|
XR Tibia/Fibula Right
|
Facility
|
IP
|
$606.00
|
|
|
Service Code
|
CPT 73590 RT,TC
|
| Hospital Charge Code |
1537395
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$308.82 |
| Max. Negotiated Rate |
$579.82 |
| Rate for Payer: Aetna Commercial |
$567.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$542.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$334.03
|
| Rate for Payer: Cash Price |
$181.80
|
| Rate for Payer: Cigna Commercial |
$579.82
|
| Rate for Payer: Health EOS Commercial |
$560.91
|
| Rate for Payer: HFN Commercial |
$579.82
|
| Rate for Payer: Multiplan Commercial |
$504.19
|
| Rate for Payer: Preferred Network Access Commercial |
$579.82
|
| Rate for Payer: Quartz Beloit One Network |
$308.82
|
| Rate for Payer: Quartz Commercial |
$378.14
|
| Rate for Payer: WEA Trust Commercial |
$346.63
|
| Rate for Payer: WPS Commercial |
$466.80
|
|
|
XR TMJ Open and Closed Bilateral
|
Professional
|
Both
|
$1,254.00
|
|
|
Service Code
|
CPT 70330
|
| Hospital Charge Code |
629932
|
| Min. Negotiated Rate |
$53.13 |
| Max. Negotiated Rate |
$1,238.95 |
| Rate for Payer: Aetna Commercial |
$1,238.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,121.58
|
| Rate for Payer: Aetna Managed Medicare |
$53.13
|
| Rate for Payer: Anthem Medicare Advantage |
$53.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$53.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$53.13
|
| Rate for Payer: Cash Price |
$376.20
|
| Rate for Payer: Cash Price |
$376.20
|
| Rate for Payer: Cash Price |
$376.20
|
| Rate for Payer: Cigna Commercial |
$1,238.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$652.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$53.13
|
| Rate for Payer: Health EOS Commercial |
$1,186.79
|
| Rate for Payer: HFN Commercial |
$1,238.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$188.36
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$188.36
|
| Rate for Payer: Independent Care Health Plan Medicare |
$53.13
|
| Rate for Payer: Multiplan Commercial |
$1,043.33
|
| Rate for Payer: NAPHCARE Commercial |
$79.70
|
| Rate for Payer: Preferred Network Access Commercial |
$1,238.95
|
| Rate for Payer: Quartz Beloit One Network |
$573.83
|
| Rate for Payer: Quartz Commercial |
$743.37
|
| Rate for Payer: Quartz Medicare Advantage |
$53.13
|
| Rate for Payer: The Alliance Commercial |
$201.91
|
| Rate for Payer: United Healthcare Medicare Advantage |
$53.13
|
| Rate for Payer: WEA Trust Commercial |
$717.29
|
| Rate for Payer: WPS Commercial |
$265.67
|
|
|
XR TMJ Open and Closed Bilateral
|
Facility
|
OP
|
$1,254.00
|
|
|
Service Code
|
CPT 70330
|
| Hospital Charge Code |
629932
|
| Min. Negotiated Rate |
$91.58 |
| Max. Negotiated Rate |
$1,199.83 |
| Rate for Payer: Aetna Commercial |
$1,173.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,121.58
|
| Rate for Payer: Aetna Managed Medicare |
$91.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$847.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$652.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$626.00
|
| Rate for Payer: Anthem Medicare Advantage |
$91.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$691.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$91.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$91.58
|
| Rate for Payer: Cash Price |
$376.20
|
| Rate for Payer: Cash Price |
$376.20
|
| Rate for Payer: Cigna Commercial |
$1,199.83
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$91.58
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$729.83
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$91.58
|
| Rate for Payer: Health EOS Commercial |
$1,160.70
|
| Rate for Payer: HFN Commercial |
$1,199.83
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$340.69
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$91.58
|
| Rate for Payer: Independent Care Health Plan Medicare |
$91.58
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$91.58
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$91.58
|
| Rate for Payer: Multiplan Commercial |
$1,043.33
|
| Rate for Payer: NAPHCARE Commercial |
$137.37
|
| Rate for Payer: Preferred Network Access Commercial |
$1,199.83
|
| Rate for Payer: Quartz Beloit One Network |
$639.04
|
| Rate for Payer: Quartz Commercial |
$847.70
|
| Rate for Payer: Quartz Medicare Advantage |
$91.58
|
| Rate for Payer: The Alliance Commercial |
$366.33
|
| Rate for Payer: United Healthcare Medicare Advantage |
$91.58
|
| Rate for Payer: WEA Trust Commercial |
$717.29
|
| Rate for Payer: Wellcare Medicare |
$91.58
|
| Rate for Payer: WPS Commercial |
$965.96
|
|
|
XR TMJ Open and Closed Bilateral
|
Facility
|
IP
|
$1,254.00
|
|
|
Service Code
|
CPT 70330
|
| Hospital Charge Code |
629932
|
| Min. Negotiated Rate |
$639.04 |
| Max. Negotiated Rate |
$1,199.83 |
| Rate for Payer: Aetna Commercial |
$1,173.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,121.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$691.20
|
| Rate for Payer: Cash Price |
$376.20
|
| Rate for Payer: Cigna Commercial |
$1,199.83
|
| Rate for Payer: Health EOS Commercial |
$1,160.70
|
| Rate for Payer: HFN Commercial |
$1,199.83
|
| Rate for Payer: Multiplan Commercial |
$1,043.33
|
| Rate for Payer: Preferred Network Access Commercial |
$1,199.83
|
| Rate for Payer: Quartz Beloit One Network |
$639.04
|
| Rate for Payer: Quartz Commercial |
$782.50
|
| Rate for Payer: WEA Trust Commercial |
$717.29
|
| Rate for Payer: WPS Commercial |
$965.96
|
|
|
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 |
$197.14 |
| Max. Negotiated Rate |
$647.75 |
| Rate for Payer: Aetna Commercial |
$633.67
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$605.51
|
| Rate for Payer: Aetna Managed Medicare |
$197.14
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$350.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$280.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$266.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$373.16
|
| 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 |
$647.75
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$394.01
|
| Rate for Payer: Health EOS Commercial |
$626.63
|
| Rate for Payer: HFN Commercial |
$647.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$528.06
|
| Rate for Payer: Multiplan Commercial |
$563.26
|
| Rate for Payer: NAPHCARE Commercial |
$422.45
|
| Rate for Payer: Preferred Network Access Commercial |
$647.75
|
| Rate for Payer: Quartz Beloit One Network |
$345.00
|
| Rate for Payer: Quartz Commercial |
$457.65
|
| Rate for Payer: Quartz Medicare Advantage |
$422.45
|
| Rate for Payer: The Alliance Commercial |
$352.04
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$387.24
|
| Rate for Payer: WPS Commercial |
$521.49
|
|
|
XR TMJ Open and Closed Bilateral
|
Professional
|
Both
|
$677.00
|
|
|
Service Code
|
CPT 70330 TC,LT
|
| Hospital Charge Code |
1537379
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$188.36 |
| Max. Negotiated Rate |
$668.88 |
| Rate for Payer: Aetna Commercial |
$668.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$605.51
|
| 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 |
$668.88
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$352.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$422.45
|
| Rate for Payer: Health EOS Commercial |
$640.71
|
| Rate for Payer: HFN Commercial |
$668.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$188.36
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$188.36
|
| Rate for Payer: Multiplan Commercial |
$563.26
|
| Rate for Payer: Preferred Network Access Commercial |
$668.88
|
| Rate for Payer: Quartz Beloit One Network |
$309.80
|
| Rate for Payer: Quartz Commercial |
$401.33
|
| Rate for Payer: The Alliance Commercial |
$352.04
|
| Rate for Payer: WEA Trust Commercial |
$387.24
|
| Rate for Payer: WPS Commercial |
$521.49
|
|
|
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 |
$345.00 |
| Max. Negotiated Rate |
$647.75 |
| Rate for Payer: Aetna Commercial |
$633.67
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$605.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$373.16
|
| Rate for Payer: Cash Price |
$203.10
|
| Rate for Payer: Cigna Commercial |
$647.75
|
| Rate for Payer: Health EOS Commercial |
$626.63
|
| Rate for Payer: HFN Commercial |
$647.75
|
| Rate for Payer: Multiplan Commercial |
$563.26
|
| Rate for Payer: Preferred Network Access Commercial |
$647.75
|
| Rate for Payer: Quartz Beloit One Network |
$345.00
|
| Rate for Payer: Quartz Commercial |
$422.45
|
| Rate for Payer: WEA Trust Commercial |
$387.24
|
| Rate for Payer: WPS Commercial |
$521.49
|
|
|
XR TMJ Open and Closed Left
|
Professional
|
Both
|
$651.00
|
|
|
Service Code
|
CPT 70328 TC,LT
|
| Hospital Charge Code |
1537381
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$121.56 |
| Max. Negotiated Rate |
$643.19 |
| Rate for Payer: Aetna Commercial |
$643.19
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$582.25
|
| 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 |
$643.19
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$338.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$406.22
|
| Rate for Payer: Health EOS Commercial |
$616.11
|
| Rate for Payer: HFN Commercial |
$643.19
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$121.56
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$121.56
|
| Rate for Payer: Multiplan Commercial |
$541.63
|
| Rate for Payer: Preferred Network Access Commercial |
$643.19
|
| Rate for Payer: Quartz Beloit One Network |
$297.90
|
| Rate for Payer: Quartz Commercial |
$385.91
|
| Rate for Payer: The Alliance Commercial |
$338.52
|
| Rate for Payer: WEA Trust Commercial |
$372.37
|
| Rate for Payer: WPS Commercial |
$501.47
|
|
|
XR TMJ Open and Closed Left
|
Facility
|
IP
|
$626.00
|
|
|
Service Code
|
CPT 70328
|
| Hospital Charge Code |
629928
|
| Min. Negotiated Rate |
$319.01 |
| Max. Negotiated Rate |
$598.96 |
| Rate for Payer: Aetna Commercial |
$585.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$559.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$345.05
|
| Rate for Payer: Cash Price |
$187.80
|
| Rate for Payer: Cigna Commercial |
$598.96
|
| Rate for Payer: Health EOS Commercial |
$579.43
|
| Rate for Payer: HFN Commercial |
$598.96
|
| Rate for Payer: Multiplan Commercial |
$520.83
|
| Rate for Payer: Preferred Network Access Commercial |
$598.96
|
| Rate for Payer: Quartz Beloit One Network |
$319.01
|
| Rate for Payer: Quartz Commercial |
$390.62
|
| Rate for Payer: WEA Trust Commercial |
$358.07
|
| Rate for Payer: WPS Commercial |
$482.21
|
|
|
XR TMJ Open and Closed Left
|
Professional
|
Both
|
$626.00
|
|
|
Service Code
|
CPT 70328
|
| Hospital Charge Code |
629928
|
| Min. Negotiated Rate |
$33.76 |
| Max. Negotiated Rate |
$618.49 |
| Rate for Payer: Aetna Commercial |
$618.49
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$559.89
|
| Rate for Payer: Aetna Managed Medicare |
$33.76
|
| Rate for Payer: Anthem Medicare Advantage |
$33.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$33.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$33.76
|
| Rate for Payer: Cash Price |
$187.80
|
| Rate for Payer: Cash Price |
$187.80
|
| Rate for Payer: Cash Price |
$187.80
|
| Rate for Payer: Cigna Commercial |
$618.49
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$325.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$33.76
|
| Rate for Payer: Health EOS Commercial |
$592.45
|
| Rate for Payer: HFN Commercial |
$618.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$121.56
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$121.56
|
| Rate for Payer: Independent Care Health Plan Medicare |
$33.76
|
| Rate for Payer: Multiplan Commercial |
$520.83
|
| Rate for Payer: NAPHCARE Commercial |
$50.64
|
| Rate for Payer: Preferred Network Access Commercial |
$618.49
|
| Rate for Payer: Quartz Beloit One Network |
$286.46
|
| Rate for Payer: Quartz Commercial |
$371.09
|
| Rate for Payer: Quartz Medicare Advantage |
$33.76
|
| Rate for Payer: The Alliance Commercial |
$128.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$33.76
|
| Rate for Payer: WEA Trust Commercial |
$358.07
|
| Rate for Payer: WPS Commercial |
$168.79
|
|
|
XR TMJ Open and Closed Left
|
Facility
|
OP
|
$626.00
|
|
|
Service Code
|
CPT 70328
|
| Hospital Charge Code |
629928
|
| Min. Negotiated Rate |
$91.58 |
| Max. Negotiated Rate |
$598.96 |
| Rate for Payer: Aetna Commercial |
$585.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$559.89
|
| Rate for Payer: Aetna Managed Medicare |
$91.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$423.18
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$325.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$312.50
|
| Rate for Payer: Anthem Medicare Advantage |
$91.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$345.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$91.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$91.58
|
| Rate for Payer: Cash Price |
$187.80
|
| Rate for Payer: Cash Price |
$187.80
|
| Rate for Payer: Cigna Commercial |
$598.96
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$91.58
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$364.33
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$91.58
|
| Rate for Payer: Health EOS Commercial |
$579.43
|
| Rate for Payer: HFN Commercial |
$598.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$340.69
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$91.58
|
| Rate for Payer: Independent Care Health Plan Medicare |
$91.58
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$91.58
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$91.58
|
| Rate for Payer: Multiplan Commercial |
$520.83
|
| Rate for Payer: NAPHCARE Commercial |
$137.37
|
| Rate for Payer: Preferred Network Access Commercial |
$598.96
|
| Rate for Payer: Quartz Beloit One Network |
$319.01
|
| Rate for Payer: Quartz Commercial |
$423.18
|
| Rate for Payer: Quartz Medicare Advantage |
$91.58
|
| Rate for Payer: The Alliance Commercial |
$366.33
|
| Rate for Payer: United Healthcare Medicare Advantage |
$91.58
|
| Rate for Payer: WEA Trust Commercial |
$358.07
|
| Rate for Payer: Wellcare Medicare |
$91.58
|
| Rate for Payer: WPS Commercial |
$482.21
|
|
|
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 |
$331.75 |
| Max. Negotiated Rate |
$622.88 |
| Rate for Payer: Aetna Commercial |
$609.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$582.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$358.83
|
| Rate for Payer: Cash Price |
$195.30
|
| Rate for Payer: Cigna Commercial |
$622.88
|
| Rate for Payer: Health EOS Commercial |
$602.57
|
| Rate for Payer: HFN Commercial |
$622.88
|
| Rate for Payer: Multiplan Commercial |
$541.63
|
| Rate for Payer: Preferred Network Access Commercial |
$622.88
|
| Rate for Payer: Quartz Beloit One Network |
$331.75
|
| Rate for Payer: Quartz Commercial |
$406.22
|
| Rate for Payer: WEA Trust Commercial |
$372.37
|
| Rate for Payer: WPS Commercial |
$501.47
|
|
|
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 |
$189.57 |
| Max. Negotiated Rate |
$622.88 |
| Rate for Payer: Aetna Commercial |
$609.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$582.25
|
| Rate for Payer: Aetna Managed Medicare |
$189.57
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$350.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$280.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$266.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$358.83
|
| 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 |
$622.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$378.88
|
| Rate for Payer: Health EOS Commercial |
$602.57
|
| Rate for Payer: HFN Commercial |
$622.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$507.78
|
| Rate for Payer: Multiplan Commercial |
$541.63
|
| Rate for Payer: NAPHCARE Commercial |
$406.22
|
| Rate for Payer: Preferred Network Access Commercial |
$622.88
|
| Rate for Payer: Quartz Beloit One Network |
$331.75
|
| Rate for Payer: Quartz Commercial |
$440.08
|
| Rate for Payer: Quartz Medicare Advantage |
$406.22
|
| Rate for Payer: The Alliance Commercial |
$338.52
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$372.37
|
| Rate for Payer: WPS Commercial |
$501.47
|
|
|
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 |
$197.14 |
| Max. Negotiated Rate |
$647.75 |
| Rate for Payer: Aetna Commercial |
$633.67
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$605.51
|
| Rate for Payer: Aetna Managed Medicare |
$197.14
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$350.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$280.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$266.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$373.16
|
| 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 |
$647.75
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$394.01
|
| Rate for Payer: Health EOS Commercial |
$626.63
|
| Rate for Payer: HFN Commercial |
$647.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$528.06
|
| Rate for Payer: Multiplan Commercial |
$563.26
|
| Rate for Payer: NAPHCARE Commercial |
$422.45
|
| Rate for Payer: Preferred Network Access Commercial |
$647.75
|
| Rate for Payer: Quartz Beloit One Network |
$345.00
|
| Rate for Payer: Quartz Commercial |
$457.65
|
| Rate for Payer: Quartz Medicare Advantage |
$422.45
|
| Rate for Payer: The Alliance Commercial |
$352.04
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$387.24
|
| Rate for Payer: WPS Commercial |
$521.49
|
|
|
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 |
$331.75 |
| Max. Negotiated Rate |
$622.88 |
| Rate for Payer: Aetna Commercial |
$609.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$582.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$358.83
|
| Rate for Payer: Cash Price |
$195.30
|
| Rate for Payer: Cigna Commercial |
$622.88
|
| Rate for Payer: Health EOS Commercial |
$602.57
|
| Rate for Payer: HFN Commercial |
$622.88
|
| Rate for Payer: Multiplan Commercial |
$541.63
|
| Rate for Payer: Preferred Network Access Commercial |
$622.88
|
| Rate for Payer: Quartz Beloit One Network |
$331.75
|
| Rate for Payer: Quartz Commercial |
$406.22
|
| Rate for Payer: WEA Trust Commercial |
$372.37
|
| Rate for Payer: WPS Commercial |
$501.47
|
|
|
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 |
$345.00 |
| Max. Negotiated Rate |
$647.75 |
| Rate for Payer: Aetna Commercial |
$633.67
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$605.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$373.16
|
| Rate for Payer: Cash Price |
$203.10
|
| Rate for Payer: Cigna Commercial |
$647.75
|
| Rate for Payer: Health EOS Commercial |
$626.63
|
| Rate for Payer: HFN Commercial |
$647.75
|
| Rate for Payer: Multiplan Commercial |
$563.26
|
| Rate for Payer: Preferred Network Access Commercial |
$647.75
|
| Rate for Payer: Quartz Beloit One Network |
$345.00
|
| Rate for Payer: Quartz Commercial |
$422.45
|
| Rate for Payer: WEA Trust Commercial |
$387.24
|
| Rate for Payer: WPS Commercial |
$521.49
|
|
|
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 |
$189.57 |
| Max. Negotiated Rate |
$622.88 |
| Rate for Payer: Aetna Commercial |
$609.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$582.25
|
| Rate for Payer: Aetna Managed Medicare |
$189.57
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$350.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$280.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$266.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$358.83
|
| 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 |
$622.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$378.88
|
| Rate for Payer: Health EOS Commercial |
$602.57
|
| Rate for Payer: HFN Commercial |
$622.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$507.78
|
| Rate for Payer: Multiplan Commercial |
$541.63
|
| Rate for Payer: NAPHCARE Commercial |
$406.22
|
| Rate for Payer: Preferred Network Access Commercial |
$622.88
|
| Rate for Payer: Quartz Beloit One Network |
$331.75
|
| Rate for Payer: Quartz Commercial |
$440.08
|
| Rate for Payer: Quartz Medicare Advantage |
$406.22
|
| Rate for Payer: The Alliance Commercial |
$338.52
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$372.37
|
| Rate for Payer: WPS Commercial |
$501.47
|
|
|
XR TMJ Open and Closed Right
|
Facility
|
OP
|
$626.00
|
|
|
Service Code
|
CPT 70328
|
| Hospital Charge Code |
629922
|
| Min. Negotiated Rate |
$91.58 |
| Max. Negotiated Rate |
$598.96 |
| Rate for Payer: Aetna Commercial |
$585.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$559.89
|
| Rate for Payer: Aetna Managed Medicare |
$91.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$423.18
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$325.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$312.50
|
| Rate for Payer: Anthem Medicare Advantage |
$91.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$345.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$91.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$91.58
|
| Rate for Payer: Cash Price |
$187.80
|
| Rate for Payer: Cash Price |
$187.80
|
| Rate for Payer: Cigna Commercial |
$598.96
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$91.58
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$364.33
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$91.58
|
| Rate for Payer: Health EOS Commercial |
$579.43
|
| Rate for Payer: HFN Commercial |
$598.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$340.69
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$91.58
|
| Rate for Payer: Independent Care Health Plan Medicare |
$91.58
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$91.58
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$91.58
|
| Rate for Payer: Multiplan Commercial |
$520.83
|
| Rate for Payer: NAPHCARE Commercial |
$137.37
|
| Rate for Payer: Preferred Network Access Commercial |
$598.96
|
| Rate for Payer: Quartz Beloit One Network |
$319.01
|
| Rate for Payer: Quartz Commercial |
$423.18
|
| Rate for Payer: Quartz Medicare Advantage |
$91.58
|
| Rate for Payer: The Alliance Commercial |
$366.33
|
| Rate for Payer: United Healthcare Medicare Advantage |
$91.58
|
| Rate for Payer: WEA Trust Commercial |
$358.07
|
| Rate for Payer: Wellcare Medicare |
$91.58
|
| Rate for Payer: WPS Commercial |
$482.21
|
|
|
XR TMJ Open and Closed Right
|
Professional
|
Both
|
$677.00
|
|
|
Service Code
|
CPT 70330 TC,RT
|
| Hospital Charge Code |
2980136
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$188.36 |
| Max. Negotiated Rate |
$668.88 |
| Rate for Payer: Aetna Commercial |
$668.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$605.51
|
| 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 |
$668.88
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$352.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$422.45
|
| Rate for Payer: Health EOS Commercial |
$640.71
|
| Rate for Payer: HFN Commercial |
$668.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$188.36
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$188.36
|
| Rate for Payer: Multiplan Commercial |
$563.26
|
| Rate for Payer: Preferred Network Access Commercial |
$668.88
|
| Rate for Payer: Quartz Beloit One Network |
$309.80
|
| Rate for Payer: Quartz Commercial |
$401.33
|
| Rate for Payer: The Alliance Commercial |
$352.04
|
| Rate for Payer: WEA Trust Commercial |
$387.24
|
| Rate for Payer: WPS Commercial |
$521.49
|
|
|
XR TMJ Open and Closed Right
|
Professional
|
Both
|
$626.00
|
|
|
Service Code
|
CPT 70328
|
| Hospital Charge Code |
629922
|
| Min. Negotiated Rate |
$33.76 |
| Max. Negotiated Rate |
$618.49 |
| Rate for Payer: Aetna Commercial |
$618.49
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$559.89
|
| Rate for Payer: Aetna Managed Medicare |
$33.76
|
| Rate for Payer: Anthem Medicare Advantage |
$33.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$33.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$33.76
|
| Rate for Payer: Cash Price |
$187.80
|
| Rate for Payer: Cash Price |
$187.80
|
| Rate for Payer: Cash Price |
$187.80
|
| Rate for Payer: Cigna Commercial |
$618.49
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$325.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$33.76
|
| Rate for Payer: Health EOS Commercial |
$592.45
|
| Rate for Payer: HFN Commercial |
$618.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$121.56
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$121.56
|
| Rate for Payer: Independent Care Health Plan Medicare |
$33.76
|
| Rate for Payer: Multiplan Commercial |
$520.83
|
| Rate for Payer: NAPHCARE Commercial |
$50.64
|
| Rate for Payer: Preferred Network Access Commercial |
$618.49
|
| Rate for Payer: Quartz Beloit One Network |
$286.46
|
| Rate for Payer: Quartz Commercial |
$371.09
|
| Rate for Payer: Quartz Medicare Advantage |
$33.76
|
| Rate for Payer: The Alliance Commercial |
$128.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$33.76
|
| Rate for Payer: WEA Trust Commercial |
$358.07
|
| Rate for Payer: WPS Commercial |
$168.79
|
|
|
XR TMJ Open and Closed Right
|
Facility
|
IP
|
$626.00
|
|
|
Service Code
|
CPT 70328
|
| Hospital Charge Code |
629922
|
| Min. Negotiated Rate |
$319.01 |
| Max. Negotiated Rate |
$598.96 |
| Rate for Payer: Aetna Commercial |
$585.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$559.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$345.05
|
| Rate for Payer: Cash Price |
$187.80
|
| Rate for Payer: Cigna Commercial |
$598.96
|
| Rate for Payer: Health EOS Commercial |
$579.43
|
| Rate for Payer: HFN Commercial |
$598.96
|
| Rate for Payer: Multiplan Commercial |
$520.83
|
| Rate for Payer: Preferred Network Access Commercial |
$598.96
|
| Rate for Payer: Quartz Beloit One Network |
$319.01
|
| Rate for Payer: Quartz Commercial |
$390.62
|
| Rate for Payer: WEA Trust Commercial |
$358.07
|
| Rate for Payer: WPS Commercial |
$482.21
|
|
|
XR TMJ Open and Closed Right
|
Professional
|
Both
|
$651.00
|
|
|
Service Code
|
CPT 70328 RT,TC
|
| Hospital Charge Code |
1537383
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$121.56 |
| Max. Negotiated Rate |
$643.19 |
| Rate for Payer: Aetna Commercial |
$643.19
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$582.25
|
| 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 |
$643.19
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$338.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$406.22
|
| Rate for Payer: Health EOS Commercial |
$616.11
|
| Rate for Payer: HFN Commercial |
$643.19
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$121.56
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$121.56
|
| Rate for Payer: Multiplan Commercial |
$541.63
|
| Rate for Payer: Preferred Network Access Commercial |
$643.19
|
| Rate for Payer: Quartz Beloit One Network |
$297.90
|
| Rate for Payer: Quartz Commercial |
$385.91
|
| Rate for Payer: The Alliance Commercial |
$338.52
|
| Rate for Payer: WEA Trust Commercial |
$372.37
|
| Rate for Payer: WPS Commercial |
$501.47
|
|
|
XR Toes 2nd Digit Left
|
Facility
|
OP
|
$402.00
|
|
|
Service Code
|
CPT 73660 T1,TC
|
| Hospital Charge Code |
1537397
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$117.06 |
| Max. Negotiated Rate |
$384.63 |
| Rate for Payer: Aetna Commercial |
$376.27
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$359.55
|
| Rate for Payer: Aetna Managed Medicare |
$117.06
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$350.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$280.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$266.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$221.58
|
| Rate for Payer: Cash Price |
$120.60
|
| Rate for Payer: Cash Price |
$120.60
|
| Rate for Payer: Cash Price |
$120.60
|
| Rate for Payer: Cigna Commercial |
$384.63
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$233.96
|
| Rate for Payer: Health EOS Commercial |
$372.09
|
| Rate for Payer: HFN Commercial |
$384.63
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$313.56
|
| Rate for Payer: Multiplan Commercial |
$334.46
|
| Rate for Payer: NAPHCARE Commercial |
$250.85
|
| Rate for Payer: Preferred Network Access Commercial |
$384.63
|
| Rate for Payer: Quartz Beloit One Network |
$204.86
|
| Rate for Payer: Quartz Commercial |
$271.75
|
| Rate for Payer: Quartz Medicare Advantage |
$250.85
|
| Rate for Payer: The Alliance Commercial |
$209.04
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$229.94
|
| Rate for Payer: WPS Commercial |
$309.66
|
|
|
XR Toes 2nd Digit Left
|
Professional
|
Both
|
$402.00
|
|
|
Service Code
|
CPT 73660 T1,TC
|
| Hospital Charge Code |
1537397
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$101.88 |
| Max. Negotiated Rate |
$397.18 |
| Rate for Payer: Aetna Commercial |
$397.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$359.55
|
| Rate for Payer: Cash Price |
$120.60
|
| Rate for Payer: Cash Price |
$120.60
|
| Rate for Payer: Cash Price |
$120.60
|
| Rate for Payer: Cigna Commercial |
$397.18
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$209.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$250.85
|
| Rate for Payer: Health EOS Commercial |
$380.45
|
| Rate for Payer: HFN Commercial |
$397.18
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$101.88
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$101.88
|
| Rate for Payer: Multiplan Commercial |
$334.46
|
| Rate for Payer: Preferred Network Access Commercial |
$397.18
|
| Rate for Payer: Quartz Beloit One Network |
$183.96
|
| Rate for Payer: Quartz Commercial |
$238.31
|
| Rate for Payer: The Alliance Commercial |
$209.04
|
| Rate for Payer: WEA Trust Commercial |
$229.94
|
| Rate for Payer: WPS Commercial |
$309.66
|
|
|
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 |
$204.86 |
| Max. Negotiated Rate |
$384.63 |
| Rate for Payer: Aetna Commercial |
$376.27
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$359.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$221.58
|
| Rate for Payer: Cash Price |
$120.60
|
| Rate for Payer: Cigna Commercial |
$384.63
|
| Rate for Payer: Health EOS Commercial |
$372.09
|
| Rate for Payer: HFN Commercial |
$384.63
|
| Rate for Payer: Multiplan Commercial |
$334.46
|
| Rate for Payer: Preferred Network Access Commercial |
$384.63
|
| Rate for Payer: Quartz Beloit One Network |
$204.86
|
| Rate for Payer: Quartz Commercial |
$250.85
|
| Rate for Payer: WEA Trust Commercial |
$229.94
|
| Rate for Payer: WPS Commercial |
$309.66
|
|
