|
MRI Brain w/ + w/o Contrast
|
Professional
|
Both
|
$6,607.00
|
|
|
Service Code
|
CPT 70553 TC
|
| Hospital Charge Code |
1610971
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$210.31 |
| Max. Negotiated Rate |
$6,527.72 |
| Rate for Payer: Aetna Commercial |
$6,527.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,909.30
|
| Rate for Payer: Aetna Managed Medicare |
$210.31
|
| Rate for Payer: Anthem Medicare Advantage |
$210.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$210.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$210.31
|
| Rate for Payer: Cash Price |
$1,982.10
|
| Rate for Payer: Cash Price |
$1,982.10
|
| Rate for Payer: Cash Price |
$1,982.10
|
| Rate for Payer: Cigna Commercial |
$6,527.72
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3,435.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$210.31
|
| Rate for Payer: Health EOS Commercial |
$6,252.86
|
| Rate for Payer: HFN Commercial |
$6,527.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$862.37
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$862.37
|
| Rate for Payer: Independent Care Health Plan Medicare |
$210.31
|
| Rate for Payer: Multiplan Commercial |
$5,497.02
|
| Rate for Payer: NAPHCARE Commercial |
$315.46
|
| Rate for Payer: Preferred Network Access Commercial |
$6,527.72
|
| Rate for Payer: Quartz Beloit One Network |
$3,023.36
|
| Rate for Payer: Quartz Commercial |
$3,916.63
|
| Rate for Payer: Quartz Medicare Advantage |
$210.31
|
| Rate for Payer: The Alliance Commercial |
$799.17
|
| Rate for Payer: United Healthcare Medicare Advantage |
$210.31
|
| Rate for Payer: WEA Trust Commercial |
$3,779.20
|
| Rate for Payer: WPS Commercial |
$1,051.54
|
|
|
MRI Brain w/ + w/o Contrast
|
Facility
|
IP
|
$6,280.00
|
|
|
Service Code
|
CPT 70553
|
| Hospital Charge Code |
627680
|
| Min. Negotiated Rate |
$3,200.29 |
| Max. Negotiated Rate |
$6,008.70 |
| Rate for Payer: Aetna Commercial |
$5,878.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,616.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,461.54
|
| Rate for Payer: Cash Price |
$1,884.00
|
| Rate for Payer: Cigna Commercial |
$6,008.70
|
| Rate for Payer: Health EOS Commercial |
$5,812.77
|
| Rate for Payer: HFN Commercial |
$6,008.70
|
| Rate for Payer: Multiplan Commercial |
$5,224.96
|
| Rate for Payer: Preferred Network Access Commercial |
$6,008.70
|
| Rate for Payer: Quartz Beloit One Network |
$3,200.29
|
| Rate for Payer: Quartz Commercial |
$3,918.72
|
| Rate for Payer: WEA Trust Commercial |
$3,592.16
|
| Rate for Payer: WPS Commercial |
$4,837.48
|
|
|
MRI Brain w/ + w/o Contrast
|
Facility
|
OP
|
$6,280.00
|
|
|
Service Code
|
CPT 70553
|
| Hospital Charge Code |
627680
|
| Min. Negotiated Rate |
$367.15 |
| Max. Negotiated Rate |
$6,008.70 |
| Rate for Payer: Aetna Commercial |
$5,878.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,616.83
|
| Rate for Payer: Aetna Managed Medicare |
$367.15
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,245.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,265.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,134.98
|
| Rate for Payer: Anthem Medicare Advantage |
$367.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,461.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$367.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$367.15
|
| Rate for Payer: Cash Price |
$1,884.00
|
| Rate for Payer: Cash Price |
$1,884.00
|
| Rate for Payer: Cigna Commercial |
$6,008.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$367.15
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,654.96
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$367.15
|
| Rate for Payer: Health EOS Commercial |
$5,812.77
|
| Rate for Payer: HFN Commercial |
$6,008.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,365.80
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$367.15
|
| Rate for Payer: Independent Care Health Plan Medicare |
$367.15
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$367.15
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$367.15
|
| Rate for Payer: Multiplan Commercial |
$5,224.96
|
| Rate for Payer: NAPHCARE Commercial |
$550.73
|
| Rate for Payer: Preferred Network Access Commercial |
$6,008.70
|
| Rate for Payer: Quartz Beloit One Network |
$3,200.29
|
| Rate for Payer: Quartz Commercial |
$4,245.28
|
| Rate for Payer: Quartz Medicare Advantage |
$367.15
|
| Rate for Payer: The Alliance Commercial |
$1,468.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$367.15
|
| Rate for Payer: WEA Trust Commercial |
$3,592.16
|
| Rate for Payer: Wellcare Medicare |
$367.15
|
| Rate for Payer: WPS Commercial |
$4,837.48
|
|
|
MRI Brain w/ + w/o Contrast
|
Facility
|
IP
|
$6,607.00
|
|
|
Service Code
|
CPT 70553 TC
|
| Hospital Charge Code |
1610971
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$3,366.93 |
| Max. Negotiated Rate |
$6,321.58 |
| Rate for Payer: Aetna Commercial |
$6,184.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,909.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,641.78
|
| Rate for Payer: Cash Price |
$1,982.10
|
| Rate for Payer: Cigna Commercial |
$6,321.58
|
| Rate for Payer: Health EOS Commercial |
$6,115.44
|
| Rate for Payer: HFN Commercial |
$6,321.58
|
| Rate for Payer: Multiplan Commercial |
$5,497.02
|
| Rate for Payer: Preferred Network Access Commercial |
$6,321.58
|
| Rate for Payer: Quartz Beloit One Network |
$3,366.93
|
| Rate for Payer: Quartz Commercial |
$4,122.77
|
| Rate for Payer: WEA Trust Commercial |
$3,779.20
|
| Rate for Payer: WPS Commercial |
$5,089.37
|
|
|
MRI Breast w/ Contrast Bilateral
|
Professional
|
Both
|
$2,255.00
|
|
|
Service Code
|
CPT 77059 TC
|
| Hospital Charge Code |
1610992
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,031.89 |
| Max. Negotiated Rate |
$2,227.94 |
| Rate for Payer: Aetna Commercial |
$2,227.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,016.87
|
| Rate for Payer: Cash Price |
$676.50
|
| Rate for Payer: Cigna Commercial |
$2,227.94
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,172.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,407.12
|
| Rate for Payer: Health EOS Commercial |
$2,134.13
|
| Rate for Payer: HFN Commercial |
$2,227.94
|
| Rate for Payer: Multiplan Commercial |
$1,876.16
|
| Rate for Payer: Preferred Network Access Commercial |
$2,227.94
|
| Rate for Payer: Quartz Beloit One Network |
$1,031.89
|
| Rate for Payer: Quartz Commercial |
$1,336.76
|
| Rate for Payer: The Alliance Commercial |
$1,172.60
|
| Rate for Payer: WEA Trust Commercial |
$1,289.86
|
| Rate for Payer: WPS Commercial |
$1,737.03
|
|
|
MRI Breast w/ Contrast Bilateral
|
Facility
|
IP
|
$2,255.00
|
|
|
Service Code
|
CPT 77059 TC
|
| Hospital Charge Code |
1610992
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,149.15 |
| Max. Negotiated Rate |
$2,157.58 |
| Rate for Payer: Aetna Commercial |
$2,110.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,016.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,242.96
|
| Rate for Payer: Cash Price |
$676.50
|
| Rate for Payer: Cigna Commercial |
$2,157.58
|
| Rate for Payer: Health EOS Commercial |
$2,087.23
|
| Rate for Payer: HFN Commercial |
$2,157.58
|
| Rate for Payer: Multiplan Commercial |
$1,876.16
|
| Rate for Payer: Preferred Network Access Commercial |
$2,157.58
|
| Rate for Payer: Quartz Beloit One Network |
$1,149.15
|
| Rate for Payer: Quartz Commercial |
$1,407.12
|
| Rate for Payer: WEA Trust Commercial |
$1,289.86
|
| Rate for Payer: WPS Commercial |
$1,737.03
|
|
|
MRI Breast w/ Contrast Bilateral
|
Facility
|
OP
|
$2,255.00
|
|
|
Service Code
|
CPT 77059 TC
|
| Hospital Charge Code |
1610992
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$656.66 |
| Max. Negotiated Rate |
$3,635.84 |
| Rate for Payer: Aetna Commercial |
$2,110.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,016.87
|
| Rate for Payer: Aetna Managed Medicare |
$656.66
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,635.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,985.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,835.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,242.96
|
| 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 |
$2,157.58
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,312.41
|
| Rate for Payer: Health EOS Commercial |
$2,087.23
|
| Rate for Payer: HFN Commercial |
$2,157.58
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,758.90
|
| Rate for Payer: Multiplan Commercial |
$1,876.16
|
| Rate for Payer: NAPHCARE Commercial |
$1,407.12
|
| Rate for Payer: Preferred Network Access Commercial |
$2,157.58
|
| Rate for Payer: Quartz Beloit One Network |
$1,149.15
|
| Rate for Payer: Quartz Commercial |
$1,524.38
|
| Rate for Payer: Quartz Medicare Advantage |
$1,407.12
|
| Rate for Payer: The Alliance Commercial |
$1,172.60
|
| Rate for Payer: United Healthcare PPO |
$3,142.88
|
| Rate for Payer: WEA Trust Commercial |
$1,289.86
|
| Rate for Payer: WPS Commercial |
$1,737.03
|
|
|
MRI Breast w/ Contrast Bilateral
|
Facility
|
IP
|
$4,597.00
|
|
|
Service Code
|
CPT 77059
|
| Hospital Charge Code |
627698
|
| Min. Negotiated Rate |
$2,342.63 |
| Max. Negotiated Rate |
$4,398.41 |
| Rate for Payer: Aetna Commercial |
$4,302.79
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,111.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,533.87
|
| Rate for Payer: Cash Price |
$1,379.10
|
| Rate for Payer: Cigna Commercial |
$4,398.41
|
| Rate for Payer: Health EOS Commercial |
$4,254.98
|
| Rate for Payer: HFN Commercial |
$4,398.41
|
| Rate for Payer: Multiplan Commercial |
$3,824.70
|
| Rate for Payer: Preferred Network Access Commercial |
$4,398.41
|
| Rate for Payer: Quartz Beloit One Network |
$2,342.63
|
| Rate for Payer: Quartz Commercial |
$2,868.53
|
| Rate for Payer: WEA Trust Commercial |
$2,629.48
|
| Rate for Payer: WPS Commercial |
$3,541.07
|
|
|
MRI Breast w/ Contrast Bilateral
|
Facility
|
OP
|
$4,597.00
|
|
|
Service Code
|
CPT 77059
|
| Hospital Charge Code |
627698
|
| Min. Negotiated Rate |
$1,338.65 |
| Max. Negotiated Rate |
$4,398.41 |
| Rate for Payer: Aetna Commercial |
$4,302.79
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,111.56
|
| Rate for Payer: Aetna Managed Medicare |
$1,338.65
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,107.57
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,390.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,294.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,533.87
|
| Rate for Payer: Cash Price |
$1,379.10
|
| Rate for Payer: Cigna Commercial |
$4,398.41
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,675.45
|
| Rate for Payer: Health EOS Commercial |
$4,254.98
|
| Rate for Payer: HFN Commercial |
$4,398.41
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,585.66
|
| Rate for Payer: Multiplan Commercial |
$3,824.70
|
| Rate for Payer: NAPHCARE Commercial |
$2,868.53
|
| Rate for Payer: Preferred Network Access Commercial |
$4,398.41
|
| Rate for Payer: Quartz Beloit One Network |
$2,342.63
|
| Rate for Payer: Quartz Commercial |
$3,107.57
|
| Rate for Payer: Quartz Medicare Advantage |
$2,868.53
|
| Rate for Payer: The Alliance Commercial |
$2,390.44
|
| Rate for Payer: WEA Trust Commercial |
$2,629.48
|
| Rate for Payer: WPS Commercial |
$3,541.07
|
|
|
MRI Breast w/ Contrast Bilateral
|
Professional
|
Both
|
$4,597.00
|
|
|
Service Code
|
CPT 77059
|
| Hospital Charge Code |
627698
|
| Min. Negotiated Rate |
$2,103.59 |
| Max. Negotiated Rate |
$4,541.84 |
| Rate for Payer: Aetna Commercial |
$4,541.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,111.56
|
| Rate for Payer: Cash Price |
$1,379.10
|
| Rate for Payer: Cigna Commercial |
$4,541.84
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,390.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,868.53
|
| Rate for Payer: Health EOS Commercial |
$4,350.60
|
| Rate for Payer: HFN Commercial |
$4,541.84
|
| Rate for Payer: Multiplan Commercial |
$3,824.70
|
| Rate for Payer: Preferred Network Access Commercial |
$4,541.84
|
| Rate for Payer: Quartz Beloit One Network |
$2,103.59
|
| Rate for Payer: Quartz Commercial |
$2,725.10
|
| Rate for Payer: The Alliance Commercial |
$2,390.44
|
| Rate for Payer: WEA Trust Commercial |
$2,629.48
|
| Rate for Payer: WPS Commercial |
$3,541.07
|
|
|
MRI Breast w/ Contrast Left
|
Facility
|
OP
|
$2,255.00
|
|
|
Service Code
|
CPT 77058 LT,TC
|
| Hospital Charge Code |
1610994
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$656.66 |
| Max. Negotiated Rate |
$3,635.84 |
| Rate for Payer: Aetna Commercial |
$2,110.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,016.87
|
| Rate for Payer: Aetna Managed Medicare |
$656.66
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,635.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,985.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,835.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,242.96
|
| 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 |
$2,157.58
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,312.41
|
| Rate for Payer: Health EOS Commercial |
$2,087.23
|
| Rate for Payer: HFN Commercial |
$2,157.58
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,758.90
|
| Rate for Payer: Multiplan Commercial |
$1,876.16
|
| Rate for Payer: NAPHCARE Commercial |
$1,407.12
|
| Rate for Payer: Preferred Network Access Commercial |
$2,157.58
|
| Rate for Payer: Quartz Beloit One Network |
$1,149.15
|
| Rate for Payer: Quartz Commercial |
$1,524.38
|
| Rate for Payer: Quartz Medicare Advantage |
$1,407.12
|
| Rate for Payer: The Alliance Commercial |
$1,172.60
|
| Rate for Payer: United Healthcare PPO |
$3,142.88
|
| Rate for Payer: WEA Trust Commercial |
$1,289.86
|
| Rate for Payer: WPS Commercial |
$1,737.03
|
|
|
MRI Breast w/ Contrast Left
|
Facility
|
IP
|
$2,299.00
|
|
|
Service Code
|
CPT 77058
|
| Hospital Charge Code |
627700
|
| Min. Negotiated Rate |
$1,171.57 |
| Max. Negotiated Rate |
$2,199.68 |
| Rate for Payer: Aetna Commercial |
$2,151.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,056.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,267.21
|
| Rate for Payer: Cash Price |
$689.70
|
| Rate for Payer: Cigna Commercial |
$2,199.68
|
| Rate for Payer: Health EOS Commercial |
$2,127.95
|
| Rate for Payer: HFN Commercial |
$2,199.68
|
| Rate for Payer: Multiplan Commercial |
$1,912.77
|
| Rate for Payer: Preferred Network Access Commercial |
$2,199.68
|
| Rate for Payer: Quartz Beloit One Network |
$1,171.57
|
| Rate for Payer: Quartz Commercial |
$1,434.58
|
| Rate for Payer: WEA Trust Commercial |
$1,315.03
|
| Rate for Payer: WPS Commercial |
$1,770.92
|
|
|
MRI Breast w/ Contrast Left
|
Facility
|
OP
|
$2,299.00
|
|
|
Service Code
|
CPT 77058
|
| Hospital Charge Code |
627700
|
| Min. Negotiated Rate |
$669.47 |
| Max. Negotiated Rate |
$2,199.68 |
| Rate for Payer: Aetna Commercial |
$2,151.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,056.23
|
| Rate for Payer: Aetna Managed Medicare |
$669.47
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,554.12
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,195.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,147.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,267.21
|
| Rate for Payer: Cash Price |
$689.70
|
| Rate for Payer: Cigna Commercial |
$2,199.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,338.02
|
| Rate for Payer: Health EOS Commercial |
$2,127.95
|
| Rate for Payer: HFN Commercial |
$2,199.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,793.22
|
| Rate for Payer: Multiplan Commercial |
$1,912.77
|
| Rate for Payer: NAPHCARE Commercial |
$1,434.58
|
| Rate for Payer: Preferred Network Access Commercial |
$2,199.68
|
| Rate for Payer: Quartz Beloit One Network |
$1,171.57
|
| Rate for Payer: Quartz Commercial |
$1,554.12
|
| Rate for Payer: Quartz Medicare Advantage |
$1,434.58
|
| Rate for Payer: The Alliance Commercial |
$1,195.48
|
| Rate for Payer: WEA Trust Commercial |
$1,315.03
|
| Rate for Payer: WPS Commercial |
$1,770.92
|
|
|
MRI Breast w/ Contrast Left
|
Professional
|
Both
|
$2,255.00
|
|
|
Service Code
|
CPT 77058 LT,TC
|
| Hospital Charge Code |
1610994
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,031.89 |
| Max. Negotiated Rate |
$2,227.94 |
| Rate for Payer: Aetna Commercial |
$2,227.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,016.87
|
| Rate for Payer: Cash Price |
$676.50
|
| Rate for Payer: Cigna Commercial |
$2,227.94
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,172.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,407.12
|
| Rate for Payer: Health EOS Commercial |
$2,134.13
|
| Rate for Payer: HFN Commercial |
$2,227.94
|
| Rate for Payer: Multiplan Commercial |
$1,876.16
|
| Rate for Payer: Preferred Network Access Commercial |
$2,227.94
|
| Rate for Payer: Quartz Beloit One Network |
$1,031.89
|
| Rate for Payer: Quartz Commercial |
$1,336.76
|
| Rate for Payer: The Alliance Commercial |
$1,172.60
|
| Rate for Payer: WEA Trust Commercial |
$1,289.86
|
| Rate for Payer: WPS Commercial |
$1,737.03
|
|
|
MRI Breast w/ Contrast Left
|
Facility
|
IP
|
$2,255.00
|
|
|
Service Code
|
CPT 77058 LT,TC
|
| Hospital Charge Code |
1610994
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,149.15 |
| Max. Negotiated Rate |
$2,157.58 |
| Rate for Payer: Aetna Commercial |
$2,110.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,016.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,242.96
|
| Rate for Payer: Cash Price |
$676.50
|
| Rate for Payer: Cigna Commercial |
$2,157.58
|
| Rate for Payer: Health EOS Commercial |
$2,087.23
|
| Rate for Payer: HFN Commercial |
$2,157.58
|
| Rate for Payer: Multiplan Commercial |
$1,876.16
|
| Rate for Payer: Preferred Network Access Commercial |
$2,157.58
|
| Rate for Payer: Quartz Beloit One Network |
$1,149.15
|
| Rate for Payer: Quartz Commercial |
$1,407.12
|
| Rate for Payer: WEA Trust Commercial |
$1,289.86
|
| Rate for Payer: WPS Commercial |
$1,737.03
|
|
|
MRI Breast w/ Contrast Left
|
Professional
|
Both
|
$2,299.00
|
|
|
Service Code
|
CPT 77058
|
| Hospital Charge Code |
627700
|
| Min. Negotiated Rate |
$1,052.02 |
| Max. Negotiated Rate |
$2,271.41 |
| Rate for Payer: Aetna Commercial |
$2,271.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,056.23
|
| Rate for Payer: Cash Price |
$689.70
|
| Rate for Payer: Cigna Commercial |
$2,271.41
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,195.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,434.58
|
| Rate for Payer: Health EOS Commercial |
$2,175.77
|
| Rate for Payer: HFN Commercial |
$2,271.41
|
| Rate for Payer: Multiplan Commercial |
$1,912.77
|
| Rate for Payer: Preferred Network Access Commercial |
$2,271.41
|
| Rate for Payer: Quartz Beloit One Network |
$1,052.02
|
| Rate for Payer: Quartz Commercial |
$1,362.85
|
| Rate for Payer: The Alliance Commercial |
$1,195.48
|
| Rate for Payer: WEA Trust Commercial |
$1,315.03
|
| Rate for Payer: WPS Commercial |
$1,770.92
|
|
|
MRI Breast w/ Contrast Right
|
Professional
|
Both
|
$2,255.00
|
|
|
Service Code
|
CPT 77058 RT,TC
|
| Hospital Charge Code |
1610996
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,031.89 |
| Max. Negotiated Rate |
$2,227.94 |
| Rate for Payer: Aetna Commercial |
$2,227.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,016.87
|
| Rate for Payer: Cash Price |
$676.50
|
| Rate for Payer: Cigna Commercial |
$2,227.94
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,172.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,407.12
|
| Rate for Payer: Health EOS Commercial |
$2,134.13
|
| Rate for Payer: HFN Commercial |
$2,227.94
|
| Rate for Payer: Multiplan Commercial |
$1,876.16
|
| Rate for Payer: Preferred Network Access Commercial |
$2,227.94
|
| Rate for Payer: Quartz Beloit One Network |
$1,031.89
|
| Rate for Payer: Quartz Commercial |
$1,336.76
|
| Rate for Payer: The Alliance Commercial |
$1,172.60
|
| Rate for Payer: WEA Trust Commercial |
$1,289.86
|
| Rate for Payer: WPS Commercial |
$1,737.03
|
|
|
MRI Breast w/ Contrast Right
|
Facility
|
IP
|
$2,299.00
|
|
|
Service Code
|
CPT 77058
|
| Hospital Charge Code |
627702
|
| Min. Negotiated Rate |
$1,171.57 |
| Max. Negotiated Rate |
$2,199.68 |
| Rate for Payer: Aetna Commercial |
$2,151.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,056.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,267.21
|
| Rate for Payer: Cash Price |
$689.70
|
| Rate for Payer: Cigna Commercial |
$2,199.68
|
| Rate for Payer: Health EOS Commercial |
$2,127.95
|
| Rate for Payer: HFN Commercial |
$2,199.68
|
| Rate for Payer: Multiplan Commercial |
$1,912.77
|
| Rate for Payer: Preferred Network Access Commercial |
$2,199.68
|
| Rate for Payer: Quartz Beloit One Network |
$1,171.57
|
| Rate for Payer: Quartz Commercial |
$1,434.58
|
| Rate for Payer: WEA Trust Commercial |
$1,315.03
|
| Rate for Payer: WPS Commercial |
$1,770.92
|
|
|
MRI Breast w/ Contrast Right
|
Facility
|
IP
|
$2,255.00
|
|
|
Service Code
|
CPT 77058 RT,TC
|
| Hospital Charge Code |
1610996
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,149.15 |
| Max. Negotiated Rate |
$2,157.58 |
| Rate for Payer: Aetna Commercial |
$2,110.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,016.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,242.96
|
| Rate for Payer: Cash Price |
$676.50
|
| Rate for Payer: Cigna Commercial |
$2,157.58
|
| Rate for Payer: Health EOS Commercial |
$2,087.23
|
| Rate for Payer: HFN Commercial |
$2,157.58
|
| Rate for Payer: Multiplan Commercial |
$1,876.16
|
| Rate for Payer: Preferred Network Access Commercial |
$2,157.58
|
| Rate for Payer: Quartz Beloit One Network |
$1,149.15
|
| Rate for Payer: Quartz Commercial |
$1,407.12
|
| Rate for Payer: WEA Trust Commercial |
$1,289.86
|
| Rate for Payer: WPS Commercial |
$1,737.03
|
|
|
MRI Breast w/ Contrast Right
|
Professional
|
Both
|
$2,299.00
|
|
|
Service Code
|
CPT 77058
|
| Hospital Charge Code |
627702
|
| Min. Negotiated Rate |
$1,052.02 |
| Max. Negotiated Rate |
$2,271.41 |
| Rate for Payer: Aetna Commercial |
$2,271.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,056.23
|
| Rate for Payer: Cash Price |
$689.70
|
| Rate for Payer: Cigna Commercial |
$2,271.41
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,195.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,434.58
|
| Rate for Payer: Health EOS Commercial |
$2,175.77
|
| Rate for Payer: HFN Commercial |
$2,271.41
|
| Rate for Payer: Multiplan Commercial |
$1,912.77
|
| Rate for Payer: Preferred Network Access Commercial |
$2,271.41
|
| Rate for Payer: Quartz Beloit One Network |
$1,052.02
|
| Rate for Payer: Quartz Commercial |
$1,362.85
|
| Rate for Payer: The Alliance Commercial |
$1,195.48
|
| Rate for Payer: WEA Trust Commercial |
$1,315.03
|
| Rate for Payer: WPS Commercial |
$1,770.92
|
|
|
MRI Breast w/ Contrast Right
|
Facility
|
OP
|
$2,255.00
|
|
|
Service Code
|
CPT 77058 RT,TC
|
| Hospital Charge Code |
1610996
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$656.66 |
| Max. Negotiated Rate |
$3,635.84 |
| Rate for Payer: Aetna Commercial |
$2,110.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,016.87
|
| Rate for Payer: Aetna Managed Medicare |
$656.66
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,635.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,985.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,835.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,242.96
|
| 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 |
$2,157.58
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,312.41
|
| Rate for Payer: Health EOS Commercial |
$2,087.23
|
| Rate for Payer: HFN Commercial |
$2,157.58
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,758.90
|
| Rate for Payer: Multiplan Commercial |
$1,876.16
|
| Rate for Payer: NAPHCARE Commercial |
$1,407.12
|
| Rate for Payer: Preferred Network Access Commercial |
$2,157.58
|
| Rate for Payer: Quartz Beloit One Network |
$1,149.15
|
| Rate for Payer: Quartz Commercial |
$1,524.38
|
| Rate for Payer: Quartz Medicare Advantage |
$1,407.12
|
| Rate for Payer: The Alliance Commercial |
$1,172.60
|
| Rate for Payer: United Healthcare PPO |
$3,142.88
|
| Rate for Payer: WEA Trust Commercial |
$1,289.86
|
| Rate for Payer: WPS Commercial |
$1,737.03
|
|
|
MRI Breast w/ Contrast Right
|
Professional
|
Both
|
$2,255.00
|
|
|
Service Code
|
CPT 77059 TC,RT
|
| Hospital Charge Code |
2980122
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,031.89 |
| Max. Negotiated Rate |
$2,227.94 |
| Rate for Payer: Aetna Commercial |
$2,227.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,016.87
|
| Rate for Payer: Cash Price |
$676.50
|
| Rate for Payer: Cigna Commercial |
$2,227.94
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,172.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,407.12
|
| Rate for Payer: Health EOS Commercial |
$2,134.13
|
| Rate for Payer: HFN Commercial |
$2,227.94
|
| Rate for Payer: Multiplan Commercial |
$1,876.16
|
| Rate for Payer: Preferred Network Access Commercial |
$2,227.94
|
| Rate for Payer: Quartz Beloit One Network |
$1,031.89
|
| Rate for Payer: Quartz Commercial |
$1,336.76
|
| Rate for Payer: The Alliance Commercial |
$1,172.60
|
| Rate for Payer: WEA Trust Commercial |
$1,289.86
|
| Rate for Payer: WPS Commercial |
$1,737.03
|
|
|
MRI Breast w/ Contrast Right
|
Facility
|
IP
|
$2,255.00
|
|
|
Service Code
|
CPT 77059 TC,RT
|
| Hospital Charge Code |
2980122
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,149.15 |
| Max. Negotiated Rate |
$2,157.58 |
| Rate for Payer: Aetna Commercial |
$2,110.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,016.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,242.96
|
| Rate for Payer: Cash Price |
$676.50
|
| Rate for Payer: Cigna Commercial |
$2,157.58
|
| Rate for Payer: Health EOS Commercial |
$2,087.23
|
| Rate for Payer: HFN Commercial |
$2,157.58
|
| Rate for Payer: Multiplan Commercial |
$1,876.16
|
| Rate for Payer: Preferred Network Access Commercial |
$2,157.58
|
| Rate for Payer: Quartz Beloit One Network |
$1,149.15
|
| Rate for Payer: Quartz Commercial |
$1,407.12
|
| Rate for Payer: WEA Trust Commercial |
$1,289.86
|
| Rate for Payer: WPS Commercial |
$1,737.03
|
|
|
MRI Breast w/ Contrast Right
|
Facility
|
OP
|
$2,255.00
|
|
|
Service Code
|
CPT 77059 TC,RT
|
| Hospital Charge Code |
2980122
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$656.66 |
| Max. Negotiated Rate |
$3,635.84 |
| Rate for Payer: Aetna Commercial |
$2,110.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,016.87
|
| Rate for Payer: Aetna Managed Medicare |
$656.66
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,635.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,985.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,835.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,242.96
|
| 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 |
$2,157.58
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,312.41
|
| Rate for Payer: Health EOS Commercial |
$2,087.23
|
| Rate for Payer: HFN Commercial |
$2,157.58
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,758.90
|
| Rate for Payer: Multiplan Commercial |
$1,876.16
|
| Rate for Payer: NAPHCARE Commercial |
$1,407.12
|
| Rate for Payer: Preferred Network Access Commercial |
$2,157.58
|
| Rate for Payer: Quartz Beloit One Network |
$1,149.15
|
| Rate for Payer: Quartz Commercial |
$1,524.38
|
| Rate for Payer: Quartz Medicare Advantage |
$1,407.12
|
| Rate for Payer: The Alliance Commercial |
$1,172.60
|
| Rate for Payer: United Healthcare PPO |
$3,142.88
|
| Rate for Payer: WEA Trust Commercial |
$1,289.86
|
| Rate for Payer: WPS Commercial |
$1,737.03
|
|
|
MRI Breast w/ Contrast Right
|
Facility
|
OP
|
$2,299.00
|
|
|
Service Code
|
CPT 77058
|
| Hospital Charge Code |
627702
|
| Min. Negotiated Rate |
$669.47 |
| Max. Negotiated Rate |
$2,199.68 |
| Rate for Payer: Aetna Commercial |
$2,151.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,056.23
|
| Rate for Payer: Aetna Managed Medicare |
$669.47
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,554.12
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,195.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,147.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,267.21
|
| Rate for Payer: Cash Price |
$689.70
|
| Rate for Payer: Cigna Commercial |
$2,199.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,338.02
|
| Rate for Payer: Health EOS Commercial |
$2,127.95
|
| Rate for Payer: HFN Commercial |
$2,199.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,793.22
|
| Rate for Payer: Multiplan Commercial |
$1,912.77
|
| Rate for Payer: NAPHCARE Commercial |
$1,434.58
|
| Rate for Payer: Preferred Network Access Commercial |
$2,199.68
|
| Rate for Payer: Quartz Beloit One Network |
$1,171.57
|
| Rate for Payer: Quartz Commercial |
$1,554.12
|
| Rate for Payer: Quartz Medicare Advantage |
$1,434.58
|
| Rate for Payer: The Alliance Commercial |
$1,195.48
|
| Rate for Payer: WEA Trust Commercial |
$1,315.03
|
| Rate for Payer: WPS Commercial |
$1,770.92
|
|
