|
Factor VIII Assay
|
Facility
|
OP
|
$947.00
|
|
|
Service Code
|
CPT 85240
|
| Hospital Charge Code |
977943
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$9.84 |
| Max. Negotiated Rate |
$871.24 |
| Rate for Payer: Aetna Commercial |
$852.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$814.42
|
| Rate for Payer: Aetna Managed Medicare |
$17.90
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$67.12
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$31.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$29.71
|
| Rate for Payer: Anthem Medicaid |
$9.84
|
| Rate for Payer: Anthem Medicare Advantage |
$17.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$501.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.90
|
| Rate for Payer: Cash Price |
$284.10
|
| Rate for Payer: Cash Price |
$284.10
|
| Rate for Payer: Cigna Commercial |
$871.24
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$17.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$9.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$529.94
|
| Rate for Payer: Dean Health Medicaid |
$9.84
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$17.90
|
| Rate for Payer: Health EOS Commercial |
$842.83
|
| Rate for Payer: HFN Commercial |
$871.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$66.59
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17.90
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$9.84
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.90
|
| Rate for Payer: Managed Health Services Medicaid |
$10.23
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$17.90
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$17.90
|
| Rate for Payer: Multiplan Commercial |
$757.60
|
| Rate for Payer: NAPHCARE Commercial |
$26.85
|
| Rate for Payer: Preferred Network Access Commercial |
$871.24
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$9.84
|
| Rate for Payer: Quartz Beloit One Network |
$464.03
|
| Rate for Payer: Quartz Commercial |
$615.55
|
| Rate for Payer: Quartz Medicare Advantage |
$17.90
|
| Rate for Payer: The Alliance Commercial |
$71.60
|
| Rate for Payer: United Healthcare Medicaid |
$9.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.90
|
| Rate for Payer: United Healthcare PPO |
$710.25
|
| Rate for Payer: WEA Trust Commercial |
$520.85
|
| Rate for Payer: Wellcare Medicare |
$17.90
|
| Rate for Payer: WMAP Medicaid |
$9.84
|
| Rate for Payer: WPS Commercial |
$701.44
|
|
|
Factor VIII Assay
|
Facility
|
IP
|
$947.00
|
|
|
Service Code
|
CPT 85240
|
| Hospital Charge Code |
977943
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$464.03 |
| Max. Negotiated Rate |
$871.24 |
| Rate for Payer: Aetna Commercial |
$852.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$814.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$501.91
|
| Rate for Payer: Cash Price |
$284.10
|
| Rate for Payer: Cigna Commercial |
$871.24
|
| Rate for Payer: Health EOS Commercial |
$842.83
|
| Rate for Payer: HFN Commercial |
$871.24
|
| Rate for Payer: Multiplan Commercial |
$757.60
|
| Rate for Payer: NAPHCARE Commercial |
$568.20
|
| Rate for Payer: Preferred Network Access Commercial |
$871.24
|
| Rate for Payer: Quartz Beloit One Network |
$464.03
|
| Rate for Payer: Quartz Commercial |
$568.20
|
| Rate for Payer: WEA Trust Commercial |
$520.85
|
| Rate for Payer: WPS Commercial |
$701.44
|
|
|
Factor VIII Assay
|
Facility
|
IP
|
$967.00
|
|
|
Service Code
|
CPT 85240
|
| Hospital Charge Code |
2943026
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$473.83 |
| Max. Negotiated Rate |
$889.64 |
| Rate for Payer: Aetna Commercial |
$870.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$831.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$512.51
|
| Rate for Payer: Cash Price |
$290.10
|
| Rate for Payer: Cigna Commercial |
$889.64
|
| Rate for Payer: Health EOS Commercial |
$860.63
|
| Rate for Payer: HFN Commercial |
$889.64
|
| Rate for Payer: Multiplan Commercial |
$773.60
|
| Rate for Payer: NAPHCARE Commercial |
$580.20
|
| Rate for Payer: Preferred Network Access Commercial |
$889.64
|
| Rate for Payer: Quartz Beloit One Network |
$473.83
|
| Rate for Payer: Quartz Commercial |
$580.20
|
| Rate for Payer: WEA Trust Commercial |
$531.85
|
| Rate for Payer: WPS Commercial |
$716.26
|
|
|
Factor VIII Assay
|
Facility
|
OP
|
$967.00
|
|
|
Service Code
|
CPT 85240
|
| Hospital Charge Code |
2943026
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$9.84 |
| Max. Negotiated Rate |
$889.64 |
| Rate for Payer: Aetna Commercial |
$870.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$831.62
|
| Rate for Payer: Aetna Managed Medicare |
$17.90
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$67.12
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$31.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$29.71
|
| Rate for Payer: Anthem Medicaid |
$9.84
|
| Rate for Payer: Anthem Medicare Advantage |
$17.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$512.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.90
|
| Rate for Payer: Cash Price |
$290.10
|
| Rate for Payer: Cash Price |
$290.10
|
| Rate for Payer: Cigna Commercial |
$889.64
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$17.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$9.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$541.13
|
| Rate for Payer: Dean Health Medicaid |
$9.84
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$17.90
|
| Rate for Payer: Health EOS Commercial |
$860.63
|
| Rate for Payer: HFN Commercial |
$889.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$66.59
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17.90
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$9.84
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.90
|
| Rate for Payer: Managed Health Services Medicaid |
$10.23
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$17.90
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$17.90
|
| Rate for Payer: Multiplan Commercial |
$773.60
|
| Rate for Payer: NAPHCARE Commercial |
$26.85
|
| Rate for Payer: Preferred Network Access Commercial |
$889.64
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$9.84
|
| Rate for Payer: Quartz Beloit One Network |
$473.83
|
| Rate for Payer: Quartz Commercial |
$628.55
|
| Rate for Payer: Quartz Medicare Advantage |
$17.90
|
| Rate for Payer: The Alliance Commercial |
$71.60
|
| Rate for Payer: United Healthcare Medicaid |
$9.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.90
|
| Rate for Payer: United Healthcare PPO |
$725.25
|
| Rate for Payer: WEA Trust Commercial |
$531.85
|
| Rate for Payer: Wellcare Medicare |
$17.90
|
| Rate for Payer: WMAP Medicaid |
$9.84
|
| Rate for Payer: WPS Commercial |
$716.26
|
|
|
Factor VIII Assay
|
Professional
|
Both
|
$947.00
|
|
|
Service Code
|
CPT 85240
|
| Hospital Charge Code |
977943
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$63.19 |
| Max. Negotiated Rate |
$899.65 |
| Rate for Payer: Aetna Commercial |
$899.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$814.42
|
| Rate for Payer: Cash Price |
$284.10
|
| Rate for Payer: Cash Price |
$284.10
|
| Rate for Payer: Cigna Commercial |
$899.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$473.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$568.20
|
| Rate for Payer: Health EOS Commercial |
$861.77
|
| Rate for Payer: HFN Commercial |
$899.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$63.19
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$63.19
|
| Rate for Payer: Multiplan Commercial |
$757.60
|
| Rate for Payer: Preferred Network Access Commercial |
$899.65
|
| Rate for Payer: Quartz Beloit One Network |
$416.68
|
| Rate for Payer: Quartz Commercial |
$539.79
|
| Rate for Payer: The Alliance Commercial |
$473.50
|
| Rate for Payer: WEA Trust Commercial |
$520.85
|
| Rate for Payer: WPS Commercial |
$701.44
|
|
|
Factor V Leiden
|
Professional
|
Both
|
$788.00
|
|
|
Service Code
|
CPT 81241
|
| Hospital Charge Code |
977942
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$259.00 |
| Max. Negotiated Rate |
$748.60 |
| Rate for Payer: Aetna Commercial |
$748.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$677.68
|
| Rate for Payer: Cash Price |
$236.40
|
| Rate for Payer: Cash Price |
$236.40
|
| Rate for Payer: Cigna Commercial |
$748.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$394.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$472.80
|
| Rate for Payer: Health EOS Commercial |
$717.08
|
| Rate for Payer: HFN Commercial |
$748.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$259.00
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$259.00
|
| Rate for Payer: Multiplan Commercial |
$630.40
|
| Rate for Payer: Preferred Network Access Commercial |
$748.60
|
| Rate for Payer: Quartz Beloit One Network |
$346.72
|
| Rate for Payer: Quartz Commercial |
$449.16
|
| Rate for Payer: The Alliance Commercial |
$394.00
|
| Rate for Payer: WEA Trust Commercial |
$433.40
|
| Rate for Payer: WPS Commercial |
$583.67
|
|
|
Factor V Leiden
|
Facility
|
IP
|
$788.00
|
|
|
Service Code
|
CPT 81241
|
| Hospital Charge Code |
977942
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$386.12 |
| Max. Negotiated Rate |
$724.96 |
| Rate for Payer: Aetna Commercial |
$709.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$677.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$417.64
|
| Rate for Payer: Cash Price |
$236.40
|
| Rate for Payer: Cigna Commercial |
$724.96
|
| Rate for Payer: Health EOS Commercial |
$701.32
|
| Rate for Payer: HFN Commercial |
$724.96
|
| Rate for Payer: Multiplan Commercial |
$630.40
|
| Rate for Payer: NAPHCARE Commercial |
$472.80
|
| Rate for Payer: Preferred Network Access Commercial |
$724.96
|
| Rate for Payer: Quartz Beloit One Network |
$386.12
|
| Rate for Payer: Quartz Commercial |
$472.80
|
| Rate for Payer: WEA Trust Commercial |
$433.40
|
| Rate for Payer: WPS Commercial |
$583.67
|
|
|
Factor V Leiden
|
Facility
|
OP
|
$788.00
|
|
|
Service Code
|
CPT 81241
|
| Hospital Charge Code |
977942
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$66.70 |
| Max. Negotiated Rate |
$724.96 |
| Rate for Payer: Aetna Commercial |
$709.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$677.68
|
| Rate for Payer: Aetna Managed Medicare |
$73.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$275.14
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$128.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$121.79
|
| Rate for Payer: Anthem Medicaid |
$66.70
|
| Rate for Payer: Anthem Medicare Advantage |
$73.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$417.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$73.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$73.37
|
| Rate for Payer: Cash Price |
$236.40
|
| Rate for Payer: Cash Price |
$236.40
|
| Rate for Payer: Cigna Commercial |
$724.96
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$73.37
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$66.70
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$440.96
|
| Rate for Payer: Dean Health Medicaid |
$66.70
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$73.37
|
| Rate for Payer: Health EOS Commercial |
$701.32
|
| Rate for Payer: HFN Commercial |
$724.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$272.94
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$73.37
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$66.70
|
| Rate for Payer: Independent Care Health Plan Medicare |
$73.37
|
| Rate for Payer: Managed Health Services Medicaid |
$69.37
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$73.37
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$73.37
|
| Rate for Payer: Multiplan Commercial |
$630.40
|
| Rate for Payer: NAPHCARE Commercial |
$110.06
|
| Rate for Payer: Preferred Network Access Commercial |
$724.96
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$66.70
|
| Rate for Payer: Quartz Beloit One Network |
$386.12
|
| Rate for Payer: Quartz Commercial |
$512.20
|
| Rate for Payer: Quartz Medicare Advantage |
$73.37
|
| Rate for Payer: The Alliance Commercial |
$293.48
|
| Rate for Payer: United Healthcare Medicaid |
$66.70
|
| Rate for Payer: United Healthcare Medicare Advantage |
$73.37
|
| Rate for Payer: United Healthcare PPO |
$591.00
|
| Rate for Payer: WEA Trust Commercial |
$433.40
|
| Rate for Payer: Wellcare Medicare |
$73.37
|
| Rate for Payer: WMAP Medicaid |
$66.70
|
| Rate for Payer: WPS Commercial |
$583.67
|
|
|
Factor X Assay
|
Facility
|
IP
|
$488.00
|
|
|
Service Code
|
CPT 85260
|
| Hospital Charge Code |
977944
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$239.12 |
| Max. Negotiated Rate |
$448.96 |
| Rate for Payer: Aetna Commercial |
$439.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$419.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$258.64
|
| Rate for Payer: Cash Price |
$146.40
|
| Rate for Payer: Cigna Commercial |
$448.96
|
| Rate for Payer: Health EOS Commercial |
$434.32
|
| Rate for Payer: HFN Commercial |
$448.96
|
| Rate for Payer: Multiplan Commercial |
$390.40
|
| Rate for Payer: NAPHCARE Commercial |
$292.80
|
| Rate for Payer: Preferred Network Access Commercial |
$448.96
|
| Rate for Payer: Quartz Beloit One Network |
$239.12
|
| Rate for Payer: Quartz Commercial |
$292.80
|
| Rate for Payer: WEA Trust Commercial |
$268.40
|
| Rate for Payer: WPS Commercial |
$361.46
|
|
|
Factor X Assay
|
Facility
|
OP
|
$488.00
|
|
|
Service Code
|
CPT 85260
|
| Hospital Charge Code |
977944
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.90 |
| Max. Negotiated Rate |
$448.96 |
| Rate for Payer: Aetna Commercial |
$439.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$419.68
|
| Rate for Payer: Aetna Managed Medicare |
$17.90
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$67.12
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$31.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$29.71
|
| Rate for Payer: Anthem Medicaid |
$18.50
|
| Rate for Payer: Anthem Medicare Advantage |
$17.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$258.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.90
|
| Rate for Payer: Cash Price |
$146.40
|
| Rate for Payer: Cash Price |
$146.40
|
| Rate for Payer: Cigna Commercial |
$448.96
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$17.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$18.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$273.08
|
| Rate for Payer: Dean Health Medicaid |
$18.50
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$17.90
|
| Rate for Payer: Health EOS Commercial |
$434.32
|
| Rate for Payer: HFN Commercial |
$448.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$66.59
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17.90
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$18.50
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.90
|
| Rate for Payer: Managed Health Services Medicaid |
$19.24
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$17.90
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$17.90
|
| Rate for Payer: Multiplan Commercial |
$390.40
|
| Rate for Payer: NAPHCARE Commercial |
$26.85
|
| Rate for Payer: Preferred Network Access Commercial |
$448.96
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$18.50
|
| Rate for Payer: Quartz Beloit One Network |
$239.12
|
| Rate for Payer: Quartz Commercial |
$317.20
|
| Rate for Payer: Quartz Medicare Advantage |
$17.90
|
| Rate for Payer: The Alliance Commercial |
$71.60
|
| Rate for Payer: United Healthcare Medicaid |
$18.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.90
|
| Rate for Payer: United Healthcare PPO |
$366.00
|
| Rate for Payer: WEA Trust Commercial |
$268.40
|
| Rate for Payer: Wellcare Medicare |
$17.90
|
| Rate for Payer: WMAP Medicaid |
$18.50
|
| Rate for Payer: WPS Commercial |
$361.46
|
|
|
Factor X Assay
|
Professional
|
Both
|
$488.00
|
|
|
Service Code
|
CPT 85260
|
| Hospital Charge Code |
977944
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$63.19 |
| Max. Negotiated Rate |
$463.60 |
| Rate for Payer: Aetna Commercial |
$463.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$419.68
|
| Rate for Payer: Cash Price |
$146.40
|
| Rate for Payer: Cash Price |
$146.40
|
| Rate for Payer: Cigna Commercial |
$463.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$244.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$292.80
|
| Rate for Payer: Health EOS Commercial |
$444.08
|
| Rate for Payer: HFN Commercial |
$463.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$63.19
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$63.19
|
| Rate for Payer: Multiplan Commercial |
$390.40
|
| Rate for Payer: Preferred Network Access Commercial |
$463.60
|
| Rate for Payer: Quartz Beloit One Network |
$214.72
|
| Rate for Payer: Quartz Commercial |
$278.16
|
| Rate for Payer: The Alliance Commercial |
$244.00
|
| Rate for Payer: WEA Trust Commercial |
$268.40
|
| Rate for Payer: WPS Commercial |
$361.46
|
|
|
Factor XI Assay
|
Professional
|
Both
|
$389.00
|
|
|
Service Code
|
CPT 85270
|
| Hospital Charge Code |
977945
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$63.19 |
| Max. Negotiated Rate |
$369.55 |
| Rate for Payer: Aetna Commercial |
$369.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$334.54
|
| Rate for Payer: Cash Price |
$116.70
|
| Rate for Payer: Cash Price |
$116.70
|
| Rate for Payer: Cigna Commercial |
$369.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$194.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$233.40
|
| Rate for Payer: Health EOS Commercial |
$353.99
|
| Rate for Payer: HFN Commercial |
$369.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$63.19
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$63.19
|
| Rate for Payer: Multiplan Commercial |
$311.20
|
| Rate for Payer: Preferred Network Access Commercial |
$369.55
|
| Rate for Payer: Quartz Beloit One Network |
$171.16
|
| Rate for Payer: Quartz Commercial |
$221.73
|
| Rate for Payer: The Alliance Commercial |
$194.50
|
| Rate for Payer: WEA Trust Commercial |
$213.95
|
| Rate for Payer: WPS Commercial |
$288.13
|
|
|
Factor XI Assay
|
Facility
|
OP
|
$389.00
|
|
|
Service Code
|
CPT 85270
|
| Hospital Charge Code |
977945
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.90 |
| Max. Negotiated Rate |
$357.88 |
| Rate for Payer: Aetna Commercial |
$350.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$334.54
|
| Rate for Payer: Aetna Managed Medicare |
$17.90
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$67.12
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$31.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$29.71
|
| Rate for Payer: Anthem Medicaid |
$18.50
|
| Rate for Payer: Anthem Medicare Advantage |
$17.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$206.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.90
|
| Rate for Payer: Cash Price |
$116.70
|
| Rate for Payer: Cash Price |
$116.70
|
| Rate for Payer: Cigna Commercial |
$357.88
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$17.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$18.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$217.68
|
| Rate for Payer: Dean Health Medicaid |
$18.50
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$17.90
|
| Rate for Payer: Health EOS Commercial |
$346.21
|
| Rate for Payer: HFN Commercial |
$357.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$66.59
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17.90
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$18.50
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.90
|
| Rate for Payer: Managed Health Services Medicaid |
$19.24
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$17.90
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$17.90
|
| Rate for Payer: Multiplan Commercial |
$311.20
|
| Rate for Payer: NAPHCARE Commercial |
$26.85
|
| Rate for Payer: Preferred Network Access Commercial |
$357.88
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$18.50
|
| Rate for Payer: Quartz Beloit One Network |
$190.61
|
| Rate for Payer: Quartz Commercial |
$252.85
|
| Rate for Payer: Quartz Medicare Advantage |
$17.90
|
| Rate for Payer: The Alliance Commercial |
$71.60
|
| Rate for Payer: United Healthcare Medicaid |
$18.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.90
|
| Rate for Payer: United Healthcare PPO |
$291.75
|
| Rate for Payer: WEA Trust Commercial |
$213.95
|
| Rate for Payer: Wellcare Medicare |
$17.90
|
| Rate for Payer: WMAP Medicaid |
$18.50
|
| Rate for Payer: WPS Commercial |
$288.13
|
|
|
Factor XI Assay
|
Facility
|
IP
|
$389.00
|
|
|
Service Code
|
CPT 85270
|
| Hospital Charge Code |
977945
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$190.61 |
| Max. Negotiated Rate |
$357.88 |
| Rate for Payer: Aetna Commercial |
$350.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$334.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$206.17
|
| Rate for Payer: Cash Price |
$116.70
|
| Rate for Payer: Cigna Commercial |
$357.88
|
| Rate for Payer: Health EOS Commercial |
$346.21
|
| Rate for Payer: HFN Commercial |
$357.88
|
| Rate for Payer: Multiplan Commercial |
$311.20
|
| Rate for Payer: NAPHCARE Commercial |
$233.40
|
| Rate for Payer: Preferred Network Access Commercial |
$357.88
|
| Rate for Payer: Quartz Beloit One Network |
$190.61
|
| Rate for Payer: Quartz Commercial |
$233.40
|
| Rate for Payer: WEA Trust Commercial |
$213.95
|
| Rate for Payer: WPS Commercial |
$288.13
|
|
|
Factor XII Assay
|
Professional
|
Both
|
$396.00
|
|
|
Service Code
|
CPT 85280
|
| Hospital Charge Code |
977946
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$68.31 |
| Max. Negotiated Rate |
$376.20 |
| Rate for Payer: Aetna Commercial |
$376.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$340.56
|
| Rate for Payer: Cash Price |
$118.80
|
| Rate for Payer: Cash Price |
$118.80
|
| Rate for Payer: Cigna Commercial |
$376.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$198.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$237.60
|
| Rate for Payer: Health EOS Commercial |
$360.36
|
| Rate for Payer: HFN Commercial |
$376.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$68.31
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$68.31
|
| Rate for Payer: Multiplan Commercial |
$316.80
|
| Rate for Payer: Preferred Network Access Commercial |
$376.20
|
| Rate for Payer: Quartz Beloit One Network |
$174.24
|
| Rate for Payer: Quartz Commercial |
$225.72
|
| Rate for Payer: The Alliance Commercial |
$198.00
|
| Rate for Payer: WEA Trust Commercial |
$217.80
|
| Rate for Payer: WPS Commercial |
$293.32
|
|
|
Factor XII Assay
|
Facility
|
OP
|
$396.00
|
|
|
Service Code
|
CPT 85280
|
| Hospital Charge Code |
977946
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.35 |
| Max. Negotiated Rate |
$364.32 |
| Rate for Payer: Aetna Commercial |
$356.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$340.56
|
| Rate for Payer: Aetna Managed Medicare |
$19.35
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$72.56
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$33.86
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$32.12
|
| Rate for Payer: Anthem Medicaid |
$19.99
|
| Rate for Payer: Anthem Medicare Advantage |
$19.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$209.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$19.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$19.35
|
| Rate for Payer: Cash Price |
$118.80
|
| Rate for Payer: Cash Price |
$118.80
|
| Rate for Payer: Cigna Commercial |
$364.32
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$19.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$19.99
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$221.60
|
| Rate for Payer: Dean Health Medicaid |
$19.99
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$19.35
|
| Rate for Payer: Health EOS Commercial |
$352.44
|
| Rate for Payer: HFN Commercial |
$364.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$71.98
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$19.35
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$19.99
|
| Rate for Payer: Independent Care Health Plan Medicare |
$19.35
|
| Rate for Payer: Managed Health Services Medicaid |
$20.79
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$19.35
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$19.35
|
| Rate for Payer: Multiplan Commercial |
$316.80
|
| Rate for Payer: NAPHCARE Commercial |
$29.02
|
| Rate for Payer: Preferred Network Access Commercial |
$364.32
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$19.99
|
| Rate for Payer: Quartz Beloit One Network |
$194.04
|
| Rate for Payer: Quartz Commercial |
$257.40
|
| Rate for Payer: Quartz Medicare Advantage |
$19.35
|
| Rate for Payer: The Alliance Commercial |
$77.40
|
| Rate for Payer: United Healthcare Medicaid |
$19.99
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.35
|
| Rate for Payer: United Healthcare PPO |
$297.00
|
| Rate for Payer: WEA Trust Commercial |
$217.80
|
| Rate for Payer: Wellcare Medicare |
$19.35
|
| Rate for Payer: WMAP Medicaid |
$19.99
|
| Rate for Payer: WPS Commercial |
$293.32
|
|
|
Factor XII Assay
|
Facility
|
IP
|
$396.00
|
|
|
Service Code
|
CPT 85280
|
| Hospital Charge Code |
977946
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$194.04 |
| Max. Negotiated Rate |
$364.32 |
| Rate for Payer: Aetna Commercial |
$356.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$340.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$209.88
|
| Rate for Payer: Cash Price |
$118.80
|
| Rate for Payer: Cigna Commercial |
$364.32
|
| Rate for Payer: Health EOS Commercial |
$352.44
|
| Rate for Payer: HFN Commercial |
$364.32
|
| Rate for Payer: Multiplan Commercial |
$316.80
|
| Rate for Payer: NAPHCARE Commercial |
$237.60
|
| Rate for Payer: Preferred Network Access Commercial |
$364.32
|
| Rate for Payer: Quartz Beloit One Network |
$194.04
|
| Rate for Payer: Quartz Commercial |
$237.60
|
| Rate for Payer: WEA Trust Commercial |
$217.80
|
| Rate for Payer: WPS Commercial |
$293.32
|
|
|
Fam Care Observation Per Hour
|
Facility
|
OP
|
$69.00
|
|
|
Service Code
|
HCPCS G0378
|
| Hospital Charge Code |
3040435
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$19.32 |
| Max. Negotiated Rate |
$6,992.00 |
| Rate for Payer: Aetna Commercial |
$62.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$59.34
|
| Rate for Payer: Aetna Managed Medicare |
$19.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,992.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,030.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,729.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$36.57
|
| Rate for Payer: Cash Price |
$20.70
|
| Rate for Payer: Cash Price |
$20.70
|
| Rate for Payer: Cigna Commercial |
$63.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$38.61
|
| Rate for Payer: Health EOS Commercial |
$61.41
|
| Rate for Payer: HFN Commercial |
$63.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$51.75
|
| Rate for Payer: Multiplan Commercial |
$55.20
|
| Rate for Payer: NAPHCARE Commercial |
$41.40
|
| Rate for Payer: Preferred Network Access Commercial |
$63.48
|
| Rate for Payer: Quartz Beloit One Network |
$33.81
|
| Rate for Payer: Quartz Commercial |
$44.85
|
| Rate for Payer: Quartz Medicare Advantage |
$41.40
|
| Rate for Payer: The Alliance Commercial |
$276.00
|
| Rate for Payer: United Healthcare PPO |
$2,598.00
|
| Rate for Payer: WEA Trust Commercial |
$37.95
|
| Rate for Payer: WPS Commercial |
$51.11
|
|
|
Fam Care Observation Per Hour
|
Facility
|
IP
|
$69.00
|
|
|
Service Code
|
HCPCS G0378
|
| Hospital Charge Code |
3040435
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$33.81 |
| Max. Negotiated Rate |
$63.48 |
| Rate for Payer: Aetna Commercial |
$62.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$59.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$36.57
|
| Rate for Payer: Cash Price |
$20.70
|
| Rate for Payer: Cigna Commercial |
$63.48
|
| Rate for Payer: Health EOS Commercial |
$61.41
|
| Rate for Payer: HFN Commercial |
$63.48
|
| Rate for Payer: Multiplan Commercial |
$55.20
|
| Rate for Payer: NAPHCARE Commercial |
$41.40
|
| Rate for Payer: Preferred Network Access Commercial |
$63.48
|
| Rate for Payer: Quartz Beloit One Network |
$33.81
|
| Rate for Payer: Quartz Commercial |
$41.40
|
| Rate for Payer: WEA Trust Commercial |
$37.95
|
| Rate for Payer: WPS Commercial |
$51.11
|
|
|
Familial Mutation, Targeted Testing
|
Professional
|
Both
|
$703.00
|
|
|
Service Code
|
CPT 81403
|
| Hospital Charge Code |
6172313
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$309.32 |
| Max. Negotiated Rate |
$667.85 |
| Rate for Payer: Aetna Commercial |
$667.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$604.58
|
| Rate for Payer: Cash Price |
$210.90
|
| Rate for Payer: Cash Price |
$210.90
|
| Rate for Payer: Cigna Commercial |
$667.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$351.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$421.80
|
| Rate for Payer: Health EOS Commercial |
$639.73
|
| Rate for Payer: HFN Commercial |
$667.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$653.76
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$653.76
|
| Rate for Payer: Multiplan Commercial |
$562.40
|
| Rate for Payer: Preferred Network Access Commercial |
$667.85
|
| Rate for Payer: Quartz Beloit One Network |
$309.32
|
| Rate for Payer: Quartz Commercial |
$400.71
|
| Rate for Payer: The Alliance Commercial |
$351.50
|
| Rate for Payer: WEA Trust Commercial |
$386.65
|
| Rate for Payer: WPS Commercial |
$520.71
|
|
|
Familial Mutation, Targeted Testing
|
Facility
|
OP
|
$703.00
|
|
|
Service Code
|
CPT 81403
|
| Hospital Charge Code |
6172313
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$185.20 |
| Max. Negotiated Rate |
$740.80 |
| Rate for Payer: Aetna Commercial |
$632.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$604.58
|
| Rate for Payer: Aetna Managed Medicare |
$185.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$694.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$324.10
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$307.43
|
| Rate for Payer: Anthem Medicaid |
$185.20
|
| Rate for Payer: Anthem Medicare Advantage |
$185.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$372.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$185.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$185.20
|
| Rate for Payer: Cash Price |
$210.90
|
| Rate for Payer: Cash Price |
$210.90
|
| Rate for Payer: Cigna Commercial |
$646.76
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$185.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$185.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$393.40
|
| Rate for Payer: Dean Health Medicaid |
$185.20
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$185.20
|
| Rate for Payer: Health EOS Commercial |
$625.67
|
| Rate for Payer: HFN Commercial |
$646.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$688.94
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$185.20
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$185.20
|
| Rate for Payer: Independent Care Health Plan Medicare |
$185.20
|
| Rate for Payer: Managed Health Services Medicaid |
$192.61
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$185.20
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$185.20
|
| Rate for Payer: Multiplan Commercial |
$562.40
|
| Rate for Payer: NAPHCARE Commercial |
$277.80
|
| Rate for Payer: Preferred Network Access Commercial |
$646.76
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$185.20
|
| Rate for Payer: Quartz Beloit One Network |
$344.47
|
| Rate for Payer: Quartz Commercial |
$456.95
|
| Rate for Payer: Quartz Medicare Advantage |
$185.20
|
| Rate for Payer: The Alliance Commercial |
$740.80
|
| Rate for Payer: United Healthcare Medicaid |
$185.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$185.20
|
| Rate for Payer: United Healthcare PPO |
$527.25
|
| Rate for Payer: WEA Trust Commercial |
$386.65
|
| Rate for Payer: Wellcare Medicare |
$185.20
|
| Rate for Payer: WMAP Medicaid |
$185.20
|
| Rate for Payer: WPS Commercial |
$520.71
|
|
|
Familial Mutation, Targeted Testing
|
Facility
|
IP
|
$703.00
|
|
|
Service Code
|
CPT 81403
|
| Hospital Charge Code |
6172313
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$344.47 |
| Max. Negotiated Rate |
$646.76 |
| Rate for Payer: Aetna Commercial |
$632.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$604.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$372.59
|
| Rate for Payer: Cash Price |
$210.90
|
| Rate for Payer: Cigna Commercial |
$646.76
|
| Rate for Payer: Health EOS Commercial |
$625.67
|
| Rate for Payer: HFN Commercial |
$646.76
|
| Rate for Payer: Multiplan Commercial |
$562.40
|
| Rate for Payer: NAPHCARE Commercial |
$421.80
|
| Rate for Payer: Preferred Network Access Commercial |
$646.76
|
| Rate for Payer: Quartz Beloit One Network |
$344.47
|
| Rate for Payer: Quartz Commercial |
$421.80
|
| Rate for Payer: WEA Trust Commercial |
$386.65
|
| Rate for Payer: WPS Commercial |
$520.71
|
|
|
Faricimab Ophthalmic (Vabysmo) 0.1 mg J2777
|
Facility
|
OP
|
$79.00
|
|
|
Service Code
|
HCPCS J2777
|
| Hospital Charge Code |
6178013
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.44 |
| Max. Negotiated Rate |
$149.76 |
| Rate for Payer: Aetna Commercial |
$71.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.94
|
| Rate for Payer: Aetna Managed Medicare |
$37.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$51.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$39.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$37.92
|
| Rate for Payer: Anthem Medicare Advantage |
$37.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$41.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$37.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$37.44
|
| Rate for Payer: Cash Price |
$23.70
|
| Rate for Payer: Cash Price |
$23.70
|
| Rate for Payer: Cigna Commercial |
$72.68
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$37.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$46.89
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$37.44
|
| Rate for Payer: Health EOS Commercial |
$70.31
|
| Rate for Payer: HFN Commercial |
$72.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$139.28
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$37.44
|
| Rate for Payer: Independent Care Health Plan Medicare |
$37.44
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$37.44
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$37.44
|
| Rate for Payer: Multiplan Commercial |
$63.20
|
| Rate for Payer: NAPHCARE Commercial |
$56.16
|
| Rate for Payer: Preferred Network Access Commercial |
$72.68
|
| Rate for Payer: Quartz Beloit One Network |
$38.71
|
| Rate for Payer: Quartz Commercial |
$51.35
|
| Rate for Payer: Quartz Medicare Advantage |
$37.44
|
| Rate for Payer: The Alliance Commercial |
$149.76
|
| Rate for Payer: United Healthcare Medicare Advantage |
$37.44
|
| Rate for Payer: WEA Trust Commercial |
$43.45
|
| Rate for Payer: Wellcare Medicare |
$37.44
|
| Rate for Payer: WPS Commercial |
$88.60
|
|
|
Faricimab Ophthalmic (Vabysmo) 0.1 mg J2777
|
Facility
|
IP
|
$79.00
|
|
|
Service Code
|
HCPCS J2777
|
| Hospital Charge Code |
6178013
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$38.71 |
| Max. Negotiated Rate |
$72.68 |
| Rate for Payer: Aetna Commercial |
$71.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$41.87
|
| Rate for Payer: Cash Price |
$23.70
|
| Rate for Payer: Cigna Commercial |
$72.68
|
| Rate for Payer: Health EOS Commercial |
$70.31
|
| Rate for Payer: HFN Commercial |
$72.68
|
| Rate for Payer: Multiplan Commercial |
$63.20
|
| Rate for Payer: NAPHCARE Commercial |
$47.40
|
| Rate for Payer: Preferred Network Access Commercial |
$72.68
|
| Rate for Payer: Quartz Beloit One Network |
$38.71
|
| Rate for Payer: Quartz Commercial |
$47.40
|
| Rate for Payer: WEA Trust Commercial |
$43.45
|
| Rate for Payer: WPS Commercial |
$58.52
|
|
|
Faricimab Ophthalmic (Vabysmo) 0.1 mg J2777
|
Professional
|
Both
|
$79.00
|
|
|
Service Code
|
HCPCS J2777
|
| Hospital Charge Code |
6178013
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.76 |
| Max. Negotiated Rate |
$88.60 |
| Rate for Payer: Aetna Commercial |
$75.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.94
|
| Rate for Payer: Cash Price |
$23.70
|
| Rate for Payer: Cash Price |
$23.70
|
| Rate for Payer: Cigna Commercial |
$75.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$35.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$35.44
|
| Rate for Payer: Health EOS Commercial |
$71.89
|
| Rate for Payer: HFN Commercial |
$75.05
|
| Rate for Payer: Multiplan Commercial |
$63.20
|
| Rate for Payer: Preferred Network Access Commercial |
$75.05
|
| Rate for Payer: Quartz Beloit One Network |
$34.76
|
| Rate for Payer: Quartz Commercial |
$45.03
|
| Rate for Payer: The Alliance Commercial |
$39.50
|
| Rate for Payer: United Healthcare Medicaid |
$35.44
|
| Rate for Payer: WEA Trust Commercial |
$43.45
|
| Rate for Payer: WPS Commercial |
$88.60
|
|
