|
MA Mammogram Digital Screening Left
|
Facility
|
IP
|
$495.00
|
|
|
Service Code
|
CPT 77067 LT,TC
|
| Hospital Charge Code |
1360819
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$252.25 |
| Max. Negotiated Rate |
$473.62 |
| Rate for Payer: Aetna Commercial |
$463.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$442.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$272.84
|
| Rate for Payer: Cash Price |
$148.50
|
| Rate for Payer: Cigna Commercial |
$473.62
|
| Rate for Payer: Health EOS Commercial |
$458.17
|
| Rate for Payer: HFN Commercial |
$473.62
|
| Rate for Payer: Multiplan Commercial |
$411.84
|
| Rate for Payer: Preferred Network Access Commercial |
$473.62
|
| Rate for Payer: Quartz Beloit One Network |
$252.25
|
| Rate for Payer: Quartz Commercial |
$308.88
|
| Rate for Payer: WEA Trust Commercial |
$283.14
|
| Rate for Payer: WPS Commercial |
$381.30
|
|
|
MA Mammogram Digital Screening Left
|
Facility
|
OP
|
$495.00
|
|
|
Service Code
|
CPT 77067 LT,TC
|
| Hospital Charge Code |
1360819
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$144.14 |
| Max. Negotiated Rate |
$473.62 |
| Rate for Payer: Aetna Commercial |
$463.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$442.73
|
| Rate for Payer: Aetna Managed Medicare |
$144.14
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$362.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$269.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$255.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$272.84
|
| Rate for Payer: Cash Price |
$148.50
|
| Rate for Payer: Cash Price |
$148.50
|
| Rate for Payer: Cigna Commercial |
$473.62
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$288.09
|
| Rate for Payer: Health EOS Commercial |
$458.17
|
| Rate for Payer: HFN Commercial |
$473.62
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$386.10
|
| Rate for Payer: Multiplan Commercial |
$411.84
|
| Rate for Payer: NAPHCARE Commercial |
$308.88
|
| Rate for Payer: Preferred Network Access Commercial |
$473.62
|
| Rate for Payer: Quartz Beloit One Network |
$252.25
|
| Rate for Payer: Quartz Commercial |
$334.62
|
| Rate for Payer: Quartz Medicare Advantage |
$308.88
|
| Rate for Payer: The Alliance Commercial |
$257.40
|
| Rate for Payer: United Healthcare PPO |
$386.10
|
| Rate for Payer: WEA Trust Commercial |
$283.14
|
| Rate for Payer: WPS Commercial |
$381.30
|
|
|
MA Mammogram Digital Screening Left
|
Professional
|
Both
|
$495.00
|
|
|
Service Code
|
CPT 77067 LT,TC
|
| Hospital Charge Code |
1360819
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$226.51 |
| Max. Negotiated Rate |
$489.06 |
| Rate for Payer: Aetna Commercial |
$489.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$442.73
|
| Rate for Payer: Cash Price |
$148.50
|
| Rate for Payer: Cash Price |
$148.50
|
| Rate for Payer: Cash Price |
$148.50
|
| Rate for Payer: Cigna Commercial |
$489.06
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$257.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$308.88
|
| Rate for Payer: Health EOS Commercial |
$468.47
|
| Rate for Payer: HFN Commercial |
$489.06
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$466.10
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$466.10
|
| Rate for Payer: Multiplan Commercial |
$411.84
|
| Rate for Payer: Preferred Network Access Commercial |
$489.06
|
| Rate for Payer: Quartz Beloit One Network |
$226.51
|
| Rate for Payer: Quartz Commercial |
$293.44
|
| Rate for Payer: The Alliance Commercial |
$257.40
|
| Rate for Payer: WEA Trust Commercial |
$283.14
|
| Rate for Payer: WPS Commercial |
$381.30
|
|
|
MA Mammogram Digital Screening LT w/ CAD
|
Facility
|
IP
|
$405.00
|
|
|
Service Code
|
CPT 77067 TC,LT
|
| Hospital Charge Code |
5144752
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$206.39 |
| Max. Negotiated Rate |
$387.50 |
| Rate for Payer: Aetna Commercial |
$379.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$362.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$223.24
|
| Rate for Payer: Cash Price |
$121.50
|
| Rate for Payer: Cigna Commercial |
$387.50
|
| Rate for Payer: Health EOS Commercial |
$374.87
|
| Rate for Payer: HFN Commercial |
$387.50
|
| Rate for Payer: Multiplan Commercial |
$336.96
|
| Rate for Payer: Preferred Network Access Commercial |
$387.50
|
| Rate for Payer: Quartz Beloit One Network |
$206.39
|
| Rate for Payer: Quartz Commercial |
$252.72
|
| Rate for Payer: WEA Trust Commercial |
$231.66
|
| Rate for Payer: WPS Commercial |
$311.97
|
|
|
MA Mammogram Digital Screening LT w/ CAD
|
Facility
|
OP
|
$405.00
|
|
|
Service Code
|
CPT 77067 TC,LT
|
| Hospital Charge Code |
5144752
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$117.94 |
| Max. Negotiated Rate |
$387.50 |
| Rate for Payer: Aetna Commercial |
$379.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$362.23
|
| Rate for Payer: Aetna Managed Medicare |
$117.94
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$362.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$269.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$255.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$223.24
|
| Rate for Payer: Cash Price |
$121.50
|
| Rate for Payer: Cash Price |
$121.50
|
| Rate for Payer: Cigna Commercial |
$387.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$235.71
|
| Rate for Payer: Health EOS Commercial |
$374.87
|
| Rate for Payer: HFN Commercial |
$387.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$315.90
|
| Rate for Payer: Multiplan Commercial |
$336.96
|
| Rate for Payer: NAPHCARE Commercial |
$252.72
|
| Rate for Payer: Preferred Network Access Commercial |
$387.50
|
| Rate for Payer: Quartz Beloit One Network |
$206.39
|
| Rate for Payer: Quartz Commercial |
$273.78
|
| Rate for Payer: Quartz Medicare Advantage |
$252.72
|
| Rate for Payer: The Alliance Commercial |
$210.60
|
| Rate for Payer: United Healthcare PPO |
$315.90
|
| Rate for Payer: WEA Trust Commercial |
$231.66
|
| Rate for Payer: WPS Commercial |
$311.97
|
|
|
MA Mammogram Digital Screening LT w/ CAD
|
Professional
|
Both
|
$405.00
|
|
|
Service Code
|
CPT 77067 TC,LT
|
| Hospital Charge Code |
5144752
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$185.33 |
| Max. Negotiated Rate |
$466.10 |
| Rate for Payer: Aetna Commercial |
$400.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$362.23
|
| Rate for Payer: Cash Price |
$121.50
|
| Rate for Payer: Cash Price |
$121.50
|
| Rate for Payer: Cash Price |
$121.50
|
| Rate for Payer: Cigna Commercial |
$400.14
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$210.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$252.72
|
| Rate for Payer: Health EOS Commercial |
$383.29
|
| Rate for Payer: HFN Commercial |
$400.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$466.10
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$466.10
|
| Rate for Payer: Multiplan Commercial |
$336.96
|
| Rate for Payer: Preferred Network Access Commercial |
$400.14
|
| Rate for Payer: Quartz Beloit One Network |
$185.33
|
| Rate for Payer: Quartz Commercial |
$240.08
|
| Rate for Payer: The Alliance Commercial |
$210.60
|
| Rate for Payer: WEA Trust Commercial |
$231.66
|
| Rate for Payer: WPS Commercial |
$311.97
|
|
|
MA Mammogram Digital Screening Right
|
Facility
|
OP
|
$495.00
|
|
|
Service Code
|
CPT 77067 RT,TC
|
| Hospital Charge Code |
1360822
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$144.14 |
| Max. Negotiated Rate |
$473.62 |
| Rate for Payer: Aetna Commercial |
$463.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$442.73
|
| Rate for Payer: Aetna Managed Medicare |
$144.14
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$362.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$269.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$255.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$272.84
|
| Rate for Payer: Cash Price |
$148.50
|
| Rate for Payer: Cash Price |
$148.50
|
| Rate for Payer: Cigna Commercial |
$473.62
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$288.09
|
| Rate for Payer: Health EOS Commercial |
$458.17
|
| Rate for Payer: HFN Commercial |
$473.62
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$386.10
|
| Rate for Payer: Multiplan Commercial |
$411.84
|
| Rate for Payer: NAPHCARE Commercial |
$308.88
|
| Rate for Payer: Preferred Network Access Commercial |
$473.62
|
| Rate for Payer: Quartz Beloit One Network |
$252.25
|
| Rate for Payer: Quartz Commercial |
$334.62
|
| Rate for Payer: Quartz Medicare Advantage |
$308.88
|
| Rate for Payer: The Alliance Commercial |
$257.40
|
| Rate for Payer: United Healthcare PPO |
$386.10
|
| Rate for Payer: WEA Trust Commercial |
$283.14
|
| Rate for Payer: WPS Commercial |
$381.30
|
|
|
MA Mammogram Digital Screening Right
|
Facility
|
IP
|
$495.00
|
|
|
Service Code
|
CPT 77067 RT,TC
|
| Hospital Charge Code |
1360822
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$252.25 |
| Max. Negotiated Rate |
$473.62 |
| Rate for Payer: Aetna Commercial |
$463.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$442.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$272.84
|
| Rate for Payer: Cash Price |
$148.50
|
| Rate for Payer: Cigna Commercial |
$473.62
|
| Rate for Payer: Health EOS Commercial |
$458.17
|
| Rate for Payer: HFN Commercial |
$473.62
|
| Rate for Payer: Multiplan Commercial |
$411.84
|
| Rate for Payer: Preferred Network Access Commercial |
$473.62
|
| Rate for Payer: Quartz Beloit One Network |
$252.25
|
| Rate for Payer: Quartz Commercial |
$308.88
|
| Rate for Payer: WEA Trust Commercial |
$283.14
|
| Rate for Payer: WPS Commercial |
$381.30
|
|
|
MA Mammogram Digital Screening Right
|
Professional
|
Both
|
$495.00
|
|
|
Service Code
|
CPT 77067 RT,TC
|
| Hospital Charge Code |
1360822
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$226.51 |
| Max. Negotiated Rate |
$489.06 |
| Rate for Payer: Aetna Commercial |
$489.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$442.73
|
| Rate for Payer: Cash Price |
$148.50
|
| Rate for Payer: Cash Price |
$148.50
|
| Rate for Payer: Cash Price |
$148.50
|
| Rate for Payer: Cigna Commercial |
$489.06
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$257.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$308.88
|
| Rate for Payer: Health EOS Commercial |
$468.47
|
| Rate for Payer: HFN Commercial |
$489.06
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$466.10
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$466.10
|
| Rate for Payer: Multiplan Commercial |
$411.84
|
| Rate for Payer: Preferred Network Access Commercial |
$489.06
|
| Rate for Payer: Quartz Beloit One Network |
$226.51
|
| Rate for Payer: Quartz Commercial |
$293.44
|
| Rate for Payer: The Alliance Commercial |
$257.40
|
| Rate for Payer: WEA Trust Commercial |
$283.14
|
| Rate for Payer: WPS Commercial |
$381.30
|
|
|
MA Mammogram Digital Screening RT w/ CAD
|
Facility
|
OP
|
$405.00
|
|
|
Service Code
|
CPT 77067 TC,RT
|
| Hospital Charge Code |
5144755
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$117.94 |
| Max. Negotiated Rate |
$387.50 |
| Rate for Payer: Aetna Commercial |
$379.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$362.23
|
| Rate for Payer: Aetna Managed Medicare |
$117.94
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$362.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$269.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$255.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$223.24
|
| Rate for Payer: Cash Price |
$121.50
|
| Rate for Payer: Cash Price |
$121.50
|
| Rate for Payer: Cigna Commercial |
$387.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$235.71
|
| Rate for Payer: Health EOS Commercial |
$374.87
|
| Rate for Payer: HFN Commercial |
$387.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$315.90
|
| Rate for Payer: Multiplan Commercial |
$336.96
|
| Rate for Payer: NAPHCARE Commercial |
$252.72
|
| Rate for Payer: Preferred Network Access Commercial |
$387.50
|
| Rate for Payer: Quartz Beloit One Network |
$206.39
|
| Rate for Payer: Quartz Commercial |
$273.78
|
| Rate for Payer: Quartz Medicare Advantage |
$252.72
|
| Rate for Payer: The Alliance Commercial |
$210.60
|
| Rate for Payer: United Healthcare PPO |
$315.90
|
| Rate for Payer: WEA Trust Commercial |
$231.66
|
| Rate for Payer: WPS Commercial |
$311.97
|
|
|
MA Mammogram Digital Screening RT w/ CAD
|
Facility
|
IP
|
$405.00
|
|
|
Service Code
|
CPT 77067 TC,RT
|
| Hospital Charge Code |
5144755
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$206.39 |
| Max. Negotiated Rate |
$387.50 |
| Rate for Payer: Aetna Commercial |
$379.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$362.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$223.24
|
| Rate for Payer: Cash Price |
$121.50
|
| Rate for Payer: Cigna Commercial |
$387.50
|
| Rate for Payer: Health EOS Commercial |
$374.87
|
| Rate for Payer: HFN Commercial |
$387.50
|
| Rate for Payer: Multiplan Commercial |
$336.96
|
| Rate for Payer: Preferred Network Access Commercial |
$387.50
|
| Rate for Payer: Quartz Beloit One Network |
$206.39
|
| Rate for Payer: Quartz Commercial |
$252.72
|
| Rate for Payer: WEA Trust Commercial |
$231.66
|
| Rate for Payer: WPS Commercial |
$311.97
|
|
|
MA Mammogram Digital Screening RT w/ CAD
|
Professional
|
Both
|
$405.00
|
|
|
Service Code
|
CPT 77067 TC,RT
|
| Hospital Charge Code |
5144755
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$185.33 |
| Max. Negotiated Rate |
$466.10 |
| Rate for Payer: Aetna Commercial |
$400.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$362.23
|
| Rate for Payer: Cash Price |
$121.50
|
| Rate for Payer: Cash Price |
$121.50
|
| Rate for Payer: Cash Price |
$121.50
|
| Rate for Payer: Cigna Commercial |
$400.14
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$210.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$252.72
|
| Rate for Payer: Health EOS Commercial |
$383.29
|
| Rate for Payer: HFN Commercial |
$400.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$466.10
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$466.10
|
| Rate for Payer: Multiplan Commercial |
$336.96
|
| Rate for Payer: Preferred Network Access Commercial |
$400.14
|
| Rate for Payer: Quartz Beloit One Network |
$185.33
|
| Rate for Payer: Quartz Commercial |
$240.08
|
| Rate for Payer: The Alliance Commercial |
$210.60
|
| Rate for Payer: WEA Trust Commercial |
$231.66
|
| Rate for Payer: WPS Commercial |
$311.97
|
|
|
Ma Mammogram Digital Screening w/ CAD
|
Facility
|
OP
|
$394.00
|
|
|
Service Code
|
CPT 77067 TC
|
| Hospital Charge Code |
5144758
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$114.73 |
| Max. Negotiated Rate |
$376.98 |
| Rate for Payer: Aetna Commercial |
$368.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$352.39
|
| Rate for Payer: Aetna Managed Medicare |
$114.73
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$362.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$269.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$255.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$217.17
|
| Rate for Payer: Cash Price |
$118.20
|
| Rate for Payer: Cash Price |
$118.20
|
| Rate for Payer: Cash Price |
$118.20
|
| Rate for Payer: Cigna Commercial |
$376.98
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$229.31
|
| Rate for Payer: Health EOS Commercial |
$364.69
|
| Rate for Payer: HFN Commercial |
$376.98
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$307.32
|
| Rate for Payer: Multiplan Commercial |
$327.81
|
| Rate for Payer: NAPHCARE Commercial |
$245.86
|
| Rate for Payer: Preferred Network Access Commercial |
$376.98
|
| Rate for Payer: Quartz Beloit One Network |
$200.78
|
| Rate for Payer: Quartz Commercial |
$266.34
|
| Rate for Payer: Quartz Medicare Advantage |
$245.86
|
| Rate for Payer: The Alliance Commercial |
$362.50
|
| Rate for Payer: United Healthcare PPO |
$307.32
|
| Rate for Payer: WEA Trust Commercial |
$225.37
|
| Rate for Payer: WPS Commercial |
$303.50
|
|
|
Ma Mammogram Digital Screening w/ CAD
|
Facility
|
IP
|
$394.00
|
|
|
Service Code
|
CPT 77067 TC
|
| Hospital Charge Code |
5144758
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$200.78 |
| Max. Negotiated Rate |
$376.98 |
| Rate for Payer: Aetna Commercial |
$368.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$352.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$217.17
|
| Rate for Payer: Cash Price |
$118.20
|
| Rate for Payer: Cigna Commercial |
$376.98
|
| Rate for Payer: Health EOS Commercial |
$364.69
|
| Rate for Payer: HFN Commercial |
$376.98
|
| Rate for Payer: Multiplan Commercial |
$327.81
|
| Rate for Payer: Preferred Network Access Commercial |
$376.98
|
| Rate for Payer: Quartz Beloit One Network |
$200.78
|
| Rate for Payer: Quartz Commercial |
$245.86
|
| Rate for Payer: WEA Trust Commercial |
$225.37
|
| Rate for Payer: WPS Commercial |
$303.50
|
|
|
Ma Mammogram Digital Screening w/ CAD
|
Professional
|
Both
|
$394.00
|
|
|
Service Code
|
CPT 77067 TC
|
| Hospital Charge Code |
5144758
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$90.63 |
| Max. Negotiated Rate |
$453.13 |
| Rate for Payer: Aetna Commercial |
$389.27
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$352.39
|
| Rate for Payer: Aetna Managed Medicare |
$90.63
|
| Rate for Payer: Anthem Medicare Advantage |
$90.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$90.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$90.63
|
| Rate for Payer: Cash Price |
$118.20
|
| Rate for Payer: Cash Price |
$118.20
|
| Rate for Payer: Cash Price |
$118.20
|
| Rate for Payer: Cigna Commercial |
$389.27
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$204.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$90.63
|
| Rate for Payer: Health EOS Commercial |
$372.88
|
| Rate for Payer: HFN Commercial |
$389.27
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$333.41
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$333.41
|
| Rate for Payer: Independent Care Health Plan Medicare |
$90.63
|
| Rate for Payer: Multiplan Commercial |
$327.81
|
| Rate for Payer: NAPHCARE Commercial |
$135.94
|
| Rate for Payer: Preferred Network Access Commercial |
$389.27
|
| Rate for Payer: Quartz Beloit One Network |
$180.29
|
| Rate for Payer: Quartz Commercial |
$233.56
|
| Rate for Payer: Quartz Medicare Advantage |
$90.63
|
| Rate for Payer: The Alliance Commercial |
$344.38
|
| Rate for Payer: United Healthcare Medicare Advantage |
$90.63
|
| Rate for Payer: WEA Trust Commercial |
$225.37
|
| Rate for Payer: WPS Commercial |
$453.13
|
|
|
MA Mammogram Digital WWHSP Diag Bilat
|
Facility
|
IP
|
$445.00
|
|
|
Service Code
|
CPT 77066
|
| Hospital Charge Code |
1360825
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$226.77 |
| Max. Negotiated Rate |
$425.78 |
| Rate for Payer: Aetna Commercial |
$416.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$398.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$245.28
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cigna Commercial |
$425.78
|
| Rate for Payer: Health EOS Commercial |
$411.89
|
| Rate for Payer: HFN Commercial |
$425.78
|
| Rate for Payer: Multiplan Commercial |
$370.24
|
| Rate for Payer: Preferred Network Access Commercial |
$425.78
|
| Rate for Payer: Quartz Beloit One Network |
$226.77
|
| Rate for Payer: Quartz Commercial |
$277.68
|
| Rate for Payer: WEA Trust Commercial |
$254.54
|
| Rate for Payer: WPS Commercial |
$342.78
|
|
|
MA Mammogram Digital WWHSP Diag Bilat
|
Facility
|
OP
|
$445.00
|
|
|
Service Code
|
CPT 77066
|
| Hospital Charge Code |
1360825
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$129.58 |
| Max. Negotiated Rate |
$624.12 |
| Rate for Payer: Aetna Commercial |
$416.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$398.01
|
| Rate for Payer: Aetna Managed Medicare |
$129.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$362.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$269.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$255.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$245.28
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cigna Commercial |
$425.78
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$258.99
|
| Rate for Payer: Health EOS Commercial |
$411.89
|
| Rate for Payer: HFN Commercial |
$425.78
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$347.10
|
| Rate for Payer: Multiplan Commercial |
$370.24
|
| Rate for Payer: NAPHCARE Commercial |
$277.68
|
| Rate for Payer: Preferred Network Access Commercial |
$425.78
|
| Rate for Payer: Quartz Beloit One Network |
$226.77
|
| Rate for Payer: Quartz Commercial |
$300.82
|
| Rate for Payer: Quartz Medicare Advantage |
$277.68
|
| Rate for Payer: The Alliance Commercial |
$624.12
|
| Rate for Payer: United Healthcare PPO |
$347.10
|
| Rate for Payer: WEA Trust Commercial |
$254.54
|
| Rate for Payer: WPS Commercial |
$342.78
|
|
|
MA Mammogram Digital WWHSP Diag Bilat
|
Professional
|
Both
|
$701.00
|
|
| Hospital Charge Code |
1360804
|
| Min. Negotiated Rate |
$320.78 |
| Max. Negotiated Rate |
$692.59 |
| Rate for Payer: Aetna Commercial |
$692.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$626.97
|
| Rate for Payer: Cash Price |
$210.30
|
| Rate for Payer: Cigna Commercial |
$692.59
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$364.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$437.42
|
| Rate for Payer: Health EOS Commercial |
$663.43
|
| Rate for Payer: HFN Commercial |
$692.59
|
| Rate for Payer: Multiplan Commercial |
$583.23
|
| Rate for Payer: Preferred Network Access Commercial |
$692.59
|
| Rate for Payer: Quartz Beloit One Network |
$320.78
|
| Rate for Payer: Quartz Commercial |
$415.55
|
| Rate for Payer: The Alliance Commercial |
$364.52
|
| Rate for Payer: WEA Trust Commercial |
$400.97
|
| Rate for Payer: WPS Commercial |
$539.98
|
|
|
MA Mammogram Digital WWHSP Diag Bilat
|
Professional
|
Both
|
$445.00
|
|
|
Service Code
|
CPT 77066
|
| Hospital Charge Code |
1360825
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$156.03 |
| Max. Negotiated Rate |
$780.16 |
| Rate for Payer: Aetna Commercial |
$439.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$398.01
|
| Rate for Payer: Aetna Managed Medicare |
$156.03
|
| Rate for Payer: Anthem Medicare Advantage |
$156.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$156.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$156.03
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cigna Commercial |
$439.66
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$231.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$156.03
|
| Rate for Payer: Health EOS Commercial |
$421.15
|
| Rate for Payer: HFN Commercial |
$439.66
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$576.86
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$576.86
|
| Rate for Payer: Independent Care Health Plan Medicare |
$156.03
|
| Rate for Payer: Multiplan Commercial |
$370.24
|
| Rate for Payer: NAPHCARE Commercial |
$234.05
|
| Rate for Payer: Preferred Network Access Commercial |
$439.66
|
| Rate for Payer: Quartz Beloit One Network |
$203.63
|
| Rate for Payer: Quartz Commercial |
$263.80
|
| Rate for Payer: Quartz Medicare Advantage |
$156.03
|
| Rate for Payer: The Alliance Commercial |
$592.92
|
| Rate for Payer: United Healthcare Medicare Advantage |
$156.03
|
| Rate for Payer: WEA Trust Commercial |
$254.54
|
| Rate for Payer: WPS Commercial |
$780.16
|
|
|
MA Mammogram Digital WWHSP Diag Bilat
|
Facility
|
OP
|
$701.00
|
|
| Hospital Charge Code |
1360804
|
| Min. Negotiated Rate |
$204.13 |
| Max. Negotiated Rate |
$670.72 |
| Rate for Payer: Aetna Commercial |
$656.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$626.97
|
| Rate for Payer: Aetna Managed Medicare |
$204.13
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$473.88
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$364.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$349.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$386.39
|
| Rate for Payer: Cash Price |
$210.30
|
| Rate for Payer: Cigna Commercial |
$670.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$407.98
|
| Rate for Payer: Health EOS Commercial |
$648.85
|
| Rate for Payer: HFN Commercial |
$670.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$546.78
|
| Rate for Payer: Multiplan Commercial |
$583.23
|
| Rate for Payer: NAPHCARE Commercial |
$437.42
|
| Rate for Payer: Preferred Network Access Commercial |
$670.72
|
| Rate for Payer: Quartz Beloit One Network |
$357.23
|
| Rate for Payer: Quartz Commercial |
$473.88
|
| Rate for Payer: Quartz Medicare Advantage |
$437.42
|
| Rate for Payer: The Alliance Commercial |
$364.52
|
| Rate for Payer: WEA Trust Commercial |
$400.97
|
| Rate for Payer: WPS Commercial |
$539.98
|
|
|
MA Mammogram Digital WWHSP Diag Bilat
|
Facility
|
IP
|
$701.00
|
|
| Hospital Charge Code |
1360804
|
| Min. Negotiated Rate |
$357.23 |
| Max. Negotiated Rate |
$670.72 |
| Rate for Payer: Aetna Commercial |
$656.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$626.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$386.39
|
| Rate for Payer: Cash Price |
$210.30
|
| Rate for Payer: Cigna Commercial |
$670.72
|
| Rate for Payer: Health EOS Commercial |
$648.85
|
| Rate for Payer: HFN Commercial |
$670.72
|
| Rate for Payer: Multiplan Commercial |
$583.23
|
| Rate for Payer: Preferred Network Access Commercial |
$670.72
|
| Rate for Payer: Quartz Beloit One Network |
$357.23
|
| Rate for Payer: Quartz Commercial |
$437.42
|
| Rate for Payer: WEA Trust Commercial |
$400.97
|
| Rate for Payer: WPS Commercial |
$539.98
|
|
|
MA Mammogram Digital WWHSP Diag LT
|
Facility
|
OP
|
$301.00
|
|
| Hospital Charge Code |
1360803
|
| Min. Negotiated Rate |
$87.65 |
| Max. Negotiated Rate |
$288.00 |
| Rate for Payer: Aetna Commercial |
$281.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$269.21
|
| Rate for Payer: Aetna Managed Medicare |
$87.65
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$203.48
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$156.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$150.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$165.91
|
| Rate for Payer: Cash Price |
$90.30
|
| Rate for Payer: Cigna Commercial |
$288.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$175.18
|
| Rate for Payer: Health EOS Commercial |
$278.61
|
| Rate for Payer: HFN Commercial |
$288.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$234.78
|
| Rate for Payer: Multiplan Commercial |
$250.43
|
| Rate for Payer: NAPHCARE Commercial |
$187.82
|
| Rate for Payer: Preferred Network Access Commercial |
$288.00
|
| Rate for Payer: Quartz Beloit One Network |
$153.39
|
| Rate for Payer: Quartz Commercial |
$203.48
|
| Rate for Payer: Quartz Medicare Advantage |
$187.82
|
| Rate for Payer: The Alliance Commercial |
$156.52
|
| Rate for Payer: WEA Trust Commercial |
$172.17
|
| Rate for Payer: WPS Commercial |
$231.86
|
|
|
MA Mammogram Digital WWHSP Diag LT
|
Professional
|
Both
|
$301.00
|
|
| Hospital Charge Code |
1360803
|
| Min. Negotiated Rate |
$137.74 |
| Max. Negotiated Rate |
$297.39 |
| Rate for Payer: Aetna Commercial |
$297.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$269.21
|
| Rate for Payer: Cash Price |
$90.30
|
| Rate for Payer: Cigna Commercial |
$297.39
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$156.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$187.82
|
| Rate for Payer: Health EOS Commercial |
$284.87
|
| Rate for Payer: HFN Commercial |
$297.39
|
| Rate for Payer: Multiplan Commercial |
$250.43
|
| Rate for Payer: Preferred Network Access Commercial |
$297.39
|
| Rate for Payer: Quartz Beloit One Network |
$137.74
|
| Rate for Payer: Quartz Commercial |
$178.43
|
| Rate for Payer: The Alliance Commercial |
$156.52
|
| Rate for Payer: WEA Trust Commercial |
$172.17
|
| Rate for Payer: WPS Commercial |
$231.86
|
|
|
MA Mammogram Digital WWHSP Diag LT
|
Facility
|
IP
|
$301.00
|
|
| Hospital Charge Code |
1360803
|
| Min. Negotiated Rate |
$153.39 |
| Max. Negotiated Rate |
$288.00 |
| Rate for Payer: Aetna Commercial |
$281.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$269.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$165.91
|
| Rate for Payer: Cash Price |
$90.30
|
| Rate for Payer: Cigna Commercial |
$288.00
|
| Rate for Payer: Health EOS Commercial |
$278.61
|
| Rate for Payer: HFN Commercial |
$288.00
|
| Rate for Payer: Multiplan Commercial |
$250.43
|
| Rate for Payer: Preferred Network Access Commercial |
$288.00
|
| Rate for Payer: Quartz Beloit One Network |
$153.39
|
| Rate for Payer: Quartz Commercial |
$187.82
|
| Rate for Payer: WEA Trust Commercial |
$172.17
|
| Rate for Payer: WPS Commercial |
$231.86
|
|
|
MA Mammogram Digital WWHSP Diag LT
|
Professional
|
Both
|
$393.00
|
|
|
Service Code
|
CPT 77065 LT
|
| Hospital Charge Code |
1360828
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$179.84 |
| Max. Negotiated Rate |
$455.59 |
| Rate for Payer: Aetna Commercial |
$388.28
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$351.50
|
| Rate for Payer: Cash Price |
$117.90
|
| Rate for Payer: Cash Price |
$117.90
|
| Rate for Payer: Cash Price |
$117.90
|
| Rate for Payer: Cigna Commercial |
$388.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$204.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$245.23
|
| Rate for Payer: Health EOS Commercial |
$371.94
|
| Rate for Payer: HFN Commercial |
$388.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$455.59
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$455.59
|
| Rate for Payer: Multiplan Commercial |
$326.98
|
| Rate for Payer: Preferred Network Access Commercial |
$388.28
|
| Rate for Payer: Quartz Beloit One Network |
$179.84
|
| Rate for Payer: Quartz Commercial |
$232.97
|
| Rate for Payer: The Alliance Commercial |
$204.36
|
| Rate for Payer: WEA Trust Commercial |
$224.80
|
| Rate for Payer: WPS Commercial |
$302.73
|
|
