|
MRI Ankle w/o Contrast Right
|
Facility
|
OP
|
$4,732.00
|
|
|
Service Code
|
CPT 73721 RT,TC
|
| Hospital Charge Code |
1610924
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,377.96 |
| Max. Negotiated Rate |
$4,527.58 |
| Rate for Payer: Aetna Commercial |
$4,429.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,232.30
|
| Rate for Payer: Aetna Managed Medicare |
$1,377.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,635.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,985.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,835.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,608.28
|
| Rate for Payer: Cash Price |
$1,419.60
|
| Rate for Payer: Cash Price |
$1,419.60
|
| Rate for Payer: Cash Price |
$1,419.60
|
| Rate for Payer: Cigna Commercial |
$4,527.58
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,754.02
|
| Rate for Payer: Health EOS Commercial |
$4,379.94
|
| Rate for Payer: HFN Commercial |
$4,527.58
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,690.96
|
| Rate for Payer: Multiplan Commercial |
$3,937.02
|
| Rate for Payer: NAPHCARE Commercial |
$2,952.77
|
| Rate for Payer: Preferred Network Access Commercial |
$4,527.58
|
| Rate for Payer: Quartz Beloit One Network |
$2,411.43
|
| Rate for Payer: Quartz Commercial |
$3,198.83
|
| Rate for Payer: Quartz Medicare Advantage |
$2,952.77
|
| Rate for Payer: The Alliance Commercial |
$2,460.64
|
| Rate for Payer: United Healthcare PPO |
$3,142.88
|
| Rate for Payer: WEA Trust Commercial |
$2,706.70
|
| Rate for Payer: WPS Commercial |
$3,645.06
|
|
|
MRI Ankle w/o Contrast Right
|
Facility
|
IP
|
$4,732.00
|
|
|
Service Code
|
CPT 73721 RT,TC
|
| Hospital Charge Code |
1610924
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$2,411.43 |
| Max. Negotiated Rate |
$4,527.58 |
| Rate for Payer: Aetna Commercial |
$4,429.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,232.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,608.28
|
| Rate for Payer: Cash Price |
$1,419.60
|
| Rate for Payer: Cigna Commercial |
$4,527.58
|
| Rate for Payer: Health EOS Commercial |
$4,379.94
|
| Rate for Payer: HFN Commercial |
$4,527.58
|
| Rate for Payer: Multiplan Commercial |
$3,937.02
|
| Rate for Payer: Preferred Network Access Commercial |
$4,527.58
|
| Rate for Payer: Quartz Beloit One Network |
$2,411.43
|
| Rate for Payer: Quartz Commercial |
$2,952.77
|
| Rate for Payer: WEA Trust Commercial |
$2,706.70
|
| Rate for Payer: WPS Commercial |
$3,645.06
|
|
|
MRI Ankle w/o Contrast Right
|
Professional
|
Both
|
$4,732.00
|
|
|
Service Code
|
CPT 73721 RT,TC
|
| Hospital Charge Code |
1610924
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$792.57 |
| Max. Negotiated Rate |
$4,675.22 |
| Rate for Payer: Aetna Commercial |
$4,675.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,232.30
|
| Rate for Payer: Cash Price |
$1,419.60
|
| Rate for Payer: Cash Price |
$1,419.60
|
| Rate for Payer: Cash Price |
$1,419.60
|
| Rate for Payer: Cigna Commercial |
$4,675.22
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,460.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,952.77
|
| Rate for Payer: Health EOS Commercial |
$4,478.36
|
| Rate for Payer: HFN Commercial |
$4,675.22
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$792.57
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$792.57
|
| Rate for Payer: Multiplan Commercial |
$3,937.02
|
| Rate for Payer: Preferred Network Access Commercial |
$4,675.22
|
| Rate for Payer: Quartz Beloit One Network |
$2,165.36
|
| Rate for Payer: Quartz Commercial |
$2,805.13
|
| Rate for Payer: The Alliance Commercial |
$2,460.64
|
| Rate for Payer: WEA Trust Commercial |
$2,706.70
|
| Rate for Payer: WPS Commercial |
$3,645.06
|
|
|
MRI Ankle w/o Contrast Right
|
Facility
|
IP
|
$4,524.00
|
|
|
Service Code
|
CPT 73721
|
| Hospital Charge Code |
625714
|
| Min. Negotiated Rate |
$2,305.43 |
| Max. Negotiated Rate |
$4,328.56 |
| Rate for Payer: Aetna Commercial |
$4,234.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,046.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,493.63
|
| Rate for Payer: Cash Price |
$1,357.20
|
| Rate for Payer: Cigna Commercial |
$4,328.56
|
| Rate for Payer: Health EOS Commercial |
$4,187.41
|
| Rate for Payer: HFN Commercial |
$4,328.56
|
| Rate for Payer: Multiplan Commercial |
$3,763.97
|
| Rate for Payer: Preferred Network Access Commercial |
$4,328.56
|
| Rate for Payer: Quartz Beloit One Network |
$2,305.43
|
| Rate for Payer: Quartz Commercial |
$2,822.98
|
| Rate for Payer: WEA Trust Commercial |
$2,587.73
|
| Rate for Payer: WPS Commercial |
$3,484.84
|
|
|
MRI Ankle w/o Contrast Right
|
Professional
|
Both
|
$4,557.00
|
|
|
Service Code
|
CPT 73721 TC,RT
|
| Hospital Charge Code |
2980103
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$792.57 |
| Max. Negotiated Rate |
$4,502.32 |
| Rate for Payer: Aetna Commercial |
$4,502.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,075.78
|
| Rate for Payer: Cash Price |
$1,367.10
|
| Rate for Payer: Cash Price |
$1,367.10
|
| Rate for Payer: Cash Price |
$1,367.10
|
| Rate for Payer: Cigna Commercial |
$4,502.32
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,369.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,843.57
|
| Rate for Payer: Health EOS Commercial |
$4,312.74
|
| Rate for Payer: HFN Commercial |
$4,502.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$792.57
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$792.57
|
| Rate for Payer: Multiplan Commercial |
$3,791.42
|
| Rate for Payer: Preferred Network Access Commercial |
$4,502.32
|
| Rate for Payer: Quartz Beloit One Network |
$2,085.28
|
| Rate for Payer: Quartz Commercial |
$2,701.39
|
| Rate for Payer: The Alliance Commercial |
$2,369.64
|
| Rate for Payer: WEA Trust Commercial |
$2,606.60
|
| Rate for Payer: WPS Commercial |
$3,510.26
|
|
|
MRI Ankle w/o Contrast Right
|
Facility
|
OP
|
$4,524.00
|
|
|
Service Code
|
CPT 73721
|
| Hospital Charge Code |
625714
|
| Min. Negotiated Rate |
$251.10 |
| Max. Negotiated Rate |
$4,328.56 |
| Rate for Payer: Aetna Commercial |
$4,234.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,046.27
|
| Rate for Payer: Aetna Managed Medicare |
$251.10
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,058.22
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,352.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,258.38
|
| Rate for Payer: Anthem Medicare Advantage |
$251.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,493.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$251.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$251.10
|
| Rate for Payer: Cash Price |
$1,357.20
|
| Rate for Payer: Cash Price |
$1,357.20
|
| Rate for Payer: Cigna Commercial |
$4,328.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$251.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,632.97
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$251.10
|
| Rate for Payer: Health EOS Commercial |
$4,187.41
|
| Rate for Payer: HFN Commercial |
$4,328.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$934.08
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$251.10
|
| Rate for Payer: Independent Care Health Plan Medicare |
$251.10
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$251.10
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$251.10
|
| Rate for Payer: Multiplan Commercial |
$3,763.97
|
| Rate for Payer: NAPHCARE Commercial |
$376.65
|
| Rate for Payer: Preferred Network Access Commercial |
$4,328.56
|
| Rate for Payer: Quartz Beloit One Network |
$2,305.43
|
| Rate for Payer: Quartz Commercial |
$3,058.22
|
| Rate for Payer: Quartz Medicare Advantage |
$251.10
|
| Rate for Payer: The Alliance Commercial |
$1,004.39
|
| Rate for Payer: United Healthcare Medicare Advantage |
$251.10
|
| Rate for Payer: WEA Trust Commercial |
$2,587.73
|
| Rate for Payer: Wellcare Medicare |
$251.10
|
| Rate for Payer: WPS Commercial |
$3,484.84
|
|
|
MRI Ankle w/o Contrast Right
|
Facility
|
OP
|
$4,557.00
|
|
|
Service Code
|
CPT 73721 TC,RT
|
| Hospital Charge Code |
2980103
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,327.00 |
| Max. Negotiated Rate |
$4,360.14 |
| Rate for Payer: Aetna Commercial |
$4,265.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,075.78
|
| Rate for Payer: Aetna Managed Medicare |
$1,327.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,635.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,985.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,835.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,511.82
|
| Rate for Payer: Cash Price |
$1,367.10
|
| Rate for Payer: Cash Price |
$1,367.10
|
| Rate for Payer: Cash Price |
$1,367.10
|
| Rate for Payer: Cigna Commercial |
$4,360.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,652.17
|
| Rate for Payer: Health EOS Commercial |
$4,217.96
|
| Rate for Payer: HFN Commercial |
$4,360.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,554.46
|
| Rate for Payer: Multiplan Commercial |
$3,791.42
|
| Rate for Payer: NAPHCARE Commercial |
$2,843.57
|
| Rate for Payer: Preferred Network Access Commercial |
$4,360.14
|
| Rate for Payer: Quartz Beloit One Network |
$2,322.25
|
| Rate for Payer: Quartz Commercial |
$3,080.53
|
| Rate for Payer: Quartz Medicare Advantage |
$2,843.57
|
| Rate for Payer: The Alliance Commercial |
$2,369.64
|
| Rate for Payer: United Healthcare PPO |
$3,142.88
|
| Rate for Payer: WEA Trust Commercial |
$2,606.60
|
| Rate for Payer: WPS Commercial |
$3,510.26
|
|
|
MRI Ankle w/ + w/o Contrast Bilateral
|
Facility
|
IP
|
$5,965.00
|
|
|
Service Code
|
CPT 73723 LT,TC
|
| Hospital Charge Code |
1610908
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$3,039.76 |
| Max. Negotiated Rate |
$5,707.31 |
| Rate for Payer: Aetna Commercial |
$5,583.24
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,335.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,287.91
|
| Rate for Payer: Cash Price |
$1,789.50
|
| Rate for Payer: Cigna Commercial |
$5,707.31
|
| Rate for Payer: Health EOS Commercial |
$5,521.20
|
| Rate for Payer: HFN Commercial |
$5,707.31
|
| Rate for Payer: Multiplan Commercial |
$4,962.88
|
| Rate for Payer: Preferred Network Access Commercial |
$5,707.31
|
| Rate for Payer: Quartz Beloit One Network |
$3,039.76
|
| Rate for Payer: Quartz Commercial |
$3,722.16
|
| Rate for Payer: WEA Trust Commercial |
$3,411.98
|
| Rate for Payer: WPS Commercial |
$4,594.84
|
|
|
MRI Ankle w/ + w/o Contrast Bilateral
|
Professional
|
Both
|
$12,160.00
|
|
|
Service Code
|
CPT 73723
|
| Hospital Charge Code |
625698
|
| Min. Negotiated Rate |
$379.71 |
| Max. Negotiated Rate |
$12,014.08 |
| Rate for Payer: Aetna Commercial |
$12,014.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,875.90
|
| Rate for Payer: Aetna Managed Medicare |
$379.71
|
| Rate for Payer: Anthem Medicare Advantage |
$379.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$379.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$379.71
|
| Rate for Payer: Cash Price |
$3,648.00
|
| Rate for Payer: Cash Price |
$3,648.00
|
| Rate for Payer: Cash Price |
$3,648.00
|
| Rate for Payer: Cigna Commercial |
$12,014.08
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$6,323.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$379.71
|
| Rate for Payer: Health EOS Commercial |
$11,508.22
|
| Rate for Payer: HFN Commercial |
$12,014.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,562.68
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,562.68
|
| Rate for Payer: Independent Care Health Plan Medicare |
$379.71
|
| Rate for Payer: Multiplan Commercial |
$10,117.12
|
| Rate for Payer: NAPHCARE Commercial |
$569.57
|
| Rate for Payer: Preferred Network Access Commercial |
$12,014.08
|
| Rate for Payer: Quartz Beloit One Network |
$5,564.42
|
| Rate for Payer: Quartz Commercial |
$7,208.45
|
| Rate for Payer: Quartz Medicare Advantage |
$379.71
|
| Rate for Payer: The Alliance Commercial |
$1,442.91
|
| Rate for Payer: United Healthcare Medicare Advantage |
$379.71
|
| Rate for Payer: WEA Trust Commercial |
$6,955.52
|
| Rate for Payer: WPS Commercial |
$1,898.57
|
|
|
MRI Ankle w/ + w/o Contrast Bilateral
|
Facility
|
OP
|
$5,965.00
|
|
|
Service Code
|
CPT 73723 LT,TC
|
| Hospital Charge Code |
1610908
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,737.01 |
| Max. Negotiated Rate |
$5,707.31 |
| Rate for Payer: Aetna Commercial |
$5,583.24
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,335.10
|
| Rate for Payer: Aetna Managed Medicare |
$1,737.01
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,635.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,985.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,835.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,287.91
|
| Rate for Payer: Cash Price |
$1,789.50
|
| Rate for Payer: Cash Price |
$1,789.50
|
| Rate for Payer: Cash Price |
$1,789.50
|
| Rate for Payer: Cigna Commercial |
$5,707.31
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,471.63
|
| Rate for Payer: Health EOS Commercial |
$5,521.20
|
| Rate for Payer: HFN Commercial |
$5,707.31
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,652.70
|
| Rate for Payer: Multiplan Commercial |
$4,962.88
|
| Rate for Payer: NAPHCARE Commercial |
$3,722.16
|
| Rate for Payer: Preferred Network Access Commercial |
$5,707.31
|
| Rate for Payer: Quartz Beloit One Network |
$3,039.76
|
| Rate for Payer: Quartz Commercial |
$4,032.34
|
| Rate for Payer: Quartz Medicare Advantage |
$3,722.16
|
| Rate for Payer: The Alliance Commercial |
$3,101.80
|
| Rate for Payer: United Healthcare PPO |
$3,142.88
|
| Rate for Payer: WEA Trust Commercial |
$3,411.98
|
| Rate for Payer: WPS Commercial |
$4,594.84
|
|
|
MRI Ankle w/ + w/o Contrast Bilateral
|
Professional
|
Both
|
$5,965.00
|
|
|
Service Code
|
CPT 73723 LT,TC
|
| Hospital Charge Code |
1610908
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,562.68 |
| Max. Negotiated Rate |
$5,893.42 |
| Rate for Payer: Aetna Commercial |
$5,893.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,335.10
|
| Rate for Payer: Cash Price |
$1,789.50
|
| Rate for Payer: Cash Price |
$1,789.50
|
| Rate for Payer: Cash Price |
$1,789.50
|
| Rate for Payer: Cigna Commercial |
$5,893.42
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3,101.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,722.16
|
| Rate for Payer: Health EOS Commercial |
$5,645.28
|
| Rate for Payer: HFN Commercial |
$5,893.42
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,562.68
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,562.68
|
| Rate for Payer: Multiplan Commercial |
$4,962.88
|
| Rate for Payer: Preferred Network Access Commercial |
$5,893.42
|
| Rate for Payer: Quartz Beloit One Network |
$2,729.58
|
| Rate for Payer: Quartz Commercial |
$3,536.05
|
| Rate for Payer: The Alliance Commercial |
$3,101.80
|
| Rate for Payer: WEA Trust Commercial |
$3,411.98
|
| Rate for Payer: WPS Commercial |
$4,594.84
|
|
|
MRI Ankle w/ + w/o Contrast Bilateral
|
Facility
|
OP
|
$12,160.00
|
|
|
Service Code
|
CPT 73723
|
| Hospital Charge Code |
625698
|
| Min. Negotiated Rate |
$367.15 |
| Max. Negotiated Rate |
$11,634.69 |
| Rate for Payer: Aetna Commercial |
$11,381.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,875.90
|
| Rate for Payer: Aetna Managed Medicare |
$367.15
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$8,220.16
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,323.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,070.27
|
| Rate for Payer: Anthem Medicare Advantage |
$367.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,702.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$367.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$367.15
|
| Rate for Payer: Cash Price |
$3,648.00
|
| Rate for Payer: Cash Price |
$3,648.00
|
| Rate for Payer: Cigna Commercial |
$11,634.69
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$367.15
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,077.12
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$367.15
|
| Rate for Payer: Health EOS Commercial |
$11,255.30
|
| Rate for Payer: HFN Commercial |
$11,634.69
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,365.80
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$367.15
|
| Rate for Payer: Independent Care Health Plan Medicare |
$367.15
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$367.15
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$367.15
|
| Rate for Payer: Multiplan Commercial |
$10,117.12
|
| Rate for Payer: NAPHCARE Commercial |
$550.73
|
| Rate for Payer: Preferred Network Access Commercial |
$11,634.69
|
| Rate for Payer: Quartz Beloit One Network |
$6,196.74
|
| Rate for Payer: Quartz Commercial |
$8,220.16
|
| Rate for Payer: Quartz Medicare Advantage |
$367.15
|
| Rate for Payer: The Alliance Commercial |
$1,468.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$367.15
|
| Rate for Payer: WEA Trust Commercial |
$6,955.52
|
| Rate for Payer: Wellcare Medicare |
$367.15
|
| Rate for Payer: WPS Commercial |
$9,366.85
|
|
|
MRI Ankle w/ + w/o Contrast Bilateral
|
Facility
|
IP
|
$12,160.00
|
|
|
Service Code
|
CPT 73723
|
| Hospital Charge Code |
625698
|
| Min. Negotiated Rate |
$6,196.74 |
| Max. Negotiated Rate |
$11,634.69 |
| Rate for Payer: Aetna Commercial |
$11,381.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,875.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,702.59
|
| Rate for Payer: Cash Price |
$3,648.00
|
| Rate for Payer: Cigna Commercial |
$11,634.69
|
| Rate for Payer: Health EOS Commercial |
$11,255.30
|
| Rate for Payer: HFN Commercial |
$11,634.69
|
| Rate for Payer: Multiplan Commercial |
$10,117.12
|
| Rate for Payer: Preferred Network Access Commercial |
$11,634.69
|
| Rate for Payer: Quartz Beloit One Network |
$6,196.74
|
| Rate for Payer: Quartz Commercial |
$7,587.84
|
| Rate for Payer: WEA Trust Commercial |
$6,955.52
|
| Rate for Payer: WPS Commercial |
$9,366.85
|
|
|
MRI Ankle w/ + w/o Contrast Left
|
Professional
|
Both
|
$6,295.00
|
|
|
Service Code
|
CPT 73723 TC,LT
|
| Hospital Charge Code |
1610910
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,562.68 |
| Max. Negotiated Rate |
$6,219.46 |
| Rate for Payer: Aetna Commercial |
$6,219.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,630.25
|
| Rate for Payer: Cash Price |
$1,888.50
|
| Rate for Payer: Cash Price |
$1,888.50
|
| Rate for Payer: Cash Price |
$1,888.50
|
| Rate for Payer: Cigna Commercial |
$6,219.46
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3,273.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,928.08
|
| Rate for Payer: Health EOS Commercial |
$5,957.59
|
| Rate for Payer: HFN Commercial |
$6,219.46
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,562.68
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,562.68
|
| Rate for Payer: Multiplan Commercial |
$5,237.44
|
| Rate for Payer: Preferred Network Access Commercial |
$6,219.46
|
| Rate for Payer: Quartz Beloit One Network |
$2,880.59
|
| Rate for Payer: Quartz Commercial |
$3,731.68
|
| Rate for Payer: The Alliance Commercial |
$3,273.40
|
| Rate for Payer: WEA Trust Commercial |
$3,600.74
|
| Rate for Payer: WPS Commercial |
$4,849.04
|
|
|
MRI Ankle w/ + w/o Contrast Left
|
Facility
|
OP
|
$6,080.00
|
|
|
Service Code
|
CPT 73723
|
| Hospital Charge Code |
625700
|
| Min. Negotiated Rate |
$367.15 |
| Max. Negotiated Rate |
$5,817.34 |
| Rate for Payer: Aetna Commercial |
$5,690.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,437.95
|
| Rate for Payer: Aetna Managed Medicare |
$367.15
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,110.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,161.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,035.14
|
| Rate for Payer: Anthem Medicare Advantage |
$367.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,351.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$367.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$367.15
|
| Rate for Payer: Cash Price |
$1,824.00
|
| Rate for Payer: Cash Price |
$1,824.00
|
| Rate for Payer: Cigna Commercial |
$5,817.34
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$367.15
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,538.56
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$367.15
|
| Rate for Payer: Health EOS Commercial |
$5,627.65
|
| Rate for Payer: HFN Commercial |
$5,817.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,365.80
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$367.15
|
| Rate for Payer: Independent Care Health Plan Medicare |
$367.15
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$367.15
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$367.15
|
| Rate for Payer: Multiplan Commercial |
$5,058.56
|
| Rate for Payer: NAPHCARE Commercial |
$550.73
|
| Rate for Payer: Preferred Network Access Commercial |
$5,817.34
|
| Rate for Payer: Quartz Beloit One Network |
$3,098.37
|
| Rate for Payer: Quartz Commercial |
$4,110.08
|
| Rate for Payer: Quartz Medicare Advantage |
$367.15
|
| Rate for Payer: The Alliance Commercial |
$1,468.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$367.15
|
| Rate for Payer: WEA Trust Commercial |
$3,477.76
|
| Rate for Payer: Wellcare Medicare |
$367.15
|
| Rate for Payer: WPS Commercial |
$4,683.42
|
|
|
MRI Ankle w/ + w/o Contrast Left
|
Facility
|
OP
|
$6,295.00
|
|
|
Service Code
|
CPT 73723 TC,LT
|
| Hospital Charge Code |
1610910
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,833.10 |
| Max. Negotiated Rate |
$6,023.06 |
| Rate for Payer: Aetna Commercial |
$5,892.12
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,630.25
|
| Rate for Payer: Aetna Managed Medicare |
$1,833.10
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,635.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,985.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,835.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,469.80
|
| Rate for Payer: Cash Price |
$1,888.50
|
| Rate for Payer: Cash Price |
$1,888.50
|
| Rate for Payer: Cash Price |
$1,888.50
|
| Rate for Payer: Cigna Commercial |
$6,023.06
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,663.69
|
| Rate for Payer: Health EOS Commercial |
$5,826.65
|
| Rate for Payer: HFN Commercial |
$6,023.06
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,910.10
|
| Rate for Payer: Multiplan Commercial |
$5,237.44
|
| Rate for Payer: NAPHCARE Commercial |
$3,928.08
|
| Rate for Payer: Preferred Network Access Commercial |
$6,023.06
|
| Rate for Payer: Quartz Beloit One Network |
$3,207.93
|
| Rate for Payer: Quartz Commercial |
$4,255.42
|
| Rate for Payer: Quartz Medicare Advantage |
$3,928.08
|
| Rate for Payer: The Alliance Commercial |
$3,273.40
|
| Rate for Payer: United Healthcare PPO |
$3,142.88
|
| Rate for Payer: WEA Trust Commercial |
$3,600.74
|
| Rate for Payer: WPS Commercial |
$4,849.04
|
|
|
MRI Ankle w/ + w/o Contrast Left
|
Professional
|
Both
|
$6,080.00
|
|
|
Service Code
|
CPT 73723
|
| Hospital Charge Code |
625700
|
| Min. Negotiated Rate |
$379.71 |
| Max. Negotiated Rate |
$6,007.04 |
| Rate for Payer: Aetna Commercial |
$6,007.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,437.95
|
| Rate for Payer: Aetna Managed Medicare |
$379.71
|
| Rate for Payer: Anthem Medicare Advantage |
$379.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$379.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$379.71
|
| Rate for Payer: Cash Price |
$1,824.00
|
| Rate for Payer: Cash Price |
$1,824.00
|
| Rate for Payer: Cash Price |
$1,824.00
|
| Rate for Payer: Cigna Commercial |
$6,007.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3,161.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$379.71
|
| Rate for Payer: Health EOS Commercial |
$5,754.11
|
| Rate for Payer: HFN Commercial |
$6,007.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,562.68
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,562.68
|
| Rate for Payer: Independent Care Health Plan Medicare |
$379.71
|
| Rate for Payer: Multiplan Commercial |
$5,058.56
|
| Rate for Payer: NAPHCARE Commercial |
$569.57
|
| Rate for Payer: Preferred Network Access Commercial |
$6,007.04
|
| Rate for Payer: Quartz Beloit One Network |
$2,782.21
|
| Rate for Payer: Quartz Commercial |
$3,604.22
|
| Rate for Payer: Quartz Medicare Advantage |
$379.71
|
| Rate for Payer: The Alliance Commercial |
$1,442.91
|
| Rate for Payer: United Healthcare Medicare Advantage |
$379.71
|
| Rate for Payer: WEA Trust Commercial |
$3,477.76
|
| Rate for Payer: WPS Commercial |
$1,898.57
|
|
|
MRI Ankle w/ + w/o Contrast Left
|
Facility
|
IP
|
$6,295.00
|
|
|
Service Code
|
CPT 73723 TC,LT
|
| Hospital Charge Code |
1610910
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$3,207.93 |
| Max. Negotiated Rate |
$6,023.06 |
| Rate for Payer: Aetna Commercial |
$5,892.12
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,630.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,469.80
|
| Rate for Payer: Cash Price |
$1,888.50
|
| Rate for Payer: Cigna Commercial |
$6,023.06
|
| Rate for Payer: Health EOS Commercial |
$5,826.65
|
| Rate for Payer: HFN Commercial |
$6,023.06
|
| Rate for Payer: Multiplan Commercial |
$5,237.44
|
| Rate for Payer: Preferred Network Access Commercial |
$6,023.06
|
| Rate for Payer: Quartz Beloit One Network |
$3,207.93
|
| Rate for Payer: Quartz Commercial |
$3,928.08
|
| Rate for Payer: WEA Trust Commercial |
$3,600.74
|
| Rate for Payer: WPS Commercial |
$4,849.04
|
|
|
MRI Ankle w/ + w/o Contrast Left
|
Facility
|
IP
|
$6,080.00
|
|
|
Service Code
|
CPT 73723
|
| Hospital Charge Code |
625700
|
| Min. Negotiated Rate |
$3,098.37 |
| Max. Negotiated Rate |
$5,817.34 |
| Rate for Payer: Aetna Commercial |
$5,690.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,437.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,351.30
|
| Rate for Payer: Cash Price |
$1,824.00
|
| Rate for Payer: Cigna Commercial |
$5,817.34
|
| Rate for Payer: Health EOS Commercial |
$5,627.65
|
| Rate for Payer: HFN Commercial |
$5,817.34
|
| Rate for Payer: Multiplan Commercial |
$5,058.56
|
| Rate for Payer: Preferred Network Access Commercial |
$5,817.34
|
| Rate for Payer: Quartz Beloit One Network |
$3,098.37
|
| Rate for Payer: Quartz Commercial |
$3,793.92
|
| Rate for Payer: WEA Trust Commercial |
$3,477.76
|
| Rate for Payer: WPS Commercial |
$4,683.42
|
|
|
MRI Ankle w/ + w/o Contrast Right
|
Facility
|
IP
|
$6,295.00
|
|
|
Service Code
|
CPT 73723 RT,TC
|
| Hospital Charge Code |
1610912
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$3,207.93 |
| Max. Negotiated Rate |
$6,023.06 |
| Rate for Payer: Aetna Commercial |
$5,892.12
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,630.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,469.80
|
| Rate for Payer: Cash Price |
$1,888.50
|
| Rate for Payer: Cigna Commercial |
$6,023.06
|
| Rate for Payer: Health EOS Commercial |
$5,826.65
|
| Rate for Payer: HFN Commercial |
$6,023.06
|
| Rate for Payer: Multiplan Commercial |
$5,237.44
|
| Rate for Payer: Preferred Network Access Commercial |
$6,023.06
|
| Rate for Payer: Quartz Beloit One Network |
$3,207.93
|
| Rate for Payer: Quartz Commercial |
$3,928.08
|
| Rate for Payer: WEA Trust Commercial |
$3,600.74
|
| Rate for Payer: WPS Commercial |
$4,849.04
|
|
|
MRI Ankle w/ + w/o Contrast Right
|
Professional
|
Both
|
$5,965.00
|
|
|
Service Code
|
CPT 73723 TC,RT
|
| Hospital Charge Code |
2980111
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,562.68 |
| Max. Negotiated Rate |
$5,893.42 |
| Rate for Payer: Aetna Commercial |
$5,893.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,335.10
|
| Rate for Payer: Cash Price |
$1,789.50
|
| Rate for Payer: Cash Price |
$1,789.50
|
| Rate for Payer: Cash Price |
$1,789.50
|
| Rate for Payer: Cigna Commercial |
$5,893.42
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3,101.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,722.16
|
| Rate for Payer: Health EOS Commercial |
$5,645.28
|
| Rate for Payer: HFN Commercial |
$5,893.42
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,562.68
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,562.68
|
| Rate for Payer: Multiplan Commercial |
$4,962.88
|
| Rate for Payer: Preferred Network Access Commercial |
$5,893.42
|
| Rate for Payer: Quartz Beloit One Network |
$2,729.58
|
| Rate for Payer: Quartz Commercial |
$3,536.05
|
| Rate for Payer: The Alliance Commercial |
$3,101.80
|
| Rate for Payer: WEA Trust Commercial |
$3,411.98
|
| Rate for Payer: WPS Commercial |
$4,594.84
|
|
|
MRI Ankle w/ + w/o Contrast Right
|
Professional
|
Both
|
$6,295.00
|
|
|
Service Code
|
CPT 73723 RT,TC
|
| Hospital Charge Code |
1610912
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,562.68 |
| Max. Negotiated Rate |
$6,219.46 |
| Rate for Payer: Aetna Commercial |
$6,219.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,630.25
|
| Rate for Payer: Cash Price |
$1,888.50
|
| Rate for Payer: Cash Price |
$1,888.50
|
| Rate for Payer: Cash Price |
$1,888.50
|
| Rate for Payer: Cigna Commercial |
$6,219.46
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3,273.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,928.08
|
| Rate for Payer: Health EOS Commercial |
$5,957.59
|
| Rate for Payer: HFN Commercial |
$6,219.46
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,562.68
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,562.68
|
| Rate for Payer: Multiplan Commercial |
$5,237.44
|
| Rate for Payer: Preferred Network Access Commercial |
$6,219.46
|
| Rate for Payer: Quartz Beloit One Network |
$2,880.59
|
| Rate for Payer: Quartz Commercial |
$3,731.68
|
| Rate for Payer: The Alliance Commercial |
$3,273.40
|
| Rate for Payer: WEA Trust Commercial |
$3,600.74
|
| Rate for Payer: WPS Commercial |
$4,849.04
|
|
|
MRI Ankle w/ + w/o Contrast Right
|
Facility
|
OP
|
$5,965.00
|
|
|
Service Code
|
CPT 73723 TC,RT
|
| Hospital Charge Code |
2980111
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,737.01 |
| Max. Negotiated Rate |
$5,707.31 |
| Rate for Payer: Aetna Commercial |
$5,583.24
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,335.10
|
| Rate for Payer: Aetna Managed Medicare |
$1,737.01
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,635.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,985.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,835.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,287.91
|
| Rate for Payer: Cash Price |
$1,789.50
|
| Rate for Payer: Cash Price |
$1,789.50
|
| Rate for Payer: Cash Price |
$1,789.50
|
| Rate for Payer: Cigna Commercial |
$5,707.31
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,471.63
|
| Rate for Payer: Health EOS Commercial |
$5,521.20
|
| Rate for Payer: HFN Commercial |
$5,707.31
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,652.70
|
| Rate for Payer: Multiplan Commercial |
$4,962.88
|
| Rate for Payer: NAPHCARE Commercial |
$3,722.16
|
| Rate for Payer: Preferred Network Access Commercial |
$5,707.31
|
| Rate for Payer: Quartz Beloit One Network |
$3,039.76
|
| Rate for Payer: Quartz Commercial |
$4,032.34
|
| Rate for Payer: Quartz Medicare Advantage |
$3,722.16
|
| Rate for Payer: The Alliance Commercial |
$3,101.80
|
| Rate for Payer: United Healthcare PPO |
$3,142.88
|
| Rate for Payer: WEA Trust Commercial |
$3,411.98
|
| Rate for Payer: WPS Commercial |
$4,594.84
|
|
|
MRI Ankle w/ + w/o Contrast Right
|
Facility
|
OP
|
$6,295.00
|
|
|
Service Code
|
CPT 73723 RT,TC
|
| Hospital Charge Code |
1610912
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,833.10 |
| Max. Negotiated Rate |
$6,023.06 |
| Rate for Payer: Aetna Commercial |
$5,892.12
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,630.25
|
| Rate for Payer: Aetna Managed Medicare |
$1,833.10
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,635.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,985.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,835.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,469.80
|
| Rate for Payer: Cash Price |
$1,888.50
|
| Rate for Payer: Cash Price |
$1,888.50
|
| Rate for Payer: Cash Price |
$1,888.50
|
| Rate for Payer: Cigna Commercial |
$6,023.06
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,663.69
|
| Rate for Payer: Health EOS Commercial |
$5,826.65
|
| Rate for Payer: HFN Commercial |
$6,023.06
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,910.10
|
| Rate for Payer: Multiplan Commercial |
$5,237.44
|
| Rate for Payer: NAPHCARE Commercial |
$3,928.08
|
| Rate for Payer: Preferred Network Access Commercial |
$6,023.06
|
| Rate for Payer: Quartz Beloit One Network |
$3,207.93
|
| Rate for Payer: Quartz Commercial |
$4,255.42
|
| Rate for Payer: Quartz Medicare Advantage |
$3,928.08
|
| Rate for Payer: The Alliance Commercial |
$3,273.40
|
| Rate for Payer: United Healthcare PPO |
$3,142.88
|
| Rate for Payer: WEA Trust Commercial |
$3,600.74
|
| Rate for Payer: WPS Commercial |
$4,849.04
|
|
|
MRI Ankle w/ + w/o Contrast Right
|
Facility
|
IP
|
$5,965.00
|
|
|
Service Code
|
CPT 73723 TC,RT
|
| Hospital Charge Code |
2980111
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$3,039.76 |
| Max. Negotiated Rate |
$5,707.31 |
| Rate for Payer: Aetna Commercial |
$5,583.24
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,335.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,287.91
|
| Rate for Payer: Cash Price |
$1,789.50
|
| Rate for Payer: Cigna Commercial |
$5,707.31
|
| Rate for Payer: Health EOS Commercial |
$5,521.20
|
| Rate for Payer: HFN Commercial |
$5,707.31
|
| Rate for Payer: Multiplan Commercial |
$4,962.88
|
| Rate for Payer: Preferred Network Access Commercial |
$5,707.31
|
| Rate for Payer: Quartz Beloit One Network |
$3,039.76
|
| Rate for Payer: Quartz Commercial |
$3,722.16
|
| Rate for Payer: WEA Trust Commercial |
$3,411.98
|
| Rate for Payer: WPS Commercial |
$4,594.84
|
|
