|
IA-2 Antibody
|
Facility
|
IP
|
$277.00
|
|
|
Service Code
|
CPT 86341
|
| Hospital Charge Code |
4163506
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$141.16 |
| Max. Negotiated Rate |
$265.03 |
| Rate for Payer: Aetna Commercial |
$259.27
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$247.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$152.68
|
| Rate for Payer: Cash Price |
$83.10
|
| Rate for Payer: Cigna Commercial |
$265.03
|
| Rate for Payer: Health EOS Commercial |
$256.39
|
| Rate for Payer: HFN Commercial |
$265.03
|
| Rate for Payer: Multiplan Commercial |
$230.46
|
| Rate for Payer: Preferred Network Access Commercial |
$265.03
|
| Rate for Payer: Quartz Beloit One Network |
$141.16
|
| Rate for Payer: Quartz Commercial |
$172.85
|
| Rate for Payer: WEA Trust Commercial |
$158.44
|
| Rate for Payer: WPS Commercial |
$213.37
|
|
|
IA-2 Antibody
|
Facility
|
OP
|
$277.00
|
|
|
Service Code
|
CPT 86341
|
| Hospital Charge Code |
4163506
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$24.51 |
| Max. Negotiated Rate |
$265.03 |
| Rate for Payer: Aetna Commercial |
$259.27
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$247.75
|
| Rate for Payer: Aetna Managed Medicare |
$24.51
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$91.92
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$42.90
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$40.69
|
| Rate for Payer: Anthem Medicare Advantage |
$24.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$152.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$24.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$24.51
|
| Rate for Payer: Cash Price |
$83.10
|
| Rate for Payer: Cash Price |
$83.10
|
| Rate for Payer: Cigna Commercial |
$265.03
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$24.51
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$161.21
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$24.51
|
| Rate for Payer: Health EOS Commercial |
$256.39
|
| Rate for Payer: HFN Commercial |
$265.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$91.19
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$24.51
|
| Rate for Payer: Independent Care Health Plan Medicare |
$24.51
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$24.51
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$24.51
|
| Rate for Payer: Multiplan Commercial |
$230.46
|
| Rate for Payer: NAPHCARE Commercial |
$36.77
|
| Rate for Payer: Preferred Network Access Commercial |
$265.03
|
| Rate for Payer: Quartz Beloit One Network |
$141.16
|
| Rate for Payer: Quartz Commercial |
$187.25
|
| Rate for Payer: Quartz Medicare Advantage |
$24.51
|
| Rate for Payer: The Alliance Commercial |
$98.05
|
| Rate for Payer: United Healthcare Medicare Advantage |
$24.51
|
| Rate for Payer: United Healthcare PPO |
$216.06
|
| Rate for Payer: WEA Trust Commercial |
$158.44
|
| Rate for Payer: Wellcare Medicare |
$24.51
|
| Rate for Payer: WPS Commercial |
$213.37
|
|
|
IA-2 Antibody
|
Professional
|
Both
|
$277.00
|
|
|
Service Code
|
CPT 86341
|
| Hospital Charge Code |
4163506
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$24.51 |
| Max. Negotiated Rate |
$273.68 |
| Rate for Payer: Aetna Commercial |
$273.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$247.75
|
| Rate for Payer: Aetna Managed Medicare |
$24.51
|
| Rate for Payer: Anthem Medicare Advantage |
$24.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$24.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$24.51
|
| Rate for Payer: Cash Price |
$83.10
|
| Rate for Payer: Cash Price |
$83.10
|
| Rate for Payer: Cigna Commercial |
$273.68
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$144.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$24.51
|
| Rate for Payer: Health EOS Commercial |
$262.15
|
| Rate for Payer: HFN Commercial |
$273.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$86.53
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$86.53
|
| Rate for Payer: Independent Care Health Plan Medicare |
$24.51
|
| Rate for Payer: Multiplan Commercial |
$230.46
|
| Rate for Payer: NAPHCARE Commercial |
$36.77
|
| Rate for Payer: Preferred Network Access Commercial |
$273.68
|
| Rate for Payer: Quartz Beloit One Network |
$126.76
|
| Rate for Payer: Quartz Commercial |
$164.21
|
| Rate for Payer: Quartz Medicare Advantage |
$24.51
|
| Rate for Payer: The Alliance Commercial |
$96.83
|
| Rate for Payer: United Healthcare Medicare Advantage |
$24.51
|
| Rate for Payer: WEA Trust Commercial |
$158.44
|
| Rate for Payer: WPS Commercial |
$107.86
|
|
|
IABP Activity - Insert New Site
|
Facility
|
OP
|
$9,674.00
|
|
| Hospital Charge Code |
3034564
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,817.07 |
| Max. Negotiated Rate |
$9,256.08 |
| Rate for Payer: Aetna Commercial |
$9,054.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,652.43
|
| Rate for Payer: Aetna Managed Medicare |
$2,817.07
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,539.62
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,030.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,829.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,332.31
|
| Rate for Payer: Cash Price |
$2,902.20
|
| Rate for Payer: Cigna Commercial |
$9,256.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,630.27
|
| Rate for Payer: Health EOS Commercial |
$8,954.25
|
| Rate for Payer: HFN Commercial |
$9,256.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,545.72
|
| Rate for Payer: Multiplan Commercial |
$8,048.77
|
| Rate for Payer: NAPHCARE Commercial |
$6,036.58
|
| Rate for Payer: Preferred Network Access Commercial |
$9,256.08
|
| Rate for Payer: Quartz Beloit One Network |
$4,929.87
|
| Rate for Payer: Quartz Commercial |
$6,539.62
|
| Rate for Payer: Quartz Medicare Advantage |
$6,036.58
|
| Rate for Payer: The Alliance Commercial |
$5,030.48
|
| Rate for Payer: WEA Trust Commercial |
$5,533.53
|
| Rate for Payer: WPS Commercial |
$7,451.88
|
|
|
IABP Activity - Insert New Site
|
Facility
|
IP
|
$9,674.00
|
|
| Hospital Charge Code |
3034564
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,929.87 |
| Max. Negotiated Rate |
$9,256.08 |
| Rate for Payer: Aetna Commercial |
$9,054.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,652.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,332.31
|
| Rate for Payer: Cash Price |
$2,902.20
|
| Rate for Payer: Cigna Commercial |
$9,256.08
|
| Rate for Payer: Health EOS Commercial |
$8,954.25
|
| Rate for Payer: HFN Commercial |
$9,256.08
|
| Rate for Payer: Multiplan Commercial |
$8,048.77
|
| Rate for Payer: Preferred Network Access Commercial |
$9,256.08
|
| Rate for Payer: Quartz Beloit One Network |
$4,929.87
|
| Rate for Payer: Quartz Commercial |
$6,036.58
|
| Rate for Payer: WEA Trust Commercial |
$5,533.53
|
| Rate for Payer: WPS Commercial |
$7,451.88
|
|
|
IABP Activity - Insert New Site
|
Professional
|
Both
|
$9,674.00
|
|
| Hospital Charge Code |
3034564
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,426.82 |
| Max. Negotiated Rate |
$9,557.91 |
| Rate for Payer: Aetna Commercial |
$9,557.91
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,652.43
|
| Rate for Payer: Cash Price |
$2,902.20
|
| Rate for Payer: Cigna Commercial |
$9,557.91
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5,030.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,036.58
|
| Rate for Payer: Health EOS Commercial |
$9,155.47
|
| Rate for Payer: HFN Commercial |
$9,557.91
|
| Rate for Payer: Multiplan Commercial |
$8,048.77
|
| Rate for Payer: Preferred Network Access Commercial |
$9,557.91
|
| Rate for Payer: Quartz Beloit One Network |
$4,426.82
|
| Rate for Payer: Quartz Commercial |
$5,734.75
|
| Rate for Payer: The Alliance Commercial |
$5,030.48
|
| Rate for Payer: WEA Trust Commercial |
$5,533.53
|
| Rate for Payer: WPS Commercial |
$7,451.88
|
|
|
IABP Insertion
|
Facility
|
OP
|
$1,156.00
|
|
|
Service Code
|
CPT 33967
|
| Hospital Charge Code |
3052403
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$336.63 |
| Max. Negotiated Rate |
$12,349.86 |
| Rate for Payer: Aetna Commercial |
$1,082.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,033.93
|
| Rate for Payer: Aetna Managed Medicare |
$336.63
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$781.46
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$601.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$577.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$637.19
|
| Rate for Payer: Cash Price |
$346.80
|
| Rate for Payer: Cash Price |
$346.80
|
| Rate for Payer: Cigna Commercial |
$1,106.06
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,349.86
|
| Rate for Payer: Health EOS Commercial |
$1,069.99
|
| Rate for Payer: HFN Commercial |
$1,106.06
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$901.68
|
| Rate for Payer: Multiplan Commercial |
$961.79
|
| Rate for Payer: NAPHCARE Commercial |
$721.34
|
| Rate for Payer: Preferred Network Access Commercial |
$1,106.06
|
| Rate for Payer: Quartz Beloit One Network |
$589.10
|
| Rate for Payer: Quartz Commercial |
$781.46
|
| Rate for Payer: Quartz Medicare Advantage |
$721.34
|
| Rate for Payer: The Alliance Commercial |
$824.93
|
| Rate for Payer: WEA Trust Commercial |
$661.23
|
| Rate for Payer: WPS Commercial |
$890.47
|
|
|
IABP Insertion
|
Facility
|
IP
|
$1,156.00
|
|
|
Service Code
|
CPT 33967
|
| Hospital Charge Code |
3052403
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$589.10 |
| Max. Negotiated Rate |
$1,106.06 |
| Rate for Payer: Aetna Commercial |
$1,082.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,033.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$637.19
|
| Rate for Payer: Cash Price |
$346.80
|
| Rate for Payer: Cigna Commercial |
$1,106.06
|
| Rate for Payer: Health EOS Commercial |
$1,069.99
|
| Rate for Payer: HFN Commercial |
$1,106.06
|
| Rate for Payer: Multiplan Commercial |
$961.79
|
| Rate for Payer: Preferred Network Access Commercial |
$1,106.06
|
| Rate for Payer: Quartz Beloit One Network |
$589.10
|
| Rate for Payer: Quartz Commercial |
$721.34
|
| Rate for Payer: WEA Trust Commercial |
$661.23
|
| Rate for Payer: WPS Commercial |
$890.47
|
|
|
IABP Removal
|
Facility
|
IP
|
$172.00
|
|
|
Service Code
|
CPT 33968
|
| Hospital Charge Code |
3052404
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$87.65 |
| Max. Negotiated Rate |
$164.57 |
| Rate for Payer: Aetna Commercial |
$160.99
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$153.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$94.81
|
| Rate for Payer: Cash Price |
$51.60
|
| Rate for Payer: Cigna Commercial |
$164.57
|
| Rate for Payer: Health EOS Commercial |
$159.20
|
| Rate for Payer: HFN Commercial |
$164.57
|
| Rate for Payer: Multiplan Commercial |
$143.10
|
| Rate for Payer: Preferred Network Access Commercial |
$164.57
|
| Rate for Payer: Quartz Beloit One Network |
$87.65
|
| Rate for Payer: Quartz Commercial |
$107.33
|
| Rate for Payer: WEA Trust Commercial |
$98.38
|
| Rate for Payer: WPS Commercial |
$132.49
|
|
|
IABP Removal
|
Facility
|
OP
|
$172.00
|
|
|
Service Code
|
CPT 33968
|
| Hospital Charge Code |
3052404
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$50.09 |
| Max. Negotiated Rate |
$12,349.86 |
| Rate for Payer: Aetna Commercial |
$160.99
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$153.84
|
| Rate for Payer: Aetna Managed Medicare |
$50.09
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,303.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,364.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,944.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$94.81
|
| Rate for Payer: Cash Price |
$51.60
|
| Rate for Payer: Cash Price |
$51.60
|
| Rate for Payer: Cash Price |
$51.60
|
| Rate for Payer: Cigna Commercial |
$164.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,349.86
|
| Rate for Payer: Health EOS Commercial |
$159.20
|
| Rate for Payer: HFN Commercial |
$164.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$134.16
|
| Rate for Payer: Multiplan Commercial |
$143.10
|
| Rate for Payer: NAPHCARE Commercial |
$107.33
|
| Rate for Payer: Preferred Network Access Commercial |
$164.57
|
| Rate for Payer: Quartz Beloit One Network |
$87.65
|
| Rate for Payer: Quartz Commercial |
$116.27
|
| Rate for Payer: Quartz Medicare Advantage |
$107.33
|
| Rate for Payer: The Alliance Commercial |
$109.45
|
| Rate for Payer: United Healthcare PPO |
$4,267.12
|
| Rate for Payer: WEA Trust Commercial |
$98.38
|
| Rate for Payer: WPS Commercial |
$132.49
|
|
|
IBD ASCA IgA
|
Facility
|
OP
|
$120.00
|
|
|
Service Code
|
CPT 86671
|
| Hospital Charge Code |
5439034
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.74 |
| Max. Negotiated Rate |
$114.82 |
| Rate for Payer: Aetna Commercial |
$112.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$107.33
|
| Rate for Payer: Aetna Managed Medicare |
$12.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$47.77
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$22.30
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$21.15
|
| Rate for Payer: Anthem Medicare Advantage |
$12.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$66.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.74
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$114.82
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$69.84
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12.74
|
| Rate for Payer: Health EOS Commercial |
$111.07
|
| Rate for Payer: HFN Commercial |
$114.82
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$47.39
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.74
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.74
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12.74
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12.74
|
| Rate for Payer: Multiplan Commercial |
$99.84
|
| Rate for Payer: NAPHCARE Commercial |
$19.11
|
| Rate for Payer: Preferred Network Access Commercial |
$114.82
|
| Rate for Payer: Quartz Beloit One Network |
$61.15
|
| Rate for Payer: Quartz Commercial |
$81.12
|
| Rate for Payer: Quartz Medicare Advantage |
$12.74
|
| Rate for Payer: The Alliance Commercial |
$50.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.74
|
| Rate for Payer: United Healthcare PPO |
$93.60
|
| Rate for Payer: WEA Trust Commercial |
$68.64
|
| Rate for Payer: Wellcare Medicare |
$12.74
|
| Rate for Payer: WPS Commercial |
$92.44
|
|
|
IBD ASCA IgA
|
Facility
|
IP
|
$120.00
|
|
|
Service Code
|
CPT 86671
|
| Hospital Charge Code |
5439034
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$61.15 |
| Max. Negotiated Rate |
$114.82 |
| Rate for Payer: Aetna Commercial |
$112.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$107.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$66.14
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$114.82
|
| Rate for Payer: Health EOS Commercial |
$111.07
|
| Rate for Payer: HFN Commercial |
$114.82
|
| Rate for Payer: Multiplan Commercial |
$99.84
|
| Rate for Payer: Preferred Network Access Commercial |
$114.82
|
| Rate for Payer: Quartz Beloit One Network |
$61.15
|
| Rate for Payer: Quartz Commercial |
$74.88
|
| Rate for Payer: WEA Trust Commercial |
$68.64
|
| Rate for Payer: WPS Commercial |
$92.44
|
|
|
IBD ASCA IgA
|
Professional
|
Both
|
$120.00
|
|
|
Service Code
|
CPT 86671
|
| Hospital Charge Code |
5439034
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.74 |
| Max. Negotiated Rate |
$118.56 |
| Rate for Payer: Aetna Commercial |
$118.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$107.33
|
| Rate for Payer: Aetna Managed Medicare |
$12.74
|
| Rate for Payer: Anthem Medicare Advantage |
$12.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.74
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$118.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$62.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.74
|
| Rate for Payer: Health EOS Commercial |
$113.57
|
| Rate for Payer: HFN Commercial |
$118.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44.97
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$44.97
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.74
|
| Rate for Payer: Multiplan Commercial |
$99.84
|
| Rate for Payer: NAPHCARE Commercial |
$19.11
|
| Rate for Payer: Preferred Network Access Commercial |
$118.56
|
| Rate for Payer: Quartz Beloit One Network |
$54.91
|
| Rate for Payer: Quartz Commercial |
$71.14
|
| Rate for Payer: Quartz Medicare Advantage |
$12.74
|
| Rate for Payer: The Alliance Commercial |
$50.32
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.74
|
| Rate for Payer: WEA Trust Commercial |
$68.64
|
| Rate for Payer: WPS Commercial |
$56.06
|
|
|
IBD ASCA IgG
|
Professional
|
Both
|
$120.00
|
|
|
Service Code
|
CPT 86671
|
| Hospital Charge Code |
5439033
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.74 |
| Max. Negotiated Rate |
$118.56 |
| Rate for Payer: Aetna Commercial |
$118.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$107.33
|
| Rate for Payer: Aetna Managed Medicare |
$12.74
|
| Rate for Payer: Anthem Medicare Advantage |
$12.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.74
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$118.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$62.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.74
|
| Rate for Payer: Health EOS Commercial |
$113.57
|
| Rate for Payer: HFN Commercial |
$118.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44.97
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$44.97
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.74
|
| Rate for Payer: Multiplan Commercial |
$99.84
|
| Rate for Payer: NAPHCARE Commercial |
$19.11
|
| Rate for Payer: Preferred Network Access Commercial |
$118.56
|
| Rate for Payer: Quartz Beloit One Network |
$54.91
|
| Rate for Payer: Quartz Commercial |
$71.14
|
| Rate for Payer: Quartz Medicare Advantage |
$12.74
|
| Rate for Payer: The Alliance Commercial |
$50.32
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.74
|
| Rate for Payer: WEA Trust Commercial |
$68.64
|
| Rate for Payer: WPS Commercial |
$56.06
|
|
|
IBD ASCA IgG
|
Facility
|
OP
|
$120.00
|
|
|
Service Code
|
CPT 86671
|
| Hospital Charge Code |
5439033
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.74 |
| Max. Negotiated Rate |
$114.82 |
| Rate for Payer: Aetna Commercial |
$112.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$107.33
|
| Rate for Payer: Aetna Managed Medicare |
$12.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$47.77
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$22.30
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$21.15
|
| Rate for Payer: Anthem Medicare Advantage |
$12.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$66.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.74
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$114.82
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$69.84
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12.74
|
| Rate for Payer: Health EOS Commercial |
$111.07
|
| Rate for Payer: HFN Commercial |
$114.82
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$47.39
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.74
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.74
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12.74
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12.74
|
| Rate for Payer: Multiplan Commercial |
$99.84
|
| Rate for Payer: NAPHCARE Commercial |
$19.11
|
| Rate for Payer: Preferred Network Access Commercial |
$114.82
|
| Rate for Payer: Quartz Beloit One Network |
$61.15
|
| Rate for Payer: Quartz Commercial |
$81.12
|
| Rate for Payer: Quartz Medicare Advantage |
$12.74
|
| Rate for Payer: The Alliance Commercial |
$50.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.74
|
| Rate for Payer: United Healthcare PPO |
$93.60
|
| Rate for Payer: WEA Trust Commercial |
$68.64
|
| Rate for Payer: Wellcare Medicare |
$12.74
|
| Rate for Payer: WPS Commercial |
$92.44
|
|
|
IBD ASCA IgG
|
Facility
|
IP
|
$120.00
|
|
|
Service Code
|
CPT 86671
|
| Hospital Charge Code |
5439033
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$61.15 |
| Max. Negotiated Rate |
$114.82 |
| Rate for Payer: Aetna Commercial |
$112.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$107.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$66.14
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$114.82
|
| Rate for Payer: Health EOS Commercial |
$111.07
|
| Rate for Payer: HFN Commercial |
$114.82
|
| Rate for Payer: Multiplan Commercial |
$99.84
|
| Rate for Payer: Preferred Network Access Commercial |
$114.82
|
| Rate for Payer: Quartz Beloit One Network |
$61.15
|
| Rate for Payer: Quartz Commercial |
$74.88
|
| Rate for Payer: WEA Trust Commercial |
$68.64
|
| Rate for Payer: WPS Commercial |
$92.44
|
|
|
IBD DNA
|
Professional
|
Both
|
$277.00
|
|
|
Service Code
|
CPT 88350
|
| Hospital Charge Code |
4597204
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$23.41 |
| Max. Negotiated Rate |
$470.28 |
| Rate for Payer: Aetna Commercial |
$273.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$247.75
|
| Rate for Payer: Aetna Managed Medicare |
$106.88
|
| Rate for Payer: Anthem Commercial |
$23.41
|
| Rate for Payer: Anthem Medicare Advantage |
$106.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$106.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$106.88
|
| Rate for Payer: Cash Price |
$83.10
|
| Rate for Payer: Cash Price |
$83.10
|
| Rate for Payer: Cigna Commercial |
$273.68
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$144.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$106.88
|
| Rate for Payer: Health EOS Commercial |
$262.15
|
| Rate for Payer: HFN Commercial |
$273.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$385.26
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$385.26
|
| Rate for Payer: Independent Care Health Plan Medicare |
$106.88
|
| Rate for Payer: Multiplan Commercial |
$230.46
|
| Rate for Payer: NAPHCARE Commercial |
$160.32
|
| Rate for Payer: Preferred Network Access Commercial |
$273.68
|
| Rate for Payer: Quartz Beloit One Network |
$126.76
|
| Rate for Payer: Quartz Commercial |
$164.21
|
| Rate for Payer: Quartz Medicare Advantage |
$106.88
|
| Rate for Payer: The Alliance Commercial |
$422.18
|
| Rate for Payer: United Healthcare Medicare Advantage |
$106.88
|
| Rate for Payer: WEA Trust Commercial |
$158.44
|
| Rate for Payer: WPS Commercial |
$470.28
|
|
|
IBD DNA
|
Facility
|
OP
|
$277.00
|
|
|
Service Code
|
CPT 88350
|
| Hospital Charge Code |
4597204
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$80.66 |
| Max. Negotiated Rate |
$427.52 |
| Rate for Payer: Aetna Commercial |
$259.27
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$247.75
|
| Rate for Payer: Aetna Managed Medicare |
$80.66
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$187.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$144.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$138.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$152.68
|
| Rate for Payer: Cash Price |
$83.10
|
| Rate for Payer: Cash Price |
$83.10
|
| Rate for Payer: Cigna Commercial |
$265.03
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$161.21
|
| Rate for Payer: Health EOS Commercial |
$256.39
|
| Rate for Payer: HFN Commercial |
$265.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$216.06
|
| Rate for Payer: Multiplan Commercial |
$230.46
|
| Rate for Payer: NAPHCARE Commercial |
$172.85
|
| Rate for Payer: Preferred Network Access Commercial |
$265.03
|
| Rate for Payer: Quartz Beloit One Network |
$141.16
|
| Rate for Payer: Quartz Commercial |
$187.25
|
| Rate for Payer: Quartz Medicare Advantage |
$172.85
|
| Rate for Payer: The Alliance Commercial |
$427.52
|
| Rate for Payer: United Healthcare PPO |
$216.06
|
| Rate for Payer: WEA Trust Commercial |
$158.44
|
| Rate for Payer: WPS Commercial |
$213.37
|
|
|
IBD DNA
|
Facility
|
IP
|
$277.00
|
|
|
Service Code
|
CPT 88350
|
| Hospital Charge Code |
4597204
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$141.16 |
| Max. Negotiated Rate |
$265.03 |
| Rate for Payer: Aetna Commercial |
$259.27
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$247.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$152.68
|
| Rate for Payer: Cash Price |
$83.10
|
| Rate for Payer: Cigna Commercial |
$265.03
|
| Rate for Payer: Health EOS Commercial |
$256.39
|
| Rate for Payer: HFN Commercial |
$265.03
|
| Rate for Payer: Multiplan Commercial |
$230.46
|
| Rate for Payer: Preferred Network Access Commercial |
$265.03
|
| Rate for Payer: Quartz Beloit One Network |
$141.16
|
| Rate for Payer: Quartz Commercial |
$172.85
|
| Rate for Payer: WEA Trust Commercial |
$158.44
|
| Rate for Payer: WPS Commercial |
$213.37
|
|
|
IBD Interp & Report
|
Facility
|
IP
|
$116.00
|
|
| Hospital Charge Code |
2808809
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$59.11 |
| Max. Negotiated Rate |
$110.99 |
| Rate for Payer: Aetna Commercial |
$108.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$103.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$63.94
|
| Rate for Payer: Cash Price |
$34.80
|
| Rate for Payer: Cigna Commercial |
$110.99
|
| Rate for Payer: Health EOS Commercial |
$107.37
|
| Rate for Payer: HFN Commercial |
$110.99
|
| Rate for Payer: Multiplan Commercial |
$96.51
|
| Rate for Payer: Preferred Network Access Commercial |
$110.99
|
| Rate for Payer: Quartz Beloit One Network |
$59.11
|
| Rate for Payer: Quartz Commercial |
$72.38
|
| Rate for Payer: WEA Trust Commercial |
$66.35
|
| Rate for Payer: WPS Commercial |
$89.35
|
|
|
IBD Interp & Report
|
Facility
|
OP
|
$116.00
|
|
| Hospital Charge Code |
2808809
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$33.78 |
| Max. Negotiated Rate |
$110.99 |
| Rate for Payer: Aetna Commercial |
$108.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$103.75
|
| Rate for Payer: Aetna Managed Medicare |
$33.78
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$78.42
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$60.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$57.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$63.94
|
| Rate for Payer: Cash Price |
$34.80
|
| Rate for Payer: Cigna Commercial |
$110.99
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$67.51
|
| Rate for Payer: Health EOS Commercial |
$107.37
|
| Rate for Payer: HFN Commercial |
$110.99
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$90.48
|
| Rate for Payer: Multiplan Commercial |
$96.51
|
| Rate for Payer: NAPHCARE Commercial |
$72.38
|
| Rate for Payer: Preferred Network Access Commercial |
$110.99
|
| Rate for Payer: Quartz Beloit One Network |
$59.11
|
| Rate for Payer: Quartz Commercial |
$78.42
|
| Rate for Payer: Quartz Medicare Advantage |
$72.38
|
| Rate for Payer: The Alliance Commercial |
$60.32
|
| Rate for Payer: United Healthcare PPO |
$90.48
|
| Rate for Payer: WEA Trust Commercial |
$66.35
|
| Rate for Payer: WPS Commercial |
$89.35
|
|
|
IBD Interp & Report
|
Professional
|
Both
|
$116.00
|
|
| Hospital Charge Code |
2808809
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$53.08 |
| Max. Negotiated Rate |
$114.61 |
| Rate for Payer: Aetna Commercial |
$114.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$103.75
|
| Rate for Payer: Cash Price |
$34.80
|
| Rate for Payer: Cigna Commercial |
$114.61
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$60.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$72.38
|
| Rate for Payer: Health EOS Commercial |
$109.78
|
| Rate for Payer: HFN Commercial |
$114.61
|
| Rate for Payer: Multiplan Commercial |
$96.51
|
| Rate for Payer: Preferred Network Access Commercial |
$114.61
|
| Rate for Payer: Quartz Beloit One Network |
$53.08
|
| Rate for Payer: Quartz Commercial |
$68.76
|
| Rate for Payer: The Alliance Commercial |
$60.32
|
| Rate for Payer: WEA Trust Commercial |
$66.35
|
| Rate for Payer: WPS Commercial |
$89.35
|
|
|
IBD SGI Diagnostic to Prometheus
|
Facility
|
OP
|
$152.00
|
|
|
Service Code
|
CPT 81479
|
| Hospital Charge Code |
3062684
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$44.26 |
| Max. Negotiated Rate |
$145.43 |
| Rate for Payer: Aetna Commercial |
$142.27
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$135.95
|
| Rate for Payer: Aetna Managed Medicare |
$44.26
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$102.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$79.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$75.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$83.78
|
| Rate for Payer: Cash Price |
$45.60
|
| Rate for Payer: Cigna Commercial |
$145.43
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$88.46
|
| Rate for Payer: Health EOS Commercial |
$140.69
|
| Rate for Payer: HFN Commercial |
$145.43
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$118.56
|
| Rate for Payer: Multiplan Commercial |
$126.46
|
| Rate for Payer: NAPHCARE Commercial |
$94.85
|
| Rate for Payer: Preferred Network Access Commercial |
$145.43
|
| Rate for Payer: Quartz Beloit One Network |
$77.46
|
| Rate for Payer: Quartz Commercial |
$102.75
|
| Rate for Payer: Quartz Medicare Advantage |
$94.85
|
| Rate for Payer: The Alliance Commercial |
$79.04
|
| Rate for Payer: United Healthcare PPO |
$118.56
|
| Rate for Payer: WEA Trust Commercial |
$86.94
|
| Rate for Payer: WPS Commercial |
$117.09
|
|
|
IBD SGI Diagnostic to Prometheus
|
Facility
|
IP
|
$152.00
|
|
|
Service Code
|
CPT 81479
|
| Hospital Charge Code |
3062684
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$77.46 |
| Max. Negotiated Rate |
$145.43 |
| Rate for Payer: Aetna Commercial |
$142.27
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$135.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$83.78
|
| Rate for Payer: Cash Price |
$45.60
|
| Rate for Payer: Cigna Commercial |
$145.43
|
| Rate for Payer: Health EOS Commercial |
$140.69
|
| Rate for Payer: HFN Commercial |
$145.43
|
| Rate for Payer: Multiplan Commercial |
$126.46
|
| Rate for Payer: Preferred Network Access Commercial |
$145.43
|
| Rate for Payer: Quartz Beloit One Network |
$77.46
|
| Rate for Payer: Quartz Commercial |
$94.85
|
| Rate for Payer: WEA Trust Commercial |
$86.94
|
| Rate for Payer: WPS Commercial |
$117.09
|
|
|
IBD SGI Diagnostic to Prometheus
|
Professional
|
Both
|
$152.00
|
|
|
Service Code
|
CPT 81479
|
| Hospital Charge Code |
3062684
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$69.56 |
| Max. Negotiated Rate |
$150.18 |
| Rate for Payer: Aetna Commercial |
$150.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$135.95
|
| Rate for Payer: Cash Price |
$45.60
|
| Rate for Payer: Cigna Commercial |
$150.18
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$79.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$94.85
|
| Rate for Payer: Health EOS Commercial |
$143.85
|
| Rate for Payer: HFN Commercial |
$150.18
|
| Rate for Payer: Multiplan Commercial |
$126.46
|
| Rate for Payer: Preferred Network Access Commercial |
$150.18
|
| Rate for Payer: Quartz Beloit One Network |
$69.56
|
| Rate for Payer: Quartz Commercial |
$90.11
|
| Rate for Payer: The Alliance Commercial |
$79.04
|
| Rate for Payer: WEA Trust Commercial |
$86.94
|
| Rate for Payer: WPS Commercial |
$117.09
|
|
