|
CT TMJ w/ Contrast Right
|
Facility
OP
|
$3,089.00
|
|
|
Service Code
|
CPT 70487 TC,RT
|
| Hospital Charge Code |
2979988
|
|
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/o Contrast Bilateral
|
Professional
|
$5,225.00
|
|
|
Service Code
|
CPT 70486
|
| Hospital Charge Code |
711758
|
| Min. Negotiated Rate |
$128.49 |
| Max. Negotiated Rate |
$4,963.75 |
| Rate for Payer: Aetna Commercial |
$4,963.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,493.50
|
| Rate for Payer: Aetna Managed Medicare |
$128.49
|
| Rate for Payer: Anthem Medicare Advantage |
$128.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$128.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$128.49
|
| Rate for Payer: Cash Price |
$1,567.50
|
| Rate for Payer: Cash Price |
$1,567.50
|
| Rate for Payer: Cigna Commercial |
$4,963.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,612.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$128.49
|
| Rate for Payer: Health EOS Commercial |
$4,754.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$469.70
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$469.70
|
| Rate for Payer: Independent Care Health Plan Medicare |
$128.49
|
| Rate for Payer: Multiplan Commercial |
$4,180.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,963.75
|
| Rate for Payer: Quartz Beloit One Network |
$2,299.00
|
| Rate for Payer: Quartz Commercial |
$2,978.25
|
| Rate for Payer: Quartz Medicare Advantage |
$128.49
|
| Rate for Payer: The Alliance Commercial |
$488.26
|
| Rate for Payer: United Healthcare Medicare Advantage |
$128.49
|
| Rate for Payer: WEA Trust Commercial |
$2,873.75
|
| Rate for Payer: WPS Commercial |
$642.45
|
|
|
CT TMJ w/o Contrast Bilateral
|
Facility
OP
|
$5,225.00
|
|
|
Service Code
|
CPT 70486
|
| Hospital Charge Code |
711758
|
| Min. Negotiated Rate |
$85.36 |
| Max. Negotiated Rate |
$4,807.00 |
| Rate for Payer: Aetna Commercial |
$4,702.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,493.50
|
| Rate for Payer: Aetna Managed Medicare |
$108.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,396.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,612.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,508.00
|
| Rate for Payer: Anthem Medicare Advantage |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,769.25
|
| 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 |
$1,567.50
|
| Rate for Payer: Cash Price |
$1,567.50
|
| Rate for Payer: Cigna Commercial |
$4,807.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$108.67
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$108.67
|
| Rate for Payer: Health EOS Commercial |
$4,650.25
|
| Rate for Payer: HFN Commercial |
$4,807.00
|
| 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 |
$4,180.00
|
| Rate for Payer: NAPHCARE Commercial |
$163.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,807.00
|
| Rate for Payer: Quartz Beloit One Network |
$2,560.25
|
| Rate for Payer: Quartz Commercial |
$3,396.25
|
| Rate for Payer: Quartz Medicare Advantage |
$108.67
|
| Rate for Payer: The Alliance Commercial |
$85.36
|
| Rate for Payer: United Healthcare Medicare Advantage |
$108.67
|
| Rate for Payer: WEA Trust Commercial |
$2,873.75
|
| Rate for Payer: Wellcare Medicare |
$108.67
|
| Rate for Payer: WPS Commercial |
$3,870.16
|
|
|
CT TMJ w/o Contrast Bilateral
|
Facility
OP
|
$2,760.00
|
|
|
Service Code
|
CPT 70486 LT,TC
|
| Hospital Charge Code |
1241326
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$772.80 |
| Max. Negotiated Rate |
$11,040.00 |
| Rate for Payer: Aetna Commercial |
$2,484.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,373.60
|
| Rate for Payer: Aetna Managed Medicare |
$772.80
|
| 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 |
$1,462.80
|
| Rate for Payer: Cash Price |
$828.00
|
| Rate for Payer: Cash Price |
$828.00
|
| Rate for Payer: Cash Price |
$828.00
|
| Rate for Payer: Cash Price |
$828.00
|
| Rate for Payer: Cigna Commercial |
$2,539.20
|
| Rate for Payer: Health EOS Commercial |
$2,456.40
|
| Rate for Payer: HFN Commercial |
$2,539.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,070.00
|
| Rate for Payer: Multiplan Commercial |
$2,208.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,656.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,539.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,352.40
|
| Rate for Payer: Quartz Commercial |
$1,794.00
|
| Rate for Payer: Quartz Medicare Advantage |
$1,656.00
|
| Rate for Payer: The Alliance Commercial |
$11,040.00
|
| Rate for Payer: United Healthcare PPO |
$2,065.00
|
| Rate for Payer: WEA Trust Commercial |
$1,518.00
|
| Rate for Payer: WPS Commercial |
$2,044.33
|
|
|
CT TMJ w/o Contrast Bilateral
|
Professional
|
$2,760.00
|
|
|
Service Code
|
CPT 70486 LT,TC
|
| Hospital Charge Code |
1241326
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,214.40 |
| Max. Negotiated Rate |
$2,622.00 |
| Rate for Payer: Aetna Commercial |
$2,622.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,373.60
|
| Rate for Payer: Cash Price |
$828.00
|
| Rate for Payer: Cash Price |
$828.00
|
| Rate for Payer: Cigna Commercial |
$2,622.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,380.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,656.00
|
| Rate for Payer: Health EOS Commercial |
$2,511.60
|
| Rate for Payer: Multiplan Commercial |
$2,208.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,622.00
|
| Rate for Payer: Quartz Beloit One Network |
$1,214.40
|
| Rate for Payer: Quartz Commercial |
$1,573.20
|
| Rate for Payer: The Alliance Commercial |
$1,380.00
|
| Rate for Payer: WEA Trust Commercial |
$1,518.00
|
| Rate for Payer: WPS Commercial |
$2,044.33
|
|
|
CT TMJ w/o Contrast Bilateral
|
Facility
IP
|
$2,760.00
|
|
|
Service Code
|
CPT 70486 LT,TC
|
| Hospital Charge Code |
1241326
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,352.40 |
| Max. Negotiated Rate |
$2,539.20 |
| Rate for Payer: Aetna Commercial |
$2,484.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,462.80
|
| Rate for Payer: Cash Price |
$828.00
|
| Rate for Payer: Cigna Commercial |
$2,539.20
|
| Rate for Payer: Health EOS Commercial |
$2,456.40
|
| Rate for Payer: HFN Commercial |
$2,539.20
|
| Rate for Payer: Multiplan Commercial |
$2,208.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,656.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,539.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,352.40
|
| Rate for Payer: Quartz Commercial |
$1,656.00
|
| Rate for Payer: WEA Trust Commercial |
$1,518.00
|
| Rate for Payer: WPS Commercial |
$2,044.33
|
|
|
CT TMJ w/o Contrast Bilateral
|
Facility
IP
|
$5,225.00
|
|
|
Service Code
|
CPT 70486
|
| Hospital Charge Code |
711758
|
| Min. Negotiated Rate |
$2,560.25 |
| Max. Negotiated Rate |
$4,807.00 |
| Rate for Payer: Aetna Commercial |
$4,702.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,769.25
|
| Rate for Payer: Cash Price |
$1,567.50
|
| Rate for Payer: Cigna Commercial |
$4,807.00
|
| Rate for Payer: Health EOS Commercial |
$4,650.25
|
| Rate for Payer: HFN Commercial |
$4,807.00
|
| Rate for Payer: Multiplan Commercial |
$4,180.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,135.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,807.00
|
| Rate for Payer: Quartz Beloit One Network |
$2,560.25
|
| Rate for Payer: Quartz Commercial |
$3,135.00
|
| Rate for Payer: WEA Trust Commercial |
$2,873.75
|
| Rate for Payer: WPS Commercial |
$3,870.16
|
|
|
CT TMJ w/o Contrast Left
|
Facility
IP
|
$2,612.00
|
|
|
Service Code
|
CPT 70486
|
| Hospital Charge Code |
711759
|
| Min. Negotiated Rate |
$1,279.88 |
| Max. Negotiated Rate |
$2,403.04 |
| Rate for Payer: Aetna Commercial |
$2,350.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,384.36
|
| Rate for Payer: Cash Price |
$783.60
|
| Rate for Payer: Cigna Commercial |
$2,403.04
|
| Rate for Payer: Health EOS Commercial |
$2,324.68
|
| Rate for Payer: HFN Commercial |
$2,403.04
|
| Rate for Payer: Multiplan Commercial |
$2,089.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,567.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,403.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,279.88
|
| Rate for Payer: Quartz Commercial |
$1,567.20
|
| Rate for Payer: WEA Trust Commercial |
$1,436.60
|
| Rate for Payer: WPS Commercial |
$1,934.71
|
|
|
CT TMJ w/o Contrast Left
|
Professional
|
$2,760.00
|
|
|
Service Code
|
CPT 70486 LT,TC
|
| Hospital Charge Code |
1241329
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,214.40 |
| Max. Negotiated Rate |
$2,622.00 |
| Rate for Payer: Aetna Commercial |
$2,622.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,373.60
|
| Rate for Payer: Cash Price |
$828.00
|
| Rate for Payer: Cash Price |
$828.00
|
| Rate for Payer: Cigna Commercial |
$2,622.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,380.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,656.00
|
| Rate for Payer: Health EOS Commercial |
$2,511.60
|
| Rate for Payer: Multiplan Commercial |
$2,208.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,622.00
|
| Rate for Payer: Quartz Beloit One Network |
$1,214.40
|
| Rate for Payer: Quartz Commercial |
$1,573.20
|
| Rate for Payer: The Alliance Commercial |
$1,380.00
|
| Rate for Payer: WEA Trust Commercial |
$1,518.00
|
| Rate for Payer: WPS Commercial |
$2,044.33
|
|
|
CT TMJ w/o Contrast Left
|
Professional
|
$2,612.00
|
|
|
Service Code
|
CPT 70486
|
| Hospital Charge Code |
711759
|
| Min. Negotiated Rate |
$128.49 |
| Max. Negotiated Rate |
$2,481.40 |
| Rate for Payer: Aetna Commercial |
$2,481.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,246.32
|
| Rate for Payer: Aetna Managed Medicare |
$128.49
|
| Rate for Payer: Anthem Medicare Advantage |
$128.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$128.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$128.49
|
| Rate for Payer: Cash Price |
$783.60
|
| Rate for Payer: Cash Price |
$783.60
|
| Rate for Payer: Cigna Commercial |
$2,481.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,306.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$128.49
|
| Rate for Payer: Health EOS Commercial |
$2,376.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$469.70
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$469.70
|
| Rate for Payer: Independent Care Health Plan Medicare |
$128.49
|
| Rate for Payer: Multiplan Commercial |
$2,089.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,481.40
|
| Rate for Payer: Quartz Beloit One Network |
$1,149.28
|
| Rate for Payer: Quartz Commercial |
$1,488.84
|
| Rate for Payer: Quartz Medicare Advantage |
$128.49
|
| Rate for Payer: The Alliance Commercial |
$488.26
|
| Rate for Payer: United Healthcare Medicare Advantage |
$128.49
|
| Rate for Payer: WEA Trust Commercial |
$1,436.60
|
| Rate for Payer: WPS Commercial |
$642.45
|
|
|
CT TMJ w/o Contrast Left
|
Facility
OP
|
$2,760.00
|
|
|
Service Code
|
CPT 70486 LT,TC
|
| Hospital Charge Code |
1241329
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$772.80 |
| Max. Negotiated Rate |
$11,040.00 |
| Rate for Payer: Aetna Commercial |
$2,484.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,373.60
|
| Rate for Payer: Aetna Managed Medicare |
$772.80
|
| 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 |
$1,462.80
|
| Rate for Payer: Cash Price |
$828.00
|
| Rate for Payer: Cash Price |
$828.00
|
| Rate for Payer: Cash Price |
$828.00
|
| Rate for Payer: Cash Price |
$828.00
|
| Rate for Payer: Cigna Commercial |
$2,539.20
|
| Rate for Payer: Health EOS Commercial |
$2,456.40
|
| Rate for Payer: HFN Commercial |
$2,539.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,070.00
|
| Rate for Payer: Multiplan Commercial |
$2,208.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,656.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,539.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,352.40
|
| Rate for Payer: Quartz Commercial |
$1,794.00
|
| Rate for Payer: Quartz Medicare Advantage |
$1,656.00
|
| Rate for Payer: The Alliance Commercial |
$11,040.00
|
| Rate for Payer: United Healthcare PPO |
$2,065.00
|
| Rate for Payer: WEA Trust Commercial |
$1,518.00
|
| Rate for Payer: WPS Commercial |
$2,044.33
|
|
|
CT TMJ w/o Contrast Left
|
Facility
IP
|
$2,760.00
|
|
|
Service Code
|
CPT 70486 LT,TC
|
| Hospital Charge Code |
1241329
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,352.40 |
| Max. Negotiated Rate |
$2,539.20 |
| Rate for Payer: Aetna Commercial |
$2,484.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,462.80
|
| Rate for Payer: Cash Price |
$828.00
|
| Rate for Payer: Cigna Commercial |
$2,539.20
|
| Rate for Payer: Health EOS Commercial |
$2,456.40
|
| Rate for Payer: HFN Commercial |
$2,539.20
|
| Rate for Payer: Multiplan Commercial |
$2,208.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,656.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,539.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,352.40
|
| Rate for Payer: Quartz Commercial |
$1,656.00
|
| Rate for Payer: WEA Trust Commercial |
$1,518.00
|
| Rate for Payer: WPS Commercial |
$2,044.33
|
|
|
CT TMJ w/o Contrast Left
|
Facility
OP
|
$2,612.00
|
|
|
Service Code
|
CPT 70486
|
| Hospital Charge Code |
711759
|
| Min. Negotiated Rate |
$85.36 |
| Max. Negotiated Rate |
$2,403.04 |
| Rate for Payer: Aetna Commercial |
$2,350.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,246.32
|
| Rate for Payer: Aetna Managed Medicare |
$108.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,697.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,306.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,253.76
|
| Rate for Payer: Anthem Medicare Advantage |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,384.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$108.67
|
| Rate for Payer: Cash Price |
$783.60
|
| Rate for Payer: Cash Price |
$783.60
|
| Rate for Payer: Cigna Commercial |
$2,403.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$108.67
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$108.67
|
| Rate for Payer: Health EOS Commercial |
$2,324.68
|
| Rate for Payer: HFN Commercial |
$2,403.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$404.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$108.67
|
| Rate for Payer: Independent Care Health Plan Medicare |
$108.67
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$108.67
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$108.67
|
| Rate for Payer: Multiplan Commercial |
$2,089.60
|
| Rate for Payer: NAPHCARE Commercial |
$163.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,403.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,279.88
|
| Rate for Payer: Quartz Commercial |
$1,697.80
|
| Rate for Payer: Quartz Medicare Advantage |
$108.67
|
| Rate for Payer: The Alliance Commercial |
$85.36
|
| Rate for Payer: United Healthcare Medicare Advantage |
$108.67
|
| Rate for Payer: WEA Trust Commercial |
$1,436.60
|
| Rate for Payer: Wellcare Medicare |
$108.67
|
| Rate for Payer: WPS Commercial |
$1,934.71
|
|
|
CT TMJ w/o Contrast Right
|
Facility
IP
|
$2,612.00
|
|
|
Service Code
|
CPT 70486
|
| Hospital Charge Code |
711760
|
| Min. Negotiated Rate |
$1,279.88 |
| Max. Negotiated Rate |
$2,403.04 |
| Rate for Payer: Aetna Commercial |
$2,350.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,384.36
|
| Rate for Payer: Cash Price |
$783.60
|
| Rate for Payer: Cigna Commercial |
$2,403.04
|
| Rate for Payer: Health EOS Commercial |
$2,324.68
|
| Rate for Payer: HFN Commercial |
$2,403.04
|
| Rate for Payer: Multiplan Commercial |
$2,089.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,567.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,403.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,279.88
|
| Rate for Payer: Quartz Commercial |
$1,567.20
|
| Rate for Payer: WEA Trust Commercial |
$1,436.60
|
| Rate for Payer: WPS Commercial |
$1,934.71
|
|
|
CT TMJ w/o Contrast Right
|
Professional
|
$2,760.00
|
|
|
Service Code
|
CPT 70486 TC,RT
|
| Hospital Charge Code |
2979987
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,214.40 |
| Max. Negotiated Rate |
$2,622.00 |
| Rate for Payer: Aetna Commercial |
$2,622.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,373.60
|
| Rate for Payer: Cash Price |
$828.00
|
| Rate for Payer: Cash Price |
$828.00
|
| Rate for Payer: Cigna Commercial |
$2,622.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,380.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,656.00
|
| Rate for Payer: Health EOS Commercial |
$2,511.60
|
| Rate for Payer: Multiplan Commercial |
$2,208.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,622.00
|
| Rate for Payer: Quartz Beloit One Network |
$1,214.40
|
| Rate for Payer: Quartz Commercial |
$1,573.20
|
| Rate for Payer: The Alliance Commercial |
$1,380.00
|
| Rate for Payer: WEA Trust Commercial |
$1,518.00
|
| Rate for Payer: WPS Commercial |
$2,044.33
|
|
|
CT TMJ w/o Contrast Right
|
Facility
OP
|
$2,760.00
|
|
|
Service Code
|
CPT 70486 RT,TC
|
| Hospital Charge Code |
1241332
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$772.80 |
| Max. Negotiated Rate |
$11,040.00 |
| Rate for Payer: Aetna Commercial |
$2,484.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,373.60
|
| Rate for Payer: Aetna Managed Medicare |
$772.80
|
| 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 |
$1,462.80
|
| Rate for Payer: Cash Price |
$828.00
|
| Rate for Payer: Cash Price |
$828.00
|
| Rate for Payer: Cash Price |
$828.00
|
| Rate for Payer: Cash Price |
$828.00
|
| Rate for Payer: Cigna Commercial |
$2,539.20
|
| Rate for Payer: Health EOS Commercial |
$2,456.40
|
| Rate for Payer: HFN Commercial |
$2,539.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,070.00
|
| Rate for Payer: Multiplan Commercial |
$2,208.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,656.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,539.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,352.40
|
| Rate for Payer: Quartz Commercial |
$1,794.00
|
| Rate for Payer: Quartz Medicare Advantage |
$1,656.00
|
| Rate for Payer: The Alliance Commercial |
$11,040.00
|
| Rate for Payer: United Healthcare PPO |
$2,065.00
|
| Rate for Payer: WEA Trust Commercial |
$1,518.00
|
| Rate for Payer: WPS Commercial |
$2,044.33
|
|
|
CT TMJ w/o Contrast Right
|
Facility
OP
|
$2,760.00
|
|
|
Service Code
|
CPT 70486 TC,RT
|
| Hospital Charge Code |
2979987
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$772.80 |
| Max. Negotiated Rate |
$11,040.00 |
| Rate for Payer: Aetna Commercial |
$2,484.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,373.60
|
| Rate for Payer: Aetna Managed Medicare |
$772.80
|
| 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 |
$1,462.80
|
| Rate for Payer: Cash Price |
$828.00
|
| Rate for Payer: Cash Price |
$828.00
|
| Rate for Payer: Cash Price |
$828.00
|
| Rate for Payer: Cash Price |
$828.00
|
| Rate for Payer: Cigna Commercial |
$2,539.20
|
| Rate for Payer: Health EOS Commercial |
$2,456.40
|
| Rate for Payer: HFN Commercial |
$2,539.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,070.00
|
| Rate for Payer: Multiplan Commercial |
$2,208.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,656.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,539.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,352.40
|
| Rate for Payer: Quartz Commercial |
$1,794.00
|
| Rate for Payer: Quartz Medicare Advantage |
$1,656.00
|
| Rate for Payer: The Alliance Commercial |
$11,040.00
|
| Rate for Payer: United Healthcare PPO |
$2,065.00
|
| Rate for Payer: WEA Trust Commercial |
$1,518.00
|
| Rate for Payer: WPS Commercial |
$2,044.33
|
|
|
CT TMJ w/o Contrast Right
|
Facility
OP
|
$2,612.00
|
|
|
Service Code
|
CPT 70486
|
| Hospital Charge Code |
711760
|
| Min. Negotiated Rate |
$85.36 |
| Max. Negotiated Rate |
$2,403.04 |
| Rate for Payer: Aetna Commercial |
$2,350.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,246.32
|
| Rate for Payer: Aetna Managed Medicare |
$108.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,697.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,306.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,253.76
|
| Rate for Payer: Anthem Medicare Advantage |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,384.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$108.67
|
| Rate for Payer: Cash Price |
$783.60
|
| Rate for Payer: Cash Price |
$783.60
|
| Rate for Payer: Cigna Commercial |
$2,403.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$108.67
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$108.67
|
| Rate for Payer: Health EOS Commercial |
$2,324.68
|
| Rate for Payer: HFN Commercial |
$2,403.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$404.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$108.67
|
| Rate for Payer: Independent Care Health Plan Medicare |
$108.67
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$108.67
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$108.67
|
| Rate for Payer: Multiplan Commercial |
$2,089.60
|
| Rate for Payer: NAPHCARE Commercial |
$163.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,403.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,279.88
|
| Rate for Payer: Quartz Commercial |
$1,697.80
|
| Rate for Payer: Quartz Medicare Advantage |
$108.67
|
| Rate for Payer: The Alliance Commercial |
$85.36
|
| Rate for Payer: United Healthcare Medicare Advantage |
$108.67
|
| Rate for Payer: WEA Trust Commercial |
$1,436.60
|
| Rate for Payer: Wellcare Medicare |
$108.67
|
| Rate for Payer: WPS Commercial |
$1,934.71
|
|
|
CT TMJ w/o Contrast Right
|
Facility
IP
|
$2,760.00
|
|
|
Service Code
|
CPT 70486 RT,TC
|
| Hospital Charge Code |
1241332
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,352.40 |
| Max. Negotiated Rate |
$2,539.20 |
| Rate for Payer: Aetna Commercial |
$2,484.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,462.80
|
| Rate for Payer: Cash Price |
$828.00
|
| Rate for Payer: Cigna Commercial |
$2,539.20
|
| Rate for Payer: Health EOS Commercial |
$2,456.40
|
| Rate for Payer: HFN Commercial |
$2,539.20
|
| Rate for Payer: Multiplan Commercial |
$2,208.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,656.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,539.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,352.40
|
| Rate for Payer: Quartz Commercial |
$1,656.00
|
| Rate for Payer: WEA Trust Commercial |
$1,518.00
|
| Rate for Payer: WPS Commercial |
$2,044.33
|
|
|
CT TMJ w/o Contrast Right
|
Professional
|
$2,612.00
|
|
|
Service Code
|
CPT 70486
|
| Hospital Charge Code |
711760
|
| Min. Negotiated Rate |
$128.49 |
| Max. Negotiated Rate |
$2,481.40 |
| Rate for Payer: Aetna Commercial |
$2,481.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,246.32
|
| Rate for Payer: Aetna Managed Medicare |
$128.49
|
| Rate for Payer: Anthem Medicare Advantage |
$128.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$128.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$128.49
|
| Rate for Payer: Cash Price |
$783.60
|
| Rate for Payer: Cash Price |
$783.60
|
| Rate for Payer: Cigna Commercial |
$2,481.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,306.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$128.49
|
| Rate for Payer: Health EOS Commercial |
$2,376.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$469.70
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$469.70
|
| Rate for Payer: Independent Care Health Plan Medicare |
$128.49
|
| Rate for Payer: Multiplan Commercial |
$2,089.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,481.40
|
| Rate for Payer: Quartz Beloit One Network |
$1,149.28
|
| Rate for Payer: Quartz Commercial |
$1,488.84
|
| Rate for Payer: Quartz Medicare Advantage |
$128.49
|
| Rate for Payer: The Alliance Commercial |
$488.26
|
| Rate for Payer: United Healthcare Medicare Advantage |
$128.49
|
| Rate for Payer: WEA Trust Commercial |
$1,436.60
|
| Rate for Payer: WPS Commercial |
$642.45
|
|
|
CT TMJ w/o Contrast Right
|
Facility
IP
|
$2,760.00
|
|
|
Service Code
|
CPT 70486 TC,RT
|
| Hospital Charge Code |
2979987
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,352.40 |
| Max. Negotiated Rate |
$2,539.20 |
| Rate for Payer: Aetna Commercial |
$2,484.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,462.80
|
| Rate for Payer: Cash Price |
$828.00
|
| Rate for Payer: Cigna Commercial |
$2,539.20
|
| Rate for Payer: Health EOS Commercial |
$2,456.40
|
| Rate for Payer: HFN Commercial |
$2,539.20
|
| Rate for Payer: Multiplan Commercial |
$2,208.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,656.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,539.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,352.40
|
| Rate for Payer: Quartz Commercial |
$1,656.00
|
| Rate for Payer: WEA Trust Commercial |
$1,518.00
|
| Rate for Payer: WPS Commercial |
$2,044.33
|
|
|
CT TMJ w/o Contrast Right
|
Professional
|
$2,760.00
|
|
|
Service Code
|
CPT 70486 RT,TC
|
| Hospital Charge Code |
1241332
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,214.40 |
| Max. Negotiated Rate |
$2,622.00 |
| Rate for Payer: Aetna Commercial |
$2,622.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,373.60
|
| Rate for Payer: Cash Price |
$828.00
|
| Rate for Payer: Cash Price |
$828.00
|
| Rate for Payer: Cigna Commercial |
$2,622.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,380.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,656.00
|
| Rate for Payer: Health EOS Commercial |
$2,511.60
|
| Rate for Payer: Multiplan Commercial |
$2,208.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,622.00
|
| Rate for Payer: Quartz Beloit One Network |
$1,214.40
|
| Rate for Payer: Quartz Commercial |
$1,573.20
|
| Rate for Payer: The Alliance Commercial |
$1,380.00
|
| Rate for Payer: WEA Trust Commercial |
$1,518.00
|
| Rate for Payer: WPS Commercial |
$2,044.33
|
|
|
CT TMJ w/ + w/o Contrast Bilateral
|
Facility
OP
|
$7,766.00
|
|
|
Service Code
|
CPT 70488
|
| Hospital Charge Code |
711755
|
| Min. Negotiated Rate |
$181.60 |
| Max. Negotiated Rate |
$261,906.32 |
| Rate for Payer: Aetna Commercial |
$6,989.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,678.76
|
| Rate for Payer: Aetna Managed Medicare |
$181.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,047.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,883.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,727.68
|
| Rate for Payer: Anthem Medicare Advantage |
$181.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,115.98
|
| 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 |
$2,329.80
|
| Rate for Payer: Cash Price |
$2,329.80
|
| Rate for Payer: Cigna Commercial |
$7,144.72
|
| 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 |
$6,911.74
|
| Rate for Payer: HFN Commercial |
$7,144.72
|
| 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 |
$6,212.80
|
| Rate for Payer: NAPHCARE Commercial |
$272.40
|
| Rate for Payer: Preferred Network Access Commercial |
$7,144.72
|
| Rate for Payer: Quartz Beloit One Network |
$3,805.34
|
| Rate for Payer: Quartz Commercial |
$5,047.90
|
| Rate for Payer: Quartz Medicare Advantage |
$181.60
|
| Rate for Payer: The Alliance Commercial |
$261,906.32
|
| Rate for Payer: United Healthcare Medicare Advantage |
$181.60
|
| Rate for Payer: WEA Trust Commercial |
$4,271.30
|
| Rate for Payer: Wellcare Medicare |
$181.60
|
| Rate for Payer: WPS Commercial |
$5,752.28
|
|
|
CT TMJ w/ + w/o Contrast Bilateral
|
Facility
OP
|
$3,808.00
|
|
|
Service Code
|
CPT 70488 LT,TC
|
| Hospital Charge Code |
1241308
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,066.24 |
| Max. Negotiated Rate |
$15,232.00 |
| Rate for Payer: Aetna Commercial |
$3,427.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,274.88
|
| Rate for Payer: Aetna Managed Medicare |
$1,066.24
|
| 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 |
$2,018.24
|
| Rate for Payer: Cash Price |
$1,142.40
|
| Rate for Payer: Cash Price |
$1,142.40
|
| Rate for Payer: Cash Price |
$1,142.40
|
| Rate for Payer: Cash Price |
$1,142.40
|
| Rate for Payer: Cigna Commercial |
$3,503.36
|
| Rate for Payer: Health EOS Commercial |
$3,389.12
|
| Rate for Payer: HFN Commercial |
$3,503.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,856.00
|
| Rate for Payer: Multiplan Commercial |
$3,046.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,284.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,503.36
|
| Rate for Payer: Quartz Beloit One Network |
$1,865.92
|
| Rate for Payer: Quartz Commercial |
$2,475.20
|
| Rate for Payer: Quartz Medicare Advantage |
$2,284.80
|
| Rate for Payer: The Alliance Commercial |
$15,232.00
|
| Rate for Payer: United Healthcare PPO |
$2,065.00
|
| Rate for Payer: WEA Trust Commercial |
$2,094.40
|
| Rate for Payer: WPS Commercial |
$2,820.59
|
|
|
CT TMJ w/ + w/o Contrast Bilateral
|
Facility
IP
|
$7,766.00
|
|
|
Service Code
|
CPT 70488
|
| Hospital Charge Code |
711755
|
| Min. Negotiated Rate |
$3,805.34 |
| Max. Negotiated Rate |
$7,144.72 |
| Rate for Payer: Aetna Commercial |
$6,989.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,115.98
|
| Rate for Payer: Cash Price |
$2,329.80
|
| Rate for Payer: Cigna Commercial |
$7,144.72
|
| Rate for Payer: Health EOS Commercial |
$6,911.74
|
| Rate for Payer: HFN Commercial |
$7,144.72
|
| Rate for Payer: Multiplan Commercial |
$6,212.80
|
| Rate for Payer: NAPHCARE Commercial |
$4,659.60
|
| Rate for Payer: Preferred Network Access Commercial |
$7,144.72
|
| Rate for Payer: Quartz Beloit One Network |
$3,805.34
|
| Rate for Payer: Quartz Commercial |
$4,659.60
|
| Rate for Payer: WEA Trust Commercial |
$4,271.30
|
| Rate for Payer: WPS Commercial |
$5,752.28
|
|
