|
MA Mammogram Digital Diag Right w/ CAD
|
Facility
|
IP
|
$393.00
|
|
|
Service Code
|
CPT 77065 TC,RT
|
| Hospital Charge Code |
5144749
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$192.57 |
| Max. Negotiated Rate |
$361.56 |
| Rate for Payer: Aetna Commercial |
$353.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$337.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$208.29
|
| Rate for Payer: Cash Price |
$117.90
|
| Rate for Payer: Cigna Commercial |
$361.56
|
| Rate for Payer: Health EOS Commercial |
$349.77
|
| Rate for Payer: HFN Commercial |
$361.56
|
| Rate for Payer: Multiplan Commercial |
$314.40
|
| Rate for Payer: NAPHCARE Commercial |
$235.80
|
| Rate for Payer: Preferred Network Access Commercial |
$361.56
|
| Rate for Payer: Quartz Beloit One Network |
$192.57
|
| Rate for Payer: Quartz Commercial |
$235.80
|
| Rate for Payer: WEA Trust Commercial |
$216.15
|
| Rate for Payer: WPS Commercial |
$291.10
|
|
|
MA Mammogram Digital Screening
|
Facility
|
OP
|
$495.00
|
|
|
Service Code
|
CPT 77067 TC
|
| Hospital Charge Code |
1268831
|
|
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 Mammogram Digital Screening
|
Professional
|
Both
|
$495.00
|
|
|
Service Code
|
CPT 77067 TC
|
| Hospital Charge Code |
1268831
|
|
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 |
$320.59
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$320.59
|
| 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 Mammogram Digital Screening
|
Facility
|
IP
|
$495.00
|
|
|
Service Code
|
CPT 77067 TC
|
| Hospital Charge Code |
1268831
|
|
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 Mammogram Digital Screening Left
|
Facility
|
IP
|
$495.00
|
|
|
Service Code
|
CPT 77067 LT,TC
|
| Hospital Charge Code |
1360819
|
|
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 Mammogram Digital Screening Left
|
Facility
|
OP
|
$495.00
|
|
|
Service Code
|
CPT 77067 LT,TC
|
| Hospital Charge Code |
1360819
|
|
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 Mammogram Digital Screening Left
|
Professional
|
Both
|
$495.00
|
|
|
Service Code
|
CPT 77067 LT,TC
|
| Hospital Charge Code |
1360819
|
|
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 Mammogram Digital Screening LT w/ CAD
|
Professional
|
Both
|
$405.00
|
|
|
Service Code
|
CPT 77067 TC,LT
|
| Hospital Charge Code |
5144752
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$178.20 |
| Max. Negotiated Rate |
$448.17 |
| Rate for Payer: Aetna Commercial |
$384.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$348.30
|
| Rate for Payer: Cash Price |
$121.50
|
| Rate for Payer: Cash Price |
$121.50
|
| Rate for Payer: Cash Price |
$121.50
|
| Rate for Payer: Cigna Commercial |
$384.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$202.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$243.00
|
| Rate for Payer: Health EOS Commercial |
$368.55
|
| Rate for Payer: HFN Commercial |
$384.75
|
| 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 |
$324.00
|
| Rate for Payer: Preferred Network Access Commercial |
$384.75
|
| Rate for Payer: Quartz Beloit One Network |
$178.20
|
| Rate for Payer: Quartz Commercial |
$230.85
|
| Rate for Payer: The Alliance Commercial |
$202.50
|
| Rate for Payer: WEA Trust Commercial |
$222.75
|
| Rate for Payer: WPS Commercial |
$299.98
|
|
|
MA Mammogram Digital Screening LT w/ CAD
|
Facility
|
IP
|
$405.00
|
|
|
Service Code
|
CPT 77067 TC,LT
|
| Hospital Charge Code |
5144752
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$198.45 |
| Max. Negotiated Rate |
$372.60 |
| Rate for Payer: Aetna Commercial |
$364.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$348.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$214.65
|
| Rate for Payer: Cash Price |
$121.50
|
| Rate for Payer: Cigna Commercial |
$372.60
|
| Rate for Payer: Health EOS Commercial |
$360.45
|
| Rate for Payer: HFN Commercial |
$372.60
|
| Rate for Payer: Multiplan Commercial |
$324.00
|
| Rate for Payer: NAPHCARE Commercial |
$243.00
|
| Rate for Payer: Preferred Network Access Commercial |
$372.60
|
| Rate for Payer: Quartz Beloit One Network |
$198.45
|
| Rate for Payer: Quartz Commercial |
$243.00
|
| Rate for Payer: WEA Trust Commercial |
$222.75
|
| Rate for Payer: WPS Commercial |
$299.98
|
|
|
MA Mammogram Digital Screening LT w/ CAD
|
Facility
|
OP
|
$405.00
|
|
|
Service Code
|
CPT 77067 TC,LT
|
| Hospital Charge Code |
5144752
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$113.40 |
| Max. Negotiated Rate |
$1,620.00 |
| Rate for Payer: Aetna Commercial |
$364.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$348.30
|
| Rate for Payer: Aetna Managed Medicare |
$113.40
|
| 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 |
$214.65
|
| Rate for Payer: Cash Price |
$121.50
|
| Rate for Payer: Cash Price |
$121.50
|
| Rate for Payer: Cigna Commercial |
$372.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$226.64
|
| Rate for Payer: Health EOS Commercial |
$360.45
|
| Rate for Payer: HFN Commercial |
$372.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$303.75
|
| Rate for Payer: Multiplan Commercial |
$324.00
|
| Rate for Payer: NAPHCARE Commercial |
$243.00
|
| Rate for Payer: Preferred Network Access Commercial |
$372.60
|
| Rate for Payer: Quartz Beloit One Network |
$198.45
|
| Rate for Payer: Quartz Commercial |
$263.25
|
| Rate for Payer: Quartz Medicare Advantage |
$243.00
|
| Rate for Payer: The Alliance Commercial |
$1,620.00
|
| Rate for Payer: United Healthcare PPO |
$303.75
|
| Rate for Payer: WEA Trust Commercial |
$222.75
|
| Rate for Payer: WPS Commercial |
$299.98
|
|
|
MA Mammogram Digital Screening Right
|
Facility
|
OP
|
$495.00
|
|
|
Service Code
|
CPT 77067 RT,TC
|
| Hospital Charge Code |
1360822
|
|
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 Mammogram Digital Screening Right
|
Professional
|
Both
|
$495.00
|
|
|
Service Code
|
CPT 77067 RT,TC
|
| Hospital Charge Code |
1360822
|
|
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 Mammogram Digital Screening Right
|
Facility
|
IP
|
$495.00
|
|
|
Service Code
|
CPT 77067 RT,TC
|
| Hospital Charge Code |
1360822
|
|
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 Mammogram Digital Screening RT w/ CAD
|
Facility
|
IP
|
$405.00
|
|
|
Service Code
|
CPT 77067 TC,RT
|
| Hospital Charge Code |
5144755
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$198.45 |
| Max. Negotiated Rate |
$372.60 |
| Rate for Payer: Aetna Commercial |
$364.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$348.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$214.65
|
| Rate for Payer: Cash Price |
$121.50
|
| Rate for Payer: Cigna Commercial |
$372.60
|
| Rate for Payer: Health EOS Commercial |
$360.45
|
| Rate for Payer: HFN Commercial |
$372.60
|
| Rate for Payer: Multiplan Commercial |
$324.00
|
| Rate for Payer: NAPHCARE Commercial |
$243.00
|
| Rate for Payer: Preferred Network Access Commercial |
$372.60
|
| Rate for Payer: Quartz Beloit One Network |
$198.45
|
| Rate for Payer: Quartz Commercial |
$243.00
|
| Rate for Payer: WEA Trust Commercial |
$222.75
|
| Rate for Payer: WPS Commercial |
$299.98
|
|
|
MA Mammogram Digital Screening RT w/ CAD
|
Facility
|
OP
|
$405.00
|
|
|
Service Code
|
CPT 77067 TC,RT
|
| Hospital Charge Code |
5144755
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$113.40 |
| Max. Negotiated Rate |
$1,620.00 |
| Rate for Payer: Aetna Commercial |
$364.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$348.30
|
| Rate for Payer: Aetna Managed Medicare |
$113.40
|
| 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 |
$214.65
|
| Rate for Payer: Cash Price |
$121.50
|
| Rate for Payer: Cash Price |
$121.50
|
| Rate for Payer: Cigna Commercial |
$372.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$226.64
|
| Rate for Payer: Health EOS Commercial |
$360.45
|
| Rate for Payer: HFN Commercial |
$372.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$303.75
|
| Rate for Payer: Multiplan Commercial |
$324.00
|
| Rate for Payer: NAPHCARE Commercial |
$243.00
|
| Rate for Payer: Preferred Network Access Commercial |
$372.60
|
| Rate for Payer: Quartz Beloit One Network |
$198.45
|
| Rate for Payer: Quartz Commercial |
$263.25
|
| Rate for Payer: Quartz Medicare Advantage |
$243.00
|
| Rate for Payer: The Alliance Commercial |
$1,620.00
|
| Rate for Payer: United Healthcare PPO |
$303.75
|
| Rate for Payer: WEA Trust Commercial |
$222.75
|
| Rate for Payer: WPS Commercial |
$299.98
|
|
|
MA Mammogram Digital Screening RT w/ CAD
|
Professional
|
Both
|
$405.00
|
|
|
Service Code
|
CPT 77067 TC,RT
|
| Hospital Charge Code |
5144755
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$178.20 |
| Max. Negotiated Rate |
$448.17 |
| Rate for Payer: Aetna Commercial |
$384.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$348.30
|
| Rate for Payer: Cash Price |
$121.50
|
| Rate for Payer: Cash Price |
$121.50
|
| Rate for Payer: Cash Price |
$121.50
|
| Rate for Payer: Cigna Commercial |
$384.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$202.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$243.00
|
| Rate for Payer: Health EOS Commercial |
$368.55
|
| Rate for Payer: HFN Commercial |
$384.75
|
| 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 |
$324.00
|
| Rate for Payer: Preferred Network Access Commercial |
$384.75
|
| Rate for Payer: Quartz Beloit One Network |
$178.20
|
| Rate for Payer: Quartz Commercial |
$230.85
|
| Rate for Payer: The Alliance Commercial |
$202.50
|
| Rate for Payer: WEA Trust Commercial |
$222.75
|
| Rate for Payer: WPS Commercial |
$299.98
|
|
|
Ma Mammogram Digital Screening w/ CAD
|
Facility
|
OP
|
$394.00
|
|
|
Service Code
|
CPT 77067 TC
|
| Hospital Charge Code |
5144758
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$110.32 |
| Max. Negotiated Rate |
$1,576.00 |
| Rate for Payer: Aetna Commercial |
$354.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$338.84
|
| Rate for Payer: Aetna Managed Medicare |
$110.32
|
| 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 |
$208.82
|
| Rate for Payer: Cash Price |
$118.20
|
| Rate for Payer: Cash Price |
$118.20
|
| Rate for Payer: Cigna Commercial |
$362.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$220.48
|
| Rate for Payer: Health EOS Commercial |
$350.66
|
| Rate for Payer: HFN Commercial |
$362.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$295.50
|
| Rate for Payer: Multiplan Commercial |
$315.20
|
| Rate for Payer: NAPHCARE Commercial |
$236.40
|
| Rate for Payer: Preferred Network Access Commercial |
$362.48
|
| Rate for Payer: Quartz Beloit One Network |
$193.06
|
| Rate for Payer: Quartz Commercial |
$256.10
|
| Rate for Payer: Quartz Medicare Advantage |
$236.40
|
| Rate for Payer: The Alliance Commercial |
$1,576.00
|
| Rate for Payer: United Healthcare PPO |
$295.50
|
| Rate for Payer: WEA Trust Commercial |
$216.70
|
| Rate for Payer: WPS Commercial |
$291.84
|
|
|
Ma Mammogram Digital Screening w/ CAD
|
Professional
|
Both
|
$394.00
|
|
|
Service Code
|
CPT 77067 TC
|
| Hospital Charge Code |
5144758
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$173.36 |
| Max. Negotiated Rate |
$374.30 |
| Rate for Payer: Aetna Commercial |
$374.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$338.84
|
| Rate for Payer: Cash Price |
$118.20
|
| Rate for Payer: Cash Price |
$118.20
|
| Rate for Payer: Cash Price |
$118.20
|
| Rate for Payer: Cigna Commercial |
$374.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$197.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$236.40
|
| Rate for Payer: Health EOS Commercial |
$358.54
|
| Rate for Payer: HFN Commercial |
$374.30
|
| 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 |
$315.20
|
| Rate for Payer: Preferred Network Access Commercial |
$374.30
|
| Rate for Payer: Quartz Beloit One Network |
$173.36
|
| Rate for Payer: Quartz Commercial |
$224.58
|
| Rate for Payer: The Alliance Commercial |
$197.00
|
| Rate for Payer: WEA Trust Commercial |
$216.70
|
| Rate for Payer: WPS Commercial |
$291.84
|
|
|
Ma Mammogram Digital Screening w/ CAD
|
Facility
|
IP
|
$394.00
|
|
|
Service Code
|
CPT 77067 TC
|
| Hospital Charge Code |
5144758
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$193.06 |
| Max. Negotiated Rate |
$362.48 |
| Rate for Payer: Aetna Commercial |
$354.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$338.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$208.82
|
| Rate for Payer: Cash Price |
$118.20
|
| Rate for Payer: Cigna Commercial |
$362.48
|
| Rate for Payer: Health EOS Commercial |
$350.66
|
| Rate for Payer: HFN Commercial |
$362.48
|
| Rate for Payer: Multiplan Commercial |
$315.20
|
| Rate for Payer: NAPHCARE Commercial |
$236.40
|
| Rate for Payer: Preferred Network Access Commercial |
$362.48
|
| Rate for Payer: Quartz Beloit One Network |
$193.06
|
| Rate for Payer: Quartz Commercial |
$236.40
|
| Rate for Payer: WEA Trust Commercial |
$216.70
|
| Rate for Payer: WPS Commercial |
$291.84
|
|
|
MA Mammogram Digital WWHSP Diag Bilat
|
Facility
|
IP
|
$445.00
|
|
|
Service Code
|
CPT 77066
|
| Hospital Charge Code |
1360825
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$218.05 |
| Max. Negotiated Rate |
$409.40 |
| Rate for Payer: Aetna Commercial |
$400.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$382.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$235.85
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cigna Commercial |
$409.40
|
| Rate for Payer: Health EOS Commercial |
$396.05
|
| Rate for Payer: HFN Commercial |
$409.40
|
| Rate for Payer: Multiplan Commercial |
$356.00
|
| Rate for Payer: NAPHCARE Commercial |
$267.00
|
| Rate for Payer: Preferred Network Access Commercial |
$409.40
|
| Rate for Payer: Quartz Beloit One Network |
$218.05
|
| Rate for Payer: Quartz Commercial |
$267.00
|
| Rate for Payer: WEA Trust Commercial |
$244.75
|
| Rate for Payer: WPS Commercial |
$329.61
|
|
|
MA Mammogram Digital WWHSP Diag Bilat
|
Facility
|
OP
|
$701.00
|
|
| Hospital Charge Code |
1360804
|
| Min. Negotiated Rate |
$196.28 |
| Max. Negotiated Rate |
$2,804.00 |
| Rate for Payer: Aetna Commercial |
$630.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$602.86
|
| Rate for Payer: Aetna Managed Medicare |
$196.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$455.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$350.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$336.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$371.53
|
| Rate for Payer: Cash Price |
$210.30
|
| Rate for Payer: Cigna Commercial |
$644.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$392.28
|
| Rate for Payer: Health EOS Commercial |
$623.89
|
| Rate for Payer: HFN Commercial |
$644.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$525.75
|
| Rate for Payer: Multiplan Commercial |
$560.80
|
| Rate for Payer: NAPHCARE Commercial |
$420.60
|
| Rate for Payer: Preferred Network Access Commercial |
$644.92
|
| Rate for Payer: Quartz Beloit One Network |
$343.49
|
| Rate for Payer: Quartz Commercial |
$455.65
|
| Rate for Payer: Quartz Medicare Advantage |
$420.60
|
| Rate for Payer: The Alliance Commercial |
$2,804.00
|
| Rate for Payer: WEA Trust Commercial |
$385.55
|
| Rate for Payer: WPS Commercial |
$519.23
|
|
|
MA Mammogram Digital WWHSP Diag Bilat
|
Professional
|
Both
|
$701.00
|
|
| Hospital Charge Code |
1360804
|
| Min. Negotiated Rate |
$308.44 |
| Max. Negotiated Rate |
$665.95 |
| Rate for Payer: Aetna Commercial |
$665.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$602.86
|
| Rate for Payer: Cash Price |
$210.30
|
| Rate for Payer: Cigna Commercial |
$665.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$350.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$420.60
|
| Rate for Payer: Health EOS Commercial |
$637.91
|
| Rate for Payer: HFN Commercial |
$665.95
|
| Rate for Payer: Multiplan Commercial |
$560.80
|
| Rate for Payer: Preferred Network Access Commercial |
$665.95
|
| Rate for Payer: Quartz Beloit One Network |
$308.44
|
| Rate for Payer: Quartz Commercial |
$399.57
|
| Rate for Payer: The Alliance Commercial |
$350.50
|
| Rate for Payer: WEA Trust Commercial |
$385.55
|
| Rate for Payer: WPS Commercial |
$519.23
|
|
|
MA Mammogram Digital WWHSP Diag Bilat
|
Facility
|
IP
|
$701.00
|
|
| Hospital Charge Code |
1360804
|
| Min. Negotiated Rate |
$343.49 |
| Max. Negotiated Rate |
$644.92 |
| Rate for Payer: Aetna Commercial |
$630.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$602.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$371.53
|
| Rate for Payer: Cash Price |
$210.30
|
| Rate for Payer: Cigna Commercial |
$644.92
|
| Rate for Payer: Health EOS Commercial |
$623.89
|
| Rate for Payer: HFN Commercial |
$644.92
|
| Rate for Payer: Multiplan Commercial |
$560.80
|
| Rate for Payer: NAPHCARE Commercial |
$420.60
|
| Rate for Payer: Preferred Network Access Commercial |
$644.92
|
| Rate for Payer: Quartz Beloit One Network |
$343.49
|
| Rate for Payer: Quartz Commercial |
$420.60
|
| Rate for Payer: WEA Trust Commercial |
$385.55
|
| Rate for Payer: WPS Commercial |
$519.23
|
|
|
MA Mammogram Digital WWHSP Diag Bilat
|
Professional
|
Both
|
$445.00
|
|
|
Service Code
|
CPT 77066
|
| Hospital Charge Code |
1360825
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$195.80 |
| Max. Negotiated Rate |
$554.67 |
| Rate for Payer: Aetna Commercial |
$422.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$382.70
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cigna Commercial |
$422.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$222.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$267.00
|
| Rate for Payer: Health EOS Commercial |
$404.95
|
| Rate for Payer: HFN Commercial |
$422.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$554.67
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$554.67
|
| Rate for Payer: Multiplan Commercial |
$356.00
|
| Rate for Payer: Preferred Network Access Commercial |
$422.75
|
| Rate for Payer: Quartz Beloit One Network |
$195.80
|
| Rate for Payer: Quartz Commercial |
$253.65
|
| Rate for Payer: The Alliance Commercial |
$222.50
|
| Rate for Payer: WEA Trust Commercial |
$244.75
|
| Rate for Payer: WPS Commercial |
$329.61
|
|
|
MA Mammogram Digital WWHSP Diag Bilat
|
Facility
|
OP
|
$445.00
|
|
|
Service Code
|
CPT 77066
|
| Hospital Charge Code |
1360825
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$124.60 |
| Max. Negotiated Rate |
$1,780.00 |
| Rate for Payer: Aetna Commercial |
$400.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$382.70
|
| Rate for Payer: Aetna Managed Medicare |
$124.60
|
| 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 |
$235.85
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cigna Commercial |
$409.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$249.02
|
| Rate for Payer: Health EOS Commercial |
$396.05
|
| Rate for Payer: HFN Commercial |
$409.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$333.75
|
| Rate for Payer: Multiplan Commercial |
$356.00
|
| Rate for Payer: NAPHCARE Commercial |
$267.00
|
| Rate for Payer: Preferred Network Access Commercial |
$409.40
|
| Rate for Payer: Quartz Beloit One Network |
$218.05
|
| Rate for Payer: Quartz Commercial |
$289.25
|
| Rate for Payer: Quartz Medicare Advantage |
$267.00
|
| Rate for Payer: The Alliance Commercial |
$1,780.00
|
| Rate for Payer: United Healthcare PPO |
$333.75
|
| Rate for Payer: WEA Trust Commercial |
$244.75
|
| Rate for Payer: WPS Commercial |
$329.61
|
|
