|
MA Mammogram 3D Screening Bilateral
|
Facility
|
IP
|
$83.00
|
|
|
Service Code
|
CPT 77063 TC
|
| Hospital Charge Code |
5472797
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$42.30 |
| Max. Negotiated Rate |
$79.41 |
| Rate for Payer: Aetna Commercial |
$77.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$74.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$45.75
|
| Rate for Payer: Cash Price |
$24.90
|
| Rate for Payer: Cigna Commercial |
$79.41
|
| Rate for Payer: Health EOS Commercial |
$76.82
|
| Rate for Payer: HFN Commercial |
$79.41
|
| Rate for Payer: Multiplan Commercial |
$69.06
|
| Rate for Payer: Preferred Network Access Commercial |
$79.41
|
| Rate for Payer: Quartz Beloit One Network |
$42.30
|
| Rate for Payer: Quartz Commercial |
$51.79
|
| Rate for Payer: WEA Trust Commercial |
$47.48
|
| Rate for Payer: WPS Commercial |
$63.93
|
|
|
MA Mammogram 3D Screening Left
|
Facility
|
OP
|
$83.00
|
|
|
Service Code
|
CPT 77063 TC,LT
|
| Hospital Charge Code |
5472800
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$24.17 |
| Max. Negotiated Rate |
$79.41 |
| Rate for Payer: Aetna Commercial |
$77.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$74.24
|
| Rate for Payer: Aetna Managed Medicare |
$24.17
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$56.11
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$43.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$41.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$45.75
|
| Rate for Payer: Cash Price |
$24.90
|
| Rate for Payer: Cigna Commercial |
$79.41
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$48.31
|
| Rate for Payer: Health EOS Commercial |
$76.82
|
| Rate for Payer: HFN Commercial |
$79.41
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$64.74
|
| Rate for Payer: Multiplan Commercial |
$69.06
|
| Rate for Payer: NAPHCARE Commercial |
$51.79
|
| Rate for Payer: Preferred Network Access Commercial |
$79.41
|
| Rate for Payer: Quartz Beloit One Network |
$42.30
|
| Rate for Payer: Quartz Commercial |
$56.11
|
| Rate for Payer: Quartz Medicare Advantage |
$51.79
|
| Rate for Payer: The Alliance Commercial |
$43.16
|
| Rate for Payer: United Healthcare PPO |
$64.74
|
| Rate for Payer: WEA Trust Commercial |
$47.48
|
| Rate for Payer: WPS Commercial |
$63.93
|
|
|
MA Mammogram 3D Screening Left
|
Facility
|
IP
|
$83.00
|
|
|
Service Code
|
CPT 77063 TC,LT
|
| Hospital Charge Code |
5472800
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$42.30 |
| Max. Negotiated Rate |
$79.41 |
| Rate for Payer: Aetna Commercial |
$77.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$74.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$45.75
|
| Rate for Payer: Cash Price |
$24.90
|
| Rate for Payer: Cigna Commercial |
$79.41
|
| Rate for Payer: Health EOS Commercial |
$76.82
|
| Rate for Payer: HFN Commercial |
$79.41
|
| Rate for Payer: Multiplan Commercial |
$69.06
|
| Rate for Payer: Preferred Network Access Commercial |
$79.41
|
| Rate for Payer: Quartz Beloit One Network |
$42.30
|
| Rate for Payer: Quartz Commercial |
$51.79
|
| Rate for Payer: WEA Trust Commercial |
$47.48
|
| Rate for Payer: WPS Commercial |
$63.93
|
|
|
MA Mammogram 3D Screening Left
|
Professional
|
Both
|
$83.00
|
|
|
Service Code
|
CPT 77063 TC,LT
|
| Hospital Charge Code |
5472800
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$37.98 |
| Max. Negotiated Rate |
$192.99 |
| Rate for Payer: Aetna Commercial |
$82.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$74.24
|
| Rate for Payer: Cash Price |
$24.90
|
| Rate for Payer: Cash Price |
$24.90
|
| Rate for Payer: Cash Price |
$24.90
|
| Rate for Payer: Cigna Commercial |
$82.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$43.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$51.79
|
| Rate for Payer: Health EOS Commercial |
$78.55
|
| Rate for Payer: HFN Commercial |
$82.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$192.99
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$192.99
|
| Rate for Payer: Multiplan Commercial |
$69.06
|
| Rate for Payer: Preferred Network Access Commercial |
$82.00
|
| Rate for Payer: Quartz Beloit One Network |
$37.98
|
| Rate for Payer: Quartz Commercial |
$49.20
|
| Rate for Payer: The Alliance Commercial |
$43.16
|
| Rate for Payer: WEA Trust Commercial |
$47.48
|
| Rate for Payer: WPS Commercial |
$63.93
|
|
|
MA Mammogram 3D Screening Right
|
Facility
|
OP
|
$83.00
|
|
|
Service Code
|
CPT 77063 TC,RT
|
| Hospital Charge Code |
5472803
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$24.17 |
| Max. Negotiated Rate |
$79.41 |
| Rate for Payer: Aetna Commercial |
$77.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$74.24
|
| Rate for Payer: Aetna Managed Medicare |
$24.17
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$56.11
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$43.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$41.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$45.75
|
| Rate for Payer: Cash Price |
$24.90
|
| Rate for Payer: Cigna Commercial |
$79.41
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$48.31
|
| Rate for Payer: Health EOS Commercial |
$76.82
|
| Rate for Payer: HFN Commercial |
$79.41
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$64.74
|
| Rate for Payer: Multiplan Commercial |
$69.06
|
| Rate for Payer: NAPHCARE Commercial |
$51.79
|
| Rate for Payer: Preferred Network Access Commercial |
$79.41
|
| Rate for Payer: Quartz Beloit One Network |
$42.30
|
| Rate for Payer: Quartz Commercial |
$56.11
|
| Rate for Payer: Quartz Medicare Advantage |
$51.79
|
| Rate for Payer: The Alliance Commercial |
$43.16
|
| Rate for Payer: United Healthcare PPO |
$64.74
|
| Rate for Payer: WEA Trust Commercial |
$47.48
|
| Rate for Payer: WPS Commercial |
$63.93
|
|
|
MA Mammogram 3D Screening Right
|
Professional
|
Both
|
$83.00
|
|
|
Service Code
|
CPT 77063 TC,RT
|
| Hospital Charge Code |
5472803
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$37.98 |
| Max. Negotiated Rate |
$192.99 |
| Rate for Payer: Aetna Commercial |
$82.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$74.24
|
| Rate for Payer: Cash Price |
$24.90
|
| Rate for Payer: Cash Price |
$24.90
|
| Rate for Payer: Cash Price |
$24.90
|
| Rate for Payer: Cigna Commercial |
$82.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$43.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$51.79
|
| Rate for Payer: Health EOS Commercial |
$78.55
|
| Rate for Payer: HFN Commercial |
$82.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$192.99
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$192.99
|
| Rate for Payer: Multiplan Commercial |
$69.06
|
| Rate for Payer: Preferred Network Access Commercial |
$82.00
|
| Rate for Payer: Quartz Beloit One Network |
$37.98
|
| Rate for Payer: Quartz Commercial |
$49.20
|
| Rate for Payer: The Alliance Commercial |
$43.16
|
| Rate for Payer: WEA Trust Commercial |
$47.48
|
| Rate for Payer: WPS Commercial |
$63.93
|
|
|
MA Mammogram 3D Screening Right
|
Facility
|
IP
|
$83.00
|
|
|
Service Code
|
CPT 77063 TC,RT
|
| Hospital Charge Code |
5472803
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$42.30 |
| Max. Negotiated Rate |
$79.41 |
| Rate for Payer: Aetna Commercial |
$77.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$74.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$45.75
|
| Rate for Payer: Cash Price |
$24.90
|
| Rate for Payer: Cigna Commercial |
$79.41
|
| Rate for Payer: Health EOS Commercial |
$76.82
|
| Rate for Payer: HFN Commercial |
$79.41
|
| Rate for Payer: Multiplan Commercial |
$69.06
|
| Rate for Payer: Preferred Network Access Commercial |
$79.41
|
| Rate for Payer: Quartz Beloit One Network |
$42.30
|
| Rate for Payer: Quartz Commercial |
$51.79
|
| Rate for Payer: WEA Trust Commercial |
$47.48
|
| Rate for Payer: WPS Commercial |
$63.93
|
|
|
MA Mammogram Digital Diag Bilat w/ CAD
|
Professional
|
Both
|
$445.00
|
|
|
Service Code
|
CPT 77066 TC
|
| Hospital Charge Code |
5144743
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$109.70 |
| Max. Negotiated Rate |
$548.50 |
| Rate for Payer: Aetna Commercial |
$439.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$398.01
|
| Rate for Payer: Aetna Managed Medicare |
$109.70
|
| Rate for Payer: Anthem Medicare Advantage |
$109.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$109.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$109.70
|
| 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 |
$109.70
|
| Rate for Payer: Health EOS Commercial |
$421.15
|
| Rate for Payer: HFN Commercial |
$439.66
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$403.43
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$403.43
|
| Rate for Payer: Independent Care Health Plan Medicare |
$109.70
|
| Rate for Payer: Multiplan Commercial |
$370.24
|
| Rate for Payer: NAPHCARE Commercial |
$164.55
|
| 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 |
$109.70
|
| Rate for Payer: The Alliance Commercial |
$416.86
|
| Rate for Payer: United Healthcare Medicare Advantage |
$109.70
|
| Rate for Payer: WEA Trust Commercial |
$254.54
|
| Rate for Payer: WPS Commercial |
$548.50
|
|
|
MA Mammogram Digital Diag Bilat w/ CAD
|
Facility
|
IP
|
$445.00
|
|
|
Service Code
|
CPT 77066 TC
|
| Hospital Charge Code |
5144743
|
|
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 Diag Bilat w/ CAD
|
Facility
|
OP
|
$445.00
|
|
|
Service Code
|
CPT 77066 TC
|
| Hospital Charge Code |
5144743
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$129.58 |
| Max. Negotiated Rate |
$438.80 |
| 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 |
$438.80
|
| 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 Diag Left w/ CAD
|
Facility
|
OP
|
$393.00
|
|
|
Service Code
|
CPT 77065 TC,LT
|
| Hospital Charge Code |
5144746
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$114.44 |
| Max. Negotiated Rate |
$376.02 |
| Rate for Payer: Aetna Commercial |
$367.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$351.50
|
| Rate for Payer: Aetna Managed Medicare |
$114.44
|
| 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 |
$216.62
|
| Rate for Payer: Cash Price |
$117.90
|
| Rate for Payer: Cash Price |
$117.90
|
| Rate for Payer: Cigna Commercial |
$376.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$228.73
|
| Rate for Payer: Health EOS Commercial |
$363.76
|
| Rate for Payer: HFN Commercial |
$376.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$306.54
|
| Rate for Payer: Multiplan Commercial |
$326.98
|
| Rate for Payer: NAPHCARE Commercial |
$245.23
|
| Rate for Payer: Preferred Network Access Commercial |
$376.02
|
| Rate for Payer: Quartz Beloit One Network |
$200.27
|
| Rate for Payer: Quartz Commercial |
$265.67
|
| Rate for Payer: Quartz Medicare Advantage |
$245.23
|
| Rate for Payer: The Alliance Commercial |
$204.36
|
| Rate for Payer: United Healthcare PPO |
$306.54
|
| Rate for Payer: WEA Trust Commercial |
$224.80
|
| Rate for Payer: WPS Commercial |
$302.73
|
|
|
MA Mammogram Digital Diag Left w/ CAD
|
Facility
|
IP
|
$393.00
|
|
|
Service Code
|
CPT 77065 TC,LT
|
| Hospital Charge Code |
5144746
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$200.27 |
| Max. Negotiated Rate |
$376.02 |
| Rate for Payer: Aetna Commercial |
$367.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$351.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$216.62
|
| Rate for Payer: Cash Price |
$117.90
|
| Rate for Payer: Cigna Commercial |
$376.02
|
| Rate for Payer: Health EOS Commercial |
$363.76
|
| Rate for Payer: HFN Commercial |
$376.02
|
| Rate for Payer: Multiplan Commercial |
$326.98
|
| Rate for Payer: Preferred Network Access Commercial |
$376.02
|
| Rate for Payer: Quartz Beloit One Network |
$200.27
|
| Rate for Payer: Quartz Commercial |
$245.23
|
| Rate for Payer: WEA Trust Commercial |
$224.80
|
| Rate for Payer: WPS Commercial |
$302.73
|
|
|
MA Mammogram Digital Diag Left w/ CAD
|
Professional
|
Both
|
$393.00
|
|
|
Service Code
|
CPT 77065 TC,LT
|
| Hospital Charge Code |
5144746
|
|
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
|
|
|
MA Mammogram Digital Diagnostic Bilat
|
Professional
|
Both
|
$557.00
|
|
|
Service Code
|
CPT 77066 TC
|
| Hospital Charge Code |
1268825
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$109.70 |
| Max. Negotiated Rate |
$550.32 |
| Rate for Payer: Aetna Commercial |
$550.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$498.18
|
| Rate for Payer: Aetna Managed Medicare |
$109.70
|
| Rate for Payer: Anthem Medicare Advantage |
$109.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$109.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$109.70
|
| Rate for Payer: Cash Price |
$167.10
|
| Rate for Payer: Cash Price |
$167.10
|
| Rate for Payer: Cash Price |
$167.10
|
| Rate for Payer: Cigna Commercial |
$550.32
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$289.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$109.70
|
| Rate for Payer: Health EOS Commercial |
$527.14
|
| Rate for Payer: HFN Commercial |
$550.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$403.43
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$403.43
|
| Rate for Payer: Independent Care Health Plan Medicare |
$109.70
|
| Rate for Payer: Multiplan Commercial |
$463.42
|
| Rate for Payer: NAPHCARE Commercial |
$164.55
|
| Rate for Payer: Preferred Network Access Commercial |
$550.32
|
| Rate for Payer: Quartz Beloit One Network |
$254.88
|
| Rate for Payer: Quartz Commercial |
$330.19
|
| Rate for Payer: Quartz Medicare Advantage |
$109.70
|
| Rate for Payer: The Alliance Commercial |
$416.86
|
| Rate for Payer: United Healthcare Medicare Advantage |
$109.70
|
| Rate for Payer: WEA Trust Commercial |
$318.60
|
| Rate for Payer: WPS Commercial |
$548.50
|
|
|
MA Mammogram Digital Diagnostic Bilat
|
Facility
|
OP
|
$557.00
|
|
|
Service Code
|
CPT 77066 TC
|
| Hospital Charge Code |
1268825
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$162.20 |
| Max. Negotiated Rate |
$532.94 |
| Rate for Payer: Aetna Commercial |
$521.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$498.18
|
| Rate for Payer: Aetna Managed Medicare |
$162.20
|
| 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 |
$307.02
|
| Rate for Payer: Cash Price |
$167.10
|
| Rate for Payer: Cash Price |
$167.10
|
| Rate for Payer: Cash Price |
$167.10
|
| Rate for Payer: Cigna Commercial |
$532.94
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$324.17
|
| Rate for Payer: Health EOS Commercial |
$515.56
|
| Rate for Payer: HFN Commercial |
$532.94
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$434.46
|
| Rate for Payer: Multiplan Commercial |
$463.42
|
| Rate for Payer: NAPHCARE Commercial |
$347.57
|
| Rate for Payer: Preferred Network Access Commercial |
$532.94
|
| Rate for Payer: Quartz Beloit One Network |
$283.85
|
| Rate for Payer: Quartz Commercial |
$376.53
|
| Rate for Payer: Quartz Medicare Advantage |
$347.57
|
| Rate for Payer: The Alliance Commercial |
$438.80
|
| Rate for Payer: United Healthcare PPO |
$434.46
|
| Rate for Payer: WEA Trust Commercial |
$318.60
|
| Rate for Payer: WPS Commercial |
$429.06
|
|
|
MA Mammogram Digital Diagnostic Bilat
|
Facility
|
OP
|
$349.00
|
|
| Hospital Charge Code |
675654
|
| Min. Negotiated Rate |
$101.63 |
| Max. Negotiated Rate |
$333.92 |
| Rate for Payer: Aetna Commercial |
$326.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$312.15
|
| Rate for Payer: Aetna Managed Medicare |
$101.63
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$235.92
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$181.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$174.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$192.37
|
| Rate for Payer: Cash Price |
$104.70
|
| Rate for Payer: Cigna Commercial |
$333.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$203.12
|
| Rate for Payer: Health EOS Commercial |
$323.03
|
| Rate for Payer: HFN Commercial |
$333.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$272.22
|
| Rate for Payer: Multiplan Commercial |
$290.37
|
| Rate for Payer: NAPHCARE Commercial |
$217.78
|
| Rate for Payer: Preferred Network Access Commercial |
$333.92
|
| Rate for Payer: Quartz Beloit One Network |
$177.85
|
| Rate for Payer: Quartz Commercial |
$235.92
|
| Rate for Payer: Quartz Medicare Advantage |
$217.78
|
| Rate for Payer: The Alliance Commercial |
$181.48
|
| Rate for Payer: WEA Trust Commercial |
$199.63
|
| Rate for Payer: WPS Commercial |
$268.83
|
|
|
MA Mammogram Digital Diagnostic Bilat
|
Facility
|
IP
|
$557.00
|
|
|
Service Code
|
CPT 77066 TC
|
| Hospital Charge Code |
1268825
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$283.85 |
| Max. Negotiated Rate |
$532.94 |
| Rate for Payer: Aetna Commercial |
$521.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$498.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$307.02
|
| Rate for Payer: Cash Price |
$167.10
|
| Rate for Payer: Cigna Commercial |
$532.94
|
| Rate for Payer: Health EOS Commercial |
$515.56
|
| Rate for Payer: HFN Commercial |
$532.94
|
| Rate for Payer: Multiplan Commercial |
$463.42
|
| Rate for Payer: Preferred Network Access Commercial |
$532.94
|
| Rate for Payer: Quartz Beloit One Network |
$283.85
|
| Rate for Payer: Quartz Commercial |
$347.57
|
| Rate for Payer: WEA Trust Commercial |
$318.60
|
| Rate for Payer: WPS Commercial |
$429.06
|
|
|
MA Mammogram Digital Diagnostic Bilat
|
Facility
|
IP
|
$349.00
|
|
| Hospital Charge Code |
675654
|
| Min. Negotiated Rate |
$177.85 |
| Max. Negotiated Rate |
$333.92 |
| Rate for Payer: Aetna Commercial |
$326.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$312.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$192.37
|
| Rate for Payer: Cash Price |
$104.70
|
| Rate for Payer: Cigna Commercial |
$333.92
|
| Rate for Payer: Health EOS Commercial |
$323.03
|
| Rate for Payer: HFN Commercial |
$333.92
|
| Rate for Payer: Multiplan Commercial |
$290.37
|
| Rate for Payer: Preferred Network Access Commercial |
$333.92
|
| Rate for Payer: Quartz Beloit One Network |
$177.85
|
| Rate for Payer: Quartz Commercial |
$217.78
|
| Rate for Payer: WEA Trust Commercial |
$199.63
|
| Rate for Payer: WPS Commercial |
$268.83
|
|
|
MA Mammogram Digital Diagnostic Bilat
|
Professional
|
Both
|
$349.00
|
|
| Hospital Charge Code |
675654
|
| Min. Negotiated Rate |
$159.70 |
| Max. Negotiated Rate |
$344.81 |
| Rate for Payer: Aetna Commercial |
$344.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$312.15
|
| Rate for Payer: Cash Price |
$104.70
|
| Rate for Payer: Cigna Commercial |
$344.81
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$181.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$217.78
|
| Rate for Payer: Health EOS Commercial |
$330.29
|
| Rate for Payer: HFN Commercial |
$344.81
|
| Rate for Payer: Multiplan Commercial |
$290.37
|
| Rate for Payer: Preferred Network Access Commercial |
$344.81
|
| Rate for Payer: Quartz Beloit One Network |
$159.70
|
| Rate for Payer: Quartz Commercial |
$206.89
|
| Rate for Payer: The Alliance Commercial |
$181.48
|
| Rate for Payer: WEA Trust Commercial |
$199.63
|
| Rate for Payer: WPS Commercial |
$268.83
|
|
|
MA Mammogram Digital Diagnostic Left
|
Professional
|
Both
|
$326.00
|
|
| Hospital Charge Code |
3072685
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$149.18 |
| Max. Negotiated Rate |
$322.09 |
| Rate for Payer: Aetna Commercial |
$322.09
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$291.57
|
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cigna Commercial |
$322.09
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$169.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$203.42
|
| Rate for Payer: Health EOS Commercial |
$308.53
|
| Rate for Payer: HFN Commercial |
$322.09
|
| Rate for Payer: Multiplan Commercial |
$271.23
|
| Rate for Payer: Preferred Network Access Commercial |
$322.09
|
| Rate for Payer: Quartz Beloit One Network |
$149.18
|
| Rate for Payer: Quartz Commercial |
$193.25
|
| Rate for Payer: The Alliance Commercial |
$169.52
|
| Rate for Payer: WEA Trust Commercial |
$186.47
|
| Rate for Payer: WPS Commercial |
$251.12
|
|
|
MA Mammogram Digital Diagnostic Left
|
Facility
|
OP
|
$326.00
|
|
| Hospital Charge Code |
3072685
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$94.93 |
| Max. Negotiated Rate |
$311.92 |
| Rate for Payer: Aetna Commercial |
$305.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$291.57
|
| Rate for Payer: Aetna Managed Medicare |
$94.93
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$220.38
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$169.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$162.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$179.69
|
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cigna Commercial |
$311.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$189.73
|
| Rate for Payer: Health EOS Commercial |
$301.75
|
| Rate for Payer: HFN Commercial |
$311.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$254.28
|
| Rate for Payer: Multiplan Commercial |
$271.23
|
| Rate for Payer: NAPHCARE Commercial |
$203.42
|
| Rate for Payer: Preferred Network Access Commercial |
$311.92
|
| Rate for Payer: Quartz Beloit One Network |
$166.13
|
| Rate for Payer: Quartz Commercial |
$220.38
|
| Rate for Payer: Quartz Medicare Advantage |
$203.42
|
| Rate for Payer: The Alliance Commercial |
$169.52
|
| Rate for Payer: United Healthcare PPO |
$254.28
|
| Rate for Payer: WEA Trust Commercial |
$186.47
|
| Rate for Payer: WPS Commercial |
$251.12
|
|
|
MA Mammogram Digital Diagnostic Left
|
Facility
|
IP
|
$491.00
|
|
|
Service Code
|
CPT 77065 LT,TC
|
| Hospital Charge Code |
1268827
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$250.21 |
| Max. Negotiated Rate |
$469.79 |
| Rate for Payer: Aetna Commercial |
$459.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$439.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$270.64
|
| Rate for Payer: Cash Price |
$147.30
|
| Rate for Payer: Cigna Commercial |
$469.79
|
| Rate for Payer: Health EOS Commercial |
$454.47
|
| Rate for Payer: HFN Commercial |
$469.79
|
| Rate for Payer: Multiplan Commercial |
$408.51
|
| Rate for Payer: Preferred Network Access Commercial |
$469.79
|
| Rate for Payer: Quartz Beloit One Network |
$250.21
|
| Rate for Payer: Quartz Commercial |
$306.38
|
| Rate for Payer: WEA Trust Commercial |
$280.85
|
| Rate for Payer: WPS Commercial |
$378.22
|
|
|
MA Mammogram Digital Diagnostic Left
|
Facility
|
IP
|
$326.00
|
|
| Hospital Charge Code |
3072685
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$166.13 |
| Max. Negotiated Rate |
$311.92 |
| Rate for Payer: Aetna Commercial |
$305.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$291.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$179.69
|
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cigna Commercial |
$311.92
|
| Rate for Payer: Health EOS Commercial |
$301.75
|
| Rate for Payer: HFN Commercial |
$311.92
|
| Rate for Payer: Multiplan Commercial |
$271.23
|
| Rate for Payer: Preferred Network Access Commercial |
$311.92
|
| Rate for Payer: Quartz Beloit One Network |
$166.13
|
| Rate for Payer: Quartz Commercial |
$203.42
|
| Rate for Payer: WEA Trust Commercial |
$186.47
|
| Rate for Payer: WPS Commercial |
$251.12
|
|
|
MA Mammogram Digital Diagnostic Left
|
Facility
|
IP
|
$301.00
|
|
| Hospital Charge Code |
675656
|
| 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 Diagnostic Left
|
Facility
|
OP
|
$301.00
|
|
| Hospital Charge Code |
675656
|
| 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
|
|
