|
CT Lung Screening Follow Up 3-6 Months
|
Professional
|
$3,386.00
|
|
|
Service Code
|
CPT 71250 TC
|
| Hospital Charge Code |
5595333
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$83.49 |
| Max. Negotiated Rate |
$3,216.70 |
| Rate for Payer: Aetna Commercial |
$3,216.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,911.96
|
| Rate for Payer: Aetna Managed Medicare |
$83.49
|
| Rate for Payer: Anthem Medicare Advantage |
$83.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$83.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$83.49
|
| Rate for Payer: Cash Price |
$1,015.80
|
| Rate for Payer: Cash Price |
$1,015.80
|
| Rate for Payer: Cigna Commercial |
$3,216.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,693.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$83.49
|
| Rate for Payer: Health EOS Commercial |
$3,081.26
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$307.85
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$307.85
|
| Rate for Payer: Independent Care Health Plan Medicare |
$83.49
|
| Rate for Payer: Multiplan Commercial |
$2,708.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,216.70
|
| Rate for Payer: Quartz Beloit One Network |
$1,489.84
|
| Rate for Payer: Quartz Commercial |
$1,930.02
|
| Rate for Payer: Quartz Medicare Advantage |
$83.49
|
| Rate for Payer: The Alliance Commercial |
$317.26
|
| Rate for Payer: United Healthcare Medicare Advantage |
$83.49
|
| Rate for Payer: WEA Trust Commercial |
$1,862.30
|
| Rate for Payer: WPS Commercial |
$417.45
|
|
|
CT Lung Screening Follow Up 3-6 Months
|
Facility
IP
|
$3,386.00
|
|
|
Service Code
|
CPT 71250 TC
|
| Hospital Charge Code |
5595333
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,659.14 |
| Max. Negotiated Rate |
$3,115.12 |
| Rate for Payer: Aetna Commercial |
$3,047.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,794.58
|
| Rate for Payer: Cash Price |
$1,015.80
|
| Rate for Payer: Cigna Commercial |
$3,115.12
|
| Rate for Payer: Health EOS Commercial |
$3,013.54
|
| Rate for Payer: HFN Commercial |
$3,115.12
|
| Rate for Payer: Multiplan Commercial |
$2,708.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,031.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,115.12
|
| Rate for Payer: Quartz Beloit One Network |
$1,659.14
|
| Rate for Payer: Quartz Commercial |
$2,031.60
|
| Rate for Payer: WEA Trust Commercial |
$1,862.30
|
| Rate for Payer: WPS Commercial |
$2,508.01
|
|
|
CT Lung Screening Low Dose Initial
|
Facility
OP
|
$3,386.00
|
|
| Hospital Charge Code |
5595337
|
| Min. Negotiated Rate |
$948.08 |
| Max. Negotiated Rate |
$13,544.00 |
| Rate for Payer: Aetna Commercial |
$3,047.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,911.96
|
| Rate for Payer: Aetna Managed Medicare |
$948.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,200.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,693.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,625.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,794.58
|
| Rate for Payer: Cash Price |
$1,015.80
|
| Rate for Payer: Cigna Commercial |
$3,115.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,894.81
|
| Rate for Payer: Health EOS Commercial |
$3,013.54
|
| Rate for Payer: HFN Commercial |
$3,115.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,539.50
|
| Rate for Payer: Multiplan Commercial |
$2,708.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,031.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,115.12
|
| Rate for Payer: Quartz Beloit One Network |
$1,659.14
|
| Rate for Payer: Quartz Commercial |
$2,200.90
|
| Rate for Payer: Quartz Medicare Advantage |
$2,031.60
|
| Rate for Payer: The Alliance Commercial |
$13,544.00
|
| Rate for Payer: WEA Trust Commercial |
$1,862.30
|
| Rate for Payer: WPS Commercial |
$2,508.01
|
|
|
CT Lung Screening Low Dose Initial
|
Professional
|
$3,386.00
|
|
|
Service Code
|
CPT 71271 TC
|
| Hospital Charge Code |
5595336
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$87.99 |
| Max. Negotiated Rate |
$3,216.70 |
| Rate for Payer: Aetna Commercial |
$3,216.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,911.96
|
| Rate for Payer: Aetna Managed Medicare |
$87.99
|
| Rate for Payer: Anthem Medicare Advantage |
$87.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$87.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$87.99
|
| Rate for Payer: Cash Price |
$1,015.80
|
| Rate for Payer: Cash Price |
$1,015.80
|
| Rate for Payer: Cigna Commercial |
$3,216.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,693.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$87.99
|
| Rate for Payer: Health EOS Commercial |
$3,081.26
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$324.09
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$324.09
|
| Rate for Payer: Independent Care Health Plan Medicare |
$87.99
|
| Rate for Payer: Multiplan Commercial |
$2,708.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,216.70
|
| Rate for Payer: Quartz Beloit One Network |
$1,489.84
|
| Rate for Payer: Quartz Commercial |
$1,930.02
|
| Rate for Payer: Quartz Medicare Advantage |
$87.99
|
| Rate for Payer: The Alliance Commercial |
$334.36
|
| Rate for Payer: United Healthcare Medicare Advantage |
$87.99
|
| Rate for Payer: WEA Trust Commercial |
$1,862.30
|
| Rate for Payer: WPS Commercial |
$439.95
|
|
|
CT Lung Screening Low Dose Initial
|
Facility
IP
|
$3,386.00
|
|
|
Service Code
|
CPT 71271 TC
|
| Hospital Charge Code |
5595336
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,659.14 |
| Max. Negotiated Rate |
$3,115.12 |
| Rate for Payer: Aetna Commercial |
$3,047.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,794.58
|
| Rate for Payer: Cash Price |
$1,015.80
|
| Rate for Payer: Cigna Commercial |
$3,115.12
|
| Rate for Payer: Health EOS Commercial |
$3,013.54
|
| Rate for Payer: HFN Commercial |
$3,115.12
|
| Rate for Payer: Multiplan Commercial |
$2,708.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,031.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,115.12
|
| Rate for Payer: Quartz Beloit One Network |
$1,659.14
|
| Rate for Payer: Quartz Commercial |
$2,031.60
|
| Rate for Payer: WEA Trust Commercial |
$1,862.30
|
| Rate for Payer: WPS Commercial |
$2,508.01
|
|
|
CT Lung Screening Low Dose Initial
|
Facility
IP
|
$3,386.00
|
|
| Hospital Charge Code |
5595337
|
| Min. Negotiated Rate |
$1,659.14 |
| Max. Negotiated Rate |
$3,115.12 |
| Rate for Payer: Aetna Commercial |
$3,047.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,794.58
|
| Rate for Payer: Cash Price |
$1,015.80
|
| Rate for Payer: Cigna Commercial |
$3,115.12
|
| Rate for Payer: Health EOS Commercial |
$3,013.54
|
| Rate for Payer: HFN Commercial |
$3,115.12
|
| Rate for Payer: Multiplan Commercial |
$2,708.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,031.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,115.12
|
| Rate for Payer: Quartz Beloit One Network |
$1,659.14
|
| Rate for Payer: Quartz Commercial |
$2,031.60
|
| Rate for Payer: WEA Trust Commercial |
$1,862.30
|
| Rate for Payer: WPS Commercial |
$2,508.01
|
|
|
CT Lung Screening Low Dose Initial
|
Facility
OP
|
$3,386.00
|
|
|
Service Code
|
CPT 71271 TC
|
| Hospital Charge Code |
5595336
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$615.93 |
| Max. Negotiated Rate |
$13,544.00 |
| Rate for Payer: Aetna Commercial |
$3,047.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,911.96
|
| Rate for Payer: Aetna Managed Medicare |
$948.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,205.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,586.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,454.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,794.58
|
| Rate for Payer: Cash Price |
$1,015.80
|
| Rate for Payer: Cash Price |
$1,015.80
|
| Rate for Payer: Cash Price |
$1,015.80
|
| Rate for Payer: Cash Price |
$1,015.80
|
| Rate for Payer: Cigna Commercial |
$3,115.12
|
| Rate for Payer: Health EOS Commercial |
$3,013.54
|
| Rate for Payer: HFN Commercial |
$3,115.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,539.50
|
| Rate for Payer: Multiplan Commercial |
$2,708.80
|
| Rate for Payer: NAPHCARE Commercial |
$2,031.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,115.12
|
| Rate for Payer: Quartz Beloit One Network |
$1,659.14
|
| Rate for Payer: Quartz Commercial |
$2,200.90
|
| Rate for Payer: Quartz Medicare Advantage |
$2,031.60
|
| Rate for Payer: The Alliance Commercial |
$13,544.00
|
| Rate for Payer: United Healthcare PPO |
$2,065.00
|
| Rate for Payer: WEA Trust Commercial |
$1,862.30
|
| Rate for Payer: WPS Commercial |
$615.93
|
|
|
CT Maxillofacial w/ Contrast
|
Facility
OP
|
$3,307.00
|
|
|
Service Code
|
CPT 70487 TC
|
| Hospital Charge Code |
1241202
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$701.61 |
| Max. Negotiated Rate |
$13,228.00 |
| Rate for Payer: Aetna Commercial |
$2,976.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,844.02
|
| Rate for Payer: Aetna Managed Medicare |
$925.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,205.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,586.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,454.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,752.71
|
| Rate for Payer: Cash Price |
$992.10
|
| Rate for Payer: Cash Price |
$992.10
|
| Rate for Payer: Cash Price |
$992.10
|
| Rate for Payer: Cash Price |
$992.10
|
| Rate for Payer: Cigna Commercial |
$3,042.44
|
| Rate for Payer: Health EOS Commercial |
$2,943.23
|
| Rate for Payer: HFN Commercial |
$3,042.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,480.25
|
| Rate for Payer: Multiplan Commercial |
$2,645.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,984.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,042.44
|
| Rate for Payer: Quartz Beloit One Network |
$1,620.43
|
| Rate for Payer: Quartz Commercial |
$2,149.55
|
| Rate for Payer: Quartz Medicare Advantage |
$1,984.20
|
| Rate for Payer: The Alliance Commercial |
$13,228.00
|
| Rate for Payer: United Healthcare PPO |
$2,065.00
|
| Rate for Payer: WEA Trust Commercial |
$1,818.85
|
| Rate for Payer: WPS Commercial |
$701.61
|
|
|
CT Maxillofacial w/ Contrast
|
Facility
OP
|
$3,148.00
|
|
|
Service Code
|
CPT 70487
|
| Hospital Charge Code |
630090
|
| Min. Negotiated Rate |
$81.60 |
| Max. Negotiated Rate |
$2,896.16 |
| Rate for Payer: Aetna Commercial |
$2,833.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,707.28
|
| Rate for Payer: Aetna Managed Medicare |
$181.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,046.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,574.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,511.04
|
| Rate for Payer: Anthem Medicare Advantage |
$181.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,668.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$181.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$181.60
|
| Rate for Payer: Cash Price |
$944.40
|
| Rate for Payer: Cash Price |
$944.40
|
| Rate for Payer: Cigna Commercial |
$2,896.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$181.60
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$181.60
|
| Rate for Payer: Health EOS Commercial |
$2,801.72
|
| Rate for Payer: HFN Commercial |
$2,896.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$675.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$181.60
|
| Rate for Payer: Independent Care Health Plan Medicare |
$181.60
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$181.60
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$181.60
|
| Rate for Payer: Multiplan Commercial |
$2,518.40
|
| Rate for Payer: NAPHCARE Commercial |
$272.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,896.16
|
| Rate for Payer: Quartz Beloit One Network |
$1,542.52
|
| Rate for Payer: Quartz Commercial |
$2,046.20
|
| Rate for Payer: Quartz Medicare Advantage |
$181.60
|
| Rate for Payer: The Alliance Commercial |
$81.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$181.60
|
| Rate for Payer: WEA Trust Commercial |
$1,731.40
|
| Rate for Payer: Wellcare Medicare |
$181.60
|
| Rate for Payer: WPS Commercial |
$2,331.72
|
|
|
CT Maxillofacial w/ Contrast
|
Facility
IP
|
$3,148.00
|
|
|
Service Code
|
CPT 70487
|
| Hospital Charge Code |
630090
|
| Min. Negotiated Rate |
$1,542.52 |
| Max. Negotiated Rate |
$2,896.16 |
| Rate for Payer: Aetna Commercial |
$2,833.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,668.44
|
| Rate for Payer: Cash Price |
$944.40
|
| Rate for Payer: Cigna Commercial |
$2,896.16
|
| Rate for Payer: Health EOS Commercial |
$2,801.72
|
| Rate for Payer: HFN Commercial |
$2,896.16
|
| Rate for Payer: Multiplan Commercial |
$2,518.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,888.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,896.16
|
| Rate for Payer: Quartz Beloit One Network |
$1,542.52
|
| Rate for Payer: Quartz Commercial |
$1,888.80
|
| Rate for Payer: WEA Trust Commercial |
$1,731.40
|
| Rate for Payer: WPS Commercial |
$2,331.72
|
|
|
CT Maxillofacial w/ Contrast
|
Facility
IP
|
$3,307.00
|
|
|
Service Code
|
CPT 70487 TC
|
| Hospital Charge Code |
1241202
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,620.43 |
| Max. Negotiated Rate |
$3,042.44 |
| Rate for Payer: Aetna Commercial |
$2,976.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,752.71
|
| Rate for Payer: Cash Price |
$992.10
|
| Rate for Payer: Cigna Commercial |
$3,042.44
|
| Rate for Payer: Health EOS Commercial |
$2,943.23
|
| Rate for Payer: HFN Commercial |
$3,042.44
|
| Rate for Payer: Multiplan Commercial |
$2,645.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,984.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,042.44
|
| Rate for Payer: Quartz Beloit One Network |
$1,620.43
|
| Rate for Payer: Quartz Commercial |
$1,984.20
|
| Rate for Payer: WEA Trust Commercial |
$1,818.85
|
| Rate for Payer: WPS Commercial |
$2,449.49
|
|
|
CT Maxillofacial w/ Contrast
|
Professional
|
$3,148.00
|
|
|
Service Code
|
CPT 70487
|
| Hospital Charge Code |
630090
|
| Min. Negotiated Rate |
$152.36 |
| Max. Negotiated Rate |
$2,990.60 |
| Rate for Payer: Aetna Commercial |
$2,990.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,707.28
|
| Rate for Payer: Aetna Managed Medicare |
$152.36
|
| Rate for Payer: Anthem Medicare Advantage |
$152.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$152.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$152.36
|
| Rate for Payer: Cash Price |
$944.40
|
| Rate for Payer: Cash Price |
$944.40
|
| Rate for Payer: Cigna Commercial |
$2,990.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,574.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$152.36
|
| Rate for Payer: Health EOS Commercial |
$2,864.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$561.41
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$561.41
|
| Rate for Payer: Independent Care Health Plan Medicare |
$152.36
|
| Rate for Payer: Multiplan Commercial |
$2,518.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,990.60
|
| Rate for Payer: Quartz Beloit One Network |
$1,385.12
|
| Rate for Payer: Quartz Commercial |
$1,794.36
|
| Rate for Payer: Quartz Medicare Advantage |
$152.36
|
| Rate for Payer: The Alliance Commercial |
$578.97
|
| Rate for Payer: United Healthcare Medicare Advantage |
$152.36
|
| Rate for Payer: WEA Trust Commercial |
$1,731.40
|
| Rate for Payer: WPS Commercial |
$761.80
|
|
|
CT Maxillofacial w/ Contrast
|
Professional
|
$3,307.00
|
|
|
Service Code
|
CPT 70487 TC
|
| Hospital Charge Code |
1241202
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$100.23 |
| Max. Negotiated Rate |
$3,141.65 |
| Rate for Payer: Aetna Commercial |
$3,141.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,844.02
|
| Rate for Payer: Aetna Managed Medicare |
$100.23
|
| Rate for Payer: Anthem Medicare Advantage |
$100.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$100.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$100.23
|
| Rate for Payer: Cash Price |
$992.10
|
| Rate for Payer: Cash Price |
$992.10
|
| Rate for Payer: Cigna Commercial |
$3,141.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,653.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$100.23
|
| Rate for Payer: Health EOS Commercial |
$3,009.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$374.00
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$374.00
|
| Rate for Payer: Independent Care Health Plan Medicare |
$100.23
|
| Rate for Payer: Multiplan Commercial |
$2,645.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,141.65
|
| Rate for Payer: Quartz Beloit One Network |
$1,455.08
|
| Rate for Payer: Quartz Commercial |
$1,884.99
|
| Rate for Payer: Quartz Medicare Advantage |
$100.23
|
| Rate for Payer: The Alliance Commercial |
$380.87
|
| Rate for Payer: United Healthcare Medicare Advantage |
$100.23
|
| Rate for Payer: WEA Trust Commercial |
$1,818.85
|
| Rate for Payer: WPS Commercial |
$501.15
|
|
|
CT Maxillofacial w/o Contrast
|
Facility
IP
|
$2,867.00
|
|
|
Service Code
|
CPT 70486 TC
|
| Hospital Charge Code |
1241204
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,404.83 |
| Max. Negotiated Rate |
$2,637.64 |
| Rate for Payer: Aetna Commercial |
$2,580.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,519.51
|
| Rate for Payer: Cash Price |
$860.10
|
| Rate for Payer: Cigna Commercial |
$2,637.64
|
| Rate for Payer: Health EOS Commercial |
$2,551.63
|
| Rate for Payer: HFN Commercial |
$2,637.64
|
| Rate for Payer: Multiplan Commercial |
$2,293.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,720.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,637.64
|
| Rate for Payer: Quartz Beloit One Network |
$1,404.83
|
| Rate for Payer: Quartz Commercial |
$1,720.20
|
| Rate for Payer: WEA Trust Commercial |
$1,576.85
|
| Rate for Payer: WPS Commercial |
$2,123.59
|
|
|
CT Maxillofacial w/o Contrast
|
Professional
|
$2,867.00
|
|
|
Service Code
|
CPT 70486 TC
|
| Hospital Charge Code |
1241204
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$88.96 |
| Max. Negotiated Rate |
$2,723.65 |
| Rate for Payer: Aetna Commercial |
$2,723.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,465.62
|
| Rate for Payer: Aetna Managed Medicare |
$88.96
|
| Rate for Payer: Anthem Medicare Advantage |
$88.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$88.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$88.96
|
| Rate for Payer: Cash Price |
$860.10
|
| Rate for Payer: Cash Price |
$860.10
|
| Rate for Payer: Cigna Commercial |
$2,723.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,433.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$88.96
|
| Rate for Payer: Health EOS Commercial |
$2,608.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$327.58
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$327.58
|
| Rate for Payer: Independent Care Health Plan Medicare |
$88.96
|
| Rate for Payer: Multiplan Commercial |
$2,293.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,723.65
|
| Rate for Payer: Quartz Beloit One Network |
$1,261.48
|
| Rate for Payer: Quartz Commercial |
$1,634.19
|
| Rate for Payer: Quartz Medicare Advantage |
$88.96
|
| Rate for Payer: The Alliance Commercial |
$338.05
|
| Rate for Payer: United Healthcare Medicare Advantage |
$88.96
|
| Rate for Payer: WEA Trust Commercial |
$1,576.85
|
| Rate for Payer: WPS Commercial |
$444.80
|
|
|
CT Maxillofacial w/o Contrast
|
Facility
OP
|
$2,612.00
|
|
|
Service Code
|
CPT 70486
|
| Hospital Charge Code |
630094
|
| Min. Negotiated Rate |
$85.36 |
| Max. Negotiated Rate |
$2,403.04 |
| Rate for Payer: Aetna Commercial |
$2,350.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,246.32
|
| Rate for Payer: Aetna Managed Medicare |
$108.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,697.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,306.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,253.76
|
| Rate for Payer: Anthem Medicare Advantage |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,384.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$108.67
|
| Rate for Payer: Cash Price |
$783.60
|
| Rate for Payer: Cash Price |
$783.60
|
| Rate for Payer: Cigna Commercial |
$2,403.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$108.67
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$108.67
|
| Rate for Payer: Health EOS Commercial |
$2,324.68
|
| Rate for Payer: HFN Commercial |
$2,403.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$404.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$108.67
|
| Rate for Payer: Independent Care Health Plan Medicare |
$108.67
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$108.67
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$108.67
|
| Rate for Payer: Multiplan Commercial |
$2,089.60
|
| Rate for Payer: NAPHCARE Commercial |
$163.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,403.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,279.88
|
| Rate for Payer: Quartz Commercial |
$1,697.80
|
| Rate for Payer: Quartz Medicare Advantage |
$108.67
|
| Rate for Payer: The Alliance Commercial |
$85.36
|
| Rate for Payer: United Healthcare Medicare Advantage |
$108.67
|
| Rate for Payer: WEA Trust Commercial |
$1,436.60
|
| Rate for Payer: Wellcare Medicare |
$108.67
|
| Rate for Payer: WPS Commercial |
$1,934.71
|
|
|
CT Maxillofacial w/o Contrast
|
Facility
OP
|
$2,867.00
|
|
|
Service Code
|
CPT 70486 TC
|
| Hospital Charge Code |
1241204
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$622.72 |
| Max. Negotiated Rate |
$11,468.00 |
| Rate for Payer: Aetna Commercial |
$2,580.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,465.62
|
| Rate for Payer: Aetna Managed Medicare |
$802.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,205.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,586.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,454.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,519.51
|
| Rate for Payer: Cash Price |
$860.10
|
| Rate for Payer: Cash Price |
$860.10
|
| Rate for Payer: Cash Price |
$860.10
|
| Rate for Payer: Cash Price |
$860.10
|
| Rate for Payer: Cigna Commercial |
$2,637.64
|
| Rate for Payer: Health EOS Commercial |
$2,551.63
|
| Rate for Payer: HFN Commercial |
$2,637.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,150.25
|
| Rate for Payer: Multiplan Commercial |
$2,293.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,720.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,637.64
|
| Rate for Payer: Quartz Beloit One Network |
$1,404.83
|
| Rate for Payer: Quartz Commercial |
$1,863.55
|
| Rate for Payer: Quartz Medicare Advantage |
$1,720.20
|
| Rate for Payer: The Alliance Commercial |
$11,468.00
|
| Rate for Payer: United Healthcare PPO |
$2,065.00
|
| Rate for Payer: WEA Trust Commercial |
$1,576.85
|
| Rate for Payer: WPS Commercial |
$622.72
|
|
|
CT Maxillofacial w/o Contrast
|
Facility
IP
|
$2,612.00
|
|
|
Service Code
|
CPT 70486
|
| Hospital Charge Code |
630094
|
| Min. Negotiated Rate |
$1,279.88 |
| Max. Negotiated Rate |
$2,403.04 |
| Rate for Payer: Aetna Commercial |
$2,350.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,384.36
|
| Rate for Payer: Cash Price |
$783.60
|
| Rate for Payer: Cigna Commercial |
$2,403.04
|
| Rate for Payer: Health EOS Commercial |
$2,324.68
|
| Rate for Payer: HFN Commercial |
$2,403.04
|
| Rate for Payer: Multiplan Commercial |
$2,089.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,567.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,403.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,279.88
|
| Rate for Payer: Quartz Commercial |
$1,567.20
|
| Rate for Payer: WEA Trust Commercial |
$1,436.60
|
| Rate for Payer: WPS Commercial |
$1,934.71
|
|
|
CT Maxillofacial w/o Contrast
|
Professional
|
$2,612.00
|
|
|
Service Code
|
CPT 70486
|
| Hospital Charge Code |
630094
|
| Min. Negotiated Rate |
$128.49 |
| Max. Negotiated Rate |
$2,481.40 |
| Rate for Payer: Aetna Commercial |
$2,481.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,246.32
|
| Rate for Payer: Aetna Managed Medicare |
$128.49
|
| Rate for Payer: Anthem Medicare Advantage |
$128.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$128.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$128.49
|
| Rate for Payer: Cash Price |
$783.60
|
| Rate for Payer: Cash Price |
$783.60
|
| Rate for Payer: Cigna Commercial |
$2,481.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,306.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$128.49
|
| Rate for Payer: Health EOS Commercial |
$2,376.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$469.70
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$469.70
|
| Rate for Payer: Independent Care Health Plan Medicare |
$128.49
|
| Rate for Payer: Multiplan Commercial |
$2,089.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,481.40
|
| Rate for Payer: Quartz Beloit One Network |
$1,149.28
|
| Rate for Payer: Quartz Commercial |
$1,488.84
|
| Rate for Payer: Quartz Medicare Advantage |
$128.49
|
| Rate for Payer: The Alliance Commercial |
$488.26
|
| Rate for Payer: United Healthcare Medicare Advantage |
$128.49
|
| Rate for Payer: WEA Trust Commercial |
$1,436.60
|
| Rate for Payer: WPS Commercial |
$642.45
|
|
|
CT Maxillofacial w/ + w/o Contrast
|
Facility
IP
|
$3,883.00
|
|
|
Service Code
|
CPT 70488
|
| Hospital Charge Code |
630086
|
| Min. Negotiated Rate |
$1,902.67 |
| Max. Negotiated Rate |
$3,572.36 |
| Rate for Payer: Aetna Commercial |
$3,494.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,057.99
|
| Rate for Payer: Cash Price |
$1,164.90
|
| Rate for Payer: Cigna Commercial |
$3,572.36
|
| Rate for Payer: Health EOS Commercial |
$3,455.87
|
| Rate for Payer: HFN Commercial |
$3,572.36
|
| Rate for Payer: Multiplan Commercial |
$3,106.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,329.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,572.36
|
| Rate for Payer: Quartz Beloit One Network |
$1,902.67
|
| Rate for Payer: Quartz Commercial |
$2,329.80
|
| Rate for Payer: WEA Trust Commercial |
$2,135.65
|
| Rate for Payer: WPS Commercial |
$2,876.14
|
|
|
CT Maxillofacial w/ + w/o Contrast
|
Facility
OP
|
$3,955.00
|
|
|
Service Code
|
CPT 70488 TC
|
| Hospital Charge Code |
1241200
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$887.11 |
| Max. Negotiated Rate |
$15,820.00 |
| Rate for Payer: Aetna Commercial |
$3,559.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,401.30
|
| Rate for Payer: Aetna Managed Medicare |
$1,107.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,205.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,586.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,454.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,096.15
|
| Rate for Payer: Cash Price |
$1,186.50
|
| Rate for Payer: Cash Price |
$1,186.50
|
| Rate for Payer: Cash Price |
$1,186.50
|
| Rate for Payer: Cash Price |
$1,186.50
|
| Rate for Payer: Cigna Commercial |
$3,638.60
|
| Rate for Payer: Health EOS Commercial |
$3,519.95
|
| Rate for Payer: HFN Commercial |
$3,638.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,966.25
|
| Rate for Payer: Multiplan Commercial |
$3,164.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,373.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,638.60
|
| Rate for Payer: Quartz Beloit One Network |
$1,937.95
|
| Rate for Payer: Quartz Commercial |
$2,570.75
|
| Rate for Payer: Quartz Medicare Advantage |
$2,373.00
|
| Rate for Payer: The Alliance Commercial |
$15,820.00
|
| Rate for Payer: United Healthcare PPO |
$2,065.00
|
| Rate for Payer: WEA Trust Commercial |
$2,175.25
|
| Rate for Payer: WPS Commercial |
$887.11
|
|
|
CT Maxillofacial w/ + w/o Contrast
|
Professional
|
$3,955.00
|
|
|
Service Code
|
CPT 70488 TC
|
| Hospital Charge Code |
1241200
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$126.73 |
| Max. Negotiated Rate |
$3,757.25 |
| Rate for Payer: WEA Trust Commercial |
$2,175.25
|
| Rate for Payer: Aetna Commercial |
$3,757.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,401.30
|
| Rate for Payer: Aetna Managed Medicare |
$126.73
|
| Rate for Payer: Anthem Medicare Advantage |
$126.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$126.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$126.73
|
| Rate for Payer: Cash Price |
$1,186.50
|
| Rate for Payer: Cash Price |
$1,186.50
|
| Rate for Payer: Cigna Commercial |
$3,757.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,977.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$126.73
|
| Rate for Payer: Health EOS Commercial |
$3,599.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$476.09
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$476.09
|
| Rate for Payer: Independent Care Health Plan Medicare |
$126.73
|
| Rate for Payer: Multiplan Commercial |
$3,164.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,757.25
|
| Rate for Payer: Quartz Beloit One Network |
$1,740.20
|
| Rate for Payer: Quartz Commercial |
$2,254.35
|
| Rate for Payer: Quartz Medicare Advantage |
$126.73
|
| Rate for Payer: The Alliance Commercial |
$481.57
|
| Rate for Payer: United Healthcare Medicare Advantage |
$126.73
|
| Rate for Payer: WPS Commercial |
$633.65
|
|
|
CT Maxillofacial w/ + w/o Contrast
|
Facility
OP
|
$3,883.00
|
|
|
Service Code
|
CPT 70488
|
| Hospital Charge Code |
630086
|
| Min. Negotiated Rate |
$181.60 |
| Max. Negotiated Rate |
$261,906.32 |
| Rate for Payer: Aetna Commercial |
$3,494.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,339.38
|
| Rate for Payer: Aetna Managed Medicare |
$181.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,523.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,941.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,863.84
|
| Rate for Payer: Anthem Medicare Advantage |
$181.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,057.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$181.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$181.60
|
| Rate for Payer: Cash Price |
$1,164.90
|
| Rate for Payer: Cash Price |
$1,164.90
|
| Rate for Payer: Cigna Commercial |
$3,572.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$181.60
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$181.60
|
| Rate for Payer: Health EOS Commercial |
$3,455.87
|
| Rate for Payer: HFN Commercial |
$3,572.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$675.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$181.60
|
| Rate for Payer: Independent Care Health Plan Medicare |
$181.60
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$181.60
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$181.60
|
| Rate for Payer: Multiplan Commercial |
$3,106.40
|
| Rate for Payer: NAPHCARE Commercial |
$272.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,572.36
|
| Rate for Payer: Quartz Beloit One Network |
$1,902.67
|
| Rate for Payer: Quartz Commercial |
$2,523.95
|
| Rate for Payer: Quartz Medicare Advantage |
$181.60
|
| Rate for Payer: The Alliance Commercial |
$261,906.32
|
| Rate for Payer: United Healthcare Medicare Advantage |
$181.60
|
| Rate for Payer: WEA Trust Commercial |
$2,135.65
|
| Rate for Payer: Wellcare Medicare |
$181.60
|
| Rate for Payer: WPS Commercial |
$2,876.14
|
|
|
CT Maxillofacial w/ + w/o Contrast
|
Professional
|
$3,883.00
|
|
|
Service Code
|
CPT 70488
|
| Hospital Charge Code |
630086
|
| Min. Negotiated Rate |
$185.32 |
| Max. Negotiated Rate |
$3,688.85 |
| Rate for Payer: Aetna Commercial |
$3,688.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,339.38
|
| Rate for Payer: Aetna Managed Medicare |
$185.32
|
| Rate for Payer: Anthem Medicare Advantage |
$185.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$185.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$185.32
|
| Rate for Payer: Cash Price |
$1,164.90
|
| Rate for Payer: Cash Price |
$1,164.90
|
| Rate for Payer: Cigna Commercial |
$3,688.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,941.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$185.32
|
| Rate for Payer: Health EOS Commercial |
$3,533.53
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$687.71
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$687.71
|
| Rate for Payer: Independent Care Health Plan Medicare |
$185.32
|
| Rate for Payer: Multiplan Commercial |
$3,106.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,688.85
|
| Rate for Payer: Quartz Beloit One Network |
$1,708.52
|
| Rate for Payer: Quartz Commercial |
$2,213.31
|
| Rate for Payer: Quartz Medicare Advantage |
$185.32
|
| Rate for Payer: The Alliance Commercial |
$704.22
|
| Rate for Payer: United Healthcare Medicare Advantage |
$185.32
|
| Rate for Payer: WEA Trust Commercial |
$2,135.65
|
| Rate for Payer: WPS Commercial |
$926.60
|
|
|
CT Maxillofacial w/ + w/o Contrast
|
Facility
IP
|
$3,955.00
|
|
|
Service Code
|
CPT 70488 TC
|
| Hospital Charge Code |
1241200
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,937.95 |
| Max. Negotiated Rate |
$3,638.60 |
| Rate for Payer: Aetna Commercial |
$3,559.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,096.15
|
| Rate for Payer: Cash Price |
$1,186.50
|
| Rate for Payer: Cigna Commercial |
$3,638.60
|
| Rate for Payer: Health EOS Commercial |
$3,519.95
|
| Rate for Payer: HFN Commercial |
$3,638.60
|
| Rate for Payer: Multiplan Commercial |
$3,164.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,373.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,638.60
|
| Rate for Payer: Quartz Beloit One Network |
$1,937.95
|
| Rate for Payer: Quartz Commercial |
$2,373.00
|
| Rate for Payer: WEA Trust Commercial |
$2,175.25
|
| Rate for Payer: WPS Commercial |
$2,929.47
|
|
