|
CT Tibia/Fibula w/ + w/o Contrast Right
|
Facility
IP
|
$3,845.00
|
|
|
Service Code
|
CPT 73702
|
| Hospital Charge Code |
630188
|
| Min. Negotiated Rate |
$1,884.05 |
| Max. Negotiated Rate |
$3,537.40 |
| Rate for Payer: Aetna Commercial |
$3,460.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,037.85
|
| Rate for Payer: Cash Price |
$1,153.50
|
| Rate for Payer: Cigna Commercial |
$3,537.40
|
| Rate for Payer: Health EOS Commercial |
$3,422.05
|
| Rate for Payer: HFN Commercial |
$3,537.40
|
| Rate for Payer: Multiplan Commercial |
$3,076.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,307.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,537.40
|
| Rate for Payer: Quartz Beloit One Network |
$1,884.05
|
| Rate for Payer: Quartz Commercial |
$2,307.00
|
| Rate for Payer: WEA Trust Commercial |
$2,114.75
|
| Rate for Payer: WPS Commercial |
$2,847.99
|
|
|
CT Tibia/Fibula w/ + w/o Contrast Right
|
Facility
OP
|
$3,773.00
|
|
|
Service Code
|
CPT 73702 TC,RT
|
| Hospital Charge Code |
2980089
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,056.44 |
| Max. Negotiated Rate |
$15,092.00 |
| Rate for Payer: Aetna Commercial |
$3,395.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,244.78
|
| Rate for Payer: Aetna Managed Medicare |
$1,056.44
|
| 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 |
$1,999.69
|
| Rate for Payer: Cash Price |
$1,131.90
|
| Rate for Payer: Cash Price |
$1,131.90
|
| Rate for Payer: Cash Price |
$1,131.90
|
| Rate for Payer: Cash Price |
$1,131.90
|
| Rate for Payer: Cigna Commercial |
$3,471.16
|
| Rate for Payer: Health EOS Commercial |
$3,357.97
|
| Rate for Payer: HFN Commercial |
$3,471.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,829.75
|
| Rate for Payer: Multiplan Commercial |
$3,018.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,263.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,471.16
|
| Rate for Payer: Quartz Beloit One Network |
$1,848.77
|
| Rate for Payer: Quartz Commercial |
$2,452.45
|
| Rate for Payer: Quartz Medicare Advantage |
$2,263.80
|
| Rate for Payer: The Alliance Commercial |
$15,092.00
|
| Rate for Payer: United Healthcare PPO |
$2,065.00
|
| Rate for Payer: WEA Trust Commercial |
$2,075.15
|
| Rate for Payer: WPS Commercial |
$2,794.66
|
|
|
CT Tibia/Fibula w/ + w/o Contrast Right
|
Facility
OP
|
$3,918.00
|
|
|
Service Code
|
CPT 73702 RT,TC
|
| Hospital Charge Code |
1241294
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,097.04 |
| Max. Negotiated Rate |
$15,672.00 |
| Rate for Payer: Aetna Commercial |
$3,526.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,369.48
|
| Rate for Payer: Aetna Managed Medicare |
$1,097.04
|
| 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 |
$2,076.54
|
| Rate for Payer: Cash Price |
$1,175.40
|
| Rate for Payer: Cash Price |
$1,175.40
|
| Rate for Payer: Cash Price |
$1,175.40
|
| Rate for Payer: Cash Price |
$1,175.40
|
| Rate for Payer: Cigna Commercial |
$3,604.56
|
| Rate for Payer: Health EOS Commercial |
$3,487.02
|
| Rate for Payer: HFN Commercial |
$3,604.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,938.50
|
| Rate for Payer: Multiplan Commercial |
$3,134.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,350.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,604.56
|
| Rate for Payer: Quartz Beloit One Network |
$1,919.82
|
| Rate for Payer: Quartz Commercial |
$2,546.70
|
| Rate for Payer: Quartz Medicare Advantage |
$2,350.80
|
| Rate for Payer: The Alliance Commercial |
$15,672.00
|
| Rate for Payer: United Healthcare PPO |
$2,065.00
|
| Rate for Payer: WEA Trust Commercial |
$2,154.90
|
| Rate for Payer: WPS Commercial |
$2,902.06
|
|
|
CT Tibia/Fibula w/ + w/o Contrast Right
|
Professional
|
$3,845.00
|
|
|
Service Code
|
CPT 73702
|
| Hospital Charge Code |
630188
|
| Min. Negotiated Rate |
$195.75 |
| Max. Negotiated Rate |
$3,652.75 |
| Rate for Payer: Aetna Commercial |
$3,652.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,306.70
|
| Rate for Payer: Aetna Managed Medicare |
$195.75
|
| Rate for Payer: Anthem Medicare Advantage |
$195.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$195.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$195.75
|
| Rate for Payer: Cash Price |
$1,153.50
|
| Rate for Payer: Cash Price |
$1,153.50
|
| Rate for Payer: Cigna Commercial |
$3,652.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,922.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$195.75
|
| Rate for Payer: Health EOS Commercial |
$3,498.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$718.67
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$718.67
|
| Rate for Payer: Independent Care Health Plan Medicare |
$195.75
|
| Rate for Payer: Multiplan Commercial |
$3,076.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,652.75
|
| Rate for Payer: Quartz Beloit One Network |
$1,691.80
|
| Rate for Payer: Quartz Commercial |
$2,191.65
|
| Rate for Payer: Quartz Medicare Advantage |
$195.75
|
| Rate for Payer: The Alliance Commercial |
$743.85
|
| Rate for Payer: United Healthcare Medicare Advantage |
$195.75
|
| Rate for Payer: WEA Trust Commercial |
$2,114.75
|
| Rate for Payer: WPS Commercial |
$978.75
|
|
|
CT Tibia/Fibula w/ + w/o Contrast Right
|
Professional
|
$3,773.00
|
|
|
Service Code
|
CPT 73702 TC,RT
|
| Hospital Charge Code |
2980089
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,660.12 |
| Max. Negotiated Rate |
$3,584.35 |
| Rate for Payer: Aetna Commercial |
$3,584.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,244.78
|
| Rate for Payer: Cash Price |
$1,131.90
|
| Rate for Payer: Cash Price |
$1,131.90
|
| Rate for Payer: Cigna Commercial |
$3,584.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,886.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,263.80
|
| Rate for Payer: Health EOS Commercial |
$3,433.43
|
| Rate for Payer: Multiplan Commercial |
$3,018.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,584.35
|
| Rate for Payer: Quartz Beloit One Network |
$1,660.12
|
| Rate for Payer: Quartz Commercial |
$2,150.61
|
| Rate for Payer: The Alliance Commercial |
$1,886.50
|
| Rate for Payer: WEA Trust Commercial |
$2,075.15
|
| Rate for Payer: WPS Commercial |
$2,794.66
|
|
|
CT TMJ w/ Contrast Bilateral
|
Facility
OP
|
$3,089.00
|
|
|
Service Code
|
CPT 70487 LT,TC
|
| Hospital Charge Code |
1241317
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$864.92 |
| Max. Negotiated Rate |
$12,356.00 |
| Rate for Payer: Aetna Commercial |
$2,780.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,656.54
|
| Rate for Payer: Aetna Managed Medicare |
$864.92
|
| 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 |
$1,637.17
|
| Rate for Payer: Cash Price |
$926.70
|
| Rate for Payer: Cash Price |
$926.70
|
| Rate for Payer: Cash Price |
$926.70
|
| Rate for Payer: Cash Price |
$926.70
|
| Rate for Payer: Cigna Commercial |
$2,841.88
|
| Rate for Payer: Health EOS Commercial |
$2,749.21
|
| Rate for Payer: HFN Commercial |
$2,841.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,316.75
|
| Rate for Payer: Multiplan Commercial |
$2,471.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,853.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,841.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,513.61
|
| Rate for Payer: Quartz Commercial |
$2,007.85
|
| Rate for Payer: Quartz Medicare Advantage |
$1,853.40
|
| Rate for Payer: The Alliance Commercial |
$12,356.00
|
| Rate for Payer: United Healthcare PPO |
$2,065.00
|
| Rate for Payer: WEA Trust Commercial |
$1,698.95
|
| Rate for Payer: WPS Commercial |
$2,288.02
|
|
|
CT TMJ w/ Contrast Bilateral
|
Facility
OP
|
$6,296.00
|
|
|
Service Code
|
CPT 70487
|
| Hospital Charge Code |
711753
|
| Min. Negotiated Rate |
$81.60 |
| Max. Negotiated Rate |
$5,792.32 |
| Rate for Payer: Aetna Commercial |
$5,666.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,414.56
|
| Rate for Payer: Aetna Managed Medicare |
$181.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,092.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,148.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,022.08
|
| Rate for Payer: Anthem Medicare Advantage |
$181.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,336.88
|
| 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 |
$1,888.80
|
| Rate for Payer: Cash Price |
$1,888.80
|
| Rate for Payer: Cigna Commercial |
$5,792.32
|
| 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 |
$5,603.44
|
| Rate for Payer: HFN Commercial |
$5,792.32
|
| 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 |
$5,036.80
|
| Rate for Payer: NAPHCARE Commercial |
$272.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,792.32
|
| Rate for Payer: Quartz Beloit One Network |
$3,085.04
|
| Rate for Payer: Quartz Commercial |
$4,092.40
|
| 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 |
$3,462.80
|
| Rate for Payer: Wellcare Medicare |
$181.60
|
| Rate for Payer: WPS Commercial |
$4,663.45
|
|
|
CT TMJ w/ Contrast Bilateral
|
Professional
|
$3,089.00
|
|
|
Service Code
|
CPT 70487 LT,TC
|
| Hospital Charge Code |
1241317
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,359.16 |
| Max. Negotiated Rate |
$2,934.55 |
| Rate for Payer: Aetna Commercial |
$2,934.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,656.54
|
| Rate for Payer: Cash Price |
$926.70
|
| Rate for Payer: Cash Price |
$926.70
|
| Rate for Payer: Cigna Commercial |
$2,934.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,544.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,853.40
|
| Rate for Payer: Health EOS Commercial |
$2,810.99
|
| Rate for Payer: Multiplan Commercial |
$2,471.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,934.55
|
| Rate for Payer: Quartz Beloit One Network |
$1,359.16
|
| Rate for Payer: Quartz Commercial |
$1,760.73
|
| Rate for Payer: The Alliance Commercial |
$1,544.50
|
| Rate for Payer: WEA Trust Commercial |
$1,698.95
|
| Rate for Payer: WPS Commercial |
$2,288.02
|
|
|
CT TMJ w/ Contrast Bilateral
|
Professional
|
$6,296.00
|
|
|
Service Code
|
CPT 70487
|
| Hospital Charge Code |
711753
|
| Min. Negotiated Rate |
$152.36 |
| Max. Negotiated Rate |
$5,981.20 |
| Rate for Payer: Aetna Commercial |
$5,981.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,414.56
|
| 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 |
$1,888.80
|
| Rate for Payer: Cash Price |
$1,888.80
|
| Rate for Payer: Cigna Commercial |
$5,981.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3,148.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$152.36
|
| Rate for Payer: Health EOS Commercial |
$5,729.36
|
| 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 |
$5,036.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,981.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,770.24
|
| Rate for Payer: Quartz Commercial |
$3,588.72
|
| 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 |
$3,462.80
|
| Rate for Payer: WPS Commercial |
$761.80
|
|
|
CT TMJ w/ Contrast Bilateral
|
Facility
IP
|
$3,089.00
|
|
|
Service Code
|
CPT 70487 LT,TC
|
| Hospital Charge Code |
1241317
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,513.61 |
| Max. Negotiated Rate |
$2,841.88 |
| Rate for Payer: Aetna Commercial |
$2,780.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,637.17
|
| Rate for Payer: Cash Price |
$926.70
|
| Rate for Payer: Cigna Commercial |
$2,841.88
|
| Rate for Payer: Health EOS Commercial |
$2,749.21
|
| Rate for Payer: HFN Commercial |
$2,841.88
|
| Rate for Payer: Multiplan Commercial |
$2,471.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,853.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,841.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,513.61
|
| Rate for Payer: Quartz Commercial |
$1,853.40
|
| Rate for Payer: WEA Trust Commercial |
$1,698.95
|
| Rate for Payer: WPS Commercial |
$2,288.02
|
|
|
CT TMJ w/ Contrast Bilateral
|
Facility
IP
|
$6,296.00
|
|
|
Service Code
|
CPT 70487
|
| Hospital Charge Code |
711753
|
| Min. Negotiated Rate |
$3,085.04 |
| Max. Negotiated Rate |
$5,792.32 |
| Rate for Payer: Aetna Commercial |
$5,666.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,336.88
|
| Rate for Payer: Cash Price |
$1,888.80
|
| Rate for Payer: Cigna Commercial |
$5,792.32
|
| Rate for Payer: Health EOS Commercial |
$5,603.44
|
| Rate for Payer: HFN Commercial |
$5,792.32
|
| Rate for Payer: Multiplan Commercial |
$5,036.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,777.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,792.32
|
| Rate for Payer: Quartz Beloit One Network |
$3,085.04
|
| Rate for Payer: Quartz Commercial |
$3,777.60
|
| Rate for Payer: WEA Trust Commercial |
$3,462.80
|
| Rate for Payer: WPS Commercial |
$4,663.45
|
|
|
CT TMJ w/ Contrast Left
|
Professional
|
$3,089.00
|
|
|
Service Code
|
CPT 70487 LT,TC
|
| Hospital Charge Code |
1241320
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,359.16 |
| Max. Negotiated Rate |
$2,934.55 |
| Rate for Payer: Aetna Commercial |
$2,934.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,656.54
|
| Rate for Payer: Cash Price |
$926.70
|
| Rate for Payer: Cash Price |
$926.70
|
| Rate for Payer: Cigna Commercial |
$2,934.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,544.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,853.40
|
| Rate for Payer: Health EOS Commercial |
$2,810.99
|
| Rate for Payer: Multiplan Commercial |
$2,471.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,934.55
|
| Rate for Payer: Quartz Beloit One Network |
$1,359.16
|
| Rate for Payer: Quartz Commercial |
$1,760.73
|
| Rate for Payer: The Alliance Commercial |
$1,544.50
|
| Rate for Payer: WEA Trust Commercial |
$1,698.95
|
| Rate for Payer: WPS Commercial |
$2,288.02
|
|
|
CT TMJ w/ Contrast Left
|
Facility
IP
|
$3,089.00
|
|
|
Service Code
|
CPT 70487 LT,TC
|
| Hospital Charge Code |
1241320
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,513.61 |
| Max. Negotiated Rate |
$2,841.88 |
| Rate for Payer: Aetna Commercial |
$2,780.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,637.17
|
| Rate for Payer: Cash Price |
$926.70
|
| Rate for Payer: Cigna Commercial |
$2,841.88
|
| Rate for Payer: Health EOS Commercial |
$2,749.21
|
| Rate for Payer: HFN Commercial |
$2,841.88
|
| Rate for Payer: Multiplan Commercial |
$2,471.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,853.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,841.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,513.61
|
| Rate for Payer: Quartz Commercial |
$1,853.40
|
| Rate for Payer: WEA Trust Commercial |
$1,698.95
|
| Rate for Payer: WPS Commercial |
$2,288.02
|
|
|
CT TMJ w/ Contrast Left
|
Facility
OP
|
$3,089.00
|
|
|
Service Code
|
CPT 70487 LT,TC
|
| Hospital Charge Code |
1241320
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$864.92 |
| Max. Negotiated Rate |
$12,356.00 |
| Rate for Payer: Aetna Commercial |
$2,780.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,656.54
|
| Rate for Payer: Aetna Managed Medicare |
$864.92
|
| 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 |
$1,637.17
|
| Rate for Payer: Cash Price |
$926.70
|
| Rate for Payer: Cash Price |
$926.70
|
| Rate for Payer: Cash Price |
$926.70
|
| Rate for Payer: Cash Price |
$926.70
|
| Rate for Payer: Cigna Commercial |
$2,841.88
|
| Rate for Payer: Health EOS Commercial |
$2,749.21
|
| Rate for Payer: HFN Commercial |
$2,841.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,316.75
|
| Rate for Payer: Multiplan Commercial |
$2,471.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,853.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,841.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,513.61
|
| Rate for Payer: Quartz Commercial |
$2,007.85
|
| Rate for Payer: Quartz Medicare Advantage |
$1,853.40
|
| Rate for Payer: The Alliance Commercial |
$12,356.00
|
| Rate for Payer: United Healthcare PPO |
$2,065.00
|
| Rate for Payer: WEA Trust Commercial |
$1,698.95
|
| Rate for Payer: WPS Commercial |
$2,288.02
|
|
|
CT TMJ w/ Contrast Left
|
Professional
|
$3,148.00
|
|
|
Service Code
|
CPT 70487
|
| Hospital Charge Code |
711754
|
| 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 TMJ w/ Contrast Left
|
Facility
OP
|
$3,148.00
|
|
|
Service Code
|
CPT 70487
|
| Hospital Charge Code |
711754
|
| 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 TMJ w/ Contrast Left
|
Facility
IP
|
$3,148.00
|
|
|
Service Code
|
CPT 70487
|
| Hospital Charge Code |
711754
|
| 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 TMJ w/ Contrast Right
|
Professional
|
$3,089.00
|
|
|
Service Code
|
CPT 70487 TC,RT
|
| Hospital Charge Code |
2979988
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,359.16 |
| Max. Negotiated Rate |
$2,934.55 |
| Rate for Payer: Aetna Commercial |
$2,934.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,656.54
|
| Rate for Payer: Cash Price |
$926.70
|
| Rate for Payer: Cash Price |
$926.70
|
| Rate for Payer: Cigna Commercial |
$2,934.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,544.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,853.40
|
| Rate for Payer: Health EOS Commercial |
$2,810.99
|
| Rate for Payer: Multiplan Commercial |
$2,471.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,934.55
|
| Rate for Payer: Quartz Beloit One Network |
$1,359.16
|
| Rate for Payer: Quartz Commercial |
$1,760.73
|
| Rate for Payer: The Alliance Commercial |
$1,544.50
|
| Rate for Payer: WEA Trust Commercial |
$1,698.95
|
| Rate for Payer: WPS Commercial |
$2,288.02
|
|
|
CT TMJ w/ Contrast Right
|
Facility
IP
|
$3,148.00
|
|
|
Service Code
|
CPT 70487
|
| Hospital Charge Code |
711757
|
| 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 TMJ w/ Contrast Right
|
Professional
|
$3,148.00
|
|
|
Service Code
|
CPT 70487
|
| Hospital Charge Code |
711757
|
| 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 TMJ w/ Contrast Right
|
Professional
|
$3,089.00
|
|
|
Service Code
|
CPT 70487 RT,TC
|
| Hospital Charge Code |
1241323
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,359.16 |
| Max. Negotiated Rate |
$2,934.55 |
| Rate for Payer: Aetna Commercial |
$2,934.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,656.54
|
| Rate for Payer: Cash Price |
$926.70
|
| Rate for Payer: Cash Price |
$926.70
|
| Rate for Payer: Cigna Commercial |
$2,934.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,544.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,853.40
|
| Rate for Payer: Health EOS Commercial |
$2,810.99
|
| Rate for Payer: Multiplan Commercial |
$2,471.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,934.55
|
| Rate for Payer: Quartz Beloit One Network |
$1,359.16
|
| Rate for Payer: Quartz Commercial |
$1,760.73
|
| Rate for Payer: The Alliance Commercial |
$1,544.50
|
| Rate for Payer: WEA Trust Commercial |
$1,698.95
|
| Rate for Payer: WPS Commercial |
$2,288.02
|
|
|
CT TMJ w/ Contrast Right
|
Facility
IP
|
$3,089.00
|
|
|
Service Code
|
CPT 70487 RT,TC
|
| Hospital Charge Code |
1241323
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,513.61 |
| Max. Negotiated Rate |
$2,841.88 |
| Rate for Payer: Aetna Commercial |
$2,780.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,637.17
|
| Rate for Payer: Cash Price |
$926.70
|
| Rate for Payer: Cigna Commercial |
$2,841.88
|
| Rate for Payer: Health EOS Commercial |
$2,749.21
|
| Rate for Payer: HFN Commercial |
$2,841.88
|
| Rate for Payer: Multiplan Commercial |
$2,471.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,853.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,841.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,513.61
|
| Rate for Payer: Quartz Commercial |
$1,853.40
|
| Rate for Payer: WEA Trust Commercial |
$1,698.95
|
| Rate for Payer: WPS Commercial |
$2,288.02
|
|
|
CT TMJ w/ Contrast Right
|
Facility
OP
|
$3,089.00
|
|
|
Service Code
|
CPT 70487 RT,TC
|
| Hospital Charge Code |
1241323
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$864.92 |
| Max. Negotiated Rate |
$12,356.00 |
| Rate for Payer: Aetna Commercial |
$2,780.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,656.54
|
| Rate for Payer: Aetna Managed Medicare |
$864.92
|
| 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 |
$1,637.17
|
| Rate for Payer: Cash Price |
$926.70
|
| Rate for Payer: Cash Price |
$926.70
|
| Rate for Payer: Cash Price |
$926.70
|
| Rate for Payer: Cash Price |
$926.70
|
| Rate for Payer: Cigna Commercial |
$2,841.88
|
| Rate for Payer: Health EOS Commercial |
$2,749.21
|
| Rate for Payer: HFN Commercial |
$2,841.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,316.75
|
| Rate for Payer: Multiplan Commercial |
$2,471.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,853.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,841.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,513.61
|
| Rate for Payer: Quartz Commercial |
$2,007.85
|
| Rate for Payer: Quartz Medicare Advantage |
$1,853.40
|
| Rate for Payer: The Alliance Commercial |
$12,356.00
|
| Rate for Payer: United Healthcare PPO |
$2,065.00
|
| Rate for Payer: WEA Trust Commercial |
$1,698.95
|
| Rate for Payer: WPS Commercial |
$2,288.02
|
|
|
CT TMJ w/ Contrast Right
|
Facility
OP
|
$3,148.00
|
|
|
Service Code
|
CPT 70487
|
| Hospital Charge Code |
711757
|
| 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 TMJ w/ Contrast Right
|
Facility
IP
|
$3,089.00
|
|
|
Service Code
|
CPT 70487 TC,RT
|
| Hospital Charge Code |
2979988
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,513.61 |
| Max. Negotiated Rate |
$2,841.88 |
| Rate for Payer: Aetna Commercial |
$2,780.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,637.17
|
| Rate for Payer: Cash Price |
$926.70
|
| Rate for Payer: Cigna Commercial |
$2,841.88
|
| Rate for Payer: Health EOS Commercial |
$2,749.21
|
| Rate for Payer: HFN Commercial |
$2,841.88
|
| Rate for Payer: Multiplan Commercial |
$2,471.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,853.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,841.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,513.61
|
| Rate for Payer: Quartz Commercial |
$1,853.40
|
| Rate for Payer: WEA Trust Commercial |
$1,698.95
|
| Rate for Payer: WPS Commercial |
$2,288.02
|
|
