Mammograms: Screening vs. Diagnostic Costs
By HealthPriceCompare - Jul 7, 2023
The cost of a mammogram can vary depending on various factors, including whether it's for screening or diagnostic purposes, the location, the insurance contracted prices in effect between your insurance company and provider and the individual's type of insurance coverage.
There are two types of mammograms: screening mammograms and diagnostic mammograms. Screening mammograms are used to screen for breast cancer in women who are at average risk. Diagnostic mammograms are used to investigate abnormalities that have been found on a screening mammogram or in a woman who is at high risk for breast cancer.
Hospital standard charges data indicate that contracted prices for a screening mammogram range from $40 in Missouri to $2,457 in Nevada. Discounted cash prices similarly range from $41 in Illinois to $1,676 in California.
For diagnostic procedures, insurance contracted prices for a diagnostic mammogram range from $1,871 in New York to $14 in Washington DC while discounted cash prices range from $2,688 in Massachusetts to $29 in California.
If more detailed imaging is needed an MRI scan of both breasts will be ordered and can range from $76 in Iowa to $11,881 in Florida. Discounted cash prices correspondingly range from $146 in Massachusetts to $10,001 in Alabama.
The cost of a mammogram can vary depending on the location where the mammogram is performed. Mammograms that are performed in rural areas are often less expensive than mammograms that are performed in urban areas.
The exact cost will ultimately depend on the specific insurance plan and the payer-specific negotiated charges, which can vary significantly, between the healthcare provider and the insurer. Healthcare consumers have traditionally been unable to access this information but digital tools like HealthPriceCompare can now inform these decisions.
The Role of Insurance Coverage
If you have insurance, your insurance may cover part or all of the cost of the mammogram. However, you may still have to pay a copayment or deductible.
The Affordable Care Act (ACA) requires most health insurance plans to cover screening mammograms for women ages 40 and older with no out-of-pocket expenses. The ACA also requires most health insurance plans to cover diagnostic mammograms for women with symptoms or a family history of breast cancer. Additional factors may affect your insurance coverage for mammograms including:
Age: If you are under the age of 40, your insurance may not cover screening mammograms. Some insurance plans do cover screening mammograms for women under the age of 40 if they are at high risk for breast cancer.
Insurance Plan: The specific coverage of mammograms can vary depending on your insurance plan. Some insurance plans cover all screening mammograms, while others only cover mammograms every two years or every three years.
Plan Deductible: If you have a deductible, you may have to pay a portion of the cost of the mammogram until you meet your deductible.
Plan Coinsurance: If you have coinsurance, you may have to pay a percentage of the cost of the mammogram after you have met your deductible.
An Important Difference
90% women will typically have a normal mammogram result that will not require additional testing. After that first mammogram, women who did not have a normal mammogram will then need to be tested diagnostically which will require another mammogram, a breast ultrasound, breast MRI, or even a biopsy will be ordered by their physician. This is where it can get expensive because these additional tests are typically not covered by insurance if the patient is a high-deductible health plan.
Mammograms continue to be a clinically proven screening tool that is typically covered in full by insurance. For the 10% of patients that need additional testing, the right financially preventive measures can and should be taken to determine your insurance plan's contracted prices and the discounted cash prices offered by your provider.