|
MRI Breast w/o Contrast Bilateral
|
Facility
|
OP
|
$4,597.00
|
|
|
Service Code
|
CPT 77059
|
| Hospital Charge Code |
627704
|
| 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/o Contrast Bilateral
|
Facility
|
IP
|
$4,597.00
|
|
|
Service Code
|
CPT 77059
|
| Hospital Charge Code |
627704
|
| 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/o Contrast Bilateral
|
Professional
|
Both
|
$2,342.00
|
|
|
Service Code
|
CPT 77047 TC
|
| Hospital Charge Code |
1610998
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$142.31 |
| Max. Negotiated Rate |
$2,313.90 |
| Rate for Payer: Aetna Commercial |
$2,313.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,094.68
|
| Rate for Payer: Aetna Managed Medicare |
$142.31
|
| Rate for Payer: Anthem Medicare Advantage |
$142.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$142.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$142.31
|
| Rate for Payer: Cash Price |
$702.60
|
| Rate for Payer: Cash Price |
$702.60
|
| Rate for Payer: Cash Price |
$702.60
|
| Rate for Payer: Cigna Commercial |
$2,313.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,217.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$142.31
|
| Rate for Payer: Health EOS Commercial |
$2,216.47
|
| Rate for Payer: HFN Commercial |
$2,313.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$592.05
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$592.05
|
| Rate for Payer: Independent Care Health Plan Medicare |
$142.31
|
| Rate for Payer: Multiplan Commercial |
$1,948.54
|
| Rate for Payer: NAPHCARE Commercial |
$213.47
|
| Rate for Payer: Preferred Network Access Commercial |
$2,313.90
|
| Rate for Payer: Quartz Beloit One Network |
$1,071.70
|
| Rate for Payer: Quartz Commercial |
$1,388.34
|
| Rate for Payer: Quartz Medicare Advantage |
$142.31
|
| Rate for Payer: The Alliance Commercial |
$540.79
|
| Rate for Payer: United Healthcare Medicare Advantage |
$142.31
|
| Rate for Payer: WEA Trust Commercial |
$1,339.62
|
| Rate for Payer: WPS Commercial |
$711.57
|
|
|
MRI Breast w/o Contrast Bilateral
|
Facility
|
OP
|
$2,342.00
|
|
|
Service Code
|
CPT 77047 TC
|
| Hospital Charge Code |
1610998
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$569.25 |
| Max. Negotiated Rate |
$3,635.84 |
| Rate for Payer: Aetna Commercial |
$2,192.11
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,094.68
|
| Rate for Payer: Aetna Managed Medicare |
$681.99
|
| 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 |
$1,290.91
|
| Rate for Payer: Cash Price |
$702.60
|
| Rate for Payer: Cash Price |
$702.60
|
| Rate for Payer: Cash Price |
$702.60
|
| Rate for Payer: Cash Price |
$702.60
|
| Rate for Payer: Cigna Commercial |
$2,240.83
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,363.04
|
| Rate for Payer: Health EOS Commercial |
$2,167.76
|
| Rate for Payer: HFN Commercial |
$2,240.83
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,826.76
|
| Rate for Payer: Multiplan Commercial |
$1,948.54
|
| Rate for Payer: NAPHCARE Commercial |
$1,461.41
|
| Rate for Payer: Preferred Network Access Commercial |
$2,240.83
|
| Rate for Payer: Quartz Beloit One Network |
$1,193.48
|
| Rate for Payer: Quartz Commercial |
$1,583.19
|
| Rate for Payer: Quartz Medicare Advantage |
$1,461.41
|
| Rate for Payer: The Alliance Commercial |
$569.25
|
| Rate for Payer: United Healthcare PPO |
$3,142.88
|
| Rate for Payer: WEA Trust Commercial |
$1,339.62
|
| Rate for Payer: WPS Commercial |
$996.20
|
|
|
MRI Breast w/o Contrast Bilateral
|
Professional
|
Both
|
$4,597.00
|
|
|
Service Code
|
CPT 77059
|
| Hospital Charge Code |
627704
|
| 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/o Contrast Bilateral
|
Facility
|
IP
|
$2,342.00
|
|
|
Service Code
|
CPT 77047 TC
|
| Hospital Charge Code |
1610998
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,193.48 |
| Max. Negotiated Rate |
$2,240.83 |
| Rate for Payer: Aetna Commercial |
$2,192.11
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,094.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,290.91
|
| Rate for Payer: Cash Price |
$702.60
|
| Rate for Payer: Cigna Commercial |
$2,240.83
|
| Rate for Payer: Health EOS Commercial |
$2,167.76
|
| Rate for Payer: HFN Commercial |
$2,240.83
|
| Rate for Payer: Multiplan Commercial |
$1,948.54
|
| Rate for Payer: Preferred Network Access Commercial |
$2,240.83
|
| Rate for Payer: Quartz Beloit One Network |
$1,193.48
|
| Rate for Payer: Quartz Commercial |
$1,461.41
|
| Rate for Payer: WEA Trust Commercial |
$1,339.62
|
| Rate for Payer: WPS Commercial |
$1,804.04
|
|
|
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 |
$845.22 |
| Max. Negotiated Rate |
$4,455.88 |
| Rate for Payer: Aetna Commercial |
$4,455.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,033.74
|
| 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 |
$4,455.88
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,345.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,814.24
|
| Rate for Payer: Health EOS Commercial |
$4,268.26
|
| Rate for Payer: HFN Commercial |
$4,455.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$845.22
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$845.22
|
| Rate for Payer: Multiplan Commercial |
$3,752.32
|
| Rate for Payer: Preferred Network Access Commercial |
$4,455.88
|
| Rate for Payer: Quartz Beloit One Network |
$2,063.78
|
| Rate for Payer: Quartz Commercial |
$2,673.53
|
| Rate for Payer: The Alliance Commercial |
$2,345.20
|
| Rate for Payer: WEA Trust Commercial |
$2,579.72
|
| Rate for Payer: WPS Commercial |
$3,474.05
|
|
|
MRI Breast w/o Contrast Left
|
Professional
|
Both
|
$4,597.00
|
|
|
Service Code
|
CPT 77058
|
| Hospital Charge Code |
627706
|
| 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/o Contrast Left
|
Facility
|
IP
|
$4,597.00
|
|
|
Service Code
|
CPT 77058
|
| Hospital Charge Code |
627706
|
| 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/o Contrast Left
|
Facility
|
OP
|
$4,597.00
|
|
|
Service Code
|
CPT 77058
|
| Hospital Charge Code |
627706
|
| 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/o Contrast Left
|
Facility
|
IP
|
$4,510.00
|
|
|
Service Code
|
CPT 77046 LT,TC
|
| Hospital Charge Code |
1611000
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$2,298.30 |
| Max. Negotiated Rate |
$4,315.17 |
| Rate for Payer: Aetna Commercial |
$4,221.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,033.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,485.91
|
| Rate for Payer: Cash Price |
$1,353.00
|
| Rate for Payer: Cigna Commercial |
$4,315.17
|
| Rate for Payer: Health EOS Commercial |
$4,174.46
|
| Rate for Payer: HFN Commercial |
$4,315.17
|
| Rate for Payer: Multiplan Commercial |
$3,752.32
|
| Rate for Payer: Preferred Network Access Commercial |
$4,315.17
|
| Rate for Payer: Quartz Beloit One Network |
$2,298.30
|
| Rate for Payer: Quartz Commercial |
$2,814.24
|
| Rate for Payer: WEA Trust Commercial |
$2,579.72
|
| Rate for Payer: WPS Commercial |
$3,474.05
|
|
|
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 |
$1,313.31 |
| Max. Negotiated Rate |
$4,315.17 |
| Rate for Payer: Aetna Commercial |
$4,221.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,033.74
|
| Rate for Payer: Aetna Managed Medicare |
$1,313.31
|
| 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 |
$2,485.91
|
| 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 |
$4,315.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,624.82
|
| Rate for Payer: Health EOS Commercial |
$4,174.46
|
| Rate for Payer: HFN Commercial |
$4,315.17
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,517.80
|
| Rate for Payer: Multiplan Commercial |
$3,752.32
|
| Rate for Payer: NAPHCARE Commercial |
$2,814.24
|
| Rate for Payer: Preferred Network Access Commercial |
$4,315.17
|
| Rate for Payer: Quartz Beloit One Network |
$2,298.30
|
| Rate for Payer: Quartz Commercial |
$3,048.76
|
| Rate for Payer: Quartz Medicare Advantage |
$2,814.24
|
| Rate for Payer: The Alliance Commercial |
$2,345.20
|
| Rate for Payer: United Healthcare PPO |
$3,142.88
|
| Rate for Payer: WEA Trust Commercial |
$2,579.72
|
| Rate for Payer: WPS Commercial |
$3,474.05
|
|
|
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 |
$845.22 |
| Max. Negotiated Rate |
$4,455.88 |
| Rate for Payer: Aetna Commercial |
$4,455.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,033.74
|
| 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 |
$4,455.88
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,345.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,814.24
|
| Rate for Payer: Health EOS Commercial |
$4,268.26
|
| Rate for Payer: HFN Commercial |
$4,455.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$845.22
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$845.22
|
| Rate for Payer: Multiplan Commercial |
$3,752.32
|
| Rate for Payer: Preferred Network Access Commercial |
$4,455.88
|
| Rate for Payer: Quartz Beloit One Network |
$2,063.78
|
| Rate for Payer: Quartz Commercial |
$2,673.53
|
| Rate for Payer: The Alliance Commercial |
$2,345.20
|
| Rate for Payer: WEA Trust Commercial |
$2,579.72
|
| Rate for Payer: WPS Commercial |
$3,474.05
|
|
|
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 |
$1,313.31 |
| Max. Negotiated Rate |
$4,315.17 |
| Rate for Payer: Aetna Commercial |
$4,221.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,033.74
|
| Rate for Payer: Aetna Managed Medicare |
$1,313.31
|
| 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 |
$2,485.91
|
| 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 |
$4,315.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,624.82
|
| Rate for Payer: Health EOS Commercial |
$4,174.46
|
| Rate for Payer: HFN Commercial |
$4,315.17
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,517.80
|
| Rate for Payer: Multiplan Commercial |
$3,752.32
|
| Rate for Payer: NAPHCARE Commercial |
$2,814.24
|
| Rate for Payer: Preferred Network Access Commercial |
$4,315.17
|
| Rate for Payer: Quartz Beloit One Network |
$2,298.30
|
| Rate for Payer: Quartz Commercial |
$3,048.76
|
| Rate for Payer: Quartz Medicare Advantage |
$2,814.24
|
| Rate for Payer: The Alliance Commercial |
$2,345.20
|
| Rate for Payer: United Healthcare PPO |
$3,142.88
|
| Rate for Payer: WEA Trust Commercial |
$2,579.72
|
| Rate for Payer: WPS Commercial |
$3,474.05
|
|
|
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 |
$1,149.15 |
| 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/o Contrast Right
|
Facility
|
OP
|
$4,597.00
|
|
|
Service Code
|
CPT 77058
|
| Hospital Charge Code |
627708
|
| 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/o Contrast Right
|
Facility
|
IP
|
$4,597.00
|
|
|
Service Code
|
CPT 77058
|
| Hospital Charge Code |
627708
|
| 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/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 |
$2,298.30 |
| Max. Negotiated Rate |
$4,315.17 |
| Rate for Payer: Aetna Commercial |
$4,221.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,033.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,485.91
|
| Rate for Payer: Cash Price |
$1,353.00
|
| Rate for Payer: Cigna Commercial |
$4,315.17
|
| Rate for Payer: Health EOS Commercial |
$4,174.46
|
| Rate for Payer: HFN Commercial |
$4,315.17
|
| Rate for Payer: Multiplan Commercial |
$3,752.32
|
| Rate for Payer: Preferred Network Access Commercial |
$4,315.17
|
| Rate for Payer: Quartz Beloit One Network |
$2,298.30
|
| Rate for Payer: Quartz Commercial |
$2,814.24
|
| Rate for Payer: WEA Trust Commercial |
$2,579.72
|
| Rate for Payer: WPS Commercial |
$3,474.05
|
|
|
MRI Breast w/o Contrast Right
|
Professional
|
Both
|
$4,597.00
|
|
|
Service Code
|
CPT 77058
|
| Hospital Charge Code |
627708
|
| 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/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 |
$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/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 |
$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/ + w/o Contrast Bilateral
|
Facility
|
IP
|
$4,597.00
|
|
|
Service Code
|
CPT 77059
|
| Hospital Charge Code |
627692
|
| 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/ + 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 |
$2,874.14 |
| Max. Negotiated Rate |
$5,396.35 |
| Rate for Payer: Aetna Commercial |
$5,279.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,044.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,108.77
|
| Rate for Payer: Cash Price |
$1,692.00
|
| Rate for Payer: Cigna Commercial |
$5,396.35
|
| Rate for Payer: Health EOS Commercial |
$5,220.38
|
| Rate for Payer: HFN Commercial |
$5,396.35
|
| Rate for Payer: Multiplan Commercial |
$4,692.48
|
| Rate for Payer: Preferred Network Access Commercial |
$5,396.35
|
| Rate for Payer: Quartz Beloit One Network |
$2,874.14
|
| Rate for Payer: Quartz Commercial |
$3,519.36
|
| Rate for Payer: WEA Trust Commercial |
$3,226.08
|
| Rate for Payer: WPS Commercial |
$4,344.49
|
|
|
MRI Breast w/ + w/o Contrast Bilateral
|
Facility
|
OP
|
$4,597.00
|
|
|
Service Code
|
CPT 77059
|
| Hospital Charge Code |
627692
|
| 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/ + w/o Contrast Bilateral
|
Professional
|
Both
|
$4,597.00
|
|
|
Service Code
|
CPT 77059
|
| Hospital Charge Code |
627692
|
| 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
|
|
