|
Lasix 20 mg Charge
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
HCPCS J1940
|
| Hospital Charge Code |
2958933
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$28.00 |
| Rate for Payer: Aetna Commercial |
$6.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.02
|
| Rate for Payer: Aetna Managed Medicare |
$1.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.71
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.80
|
| Rate for Payer: Health EOS Commercial |
$6.23
|
| Rate for Payer: HFN Commercial |
$6.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5.25
|
| Rate for Payer: Multiplan Commercial |
$5.60
|
| Rate for Payer: NAPHCARE Commercial |
$4.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6.44
|
| Rate for Payer: Quartz Beloit One Network |
$3.43
|
| Rate for Payer: Quartz Commercial |
$4.55
|
| Rate for Payer: Quartz Medicare Advantage |
$4.20
|
| Rate for Payer: The Alliance Commercial |
$28.00
|
| Rate for Payer: WEA Trust Commercial |
$3.85
|
| Rate for Payer: WPS Commercial |
$1.52
|
|
|
Lasix 20 mg Charge
|
Professional
|
Both
|
$7.00
|
|
|
Service Code
|
HCPCS J1940
|
| Hospital Charge Code |
2958933
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$6.65 |
| Rate for Payer: Aetna Commercial |
$6.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.02
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$0.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.61
|
| Rate for Payer: Health EOS Commercial |
$6.37
|
| Rate for Payer: HFN Commercial |
$6.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1.12
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1.12
|
| Rate for Payer: Multiplan Commercial |
$5.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6.65
|
| Rate for Payer: Quartz Beloit One Network |
$3.08
|
| Rate for Payer: Quartz Commercial |
$3.99
|
| Rate for Payer: The Alliance Commercial |
$3.50
|
| Rate for Payer: United Healthcare Medicaid |
$0.57
|
| Rate for Payer: WEA Trust Commercial |
$3.85
|
| Rate for Payer: WPS Commercial |
$1.52
|
|
|
LASSO 25DEG TIGHT LT QUICKPASS AR-6068-25TL
|
Facility
|
OP
|
$2,902.00
|
|
| Hospital Charge Code |
2964689
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$812.56 |
| Max. Negotiated Rate |
$11,608.00 |
| Rate for Payer: Aetna Commercial |
$2,611.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,495.72
|
| Rate for Payer: Aetna Managed Medicare |
$812.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,886.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,451.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,392.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,538.06
|
| Rate for Payer: Cash Price |
$870.60
|
| Rate for Payer: Cigna Commercial |
$2,669.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,623.96
|
| Rate for Payer: Health EOS Commercial |
$2,582.78
|
| Rate for Payer: HFN Commercial |
$2,669.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,176.50
|
| Rate for Payer: Multiplan Commercial |
$2,321.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,741.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,669.84
|
| Rate for Payer: Quartz Beloit One Network |
$1,421.98
|
| Rate for Payer: Quartz Commercial |
$1,886.30
|
| Rate for Payer: Quartz Medicare Advantage |
$1,741.20
|
| Rate for Payer: The Alliance Commercial |
$11,608.00
|
| Rate for Payer: WEA Trust Commercial |
$1,596.10
|
| Rate for Payer: WPS Commercial |
$2,149.51
|
|
|
LASSO 25DEG TIGHT LT QUICKPASS AR-6068-25TL
|
Facility
|
IP
|
$2,902.00
|
|
| Hospital Charge Code |
2964689
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,421.98 |
| Max. Negotiated Rate |
$2,669.84 |
| Rate for Payer: Aetna Commercial |
$2,611.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,495.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,538.06
|
| Rate for Payer: Cash Price |
$870.60
|
| Rate for Payer: Cigna Commercial |
$2,669.84
|
| Rate for Payer: Health EOS Commercial |
$2,582.78
|
| Rate for Payer: HFN Commercial |
$2,669.84
|
| Rate for Payer: Multiplan Commercial |
$2,321.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,741.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,669.84
|
| Rate for Payer: Quartz Beloit One Network |
$1,421.98
|
| Rate for Payer: Quartz Commercial |
$1,741.20
|
| Rate for Payer: WEA Trust Commercial |
$1,596.10
|
| Rate for Payer: WPS Commercial |
$2,149.51
|
|
|
LASSO 25DEG TIGHT RT QUICKPASS AR-6068-25TR
|
Facility
|
OP
|
$2,902.00
|
|
| Hospital Charge Code |
2964690
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$812.56 |
| Max. Negotiated Rate |
$11,608.00 |
| Rate for Payer: Aetna Commercial |
$2,611.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,495.72
|
| Rate for Payer: Aetna Managed Medicare |
$812.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,886.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,451.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,392.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,538.06
|
| Rate for Payer: Cash Price |
$870.60
|
| Rate for Payer: Cigna Commercial |
$2,669.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,623.96
|
| Rate for Payer: Health EOS Commercial |
$2,582.78
|
| Rate for Payer: HFN Commercial |
$2,669.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,176.50
|
| Rate for Payer: Multiplan Commercial |
$2,321.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,741.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,669.84
|
| Rate for Payer: Quartz Beloit One Network |
$1,421.98
|
| Rate for Payer: Quartz Commercial |
$1,886.30
|
| Rate for Payer: Quartz Medicare Advantage |
$1,741.20
|
| Rate for Payer: The Alliance Commercial |
$11,608.00
|
| Rate for Payer: WEA Trust Commercial |
$1,596.10
|
| Rate for Payer: WPS Commercial |
$2,149.51
|
|
|
LASSO 25DEG TIGHT RT QUICKPASS AR-6068-25TR
|
Facility
|
IP
|
$2,902.00
|
|
| Hospital Charge Code |
2964690
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,421.98 |
| Max. Negotiated Rate |
$2,669.84 |
| Rate for Payer: Aetna Commercial |
$2,611.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,495.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,538.06
|
| Rate for Payer: Cash Price |
$870.60
|
| Rate for Payer: Cigna Commercial |
$2,669.84
|
| Rate for Payer: Health EOS Commercial |
$2,582.78
|
| Rate for Payer: HFN Commercial |
$2,669.84
|
| Rate for Payer: Multiplan Commercial |
$2,321.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,741.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,669.84
|
| Rate for Payer: Quartz Beloit One Network |
$1,421.98
|
| Rate for Payer: Quartz Commercial |
$1,741.20
|
| Rate for Payer: WEA Trust Commercial |
$1,596.10
|
| Rate for Payer: WPS Commercial |
$2,149.51
|
|
|
LASSO CRESCENT QUICKPASS AR-6068C
|
Facility
|
OP
|
$2,347.00
|
|
| Hospital Charge Code |
5385160
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$657.16 |
| Max. Negotiated Rate |
$9,388.00 |
| Rate for Payer: Aetna Commercial |
$2,112.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,018.42
|
| Rate for Payer: Aetna Managed Medicare |
$657.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,525.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,173.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,126.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,243.91
|
| Rate for Payer: Cash Price |
$704.10
|
| Rate for Payer: Cigna Commercial |
$2,159.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,313.38
|
| Rate for Payer: Health EOS Commercial |
$2,088.83
|
| Rate for Payer: HFN Commercial |
$2,159.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,760.25
|
| Rate for Payer: Multiplan Commercial |
$1,877.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,408.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,159.24
|
| Rate for Payer: Quartz Beloit One Network |
$1,150.03
|
| Rate for Payer: Quartz Commercial |
$1,525.55
|
| Rate for Payer: Quartz Medicare Advantage |
$1,408.20
|
| Rate for Payer: The Alliance Commercial |
$9,388.00
|
| Rate for Payer: WEA Trust Commercial |
$1,290.85
|
| Rate for Payer: WPS Commercial |
$1,738.42
|
|
|
LASSO CRESCENT QUICKPASS AR-6068C
|
Facility
|
IP
|
$2,347.00
|
|
| Hospital Charge Code |
5385160
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,150.03 |
| Max. Negotiated Rate |
$2,159.24 |
| Rate for Payer: Aetna Commercial |
$2,112.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,018.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,243.91
|
| Rate for Payer: Cash Price |
$704.10
|
| Rate for Payer: Cigna Commercial |
$2,159.24
|
| Rate for Payer: Health EOS Commercial |
$2,088.83
|
| Rate for Payer: HFN Commercial |
$2,159.24
|
| Rate for Payer: Multiplan Commercial |
$1,877.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,408.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,159.24
|
| Rate for Payer: Quartz Beloit One Network |
$1,150.03
|
| Rate for Payer: Quartz Commercial |
$1,408.20
|
| Rate for Payer: WEA Trust Commercial |
$1,290.85
|
| Rate for Payer: WPS Commercial |
$1,738.42
|
|
|
Latanoprost 0.005% Ophth Solution 2.5ml [Med]
|
Facility
|
IP
|
$38.00
|
|
| Hospital Charge Code |
2974953
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.62 |
| Max. Negotiated Rate |
$34.96 |
| Rate for Payer: Aetna Commercial |
$34.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$32.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$20.14
|
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Cigna Commercial |
$34.96
|
| Rate for Payer: Health EOS Commercial |
$33.82
|
| Rate for Payer: HFN Commercial |
$34.96
|
| Rate for Payer: Multiplan Commercial |
$30.40
|
| Rate for Payer: NAPHCARE Commercial |
$22.80
|
| Rate for Payer: Preferred Network Access Commercial |
$34.96
|
| Rate for Payer: Quartz Beloit One Network |
$18.62
|
| Rate for Payer: Quartz Commercial |
$22.80
|
| Rate for Payer: WEA Trust Commercial |
$20.90
|
| Rate for Payer: WPS Commercial |
$28.15
|
|
|
Latanoprost 0.005% Ophth Solution 2.5ml [Med]
|
Facility
|
OP
|
$38.00
|
|
| Hospital Charge Code |
2974953
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.64 |
| Max. Negotiated Rate |
$152.00 |
| Rate for Payer: Aetna Commercial |
$34.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$32.68
|
| Rate for Payer: Aetna Managed Medicare |
$10.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$24.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$19.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$18.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$20.14
|
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Cigna Commercial |
$34.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$21.26
|
| Rate for Payer: Health EOS Commercial |
$33.82
|
| Rate for Payer: HFN Commercial |
$34.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$28.50
|
| Rate for Payer: Multiplan Commercial |
$30.40
|
| Rate for Payer: NAPHCARE Commercial |
$22.80
|
| Rate for Payer: Preferred Network Access Commercial |
$34.96
|
| Rate for Payer: Quartz Beloit One Network |
$18.62
|
| Rate for Payer: Quartz Commercial |
$24.70
|
| Rate for Payer: Quartz Medicare Advantage |
$22.80
|
| Rate for Payer: The Alliance Commercial |
$152.00
|
| Rate for Payer: WEA Trust Commercial |
$20.90
|
| Rate for Payer: WPS Commercial |
$28.15
|
|
|
LATERAL RETINACULAR RELEASE, OPEN
|
Facility
|
OP
|
$12,797.24
|
|
|
Service Code
|
CPT 27425
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,199.31 |
| Max. Negotiated Rate |
$12,797.24 |
| Rate for Payer: Aetna Managed Medicare |
$3,199.31
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,907.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,043.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,639.00
|
| Rate for Payer: Anthem Medicare Advantage |
$3,199.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3,199.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3,199.31
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$3,199.31
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,639.56
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$3,199.31
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,901.43
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3,199.31
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3,199.31
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$3,199.31
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$3,199.31
|
| Rate for Payer: NAPHCARE Commercial |
$4,798.96
|
| Rate for Payer: Quartz Medicare Advantage |
$3,199.31
|
| Rate for Payer: The Alliance Commercial |
$12,797.24
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,199.31
|
| Rate for Payer: United Healthcare PPO |
$4,103.00
|
| Rate for Payer: Wellcare Medicare |
$3,199.31
|
|
|
Layer closure of wounds (face, ears, eyelids, nose, lips, mucous membranes) <=2.5cm 12051
|
Professional
|
Both
|
$418.00
|
|
|
Service Code
|
CPT 12051
|
| Hospital Charge Code |
3013602
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$104.15 |
| Max. Negotiated Rate |
$562.89 |
| Rate for Payer: Aetna Commercial |
$397.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$359.48
|
| Rate for Payer: Cash Price |
$125.40
|
| Rate for Payer: Cash Price |
$125.40
|
| Rate for Payer: Cash Price |
$125.40
|
| Rate for Payer: Cigna Commercial |
$397.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$104.15
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$250.80
|
| Rate for Payer: Health EOS Commercial |
$380.38
|
| Rate for Payer: HFN Commercial |
$397.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$562.89
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$562.89
|
| Rate for Payer: Multiplan Commercial |
$334.40
|
| Rate for Payer: Preferred Network Access Commercial |
$397.10
|
| Rate for Payer: Quartz Beloit One Network |
$183.92
|
| Rate for Payer: Quartz Commercial |
$238.26
|
| Rate for Payer: The Alliance Commercial |
$209.00
|
| Rate for Payer: United Healthcare Medicaid |
$104.15
|
| Rate for Payer: WEA Trust Commercial |
$229.90
|
| Rate for Payer: WPS Commercial |
$309.61
|
|
|
Layer closure of wounds (face, ears, eyelids, nose, lips, mucous membranes) 2.6-5.0cm 12052
|
Professional
|
Both
|
$561.00
|
|
|
Service Code
|
CPT 12052
|
| Hospital Charge Code |
3013603
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$148.62 |
| Max. Negotiated Rate |
$665.26 |
| Rate for Payer: Aetna Commercial |
$532.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$482.46
|
| Rate for Payer: Cash Price |
$168.30
|
| Rate for Payer: Cash Price |
$168.30
|
| Rate for Payer: Cash Price |
$168.30
|
| Rate for Payer: Cigna Commercial |
$532.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$148.62
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$336.60
|
| Rate for Payer: Health EOS Commercial |
$510.51
|
| Rate for Payer: HFN Commercial |
$532.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$665.26
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$665.26
|
| Rate for Payer: Multiplan Commercial |
$448.80
|
| Rate for Payer: Preferred Network Access Commercial |
$532.95
|
| Rate for Payer: Quartz Beloit One Network |
$246.84
|
| Rate for Payer: Quartz Commercial |
$319.77
|
| Rate for Payer: The Alliance Commercial |
$280.50
|
| Rate for Payer: United Healthcare Medicaid |
$148.62
|
| Rate for Payer: WEA Trust Commercial |
$308.55
|
| Rate for Payer: WPS Commercial |
$415.53
|
|
|
Layer closure of wounds (face, ears, eyelids, nose, lips, mucous membranes) 5.1-7.5cm 12053
|
Professional
|
Both
|
$779.00
|
|
|
Service Code
|
CPT 12053
|
| Hospital Charge Code |
3013604
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$150.66 |
| Max. Negotiated Rate |
$740.05 |
| Rate for Payer: Aetna Commercial |
$740.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$669.94
|
| Rate for Payer: Cash Price |
$233.70
|
| Rate for Payer: Cash Price |
$233.70
|
| Rate for Payer: Cash Price |
$233.70
|
| Rate for Payer: Cigna Commercial |
$740.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$150.66
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$467.40
|
| Rate for Payer: Health EOS Commercial |
$708.89
|
| Rate for Payer: HFN Commercial |
$740.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$714.75
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$714.75
|
| Rate for Payer: Multiplan Commercial |
$623.20
|
| Rate for Payer: Preferred Network Access Commercial |
$740.05
|
| Rate for Payer: Quartz Beloit One Network |
$342.76
|
| Rate for Payer: Quartz Commercial |
$444.03
|
| Rate for Payer: The Alliance Commercial |
$389.50
|
| Rate for Payer: United Healthcare Medicaid |
$150.66
|
| Rate for Payer: WEA Trust Commercial |
$428.45
|
| Rate for Payer: WPS Commercial |
$577.01
|
|
|
Layer closure of wounds (face, ears, eyelids, nose, lips, mucous membranes) 7.6-12.5cm 12054
|
Professional
|
Both
|
$1,279.00
|
|
|
Service Code
|
CPT 12054
|
| Hospital Charge Code |
3013605
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$206.14 |
| Max. Negotiated Rate |
$1,215.05 |
| Rate for Payer: Aetna Commercial |
$1,215.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,099.94
|
| Rate for Payer: Cash Price |
$383.70
|
| Rate for Payer: Cash Price |
$383.70
|
| Rate for Payer: Cash Price |
$383.70
|
| Rate for Payer: Cigna Commercial |
$1,215.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$206.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$767.40
|
| Rate for Payer: Health EOS Commercial |
$1,163.89
|
| Rate for Payer: HFN Commercial |
$1,215.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$719.98
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$719.98
|
| Rate for Payer: Multiplan Commercial |
$1,023.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,215.05
|
| Rate for Payer: Quartz Beloit One Network |
$562.76
|
| Rate for Payer: Quartz Commercial |
$729.03
|
| Rate for Payer: The Alliance Commercial |
$639.50
|
| Rate for Payer: United Healthcare Medicaid |
$206.14
|
| Rate for Payer: WEA Trust Commercial |
$703.45
|
| Rate for Payer: WPS Commercial |
$947.36
|
|
|
Layer closure of wounds (neck, hands, feet, external genitalia) 12.6-20.0cm 12045
|
Professional
|
Both
|
$1,077.00
|
|
|
Service Code
|
CPT 12045
|
| Hospital Charge Code |
3013601
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$180.80 |
| Max. Negotiated Rate |
$1,023.15 |
| Rate for Payer: Aetna Commercial |
$1,023.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$926.22
|
| Rate for Payer: Cash Price |
$323.10
|
| Rate for Payer: Cash Price |
$323.10
|
| Rate for Payer: Cash Price |
$323.10
|
| Rate for Payer: Cigna Commercial |
$1,023.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$180.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$646.20
|
| Rate for Payer: Health EOS Commercial |
$980.07
|
| Rate for Payer: HFN Commercial |
$1,023.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$889.00
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$889.00
|
| Rate for Payer: Multiplan Commercial |
$861.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,023.15
|
| Rate for Payer: Quartz Beloit One Network |
$473.88
|
| Rate for Payer: Quartz Commercial |
$613.89
|
| Rate for Payer: The Alliance Commercial |
$538.50
|
| Rate for Payer: United Healthcare Medicaid |
$180.80
|
| Rate for Payer: WEA Trust Commercial |
$592.35
|
| Rate for Payer: WPS Commercial |
$797.73
|
|
|
Layer closure of wounds (neck, hands, feet, external genitalia) <=2.5cm 12041
|
Professional
|
Both
|
$388.00
|
|
|
Service Code
|
CPT 12041
|
| Hospital Charge Code |
3013598
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$70.05 |
| Max. Negotiated Rate |
$483.96 |
| Rate for Payer: Aetna Commercial |
$368.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$333.68
|
| Rate for Payer: Cash Price |
$116.40
|
| Rate for Payer: Cash Price |
$116.40
|
| Rate for Payer: Cash Price |
$116.40
|
| Rate for Payer: Cigna Commercial |
$368.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$70.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$232.80
|
| Rate for Payer: Health EOS Commercial |
$353.08
|
| Rate for Payer: HFN Commercial |
$368.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$483.96
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$483.96
|
| Rate for Payer: Multiplan Commercial |
$310.40
|
| Rate for Payer: Preferred Network Access Commercial |
$368.60
|
| Rate for Payer: Quartz Beloit One Network |
$170.72
|
| Rate for Payer: Quartz Commercial |
$221.16
|
| Rate for Payer: The Alliance Commercial |
$194.00
|
| Rate for Payer: United Healthcare Medicaid |
$70.05
|
| Rate for Payer: WEA Trust Commercial |
$213.40
|
| Rate for Payer: WPS Commercial |
$287.39
|
|
|
Layer closure of wounds (neck, hands, feet, external genitalia) 2.6-7.5cm 12042
|
Professional
|
Both
|
$590.00
|
|
|
Service Code
|
CPT 12042
|
| Hospital Charge Code |
3013599
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$101.06 |
| Max. Negotiated Rate |
$654.32 |
| Rate for Payer: Aetna Commercial |
$560.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$507.40
|
| Rate for Payer: Cash Price |
$177.00
|
| Rate for Payer: Cash Price |
$177.00
|
| Rate for Payer: Cash Price |
$177.00
|
| Rate for Payer: Cigna Commercial |
$560.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$101.06
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$354.00
|
| Rate for Payer: Health EOS Commercial |
$536.90
|
| Rate for Payer: HFN Commercial |
$560.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$654.32
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$654.32
|
| Rate for Payer: Multiplan Commercial |
$472.00
|
| Rate for Payer: Preferred Network Access Commercial |
$560.50
|
| Rate for Payer: Quartz Beloit One Network |
$259.60
|
| Rate for Payer: Quartz Commercial |
$336.30
|
| Rate for Payer: The Alliance Commercial |
$295.00
|
| Rate for Payer: United Healthcare Medicaid |
$101.06
|
| Rate for Payer: WEA Trust Commercial |
$324.50
|
| Rate for Payer: WPS Commercial |
$437.01
|
|
|
Layer closure of wounds (neck, hands, feet, external genitalia) >30.0cm 12047
|
Professional
|
Both
|
$2,341.00
|
|
|
Service Code
|
CPT 12047
|
| Hospital Charge Code |
5404640
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$273.99 |
| Max. Negotiated Rate |
$2,223.95 |
| Rate for Payer: Aetna Commercial |
$2,223.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,013.26
|
| Rate for Payer: Cash Price |
$702.30
|
| Rate for Payer: Cash Price |
$702.30
|
| Rate for Payer: Cash Price |
$702.30
|
| Rate for Payer: Cigna Commercial |
$2,223.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$273.99
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,404.60
|
| Rate for Payer: Health EOS Commercial |
$2,130.31
|
| Rate for Payer: HFN Commercial |
$2,223.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,144.64
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,144.64
|
| Rate for Payer: Multiplan Commercial |
$1,872.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,223.95
|
| Rate for Payer: Quartz Beloit One Network |
$1,030.04
|
| Rate for Payer: Quartz Commercial |
$1,334.37
|
| Rate for Payer: The Alliance Commercial |
$1,170.50
|
| Rate for Payer: United Healthcare Medicaid |
$273.99
|
| Rate for Payer: WEA Trust Commercial |
$1,287.55
|
| Rate for Payer: WPS Commercial |
$1,733.98
|
|
|
Layer closure of wounds (neck, hands, feet, external genitalia) 7.6-12.5cm 12044
|
Professional
|
Both
|
$765.00
|
|
|
Service Code
|
CPT 12044
|
| Hospital Charge Code |
3013600
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$135.57 |
| Max. Negotiated Rate |
$726.75 |
| Rate for Payer: Aetna Commercial |
$726.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$657.90
|
| Rate for Payer: Cash Price |
$229.50
|
| Rate for Payer: Cash Price |
$229.50
|
| Rate for Payer: Cash Price |
$229.50
|
| Rate for Payer: Cigna Commercial |
$726.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$135.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$459.00
|
| Rate for Payer: Health EOS Commercial |
$696.15
|
| Rate for Payer: HFN Commercial |
$726.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$707.52
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$707.52
|
| Rate for Payer: Multiplan Commercial |
$612.00
|
| Rate for Payer: Preferred Network Access Commercial |
$726.75
|
| Rate for Payer: Quartz Beloit One Network |
$336.60
|
| Rate for Payer: Quartz Commercial |
$436.05
|
| Rate for Payer: The Alliance Commercial |
$382.50
|
| Rate for Payer: United Healthcare Medicaid |
$135.57
|
| Rate for Payer: WEA Trust Commercial |
$420.75
|
| Rate for Payer: WPS Commercial |
$566.64
|
|
|
Layer closure of wounds (scalp, axillae, trunk, extremities) 12.6-20.0cm 12035
|
Professional
|
Both
|
$1,016.00
|
|
|
Service Code
|
CPT 12035
|
| Hospital Charge Code |
3013595
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$196.77 |
| Max. Negotiated Rate |
$965.20 |
| Rate for Payer: Aetna Commercial |
$965.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$873.76
|
| Rate for Payer: Cash Price |
$304.80
|
| Rate for Payer: Cash Price |
$304.80
|
| Rate for Payer: Cash Price |
$304.80
|
| Rate for Payer: Cigna Commercial |
$965.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$196.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$609.60
|
| Rate for Payer: Health EOS Commercial |
$924.56
|
| Rate for Payer: HFN Commercial |
$965.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$793.23
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$793.23
|
| Rate for Payer: Multiplan Commercial |
$812.80
|
| Rate for Payer: Preferred Network Access Commercial |
$965.20
|
| Rate for Payer: Quartz Beloit One Network |
$447.04
|
| Rate for Payer: Quartz Commercial |
$579.12
|
| Rate for Payer: The Alliance Commercial |
$508.00
|
| Rate for Payer: United Healthcare Medicaid |
$196.77
|
| Rate for Payer: WEA Trust Commercial |
$558.80
|
| Rate for Payer: WPS Commercial |
$752.55
|
|
|
Layer closure of wounds (scalp, axillae, trunk, extremities) 20.1-30.0cm 12036
|
Professional
|
Both
|
$1,180.00
|
|
|
Service Code
|
CPT 12036
|
| Hospital Charge Code |
3013596
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$210.92 |
| Max. Negotiated Rate |
$1,121.00 |
| Rate for Payer: Aetna Commercial |
$1,121.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,014.80
|
| Rate for Payer: Cash Price |
$354.00
|
| Rate for Payer: Cash Price |
$354.00
|
| Rate for Payer: Cash Price |
$354.00
|
| Rate for Payer: Cigna Commercial |
$1,121.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$210.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$708.00
|
| Rate for Payer: Health EOS Commercial |
$1,073.80
|
| Rate for Payer: HFN Commercial |
$1,121.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$925.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$925.25
|
| Rate for Payer: Multiplan Commercial |
$944.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,121.00
|
| Rate for Payer: Quartz Beloit One Network |
$519.20
|
| Rate for Payer: Quartz Commercial |
$672.60
|
| Rate for Payer: The Alliance Commercial |
$590.00
|
| Rate for Payer: United Healthcare Medicaid |
$210.92
|
| Rate for Payer: WEA Trust Commercial |
$649.00
|
| Rate for Payer: WPS Commercial |
$874.03
|
|
|
Layer closure of wounds (scalp, axillae, trunk, extremities) <= 2.5cm 12031
|
Professional
|
Both
|
$488.00
|
|
|
Service Code
|
CPT 12031
|
| Hospital Charge Code |
3013592
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$59.29 |
| Max. Negotiated Rate |
$504.93 |
| Rate for Payer: Aetna Commercial |
$463.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$419.68
|
| Rate for Payer: Cash Price |
$146.40
|
| Rate for Payer: Cash Price |
$146.40
|
| Rate for Payer: Cash Price |
$146.40
|
| Rate for Payer: Cigna Commercial |
$463.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$59.29
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$292.80
|
| Rate for Payer: Health EOS Commercial |
$444.08
|
| Rate for Payer: HFN Commercial |
$463.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$504.93
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$504.93
|
| Rate for Payer: Multiplan Commercial |
$390.40
|
| Rate for Payer: Preferred Network Access Commercial |
$463.60
|
| Rate for Payer: Quartz Beloit One Network |
$214.72
|
| Rate for Payer: Quartz Commercial |
$278.16
|
| Rate for Payer: The Alliance Commercial |
$244.00
|
| Rate for Payer: United Healthcare Medicaid |
$59.29
|
| Rate for Payer: WEA Trust Commercial |
$268.40
|
| Rate for Payer: WPS Commercial |
$361.46
|
|
|
Layer closure of wounds (scalp, axillae, trunk, extremities) 2.6-7.5cm 12032
|
Professional
|
Both
|
$510.00
|
|
|
Service Code
|
CPT 12032
|
| Hospital Charge Code |
3013593
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$80.86 |
| Max. Negotiated Rate |
$634.31 |
| Rate for Payer: Aetna Commercial |
$484.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$438.60
|
| Rate for Payer: Cash Price |
$153.00
|
| Rate for Payer: Cash Price |
$153.00
|
| Rate for Payer: Cash Price |
$153.00
|
| Rate for Payer: Cigna Commercial |
$484.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$80.86
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$306.00
|
| Rate for Payer: Health EOS Commercial |
$464.10
|
| Rate for Payer: HFN Commercial |
$484.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$634.31
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$634.31
|
| Rate for Payer: Multiplan Commercial |
$408.00
|
| Rate for Payer: Preferred Network Access Commercial |
$484.50
|
| Rate for Payer: Quartz Beloit One Network |
$224.40
|
| Rate for Payer: Quartz Commercial |
$290.70
|
| Rate for Payer: The Alliance Commercial |
$255.00
|
| Rate for Payer: United Healthcare Medicaid |
$80.86
|
| Rate for Payer: WEA Trust Commercial |
$280.50
|
| Rate for Payer: WPS Commercial |
$377.76
|
|
|
Layer closure of wounds (scalp, axillae, trunk, extremities) >30.0cm 12037
|
Professional
|
Both
|
$1,605.00
|
|
|
Service Code
|
CPT 12037
|
| Hospital Charge Code |
3013597
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$253.09 |
| Max. Negotiated Rate |
$1,524.75 |
| Rate for Payer: Aetna Commercial |
$1,524.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,380.30
|
| Rate for Payer: Cash Price |
$481.50
|
| Rate for Payer: Cash Price |
$481.50
|
| Rate for Payer: Cash Price |
$481.50
|
| Rate for Payer: Cigna Commercial |
$1,524.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$253.09
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$963.00
|
| Rate for Payer: Health EOS Commercial |
$1,460.55
|
| Rate for Payer: HFN Commercial |
$1,524.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,071.92
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,071.92
|
| Rate for Payer: Multiplan Commercial |
$1,284.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,524.75
|
| Rate for Payer: Quartz Beloit One Network |
$706.20
|
| Rate for Payer: Quartz Commercial |
$914.85
|
| Rate for Payer: The Alliance Commercial |
$802.50
|
| Rate for Payer: United Healthcare Medicaid |
$253.09
|
| Rate for Payer: WEA Trust Commercial |
$882.75
|
| Rate for Payer: WPS Commercial |
$1,188.82
|
|
