|
GC RNA Ocular
|
Professional
|
Both
|
$101.00
|
|
|
Service Code
|
CPT 87591
|
| Hospital Charge Code |
6181481
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$36.49 |
| Max. Negotiated Rate |
$160.57 |
| Rate for Payer: Aetna Commercial |
$99.79
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$90.33
|
| Rate for Payer: Aetna Managed Medicare |
$36.49
|
| Rate for Payer: Anthem Medicare Advantage |
$36.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$36.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$36.49
|
| Rate for Payer: Cash Price |
$30.30
|
| Rate for Payer: Cash Price |
$30.30
|
| Rate for Payer: Cigna Commercial |
$99.79
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$52.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$36.49
|
| Rate for Payer: Health EOS Commercial |
$95.59
|
| Rate for Payer: HFN Commercial |
$99.79
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$128.82
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$128.82
|
| Rate for Payer: Independent Care Health Plan Medicare |
$36.49
|
| Rate for Payer: Multiplan Commercial |
$84.03
|
| Rate for Payer: NAPHCARE Commercial |
$54.74
|
| Rate for Payer: Preferred Network Access Commercial |
$99.79
|
| Rate for Payer: Quartz Beloit One Network |
$46.22
|
| Rate for Payer: Quartz Commercial |
$59.87
|
| Rate for Payer: Quartz Medicare Advantage |
$36.49
|
| Rate for Payer: The Alliance Commercial |
$144.15
|
| Rate for Payer: United Healthcare Medicare Advantage |
$36.49
|
| Rate for Payer: WEA Trust Commercial |
$57.77
|
| Rate for Payer: WPS Commercial |
$160.57
|
|
|
GC RNA Ocular
|
Facility
|
IP
|
$101.00
|
|
|
Service Code
|
CPT 87591
|
| Hospital Charge Code |
6181481
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$51.47 |
| Max. Negotiated Rate |
$96.64 |
| Rate for Payer: Aetna Commercial |
$94.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$90.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$55.67
|
| Rate for Payer: Cash Price |
$30.30
|
| Rate for Payer: Cigna Commercial |
$96.64
|
| Rate for Payer: Health EOS Commercial |
$93.49
|
| Rate for Payer: HFN Commercial |
$96.64
|
| Rate for Payer: Multiplan Commercial |
$84.03
|
| Rate for Payer: Preferred Network Access Commercial |
$96.64
|
| Rate for Payer: Quartz Beloit One Network |
$51.47
|
| Rate for Payer: Quartz Commercial |
$63.02
|
| Rate for Payer: WEA Trust Commercial |
$57.77
|
| Rate for Payer: WPS Commercial |
$77.80
|
|
|
GD Amplification
|
Professional
|
Both
|
$37.00
|
|
| Hospital Charge Code |
2802805
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.93 |
| Max. Negotiated Rate |
$36.56 |
| Rate for Payer: Aetna Commercial |
$36.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$33.09
|
| Rate for Payer: Cash Price |
$11.10
|
| Rate for Payer: Cigna Commercial |
$36.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$19.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$23.09
|
| Rate for Payer: Health EOS Commercial |
$35.02
|
| Rate for Payer: HFN Commercial |
$36.56
|
| Rate for Payer: Multiplan Commercial |
$30.78
|
| Rate for Payer: Preferred Network Access Commercial |
$36.56
|
| Rate for Payer: Quartz Beloit One Network |
$16.93
|
| Rate for Payer: Quartz Commercial |
$21.93
|
| Rate for Payer: The Alliance Commercial |
$19.24
|
| Rate for Payer: WEA Trust Commercial |
$21.16
|
| Rate for Payer: WPS Commercial |
$28.50
|
|
|
GD Amplification
|
Facility
|
OP
|
$37.00
|
|
| Hospital Charge Code |
2802805
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.77 |
| Max. Negotiated Rate |
$35.40 |
| Rate for Payer: Aetna Commercial |
$34.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$33.09
|
| Rate for Payer: Aetna Managed Medicare |
$10.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$25.01
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$19.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$18.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$20.39
|
| Rate for Payer: Cash Price |
$11.10
|
| Rate for Payer: Cigna Commercial |
$35.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$21.53
|
| Rate for Payer: Health EOS Commercial |
$34.25
|
| Rate for Payer: HFN Commercial |
$35.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$28.86
|
| Rate for Payer: Multiplan Commercial |
$30.78
|
| Rate for Payer: NAPHCARE Commercial |
$23.09
|
| Rate for Payer: Preferred Network Access Commercial |
$35.40
|
| Rate for Payer: Quartz Beloit One Network |
$18.86
|
| Rate for Payer: Quartz Commercial |
$25.01
|
| Rate for Payer: Quartz Medicare Advantage |
$23.09
|
| Rate for Payer: The Alliance Commercial |
$19.24
|
| Rate for Payer: United Healthcare PPO |
$28.86
|
| Rate for Payer: WEA Trust Commercial |
$21.16
|
| Rate for Payer: WPS Commercial |
$28.50
|
|
|
GD Amplification
|
Facility
|
IP
|
$37.00
|
|
| Hospital Charge Code |
2802805
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.86 |
| Max. Negotiated Rate |
$35.40 |
| Rate for Payer: Aetna Commercial |
$34.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$33.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$20.39
|
| Rate for Payer: Cash Price |
$11.10
|
| Rate for Payer: Cigna Commercial |
$35.40
|
| Rate for Payer: Health EOS Commercial |
$34.25
|
| Rate for Payer: HFN Commercial |
$35.40
|
| Rate for Payer: Multiplan Commercial |
$30.78
|
| Rate for Payer: Preferred Network Access Commercial |
$35.40
|
| Rate for Payer: Quartz Beloit One Network |
$18.86
|
| Rate for Payer: Quartz Commercial |
$23.09
|
| Rate for Payer: WEA Trust Commercial |
$21.16
|
| Rate for Payer: WPS Commercial |
$28.50
|
|
|
GD DNA Isolation
|
Professional
|
Both
|
$37.00
|
|
| Hospital Charge Code |
2802806
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.93 |
| Max. Negotiated Rate |
$36.56 |
| Rate for Payer: Aetna Commercial |
$36.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$33.09
|
| Rate for Payer: Cash Price |
$11.10
|
| Rate for Payer: Cigna Commercial |
$36.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$19.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$23.09
|
| Rate for Payer: Health EOS Commercial |
$35.02
|
| Rate for Payer: HFN Commercial |
$36.56
|
| Rate for Payer: Multiplan Commercial |
$30.78
|
| Rate for Payer: Preferred Network Access Commercial |
$36.56
|
| Rate for Payer: Quartz Beloit One Network |
$16.93
|
| Rate for Payer: Quartz Commercial |
$21.93
|
| Rate for Payer: The Alliance Commercial |
$19.24
|
| Rate for Payer: WEA Trust Commercial |
$21.16
|
| Rate for Payer: WPS Commercial |
$28.50
|
|
|
GD DNA Isolation
|
Facility
|
OP
|
$37.00
|
|
| Hospital Charge Code |
2802806
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.77 |
| Max. Negotiated Rate |
$35.40 |
| Rate for Payer: Aetna Commercial |
$34.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$33.09
|
| Rate for Payer: Aetna Managed Medicare |
$10.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$25.01
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$19.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$18.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$20.39
|
| Rate for Payer: Cash Price |
$11.10
|
| Rate for Payer: Cigna Commercial |
$35.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$21.53
|
| Rate for Payer: Health EOS Commercial |
$34.25
|
| Rate for Payer: HFN Commercial |
$35.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$28.86
|
| Rate for Payer: Multiplan Commercial |
$30.78
|
| Rate for Payer: NAPHCARE Commercial |
$23.09
|
| Rate for Payer: Preferred Network Access Commercial |
$35.40
|
| Rate for Payer: Quartz Beloit One Network |
$18.86
|
| Rate for Payer: Quartz Commercial |
$25.01
|
| Rate for Payer: Quartz Medicare Advantage |
$23.09
|
| Rate for Payer: The Alliance Commercial |
$19.24
|
| Rate for Payer: United Healthcare PPO |
$28.86
|
| Rate for Payer: WEA Trust Commercial |
$21.16
|
| Rate for Payer: WPS Commercial |
$28.50
|
|
|
GD DNA Isolation
|
Facility
|
IP
|
$37.00
|
|
| Hospital Charge Code |
2802806
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.86 |
| Max. Negotiated Rate |
$35.40 |
| Rate for Payer: Aetna Commercial |
$34.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$33.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$20.39
|
| Rate for Payer: Cash Price |
$11.10
|
| Rate for Payer: Cigna Commercial |
$35.40
|
| Rate for Payer: Health EOS Commercial |
$34.25
|
| Rate for Payer: HFN Commercial |
$35.40
|
| Rate for Payer: Multiplan Commercial |
$30.78
|
| Rate for Payer: Preferred Network Access Commercial |
$35.40
|
| Rate for Payer: Quartz Beloit One Network |
$18.86
|
| Rate for Payer: Quartz Commercial |
$23.09
|
| Rate for Payer: WEA Trust Commercial |
$21.16
|
| Rate for Payer: WPS Commercial |
$28.50
|
|
|
GD Enzyme Digestion
|
Professional
|
Both
|
$37.00
|
|
| Hospital Charge Code |
2804799
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.93 |
| Max. Negotiated Rate |
$36.56 |
| Rate for Payer: Aetna Commercial |
$36.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$33.09
|
| Rate for Payer: Cash Price |
$11.10
|
| Rate for Payer: Cigna Commercial |
$36.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$19.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$23.09
|
| Rate for Payer: Health EOS Commercial |
$35.02
|
| Rate for Payer: HFN Commercial |
$36.56
|
| Rate for Payer: Multiplan Commercial |
$30.78
|
| Rate for Payer: Preferred Network Access Commercial |
$36.56
|
| Rate for Payer: Quartz Beloit One Network |
$16.93
|
| Rate for Payer: Quartz Commercial |
$21.93
|
| Rate for Payer: The Alliance Commercial |
$19.24
|
| Rate for Payer: WEA Trust Commercial |
$21.16
|
| Rate for Payer: WPS Commercial |
$28.50
|
|
|
GD Enzyme Digestion
|
Facility
|
OP
|
$37.00
|
|
| Hospital Charge Code |
2804799
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.77 |
| Max. Negotiated Rate |
$35.40 |
| Rate for Payer: Aetna Commercial |
$34.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$33.09
|
| Rate for Payer: Aetna Managed Medicare |
$10.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$25.01
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$19.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$18.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$20.39
|
| Rate for Payer: Cash Price |
$11.10
|
| Rate for Payer: Cigna Commercial |
$35.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$21.53
|
| Rate for Payer: Health EOS Commercial |
$34.25
|
| Rate for Payer: HFN Commercial |
$35.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$28.86
|
| Rate for Payer: Multiplan Commercial |
$30.78
|
| Rate for Payer: NAPHCARE Commercial |
$23.09
|
| Rate for Payer: Preferred Network Access Commercial |
$35.40
|
| Rate for Payer: Quartz Beloit One Network |
$18.86
|
| Rate for Payer: Quartz Commercial |
$25.01
|
| Rate for Payer: Quartz Medicare Advantage |
$23.09
|
| Rate for Payer: The Alliance Commercial |
$19.24
|
| Rate for Payer: United Healthcare PPO |
$28.86
|
| Rate for Payer: WEA Trust Commercial |
$21.16
|
| Rate for Payer: WPS Commercial |
$28.50
|
|
|
GD Enzyme Digestion
|
Facility
|
IP
|
$37.00
|
|
| Hospital Charge Code |
2804799
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.86 |
| Max. Negotiated Rate |
$35.40 |
| Rate for Payer: Aetna Commercial |
$34.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$33.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$20.39
|
| Rate for Payer: Cash Price |
$11.10
|
| Rate for Payer: Cigna Commercial |
$35.40
|
| Rate for Payer: Health EOS Commercial |
$34.25
|
| Rate for Payer: HFN Commercial |
$35.40
|
| Rate for Payer: Multiplan Commercial |
$30.78
|
| Rate for Payer: Preferred Network Access Commercial |
$35.40
|
| Rate for Payer: Quartz Beloit One Network |
$18.86
|
| Rate for Payer: Quartz Commercial |
$23.09
|
| Rate for Payer: WEA Trust Commercial |
$21.16
|
| Rate for Payer: WPS Commercial |
$28.50
|
|
|
GD Interp & Report
|
Facility
|
OP
|
$37.00
|
|
| Hospital Charge Code |
2804800
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.77 |
| Max. Negotiated Rate |
$35.40 |
| Rate for Payer: Aetna Commercial |
$34.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$33.09
|
| Rate for Payer: Aetna Managed Medicare |
$10.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$25.01
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$19.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$18.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$20.39
|
| Rate for Payer: Cash Price |
$11.10
|
| Rate for Payer: Cigna Commercial |
$35.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$21.53
|
| Rate for Payer: Health EOS Commercial |
$34.25
|
| Rate for Payer: HFN Commercial |
$35.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$28.86
|
| Rate for Payer: Multiplan Commercial |
$30.78
|
| Rate for Payer: NAPHCARE Commercial |
$23.09
|
| Rate for Payer: Preferred Network Access Commercial |
$35.40
|
| Rate for Payer: Quartz Beloit One Network |
$18.86
|
| Rate for Payer: Quartz Commercial |
$25.01
|
| Rate for Payer: Quartz Medicare Advantage |
$23.09
|
| Rate for Payer: The Alliance Commercial |
$19.24
|
| Rate for Payer: United Healthcare PPO |
$28.86
|
| Rate for Payer: WEA Trust Commercial |
$21.16
|
| Rate for Payer: WPS Commercial |
$28.50
|
|
|
GD Interp & Report
|
Facility
|
IP
|
$37.00
|
|
| Hospital Charge Code |
2804800
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.86 |
| Max. Negotiated Rate |
$35.40 |
| Rate for Payer: Aetna Commercial |
$34.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$33.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$20.39
|
| Rate for Payer: Cash Price |
$11.10
|
| Rate for Payer: Cigna Commercial |
$35.40
|
| Rate for Payer: Health EOS Commercial |
$34.25
|
| Rate for Payer: HFN Commercial |
$35.40
|
| Rate for Payer: Multiplan Commercial |
$30.78
|
| Rate for Payer: Preferred Network Access Commercial |
$35.40
|
| Rate for Payer: Quartz Beloit One Network |
$18.86
|
| Rate for Payer: Quartz Commercial |
$23.09
|
| Rate for Payer: WEA Trust Commercial |
$21.16
|
| Rate for Payer: WPS Commercial |
$28.50
|
|
|
GD Interp & Report
|
Professional
|
Both
|
$37.00
|
|
| Hospital Charge Code |
2804800
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.93 |
| Max. Negotiated Rate |
$36.56 |
| Rate for Payer: Aetna Commercial |
$36.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$33.09
|
| Rate for Payer: Cash Price |
$11.10
|
| Rate for Payer: Cigna Commercial |
$36.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$19.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$23.09
|
| Rate for Payer: Health EOS Commercial |
$35.02
|
| Rate for Payer: HFN Commercial |
$36.56
|
| Rate for Payer: Multiplan Commercial |
$30.78
|
| Rate for Payer: Preferred Network Access Commercial |
$36.56
|
| Rate for Payer: Quartz Beloit One Network |
$16.93
|
| Rate for Payer: Quartz Commercial |
$21.93
|
| Rate for Payer: The Alliance Commercial |
$19.24
|
| Rate for Payer: WEA Trust Commercial |
$21.16
|
| Rate for Payer: WPS Commercial |
$28.50
|
|
|
GD Mutation ID
|
Facility
|
OP
|
$37.00
|
|
| Hospital Charge Code |
2806799
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.77 |
| Max. Negotiated Rate |
$35.40 |
| Rate for Payer: Aetna Commercial |
$34.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$33.09
|
| Rate for Payer: Aetna Managed Medicare |
$10.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$25.01
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$19.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$18.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$20.39
|
| Rate for Payer: Cash Price |
$11.10
|
| Rate for Payer: Cigna Commercial |
$35.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$21.53
|
| Rate for Payer: Health EOS Commercial |
$34.25
|
| Rate for Payer: HFN Commercial |
$35.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$28.86
|
| Rate for Payer: Multiplan Commercial |
$30.78
|
| Rate for Payer: NAPHCARE Commercial |
$23.09
|
| Rate for Payer: Preferred Network Access Commercial |
$35.40
|
| Rate for Payer: Quartz Beloit One Network |
$18.86
|
| Rate for Payer: Quartz Commercial |
$25.01
|
| Rate for Payer: Quartz Medicare Advantage |
$23.09
|
| Rate for Payer: The Alliance Commercial |
$19.24
|
| Rate for Payer: United Healthcare PPO |
$28.86
|
| Rate for Payer: WEA Trust Commercial |
$21.16
|
| Rate for Payer: WPS Commercial |
$28.50
|
|
|
GD Mutation ID
|
Professional
|
Both
|
$37.00
|
|
| Hospital Charge Code |
2806799
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.93 |
| Max. Negotiated Rate |
$36.56 |
| Rate for Payer: Aetna Commercial |
$36.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$33.09
|
| Rate for Payer: Cash Price |
$11.10
|
| Rate for Payer: Cigna Commercial |
$36.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$19.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$23.09
|
| Rate for Payer: Health EOS Commercial |
$35.02
|
| Rate for Payer: HFN Commercial |
$36.56
|
| Rate for Payer: Multiplan Commercial |
$30.78
|
| Rate for Payer: Preferred Network Access Commercial |
$36.56
|
| Rate for Payer: Quartz Beloit One Network |
$16.93
|
| Rate for Payer: Quartz Commercial |
$21.93
|
| Rate for Payer: The Alliance Commercial |
$19.24
|
| Rate for Payer: WEA Trust Commercial |
$21.16
|
| Rate for Payer: WPS Commercial |
$28.50
|
|
|
GD Mutation ID
|
Facility
|
IP
|
$37.00
|
|
| Hospital Charge Code |
2806799
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.86 |
| Max. Negotiated Rate |
$35.40 |
| Rate for Payer: Aetna Commercial |
$34.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$33.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$20.39
|
| Rate for Payer: Cash Price |
$11.10
|
| Rate for Payer: Cigna Commercial |
$35.40
|
| Rate for Payer: Health EOS Commercial |
$34.25
|
| Rate for Payer: HFN Commercial |
$35.40
|
| Rate for Payer: Multiplan Commercial |
$30.78
|
| Rate for Payer: Preferred Network Access Commercial |
$35.40
|
| Rate for Payer: Quartz Beloit One Network |
$18.86
|
| Rate for Payer: Quartz Commercial |
$23.09
|
| Rate for Payer: WEA Trust Commercial |
$21.16
|
| Rate for Payer: WPS Commercial |
$28.50
|
|
|
GD Separation
|
Professional
|
Both
|
$37.00
|
|
| Hospital Charge Code |
2806800
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.93 |
| Max. Negotiated Rate |
$36.56 |
| Rate for Payer: Aetna Commercial |
$36.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$33.09
|
| Rate for Payer: Cash Price |
$11.10
|
| Rate for Payer: Cigna Commercial |
$36.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$19.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$23.09
|
| Rate for Payer: Health EOS Commercial |
$35.02
|
| Rate for Payer: HFN Commercial |
$36.56
|
| Rate for Payer: Multiplan Commercial |
$30.78
|
| Rate for Payer: Preferred Network Access Commercial |
$36.56
|
| Rate for Payer: Quartz Beloit One Network |
$16.93
|
| Rate for Payer: Quartz Commercial |
$21.93
|
| Rate for Payer: The Alliance Commercial |
$19.24
|
| Rate for Payer: WEA Trust Commercial |
$21.16
|
| Rate for Payer: WPS Commercial |
$28.50
|
|
|
GD Separation
|
Facility
|
OP
|
$37.00
|
|
| Hospital Charge Code |
2806800
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.77 |
| Max. Negotiated Rate |
$35.40 |
| Rate for Payer: Aetna Commercial |
$34.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$33.09
|
| Rate for Payer: Aetna Managed Medicare |
$10.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$25.01
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$19.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$18.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$20.39
|
| Rate for Payer: Cash Price |
$11.10
|
| Rate for Payer: Cigna Commercial |
$35.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$21.53
|
| Rate for Payer: Health EOS Commercial |
$34.25
|
| Rate for Payer: HFN Commercial |
$35.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$28.86
|
| Rate for Payer: Multiplan Commercial |
$30.78
|
| Rate for Payer: NAPHCARE Commercial |
$23.09
|
| Rate for Payer: Preferred Network Access Commercial |
$35.40
|
| Rate for Payer: Quartz Beloit One Network |
$18.86
|
| Rate for Payer: Quartz Commercial |
$25.01
|
| Rate for Payer: Quartz Medicare Advantage |
$23.09
|
| Rate for Payer: The Alliance Commercial |
$19.24
|
| Rate for Payer: United Healthcare PPO |
$28.86
|
| Rate for Payer: WEA Trust Commercial |
$21.16
|
| Rate for Payer: WPS Commercial |
$28.50
|
|
|
GD Separation
|
Facility
|
IP
|
$37.00
|
|
| Hospital Charge Code |
2806800
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.86 |
| Max. Negotiated Rate |
$35.40 |
| Rate for Payer: Aetna Commercial |
$34.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$33.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$20.39
|
| Rate for Payer: Cash Price |
$11.10
|
| Rate for Payer: Cigna Commercial |
$35.40
|
| Rate for Payer: Health EOS Commercial |
$34.25
|
| Rate for Payer: HFN Commercial |
$35.40
|
| Rate for Payer: Multiplan Commercial |
$30.78
|
| Rate for Payer: Preferred Network Access Commercial |
$35.40
|
| Rate for Payer: Quartz Beloit One Network |
$18.86
|
| Rate for Payer: Quartz Commercial |
$23.09
|
| Rate for Payer: WEA Trust Commercial |
$21.16
|
| Rate for Payer: WPS Commercial |
$28.50
|
|
|
Gel-1 1 Unit Charge
|
Facility
|
OP
|
$1,829.00
|
|
|
Service Code
|
HCPCS J7326
|
| Hospital Charge Code |
2958867
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$549.17 |
| Max. Negotiated Rate |
$2,196.69 |
| Rate for Payer: Aetna Commercial |
$1,711.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,635.86
|
| Rate for Payer: Aetna Managed Medicare |
$549.17
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,236.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$951.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$913.04
|
| Rate for Payer: Anthem Medicare Advantage |
$549.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,008.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$549.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$549.17
|
| Rate for Payer: Cash Price |
$548.70
|
| Rate for Payer: Cash Price |
$548.70
|
| Rate for Payer: Cigna Commercial |
$1,749.99
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$549.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$718.73
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$549.17
|
| Rate for Payer: Health EOS Commercial |
$1,692.92
|
| Rate for Payer: HFN Commercial |
$1,749.99
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,042.92
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$549.17
|
| Rate for Payer: Independent Care Health Plan Medicare |
$549.17
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$549.17
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$549.17
|
| Rate for Payer: Multiplan Commercial |
$1,521.73
|
| Rate for Payer: NAPHCARE Commercial |
$823.76
|
| Rate for Payer: Preferred Network Access Commercial |
$1,749.99
|
| Rate for Payer: Quartz Beloit One Network |
$932.06
|
| Rate for Payer: Quartz Commercial |
$1,236.40
|
| Rate for Payer: Quartz Medicare Advantage |
$549.17
|
| Rate for Payer: The Alliance Commercial |
$2,196.69
|
| Rate for Payer: United Healthcare Medicare Advantage |
$549.17
|
| Rate for Payer: WEA Trust Commercial |
$1,046.19
|
| Rate for Payer: Wellcare Medicare |
$549.17
|
| Rate for Payer: WPS Commercial |
$1,358.16
|
|
|
Gel-1 1 Unit Charge
|
Professional
|
Both
|
$1,829.00
|
|
|
Service Code
|
HCPCS J7326
|
| Hospital Charge Code |
2958867
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$543.27 |
| Max. Negotiated Rate |
$1,807.05 |
| Rate for Payer: Aetna Commercial |
$1,807.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,635.86
|
| Rate for Payer: Aetna Managed Medicare |
$549.17
|
| Rate for Payer: Anthem Medicare Advantage |
$549.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$549.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$549.17
|
| Rate for Payer: Cash Price |
$548.70
|
| Rate for Payer: Cash Price |
$548.70
|
| Rate for Payer: Cigna Commercial |
$1,807.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$549.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$543.27
|
| Rate for Payer: Health EOS Commercial |
$1,730.97
|
| Rate for Payer: HFN Commercial |
$1,807.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$815.93
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$815.93
|
| Rate for Payer: Independent Care Health Plan Medicare |
$549.17
|
| Rate for Payer: Multiplan Commercial |
$1,521.73
|
| Rate for Payer: NAPHCARE Commercial |
$823.76
|
| Rate for Payer: Preferred Network Access Commercial |
$1,807.05
|
| Rate for Payer: Quartz Beloit One Network |
$836.95
|
| Rate for Payer: Quartz Commercial |
$1,084.23
|
| Rate for Payer: Quartz Medicare Advantage |
$549.17
|
| Rate for Payer: The Alliance Commercial |
$1,510.22
|
| Rate for Payer: United Healthcare Medicaid |
$549.17
|
| Rate for Payer: United Healthcare Medicare Advantage |
$549.17
|
| Rate for Payer: WEA Trust Commercial |
$1,046.19
|
| Rate for Payer: WPS Commercial |
$1,358.16
|
|
|
Gel-1 1 Unit Charge
|
Facility
|
IP
|
$1,829.00
|
|
|
Service Code
|
HCPCS J7326
|
| Hospital Charge Code |
2958867
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$932.06 |
| Max. Negotiated Rate |
$1,749.99 |
| Rate for Payer: Aetna Commercial |
$1,711.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,635.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,008.14
|
| Rate for Payer: Cash Price |
$548.70
|
| Rate for Payer: Cigna Commercial |
$1,749.99
|
| Rate for Payer: Health EOS Commercial |
$1,692.92
|
| Rate for Payer: HFN Commercial |
$1,749.99
|
| Rate for Payer: Multiplan Commercial |
$1,521.73
|
| Rate for Payer: Preferred Network Access Commercial |
$1,749.99
|
| Rate for Payer: Quartz Beloit One Network |
$932.06
|
| Rate for Payer: Quartz Commercial |
$1,141.30
|
| Rate for Payer: WEA Trust Commercial |
$1,046.19
|
| Rate for Payer: WPS Commercial |
$1,408.88
|
|
|
GEL AQUASONIC 20 GRAM 01-01 (OR SUPPLY)
|
Facility
|
IP
|
$6.00
|
|
| Hospital Charge Code |
2965791
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3.06 |
| Max. Negotiated Rate |
$5.74 |
| Rate for Payer: Aetna Commercial |
$5.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.31
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$5.74
|
| Rate for Payer: Health EOS Commercial |
$5.55
|
| Rate for Payer: HFN Commercial |
$5.74
|
| Rate for Payer: Multiplan Commercial |
$4.99
|
| Rate for Payer: Preferred Network Access Commercial |
$5.74
|
| Rate for Payer: Quartz Beloit One Network |
$3.06
|
| Rate for Payer: Quartz Commercial |
$3.74
|
| Rate for Payer: WEA Trust Commercial |
$3.43
|
| Rate for Payer: WPS Commercial |
$4.62
|
|
|
GEL AQUASONIC 20 GRAM 01-01 (OR SUPPLY)
|
Facility
|
OP
|
$6.00
|
|
| Hospital Charge Code |
2965791
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1.75 |
| Max. Negotiated Rate |
$5.74 |
| Rate for Payer: Aetna Commercial |
$5.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5.37
|
| Rate for Payer: Aetna Managed Medicare |
$1.75
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.31
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$5.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3.49
|
| Rate for Payer: Health EOS Commercial |
$5.55
|
| Rate for Payer: HFN Commercial |
$5.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4.68
|
| Rate for Payer: Multiplan Commercial |
$4.99
|
| Rate for Payer: NAPHCARE Commercial |
$3.74
|
| Rate for Payer: Preferred Network Access Commercial |
$5.74
|
| Rate for Payer: Quartz Beloit One Network |
$3.06
|
| Rate for Payer: Quartz Commercial |
$4.06
|
| Rate for Payer: Quartz Medicare Advantage |
$3.74
|
| Rate for Payer: The Alliance Commercial |
$3.12
|
| Rate for Payer: WEA Trust Commercial |
$3.43
|
| Rate for Payer: WPS Commercial |
$4.62
|
|
