|
CT Maxillofacial w/ + w/o Contrast
|
Professional
|
Both
|
$3,883.00
|
|
|
Service Code
|
CPT 70488
|
| Hospital Charge Code |
630086
|
| Min. Negotiated Rate |
$687.71 |
| 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: 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 |
$2,329.80
|
| Rate for Payer: Health EOS Commercial |
$3,533.53
|
| Rate for Payer: HFN Commercial |
$3,688.85
|
| 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: 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: The Alliance Commercial |
$1,941.50
|
| Rate for Payer: WEA Trust Commercial |
$2,135.65
|
| Rate for Payer: WPS Commercial |
$2,876.14
|
|
|
CT Maxillofacial w/ + w/o Contrast
|
Professional
|
Both
|
$3,955.00
|
|
|
Service Code
|
CPT 70488 TC
|
| Hospital Charge Code |
1241200
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$476.09 |
| Max. Negotiated Rate |
$3,757.25 |
| Rate for Payer: Aetna Commercial |
$3,757.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,401.30
|
| 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 |
$2,373.00
|
| Rate for Payer: Health EOS Commercial |
$3,599.05
|
| Rate for Payer: HFN Commercial |
$3,757.25
|
| 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: 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: The Alliance Commercial |
$1,977.50
|
| Rate for Payer: WEA Trust Commercial |
$2,175.25
|
| Rate for Payer: WPS Commercial |
$2,929.47
|
|
|
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 |
$1,107.40 |
| 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: Cigna Commercial |
$3,638.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,213.22
|
| 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 |
$2,929.47
|
|
|
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: Aetna Gatekeeper/Not Gatekeeper |
$3,401.30
|
| 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
|
|
|
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: Aetna Gatekeeper/Not Gatekeeper |
$3,339.38
|
| 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 Maxiofacial Unenhanced
|
Professional
|
Both
|
$2,867.00
|
|
|
Service Code
|
CPT 70486 TC
|
| Hospital Charge Code |
3072764
|
|
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 Maxiofacial Unenhanced
|
Facility
|
IP
|
$2,867.00
|
|
|
Service Code
|
CPT 70486 TC
|
| Hospital Charge Code |
3072764
|
|
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 Maxiofacial Unenhanced
|
Facility
|
OP
|
$2,867.00
|
|
|
Service Code
|
CPT 70486 TC
|
| Hospital Charge Code |
3072764
|
|
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 Pancreas w + w/o Contrast
|
Professional
|
Both
|
$4,530.00
|
|
|
Service Code
|
CPT 74170 TC
|
| Hospital Charge Code |
5724154
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$737.52 |
| Max. Negotiated Rate |
$4,303.50 |
| Rate for Payer: Aetna Commercial |
$4,303.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,895.80
|
| Rate for Payer: Cash Price |
$1,359.00
|
| Rate for Payer: Cash Price |
$1,359.00
|
| Rate for Payer: Cigna Commercial |
$4,303.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,265.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,718.00
|
| Rate for Payer: Health EOS Commercial |
$4,122.30
|
| Rate for Payer: HFN Commercial |
$4,303.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$737.52
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$737.52
|
| Rate for Payer: Multiplan Commercial |
$3,624.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,303.50
|
| Rate for Payer: Quartz Beloit One Network |
$1,993.20
|
| Rate for Payer: Quartz Commercial |
$2,582.10
|
| Rate for Payer: The Alliance Commercial |
$2,265.00
|
| Rate for Payer: WEA Trust Commercial |
$2,491.50
|
| Rate for Payer: WPS Commercial |
$3,355.37
|
|
|
CT Pancreas w + w/o Contrast
|
Facility
|
IP
|
$4,530.00
|
|
|
Service Code
|
CPT 74170 TC
|
| Hospital Charge Code |
5724154
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$2,219.70 |
| Max. Negotiated Rate |
$4,167.60 |
| Rate for Payer: Aetna Commercial |
$4,077.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,895.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,400.90
|
| Rate for Payer: Cash Price |
$1,359.00
|
| Rate for Payer: Cigna Commercial |
$4,167.60
|
| Rate for Payer: Health EOS Commercial |
$4,031.70
|
| Rate for Payer: HFN Commercial |
$4,167.60
|
| Rate for Payer: Multiplan Commercial |
$3,624.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,718.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,167.60
|
| Rate for Payer: Quartz Beloit One Network |
$2,219.70
|
| Rate for Payer: Quartz Commercial |
$2,718.00
|
| Rate for Payer: WEA Trust Commercial |
$2,491.50
|
| Rate for Payer: WPS Commercial |
$3,355.37
|
|
|
CT Pancreas w + w/o Contrast
|
Facility
|
OP
|
$4,530.00
|
|
|
Service Code
|
CPT 74170 TC
|
| Hospital Charge Code |
5724154
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,268.40 |
| Max. Negotiated Rate |
$18,120.00 |
| Rate for Payer: Aetna Commercial |
$4,077.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,895.80
|
| Rate for Payer: Aetna Managed Medicare |
$1,268.40
|
| 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 |
$2,400.90
|
| Rate for Payer: Cash Price |
$1,359.00
|
| Rate for Payer: Cash Price |
$1,359.00
|
| Rate for Payer: Cash Price |
$1,359.00
|
| Rate for Payer: Cigna Commercial |
$4,167.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,534.99
|
| Rate for Payer: Health EOS Commercial |
$4,031.70
|
| Rate for Payer: HFN Commercial |
$4,167.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,397.50
|
| Rate for Payer: Multiplan Commercial |
$3,624.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,718.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,167.60
|
| Rate for Payer: Quartz Beloit One Network |
$2,219.70
|
| Rate for Payer: Quartz Commercial |
$2,944.50
|
| Rate for Payer: Quartz Medicare Advantage |
$2,718.00
|
| Rate for Payer: The Alliance Commercial |
$18,120.00
|
| Rate for Payer: United Healthcare PPO |
$2,065.00
|
| Rate for Payer: WEA Trust Commercial |
$2,491.50
|
| Rate for Payer: WPS Commercial |
$3,355.37
|
|
|
CT Pancreas w + w/o, Pelvis w/ Contrast
|
Professional
|
Both
|
$7,537.00
|
|
|
Service Code
|
CPT 74178 TC
|
| Hospital Charge Code |
5724157
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$935.91 |
| Max. Negotiated Rate |
$7,160.15 |
| Rate for Payer: Aetna Commercial |
$7,160.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,481.82
|
| Rate for Payer: Cash Price |
$2,261.10
|
| Rate for Payer: Cash Price |
$2,261.10
|
| Rate for Payer: Cigna Commercial |
$7,160.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3,768.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,522.20
|
| Rate for Payer: Health EOS Commercial |
$6,858.67
|
| Rate for Payer: HFN Commercial |
$7,160.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$935.91
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$935.91
|
| Rate for Payer: Multiplan Commercial |
$6,029.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,160.15
|
| Rate for Payer: Quartz Beloit One Network |
$3,316.28
|
| Rate for Payer: Quartz Commercial |
$4,296.09
|
| Rate for Payer: The Alliance Commercial |
$3,768.50
|
| Rate for Payer: WEA Trust Commercial |
$4,145.35
|
| Rate for Payer: WPS Commercial |
$5,582.66
|
|
|
CT Pancreas w + w/o, Pelvis w/ Contrast
|
Facility
|
IP
|
$7,537.00
|
|
|
Service Code
|
CPT 74178 TC
|
| Hospital Charge Code |
5724157
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$3,693.13 |
| Max. Negotiated Rate |
$6,934.04 |
| Rate for Payer: Aetna Commercial |
$6,783.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,481.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,994.61
|
| Rate for Payer: Cash Price |
$2,261.10
|
| Rate for Payer: Cigna Commercial |
$6,934.04
|
| Rate for Payer: Health EOS Commercial |
$6,707.93
|
| Rate for Payer: HFN Commercial |
$6,934.04
|
| Rate for Payer: Multiplan Commercial |
$6,029.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,522.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6,934.04
|
| Rate for Payer: Quartz Beloit One Network |
$3,693.13
|
| Rate for Payer: Quartz Commercial |
$4,522.20
|
| Rate for Payer: WEA Trust Commercial |
$4,145.35
|
| Rate for Payer: WPS Commercial |
$5,582.66
|
|
|
CT Pancreas w + w/o, Pelvis w/ Contrast
|
Facility
|
OP
|
$7,537.00
|
|
|
Service Code
|
CPT 74178 TC
|
| Hospital Charge Code |
5724157
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$2,065.00 |
| Max. Negotiated Rate |
$30,148.00 |
| Rate for Payer: Aetna Commercial |
$6,783.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,481.82
|
| Rate for Payer: Aetna Managed Medicare |
$2,110.36
|
| 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 |
$3,994.61
|
| Rate for Payer: Cash Price |
$2,261.10
|
| Rate for Payer: Cash Price |
$2,261.10
|
| Rate for Payer: Cash Price |
$2,261.10
|
| Rate for Payer: Cigna Commercial |
$6,934.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,217.71
|
| Rate for Payer: Health EOS Commercial |
$6,707.93
|
| Rate for Payer: HFN Commercial |
$6,934.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,652.75
|
| Rate for Payer: Multiplan Commercial |
$6,029.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,522.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6,934.04
|
| Rate for Payer: Quartz Beloit One Network |
$3,693.13
|
| Rate for Payer: Quartz Commercial |
$4,899.05
|
| Rate for Payer: Quartz Medicare Advantage |
$4,522.20
|
| Rate for Payer: The Alliance Commercial |
$30,148.00
|
| Rate for Payer: United Healthcare PPO |
$2,065.00
|
| Rate for Payer: WEA Trust Commercial |
$4,145.35
|
| Rate for Payer: WPS Commercial |
$5,582.66
|
|
|
CT Pelvis w/ Contrast
|
Facility
|
IP
|
$3,719.00
|
|
|
Service Code
|
CPT 72193 TC
|
| Hospital Charge Code |
1241208
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,822.31 |
| Max. Negotiated Rate |
$3,421.48 |
| Rate for Payer: Aetna Commercial |
$3,347.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,198.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,971.07
|
| Rate for Payer: Cash Price |
$1,115.70
|
| Rate for Payer: Cigna Commercial |
$3,421.48
|
| Rate for Payer: Health EOS Commercial |
$3,309.91
|
| Rate for Payer: HFN Commercial |
$3,421.48
|
| Rate for Payer: Multiplan Commercial |
$2,975.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,231.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,421.48
|
| Rate for Payer: Quartz Beloit One Network |
$1,822.31
|
| Rate for Payer: Quartz Commercial |
$2,231.40
|
| Rate for Payer: WEA Trust Commercial |
$2,045.45
|
| Rate for Payer: WPS Commercial |
$2,754.66
|
|
|
CT Pelvis w/ Contrast
|
Facility
|
IP
|
$3,162.00
|
|
|
Service Code
|
CPT 72193
|
| Hospital Charge Code |
630112
|
| Min. Negotiated Rate |
$1,549.38 |
| Max. Negotiated Rate |
$2,909.04 |
| Rate for Payer: Aetna Commercial |
$2,845.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,719.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,675.86
|
| Rate for Payer: Cash Price |
$948.60
|
| Rate for Payer: Cigna Commercial |
$2,909.04
|
| Rate for Payer: Health EOS Commercial |
$2,814.18
|
| Rate for Payer: HFN Commercial |
$2,909.04
|
| Rate for Payer: Multiplan Commercial |
$2,529.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,897.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,909.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,549.38
|
| Rate for Payer: Quartz Commercial |
$1,897.20
|
| Rate for Payer: WEA Trust Commercial |
$1,739.10
|
| Rate for Payer: WPS Commercial |
$2,342.09
|
|
|
CT Pelvis w/ Contrast
|
Facility
|
OP
|
$3,719.00
|
|
|
Service Code
|
CPT 72193 TC
|
| Hospital Charge Code |
1241208
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,041.32 |
| Max. Negotiated Rate |
$14,876.00 |
| Rate for Payer: Aetna Commercial |
$3,347.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,198.34
|
| Rate for Payer: Aetna Managed Medicare |
$1,041.32
|
| 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 |
$1,971.07
|
| Rate for Payer: Cash Price |
$1,115.70
|
| Rate for Payer: Cash Price |
$1,115.70
|
| Rate for Payer: Cash Price |
$1,115.70
|
| Rate for Payer: Cigna Commercial |
$3,421.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,081.15
|
| Rate for Payer: Health EOS Commercial |
$3,309.91
|
| Rate for Payer: HFN Commercial |
$3,421.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,789.25
|
| Rate for Payer: Multiplan Commercial |
$2,975.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,231.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,421.48
|
| Rate for Payer: Quartz Beloit One Network |
$1,822.31
|
| Rate for Payer: Quartz Commercial |
$2,417.35
|
| Rate for Payer: Quartz Medicare Advantage |
$2,231.40
|
| Rate for Payer: The Alliance Commercial |
$14,876.00
|
| Rate for Payer: United Healthcare PPO |
$2,065.00
|
| Rate for Payer: WEA Trust Commercial |
$2,045.45
|
| Rate for Payer: WPS Commercial |
$2,754.66
|
|
|
CT Pelvis w/ Contrast
|
Professional
|
Both
|
$3,162.00
|
|
|
Service Code
|
CPT 72193
|
| Hospital Charge Code |
630112
|
| Min. Negotiated Rate |
$847.02 |
| Max. Negotiated Rate |
$3,003.90 |
| Rate for Payer: Aetna Commercial |
$3,003.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,719.32
|
| Rate for Payer: Cash Price |
$948.60
|
| Rate for Payer: Cash Price |
$948.60
|
| Rate for Payer: Cigna Commercial |
$3,003.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,581.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,897.20
|
| Rate for Payer: Health EOS Commercial |
$2,877.42
|
| Rate for Payer: HFN Commercial |
$3,003.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$847.02
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$847.02
|
| Rate for Payer: Multiplan Commercial |
$2,529.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,003.90
|
| Rate for Payer: Quartz Beloit One Network |
$1,391.28
|
| Rate for Payer: Quartz Commercial |
$1,802.34
|
| Rate for Payer: The Alliance Commercial |
$1,581.00
|
| Rate for Payer: WEA Trust Commercial |
$1,739.10
|
| Rate for Payer: WPS Commercial |
$2,342.09
|
|
|
CT Pelvis w/ Contrast
|
Facility
|
OP
|
$3,162.00
|
|
|
Service Code
|
CPT 72193
|
| Hospital Charge Code |
630112
|
| Min. Negotiated Rate |
$181.60 |
| Max. Negotiated Rate |
$2,909.04 |
| Rate for Payer: Aetna Commercial |
$2,845.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,719.32
|
| Rate for Payer: Aetna Managed Medicare |
$181.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,055.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,581.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,517.76
|
| Rate for Payer: Anthem Medicare Advantage |
$181.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,675.86
|
| 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 |
$948.60
|
| Rate for Payer: Cash Price |
$948.60
|
| Rate for Payer: Cigna Commercial |
$2,909.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$181.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,769.46
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$181.60
|
| Rate for Payer: Health EOS Commercial |
$2,814.18
|
| Rate for Payer: HFN Commercial |
$2,909.04
|
| 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 |
$2,529.60
|
| Rate for Payer: NAPHCARE Commercial |
$272.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,909.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,549.38
|
| Rate for Payer: Quartz Commercial |
$2,055.30
|
| 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 |
$1,739.10
|
| Rate for Payer: Wellcare Medicare |
$181.60
|
| Rate for Payer: WPS Commercial |
$2,342.09
|
|
|
CT Pelvis w/ Contrast
|
Professional
|
Both
|
$3,719.00
|
|
|
Service Code
|
CPT 72193 TC
|
| Hospital Charge Code |
1241208
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$653.58 |
| Max. Negotiated Rate |
$3,533.05 |
| Rate for Payer: Aetna Commercial |
$3,533.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,198.34
|
| Rate for Payer: Cash Price |
$1,115.70
|
| Rate for Payer: Cash Price |
$1,115.70
|
| Rate for Payer: Cigna Commercial |
$3,533.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,859.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,231.40
|
| Rate for Payer: Health EOS Commercial |
$3,384.29
|
| Rate for Payer: HFN Commercial |
$3,533.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$653.58
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$653.58
|
| Rate for Payer: Multiplan Commercial |
$2,975.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,533.05
|
| Rate for Payer: Quartz Beloit One Network |
$1,636.36
|
| Rate for Payer: Quartz Commercial |
$2,119.83
|
| Rate for Payer: The Alliance Commercial |
$1,859.50
|
| Rate for Payer: WEA Trust Commercial |
$2,045.45
|
| Rate for Payer: WPS Commercial |
$2,754.66
|
|
|
CT Pelvis w/o Contrast
|
Professional
|
Both
|
$2,918.00
|
|
|
Service Code
|
CPT 72192
|
| Hospital Charge Code |
630114
|
| Min. Negotiated Rate |
$489.19 |
| Max. Negotiated Rate |
$2,772.10 |
| Rate for Payer: Aetna Commercial |
$2,772.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,509.48
|
| Rate for Payer: Cash Price |
$875.40
|
| Rate for Payer: Cash Price |
$875.40
|
| Rate for Payer: Cigna Commercial |
$2,772.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,459.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,750.80
|
| Rate for Payer: Health EOS Commercial |
$2,655.38
|
| Rate for Payer: HFN Commercial |
$2,772.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$489.19
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$489.19
|
| Rate for Payer: Multiplan Commercial |
$2,334.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,772.10
|
| Rate for Payer: Quartz Beloit One Network |
$1,283.92
|
| Rate for Payer: Quartz Commercial |
$1,663.26
|
| Rate for Payer: The Alliance Commercial |
$1,459.00
|
| Rate for Payer: WEA Trust Commercial |
$1,604.90
|
| Rate for Payer: WPS Commercial |
$2,161.36
|
|
|
CT Pelvis w/o Contrast
|
Facility
|
IP
|
$3,266.00
|
|
|
Service Code
|
CPT 72192 TC
|
| Hospital Charge Code |
1241210
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,600.34 |
| Max. Negotiated Rate |
$3,004.72 |
| Rate for Payer: Aetna Commercial |
$2,939.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,808.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,730.98
|
| Rate for Payer: Cash Price |
$979.80
|
| Rate for Payer: Cigna Commercial |
$3,004.72
|
| Rate for Payer: Health EOS Commercial |
$2,906.74
|
| Rate for Payer: HFN Commercial |
$3,004.72
|
| Rate for Payer: Multiplan Commercial |
$2,612.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,959.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,004.72
|
| Rate for Payer: Quartz Beloit One Network |
$1,600.34
|
| Rate for Payer: Quartz Commercial |
$1,959.60
|
| Rate for Payer: WEA Trust Commercial |
$1,796.30
|
| Rate for Payer: WPS Commercial |
$2,419.13
|
|
|
CT Pelvis w/o Contrast
|
Facility
|
OP
|
$2,918.00
|
|
|
Service Code
|
CPT 72192
|
| Hospital Charge Code |
630114
|
| Min. Negotiated Rate |
$108.67 |
| Max. Negotiated Rate |
$2,684.56 |
| Rate for Payer: Aetna Commercial |
$2,626.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,509.48
|
| Rate for Payer: Aetna Managed Medicare |
$108.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,896.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,459.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,400.64
|
| Rate for Payer: Anthem Medicare Advantage |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,546.54
|
| 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 |
$875.40
|
| Rate for Payer: Cash Price |
$875.40
|
| Rate for Payer: Cigna Commercial |
$2,684.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$108.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,632.91
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$108.67
|
| Rate for Payer: Health EOS Commercial |
$2,597.02
|
| Rate for Payer: HFN Commercial |
$2,684.56
|
| 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 |
$2,334.40
|
| Rate for Payer: NAPHCARE Commercial |
$163.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,684.56
|
| Rate for Payer: Quartz Beloit One Network |
$1,429.82
|
| Rate for Payer: Quartz Commercial |
$1,896.70
|
| 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 |
$1,604.90
|
| Rate for Payer: Wellcare Medicare |
$108.67
|
| Rate for Payer: WPS Commercial |
$2,161.36
|
|
|
CT Pelvis w/o Contrast
|
Facility
|
OP
|
$3,266.00
|
|
|
Service Code
|
CPT 72192 TC
|
| Hospital Charge Code |
1241210
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$914.48 |
| Max. Negotiated Rate |
$13,064.00 |
| Rate for Payer: Aetna Commercial |
$2,939.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,808.76
|
| Rate for Payer: Aetna Managed Medicare |
$914.48
|
| 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 |
$1,730.98
|
| Rate for Payer: Cash Price |
$979.80
|
| Rate for Payer: Cash Price |
$979.80
|
| Rate for Payer: Cash Price |
$979.80
|
| Rate for Payer: Cigna Commercial |
$3,004.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,827.65
|
| Rate for Payer: Health EOS Commercial |
$2,906.74
|
| Rate for Payer: HFN Commercial |
$3,004.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,449.50
|
| Rate for Payer: Multiplan Commercial |
$2,612.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,959.60
|
| Rate for Payer: Preferred Network Access Commercial |
$3,004.72
|
| Rate for Payer: Quartz Beloit One Network |
$1,600.34
|
| Rate for Payer: Quartz Commercial |
$2,122.90
|
| Rate for Payer: Quartz Medicare Advantage |
$1,959.60
|
| Rate for Payer: The Alliance Commercial |
$13,064.00
|
| Rate for Payer: United Healthcare PPO |
$2,065.00
|
| Rate for Payer: WEA Trust Commercial |
$1,796.30
|
| Rate for Payer: WPS Commercial |
$2,419.13
|
|
|
CT Pelvis w/o Contrast
|
Professional
|
Both
|
$3,266.00
|
|
|
Service Code
|
CPT 72192 TC
|
| Hospital Charge Code |
1241210
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$307.85 |
| Max. Negotiated Rate |
$3,102.70 |
| Rate for Payer: Aetna Commercial |
$3,102.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,808.76
|
| Rate for Payer: Cash Price |
$979.80
|
| Rate for Payer: Cash Price |
$979.80
|
| Rate for Payer: Cigna Commercial |
$3,102.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,633.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,959.60
|
| Rate for Payer: Health EOS Commercial |
$2,972.06
|
| Rate for Payer: HFN Commercial |
$3,102.70
|
| 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 |
$2,612.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,102.70
|
| Rate for Payer: Quartz Beloit One Network |
$1,437.04
|
| Rate for Payer: Quartz Commercial |
$1,861.62
|
| Rate for Payer: The Alliance Commercial |
$1,633.00
|
| Rate for Payer: WEA Trust Commercial |
$1,796.30
|
| Rate for Payer: WPS Commercial |
$2,419.13
|
|
