|
IgVh Interp & Report
|
Facility
|
IP
|
$151.00
|
|
| Hospital Charge Code |
2776806
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$76.95 |
| Max. Negotiated Rate |
$144.48 |
| Rate for Payer: Aetna Commercial |
$141.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$135.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$83.23
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cigna Commercial |
$144.48
|
| Rate for Payer: Health EOS Commercial |
$139.77
|
| Rate for Payer: HFN Commercial |
$144.48
|
| Rate for Payer: Multiplan Commercial |
$125.63
|
| Rate for Payer: Preferred Network Access Commercial |
$144.48
|
| Rate for Payer: Quartz Beloit One Network |
$76.95
|
| Rate for Payer: Quartz Commercial |
$94.22
|
| Rate for Payer: WEA Trust Commercial |
$86.37
|
| Rate for Payer: WPS Commercial |
$116.32
|
|
|
IgVh Interp & Report
|
Facility
|
OP
|
$151.00
|
|
| Hospital Charge Code |
2776806
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$43.97 |
| Max. Negotiated Rate |
$144.48 |
| Rate for Payer: Aetna Commercial |
$141.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$135.05
|
| Rate for Payer: Aetna Managed Medicare |
$43.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$102.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$78.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$75.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$83.23
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cigna Commercial |
$144.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$87.88
|
| Rate for Payer: Health EOS Commercial |
$139.77
|
| Rate for Payer: HFN Commercial |
$144.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$117.78
|
| Rate for Payer: Multiplan Commercial |
$125.63
|
| Rate for Payer: NAPHCARE Commercial |
$94.22
|
| Rate for Payer: Preferred Network Access Commercial |
$144.48
|
| Rate for Payer: Quartz Beloit One Network |
$76.95
|
| Rate for Payer: Quartz Commercial |
$102.08
|
| Rate for Payer: Quartz Medicare Advantage |
$94.22
|
| Rate for Payer: The Alliance Commercial |
$78.52
|
| Rate for Payer: United Healthcare PPO |
$117.78
|
| Rate for Payer: WEA Trust Commercial |
$86.37
|
| Rate for Payer: WPS Commercial |
$116.32
|
|
|
IgVh Interp & Report
|
Professional
|
Both
|
$151.00
|
|
| Hospital Charge Code |
2776806
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$69.10 |
| Max. Negotiated Rate |
$149.19 |
| Rate for Payer: Aetna Commercial |
$149.19
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$135.05
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cigna Commercial |
$149.19
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$78.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$94.22
|
| Rate for Payer: Health EOS Commercial |
$142.91
|
| Rate for Payer: HFN Commercial |
$149.19
|
| Rate for Payer: Multiplan Commercial |
$125.63
|
| Rate for Payer: Preferred Network Access Commercial |
$149.19
|
| Rate for Payer: Quartz Beloit One Network |
$69.10
|
| Rate for Payer: Quartz Commercial |
$89.51
|
| Rate for Payer: The Alliance Commercial |
$78.52
|
| Rate for Payer: WEA Trust Commercial |
$86.37
|
| Rate for Payer: WPS Commercial |
$116.32
|
|
|
IgVH Mutation Status, Cell-based
|
Facility
|
OP
|
$673.00
|
|
|
Service Code
|
CPT 81263
|
| Hospital Charge Code |
5432850
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$306.30 |
| Max. Negotiated Rate |
$1,225.20 |
| Rate for Payer: Aetna Commercial |
$629.93
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$601.93
|
| Rate for Payer: Aetna Managed Medicare |
$306.30
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,148.63
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$536.03
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$508.46
|
| Rate for Payer: Anthem Medicare Advantage |
$306.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$370.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$306.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$306.30
|
| Rate for Payer: Cash Price |
$201.90
|
| Rate for Payer: Cash Price |
$201.90
|
| Rate for Payer: Cigna Commercial |
$643.93
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$306.30
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$391.69
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$306.30
|
| Rate for Payer: Health EOS Commercial |
$622.93
|
| Rate for Payer: HFN Commercial |
$643.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,139.44
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$306.30
|
| Rate for Payer: Independent Care Health Plan Medicare |
$306.30
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$306.30
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$306.30
|
| Rate for Payer: Multiplan Commercial |
$559.94
|
| Rate for Payer: NAPHCARE Commercial |
$459.45
|
| Rate for Payer: Preferred Network Access Commercial |
$643.93
|
| Rate for Payer: Quartz Beloit One Network |
$342.96
|
| Rate for Payer: Quartz Commercial |
$454.95
|
| Rate for Payer: Quartz Medicare Advantage |
$306.30
|
| Rate for Payer: The Alliance Commercial |
$1,225.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$306.30
|
| Rate for Payer: United Healthcare PPO |
$524.94
|
| Rate for Payer: WEA Trust Commercial |
$384.96
|
| Rate for Payer: Wellcare Medicare |
$306.30
|
| Rate for Payer: WPS Commercial |
$518.41
|
|
|
IgVH Mutation Status, Cell-based
|
Facility
|
IP
|
$673.00
|
|
|
Service Code
|
CPT 81263
|
| Hospital Charge Code |
5432850
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$342.96 |
| Max. Negotiated Rate |
$643.93 |
| Rate for Payer: Aetna Commercial |
$629.93
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$601.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$370.96
|
| Rate for Payer: Cash Price |
$201.90
|
| Rate for Payer: Cigna Commercial |
$643.93
|
| Rate for Payer: Health EOS Commercial |
$622.93
|
| Rate for Payer: HFN Commercial |
$643.93
|
| Rate for Payer: Multiplan Commercial |
$559.94
|
| Rate for Payer: Preferred Network Access Commercial |
$643.93
|
| Rate for Payer: Quartz Beloit One Network |
$342.96
|
| Rate for Payer: Quartz Commercial |
$419.95
|
| Rate for Payer: WEA Trust Commercial |
$384.96
|
| Rate for Payer: WPS Commercial |
$518.41
|
|
|
IgVH Mutation Status, Cell-based
|
Professional
|
Both
|
$673.00
|
|
|
Service Code
|
CPT 81263
|
| Hospital Charge Code |
5432850
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$306.30 |
| Max. Negotiated Rate |
$1,347.72 |
| Rate for Payer: Aetna Commercial |
$664.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$601.93
|
| Rate for Payer: Aetna Managed Medicare |
$306.30
|
| Rate for Payer: Anthem Medicare Advantage |
$306.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$306.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$306.30
|
| Rate for Payer: Cash Price |
$201.90
|
| Rate for Payer: Cash Price |
$201.90
|
| Rate for Payer: Cigna Commercial |
$664.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$349.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$306.30
|
| Rate for Payer: Health EOS Commercial |
$636.93
|
| Rate for Payer: HFN Commercial |
$664.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,081.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,081.25
|
| Rate for Payer: Independent Care Health Plan Medicare |
$306.30
|
| Rate for Payer: Multiplan Commercial |
$559.94
|
| Rate for Payer: NAPHCARE Commercial |
$459.45
|
| Rate for Payer: Preferred Network Access Commercial |
$664.92
|
| Rate for Payer: Quartz Beloit One Network |
$307.96
|
| Rate for Payer: Quartz Commercial |
$398.95
|
| Rate for Payer: Quartz Medicare Advantage |
$306.30
|
| Rate for Payer: The Alliance Commercial |
$1,209.89
|
| Rate for Payer: United Healthcare Medicare Advantage |
$306.30
|
| Rate for Payer: WEA Trust Commercial |
$384.96
|
| Rate for Payer: WPS Commercial |
$1,347.72
|
|
|
IgVh Mutation to US Labs
|
Facility
|
IP
|
$2,844.00
|
|
|
Service Code
|
CPT 81263
|
| Hospital Charge Code |
1040843
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$1,449.30 |
| Max. Negotiated Rate |
$2,721.14 |
| Rate for Payer: Aetna Commercial |
$2,661.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,543.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,567.61
|
| Rate for Payer: Cash Price |
$853.20
|
| Rate for Payer: Cigna Commercial |
$2,721.14
|
| Rate for Payer: Health EOS Commercial |
$2,632.41
|
| Rate for Payer: HFN Commercial |
$2,721.14
|
| Rate for Payer: Multiplan Commercial |
$2,366.21
|
| Rate for Payer: Preferred Network Access Commercial |
$2,721.14
|
| Rate for Payer: Quartz Beloit One Network |
$1,449.30
|
| Rate for Payer: Quartz Commercial |
$1,774.66
|
| Rate for Payer: WEA Trust Commercial |
$1,626.77
|
| Rate for Payer: WPS Commercial |
$2,190.73
|
|
|
IgVh Mutation to US Labs
|
Facility
|
OP
|
$2,844.00
|
|
|
Service Code
|
CPT 81263
|
| Hospital Charge Code |
1040843
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$306.30 |
| Max. Negotiated Rate |
$2,721.14 |
| Rate for Payer: Aetna Commercial |
$2,661.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,543.67
|
| Rate for Payer: Aetna Managed Medicare |
$306.30
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,148.63
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$536.03
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$508.46
|
| Rate for Payer: Anthem Medicare Advantage |
$306.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,567.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$306.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$306.30
|
| Rate for Payer: Cash Price |
$853.20
|
| Rate for Payer: Cash Price |
$853.20
|
| Rate for Payer: Cigna Commercial |
$2,721.14
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$306.30
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,655.21
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$306.30
|
| Rate for Payer: Health EOS Commercial |
$2,632.41
|
| Rate for Payer: HFN Commercial |
$2,721.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,139.44
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$306.30
|
| Rate for Payer: Independent Care Health Plan Medicare |
$306.30
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$306.30
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$306.30
|
| Rate for Payer: Multiplan Commercial |
$2,366.21
|
| Rate for Payer: NAPHCARE Commercial |
$459.45
|
| Rate for Payer: Preferred Network Access Commercial |
$2,721.14
|
| Rate for Payer: Quartz Beloit One Network |
$1,449.30
|
| Rate for Payer: Quartz Commercial |
$1,922.54
|
| Rate for Payer: Quartz Medicare Advantage |
$306.30
|
| Rate for Payer: The Alliance Commercial |
$1,225.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$306.30
|
| Rate for Payer: United Healthcare PPO |
$2,218.32
|
| Rate for Payer: WEA Trust Commercial |
$1,626.77
|
| Rate for Payer: Wellcare Medicare |
$306.30
|
| Rate for Payer: WPS Commercial |
$2,190.73
|
|
|
IgVh Mutation to US Labs
|
Professional
|
Both
|
$2,844.00
|
|
|
Service Code
|
CPT 81263
|
| Hospital Charge Code |
1040843
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$306.30 |
| Max. Negotiated Rate |
$2,809.87 |
| Rate for Payer: Aetna Commercial |
$2,809.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,543.67
|
| Rate for Payer: Aetna Managed Medicare |
$306.30
|
| Rate for Payer: Anthem Medicare Advantage |
$306.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$306.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$306.30
|
| Rate for Payer: Cash Price |
$853.20
|
| Rate for Payer: Cash Price |
$853.20
|
| Rate for Payer: Cigna Commercial |
$2,809.87
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,478.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$306.30
|
| Rate for Payer: Health EOS Commercial |
$2,691.56
|
| Rate for Payer: HFN Commercial |
$2,809.87
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,081.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,081.25
|
| Rate for Payer: Independent Care Health Plan Medicare |
$306.30
|
| Rate for Payer: Multiplan Commercial |
$2,366.21
|
| Rate for Payer: NAPHCARE Commercial |
$459.45
|
| Rate for Payer: Preferred Network Access Commercial |
$2,809.87
|
| Rate for Payer: Quartz Beloit One Network |
$1,301.41
|
| Rate for Payer: Quartz Commercial |
$1,685.92
|
| Rate for Payer: Quartz Medicare Advantage |
$306.30
|
| Rate for Payer: The Alliance Commercial |
$1,209.89
|
| Rate for Payer: United Healthcare Medicare Advantage |
$306.30
|
| Rate for Payer: WEA Trust Commercial |
$1,626.77
|
| Rate for Payer: WPS Commercial |
$1,347.72
|
|
|
IgVh Nucleic Acid Amplification 83898
|
Facility
|
OP
|
$151.00
|
|
| Hospital Charge Code |
2776815
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$43.97 |
| Max. Negotiated Rate |
$144.48 |
| Rate for Payer: Aetna Commercial |
$141.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$135.05
|
| Rate for Payer: Aetna Managed Medicare |
$43.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$102.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$78.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$75.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$83.23
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cigna Commercial |
$144.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$87.88
|
| Rate for Payer: Health EOS Commercial |
$139.77
|
| Rate for Payer: HFN Commercial |
$144.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$117.78
|
| Rate for Payer: Multiplan Commercial |
$125.63
|
| Rate for Payer: NAPHCARE Commercial |
$94.22
|
| Rate for Payer: Preferred Network Access Commercial |
$144.48
|
| Rate for Payer: Quartz Beloit One Network |
$76.95
|
| Rate for Payer: Quartz Commercial |
$102.08
|
| Rate for Payer: Quartz Medicare Advantage |
$94.22
|
| Rate for Payer: The Alliance Commercial |
$78.52
|
| Rate for Payer: United Healthcare PPO |
$117.78
|
| Rate for Payer: WEA Trust Commercial |
$86.37
|
| Rate for Payer: WPS Commercial |
$116.32
|
|
|
IgVh Nucleic Acid Amplification 83898
|
Facility
|
IP
|
$151.00
|
|
| Hospital Charge Code |
2776815
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$76.95 |
| Max. Negotiated Rate |
$144.48 |
| Rate for Payer: Aetna Commercial |
$141.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$135.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$83.23
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cigna Commercial |
$144.48
|
| Rate for Payer: Health EOS Commercial |
$139.77
|
| Rate for Payer: HFN Commercial |
$144.48
|
| Rate for Payer: Multiplan Commercial |
$125.63
|
| Rate for Payer: Preferred Network Access Commercial |
$144.48
|
| Rate for Payer: Quartz Beloit One Network |
$76.95
|
| Rate for Payer: Quartz Commercial |
$94.22
|
| Rate for Payer: WEA Trust Commercial |
$86.37
|
| Rate for Payer: WPS Commercial |
$116.32
|
|
|
IgVh Nucleic Acid Amplification 83898
|
Professional
|
Both
|
$151.00
|
|
| Hospital Charge Code |
2776815
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$69.10 |
| Max. Negotiated Rate |
$149.19 |
| Rate for Payer: Aetna Commercial |
$149.19
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$135.05
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cigna Commercial |
$149.19
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$78.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$94.22
|
| Rate for Payer: Health EOS Commercial |
$142.91
|
| Rate for Payer: HFN Commercial |
$149.19
|
| Rate for Payer: Multiplan Commercial |
$125.63
|
| Rate for Payer: Preferred Network Access Commercial |
$149.19
|
| Rate for Payer: Quartz Beloit One Network |
$69.10
|
| Rate for Payer: Quartz Commercial |
$89.51
|
| Rate for Payer: The Alliance Commercial |
$78.52
|
| Rate for Payer: WEA Trust Commercial |
$86.37
|
| Rate for Payer: WPS Commercial |
$116.32
|
|
|
IgVh Nucleic Acid Amplification 83900
|
Facility
|
OP
|
$151.00
|
|
| Hospital Charge Code |
2776810
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$43.97 |
| Max. Negotiated Rate |
$144.48 |
| Rate for Payer: Aetna Commercial |
$141.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$135.05
|
| Rate for Payer: Aetna Managed Medicare |
$43.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$102.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$78.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$75.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$83.23
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cigna Commercial |
$144.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$87.88
|
| Rate for Payer: Health EOS Commercial |
$139.77
|
| Rate for Payer: HFN Commercial |
$144.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$117.78
|
| Rate for Payer: Multiplan Commercial |
$125.63
|
| Rate for Payer: NAPHCARE Commercial |
$94.22
|
| Rate for Payer: Preferred Network Access Commercial |
$144.48
|
| Rate for Payer: Quartz Beloit One Network |
$76.95
|
| Rate for Payer: Quartz Commercial |
$102.08
|
| Rate for Payer: Quartz Medicare Advantage |
$94.22
|
| Rate for Payer: The Alliance Commercial |
$78.52
|
| Rate for Payer: United Healthcare PPO |
$117.78
|
| Rate for Payer: WEA Trust Commercial |
$86.37
|
| Rate for Payer: WPS Commercial |
$116.32
|
|
|
IgVh Nucleic Acid Amplification 83900
|
Facility
|
IP
|
$151.00
|
|
| Hospital Charge Code |
2776810
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$76.95 |
| Max. Negotiated Rate |
$144.48 |
| Rate for Payer: Aetna Commercial |
$141.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$135.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$83.23
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cigna Commercial |
$144.48
|
| Rate for Payer: Health EOS Commercial |
$139.77
|
| Rate for Payer: HFN Commercial |
$144.48
|
| Rate for Payer: Multiplan Commercial |
$125.63
|
| Rate for Payer: Preferred Network Access Commercial |
$144.48
|
| Rate for Payer: Quartz Beloit One Network |
$76.95
|
| Rate for Payer: Quartz Commercial |
$94.22
|
| Rate for Payer: WEA Trust Commercial |
$86.37
|
| Rate for Payer: WPS Commercial |
$116.32
|
|
|
IgVh Nucleic Acid Amplification 83900
|
Professional
|
Both
|
$151.00
|
|
| Hospital Charge Code |
2776810
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$69.10 |
| Max. Negotiated Rate |
$149.19 |
| Rate for Payer: Aetna Commercial |
$149.19
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$135.05
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cigna Commercial |
$149.19
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$78.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$94.22
|
| Rate for Payer: Health EOS Commercial |
$142.91
|
| Rate for Payer: HFN Commercial |
$149.19
|
| Rate for Payer: Multiplan Commercial |
$125.63
|
| Rate for Payer: Preferred Network Access Commercial |
$149.19
|
| Rate for Payer: Quartz Beloit One Network |
$69.10
|
| Rate for Payer: Quartz Commercial |
$89.51
|
| Rate for Payer: The Alliance Commercial |
$78.52
|
| Rate for Payer: WEA Trust Commercial |
$86.37
|
| Rate for Payer: WPS Commercial |
$116.32
|
|
|
IgVh Nucleic Acid Amplification 83901
|
Professional
|
Both
|
$285.00
|
|
| Hospital Charge Code |
2776811
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$130.42 |
| Max. Negotiated Rate |
$281.58 |
| Rate for Payer: Aetna Commercial |
$281.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$254.90
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cigna Commercial |
$281.58
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$148.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$177.84
|
| Rate for Payer: Health EOS Commercial |
$269.72
|
| Rate for Payer: HFN Commercial |
$281.58
|
| Rate for Payer: Multiplan Commercial |
$237.12
|
| Rate for Payer: Preferred Network Access Commercial |
$281.58
|
| Rate for Payer: Quartz Beloit One Network |
$130.42
|
| Rate for Payer: Quartz Commercial |
$168.95
|
| Rate for Payer: The Alliance Commercial |
$148.20
|
| Rate for Payer: WEA Trust Commercial |
$163.02
|
| Rate for Payer: WPS Commercial |
$219.54
|
|
|
IgVh Nucleic Acid Amplification 83901
|
Facility
|
IP
|
$285.00
|
|
| Hospital Charge Code |
2776811
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$145.24 |
| Max. Negotiated Rate |
$272.69 |
| Rate for Payer: Aetna Commercial |
$266.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$254.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$157.09
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cigna Commercial |
$272.69
|
| Rate for Payer: Health EOS Commercial |
$263.80
|
| Rate for Payer: HFN Commercial |
$272.69
|
| Rate for Payer: Multiplan Commercial |
$237.12
|
| Rate for Payer: Preferred Network Access Commercial |
$272.69
|
| Rate for Payer: Quartz Beloit One Network |
$145.24
|
| Rate for Payer: Quartz Commercial |
$177.84
|
| Rate for Payer: WEA Trust Commercial |
$163.02
|
| Rate for Payer: WPS Commercial |
$219.54
|
|
|
IgVh Nucleic Acid Amplification 83901
|
Facility
|
OP
|
$285.00
|
|
| Hospital Charge Code |
2776811
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$82.99 |
| Max. Negotiated Rate |
$272.69 |
| Rate for Payer: Aetna Commercial |
$266.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$254.90
|
| Rate for Payer: Aetna Managed Medicare |
$82.99
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$192.66
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$148.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$142.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$157.09
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cigna Commercial |
$272.69
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$165.87
|
| Rate for Payer: Health EOS Commercial |
$263.80
|
| Rate for Payer: HFN Commercial |
$272.69
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$222.30
|
| Rate for Payer: Multiplan Commercial |
$237.12
|
| Rate for Payer: NAPHCARE Commercial |
$177.84
|
| Rate for Payer: Preferred Network Access Commercial |
$272.69
|
| Rate for Payer: Quartz Beloit One Network |
$145.24
|
| Rate for Payer: Quartz Commercial |
$192.66
|
| Rate for Payer: Quartz Medicare Advantage |
$177.84
|
| Rate for Payer: The Alliance Commercial |
$148.20
|
| Rate for Payer: United Healthcare PPO |
$222.30
|
| Rate for Payer: WEA Trust Commercial |
$163.02
|
| Rate for Payer: WPS Commercial |
$219.54
|
|
|
IgVh Nucleic Acid Extration
|
Professional
|
Both
|
$8.00
|
|
| Hospital Charge Code |
2776816
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$3.66 |
| Max. Negotiated Rate |
$7.90 |
| Rate for Payer: Aetna Commercial |
$7.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7.16
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$7.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4.99
|
| Rate for Payer: Health EOS Commercial |
$7.57
|
| Rate for Payer: HFN Commercial |
$7.90
|
| Rate for Payer: Multiplan Commercial |
$6.66
|
| Rate for Payer: Preferred Network Access Commercial |
$7.90
|
| Rate for Payer: Quartz Beloit One Network |
$3.66
|
| Rate for Payer: Quartz Commercial |
$4.74
|
| Rate for Payer: The Alliance Commercial |
$4.16
|
| Rate for Payer: WEA Trust Commercial |
$4.58
|
| Rate for Payer: WPS Commercial |
$6.16
|
|
|
IgVh Nucleic Acid Extration
|
Facility
|
IP
|
$8.00
|
|
| Hospital Charge Code |
2776816
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$4.08 |
| Max. Negotiated Rate |
$7.65 |
| Rate for Payer: Aetna Commercial |
$7.49
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4.41
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$7.65
|
| Rate for Payer: Health EOS Commercial |
$7.40
|
| Rate for Payer: HFN Commercial |
$7.65
|
| Rate for Payer: Multiplan Commercial |
$6.66
|
| Rate for Payer: Preferred Network Access Commercial |
$7.65
|
| Rate for Payer: Quartz Beloit One Network |
$4.08
|
| Rate for Payer: Quartz Commercial |
$4.99
|
| Rate for Payer: WEA Trust Commercial |
$4.58
|
| Rate for Payer: WPS Commercial |
$6.16
|
|
|
IgVh Nucleic Acid Extration
|
Facility
|
OP
|
$8.00
|
|
| Hospital Charge Code |
2776816
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$2.33 |
| Max. Negotiated Rate |
$7.65 |
| Rate for Payer: Aetna Commercial |
$7.49
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7.16
|
| Rate for Payer: Aetna Managed Medicare |
$2.33
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5.41
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4.41
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$7.65
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4.66
|
| Rate for Payer: Health EOS Commercial |
$7.40
|
| Rate for Payer: HFN Commercial |
$7.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6.24
|
| Rate for Payer: Multiplan Commercial |
$6.66
|
| Rate for Payer: NAPHCARE Commercial |
$4.99
|
| Rate for Payer: Preferred Network Access Commercial |
$7.65
|
| Rate for Payer: Quartz Beloit One Network |
$4.08
|
| Rate for Payer: Quartz Commercial |
$5.41
|
| Rate for Payer: Quartz Medicare Advantage |
$4.99
|
| Rate for Payer: The Alliance Commercial |
$4.16
|
| Rate for Payer: United Healthcare PPO |
$6.24
|
| Rate for Payer: WEA Trust Commercial |
$4.58
|
| Rate for Payer: WPS Commercial |
$6.16
|
|
|
IgVh Nucleic Acid Gel Electrophoresis
|
Facility
|
IP
|
$151.00
|
|
| Hospital Charge Code |
2776817
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$76.95 |
| Max. Negotiated Rate |
$144.48 |
| Rate for Payer: Aetna Commercial |
$141.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$135.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$83.23
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cigna Commercial |
$144.48
|
| Rate for Payer: Health EOS Commercial |
$139.77
|
| Rate for Payer: HFN Commercial |
$144.48
|
| Rate for Payer: Multiplan Commercial |
$125.63
|
| Rate for Payer: Preferred Network Access Commercial |
$144.48
|
| Rate for Payer: Quartz Beloit One Network |
$76.95
|
| Rate for Payer: Quartz Commercial |
$94.22
|
| Rate for Payer: WEA Trust Commercial |
$86.37
|
| Rate for Payer: WPS Commercial |
$116.32
|
|
|
IgVh Nucleic Acid Gel Electrophoresis
|
Facility
|
OP
|
$151.00
|
|
| Hospital Charge Code |
2776817
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$43.97 |
| Max. Negotiated Rate |
$144.48 |
| Rate for Payer: Aetna Commercial |
$141.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$135.05
|
| Rate for Payer: Aetna Managed Medicare |
$43.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$102.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$78.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$75.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$83.23
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cigna Commercial |
$144.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$87.88
|
| Rate for Payer: Health EOS Commercial |
$139.77
|
| Rate for Payer: HFN Commercial |
$144.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$117.78
|
| Rate for Payer: Multiplan Commercial |
$125.63
|
| Rate for Payer: NAPHCARE Commercial |
$94.22
|
| Rate for Payer: Preferred Network Access Commercial |
$144.48
|
| Rate for Payer: Quartz Beloit One Network |
$76.95
|
| Rate for Payer: Quartz Commercial |
$102.08
|
| Rate for Payer: Quartz Medicare Advantage |
$94.22
|
| Rate for Payer: The Alliance Commercial |
$78.52
|
| Rate for Payer: United Healthcare PPO |
$117.78
|
| Rate for Payer: WEA Trust Commercial |
$86.37
|
| Rate for Payer: WPS Commercial |
$116.32
|
|
|
IgVh Nucleic Acid Gel Electrophoresis
|
Professional
|
Both
|
$151.00
|
|
| Hospital Charge Code |
2776817
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$69.10 |
| Max. Negotiated Rate |
$149.19 |
| Rate for Payer: Aetna Commercial |
$149.19
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$135.05
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cigna Commercial |
$149.19
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$78.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$94.22
|
| Rate for Payer: Health EOS Commercial |
$142.91
|
| Rate for Payer: HFN Commercial |
$149.19
|
| Rate for Payer: Multiplan Commercial |
$125.63
|
| Rate for Payer: Preferred Network Access Commercial |
$149.19
|
| Rate for Payer: Quartz Beloit One Network |
$69.10
|
| Rate for Payer: Quartz Commercial |
$89.51
|
| Rate for Payer: The Alliance Commercial |
$78.52
|
| Rate for Payer: WEA Trust Commercial |
$86.37
|
| Rate for Payer: WPS Commercial |
$116.32
|
|
|
IgVh Nucleic Acid Separation
|
Facility
|
OP
|
$151.00
|
|
| Hospital Charge Code |
2776818
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$43.97 |
| Max. Negotiated Rate |
$144.48 |
| Rate for Payer: Aetna Commercial |
$141.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$135.05
|
| Rate for Payer: Aetna Managed Medicare |
$43.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$102.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$78.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$75.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$83.23
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cigna Commercial |
$144.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$87.88
|
| Rate for Payer: Health EOS Commercial |
$139.77
|
| Rate for Payer: HFN Commercial |
$144.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$117.78
|
| Rate for Payer: Multiplan Commercial |
$125.63
|
| Rate for Payer: NAPHCARE Commercial |
$94.22
|
| Rate for Payer: Preferred Network Access Commercial |
$144.48
|
| Rate for Payer: Quartz Beloit One Network |
$76.95
|
| Rate for Payer: Quartz Commercial |
$102.08
|
| Rate for Payer: Quartz Medicare Advantage |
$94.22
|
| Rate for Payer: The Alliance Commercial |
$78.52
|
| Rate for Payer: United Healthcare PPO |
$117.78
|
| Rate for Payer: WEA Trust Commercial |
$86.37
|
| Rate for Payer: WPS Commercial |
$116.32
|
|
