|
MA Dig Diag Bilateral
|
Facility
|
IP
|
$557.00
|
|
|
Service Code
|
CPT 77066 TC
|
| Hospital Charge Code |
5478930
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$272.93 |
| Max. Negotiated Rate |
$512.44 |
| Rate for Payer: Aetna Commercial |
$501.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$479.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$295.21
|
| Rate for Payer: Cash Price |
$167.10
|
| Rate for Payer: Cigna Commercial |
$512.44
|
| Rate for Payer: Health EOS Commercial |
$495.73
|
| Rate for Payer: HFN Commercial |
$512.44
|
| Rate for Payer: Multiplan Commercial |
$445.60
|
| Rate for Payer: NAPHCARE Commercial |
$334.20
|
| Rate for Payer: Preferred Network Access Commercial |
$512.44
|
| Rate for Payer: Quartz Beloit One Network |
$272.93
|
| Rate for Payer: Quartz Commercial |
$334.20
|
| Rate for Payer: WEA Trust Commercial |
$306.35
|
| Rate for Payer: WPS Commercial |
$412.57
|
|
|
MA Dig Diag Unilateral Left
|
Facility
|
OP
|
$491.00
|
|
|
Service Code
|
CPT 77065 TC,LT
|
| Hospital Charge Code |
5478931
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$137.48 |
| Max. Negotiated Rate |
$1,964.00 |
| Rate for Payer: Aetna Commercial |
$441.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$422.26
|
| Rate for Payer: Aetna Managed Medicare |
$137.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$349.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$259.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$246.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$260.23
|
| Rate for Payer: Cash Price |
$147.30
|
| Rate for Payer: Cash Price |
$147.30
|
| Rate for Payer: Cigna Commercial |
$451.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$274.76
|
| Rate for Payer: Health EOS Commercial |
$436.99
|
| Rate for Payer: HFN Commercial |
$451.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$368.25
|
| Rate for Payer: Multiplan Commercial |
$392.80
|
| Rate for Payer: NAPHCARE Commercial |
$294.60
|
| Rate for Payer: Preferred Network Access Commercial |
$451.72
|
| Rate for Payer: Quartz Beloit One Network |
$240.59
|
| Rate for Payer: Quartz Commercial |
$319.15
|
| Rate for Payer: Quartz Medicare Advantage |
$294.60
|
| Rate for Payer: The Alliance Commercial |
$1,964.00
|
| Rate for Payer: United Healthcare PPO |
$368.25
|
| Rate for Payer: WEA Trust Commercial |
$270.05
|
| Rate for Payer: WPS Commercial |
$363.68
|
|
|
MA Dig Diag Unilateral Left
|
Facility
|
IP
|
$491.00
|
|
|
Service Code
|
CPT 77065 TC,LT
|
| Hospital Charge Code |
5478931
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$240.59 |
| Max. Negotiated Rate |
$451.72 |
| Rate for Payer: Aetna Commercial |
$441.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$422.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$260.23
|
| Rate for Payer: Cash Price |
$147.30
|
| Rate for Payer: Cigna Commercial |
$451.72
|
| Rate for Payer: Health EOS Commercial |
$436.99
|
| Rate for Payer: HFN Commercial |
$451.72
|
| Rate for Payer: Multiplan Commercial |
$392.80
|
| Rate for Payer: NAPHCARE Commercial |
$294.60
|
| Rate for Payer: Preferred Network Access Commercial |
$451.72
|
| Rate for Payer: Quartz Beloit One Network |
$240.59
|
| Rate for Payer: Quartz Commercial |
$294.60
|
| Rate for Payer: WEA Trust Commercial |
$270.05
|
| Rate for Payer: WPS Commercial |
$363.68
|
|
|
MA Dig Diag Unilateral Left
|
Professional
|
Both
|
$491.00
|
|
|
Service Code
|
CPT 77065 TC,LT
|
| Hospital Charge Code |
5478931
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$216.04 |
| Max. Negotiated Rate |
$466.45 |
| Rate for Payer: Aetna Commercial |
$466.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$422.26
|
| Rate for Payer: Cash Price |
$147.30
|
| Rate for Payer: Cash Price |
$147.30
|
| Rate for Payer: Cash Price |
$147.30
|
| Rate for Payer: Cigna Commercial |
$466.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$245.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$294.60
|
| Rate for Payer: Health EOS Commercial |
$446.81
|
| Rate for Payer: HFN Commercial |
$466.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$438.07
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$438.07
|
| Rate for Payer: Multiplan Commercial |
$392.80
|
| Rate for Payer: Preferred Network Access Commercial |
$466.45
|
| Rate for Payer: Quartz Beloit One Network |
$216.04
|
| Rate for Payer: Quartz Commercial |
$279.87
|
| Rate for Payer: The Alliance Commercial |
$245.50
|
| Rate for Payer: WEA Trust Commercial |
$270.05
|
| Rate for Payer: WPS Commercial |
$363.68
|
|
|
MA Dig Diag Unilateral Right
|
Facility
|
OP
|
$491.00
|
|
|
Service Code
|
CPT 77065 TC,RT
|
| Hospital Charge Code |
5478932
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$137.48 |
| Max. Negotiated Rate |
$1,964.00 |
| Rate for Payer: Aetna Commercial |
$441.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$422.26
|
| Rate for Payer: Aetna Managed Medicare |
$137.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$349.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$259.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$246.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$260.23
|
| Rate for Payer: Cash Price |
$147.30
|
| Rate for Payer: Cash Price |
$147.30
|
| Rate for Payer: Cigna Commercial |
$451.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$274.76
|
| Rate for Payer: Health EOS Commercial |
$436.99
|
| Rate for Payer: HFN Commercial |
$451.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$368.25
|
| Rate for Payer: Multiplan Commercial |
$392.80
|
| Rate for Payer: NAPHCARE Commercial |
$294.60
|
| Rate for Payer: Preferred Network Access Commercial |
$451.72
|
| Rate for Payer: Quartz Beloit One Network |
$240.59
|
| Rate for Payer: Quartz Commercial |
$319.15
|
| Rate for Payer: Quartz Medicare Advantage |
$294.60
|
| Rate for Payer: The Alliance Commercial |
$1,964.00
|
| Rate for Payer: United Healthcare PPO |
$368.25
|
| Rate for Payer: WEA Trust Commercial |
$270.05
|
| Rate for Payer: WPS Commercial |
$363.68
|
|
|
MA Dig Diag Unilateral Right
|
Professional
|
Both
|
$491.00
|
|
|
Service Code
|
CPT 77065 TC,RT
|
| Hospital Charge Code |
5478932
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$216.04 |
| Max. Negotiated Rate |
$466.45 |
| Rate for Payer: Aetna Commercial |
$466.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$422.26
|
| Rate for Payer: Cash Price |
$147.30
|
| Rate for Payer: Cash Price |
$147.30
|
| Rate for Payer: Cash Price |
$147.30
|
| Rate for Payer: Cigna Commercial |
$466.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$245.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$294.60
|
| Rate for Payer: Health EOS Commercial |
$446.81
|
| Rate for Payer: HFN Commercial |
$466.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$438.07
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$438.07
|
| Rate for Payer: Multiplan Commercial |
$392.80
|
| Rate for Payer: Preferred Network Access Commercial |
$466.45
|
| Rate for Payer: Quartz Beloit One Network |
$216.04
|
| Rate for Payer: Quartz Commercial |
$279.87
|
| Rate for Payer: The Alliance Commercial |
$245.50
|
| Rate for Payer: WEA Trust Commercial |
$270.05
|
| Rate for Payer: WPS Commercial |
$363.68
|
|
|
MA Dig Diag Unilateral Right
|
Facility
|
IP
|
$491.00
|
|
|
Service Code
|
CPT 77065 TC,RT
|
| Hospital Charge Code |
5478932
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$240.59 |
| Max. Negotiated Rate |
$451.72 |
| Rate for Payer: Aetna Commercial |
$441.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$422.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$260.23
|
| Rate for Payer: Cash Price |
$147.30
|
| Rate for Payer: Cigna Commercial |
$451.72
|
| Rate for Payer: Health EOS Commercial |
$436.99
|
| Rate for Payer: HFN Commercial |
$451.72
|
| Rate for Payer: Multiplan Commercial |
$392.80
|
| Rate for Payer: NAPHCARE Commercial |
$294.60
|
| Rate for Payer: Preferred Network Access Commercial |
$451.72
|
| Rate for Payer: Quartz Beloit One Network |
$240.59
|
| Rate for Payer: Quartz Commercial |
$294.60
|
| Rate for Payer: WEA Trust Commercial |
$270.05
|
| Rate for Payer: WPS Commercial |
$363.68
|
|
|
MA Dig Screen Bilateral
|
Professional
|
Both
|
$410.00
|
|
|
Service Code
|
CPT 77067 TC
|
| Hospital Charge Code |
5478933
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$180.40 |
| Max. Negotiated Rate |
$389.50 |
| Rate for Payer: Aetna Commercial |
$389.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$352.60
|
| Rate for Payer: Cash Price |
$123.00
|
| Rate for Payer: Cash Price |
$123.00
|
| Rate for Payer: Cash Price |
$123.00
|
| Rate for Payer: Cigna Commercial |
$389.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$205.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$246.00
|
| Rate for Payer: Health EOS Commercial |
$373.10
|
| Rate for Payer: HFN Commercial |
$389.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$320.59
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$320.59
|
| Rate for Payer: Multiplan Commercial |
$328.00
|
| Rate for Payer: Preferred Network Access Commercial |
$389.50
|
| Rate for Payer: Quartz Beloit One Network |
$180.40
|
| Rate for Payer: Quartz Commercial |
$233.70
|
| Rate for Payer: The Alliance Commercial |
$205.00
|
| Rate for Payer: WEA Trust Commercial |
$225.50
|
| Rate for Payer: WPS Commercial |
$303.69
|
|
|
MA Dig Screen Bilateral
|
Facility
|
OP
|
$410.00
|
|
|
Service Code
|
CPT 77067 TC
|
| Hospital Charge Code |
5478933
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$114.80 |
| Max. Negotiated Rate |
$1,640.00 |
| Rate for Payer: Aetna Commercial |
$369.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$352.60
|
| Rate for Payer: Aetna Managed Medicare |
$114.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$349.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$259.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$246.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$217.30
|
| Rate for Payer: Cash Price |
$123.00
|
| Rate for Payer: Cash Price |
$123.00
|
| Rate for Payer: Cigna Commercial |
$377.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$229.44
|
| Rate for Payer: Health EOS Commercial |
$364.90
|
| Rate for Payer: HFN Commercial |
$377.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$307.50
|
| Rate for Payer: Multiplan Commercial |
$328.00
|
| Rate for Payer: NAPHCARE Commercial |
$246.00
|
| Rate for Payer: Preferred Network Access Commercial |
$377.20
|
| Rate for Payer: Quartz Beloit One Network |
$200.90
|
| Rate for Payer: Quartz Commercial |
$266.50
|
| Rate for Payer: Quartz Medicare Advantage |
$246.00
|
| Rate for Payer: The Alliance Commercial |
$1,640.00
|
| Rate for Payer: United Healthcare PPO |
$307.50
|
| Rate for Payer: WEA Trust Commercial |
$225.50
|
| Rate for Payer: WPS Commercial |
$303.69
|
|
|
MA Dig Screen Bilateral
|
Facility
|
IP
|
$410.00
|
|
|
Service Code
|
CPT 77067 TC
|
| Hospital Charge Code |
5478933
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$200.90 |
| Max. Negotiated Rate |
$377.20 |
| Rate for Payer: Aetna Commercial |
$369.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$352.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$217.30
|
| Rate for Payer: Cash Price |
$123.00
|
| Rate for Payer: Cigna Commercial |
$377.20
|
| Rate for Payer: Health EOS Commercial |
$364.90
|
| Rate for Payer: HFN Commercial |
$377.20
|
| Rate for Payer: Multiplan Commercial |
$328.00
|
| Rate for Payer: NAPHCARE Commercial |
$246.00
|
| Rate for Payer: Preferred Network Access Commercial |
$377.20
|
| Rate for Payer: Quartz Beloit One Network |
$200.90
|
| Rate for Payer: Quartz Commercial |
$246.00
|
| Rate for Payer: WEA Trust Commercial |
$225.50
|
| Rate for Payer: WPS Commercial |
$303.69
|
|
|
MA Dig Screen Unilateral Left
|
Professional
|
Both
|
$495.00
|
|
|
Service Code
|
CPT 77067 TC,LT
|
| Hospital Charge Code |
5478934
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$217.80 |
| Max. Negotiated Rate |
$470.25 |
| Rate for Payer: Aetna Commercial |
$470.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$425.70
|
| Rate for Payer: Cash Price |
$148.50
|
| Rate for Payer: Cash Price |
$148.50
|
| Rate for Payer: Cash Price |
$148.50
|
| Rate for Payer: Cigna Commercial |
$470.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$247.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$297.00
|
| Rate for Payer: Health EOS Commercial |
$450.45
|
| Rate for Payer: HFN Commercial |
$470.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$448.17
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$448.17
|
| Rate for Payer: Multiplan Commercial |
$396.00
|
| Rate for Payer: Preferred Network Access Commercial |
$470.25
|
| Rate for Payer: Quartz Beloit One Network |
$217.80
|
| Rate for Payer: Quartz Commercial |
$282.15
|
| Rate for Payer: The Alliance Commercial |
$247.50
|
| Rate for Payer: WEA Trust Commercial |
$272.25
|
| Rate for Payer: WPS Commercial |
$366.65
|
|
|
MA Dig Screen Unilateral Left
|
Facility
|
OP
|
$495.00
|
|
|
Service Code
|
CPT 77067 TC,LT
|
| Hospital Charge Code |
5478934
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$138.60 |
| Max. Negotiated Rate |
$1,980.00 |
| Rate for Payer: Aetna Commercial |
$445.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$425.70
|
| Rate for Payer: Aetna Managed Medicare |
$138.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$349.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$259.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$246.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$262.35
|
| Rate for Payer: Cash Price |
$148.50
|
| Rate for Payer: Cash Price |
$148.50
|
| Rate for Payer: Cigna Commercial |
$455.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$277.00
|
| Rate for Payer: Health EOS Commercial |
$440.55
|
| Rate for Payer: HFN Commercial |
$455.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$371.25
|
| Rate for Payer: Multiplan Commercial |
$396.00
|
| Rate for Payer: NAPHCARE Commercial |
$297.00
|
| Rate for Payer: Preferred Network Access Commercial |
$455.40
|
| Rate for Payer: Quartz Beloit One Network |
$242.55
|
| Rate for Payer: Quartz Commercial |
$321.75
|
| Rate for Payer: Quartz Medicare Advantage |
$297.00
|
| Rate for Payer: The Alliance Commercial |
$1,980.00
|
| Rate for Payer: United Healthcare PPO |
$371.25
|
| Rate for Payer: WEA Trust Commercial |
$272.25
|
| Rate for Payer: WPS Commercial |
$366.65
|
|
|
MA Dig Screen Unilateral Left
|
Facility
|
IP
|
$495.00
|
|
|
Service Code
|
CPT 77067 TC,LT
|
| Hospital Charge Code |
5478934
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$242.55 |
| Max. Negotiated Rate |
$455.40 |
| Rate for Payer: Aetna Commercial |
$445.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$425.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$262.35
|
| Rate for Payer: Cash Price |
$148.50
|
| Rate for Payer: Cigna Commercial |
$455.40
|
| Rate for Payer: Health EOS Commercial |
$440.55
|
| Rate for Payer: HFN Commercial |
$455.40
|
| Rate for Payer: Multiplan Commercial |
$396.00
|
| Rate for Payer: NAPHCARE Commercial |
$297.00
|
| Rate for Payer: Preferred Network Access Commercial |
$455.40
|
| Rate for Payer: Quartz Beloit One Network |
$242.55
|
| Rate for Payer: Quartz Commercial |
$297.00
|
| Rate for Payer: WEA Trust Commercial |
$272.25
|
| Rate for Payer: WPS Commercial |
$366.65
|
|
|
MA Dig Screen Unilateral Right
|
Facility
|
IP
|
$495.00
|
|
|
Service Code
|
CPT 77067 TC,RT
|
| Hospital Charge Code |
5478935
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$242.55 |
| Max. Negotiated Rate |
$455.40 |
| Rate for Payer: Aetna Commercial |
$445.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$425.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$262.35
|
| Rate for Payer: Cash Price |
$148.50
|
| Rate for Payer: Cigna Commercial |
$455.40
|
| Rate for Payer: Health EOS Commercial |
$440.55
|
| Rate for Payer: HFN Commercial |
$455.40
|
| Rate for Payer: Multiplan Commercial |
$396.00
|
| Rate for Payer: NAPHCARE Commercial |
$297.00
|
| Rate for Payer: Preferred Network Access Commercial |
$455.40
|
| Rate for Payer: Quartz Beloit One Network |
$242.55
|
| Rate for Payer: Quartz Commercial |
$297.00
|
| Rate for Payer: WEA Trust Commercial |
$272.25
|
| Rate for Payer: WPS Commercial |
$366.65
|
|
|
MA Dig Screen Unilateral Right
|
Facility
|
OP
|
$495.00
|
|
|
Service Code
|
CPT 77067 TC,RT
|
| Hospital Charge Code |
5478935
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$138.60 |
| Max. Negotiated Rate |
$1,980.00 |
| Rate for Payer: Aetna Commercial |
$445.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$425.70
|
| Rate for Payer: Aetna Managed Medicare |
$138.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$349.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$259.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$246.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$262.35
|
| Rate for Payer: Cash Price |
$148.50
|
| Rate for Payer: Cash Price |
$148.50
|
| Rate for Payer: Cigna Commercial |
$455.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$277.00
|
| Rate for Payer: Health EOS Commercial |
$440.55
|
| Rate for Payer: HFN Commercial |
$455.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$371.25
|
| Rate for Payer: Multiplan Commercial |
$396.00
|
| Rate for Payer: NAPHCARE Commercial |
$297.00
|
| Rate for Payer: Preferred Network Access Commercial |
$455.40
|
| Rate for Payer: Quartz Beloit One Network |
$242.55
|
| Rate for Payer: Quartz Commercial |
$321.75
|
| Rate for Payer: Quartz Medicare Advantage |
$297.00
|
| Rate for Payer: The Alliance Commercial |
$1,980.00
|
| Rate for Payer: United Healthcare PPO |
$371.25
|
| Rate for Payer: WEA Trust Commercial |
$272.25
|
| Rate for Payer: WPS Commercial |
$366.65
|
|
|
MA Dig Screen Unilateral Right
|
Professional
|
Both
|
$495.00
|
|
|
Service Code
|
CPT 77067 TC,RT
|
| Hospital Charge Code |
5478935
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$217.80 |
| Max. Negotiated Rate |
$470.25 |
| Rate for Payer: Aetna Commercial |
$470.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$425.70
|
| Rate for Payer: Cash Price |
$148.50
|
| Rate for Payer: Cash Price |
$148.50
|
| Rate for Payer: Cash Price |
$148.50
|
| Rate for Payer: Cigna Commercial |
$470.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$247.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$297.00
|
| Rate for Payer: Health EOS Commercial |
$450.45
|
| Rate for Payer: HFN Commercial |
$470.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$448.17
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$448.17
|
| Rate for Payer: Multiplan Commercial |
$396.00
|
| Rate for Payer: Preferred Network Access Commercial |
$470.25
|
| Rate for Payer: Quartz Beloit One Network |
$217.80
|
| Rate for Payer: Quartz Commercial |
$282.15
|
| Rate for Payer: The Alliance Commercial |
$247.50
|
| Rate for Payer: WEA Trust Commercial |
$272.25
|
| Rate for Payer: WPS Commercial |
$366.65
|
|
|
MA Ductogram Or Galactogram Multi Left
|
Facility
|
IP
|
$1,910.00
|
|
|
Service Code
|
CPT 77054
|
| Hospital Charge Code |
3072687
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$935.90 |
| Max. Negotiated Rate |
$1,757.20 |
| Rate for Payer: Aetna Commercial |
$1,719.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,642.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,012.30
|
| Rate for Payer: Cash Price |
$573.00
|
| Rate for Payer: Cigna Commercial |
$1,757.20
|
| Rate for Payer: Health EOS Commercial |
$1,699.90
|
| Rate for Payer: HFN Commercial |
$1,757.20
|
| Rate for Payer: Multiplan Commercial |
$1,528.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,146.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,757.20
|
| Rate for Payer: Quartz Beloit One Network |
$935.90
|
| Rate for Payer: Quartz Commercial |
$1,146.00
|
| Rate for Payer: WEA Trust Commercial |
$1,050.50
|
| Rate for Payer: WPS Commercial |
$1,414.74
|
|
|
MA Ductogram Or Galactogram Multi Left
|
Professional
|
Both
|
$1,910.00
|
|
|
Service Code
|
CPT 77054
|
| Hospital Charge Code |
3072687
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$244.49 |
| Max. Negotiated Rate |
$1,814.50 |
| Rate for Payer: Aetna Commercial |
$1,814.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,642.60
|
| Rate for Payer: Cash Price |
$573.00
|
| Rate for Payer: Cash Price |
$573.00
|
| Rate for Payer: Cash Price |
$573.00
|
| Rate for Payer: Cigna Commercial |
$1,814.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$955.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,146.00
|
| Rate for Payer: Health EOS Commercial |
$1,738.10
|
| Rate for Payer: HFN Commercial |
$1,814.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$244.49
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$244.49
|
| Rate for Payer: Multiplan Commercial |
$1,528.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,814.50
|
| Rate for Payer: Quartz Beloit One Network |
$840.40
|
| Rate for Payer: Quartz Commercial |
$1,088.70
|
| Rate for Payer: The Alliance Commercial |
$955.00
|
| Rate for Payer: WEA Trust Commercial |
$1,050.50
|
| Rate for Payer: WPS Commercial |
$1,414.74
|
|
|
MA Ductogram Or Galactogram Multi Left
|
Facility
|
OP
|
$1,910.00
|
|
|
Service Code
|
CPT 77054
|
| Hospital Charge Code |
3072687
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$242.20 |
| Max. Negotiated Rate |
$1,757.20 |
| Rate for Payer: Aetna Commercial |
$1,719.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,642.60
|
| Rate for Payer: Aetna Managed Medicare |
$242.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$908.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$726.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$690.27
|
| Rate for Payer: Anthem Medicare Advantage |
$242.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,012.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$242.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$242.20
|
| Rate for Payer: Cash Price |
$573.00
|
| Rate for Payer: Cash Price |
$573.00
|
| Rate for Payer: Cash Price |
$573.00
|
| Rate for Payer: Cigna Commercial |
$1,757.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$242.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,068.84
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$242.20
|
| Rate for Payer: Health EOS Commercial |
$1,699.90
|
| Rate for Payer: HFN Commercial |
$1,757.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$900.98
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$242.20
|
| Rate for Payer: Independent Care Health Plan Medicare |
$242.20
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$242.20
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$242.20
|
| Rate for Payer: Multiplan Commercial |
$1,528.00
|
| Rate for Payer: NAPHCARE Commercial |
$363.30
|
| Rate for Payer: Preferred Network Access Commercial |
$1,757.20
|
| Rate for Payer: Quartz Beloit One Network |
$935.90
|
| Rate for Payer: Quartz Commercial |
$1,241.50
|
| Rate for Payer: Quartz Medicare Advantage |
$242.20
|
| Rate for Payer: The Alliance Commercial |
$968.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$242.20
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$1,050.50
|
| Rate for Payer: Wellcare Medicare |
$242.20
|
| Rate for Payer: WPS Commercial |
$1,414.74
|
|
|
MA Ductogram Or Galactogram Single Left
|
Professional
|
Both
|
$1,619.00
|
|
|
Service Code
|
CPT 77053
|
| Hospital Charge Code |
3072688
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$188.15 |
| Max. Negotiated Rate |
$1,538.05 |
| Rate for Payer: Aetna Commercial |
$1,538.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,392.34
|
| Rate for Payer: Cash Price |
$485.70
|
| Rate for Payer: Cash Price |
$485.70
|
| Rate for Payer: Cash Price |
$485.70
|
| Rate for Payer: Cigna Commercial |
$1,538.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$809.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$971.40
|
| Rate for Payer: Health EOS Commercial |
$1,473.29
|
| Rate for Payer: HFN Commercial |
$1,538.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$188.15
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$188.15
|
| Rate for Payer: Multiplan Commercial |
$1,295.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,538.05
|
| Rate for Payer: Quartz Beloit One Network |
$712.36
|
| Rate for Payer: Quartz Commercial |
$922.83
|
| Rate for Payer: The Alliance Commercial |
$809.50
|
| Rate for Payer: WEA Trust Commercial |
$890.45
|
| Rate for Payer: WPS Commercial |
$1,199.19
|
|
|
MA Ductogram Or Galactogram Single Left
|
Facility
|
OP
|
$1,619.00
|
|
|
Service Code
|
CPT 77053
|
| Hospital Charge Code |
3072688
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$242.20 |
| Max. Negotiated Rate |
$1,489.48 |
| Rate for Payer: Aetna Commercial |
$1,457.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,392.34
|
| Rate for Payer: Aetna Managed Medicare |
$242.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$908.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$726.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$690.27
|
| Rate for Payer: Anthem Medicare Advantage |
$242.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$858.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$242.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$242.20
|
| Rate for Payer: Cash Price |
$485.70
|
| Rate for Payer: Cash Price |
$485.70
|
| Rate for Payer: Cash Price |
$485.70
|
| Rate for Payer: Cigna Commercial |
$1,489.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$242.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$905.99
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$242.20
|
| Rate for Payer: Health EOS Commercial |
$1,440.91
|
| Rate for Payer: HFN Commercial |
$1,489.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$900.98
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$242.20
|
| Rate for Payer: Independent Care Health Plan Medicare |
$242.20
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$242.20
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$242.20
|
| Rate for Payer: Multiplan Commercial |
$1,295.20
|
| Rate for Payer: NAPHCARE Commercial |
$363.30
|
| Rate for Payer: Preferred Network Access Commercial |
$1,489.48
|
| Rate for Payer: Quartz Beloit One Network |
$793.31
|
| Rate for Payer: Quartz Commercial |
$1,052.35
|
| Rate for Payer: Quartz Medicare Advantage |
$242.20
|
| Rate for Payer: The Alliance Commercial |
$968.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$242.20
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$890.45
|
| Rate for Payer: Wellcare Medicare |
$242.20
|
| Rate for Payer: WPS Commercial |
$1,199.19
|
|
|
MA Ductogram Or Galactogram Single Left
|
Facility
|
IP
|
$1,619.00
|
|
|
Service Code
|
CPT 77053
|
| Hospital Charge Code |
3072688
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$793.31 |
| Max. Negotiated Rate |
$1,489.48 |
| Rate for Payer: Aetna Commercial |
$1,457.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,392.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$858.07
|
| Rate for Payer: Cash Price |
$485.70
|
| Rate for Payer: Cigna Commercial |
$1,489.48
|
| Rate for Payer: Health EOS Commercial |
$1,440.91
|
| Rate for Payer: HFN Commercial |
$1,489.48
|
| Rate for Payer: Multiplan Commercial |
$1,295.20
|
| Rate for Payer: NAPHCARE Commercial |
$971.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,489.48
|
| Rate for Payer: Quartz Beloit One Network |
$793.31
|
| Rate for Payer: Quartz Commercial |
$971.40
|
| Rate for Payer: WEA Trust Commercial |
$890.45
|
| Rate for Payer: WPS Commercial |
$1,199.19
|
|
|
MA Ductogram Or Galactogram Single Right
|
Professional
|
Both
|
$1,619.00
|
|
|
Service Code
|
CPT 77053
|
| Hospital Charge Code |
3072689
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$188.15 |
| Max. Negotiated Rate |
$1,538.05 |
| Rate for Payer: Aetna Commercial |
$1,538.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,392.34
|
| Rate for Payer: Cash Price |
$485.70
|
| Rate for Payer: Cash Price |
$485.70
|
| Rate for Payer: Cash Price |
$485.70
|
| Rate for Payer: Cigna Commercial |
$1,538.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$809.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$971.40
|
| Rate for Payer: Health EOS Commercial |
$1,473.29
|
| Rate for Payer: HFN Commercial |
$1,538.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$188.15
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$188.15
|
| Rate for Payer: Multiplan Commercial |
$1,295.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,538.05
|
| Rate for Payer: Quartz Beloit One Network |
$712.36
|
| Rate for Payer: Quartz Commercial |
$922.83
|
| Rate for Payer: The Alliance Commercial |
$809.50
|
| Rate for Payer: WEA Trust Commercial |
$890.45
|
| Rate for Payer: WPS Commercial |
$1,199.19
|
|
|
MA Ductogram Or Galactogram Single Right
|
Facility
|
IP
|
$1,619.00
|
|
|
Service Code
|
CPT 77053
|
| Hospital Charge Code |
3072689
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$793.31 |
| Max. Negotiated Rate |
$1,489.48 |
| Rate for Payer: Aetna Commercial |
$1,457.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,392.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$858.07
|
| Rate for Payer: Cash Price |
$485.70
|
| Rate for Payer: Cigna Commercial |
$1,489.48
|
| Rate for Payer: Health EOS Commercial |
$1,440.91
|
| Rate for Payer: HFN Commercial |
$1,489.48
|
| Rate for Payer: Multiplan Commercial |
$1,295.20
|
| Rate for Payer: NAPHCARE Commercial |
$971.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,489.48
|
| Rate for Payer: Quartz Beloit One Network |
$793.31
|
| Rate for Payer: Quartz Commercial |
$971.40
|
| Rate for Payer: WEA Trust Commercial |
$890.45
|
| Rate for Payer: WPS Commercial |
$1,199.19
|
|
|
MA Ductogram Or Galactogram Single Right
|
Facility
|
OP
|
$1,619.00
|
|
|
Service Code
|
CPT 77053
|
| Hospital Charge Code |
3072689
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$242.20 |
| Max. Negotiated Rate |
$1,489.48 |
| Rate for Payer: Aetna Commercial |
$1,457.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,392.34
|
| Rate for Payer: Aetna Managed Medicare |
$242.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$908.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$726.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$690.27
|
| Rate for Payer: Anthem Medicare Advantage |
$242.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$858.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$242.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$242.20
|
| Rate for Payer: Cash Price |
$485.70
|
| Rate for Payer: Cash Price |
$485.70
|
| Rate for Payer: Cash Price |
$485.70
|
| Rate for Payer: Cigna Commercial |
$1,489.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$242.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$905.99
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$242.20
|
| Rate for Payer: Health EOS Commercial |
$1,440.91
|
| Rate for Payer: HFN Commercial |
$1,489.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$900.98
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$242.20
|
| Rate for Payer: Independent Care Health Plan Medicare |
$242.20
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$242.20
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$242.20
|
| Rate for Payer: Multiplan Commercial |
$1,295.20
|
| Rate for Payer: NAPHCARE Commercial |
$363.30
|
| Rate for Payer: Preferred Network Access Commercial |
$1,489.48
|
| Rate for Payer: Quartz Beloit One Network |
$793.31
|
| Rate for Payer: Quartz Commercial |
$1,052.35
|
| Rate for Payer: Quartz Medicare Advantage |
$242.20
|
| Rate for Payer: The Alliance Commercial |
$968.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$242.20
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$890.45
|
| Rate for Payer: Wellcare Medicare |
$242.20
|
| Rate for Payer: WPS Commercial |
$1,199.19
|
|
