Current as of June 29, 2018 Prices subject to change without notice

Transcription

1 Current as of June 29, 2018 Prices subject to change without notice Clinical: 465 Henry Mall Madison, WI (800)

2 465 Henry Mall Madison, WI Phone: (608) Fax: (608) Dear WSLH Customer, This fee schedule includes prices for clinical testing. You can send us feedback and suggestions for improvement by clicking on Contact on our website: Questions: If you have any questions regarding appropriate clinical test use, please contact WSLH Medical Director Dr. Daniel Kurtycz via at or phone If you have other Medicare Compliance questions, please contact WSLH Medicare Compliance Officer John Shalkham via at or phone

3 OBTAINING WSLH SERVICE: Setting up an account If you don t already have an account with the WSLH, call our Billing Department (608) or (800) You will be assigned an account number to use when ordering test request forms and kits. Ordering information CLINICAL: Please call our Clinical Supplies Department to order test request forms or test kits (800) Please be prepared to give your assigned account number. Operators are available to take telephone orders Monday through Friday from 8:00 a.m. to 3:00 p.m. or a message can be left at any time. Orders will be processed within three working days. Holidays Questions or comments? The WSLH strives to provide quality test results and is committed to providing our customers the best possible service. If a result appears inconsistent with clinical findings, or if repeat testing is warranted, please contact us at one of the phone numbers below: WSLH telephone numbers CLINICAL Customer Service Clinical Supplies (to order test kits and request forms only) Fax Number CLINICAL Customer Service (800) (800) (844) The WSLH is closed on the following holidays: New Year s Eve Day New Year s Day Martin Luther King Jr. Day Memorial Day Independence Day Labor Day Thanksgiving Day Christmas Eve Day Christmas Day Billing information Tests are billed monthly to the physician s office, hospital, clinic or institution whose account number appears on the test request form accompanying the specimen. Full payment is due 30 days from date of invoice. TOXICOLOGY 2601 Agriculture Drive ENVIRONMENTAL Customer Service 2601 Agriculture Drive OCCUPATIONAL HEALTH Customer Service 2601 Agriculture Drive Fax Number 2601 Agriculture Drive WSLH PROFICIENCY ING Customer Service Billing/Accounts Receivable (608) (800) (800) (608) (800) (800) CLIA ID #s: 52D (Cytology, Communicable Diseases, Newborn Screening) 52D (Toxicology) Written correspondence may be sent to the following address: (Name of WSLH Department) Wisconsin State Laboratory of Hygiene 465 Henry Mall Madison, WI

4 Fee Schedule Changes DELETED assorted Toxicology tests; RENAMED Toxicology section to Chemical Emergency Response and MOVED it to page 6 CHANGED CPT Code - IGH/MAFB Fusion, t(14;20)(q32;q12), FISH (test code 881F72), page 19 DELETED Syphilis VDRL Serum (test code SS02017), page 12 ADDED Neisseria gonorrhoeae Nucleic Acid Amplification Test (NAAT) (test code SC00112), page 11 ADDED and DELETED multiple Cytogenetics tests, pages

5 Wisconsin State Laboratory of Hygiene Clinical Testing Price Listing Biochemical Genetics Page 5 Chemical Emergency Response Page 6 Communicable Disease Page 7 Cytogenetics Page 14 Cytology Page 23 Newborn Screening Page 25 4

6 Biochemical Genetics (608) NAME CPT Acylcarnitine Profile, Quantitative, plasma or serum Amino Acids, Quantitative, (Plasma) Amino Acids, Quantitative, (Serum) Amino Acids, Quantitative (Urine) Amino Acids, Quantitative, Dietary Screen (Filter Paper) BG00540 $ $ $ $ $ Biotinidase Activity 520 $ Carnitine, Free and Total 531 $ Methylmalonic Acid BG00575 $ Methylmalonic acid/homocysteine Panel BG00576 $ Organic Acids, Quantitative 554 $ Total Homocysteine BG00595 $

7 Chemical Emergency Response (608) NAME CPT Lead, Blood, Capillary TX00468 $ Lead, Blood, Venous TX00467 $ Mercury, Blood TX00472 $

8 Communicable Disease (800) or (608) NAME CPT Antimicrobial Susceptibility, Enteric Pathogens Arbovirus IgM CEIA Ab Diagnostic Panel MP00655 $ SS02201 $ Bacillus anthracis Culture MP00330 $ Bacterial Identification, Non- Enteric Public Health Panel Bacterial Typing, Pulsed-Field Gel Electrophoresis MP00470 $ MP00628 $ Bordetella Culture MP00623 $ Bordetella pertussis/ parapertussis PCR MP00311 $ x 3 Botulism Culture MP02993 $90.00 Botulism Toxin, Food or Stool MP02913 $90.00 Brucella Antibody SS02002 $ Brucella Culture MP00350 $

9 NAME CPT Centers for Disease Control $70.00 or $90.00 depending on specimen Chikungunya Virus PCR SS02303 $280 Chlamydia-Gonorrhoea Combination Nucleic Acid Amplification Test (NAAT) Chlamydia trachomatis Nucleic Acid Amplification Test (NAAT) Crimean-Congo Hemorrhagic Fever Serology Cryptosporidium/Giardia Antigen Detection (DFA) SC00111 $ SC00118 $ SS02714 $70.00 MP00802 $ Dengue Fever, Serology SS02718 $70.00 Dengue Fever, PCR and Serotyping SS02302 $ x 4 Diphtheria Culture MP00380 $ Eastern Equine Encephalitis Antibody Ectoparasite and Arthropod Identification of Public Health Significance SS02211 $ MP00800 $

10 NAME CPT Ebola Virus Serology SS02721 $70.00 Enteric Bacteria Culture, Stool MP00660 $ , x 4 Enteric Bacteria Identification MP00460 $ Enterovirus PCR VR01703 $ Food Sampling Testing Francisella tularensis Culture MP00400 $ Francisella tularensis Serology SS02023 $ Haemophilus ducreyi Culture MP00610 $ Haemophilus influenzae PCR MP00651 $ NOTE: Testing must be approved by the WI Dept. of Health Services Hepatitis A IgM and IgG Panel SS00020 $ Hepatitis A IgG Immune Status SS00025 $ Hepatitis A IgM Antibody SS00016 $ Hepatitis B Core IgM Antibody SS00046 $ Hepatitis B Immune Status Panel Hepatitis B Serodiagnosis Panel Hepatitis B Surface Antibody (Post-Vaccine) SS00038 $ SS00037 $ SS00045 $ Hepatitis B Surface Antigen SS00047 $ Hepatitis C Antibody EIA SS00049 $ Formerly called 9

11 Hepatitis C Serodiagnosis Hepatitis C Virus PCR, Quant SS00051 $ Replaces test SS00048 Herpes simplex Virus PCR Genital/Dermal VR01704 $ x 2 HIV-1 Oral Fluid Antibody SS00009 $ HIV-1 Proviral DNA PCR SS00091 $ HIV-1/HIV-2 Antigen/Antibody SS00099 $ Jamestown Canyon IgM Antibody SS02261 $ Japanese Encephalitis Serology LaCrosse Encephalitis IgM Antibody SS02729 $70.00 SS02231 $ Lassa Fever Serology SS02730 $70.00 Legionella Clinical Culture MP00420 $ Legionella Isolate Identification MP00450 $ Legionella PCR MP00421 $ Leptospira Culture MP02933 $90.00 Lyme Disease Western Blot IgM and IgG SS02110 $ x 2 Malaria Serology SS02735 $70.00 Marburg Virus Serology SS02736 $70.00 Measles IgG Ab SS02125 $ Measles IgM and IgG Ab SS02120 $ x 2 Measles Virus PCR VR01713 $ Mumps IgG Immune Status SS02135 $ Mumps IgM and IgG Antibody SS02130 $ Mumps Virus PCR VR01714 $ Murray Valley Encephalitis Serology SS02737 $

12 NAME CPT Mycobacteria Identification MM00253 $ Mycobacteria (AFB) Smear MM00255 $ Mycobacteria (AFB) Smear and Culture MM00250 $ Mycobacterium avium complex (MAC) Susceptibility Mycobacterium avium complex (MAC) PCR Mycobacteria Rapid Grower Susceptibility Mycobacterium tuberculosis Susceptibility First Line Drugs Mycobacterium tuberculosis complex PCR MM00202 $ MM00260 $ x 1 MM00207 $ MM00204 $ x 5 MM00256 $ Neisseria gonorrhoeae Nucleic Acid Amplification Test (NAAT) SC00112 $ Neisseria meningitidis PCR MP00561 $ NOTE: Testing must be approved by the WI Dept. of Health Services Norovirus PCR VR01717 $ Ova and Parasites, Intestinal MP00840 $

13 87209 Parasites, Blood Smear MP00880 $ Parasites, Tissue Smear MP00881 $ Parasitology Trichrome Stain MP00842 $ Parasitic Worm Identification MP00860 $ Powassan IgM Antibody SS02251 $ Q Fever Antibody SS02032 $ x 2 Rabies Ag Detection (FA) VR01800 $ Rickettsia IgG Antibody SS02042 $ x 2 Ross River Virus Serology SS02742 $70.00 Rubella IgG Immune Status SS02175 $ Rubella IgM and IgG Antibody SS02025 $ x 2 Rubella Virus PCR VR01725 $ Schistosomiasis Serology SS02743 $70.00 Schistosome, Urine MP00850 $ Shiga toxin PCR Screen MP00536 $ Staphylococcus aureus, Clinical Culture MP00480 $ Syphilis Diagnostic Algorithm SS02012 $ If additional testing needed: VDRL $20 and TP-PA $30. Syphilis TP-PA SS02013 $ Syphilis VDRL (CSF) SS02018 $ Syphilis VDRL (Post-treatment) SS02019 $ Taenia solium Serology SS02717 $70.00 Toxic Shock Syndrome Toxins MP00593 $ x 6 Trichomonas vaginalis NAAT SC00200 $ Trypanosomiasis Serology SS02751 $

14 NAME CPT Varicella zoster IgG Immune Status Varicella zoster IgM and IgG Antibody SS02165 $ SS02127 $ x 2 Varicella zoster Virus PCR VR01727 $ Venezuelan Equine Encephalitis Serology West Nile Virus/St. Louis Encephalitis IgM Antibody SS02752 $70.00 SS02241 $ Yersinia pestis Serology SS02740 $70.00 Formerly called Plague Serology Zika Virus IgM Antibody SS02271 $ NOTE: Testing must be approved by the WI Dept. of Health Services 13

15 Cytogenetics (608) NAME CPT Chromosome Analysis, Blood, Abridged Examination for Familial Chromosome Rearrangements Chromosome Analysis, Amniotic Fluid, for Pre-natal Genetic Diagnosis Chromosome Analysis, Amniotic Fluid-Abridged, for Pre-natal Genetic Diagnosis 803 $ $ $ AFP 851 $ Chromosome Analysis, Chorionic Villus Sample, for Pre-natal Genetic Diagnosis Chromosome Analysis, Chorionic Villus Sample-Abridged, for Pre-natal Genetic Diagnosis Chromosome Analysis, Unstimulated Blood, for Hematologic Disorders 855 $ $ $ Chromosome Analysis, Bone Marrow, for Hematologic Disorders 812 $ Chromosome Analysis, Blood, for Genetic Diagnosis 801 $ Fragile X Molecular Diagnosis - Peripheral Blood 828 $

16 NAME CPT Chromosome Analysis, Products of Conception/Tissue Biopsy, for Genetic Diagnosis 831 $ Tissue - Cell Line Identification 835 $ (Research) Chromosome Analysis, Tumor/Pleura Effusion/Ascites fluid, for Neoplastic Disorders 836 $ CULTURE ONLY Culture Cells and Freeze 861 $ Culture Cells and Ship 860 $ Blood/Bone Culture/Hold 863 $ Tumor/Tissue Culture/Hold 864 $ DNA Banking 862 $ DNA Banking + shipping costs DNA Isolation and 1 Year Storage 868 $ FISH Centromere Probe 870 $ Duplication 15q, FISH, D15S11 870F38 $

17 NAME CPT 11q22 deletion/duplication, FISH, ATM gene 870F40 $ Trisomy 8,FISH, D8Z2 870F41 $ Deletion 7q31, Monosomy 7, FISH, D7S F42 $ x 2 Deletion 13q14, FISH, D13S F43 $ x 2 Deletion 20q, FISH, D20S F44 $ Deletion 5q31, FISH, EGR1 870F45 $ x 2 Deletion 9p21, FISH, P16 870F46 $ Deletion 17p13.1, FISH, TP53 870F47 $ Trisomy 4, FISH, CEP4 870F48 $ Trisomy 10, FISH, CEP10 870F49 $

18 NAME CPT Trisomy 17, FISH, D17Z1 870F50 $ Trisomy 12, FISH, D12Z3 870F51 $ X and Y Sex Chromosomes, FISH, DXZ1 and DYZ3 870F52 $ x 2 1q21 gain, FISH, CKS1B gene 870F55 $ x2 FISH - Deletion Detection 871 $ DiGeorge/Velo-cardiofacial/Shprintzen/Conotruncal anomaly syndrome, Deletion 22q11.2, TUPEL1, FISH, for Genetic Diagnosis 871F28 $ Chromosome Study SRY (Sex Determining Region on Y), Yp11.3. FISH, for Genetic Diagnosis 871F34 $ Chromosome Study FISH - Prenatal Panel 873 $ x 5 FISH - Stillbirth Panel (Paraffin) 875 $ x 5 CYTOGENETICS, FISH - TUMOR HER-2/neu 883 $ (For FDA approved test) FISH-deletion probes (paraffin) 886 $ x 2 17

19 NAME CPT Fish-Deletion 1 P (paraffin) 886F5 $ x 2 Fish-Deletion 19Q (paraffin) 886F6 $ x 2 CYTOGENETICS, FISH - ONCOLOGY Leukemia Fusions 881 $ x 2 API2/MALT Fusion, t(11;18)(q21;q21), FISH BCR/ABL Fusion, t(9;22)(q34;q11.2), FISH CCND1/IgH Fusion, t(11;14)(q13;q32), FISH ETO/AML1 Fusion, t(8:21)(q22;q22), FISH IgH/BCL2 Fusion, t(14;18)(q32;q21), FISH MYC/IgH Fusion, t(8;14)(q24;q32), FISH 881F60 $ x 2 881F61 $ x 2 881F62 $ x 2 881F63 $ x 2 881F64 $ x 2 881F65 $ x 2 PML/RARA Fusion, t(15;17)(q24;q21), FISH 881F66 $ x 2 TEL/AML1 Fusion, ETV6/RUNX1 Fusion, t(12;21)(p13;q22), FISH IgH/MALT1 Fusion, t(14;18)(q32;q21), FISH FGFR3/IgH Fusion, t(4;14)(p16;q32), FISH 881F67 $ x 2 881F68 $ x 2 881F69 $ x 2 18

20 NAME CPT IgH/MAF Fusion, t(14;16)(q32;q23), FISH BCR/ABL,ASS Tri-color Fusion, t(9;22)(q34;q11.2), FISH IGH/MAFB Fusion, t(14;20)(q32;q12), FISH 881F70 $ x 2 881F71 $ x 3 881F72 $ x2 Other Oncogenes 882 $ x 2 CBFB Rearrangement, inv(16)(p13.1q22), FISH 882F80 $ x 2 EWSR Rearrangement, FISH 882F81 $ x 2 IgH Rearrangement, FISH 882F82 $ x 2 MALT Rearrangement, FISH 882F83 $ x 2 KMT2A [MLL] Rearrangement, FISH 882F84 $ x 2 MYC Rearrangement, FISH 882F85 $ x 2 SYT Rearrangement, FISH 882F86 $ x 2 ALK Rearrangement, FISH 882F87 $ x 2 BCL6 Rearrangement, FISH 882F88 $ x 2 FIP1L1-PDGFRa Rearrangement, FISH 882F89 $ x 3 PDGRFB Rearrangement, FISH 882F90 $ x 2 TCR Rearrangement, FISH 882F91 $ x 2 RARA Rearrangement, 17q21, FISH 882F92 $ x 2 19

21 NAME CPT FGFR1 Rearrangement, 8p11, FISH 882F93 $ x 2 DDIT3 (CHOP) Rearrangement, FISH 882F94 $ x 2 FUS Rearrangement, FISH 882F95 $ x 2 CRLF2 Rearrangement, FISH 882F97 $ x2, MOLECULAR GENETICS Illumina Microarray Analysis 890 $ Illumina Microarray Analysis Oncology 890ONC $ Targeted Variant Analysis via Sanger DNA Sequencing 895M50 First variant: $50 per sample Subsequent variants: $35 per sample or family member in one submission Factor V Genotyping 842C90 $ Factor II Genotyping 842C92 $ Hereditary Hemochromatosis 842C91 $ Exome Sequencing with Mitochondria Analysis Cardiomypoathy/Arrhythmia Next Gen Sequencing 895M40 $6, M41 $4,

22 NAME CPT TP53 Exon Sequencing by NGS 895M45 $1, AML Mutation Panel $ 1, FLT3 Mutation Analysis 895M60 $ NPM1 Mutation Analysis 895M61 $ CEBPA Mutation Analysis 895M62 $ KIT Mutation Analysis 895M63 $ PCR ING BCR/ABL Fusion Transcript, t(9;22)(q34;q11.2), RT-PCR 887M31 $ PML/RARA Fusion Transcript, t(15;17)(q24;q21), RT-PCR 887M35 $ Methylation Specific PCR, SNRPN gene, 15q Quantitative PCR for JAK2 Mutation (V617F) Quantitative PCR for BCR/ABL Major Breakpoint Quantitative PCR for BCR/ABL Mino Breakpoint 889 $ M50 $ M51 $ M52 $ Cancer Gene Mutation Panel 840C40 $ Qualitative BRAF V600E 840C41 $ Qualitative PCR for Calreticulin 840C42 $ Microsatellite Instability Analysis 840C46 $

23 NAME CPT STR Engraftment Unseparated Lineages, Bone Marrow STR Engraftment Unseparated Lineages, Blood STR Engraftment Separated Lineages (CD3/CD33) 840C47 $ C48 $ C49 $ x2 RAS/RAF Targeted Gene Panel by NGS RAS/RAF/PIK Targeted Gene Panel by NGS 840C50 $ , 81275, 81276, 81403, C51 $ , 81275, 81276, 81311, Lung Cancer Mutation Panel by NGS 840C52 $ , 81275, 81276, 81235, B-Cell Clonality 840C53 $ , T-Cell Clonality 840C54 $ , IDH1 and IDH2 Mutation Analysis 840C55 $ x2 22

24 Cytology (608) NAME CPT Anal/Rectal Liquid-based Cytology $ Body Fluid $ Breast Secretion $49.02 Brushings $ Consultation $ Cyst Fluid $ GU $ Miscellaneous Prepared Slides $ Respiratory $ Spinal Fluid $ Viral Inclusions $ Other $ FINE NEEDLE ASPIRATION Specimen Collection Specimen Preparation and Interpretation $ Attended, Specimen Preparation, and Interpretation Specimen Preparation and Interpretation $ $ PAP Screening Conventional PAP Smear Technical Component $17.25 P3000 Medicare Only Other Insurers 23

25 NAME CPT Screening Conventional PAP Smear Professional Component Diagnostic Conventional PAP Smear Technical Component Diagnostic Conventional PAP Smear Professional Component Screening Thin Prep PAP Smear Technical Component Screening Thin Prep PAP Smear Professional Component Diagnostic Thin Prep PAP Smear Technical Component Diagnostic Thin Prep PAP Smear Professional Component $21.99 P3001 Medicare Only Other Insurers $ $ $30.50 G0123 Medicare Only Other Insurers $21.99 G0124 Medicare Only Other Insurers $ $ Requested Rescreen $9.20 NONE High Risk Human Papilloma Virus (HPV) Testing $ HISTOLOGY Conization CONIZATION $ Tissue Biopsy $ Cell Block May be performed in addition to other cytologic testing procedures $

26 Newborn Screening (608) NAME CPT Newborn Screen Panel NB28100 $ S3620 Argininosuccinic Acidemia Citrullinemia Homocystinuria Maple Syrup Urine Disease Fatty Acid Oxidation (12 disorders) Organic Acidemia (15 disorders) Biotinidase Congenital Adrenal Hyperplasia Cystic Fibrosis Galactosemia Hemoglobinopathies Hypothyroidism Tyrosinemia Phenylketonuria Severe Combined Immunodeficiency 25