|
XR TMJ Open and Closed Bilateral
|
Facility
IP
|
$677.00
|
|
|
Service Code
|
CPT 70330 TC,LT
|
| Hospital Charge Code |
1537379
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$331.73 |
| Max. Negotiated Rate |
$622.84 |
| Rate for Payer: Aetna Commercial |
$609.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$358.81
|
| Rate for Payer: Cash Price |
$203.10
|
| Rate for Payer: Cigna Commercial |
$622.84
|
| Rate for Payer: Health EOS Commercial |
$602.53
|
| Rate for Payer: HFN Commercial |
$622.84
|
| Rate for Payer: Multiplan Commercial |
$541.60
|
| Rate for Payer: NAPHCARE Commercial |
$406.20
|
| Rate for Payer: Preferred Network Access Commercial |
$622.84
|
| Rate for Payer: Quartz Beloit One Network |
$331.73
|
| Rate for Payer: Quartz Commercial |
$406.20
|
| Rate for Payer: WEA Trust Commercial |
$372.35
|
| Rate for Payer: WPS Commercial |
$501.45
|
|
|
XR TMJ Open and Closed Bilateral
|
Professional
|
$677.00
|
|
|
Service Code
|
CPT 70330 TC,LT
|
| Hospital Charge Code |
1537379
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$297.88 |
| Max. Negotiated Rate |
$643.15 |
| Rate for Payer: Aetna Commercial |
$643.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$582.22
|
| Rate for Payer: Cash Price |
$203.10
|
| Rate for Payer: Cash Price |
$203.10
|
| Rate for Payer: Cigna Commercial |
$643.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$338.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$406.20
|
| Rate for Payer: Health EOS Commercial |
$616.07
|
| Rate for Payer: Multiplan Commercial |
$541.60
|
| Rate for Payer: Preferred Network Access Commercial |
$643.15
|
| Rate for Payer: Quartz Beloit One Network |
$297.88
|
| Rate for Payer: Quartz Commercial |
$385.89
|
| Rate for Payer: The Alliance Commercial |
$338.50
|
| Rate for Payer: WEA Trust Commercial |
$372.35
|
| Rate for Payer: WPS Commercial |
$501.45
|
|
|
XR TMJ Open and Closed Bilateral
|
Facility
OP
|
$1,254.00
|
|
|
Service Code
|
CPT 70330
|
| Hospital Charge Code |
629932
|
| Min. Negotiated Rate |
$89.82 |
| Max. Negotiated Rate |
$2,153.80 |
| Rate for Payer: Aetna Commercial |
$1,128.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,078.44
|
| Rate for Payer: Aetna Managed Medicare |
$89.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$815.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$627.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$601.92
|
| Rate for Payer: Anthem Medicare Advantage |
$89.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$664.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$89.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$89.82
|
| Rate for Payer: Cash Price |
$376.20
|
| Rate for Payer: Cash Price |
$376.20
|
| Rate for Payer: Cigna Commercial |
$1,153.68
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$89.82
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$89.82
|
| Rate for Payer: Health EOS Commercial |
$1,116.06
|
| Rate for Payer: HFN Commercial |
$1,153.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$334.13
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$89.82
|
| Rate for Payer: Independent Care Health Plan Medicare |
$89.82
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$89.82
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$89.82
|
| Rate for Payer: Multiplan Commercial |
$1,003.20
|
| Rate for Payer: NAPHCARE Commercial |
$134.73
|
| Rate for Payer: Preferred Network Access Commercial |
$1,153.68
|
| Rate for Payer: Quartz Beloit One Network |
$614.46
|
| Rate for Payer: Quartz Commercial |
$815.10
|
| Rate for Payer: Quartz Medicare Advantage |
$89.82
|
| Rate for Payer: The Alliance Commercial |
$2,153.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$89.82
|
| Rate for Payer: WEA Trust Commercial |
$689.70
|
| Rate for Payer: Wellcare Medicare |
$89.82
|
| Rate for Payer: WPS Commercial |
$928.84
|
|
|
XR TMJ Open and Closed Bilateral
|
Professional
|
$1,254.00
|
|
|
Service Code
|
CPT 70330
|
| Hospital Charge Code |
629932
|
| Min. Negotiated Rate |
$51.16 |
| Max. Negotiated Rate |
$1,191.30 |
| Rate for Payer: Aetna Commercial |
$1,191.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,078.44
|
| Rate for Payer: Aetna Managed Medicare |
$51.16
|
| Rate for Payer: Anthem Medicare Advantage |
$51.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$51.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$51.16
|
| Rate for Payer: Cash Price |
$376.20
|
| Rate for Payer: Cash Price |
$376.20
|
| Rate for Payer: Cigna Commercial |
$1,191.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$627.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$51.16
|
| Rate for Payer: Health EOS Commercial |
$1,141.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$181.12
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$181.12
|
| Rate for Payer: Independent Care Health Plan Medicare |
$51.16
|
| Rate for Payer: Multiplan Commercial |
$1,003.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,191.30
|
| Rate for Payer: Quartz Beloit One Network |
$551.76
|
| Rate for Payer: Quartz Commercial |
$714.78
|
| Rate for Payer: Quartz Medicare Advantage |
$51.16
|
| Rate for Payer: The Alliance Commercial |
$194.41
|
| Rate for Payer: United Healthcare Medicare Advantage |
$51.16
|
| Rate for Payer: WEA Trust Commercial |
$689.70
|
| Rate for Payer: WPS Commercial |
$255.80
|
|
|
XR TMJ Open and Closed Bilateral
|
Facility
OP
|
$677.00
|
|
|
Service Code
|
CPT 70330 TC,LT
|
| Hospital Charge Code |
1537379
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$189.56 |
| Max. Negotiated Rate |
$2,708.00 |
| Rate for Payer: Aetna Commercial |
$609.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$582.22
|
| Rate for Payer: Aetna Managed Medicare |
$189.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$440.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$338.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$324.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$358.81
|
| Rate for Payer: Cash Price |
$203.10
|
| Rate for Payer: Cash Price |
$203.10
|
| Rate for Payer: Cash Price |
$203.10
|
| Rate for Payer: Cigna Commercial |
$622.84
|
| Rate for Payer: Health EOS Commercial |
$602.53
|
| Rate for Payer: HFN Commercial |
$622.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$507.75
|
| Rate for Payer: Multiplan Commercial |
$541.60
|
| Rate for Payer: NAPHCARE Commercial |
$406.20
|
| Rate for Payer: Preferred Network Access Commercial |
$622.84
|
| Rate for Payer: Quartz Beloit One Network |
$331.73
|
| Rate for Payer: Quartz Commercial |
$440.05
|
| Rate for Payer: Quartz Medicare Advantage |
$406.20
|
| Rate for Payer: The Alliance Commercial |
$2,708.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$372.35
|
| Rate for Payer: WPS Commercial |
$501.45
|
|
|
XR TMJ Open and Closed Left
|
Facility
IP
|
$626.00
|
|
|
Service Code
|
CPT 70328
|
| Hospital Charge Code |
629928
|
| Min. Negotiated Rate |
$306.74 |
| Max. Negotiated Rate |
$575.92 |
| Rate for Payer: Aetna Commercial |
$563.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$331.78
|
| Rate for Payer: Cash Price |
$187.80
|
| Rate for Payer: Cigna Commercial |
$575.92
|
| Rate for Payer: Health EOS Commercial |
$557.14
|
| Rate for Payer: HFN Commercial |
$575.92
|
| Rate for Payer: Multiplan Commercial |
$500.80
|
| Rate for Payer: NAPHCARE Commercial |
$375.60
|
| Rate for Payer: Preferred Network Access Commercial |
$575.92
|
| Rate for Payer: Quartz Beloit One Network |
$306.74
|
| Rate for Payer: Quartz Commercial |
$375.60
|
| Rate for Payer: WEA Trust Commercial |
$344.30
|
| Rate for Payer: WPS Commercial |
$463.68
|
|
|
XR TMJ Open and Closed Left
|
Facility
IP
|
$651.00
|
|
|
Service Code
|
CPT 70328 TC,LT
|
| Hospital Charge Code |
1537381
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$318.99 |
| Max. Negotiated Rate |
$598.92 |
| Rate for Payer: Aetna Commercial |
$585.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$345.03
|
| Rate for Payer: Cash Price |
$195.30
|
| Rate for Payer: Cigna Commercial |
$598.92
|
| Rate for Payer: Health EOS Commercial |
$579.39
|
| Rate for Payer: HFN Commercial |
$598.92
|
| Rate for Payer: Multiplan Commercial |
$520.80
|
| Rate for Payer: NAPHCARE Commercial |
$390.60
|
| Rate for Payer: Preferred Network Access Commercial |
$598.92
|
| Rate for Payer: Quartz Beloit One Network |
$318.99
|
| Rate for Payer: Quartz Commercial |
$390.60
|
| Rate for Payer: WEA Trust Commercial |
$358.05
|
| Rate for Payer: WPS Commercial |
$482.20
|
|
|
XR TMJ Open and Closed Left
|
Facility
OP
|
$651.00
|
|
|
Service Code
|
CPT 70328 TC,LT
|
| Hospital Charge Code |
1537381
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$182.28 |
| Max. Negotiated Rate |
$2,604.00 |
| Rate for Payer: Aetna Commercial |
$585.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$559.86
|
| Rate for Payer: Aetna Managed Medicare |
$182.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$423.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$325.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$312.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$345.03
|
| Rate for Payer: Cash Price |
$195.30
|
| Rate for Payer: Cash Price |
$195.30
|
| Rate for Payer: Cash Price |
$195.30
|
| Rate for Payer: Cigna Commercial |
$598.92
|
| Rate for Payer: Health EOS Commercial |
$579.39
|
| Rate for Payer: HFN Commercial |
$598.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$488.25
|
| Rate for Payer: Multiplan Commercial |
$520.80
|
| Rate for Payer: NAPHCARE Commercial |
$390.60
|
| Rate for Payer: Preferred Network Access Commercial |
$598.92
|
| Rate for Payer: Quartz Beloit One Network |
$318.99
|
| Rate for Payer: Quartz Commercial |
$423.15
|
| Rate for Payer: Quartz Medicare Advantage |
$390.60
|
| Rate for Payer: The Alliance Commercial |
$2,604.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$358.05
|
| Rate for Payer: WPS Commercial |
$482.20
|
|
|
XR TMJ Open and Closed Left
|
Professional
|
$651.00
|
|
|
Service Code
|
CPT 70328 TC,LT
|
| Hospital Charge Code |
1537381
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$286.44 |
| Max. Negotiated Rate |
$618.45 |
| Rate for Payer: Aetna Commercial |
$618.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$559.86
|
| Rate for Payer: Cash Price |
$195.30
|
| Rate for Payer: Cash Price |
$195.30
|
| Rate for Payer: Cigna Commercial |
$618.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$325.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$390.60
|
| Rate for Payer: Health EOS Commercial |
$592.41
|
| Rate for Payer: Multiplan Commercial |
$520.80
|
| Rate for Payer: Preferred Network Access Commercial |
$618.45
|
| Rate for Payer: Quartz Beloit One Network |
$286.44
|
| Rate for Payer: Quartz Commercial |
$371.07
|
| Rate for Payer: The Alliance Commercial |
$325.50
|
| Rate for Payer: WEA Trust Commercial |
$358.05
|
| Rate for Payer: WPS Commercial |
$482.20
|
|
|
XR TMJ Open and Closed Left
|
Professional
|
$626.00
|
|
|
Service Code
|
CPT 70328
|
| Hospital Charge Code |
629928
|
| Min. Negotiated Rate |
$33.35 |
| Max. Negotiated Rate |
$594.70 |
| Rate for Payer: Aetna Commercial |
$594.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$538.36
|
| Rate for Payer: Aetna Managed Medicare |
$33.35
|
| Rate for Payer: Anthem Medicare Advantage |
$33.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$33.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$33.35
|
| Rate for Payer: Cash Price |
$187.80
|
| Rate for Payer: Cash Price |
$187.80
|
| Rate for Payer: Cigna Commercial |
$594.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$313.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$33.35
|
| Rate for Payer: Health EOS Commercial |
$569.66
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$116.88
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$116.88
|
| Rate for Payer: Independent Care Health Plan Medicare |
$33.35
|
| Rate for Payer: Multiplan Commercial |
$500.80
|
| Rate for Payer: Preferred Network Access Commercial |
$594.70
|
| Rate for Payer: Quartz Beloit One Network |
$275.44
|
| Rate for Payer: Quartz Commercial |
$356.82
|
| Rate for Payer: Quartz Medicare Advantage |
$33.35
|
| Rate for Payer: The Alliance Commercial |
$126.73
|
| Rate for Payer: United Healthcare Medicare Advantage |
$33.35
|
| Rate for Payer: WEA Trust Commercial |
$344.30
|
| Rate for Payer: WPS Commercial |
$166.75
|
|
|
XR TMJ Open and Closed Left
|
Facility
OP
|
$626.00
|
|
|
Service Code
|
CPT 70328
|
| Hospital Charge Code |
629928
|
| Min. Negotiated Rate |
$29.60 |
| Max. Negotiated Rate |
$575.92 |
| Rate for Payer: Aetna Commercial |
$563.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$538.36
|
| Rate for Payer: Aetna Managed Medicare |
$89.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$406.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$313.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$300.48
|
| Rate for Payer: Anthem Medicare Advantage |
$89.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$331.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$89.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$89.82
|
| Rate for Payer: Cash Price |
$187.80
|
| Rate for Payer: Cash Price |
$187.80
|
| Rate for Payer: Cigna Commercial |
$575.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$89.82
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$89.82
|
| Rate for Payer: Health EOS Commercial |
$557.14
|
| Rate for Payer: HFN Commercial |
$575.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$334.13
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$89.82
|
| Rate for Payer: Independent Care Health Plan Medicare |
$89.82
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$89.82
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$89.82
|
| Rate for Payer: Multiplan Commercial |
$500.80
|
| Rate for Payer: NAPHCARE Commercial |
$134.73
|
| Rate for Payer: Preferred Network Access Commercial |
$575.92
|
| Rate for Payer: Quartz Beloit One Network |
$306.74
|
| Rate for Payer: Quartz Commercial |
$406.90
|
| Rate for Payer: Quartz Medicare Advantage |
$89.82
|
| Rate for Payer: The Alliance Commercial |
$29.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$89.82
|
| Rate for Payer: WEA Trust Commercial |
$344.30
|
| Rate for Payer: Wellcare Medicare |
$89.82
|
| Rate for Payer: WPS Commercial |
$463.68
|
|
|
XR TMJ Open and Closed Right
|
Facility
OP
|
$651.00
|
|
|
Service Code
|
CPT 70328 RT,TC
|
| Hospital Charge Code |
1537383
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$182.28 |
| Max. Negotiated Rate |
$2,604.00 |
| Rate for Payer: Aetna Commercial |
$585.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$559.86
|
| Rate for Payer: Aetna Managed Medicare |
$182.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$423.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$325.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$312.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$345.03
|
| Rate for Payer: Cash Price |
$195.30
|
| Rate for Payer: Cash Price |
$195.30
|
| Rate for Payer: Cash Price |
$195.30
|
| Rate for Payer: Cigna Commercial |
$598.92
|
| Rate for Payer: Health EOS Commercial |
$579.39
|
| Rate for Payer: HFN Commercial |
$598.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$488.25
|
| Rate for Payer: Multiplan Commercial |
$520.80
|
| Rate for Payer: NAPHCARE Commercial |
$390.60
|
| Rate for Payer: Preferred Network Access Commercial |
$598.92
|
| Rate for Payer: Quartz Beloit One Network |
$318.99
|
| Rate for Payer: Quartz Commercial |
$423.15
|
| Rate for Payer: Quartz Medicare Advantage |
$390.60
|
| Rate for Payer: The Alliance Commercial |
$2,604.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$358.05
|
| Rate for Payer: WPS Commercial |
$482.20
|
|
|
XR TMJ Open and Closed Right
|
Facility
OP
|
$677.00
|
|
|
Service Code
|
CPT 70330 TC,RT
|
| Hospital Charge Code |
2980136
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$189.56 |
| Max. Negotiated Rate |
$2,708.00 |
| Rate for Payer: Aetna Commercial |
$609.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$582.22
|
| Rate for Payer: Aetna Managed Medicare |
$189.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$440.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$338.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$324.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$358.81
|
| Rate for Payer: Cash Price |
$203.10
|
| Rate for Payer: Cash Price |
$203.10
|
| Rate for Payer: Cash Price |
$203.10
|
| Rate for Payer: Cigna Commercial |
$622.84
|
| Rate for Payer: Health EOS Commercial |
$602.53
|
| Rate for Payer: HFN Commercial |
$622.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$507.75
|
| Rate for Payer: Multiplan Commercial |
$541.60
|
| Rate for Payer: NAPHCARE Commercial |
$406.20
|
| Rate for Payer: Preferred Network Access Commercial |
$622.84
|
| Rate for Payer: Quartz Beloit One Network |
$331.73
|
| Rate for Payer: Quartz Commercial |
$440.05
|
| Rate for Payer: Quartz Medicare Advantage |
$406.20
|
| Rate for Payer: The Alliance Commercial |
$2,708.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$372.35
|
| Rate for Payer: WPS Commercial |
$501.45
|
|
|
XR TMJ Open and Closed Right
|
Professional
|
$651.00
|
|
|
Service Code
|
CPT 70328 RT,TC
|
| Hospital Charge Code |
1537383
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$286.44 |
| Max. Negotiated Rate |
$618.45 |
| Rate for Payer: Aetna Commercial |
$618.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$559.86
|
| Rate for Payer: Cash Price |
$195.30
|
| Rate for Payer: Cash Price |
$195.30
|
| Rate for Payer: Cigna Commercial |
$618.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$325.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$390.60
|
| Rate for Payer: Health EOS Commercial |
$592.41
|
| Rate for Payer: Multiplan Commercial |
$520.80
|
| Rate for Payer: Preferred Network Access Commercial |
$618.45
|
| Rate for Payer: Quartz Beloit One Network |
$286.44
|
| Rate for Payer: Quartz Commercial |
$371.07
|
| Rate for Payer: The Alliance Commercial |
$325.50
|
| Rate for Payer: WEA Trust Commercial |
$358.05
|
| Rate for Payer: WPS Commercial |
$482.20
|
|
|
XR TMJ Open and Closed Right
|
Professional
|
$626.00
|
|
|
Service Code
|
CPT 70328
|
| Hospital Charge Code |
629922
|
| Min. Negotiated Rate |
$33.35 |
| Max. Negotiated Rate |
$594.70 |
| Rate for Payer: Aetna Commercial |
$594.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$538.36
|
| Rate for Payer: Aetna Managed Medicare |
$33.35
|
| Rate for Payer: Anthem Medicare Advantage |
$33.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$33.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$33.35
|
| Rate for Payer: Cash Price |
$187.80
|
| Rate for Payer: Cash Price |
$187.80
|
| Rate for Payer: Cigna Commercial |
$594.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$313.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$33.35
|
| Rate for Payer: Health EOS Commercial |
$569.66
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$116.88
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$116.88
|
| Rate for Payer: Independent Care Health Plan Medicare |
$33.35
|
| Rate for Payer: Multiplan Commercial |
$500.80
|
| Rate for Payer: Preferred Network Access Commercial |
$594.70
|
| Rate for Payer: Quartz Beloit One Network |
$275.44
|
| Rate for Payer: Quartz Commercial |
$356.82
|
| Rate for Payer: Quartz Medicare Advantage |
$33.35
|
| Rate for Payer: The Alliance Commercial |
$126.73
|
| Rate for Payer: United Healthcare Medicare Advantage |
$33.35
|
| Rate for Payer: WEA Trust Commercial |
$344.30
|
| Rate for Payer: WPS Commercial |
$166.75
|
|
|
XR TMJ Open and Closed Right
|
Facility
IP
|
$677.00
|
|
|
Service Code
|
CPT 70330 TC,RT
|
| Hospital Charge Code |
2980136
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$331.73 |
| Max. Negotiated Rate |
$622.84 |
| Rate for Payer: Aetna Commercial |
$609.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$358.81
|
| Rate for Payer: Cash Price |
$203.10
|
| Rate for Payer: Cigna Commercial |
$622.84
|
| Rate for Payer: Health EOS Commercial |
$602.53
|
| Rate for Payer: HFN Commercial |
$622.84
|
| Rate for Payer: Multiplan Commercial |
$541.60
|
| Rate for Payer: NAPHCARE Commercial |
$406.20
|
| Rate for Payer: Preferred Network Access Commercial |
$622.84
|
| Rate for Payer: Quartz Beloit One Network |
$331.73
|
| Rate for Payer: Quartz Commercial |
$406.20
|
| Rate for Payer: WEA Trust Commercial |
$372.35
|
| Rate for Payer: WPS Commercial |
$501.45
|
|
|
XR TMJ Open and Closed Right
|
Facility
IP
|
$626.00
|
|
|
Service Code
|
CPT 70328
|
| Hospital Charge Code |
629922
|
| Min. Negotiated Rate |
$306.74 |
| Max. Negotiated Rate |
$575.92 |
| Rate for Payer: Aetna Commercial |
$563.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$331.78
|
| Rate for Payer: Cash Price |
$187.80
|
| Rate for Payer: Cigna Commercial |
$575.92
|
| Rate for Payer: Health EOS Commercial |
$557.14
|
| Rate for Payer: HFN Commercial |
$575.92
|
| Rate for Payer: Multiplan Commercial |
$500.80
|
| Rate for Payer: NAPHCARE Commercial |
$375.60
|
| Rate for Payer: Preferred Network Access Commercial |
$575.92
|
| Rate for Payer: Quartz Beloit One Network |
$306.74
|
| Rate for Payer: Quartz Commercial |
$375.60
|
| Rate for Payer: WEA Trust Commercial |
$344.30
|
| Rate for Payer: WPS Commercial |
$463.68
|
|
|
XR TMJ Open and Closed Right
|
Facility
OP
|
$626.00
|
|
|
Service Code
|
CPT 70328
|
| Hospital Charge Code |
629922
|
| Min. Negotiated Rate |
$29.60 |
| Max. Negotiated Rate |
$575.92 |
| Rate for Payer: Aetna Commercial |
$563.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$538.36
|
| Rate for Payer: Aetna Managed Medicare |
$89.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$406.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$313.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$300.48
|
| Rate for Payer: Anthem Medicare Advantage |
$89.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$331.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$89.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$89.82
|
| Rate for Payer: Cash Price |
$187.80
|
| Rate for Payer: Cash Price |
$187.80
|
| Rate for Payer: Cigna Commercial |
$575.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$89.82
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$89.82
|
| Rate for Payer: Health EOS Commercial |
$557.14
|
| Rate for Payer: HFN Commercial |
$575.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$334.13
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$89.82
|
| Rate for Payer: Independent Care Health Plan Medicare |
$89.82
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$89.82
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$89.82
|
| Rate for Payer: Multiplan Commercial |
$500.80
|
| Rate for Payer: NAPHCARE Commercial |
$134.73
|
| Rate for Payer: Preferred Network Access Commercial |
$575.92
|
| Rate for Payer: Quartz Beloit One Network |
$306.74
|
| Rate for Payer: Quartz Commercial |
$406.90
|
| Rate for Payer: Quartz Medicare Advantage |
$89.82
|
| Rate for Payer: The Alliance Commercial |
$29.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$89.82
|
| Rate for Payer: WEA Trust Commercial |
$344.30
|
| Rate for Payer: Wellcare Medicare |
$89.82
|
| Rate for Payer: WPS Commercial |
$463.68
|
|
|
XR TMJ Open and Closed Right
|
Facility
IP
|
$651.00
|
|
|
Service Code
|
CPT 70328 RT,TC
|
| Hospital Charge Code |
1537383
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$318.99 |
| Max. Negotiated Rate |
$598.92 |
| Rate for Payer: Aetna Commercial |
$585.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$345.03
|
| Rate for Payer: Cash Price |
$195.30
|
| Rate for Payer: Cigna Commercial |
$598.92
|
| Rate for Payer: Health EOS Commercial |
$579.39
|
| Rate for Payer: HFN Commercial |
$598.92
|
| Rate for Payer: Multiplan Commercial |
$520.80
|
| Rate for Payer: NAPHCARE Commercial |
$390.60
|
| Rate for Payer: Preferred Network Access Commercial |
$598.92
|
| Rate for Payer: Quartz Beloit One Network |
$318.99
|
| Rate for Payer: Quartz Commercial |
$390.60
|
| Rate for Payer: WEA Trust Commercial |
$358.05
|
| Rate for Payer: WPS Commercial |
$482.20
|
|
|
XR TMJ Open and Closed Right
|
Professional
|
$677.00
|
|
|
Service Code
|
CPT 70330 TC,RT
|
| Hospital Charge Code |
2980136
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$297.88 |
| Max. Negotiated Rate |
$643.15 |
| Rate for Payer: Aetna Commercial |
$643.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$582.22
|
| Rate for Payer: Cash Price |
$203.10
|
| Rate for Payer: Cash Price |
$203.10
|
| Rate for Payer: Cigna Commercial |
$643.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$338.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$406.20
|
| Rate for Payer: Health EOS Commercial |
$616.07
|
| Rate for Payer: Multiplan Commercial |
$541.60
|
| Rate for Payer: Preferred Network Access Commercial |
$643.15
|
| Rate for Payer: Quartz Beloit One Network |
$297.88
|
| Rate for Payer: Quartz Commercial |
$385.89
|
| Rate for Payer: The Alliance Commercial |
$338.50
|
| Rate for Payer: WEA Trust Commercial |
$372.35
|
| Rate for Payer: WPS Commercial |
$501.45
|
|
|
XR Toes 2nd Digit Left
|
Facility
IP
|
$391.00
|
|
|
Service Code
|
CPT 73660
|
| Hospital Charge Code |
629918
|
| Min. Negotiated Rate |
$191.59 |
| Max. Negotiated Rate |
$359.72 |
| Rate for Payer: Aetna Commercial |
$351.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$207.23
|
| Rate for Payer: Cash Price |
$117.30
|
| Rate for Payer: Cigna Commercial |
$359.72
|
| Rate for Payer: Health EOS Commercial |
$347.99
|
| Rate for Payer: HFN Commercial |
$359.72
|
| Rate for Payer: Multiplan Commercial |
$312.80
|
| Rate for Payer: NAPHCARE Commercial |
$234.60
|
| Rate for Payer: Preferred Network Access Commercial |
$359.72
|
| Rate for Payer: Quartz Beloit One Network |
$191.59
|
| Rate for Payer: Quartz Commercial |
$234.60
|
| Rate for Payer: WEA Trust Commercial |
$215.05
|
| Rate for Payer: WPS Commercial |
$289.61
|
|
|
XR Toes 2nd Digit Left
|
Facility
OP
|
$391.00
|
|
|
Service Code
|
CPT 73660
|
| Hospital Charge Code |
629918
|
| Min. Negotiated Rate |
$89.82 |
| Max. Negotiated Rate |
$515.52 |
| Rate for Payer: Aetna Commercial |
$351.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$336.26
|
| Rate for Payer: Aetna Managed Medicare |
$89.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$254.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$195.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$187.68
|
| Rate for Payer: Anthem Medicare Advantage |
$89.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$207.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$89.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$89.82
|
| Rate for Payer: Cash Price |
$117.30
|
| Rate for Payer: Cash Price |
$117.30
|
| Rate for Payer: Cigna Commercial |
$359.72
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$89.82
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$89.82
|
| Rate for Payer: Health EOS Commercial |
$347.99
|
| Rate for Payer: HFN Commercial |
$359.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$334.13
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$89.82
|
| Rate for Payer: Independent Care Health Plan Medicare |
$89.82
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$89.82
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$89.82
|
| Rate for Payer: Multiplan Commercial |
$312.80
|
| Rate for Payer: NAPHCARE Commercial |
$134.73
|
| Rate for Payer: Preferred Network Access Commercial |
$359.72
|
| Rate for Payer: Quartz Beloit One Network |
$191.59
|
| Rate for Payer: Quartz Commercial |
$254.15
|
| Rate for Payer: Quartz Medicare Advantage |
$89.82
|
| Rate for Payer: The Alliance Commercial |
$515.52
|
| Rate for Payer: United Healthcare Medicare Advantage |
$89.82
|
| Rate for Payer: WEA Trust Commercial |
$215.05
|
| Rate for Payer: Wellcare Medicare |
$89.82
|
| Rate for Payer: WPS Commercial |
$289.61
|
|
|
XR Toes 2nd Digit Left
|
Professional
|
$402.00
|
|
|
Service Code
|
CPT 73660 T1,TC
|
| Hospital Charge Code |
1537397
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$176.88 |
| Max. Negotiated Rate |
$381.90 |
| Rate for Payer: Aetna Commercial |
$381.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$345.72
|
| Rate for Payer: Cash Price |
$120.60
|
| Rate for Payer: Cash Price |
$120.60
|
| Rate for Payer: Cigna Commercial |
$381.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$201.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$241.20
|
| Rate for Payer: Health EOS Commercial |
$365.82
|
| Rate for Payer: Multiplan Commercial |
$321.60
|
| Rate for Payer: Preferred Network Access Commercial |
$381.90
|
| Rate for Payer: Quartz Beloit One Network |
$176.88
|
| Rate for Payer: Quartz Commercial |
$229.14
|
| Rate for Payer: The Alliance Commercial |
$201.00
|
| Rate for Payer: WEA Trust Commercial |
$221.10
|
| Rate for Payer: WPS Commercial |
$297.76
|
|
|
XR Toes 2nd Digit Left
|
Facility
IP
|
$402.00
|
|
|
Service Code
|
CPT 73660 T1,TC
|
| Hospital Charge Code |
1537397
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$196.98 |
| Max. Negotiated Rate |
$369.84 |
| Rate for Payer: Aetna Commercial |
$361.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$213.06
|
| Rate for Payer: Cash Price |
$120.60
|
| Rate for Payer: Cigna Commercial |
$369.84
|
| Rate for Payer: Health EOS Commercial |
$357.78
|
| Rate for Payer: HFN Commercial |
$369.84
|
| Rate for Payer: Multiplan Commercial |
$321.60
|
| Rate for Payer: NAPHCARE Commercial |
$241.20
|
| Rate for Payer: Preferred Network Access Commercial |
$369.84
|
| Rate for Payer: Quartz Beloit One Network |
$196.98
|
| Rate for Payer: Quartz Commercial |
$241.20
|
| Rate for Payer: WEA Trust Commercial |
$221.10
|
| Rate for Payer: WPS Commercial |
$297.76
|
|
|
XR Toes 2nd Digit Left
|
Professional
|
$391.00
|
|
|
Service Code
|
CPT 73660
|
| Hospital Charge Code |
629918
|
| Min. Negotiated Rate |
$28.12 |
| Max. Negotiated Rate |
$371.45 |
| Rate for Payer: Aetna Commercial |
$371.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$336.26
|
| Rate for Payer: Aetna Managed Medicare |
$28.12
|
| Rate for Payer: Anthem Medicare Advantage |
$28.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$28.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$28.12
|
| Rate for Payer: Cash Price |
$117.30
|
| Rate for Payer: Cash Price |
$117.30
|
| Rate for Payer: Cigna Commercial |
$371.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$195.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$28.12
|
| Rate for Payer: Health EOS Commercial |
$355.81
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$97.96
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$97.96
|
| Rate for Payer: Independent Care Health Plan Medicare |
$28.12
|
| Rate for Payer: Multiplan Commercial |
$312.80
|
| Rate for Payer: Preferred Network Access Commercial |
$371.45
|
| Rate for Payer: Quartz Beloit One Network |
$172.04
|
| Rate for Payer: Quartz Commercial |
$222.87
|
| Rate for Payer: Quartz Medicare Advantage |
$28.12
|
| Rate for Payer: The Alliance Commercial |
$106.86
|
| Rate for Payer: United Healthcare Medicare Advantage |
$28.12
|
| Rate for Payer: WEA Trust Commercial |
$215.05
|
| Rate for Payer: WPS Commercial |
$140.60
|
|
