|
CT TMJ w/ Contrast Right
|
Professional
|
Both
|
$3,148.00
|
|
|
Service Code
|
CPT 70487
|
| Hospital Charge Code |
711757
|
| 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 TMJ w/ Contrast Right
|
Facility
|
OP
|
$3,089.00
|
|
|
Service Code
|
CPT 70487 RT,TC
|
| Hospital Charge Code |
1241323
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$864.92 |
| Max. Negotiated Rate |
$12,356.00 |
| Rate for Payer: Aetna Commercial |
$2,780.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,656.54
|
| Rate for Payer: Aetna Managed Medicare |
$864.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,205.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,586.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,454.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,637.17
|
| Rate for Payer: Cash Price |
$926.70
|
| Rate for Payer: Cash Price |
$926.70
|
| Rate for Payer: Cash Price |
$926.70
|
| Rate for Payer: Cigna Commercial |
$2,841.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,728.60
|
| Rate for Payer: Health EOS Commercial |
$2,749.21
|
| Rate for Payer: HFN Commercial |
$2,841.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,316.75
|
| Rate for Payer: Multiplan Commercial |
$2,471.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,853.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,841.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,513.61
|
| Rate for Payer: Quartz Commercial |
$2,007.85
|
| Rate for Payer: Quartz Medicare Advantage |
$1,853.40
|
| Rate for Payer: The Alliance Commercial |
$12,356.00
|
| Rate for Payer: United Healthcare PPO |
$2,065.00
|
| Rate for Payer: WEA Trust Commercial |
$1,698.95
|
| Rate for Payer: WPS Commercial |
$2,288.02
|
|
|
CT TMJ w/ Contrast Right
|
Facility
|
IP
|
$3,148.00
|
|
|
Service Code
|
CPT 70487
|
| Hospital Charge Code |
711757
|
| Min. Negotiated Rate |
$1,542.52 |
| Max. Negotiated Rate |
$2,896.16 |
| Rate for Payer: Aetna Commercial |
$2,833.20
|
| Rate for Payer: 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 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: Cigna Commercial |
$2,841.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,728.60
|
| Rate for Payer: Health EOS Commercial |
$2,749.21
|
| Rate for Payer: HFN Commercial |
$2,841.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,316.75
|
| Rate for Payer: Multiplan Commercial |
$2,471.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,853.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,841.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,513.61
|
| Rate for Payer: Quartz Commercial |
$2,007.85
|
| Rate for Payer: Quartz Medicare Advantage |
$1,853.40
|
| Rate for Payer: The Alliance Commercial |
$12,356.00
|
| Rate for Payer: United Healthcare PPO |
$2,065.00
|
| Rate for Payer: WEA Trust Commercial |
$1,698.95
|
| Rate for Payer: WPS Commercial |
$2,288.02
|
|
|
CT TMJ w/ Contrast Right
|
Facility
|
IP
|
$3,089.00
|
|
|
Service Code
|
CPT 70487 TC,RT
|
| Hospital Charge Code |
2979988
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,513.61 |
| Max. Negotiated Rate |
$2,841.88 |
| Rate for Payer: Aetna Commercial |
$2,780.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,656.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,637.17
|
| Rate for Payer: Cash Price |
$926.70
|
| Rate for Payer: Cigna Commercial |
$2,841.88
|
| Rate for Payer: Health EOS Commercial |
$2,749.21
|
| Rate for Payer: HFN Commercial |
$2,841.88
|
| Rate for Payer: Multiplan Commercial |
$2,471.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,853.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,841.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,513.61
|
| Rate for Payer: Quartz Commercial |
$1,853.40
|
| Rate for Payer: WEA Trust Commercial |
$1,698.95
|
| Rate for Payer: WPS Commercial |
$2,288.02
|
|
|
CT TMJ w/ Contrast Right
|
Professional
|
Both
|
$3,089.00
|
|
|
Service Code
|
CPT 70487 TC,RT
|
| Hospital Charge Code |
2979988
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$1,359.16 |
| Max. Negotiated Rate |
$2,934.55 |
| Rate for Payer: Aetna Commercial |
$2,934.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,656.54
|
| Rate for Payer: Cash Price |
$926.70
|
| Rate for Payer: Cash Price |
$926.70
|
| Rate for Payer: Cigna Commercial |
$2,934.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,544.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,853.40
|
| Rate for Payer: Health EOS Commercial |
$2,810.99
|
| Rate for Payer: HFN Commercial |
$2,934.55
|
| Rate for Payer: Multiplan Commercial |
$2,471.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,934.55
|
| Rate for Payer: Quartz Beloit One Network |
$1,359.16
|
| Rate for Payer: Quartz Commercial |
$1,760.73
|
| Rate for Payer: The Alliance Commercial |
$1,544.50
|
| Rate for Payer: WEA Trust Commercial |
$1,698.95
|
| Rate for Payer: WPS Commercial |
$2,288.02
|
|
|
CT TMJ w/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: Aetna Gatekeeper/Not Gatekeeper |
$4,493.50
|
| 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 Bilateral
|
Professional
|
Both
|
$5,225.00
|
|
|
Service Code
|
CPT 70486
|
| Hospital Charge Code |
711758
|
| Min. Negotiated Rate |
$469.70 |
| 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: 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 |
$3,135.00
|
| Rate for Payer: Health EOS Commercial |
$4,754.75
|
| Rate for Payer: HFN Commercial |
$4,963.75
|
| 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: 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: The Alliance Commercial |
$2,612.50
|
| Rate for Payer: WEA Trust Commercial |
$2,873.75
|
| Rate for Payer: WPS Commercial |
$3,870.16
|
|
|
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: Aetna Gatekeeper/Not Gatekeeper |
$2,373.60
|
| 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
|
Professional
|
Both
|
$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: HFN Commercial |
$2,622.00
|
| 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
|
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: Cigna Commercial |
$2,539.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,544.50
|
| 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
|
Facility
|
OP
|
$5,225.00
|
|
|
Service Code
|
CPT 70486
|
| Hospital Charge Code |
711758
|
| Min. Negotiated Rate |
$108.67 |
| 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 DHI/DHP/ASO |
$2,923.91
|
| 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 |
$434.68
|
| 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 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: 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 TMJ w/o Contrast Left
|
Facility
|
OP
|
$2,612.00
|
|
|
Service Code
|
CPT 70486
|
| Hospital Charge Code |
711759
|
| 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 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: Cigna Commercial |
$2,539.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,544.50
|
| 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
|
Professional
|
Both
|
$2,612.00
|
|
|
Service Code
|
CPT 70486
|
| Hospital Charge Code |
711759
|
| 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 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: Aetna Gatekeeper/Not Gatekeeper |
$2,373.60
|
| 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
|
Professional
|
Both
|
$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: HFN Commercial |
$2,622.00
|
| 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
|
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: Aetna Gatekeeper/Not Gatekeeper |
$2,373.60
|
| 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
|
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: Aetna Gatekeeper/Not Gatekeeper |
$2,373.60
|
| 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
|
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: Cigna Commercial |
$2,539.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,544.50
|
| 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 |
$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 TMJ w/o Contrast Right
|
Professional
|
Both
|
$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: HFN Commercial |
$2,622.00
|
| 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
|
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: 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 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: Cigna Commercial |
$2,539.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,544.50
|
| 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
|
|
