|
MRI Breast w/o Contrast Left
|
Facility
|
OP
|
$4,510.00
|
|
|
Service Code
|
CPT 77046 LT,TC
|
| Hospital Charge Code |
1611000
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$242.20 |
| Max. Negotiated Rate |
$4,149.20 |
| Rate for Payer: Aetna Commercial |
$4,059.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,878.60
|
| Rate for Payer: Aetna Managed Medicare |
$242.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,496.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,871.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,726.00
|
| Rate for Payer: Anthem Medicare Advantage |
$242.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,390.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$242.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$242.20
|
| Rate for Payer: Cash Price |
$1,353.00
|
| Rate for Payer: Cash Price |
$1,353.00
|
| Rate for Payer: Cash Price |
$1,353.00
|
| Rate for Payer: Cash Price |
$1,353.00
|
| Rate for Payer: Cigna Commercial |
$4,149.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$242.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,523.80
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$242.20
|
| Rate for Payer: Health EOS Commercial |
$4,013.90
|
| Rate for Payer: HFN Commercial |
$4,149.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$900.98
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$242.20
|
| Rate for Payer: Independent Care Health Plan Medicare |
$242.20
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$242.20
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$242.20
|
| Rate for Payer: Multiplan Commercial |
$3,608.00
|
| Rate for Payer: NAPHCARE Commercial |
$363.30
|
| Rate for Payer: Preferred Network Access Commercial |
$4,149.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,209.90
|
| Rate for Payer: Quartz Commercial |
$2,931.50
|
| Rate for Payer: Quartz Medicare Advantage |
$242.20
|
| Rate for Payer: The Alliance Commercial |
$968.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$242.20
|
| Rate for Payer: United Healthcare PPO |
$3,022.00
|
| Rate for Payer: WEA Trust Commercial |
$2,480.50
|
| Rate for Payer: Wellcare Medicare |
$242.20
|
| Rate for Payer: WPS Commercial |
$3,340.56
|
|
|
MRI Breast w/o Contrast Left
|
Professional
|
Both
|
$4,510.00
|
|
|
Service Code
|
CPT 77046 LT,TC
|
| Hospital Charge Code |
1611000
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$812.71 |
| Max. Negotiated Rate |
$4,284.50 |
| Rate for Payer: Aetna Commercial |
$4,284.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,878.60
|
| Rate for Payer: Cash Price |
$1,353.00
|
| Rate for Payer: Cash Price |
$1,353.00
|
| Rate for Payer: Cash Price |
$1,353.00
|
| Rate for Payer: Cigna Commercial |
$4,284.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,255.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,706.00
|
| Rate for Payer: Health EOS Commercial |
$4,104.10
|
| Rate for Payer: HFN Commercial |
$4,284.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$812.71
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$812.71
|
| Rate for Payer: Multiplan Commercial |
$3,608.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,284.50
|
| Rate for Payer: Quartz Beloit One Network |
$1,984.40
|
| Rate for Payer: Quartz Commercial |
$2,570.70
|
| Rate for Payer: The Alliance Commercial |
$2,255.00
|
| Rate for Payer: WEA Trust Commercial |
$2,480.50
|
| Rate for Payer: WPS Commercial |
$3,340.56
|
|
|
MRI Breast w/o Contrast Right
|
Facility
|
OP
|
$2,255.00
|
|
|
Service Code
|
CPT 77059 TC,RT
|
| Hospital Charge Code |
2980130
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$631.40 |
| Max. Negotiated Rate |
$9,020.00 |
| Rate for Payer: Aetna Commercial |
$2,029.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,939.30
|
| Rate for Payer: Aetna Managed Medicare |
$631.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,496.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,871.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,726.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,195.15
|
| Rate for Payer: Cash Price |
$676.50
|
| Rate for Payer: Cash Price |
$676.50
|
| Rate for Payer: Cash Price |
$676.50
|
| Rate for Payer: Cigna Commercial |
$2,074.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,261.90
|
| Rate for Payer: Health EOS Commercial |
$2,006.95
|
| Rate for Payer: HFN Commercial |
$2,074.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,691.25
|
| Rate for Payer: Multiplan Commercial |
$1,804.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,353.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,074.60
|
| Rate for Payer: Quartz Beloit One Network |
$1,104.95
|
| Rate for Payer: Quartz Commercial |
$1,465.75
|
| Rate for Payer: Quartz Medicare Advantage |
$1,353.00
|
| Rate for Payer: The Alliance Commercial |
$9,020.00
|
| Rate for Payer: United Healthcare PPO |
$3,022.00
|
| Rate for Payer: WEA Trust Commercial |
$1,240.25
|
| Rate for Payer: WPS Commercial |
$1,670.28
|
|
|
MRI Breast w/o Contrast Right
|
Facility
|
IP
|
$4,597.00
|
|
|
Service Code
|
CPT 77058
|
| Hospital Charge Code |
627708
|
| Min. Negotiated Rate |
$2,252.53 |
| Max. Negotiated Rate |
$4,229.24 |
| Rate for Payer: Aetna Commercial |
$4,137.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,953.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,436.41
|
| Rate for Payer: Cash Price |
$1,379.10
|
| Rate for Payer: Cigna Commercial |
$4,229.24
|
| Rate for Payer: Health EOS Commercial |
$4,091.33
|
| Rate for Payer: HFN Commercial |
$4,229.24
|
| Rate for Payer: Multiplan Commercial |
$3,677.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,758.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,229.24
|
| Rate for Payer: Quartz Beloit One Network |
$2,252.53
|
| Rate for Payer: Quartz Commercial |
$2,758.20
|
| Rate for Payer: WEA Trust Commercial |
$2,528.35
|
| Rate for Payer: WPS Commercial |
$3,405.00
|
|
|
MRI Breast w/o Contrast Right
|
Professional
|
Both
|
$4,510.00
|
|
|
Service Code
|
CPT 77046 RT,TC
|
| Hospital Charge Code |
1611002
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$812.71 |
| Max. Negotiated Rate |
$4,284.50 |
| Rate for Payer: Aetna Commercial |
$4,284.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,878.60
|
| Rate for Payer: Cash Price |
$1,353.00
|
| Rate for Payer: Cash Price |
$1,353.00
|
| Rate for Payer: Cash Price |
$1,353.00
|
| Rate for Payer: Cigna Commercial |
$4,284.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,255.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,706.00
|
| Rate for Payer: Health EOS Commercial |
$4,104.10
|
| Rate for Payer: HFN Commercial |
$4,284.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$812.71
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$812.71
|
| Rate for Payer: Multiplan Commercial |
$3,608.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,284.50
|
| Rate for Payer: Quartz Beloit One Network |
$1,984.40
|
| Rate for Payer: Quartz Commercial |
$2,570.70
|
| Rate for Payer: The Alliance Commercial |
$2,255.00
|
| Rate for Payer: WEA Trust Commercial |
$2,480.50
|
| Rate for Payer: WPS Commercial |
$3,340.56
|
|
|
MRI Breast w/o Contrast Right
|
Professional
|
Both
|
$2,255.00
|
|
|
Service Code
|
CPT 77059 TC,RT
|
| Hospital Charge Code |
2980130
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$992.20 |
| Max. Negotiated Rate |
$2,142.25 |
| Rate for Payer: Aetna Commercial |
$2,142.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,939.30
|
| Rate for Payer: Cash Price |
$676.50
|
| Rate for Payer: Cigna Commercial |
$2,142.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,127.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,353.00
|
| Rate for Payer: Health EOS Commercial |
$2,052.05
|
| Rate for Payer: HFN Commercial |
$2,142.25
|
| Rate for Payer: Multiplan Commercial |
$1,804.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,142.25
|
| Rate for Payer: Quartz Beloit One Network |
$992.20
|
| Rate for Payer: Quartz Commercial |
$1,285.35
|
| Rate for Payer: The Alliance Commercial |
$1,127.50
|
| Rate for Payer: WEA Trust Commercial |
$1,240.25
|
| Rate for Payer: WPS Commercial |
$1,670.28
|
|
|
MRI Breast w/o Contrast Right
|
Facility
|
IP
|
$4,510.00
|
|
|
Service Code
|
CPT 77046 RT,TC
|
| Hospital Charge Code |
1611002
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$2,209.90 |
| Max. Negotiated Rate |
$4,149.20 |
| Rate for Payer: Aetna Commercial |
$4,059.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,878.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,390.30
|
| Rate for Payer: Cash Price |
$1,353.00
|
| Rate for Payer: Cigna Commercial |
$4,149.20
|
| Rate for Payer: Health EOS Commercial |
$4,013.90
|
| Rate for Payer: HFN Commercial |
$4,149.20
|
| Rate for Payer: Multiplan Commercial |
$3,608.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,706.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,149.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,209.90
|
| Rate for Payer: Quartz Commercial |
$2,706.00
|
| Rate for Payer: WEA Trust Commercial |
$2,480.50
|
| Rate for Payer: WPS Commercial |
$3,340.56
|
|
|
MRI Breast w/o Contrast Right
|
Facility
|
IP
|
$2,255.00
|
|
|
Service Code
|
CPT 77059 TC,RT
|
| Hospital Charge Code |
2980130
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,104.95 |
| Max. Negotiated Rate |
$2,074.60 |
| Rate for Payer: Aetna Commercial |
$2,029.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,939.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,195.15
|
| Rate for Payer: Cash Price |
$676.50
|
| Rate for Payer: Cigna Commercial |
$2,074.60
|
| Rate for Payer: Health EOS Commercial |
$2,006.95
|
| Rate for Payer: HFN Commercial |
$2,074.60
|
| Rate for Payer: Multiplan Commercial |
$1,804.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,353.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,074.60
|
| Rate for Payer: Quartz Beloit One Network |
$1,104.95
|
| Rate for Payer: Quartz Commercial |
$1,353.00
|
| Rate for Payer: WEA Trust Commercial |
$1,240.25
|
| Rate for Payer: WPS Commercial |
$1,670.28
|
|
|
MRI Breast w/o Contrast Right
|
Professional
|
Both
|
$4,597.00
|
|
|
Service Code
|
CPT 77058
|
| Hospital Charge Code |
627708
|
| Min. Negotiated Rate |
$2,022.68 |
| Max. Negotiated Rate |
$4,367.15 |
| Rate for Payer: Aetna Commercial |
$4,367.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,953.42
|
| Rate for Payer: Cash Price |
$1,379.10
|
| Rate for Payer: Cigna Commercial |
$4,367.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,298.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,758.20
|
| Rate for Payer: Health EOS Commercial |
$4,183.27
|
| Rate for Payer: HFN Commercial |
$4,367.15
|
| Rate for Payer: Multiplan Commercial |
$3,677.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,367.15
|
| Rate for Payer: Quartz Beloit One Network |
$2,022.68
|
| Rate for Payer: Quartz Commercial |
$2,620.29
|
| Rate for Payer: The Alliance Commercial |
$2,298.50
|
| Rate for Payer: WEA Trust Commercial |
$2,528.35
|
| Rate for Payer: WPS Commercial |
$3,405.00
|
|
|
MRI Breast w/o Contrast Right
|
Facility
|
OP
|
$4,597.00
|
|
|
Service Code
|
CPT 77058
|
| Hospital Charge Code |
627708
|
| Min. Negotiated Rate |
$1,287.16 |
| Max. Negotiated Rate |
$18,388.00 |
| Rate for Payer: Aetna Commercial |
$4,137.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,953.42
|
| Rate for Payer: Aetna Managed Medicare |
$1,287.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,988.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,298.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,206.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,436.41
|
| Rate for Payer: Cash Price |
$1,379.10
|
| Rate for Payer: Cigna Commercial |
$4,229.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,572.48
|
| Rate for Payer: Health EOS Commercial |
$4,091.33
|
| Rate for Payer: HFN Commercial |
$4,229.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,447.75
|
| Rate for Payer: Multiplan Commercial |
$3,677.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,758.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,229.24
|
| Rate for Payer: Quartz Beloit One Network |
$2,252.53
|
| Rate for Payer: Quartz Commercial |
$2,988.05
|
| Rate for Payer: Quartz Medicare Advantage |
$2,758.20
|
| Rate for Payer: The Alliance Commercial |
$18,388.00
|
| Rate for Payer: WEA Trust Commercial |
$2,528.35
|
| Rate for Payer: WPS Commercial |
$3,405.00
|
|
|
MRI Breast w/o Contrast Right
|
Facility
|
OP
|
$4,510.00
|
|
|
Service Code
|
CPT 77046 RT,TC
|
| Hospital Charge Code |
1611002
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$242.20 |
| Max. Negotiated Rate |
$4,149.20 |
| Rate for Payer: Aetna Commercial |
$4,059.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,878.60
|
| Rate for Payer: Aetna Managed Medicare |
$242.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,496.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,871.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,726.00
|
| Rate for Payer: Anthem Medicare Advantage |
$242.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,390.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$242.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$242.20
|
| Rate for Payer: Cash Price |
$1,353.00
|
| Rate for Payer: Cash Price |
$1,353.00
|
| Rate for Payer: Cash Price |
$1,353.00
|
| Rate for Payer: Cash Price |
$1,353.00
|
| Rate for Payer: Cigna Commercial |
$4,149.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$242.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,523.80
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$242.20
|
| Rate for Payer: Health EOS Commercial |
$4,013.90
|
| Rate for Payer: HFN Commercial |
$4,149.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$900.98
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$242.20
|
| Rate for Payer: Independent Care Health Plan Medicare |
$242.20
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$242.20
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$242.20
|
| Rate for Payer: Multiplan Commercial |
$3,608.00
|
| Rate for Payer: NAPHCARE Commercial |
$363.30
|
| Rate for Payer: Preferred Network Access Commercial |
$4,149.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,209.90
|
| Rate for Payer: Quartz Commercial |
$2,931.50
|
| Rate for Payer: Quartz Medicare Advantage |
$242.20
|
| Rate for Payer: The Alliance Commercial |
$968.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$242.20
|
| Rate for Payer: United Healthcare PPO |
$3,022.00
|
| Rate for Payer: WEA Trust Commercial |
$2,480.50
|
| Rate for Payer: Wellcare Medicare |
$242.20
|
| Rate for Payer: WPS Commercial |
$3,340.56
|
|
|
MRI Breast w/ + w/o Contrast Bilateral
|
Facility
|
OP
|
$4,597.00
|
|
|
Service Code
|
CPT 77059
|
| Hospital Charge Code |
627692
|
| Min. Negotiated Rate |
$1,287.16 |
| Max. Negotiated Rate |
$18,388.00 |
| Rate for Payer: Aetna Commercial |
$4,137.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,953.42
|
| Rate for Payer: Aetna Managed Medicare |
$1,287.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,988.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,298.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,206.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,436.41
|
| Rate for Payer: Cash Price |
$1,379.10
|
| Rate for Payer: Cigna Commercial |
$4,229.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,572.48
|
| Rate for Payer: Health EOS Commercial |
$4,091.33
|
| Rate for Payer: HFN Commercial |
$4,229.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,447.75
|
| Rate for Payer: Multiplan Commercial |
$3,677.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,758.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,229.24
|
| Rate for Payer: Quartz Beloit One Network |
$2,252.53
|
| Rate for Payer: Quartz Commercial |
$2,988.05
|
| Rate for Payer: Quartz Medicare Advantage |
$2,758.20
|
| Rate for Payer: The Alliance Commercial |
$18,388.00
|
| Rate for Payer: WEA Trust Commercial |
$2,528.35
|
| Rate for Payer: WPS Commercial |
$3,405.00
|
|
|
MRI Breast w/ + w/o Contrast Bilateral
|
Facility
|
IP
|
$4,597.00
|
|
|
Service Code
|
CPT 77059
|
| Hospital Charge Code |
627692
|
| Min. Negotiated Rate |
$2,252.53 |
| Max. Negotiated Rate |
$4,229.24 |
| Rate for Payer: Aetna Commercial |
$4,137.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,953.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,436.41
|
| Rate for Payer: Cash Price |
$1,379.10
|
| Rate for Payer: Cigna Commercial |
$4,229.24
|
| Rate for Payer: Health EOS Commercial |
$4,091.33
|
| Rate for Payer: HFN Commercial |
$4,229.24
|
| Rate for Payer: Multiplan Commercial |
$3,677.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,758.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,229.24
|
| Rate for Payer: Quartz Beloit One Network |
$2,252.53
|
| Rate for Payer: Quartz Commercial |
$2,758.20
|
| Rate for Payer: WEA Trust Commercial |
$2,528.35
|
| Rate for Payer: WPS Commercial |
$3,405.00
|
|
|
MRI Breast w/ + w/o Contrast Bilateral
|
Facility
|
IP
|
$5,640.00
|
|
|
Service Code
|
CPT 77049 TC
|
| Hospital Charge Code |
1610986
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$2,763.60 |
| Max. Negotiated Rate |
$5,188.80 |
| Rate for Payer: Aetna Commercial |
$5,076.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,850.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,989.20
|
| Rate for Payer: Cash Price |
$1,692.00
|
| Rate for Payer: Cigna Commercial |
$5,188.80
|
| Rate for Payer: Health EOS Commercial |
$5,019.60
|
| Rate for Payer: HFN Commercial |
$5,188.80
|
| Rate for Payer: Multiplan Commercial |
$4,512.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,384.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,188.80
|
| Rate for Payer: Quartz Beloit One Network |
$2,763.60
|
| Rate for Payer: Quartz Commercial |
$3,384.00
|
| Rate for Payer: WEA Trust Commercial |
$3,102.00
|
| Rate for Payer: WPS Commercial |
$4,177.55
|
|
|
MRI Breast w/ + w/o Contrast Bilateral
|
Professional
|
Both
|
$4,597.00
|
|
|
Service Code
|
CPT 77059
|
| Hospital Charge Code |
627692
|
| Min. Negotiated Rate |
$2,022.68 |
| Max. Negotiated Rate |
$4,367.15 |
| Rate for Payer: Aetna Commercial |
$4,367.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,953.42
|
| Rate for Payer: Cash Price |
$1,379.10
|
| Rate for Payer: Cigna Commercial |
$4,367.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,298.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,758.20
|
| Rate for Payer: Health EOS Commercial |
$4,183.27
|
| Rate for Payer: HFN Commercial |
$4,367.15
|
| Rate for Payer: Multiplan Commercial |
$3,677.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,367.15
|
| Rate for Payer: Quartz Beloit One Network |
$2,022.68
|
| Rate for Payer: Quartz Commercial |
$2,620.29
|
| Rate for Payer: The Alliance Commercial |
$2,298.50
|
| Rate for Payer: WEA Trust Commercial |
$2,528.35
|
| Rate for Payer: WPS Commercial |
$3,405.00
|
|
|
MRI Breast w/ + w/o Contrast Bilateral
|
Professional
|
Both
|
$5,640.00
|
|
|
Service Code
|
CPT 77049 TC
|
| Hospital Charge Code |
1610986
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$938.24 |
| Max. Negotiated Rate |
$5,358.00 |
| Rate for Payer: Aetna Commercial |
$5,358.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,850.40
|
| Rate for Payer: Cash Price |
$1,692.00
|
| Rate for Payer: Cash Price |
$1,692.00
|
| Rate for Payer: Cash Price |
$1,692.00
|
| Rate for Payer: Cigna Commercial |
$5,358.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,820.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,384.00
|
| Rate for Payer: Health EOS Commercial |
$5,132.40
|
| Rate for Payer: HFN Commercial |
$5,358.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$938.24
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$938.24
|
| Rate for Payer: Multiplan Commercial |
$4,512.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,358.00
|
| Rate for Payer: Quartz Beloit One Network |
$2,481.60
|
| Rate for Payer: Quartz Commercial |
$3,214.80
|
| Rate for Payer: The Alliance Commercial |
$2,820.00
|
| Rate for Payer: WEA Trust Commercial |
$3,102.00
|
| Rate for Payer: WPS Commercial |
$4,177.55
|
|
|
MRI Breast w/ + w/o Contrast Bilateral
|
Facility
|
OP
|
$5,640.00
|
|
|
Service Code
|
CPT 77049 TC
|
| Hospital Charge Code |
1610986
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$380.12 |
| Max. Negotiated Rate |
$5,188.80 |
| Rate for Payer: Aetna Commercial |
$5,076.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,850.40
|
| Rate for Payer: Aetna Managed Medicare |
$380.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,496.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,871.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,726.00
|
| Rate for Payer: Anthem Medicare Advantage |
$380.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,989.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$380.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$380.12
|
| Rate for Payer: Cash Price |
$1,692.00
|
| Rate for Payer: Cash Price |
$1,692.00
|
| Rate for Payer: Cash Price |
$1,692.00
|
| Rate for Payer: Cash Price |
$1,692.00
|
| Rate for Payer: Cigna Commercial |
$5,188.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$380.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,156.14
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$380.12
|
| Rate for Payer: Health EOS Commercial |
$5,019.60
|
| Rate for Payer: HFN Commercial |
$5,188.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,414.05
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$380.12
|
| Rate for Payer: Independent Care Health Plan Medicare |
$380.12
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$380.12
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$380.12
|
| Rate for Payer: Multiplan Commercial |
$4,512.00
|
| Rate for Payer: NAPHCARE Commercial |
$570.18
|
| Rate for Payer: Preferred Network Access Commercial |
$5,188.80
|
| Rate for Payer: Quartz Beloit One Network |
$2,763.60
|
| Rate for Payer: Quartz Commercial |
$3,666.00
|
| Rate for Payer: Quartz Medicare Advantage |
$380.12
|
| Rate for Payer: The Alliance Commercial |
$1,520.48
|
| Rate for Payer: United Healthcare Medicare Advantage |
$380.12
|
| Rate for Payer: United Healthcare PPO |
$3,022.00
|
| Rate for Payer: WEA Trust Commercial |
$3,102.00
|
| Rate for Payer: Wellcare Medicare |
$380.12
|
| Rate for Payer: WPS Commercial |
$4,177.55
|
|
|
MRI Breast w/ + w/o Contrast Left
|
Facility
|
OP
|
$2,299.00
|
|
|
Service Code
|
CPT 77058
|
| Hospital Charge Code |
627694
|
| Min. Negotiated Rate |
$643.72 |
| Max. Negotiated Rate |
$9,196.00 |
| Rate for Payer: Aetna Commercial |
$2,069.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,977.14
|
| Rate for Payer: Aetna Managed Medicare |
$643.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,494.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,149.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,103.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,218.47
|
| Rate for Payer: Cash Price |
$689.70
|
| Rate for Payer: Cigna Commercial |
$2,115.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,286.52
|
| Rate for Payer: Health EOS Commercial |
$2,046.11
|
| Rate for Payer: HFN Commercial |
$2,115.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,724.25
|
| Rate for Payer: Multiplan Commercial |
$1,839.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,379.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,115.08
|
| Rate for Payer: Quartz Beloit One Network |
$1,126.51
|
| Rate for Payer: Quartz Commercial |
$1,494.35
|
| Rate for Payer: Quartz Medicare Advantage |
$1,379.40
|
| Rate for Payer: The Alliance Commercial |
$9,196.00
|
| Rate for Payer: WEA Trust Commercial |
$1,264.45
|
| Rate for Payer: WPS Commercial |
$1,702.87
|
|
|
MRI Breast w/ + w/o Contrast Left
|
Professional
|
Both
|
$2,255.00
|
|
|
Service Code
|
CPT 77048 TC
|
| Hospital Charge Code |
1610988
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$942.86 |
| Max. Negotiated Rate |
$2,142.25 |
| Rate for Payer: Aetna Commercial |
$2,142.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,939.30
|
| Rate for Payer: Cash Price |
$676.50
|
| Rate for Payer: Cash Price |
$676.50
|
| Rate for Payer: Cash Price |
$676.50
|
| Rate for Payer: Cigna Commercial |
$2,142.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,127.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,353.00
|
| Rate for Payer: Health EOS Commercial |
$2,052.05
|
| Rate for Payer: HFN Commercial |
$2,142.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$942.86
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$942.86
|
| Rate for Payer: Multiplan Commercial |
$1,804.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,142.25
|
| Rate for Payer: Quartz Beloit One Network |
$992.20
|
| Rate for Payer: Quartz Commercial |
$1,285.35
|
| Rate for Payer: The Alliance Commercial |
$1,127.50
|
| Rate for Payer: WEA Trust Commercial |
$1,240.25
|
| Rate for Payer: WPS Commercial |
$1,670.28
|
|
|
MRI Breast w/ + w/o Contrast Left
|
Facility
|
OP
|
$2,255.00
|
|
|
Service Code
|
CPT 77048 TC
|
| Hospital Charge Code |
1610988
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$380.12 |
| Max. Negotiated Rate |
$3,496.00 |
| Rate for Payer: Aetna Commercial |
$2,029.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,939.30
|
| Rate for Payer: Aetna Managed Medicare |
$380.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,496.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,871.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,726.00
|
| Rate for Payer: Anthem Medicare Advantage |
$380.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,195.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$380.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$380.12
|
| Rate for Payer: Cash Price |
$676.50
|
| Rate for Payer: Cash Price |
$676.50
|
| Rate for Payer: Cash Price |
$676.50
|
| Rate for Payer: Cash Price |
$676.50
|
| Rate for Payer: Cigna Commercial |
$2,074.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$380.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,261.90
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$380.12
|
| Rate for Payer: Health EOS Commercial |
$2,006.95
|
| Rate for Payer: HFN Commercial |
$2,074.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,414.05
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$380.12
|
| Rate for Payer: Independent Care Health Plan Medicare |
$380.12
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$380.12
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$380.12
|
| Rate for Payer: Multiplan Commercial |
$1,804.00
|
| Rate for Payer: NAPHCARE Commercial |
$570.18
|
| Rate for Payer: Preferred Network Access Commercial |
$2,074.60
|
| Rate for Payer: Quartz Beloit One Network |
$1,104.95
|
| Rate for Payer: Quartz Commercial |
$1,465.75
|
| Rate for Payer: Quartz Medicare Advantage |
$380.12
|
| Rate for Payer: The Alliance Commercial |
$1,520.48
|
| Rate for Payer: United Healthcare Medicare Advantage |
$380.12
|
| Rate for Payer: United Healthcare PPO |
$3,022.00
|
| Rate for Payer: WEA Trust Commercial |
$1,240.25
|
| Rate for Payer: Wellcare Medicare |
$380.12
|
| Rate for Payer: WPS Commercial |
$1,670.28
|
|
|
MRI Breast w/ + w/o Contrast Left
|
Facility
|
IP
|
$2,299.00
|
|
|
Service Code
|
CPT 77058
|
| Hospital Charge Code |
627694
|
| Min. Negotiated Rate |
$1,126.51 |
| Max. Negotiated Rate |
$2,115.08 |
| Rate for Payer: Aetna Commercial |
$2,069.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,977.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,218.47
|
| Rate for Payer: Cash Price |
$689.70
|
| Rate for Payer: Cigna Commercial |
$2,115.08
|
| Rate for Payer: Health EOS Commercial |
$2,046.11
|
| Rate for Payer: HFN Commercial |
$2,115.08
|
| Rate for Payer: Multiplan Commercial |
$1,839.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,379.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,115.08
|
| Rate for Payer: Quartz Beloit One Network |
$1,126.51
|
| Rate for Payer: Quartz Commercial |
$1,379.40
|
| Rate for Payer: WEA Trust Commercial |
$1,264.45
|
| Rate for Payer: WPS Commercial |
$1,702.87
|
|
|
MRI Breast w/ + w/o Contrast Left
|
Facility
|
IP
|
$2,255.00
|
|
|
Service Code
|
CPT 77048 TC
|
| Hospital Charge Code |
1610988
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,104.95 |
| Max. Negotiated Rate |
$2,074.60 |
| Rate for Payer: Aetna Commercial |
$2,029.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,939.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,195.15
|
| Rate for Payer: Cash Price |
$676.50
|
| Rate for Payer: Cigna Commercial |
$2,074.60
|
| Rate for Payer: Health EOS Commercial |
$2,006.95
|
| Rate for Payer: HFN Commercial |
$2,074.60
|
| Rate for Payer: Multiplan Commercial |
$1,804.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,353.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,074.60
|
| Rate for Payer: Quartz Beloit One Network |
$1,104.95
|
| Rate for Payer: Quartz Commercial |
$1,353.00
|
| Rate for Payer: WEA Trust Commercial |
$1,240.25
|
| Rate for Payer: WPS Commercial |
$1,670.28
|
|
|
MRI Breast w/ + w/o Contrast Left
|
Professional
|
Both
|
$2,299.00
|
|
|
Service Code
|
CPT 77058
|
| Hospital Charge Code |
627694
|
| Min. Negotiated Rate |
$1,011.56 |
| Max. Negotiated Rate |
$2,184.05 |
| Rate for Payer: Aetna Commercial |
$2,184.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,977.14
|
| Rate for Payer: Cash Price |
$689.70
|
| Rate for Payer: Cigna Commercial |
$2,184.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,149.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,379.40
|
| Rate for Payer: Health EOS Commercial |
$2,092.09
|
| Rate for Payer: HFN Commercial |
$2,184.05
|
| Rate for Payer: Multiplan Commercial |
$1,839.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,184.05
|
| Rate for Payer: Quartz Beloit One Network |
$1,011.56
|
| Rate for Payer: Quartz Commercial |
$1,310.43
|
| Rate for Payer: The Alliance Commercial |
$1,149.50
|
| Rate for Payer: WEA Trust Commercial |
$1,264.45
|
| Rate for Payer: WPS Commercial |
$1,702.87
|
|
|
MRI Breast w/ + w/o Contrast Right
|
Facility
|
IP
|
$2,255.00
|
|
|
Service Code
|
CPT 77058 TC,RT
|
| Hospital Charge Code |
2980129
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,104.95 |
| Max. Negotiated Rate |
$2,074.60 |
| Rate for Payer: Aetna Commercial |
$2,029.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,939.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,195.15
|
| Rate for Payer: Cash Price |
$676.50
|
| Rate for Payer: Cigna Commercial |
$2,074.60
|
| Rate for Payer: Health EOS Commercial |
$2,006.95
|
| Rate for Payer: HFN Commercial |
$2,074.60
|
| Rate for Payer: Multiplan Commercial |
$1,804.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,353.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,074.60
|
| Rate for Payer: Quartz Beloit One Network |
$1,104.95
|
| Rate for Payer: Quartz Commercial |
$1,353.00
|
| Rate for Payer: WEA Trust Commercial |
$1,240.25
|
| Rate for Payer: WPS Commercial |
$1,670.28
|
|
|
MRI Breast w/ + w/o Contrast Right
|
Facility
|
OP
|
$2,255.00
|
|
|
Service Code
|
CPT 77058 TC,RT
|
| Hospital Charge Code |
2980129
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$631.40 |
| Max. Negotiated Rate |
$9,020.00 |
| Rate for Payer: Aetna Commercial |
$2,029.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,939.30
|
| Rate for Payer: Aetna Managed Medicare |
$631.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,496.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,871.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,726.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,195.15
|
| Rate for Payer: Cash Price |
$676.50
|
| Rate for Payer: Cash Price |
$676.50
|
| Rate for Payer: Cash Price |
$676.50
|
| Rate for Payer: Cigna Commercial |
$2,074.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,261.90
|
| Rate for Payer: Health EOS Commercial |
$2,006.95
|
| Rate for Payer: HFN Commercial |
$2,074.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,691.25
|
| Rate for Payer: Multiplan Commercial |
$1,804.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,353.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,074.60
|
| Rate for Payer: Quartz Beloit One Network |
$1,104.95
|
| Rate for Payer: Quartz Commercial |
$1,465.75
|
| Rate for Payer: Quartz Medicare Advantage |
$1,353.00
|
| Rate for Payer: The Alliance Commercial |
$9,020.00
|
| Rate for Payer: United Healthcare PPO |
$3,022.00
|
| Rate for Payer: WEA Trust Commercial |
$1,240.25
|
| Rate for Payer: WPS Commercial |
$1,670.28
|
|
