rate for Payer: United Healthcare Medicare Advantage |
$620.77
|
| Rate for Payer: United Healthcare PPO |
$2,257.00
|
| Rate for Payer: Wellcare Medicare |
$620.77
|
|
|
Debridement of Nails, 1-5
|
Professional
|
Both
|
$67.00
|
|
|
Service Code
|
CPT 11720
|
| Hospital Charge Code |
2572827
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$18.67 |
| Max. Negotiated Rate |
$63.65 |
| Rate for Payer: Aetna Commercial |
$63.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$57.62
|
| Rate for Payer: Cash Price |
$20.10
|
| Rate for Payer: Cash Price |
$20.10
|
| Rate for Payer: Cigna Commercial |
$63.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$18.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$40.20
|
| Rate for Payer: Health EOS Commercial |
$60.97
|
| Rate for Payer: HFN Commercial |
$63.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$49.00
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$49.00
|
| Rate for Payer: Multiplan Commercial |
$53.60
|
| Rate for Payer: Preferred Network Access Commercial |
$63.65
|
| Rate for Payer: Quartz Beloit One Network |
$29.48
|
| Rate for Payer: Quartz Commercial |
$38.19
|
| Rate for Payer: The Alliance Commercial |
$33.50
|
| Rate for Payer: United Healthcare Medicaid |
$18.67
|
| Rate for Payer: WEA Trust Commercial |
$36.85
|
| Rate for Payer: WPS Commercial |
$49.63
|
|
|
Debridement of Nails, >5
|
Professional
|
Both
|
$110.00
|
|
|
Service Code
|
CPT 11721
|
| Hospital Charge Code |
2572828
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$33.05 |
| Max. Negotiated Rate |
$104.50 |
| Rate for Payer: Aetna Commercial |
$104.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$94.60
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cigna Commercial |
$104.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$33.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$66.00
|
| Rate for Payer: Health EOS Commercial |
$100.10
|
| Rate for Payer: HFN Commercial |
$104.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$81.90
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$81.90
|
| Rate for Payer: Multiplan Commercial |
$88.00
|
| Rate for Payer: Preferred Network Access Commercial |
$104.50
|
| Rate for Payer: Quartz Beloit One Network |
$48.40
|
| Rate for Payer: Quartz Commercial |
$62.70
|
| Rate for Payer: The Alliance Commercial |
$55.00
|
| Rate for Payer: United Healthcare Medicaid |
$33.05
|
| Rate for Payer: WEA Trust Commercial |
$60.50
|
| Rate for Payer: WPS Commercial |
$81.48
|
|
|
Debridement of Open Wound; 20 sq cm or less 97597
|
Professional
|
Both
|
$186.00
|
|
|
Service Code
|
CPT 97597
|
| Hospital Charge Code |
1188992
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$43.66 |
| Max. Negotiated Rate |
$176.70 |
| Rate for Payer: Aetna Commercial |
$176.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$159.96
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cigna Commercial |
$176.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$43.66
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$111.60
|
| Rate for Payer: Health EOS Commercial |
$169.26
|
| Rate for Payer: HFN Commercial |
$176.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$122.21
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$122.21
|
| Rate for Payer: Multiplan Commercial |
$148.80
|
| Rate for Payer: Preferred Network Access Commercial |
$176.70
|
| Rate for Payer: Quartz Beloit One Network |
$81.84
|
| Rate for Payer: Quartz Commercial |
$106.02
|
| Rate for Payer: The Alliance Commercial |
$93.00
|
| Rate for Payer: United Healthcare Medicaid |
$43.66
|
| Rate for Payer: WEA Trust Commercial |
$102.30
|
| Rate for Payer: WPS Commercial |
$137.77
|
|
|
Debridement of Open Wound; 20 sq cm or less, EXT 9759722
|
Professional
|
Both
|
$224.00
|
|
|
Service Code
|
CPT 97597 22
|
| Hospital Charge Code |
6209774
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$98.56 |
| Max. Negotiated Rate |
$212.80 |
| Rate for Payer: Aetna Commercial |
$212.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$192.64
|
| Rate for Payer: Cash Price |
$67.20
|
| Rate for Payer: Cash Price |
$67.20
|
| Rate for Payer: Cigna Commercial |
$212.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$112.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$134.40
|
| Rate for Payer: Health EOS Commercial |
$203.84
|
| Rate for Payer: HFN Commercial |
$212.80
|
| Rate for Payer: Multiplan Commercial |
$179.20
|
| Rate for Payer: Preferred Network Access Commercial |
$212.80
|
| Rate for Payer: Quartz Beloit One Network |
$98.56
|
| Rate for Payer: Quartz Commercial |
$127.68
|
| Rate for Payer: The Alliance Commercial |
$112.00
|
| Rate for Payer: WEA Trust Commercial |
$123.20
|
| Rate for Payer: WPS Commercial |
$165.92
|
|
|
Debridement of Open Wound; addi'l 20 sq cm 97598
|
Professional
|
Both
|
$268.00
|
|
|
Service Code
|
CPT 97598
|
| Hospital Charge Code |
1188993
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$54.98 |
| Max. Negotiated Rate |
$254.60 |
| Rate for Payer: Aetna Commercial |
$254.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$230.48
|
| Rate for Payer: Cash Price |
$80.40
|
| Rate for Payer: Cash Price |
$80.40
|
| Rate for Payer: Cigna Commercial |
$254.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$54.98
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$160.80
|
| Rate for Payer: Health EOS Commercial |
$243.88
|
| Rate for Payer: HFN Commercial |
$254.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$84.30
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$84.30
|
| Rate for Payer: Multiplan Commercial |
$214.40
|
| Rate for Payer: Preferred Network Access Commercial |
$254.60
|
| Rate for Payer: Quartz Beloit One Network |
$117.92
|
| Rate for Payer: Quartz Commercial |
$152.76
|
| Rate for Payer: The Alliance Commercial |
$134.00
|
| Rate for Payer: United Healthcare Medicaid |
$54.98
|
| Rate for Payer: WEA Trust Commercial |
$147.40
|
| Rate for Payer: WPS Commercial |
$198.51
|
|
|
Debridement of partial thickness burn; initial or subsequent, lees than 5% BSA
|
Professional
|
Both
|
$234.00
|
|
|
Service Code
|
CPT 16020
|
| Hospital Charge Code |
1190878
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$29.66 |
| Max. Negotiated Rate |
$222.30 |
| Rate for Payer: Aetna Commercial |
$222.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$201.24
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cigna Commercial |
$222.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$29.66
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$140.40
|
| Rate for Payer: Health EOS Commercial |
$212.94
|
| Rate for Payer: HFN Commercial |
$222.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$181.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$181.55
|
| Rate for Payer: Multiplan Commercial |
$187.20
|
| Rate for Payer: Preferred Network Access Commercial |
$222.30
|
| Rate for Payer: Quartz Beloit One Network |
$102.96
|
| Rate for Payer: Quartz Commercial |
$133.38
|
| Rate for Payer: The Alliance Commercial |
$117.00
|
| Rate for Payer: United Healthcare Medicaid |
$29.66
|
| Rate for Payer: WEA Trust Commercial |
$128.70
|
| Rate for Payer: WPS Commercial |
$173.32
|
|
|
Debridement, subcutaneous tissue; ea add'l 20 sq cm 11045
|
Professional
|
Both
|
$197.00
|
|
|
Service Code
|
CPT 11045
|
| Hospital Charge Code |
3013521
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$12.38 |
| Max. Negotiated Rate |
$187.15 |
| Rate for Payer: Aetna Commercial |
$187.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$169.42
|
| Rate for Payer: Cash Price |
$59.10
|
| Rate for Payer: Cash Price |
$59.10
|
| Rate for Payer: Cigna Commercial |
$187.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$12.38
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$118.20
|
| Rate for Payer: Health EOS Commercial |
$179.27
|
| Rate for Payer: HFN Commercial |
$187.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$85.74
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$85.74
|
| Rate for Payer: Multiplan Commercial |
$157.60
|
| Rate for Payer: Preferred Network Access Commercial |
$187.15
|
| Rate for Payer: Quartz Beloit One Network |
$86.68
|
| Rate for Payer: Quartz Commercial |
$112.29
|
| Rate for Payer: The Alliance Commercial |
$98.50
|
| Rate for Payer: United Healthcare Medicaid |
$12.38
|
| Rate for Payer: WEA Trust Commercial |
$108.35
|
| Rate for Payer: WPS Commercial |
$145.92
|
|
