|
CT Lumbar Spine Unenhanced
|
Professional
|
Both
|
$3,742.00
|
|
|
Service Code
|
CPT 72131 TC
|
| Hospital Charge Code |
3072665
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$309.02 |
| Max. Negotiated Rate |
$3,554.90 |
| Rate for Payer: Aetna Commercial |
$3,554.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,218.12
|
| Rate for Payer: Cash Price |
$1,122.60
|
| Rate for Payer: Cash Price |
$1,122.60
|
| Rate for Payer: Cigna Commercial |
$3,554.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,871.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,245.20
|
| Rate for Payer: Health EOS Commercial |
$3,405.22
|
| Rate for Payer: HFN Commercial |
$3,554.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$309.02
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$309.02
|
| Rate for Payer: Multiplan Commercial |
$2,993.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,554.90
|
| Rate for Payer: Quartz Beloit One Network |
$1,646.48
|
| Rate for Payer: Quartz Commercial |
$2,132.94
|
| Rate for Payer: The Alliance Commercial |
$1,871.00
|
| Rate for Payer: WEA Trust Commercial |
$2,058.10
|
| Rate for Payer: WPS Commercial |
$2,771.70
|
|
|
CT Lung Screening Follow Up 12 Months
|
Facility
|
IP
|
$3,386.00
|
|
|
Service Code
|
CPT 71271 TC
|
| Hospital Charge Code |
5595330
|
|
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: Aetna Gatekeeper/Not Gatekeeper |
$2,911.96
|
| 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 Follow Up 12 Months
|
Professional
|
Both
|
$3,386.00
|
|
|
Service Code
|
CPT 71271 TC
|
| Hospital Charge Code |
5595330
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$324.09 |
| 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: 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 |
$2,031.60
|
| Rate for Payer: Health EOS Commercial |
$3,081.26
|
| Rate for Payer: HFN Commercial |
$3,216.70
|
| 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: 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: The Alliance Commercial |
$1,693.00
|
| Rate for Payer: WEA Trust Commercial |
$1,862.30
|
| Rate for Payer: WPS Commercial |
$2,508.01
|
|
|
CT Lung Screening Follow Up 12 Months
|
Facility
|
OP
|
$3,386.00
|
|
|
Service Code
|
CPT 71271 TC
|
| Hospital Charge Code |
5595330
|
|
Hospital Revenue Code
|
350
|
| 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 |
$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: 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: United Healthcare PPO |
$2,065.00
|
| Rate for Payer: WEA Trust Commercial |
$1,862.30
|
| Rate for Payer: WPS Commercial |
$2,508.01
|
|
|
CT Lung Screening Follow Up 3-6 Months
|
Professional
|
Both
|
$3,386.00
|
|
|
Service Code
|
CPT 71250 TC
|
| Hospital Charge Code |
5595333
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$307.85 |
| 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: 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 |
$2,031.60
|
| Rate for Payer: Health EOS Commercial |
$3,081.26
|
| Rate for Payer: HFN Commercial |
$3,216.70
|
| 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: 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: The Alliance Commercial |
$1,693.00
|
| Rate for Payer: WEA Trust Commercial |
$1,862.30
|
| Rate for Payer: WPS Commercial |
$2,508.01
|
|
|
CT Lung Screening Follow Up 3-6 Months
|
Facility
|
OP
|
$3,386.00
|
|
|
Service Code
|
CPT 71250 TC
|
| Hospital Charge Code |
5595333
|
|
Hospital Revenue Code
|
350
|
| 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 |
$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: 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: United Healthcare PPO |
$2,065.00
|
| Rate for Payer: WEA Trust Commercial |
$1,862.30
|
| Rate for Payer: WPS Commercial |
$2,508.01
|
|
|
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: Aetna Gatekeeper/Not Gatekeeper |
$2,911.96
|
| 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 |
$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 |
$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: 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: United Healthcare PPO |
$2,065.00
|
| 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: Aetna Gatekeeper/Not Gatekeeper |
$2,911.96
|
| 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
|
|
|
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: Aetna Gatekeeper/Not Gatekeeper |
$2,911.96
|
| 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
|
Both
|
$3,386.00
|
|
|
Service Code
|
CPT 71271 TC
|
| Hospital Charge Code |
5595336
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$324.09 |
| 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: 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 |
$2,031.60
|
| Rate for Payer: Health EOS Commercial |
$3,081.26
|
| Rate for Payer: HFN Commercial |
$3,216.70
|
| 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: 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: The Alliance Commercial |
$1,693.00
|
| Rate for Payer: WEA Trust Commercial |
$1,862.30
|
| Rate for Payer: WPS Commercial |
$2,508.01
|
|
|
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 |
$925.96 |
| 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: Cigna Commercial |
$3,042.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,850.60
|
| 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 |
$2,449.49
|
|
|
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: Aetna Gatekeeper/Not Gatekeeper |
$2,844.02
|
| 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
|
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: Aetna Gatekeeper/Not Gatekeeper |
$2,707.28
|
| 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
|
Professional
|
Both
|
$3,307.00
|
|
|
Service Code
|
CPT 70487 TC
|
| Hospital Charge Code |
1241202
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$374.00 |
| 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: 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 |
$1,984.20
|
| Rate for Payer: Health EOS Commercial |
$3,009.37
|
| Rate for Payer: HFN Commercial |
$3,141.65
|
| 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: 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: The Alliance Commercial |
$1,653.50
|
| Rate for Payer: WEA Trust Commercial |
$1,818.85
|
| Rate for Payer: WPS Commercial |
$2,449.49
|
|
|
CT Maxillofacial w/ Contrast
|
Professional
|
Both
|
$3,148.00
|
|
|
Service Code
|
CPT 70487
|
| Hospital Charge Code |
630090
|
| Min. Negotiated Rate |
$561.41 |
| 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: 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 |
$1,888.80
|
| Rate for Payer: Health EOS Commercial |
$2,864.68
|
| Rate for Payer: HFN Commercial |
$2,990.60
|
| 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: 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: The Alliance Commercial |
$1,574.00
|
| Rate for Payer: WEA Trust Commercial |
$1,731.40
|
| Rate for Payer: WPS Commercial |
$2,331.72
|
|
|
CT Maxillofacial w/ Contrast
|
Facility
|
OP
|
$3,148.00
|
|
|
Service Code
|
CPT 70487
|
| Hospital Charge Code |
630090
|
| Min. Negotiated Rate |
$181.60 |
| 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 DHI/DHP/ASO |
$1,761.62
|
| 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 |
$726.40
|
| 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/o Contrast
|
Facility
|
OP
|
$2,867.00
|
|
|
Service Code
|
CPT 70486 TC
|
| Hospital Charge Code |
1241204
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$802.76 |
| 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: Cigna Commercial |
$2,637.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,604.37
|
| 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 |
$2,123.59
|
|
|
CT Maxillofacial w/o Contrast
|
Professional
|
Both
|
$2,612.00
|
|
|
Service Code
|
CPT 70486
|
| Hospital Charge Code |
630094
|
| Min. Negotiated Rate |
$469.70 |
| 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: 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 |
$1,567.20
|
| Rate for Payer: Health EOS Commercial |
$2,376.92
|
| Rate for Payer: HFN Commercial |
$2,481.40
|
| 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: 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: The Alliance Commercial |
$1,306.00
|
| Rate for Payer: WEA Trust Commercial |
$1,436.60
|
| Rate for Payer: WPS Commercial |
$1,934.71
|
|
|
CT Maxillofacial w/o Contrast
|
Professional
|
Both
|
$2,867.00
|
|
|
Service Code
|
CPT 70486 TC
|
| Hospital Charge Code |
1241204
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$327.58 |
| 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: 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 |
$1,720.20
|
| Rate for Payer: Health EOS Commercial |
$2,608.97
|
| Rate for Payer: HFN Commercial |
$2,723.65
|
| 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: 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: The Alliance Commercial |
$1,433.50
|
| Rate for Payer: WEA Trust Commercial |
$1,576.85
|
| Rate for Payer: WPS Commercial |
$2,123.59
|
|
|
CT Maxillofacial w/o Contrast
|
Facility
|
OP
|
$2,612.00
|
|
|
Service Code
|
CPT 70486
|
| Hospital Charge Code |
630094
|
| Min. Negotiated Rate |
$108.67 |
| 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 DHI/DHP/ASO |
$1,461.68
|
| 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 |
$434.68
|
| 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
|
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: Aetna Gatekeeper/Not Gatekeeper |
$2,465.62
|
| 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
|
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: Aetna Gatekeeper/Not Gatekeeper |
$2,246.32
|
| 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/ + w/o Contrast
|
Facility
|
OP
|
$3,883.00
|
|
|
Service Code
|
CPT 70488
|
| Hospital Charge Code |
630086
|
| Min. Negotiated Rate |
$181.60 |
| Max. Negotiated Rate |
$3,572.36 |
| 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 DHI/DHP/ASO |
$2,172.93
|
| 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 |
$726.40
|
| 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
|
|
