|
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 |
$232.27 |
| Max. Negotiated Rate |
$5,572.32 |
| Rate for Payer: Aetna Commercial |
$5,572.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,044.42
|
| Rate for Payer: Aetna Managed Medicare |
$232.27
|
| Rate for Payer: Anthem Medicare Advantage |
$232.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$232.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$232.27
|
| 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 |
$5,572.32
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,932.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$232.27
|
| Rate for Payer: Health EOS Commercial |
$5,337.70
|
| Rate for Payer: HFN Commercial |
$5,572.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$975.77
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$975.77
|
| Rate for Payer: Independent Care Health Plan Medicare |
$232.27
|
| Rate for Payer: Multiplan Commercial |
$4,692.48
|
| Rate for Payer: NAPHCARE Commercial |
$348.41
|
| Rate for Payer: Preferred Network Access Commercial |
$5,572.32
|
| Rate for Payer: Quartz Beloit One Network |
$2,580.86
|
| Rate for Payer: Quartz Commercial |
$3,343.39
|
| Rate for Payer: Quartz Medicare Advantage |
$232.27
|
| Rate for Payer: The Alliance Commercial |
$882.64
|
| Rate for Payer: United Healthcare Medicare Advantage |
$232.27
|
| Rate for Payer: WEA Trust Commercial |
$3,226.08
|
| Rate for Payer: WPS Commercial |
$1,161.37
|
|
|
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 |
$929.09 |
| 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: Aetna Managed Medicare |
$1,642.37
|
| 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 |
$3,108.77
|
| 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 |
$5,396.35
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,282.48
|
| Rate for Payer: Health EOS Commercial |
$5,220.38
|
| Rate for Payer: HFN Commercial |
$5,396.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,399.20
|
| Rate for Payer: Multiplan Commercial |
$4,692.48
|
| Rate for Payer: NAPHCARE Commercial |
$3,519.36
|
| 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 |
$3,812.64
|
| Rate for Payer: Quartz Medicare Advantage |
$3,519.36
|
| Rate for Payer: The Alliance Commercial |
$929.09
|
| Rate for Payer: United Healthcare PPO |
$3,142.88
|
| Rate for Payer: WEA Trust Commercial |
$3,226.08
|
| Rate for Payer: WPS Commercial |
$1,625.92
|
|
|
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 |
$1,149.15 |
| 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/ + 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 |
$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: 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 |
$942.36
|
| Rate for Payer: United Healthcare PPO |
$3,142.88
|
| Rate for Payer: WEA Trust Commercial |
$1,289.86
|
| Rate for Payer: WPS Commercial |
$1,649.14
|
|
|
MRI Breast w/ + w/o Contrast Left
|
Facility
|
OP
|
$2,299.00
|
|
|
Service Code
|
CPT 77058
|
| Hospital Charge Code |
627694
|
| 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/ + w/o Contrast Left
|
Professional
|
Both
|
$2,299.00
|
|
|
Service Code
|
CPT 77058
|
| Hospital Charge Code |
627694
|
| 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/ + 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 |
$235.59 |
| 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: Aetna Managed Medicare |
$235.59
|
| Rate for Payer: Anthem Medicare Advantage |
$235.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$235.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$235.59
|
| 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 |
$2,227.94
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,172.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$235.59
|
| Rate for Payer: Health EOS Commercial |
$2,134.13
|
| Rate for Payer: HFN Commercial |
$2,227.94
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$980.57
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$980.57
|
| Rate for Payer: Independent Care Health Plan Medicare |
$235.59
|
| Rate for Payer: Multiplan Commercial |
$1,876.16
|
| Rate for Payer: NAPHCARE Commercial |
$353.39
|
| 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: Quartz Medicare Advantage |
$235.59
|
| Rate for Payer: The Alliance Commercial |
$895.25
|
| Rate for Payer: United Healthcare Medicare Advantage |
$235.59
|
| Rate for Payer: WEA Trust Commercial |
$1,289.86
|
| Rate for Payer: WPS Commercial |
$1,177.96
|
|
|
MRI Breast w/ + w/o Contrast Left
|
Facility
|
IP
|
$2,299.00
|
|
|
Service Code
|
CPT 77058
|
| Hospital Charge Code |
627694
|
| 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/ + w/o Contrast Right
|
Professional
|
Both
|
$2,255.00
|
|
|
Service Code
|
CPT 77058 TC,RT
|
| Hospital Charge Code |
2980129
|
|
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/ + w/o Contrast Right
|
Professional
|
Both
|
$2,255.00
|
|
|
Service Code
|
CPT 77048 TC
|
| Hospital Charge Code |
1610990
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$235.59 |
| 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: Aetna Managed Medicare |
$235.59
|
| Rate for Payer: Anthem Medicare Advantage |
$235.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$235.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$235.59
|
| 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 |
$2,227.94
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,172.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$235.59
|
| Rate for Payer: Health EOS Commercial |
$2,134.13
|
| Rate for Payer: HFN Commercial |
$2,227.94
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$980.57
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$980.57
|
| Rate for Payer: Independent Care Health Plan Medicare |
$235.59
|
| Rate for Payer: Multiplan Commercial |
$1,876.16
|
| Rate for Payer: NAPHCARE Commercial |
$353.39
|
| 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: Quartz Medicare Advantage |
$235.59
|
| Rate for Payer: The Alliance Commercial |
$895.25
|
| Rate for Payer: United Healthcare Medicare Advantage |
$235.59
|
| Rate for Payer: WEA Trust Commercial |
$1,289.86
|
| Rate for Payer: WPS Commercial |
$1,177.96
|
|
|
MRI Breast w/ + w/o Contrast Right
|
Facility
|
OP
|
$2,255.00
|
|
|
Service Code
|
CPT 77048 TC
|
| Hospital Charge Code |
1610990
|
|
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: 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 |
$942.36
|
| Rate for Payer: United Healthcare PPO |
$3,142.88
|
| Rate for Payer: WEA Trust Commercial |
$1,289.86
|
| Rate for Payer: WPS Commercial |
$1,649.14
|
|
|
MRI Breast w/ + w/o Contrast Right
|
Facility
|
OP
|
$2,299.00
|
|
|
Service Code
|
CPT 77058
|
| Hospital Charge Code |
627696
|
| 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/ + 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 |
$1,149.15 |
| 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/ + w/o Contrast Right
|
Facility
|
IP
|
$2,299.00
|
|
|
Service Code
|
CPT 77058
|
| Hospital Charge Code |
627696
|
| 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/ + w/o Contrast Right
|
Facility
|
IP
|
$2,255.00
|
|
|
Service Code
|
CPT 77048 TC
|
| Hospital Charge Code |
1610990
|
|
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/ + w/o Contrast Right
|
Professional
|
Both
|
$2,299.00
|
|
|
Service Code
|
CPT 77058
|
| Hospital Charge Code |
627696
|
| 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/ + 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 |
$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 Cervical Combined
|
Professional
|
Both
|
$6,351.00
|
|
|
Service Code
|
CPT 72156 TC
|
| Hospital Charge Code |
3072663
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$210.97 |
| Max. Negotiated Rate |
$6,274.79 |
| Rate for Payer: Aetna Commercial |
$6,274.79
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,680.33
|
| Rate for Payer: Aetna Managed Medicare |
$210.97
|
| Rate for Payer: Anthem Medicare Advantage |
$210.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$210.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$210.97
|
| Rate for Payer: Cash Price |
$1,905.30
|
| Rate for Payer: Cash Price |
$1,905.30
|
| Rate for Payer: Cash Price |
$1,905.30
|
| Rate for Payer: Cigna Commercial |
$6,274.79
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3,302.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$210.97
|
| Rate for Payer: Health EOS Commercial |
$6,010.59
|
| Rate for Payer: HFN Commercial |
$6,274.79
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$874.41
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$874.41
|
| Rate for Payer: Independent Care Health Plan Medicare |
$210.97
|
| Rate for Payer: Multiplan Commercial |
$5,284.03
|
| Rate for Payer: NAPHCARE Commercial |
$316.46
|
| Rate for Payer: Preferred Network Access Commercial |
$6,274.79
|
| Rate for Payer: Quartz Beloit One Network |
$2,906.22
|
| Rate for Payer: Quartz Commercial |
$3,764.87
|
| Rate for Payer: Quartz Medicare Advantage |
$210.97
|
| Rate for Payer: The Alliance Commercial |
$801.70
|
| Rate for Payer: United Healthcare Medicare Advantage |
$210.97
|
| Rate for Payer: WEA Trust Commercial |
$3,632.77
|
| Rate for Payer: WPS Commercial |
$1,054.87
|
|
|
MRI Cervical Combined
|
Facility
|
OP
|
$6,351.00
|
|
|
Service Code
|
CPT 72156 TC
|
| Hospital Charge Code |
3072663
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$843.90 |
| Max. Negotiated Rate |
$6,076.64 |
| Rate for Payer: Aetna Commercial |
$5,944.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,680.33
|
| Rate for Payer: Aetna Managed Medicare |
$1,849.41
|
| 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 |
$3,500.67
|
| Rate for Payer: Cash Price |
$1,905.30
|
| Rate for Payer: Cash Price |
$1,905.30
|
| Rate for Payer: Cash Price |
$1,905.30
|
| Rate for Payer: Cash Price |
$1,905.30
|
| Rate for Payer: Cigna Commercial |
$6,076.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,696.28
|
| Rate for Payer: Health EOS Commercial |
$5,878.49
|
| Rate for Payer: HFN Commercial |
$6,076.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,953.78
|
| Rate for Payer: Multiplan Commercial |
$5,284.03
|
| Rate for Payer: NAPHCARE Commercial |
$3,963.02
|
| Rate for Payer: Preferred Network Access Commercial |
$6,076.64
|
| Rate for Payer: Quartz Beloit One Network |
$3,236.47
|
| Rate for Payer: Quartz Commercial |
$4,293.28
|
| Rate for Payer: Quartz Medicare Advantage |
$3,963.02
|
| Rate for Payer: The Alliance Commercial |
$843.90
|
| Rate for Payer: United Healthcare PPO |
$3,142.88
|
| Rate for Payer: WEA Trust Commercial |
$3,632.77
|
| Rate for Payer: WPS Commercial |
$1,476.82
|
|
|
MRI Cervical Combined
|
Facility
|
IP
|
$6,351.00
|
|
|
Service Code
|
CPT 72156 TC
|
| Hospital Charge Code |
3072663
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$3,236.47 |
| Max. Negotiated Rate |
$6,076.64 |
| Rate for Payer: Aetna Commercial |
$5,944.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,680.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,500.67
|
| Rate for Payer: Cash Price |
$1,905.30
|
| Rate for Payer: Cigna Commercial |
$6,076.64
|
| Rate for Payer: Health EOS Commercial |
$5,878.49
|
| Rate for Payer: HFN Commercial |
$6,076.64
|
| Rate for Payer: Multiplan Commercial |
$5,284.03
|
| Rate for Payer: Preferred Network Access Commercial |
$6,076.64
|
| Rate for Payer: Quartz Beloit One Network |
$3,236.47
|
| Rate for Payer: Quartz Commercial |
$3,963.02
|
| Rate for Payer: WEA Trust Commercial |
$3,632.77
|
| Rate for Payer: WPS Commercial |
$4,892.18
|
|
|
MRI Cervical w/o Contrast
|
Professional
|
Both
|
$4,864.00
|
|
|
Service Code
|
CPT 72141 TC
|
| Hospital Charge Code |
3072662
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$121.68 |
| Max. Negotiated Rate |
$4,805.63 |
| Rate for Payer: Aetna Commercial |
$4,805.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,350.36
|
| Rate for Payer: Aetna Managed Medicare |
$121.68
|
| Rate for Payer: Anthem Medicare Advantage |
$121.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$121.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$121.68
|
| Rate for Payer: Cash Price |
$1,459.20
|
| Rate for Payer: Cash Price |
$1,459.20
|
| Rate for Payer: Cash Price |
$1,459.20
|
| Rate for Payer: Cigna Commercial |
$4,805.63
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,529.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$121.68
|
| Rate for Payer: Health EOS Commercial |
$4,603.29
|
| Rate for Payer: HFN Commercial |
$4,805.63
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$493.93
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$493.93
|
| Rate for Payer: Independent Care Health Plan Medicare |
$121.68
|
| Rate for Payer: Multiplan Commercial |
$4,046.85
|
| Rate for Payer: NAPHCARE Commercial |
$182.52
|
| Rate for Payer: Preferred Network Access Commercial |
$4,805.63
|
| Rate for Payer: Quartz Beloit One Network |
$2,225.77
|
| Rate for Payer: Quartz Commercial |
$2,883.38
|
| Rate for Payer: Quartz Medicare Advantage |
$121.68
|
| Rate for Payer: The Alliance Commercial |
$462.38
|
| Rate for Payer: United Healthcare Medicare Advantage |
$121.68
|
| Rate for Payer: WEA Trust Commercial |
$2,782.21
|
| Rate for Payer: WPS Commercial |
$608.40
|
|
|
MRI Cervical w/o Contrast
|
Facility
|
OP
|
$4,864.00
|
|
|
Service Code
|
CPT 72141 TC
|
| Hospital Charge Code |
3072662
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$486.72 |
| Max. Negotiated Rate |
$4,653.88 |
| Rate for Payer: Aetna Commercial |
$4,552.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,350.36
|
| Rate for Payer: Aetna Managed Medicare |
$1,416.40
|
| 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 |
$2,681.04
|
| Rate for Payer: Cash Price |
$1,459.20
|
| Rate for Payer: Cash Price |
$1,459.20
|
| Rate for Payer: Cash Price |
$1,459.20
|
| Rate for Payer: Cash Price |
$1,459.20
|
| Rate for Payer: Cigna Commercial |
$4,653.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,830.85
|
| Rate for Payer: Health EOS Commercial |
$4,502.12
|
| Rate for Payer: HFN Commercial |
$4,653.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,793.92
|
| Rate for Payer: Multiplan Commercial |
$4,046.85
|
| Rate for Payer: NAPHCARE Commercial |
$3,035.14
|
| Rate for Payer: Preferred Network Access Commercial |
$4,653.88
|
| Rate for Payer: Quartz Beloit One Network |
$2,478.69
|
| Rate for Payer: Quartz Commercial |
$3,288.06
|
| Rate for Payer: Quartz Medicare Advantage |
$3,035.14
|
| Rate for Payer: The Alliance Commercial |
$486.72
|
| Rate for Payer: United Healthcare PPO |
$3,142.88
|
| Rate for Payer: WEA Trust Commercial |
$2,782.21
|
| Rate for Payer: WPS Commercial |
$851.76
|
|
|
MRI Cervical w/o Contrast
|
Facility
|
IP
|
$4,864.00
|
|
|
Service Code
|
CPT 72141 TC
|
| Hospital Charge Code |
3072662
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$2,478.69 |
| Max. Negotiated Rate |
$4,653.88 |
| Rate for Payer: Aetna Commercial |
$4,552.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,350.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,681.04
|
| Rate for Payer: Cash Price |
$1,459.20
|
| Rate for Payer: Cigna Commercial |
$4,653.88
|
| Rate for Payer: Health EOS Commercial |
$4,502.12
|
| Rate for Payer: HFN Commercial |
$4,653.88
|
| Rate for Payer: Multiplan Commercial |
$4,046.85
|
| Rate for Payer: Preferred Network Access Commercial |
$4,653.88
|
| Rate for Payer: Quartz Beloit One Network |
$2,478.69
|
| Rate for Payer: Quartz Commercial |
$3,035.14
|
| Rate for Payer: WEA Trust Commercial |
$2,782.21
|
| Rate for Payer: WPS Commercial |
$3,746.74
|
|
|
MRI Chest w/ Contrast
|
Professional
|
Both
|
$7,316.00
|
|
|
Service Code
|
CPT 71551 TC
|
| Hospital Charge Code |
1611027
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$290.17 |
| Max. Negotiated Rate |
$7,228.21 |
| Rate for Payer: Aetna Commercial |
$7,228.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,543.43
|
| Rate for Payer: Aetna Managed Medicare |
$290.17
|
| Rate for Payer: Anthem Medicare Advantage |
$290.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$290.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$290.17
|
| Rate for Payer: Cash Price |
$2,194.80
|
| Rate for Payer: Cash Price |
$2,194.80
|
| Rate for Payer: Cash Price |
$2,194.80
|
| Rate for Payer: Cigna Commercial |
$7,228.21
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3,804.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$290.17
|
| Rate for Payer: Health EOS Commercial |
$6,923.86
|
| Rate for Payer: HFN Commercial |
$7,228.21
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,210.65
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,210.65
|
| Rate for Payer: Independent Care Health Plan Medicare |
$290.17
|
| Rate for Payer: Multiplan Commercial |
$6,086.91
|
| Rate for Payer: NAPHCARE Commercial |
$435.26
|
| Rate for Payer: Preferred Network Access Commercial |
$7,228.21
|
| Rate for Payer: Quartz Beloit One Network |
$3,347.80
|
| Rate for Payer: Quartz Commercial |
$4,336.92
|
| Rate for Payer: Quartz Medicare Advantage |
$290.17
|
| Rate for Payer: The Alliance Commercial |
$1,102.65
|
| Rate for Payer: United Healthcare Medicare Advantage |
$290.17
|
| Rate for Payer: WEA Trust Commercial |
$4,184.75
|
| Rate for Payer: WPS Commercial |
$1,450.85
|
|
|
MRI Chest w/ Contrast
|
Facility
|
IP
|
$7,457.00
|
|
|
Service Code
|
CPT 71551
|
| Hospital Charge Code |
629710
|
| Min. Negotiated Rate |
$3,800.09 |
| Max. Negotiated Rate |
$7,134.86 |
| Rate for Payer: Aetna Commercial |
$6,979.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,669.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,110.30
|
| Rate for Payer: Cash Price |
$2,237.10
|
| Rate for Payer: Cigna Commercial |
$7,134.86
|
| Rate for Payer: Health EOS Commercial |
$6,902.20
|
| Rate for Payer: HFN Commercial |
$7,134.86
|
| Rate for Payer: Multiplan Commercial |
$6,204.22
|
| Rate for Payer: Preferred Network Access Commercial |
$7,134.86
|
| Rate for Payer: Quartz Beloit One Network |
$3,800.09
|
| Rate for Payer: Quartz Commercial |
$4,653.17
|
| Rate for Payer: WEA Trust Commercial |
$4,265.40
|
| Rate for Payer: WPS Commercial |
$5,744.13
|
|
