|
MRI LE Non Joint w/ Contrast Right
|
Facility
|
IP
|
$4,714.00
|
|
|
Service Code
|
CPT 73719 TC,RT
|
| Hospital Charge Code |
1611217
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$2,402.25 |
| Max. Negotiated Rate |
$4,510.36 |
| Rate for Payer: Aetna Commercial |
$4,412.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,216.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,598.36
|
| Rate for Payer: Cash Price |
$1,414.20
|
| Rate for Payer: Cigna Commercial |
$4,510.36
|
| Rate for Payer: Health EOS Commercial |
$4,363.28
|
| Rate for Payer: HFN Commercial |
$4,510.36
|
| Rate for Payer: Multiplan Commercial |
$3,922.05
|
| Rate for Payer: Preferred Network Access Commercial |
$4,510.36
|
| Rate for Payer: Quartz Beloit One Network |
$2,402.25
|
| Rate for Payer: Quartz Commercial |
$2,941.54
|
| Rate for Payer: WEA Trust Commercial |
$2,696.41
|
| Rate for Payer: WPS Commercial |
$3,631.19
|
|
|
MRI LE Non Joint w/ Contrast Right
|
Facility
|
OP
|
$4,714.00
|
|
|
Service Code
|
CPT 73719 TC,RT
|
| Hospital Charge Code |
2980097
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,372.72 |
| Max. Negotiated Rate |
$4,510.36 |
| Rate for Payer: Aetna Commercial |
$4,412.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,216.20
|
| Rate for Payer: Aetna Managed Medicare |
$1,372.72
|
| 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 |
$2,598.36
|
| Rate for Payer: Cash Price |
$1,414.20
|
| Rate for Payer: Cash Price |
$1,414.20
|
| Rate for Payer: Cash Price |
$1,414.20
|
| Rate for Payer: Cigna Commercial |
$4,510.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,743.55
|
| Rate for Payer: Health EOS Commercial |
$4,363.28
|
| Rate for Payer: HFN Commercial |
$4,510.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,676.92
|
| Rate for Payer: Multiplan Commercial |
$3,922.05
|
| Rate for Payer: NAPHCARE Commercial |
$2,941.54
|
| Rate for Payer: Preferred Network Access Commercial |
$4,510.36
|
| Rate for Payer: Quartz Beloit One Network |
$2,402.25
|
| Rate for Payer: Quartz Commercial |
$3,186.66
|
| Rate for Payer: Quartz Medicare Advantage |
$2,941.54
|
| Rate for Payer: The Alliance Commercial |
$2,451.28
|
| Rate for Payer: United Healthcare PPO |
$3,142.88
|
| Rate for Payer: WEA Trust Commercial |
$2,696.41
|
| Rate for Payer: WPS Commercial |
$3,631.19
|
|
|
MRI LE Non Joint w/ Contrast Right
|
Facility
|
IP
|
$4,714.00
|
|
|
Service Code
|
CPT 73719 TC,RT
|
| Hospital Charge Code |
2980097
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$2,402.25 |
| Max. Negotiated Rate |
$4,510.36 |
| Rate for Payer: Aetna Commercial |
$4,412.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,216.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,598.36
|
| Rate for Payer: Cash Price |
$1,414.20
|
| Rate for Payer: Cigna Commercial |
$4,510.36
|
| Rate for Payer: Health EOS Commercial |
$4,363.28
|
| Rate for Payer: HFN Commercial |
$4,510.36
|
| Rate for Payer: Multiplan Commercial |
$3,922.05
|
| Rate for Payer: Preferred Network Access Commercial |
$4,510.36
|
| Rate for Payer: Quartz Beloit One Network |
$2,402.25
|
| Rate for Payer: Quartz Commercial |
$2,941.54
|
| Rate for Payer: WEA Trust Commercial |
$2,696.41
|
| Rate for Payer: WPS Commercial |
$3,631.19
|
|
|
MRI LE Non Joint w/ Contrast Right
|
Facility
|
OP
|
$4,714.00
|
|
|
Service Code
|
CPT 73719 TC,RT
|
| Hospital Charge Code |
1611217
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,372.72 |
| Max. Negotiated Rate |
$4,510.36 |
| Rate for Payer: Aetna Commercial |
$4,412.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,216.20
|
| Rate for Payer: Aetna Managed Medicare |
$1,372.72
|
| 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 |
$2,598.36
|
| Rate for Payer: Cash Price |
$1,414.20
|
| Rate for Payer: Cash Price |
$1,414.20
|
| Rate for Payer: Cash Price |
$1,414.20
|
| Rate for Payer: Cigna Commercial |
$4,510.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,743.55
|
| Rate for Payer: Health EOS Commercial |
$4,363.28
|
| Rate for Payer: HFN Commercial |
$4,510.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,676.92
|
| Rate for Payer: Multiplan Commercial |
$3,922.05
|
| Rate for Payer: NAPHCARE Commercial |
$2,941.54
|
| Rate for Payer: Preferred Network Access Commercial |
$4,510.36
|
| Rate for Payer: Quartz Beloit One Network |
$2,402.25
|
| Rate for Payer: Quartz Commercial |
$3,186.66
|
| Rate for Payer: Quartz Medicare Advantage |
$2,941.54
|
| Rate for Payer: The Alliance Commercial |
$2,451.28
|
| Rate for Payer: United Healthcare PPO |
$3,142.88
|
| Rate for Payer: WEA Trust Commercial |
$2,696.41
|
| Rate for Payer: WPS Commercial |
$3,631.19
|
|
|
MRI LE Non Joint w/o Contrast Bilat
|
Professional
|
Both
|
$4,282.00
|
|
|
Service Code
|
CPT 73718 TC,LT
|
| Hospital Charge Code |
1611219
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$891.14 |
| Max. Negotiated Rate |
$4,230.62 |
| Rate for Payer: Aetna Commercial |
$4,230.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,829.82
|
| Rate for Payer: Cash Price |
$1,284.60
|
| Rate for Payer: Cash Price |
$1,284.60
|
| Rate for Payer: Cash Price |
$1,284.60
|
| Rate for Payer: Cigna Commercial |
$4,230.62
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,226.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,671.97
|
| Rate for Payer: Health EOS Commercial |
$4,052.48
|
| Rate for Payer: HFN Commercial |
$4,230.62
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$891.14
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$891.14
|
| Rate for Payer: Multiplan Commercial |
$3,562.62
|
| Rate for Payer: Preferred Network Access Commercial |
$4,230.62
|
| Rate for Payer: Quartz Beloit One Network |
$1,959.44
|
| Rate for Payer: Quartz Commercial |
$2,538.37
|
| Rate for Payer: The Alliance Commercial |
$2,226.64
|
| Rate for Payer: WEA Trust Commercial |
$2,449.30
|
| Rate for Payer: WPS Commercial |
$3,298.42
|
|
|
MRI LE Non Joint w/o Contrast Bilat
|
Facility
|
IP
|
$9,142.00
|
|
|
Service Code
|
CPT 73718
|
| Hospital Charge Code |
631181
|
| Min. Negotiated Rate |
$4,658.76 |
| Max. Negotiated Rate |
$8,747.07 |
| Rate for Payer: Aetna Commercial |
$8,556.91
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,176.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,039.07
|
| Rate for Payer: Cash Price |
$2,742.60
|
| Rate for Payer: Cigna Commercial |
$8,747.07
|
| Rate for Payer: Health EOS Commercial |
$8,461.84
|
| Rate for Payer: HFN Commercial |
$8,747.07
|
| Rate for Payer: Multiplan Commercial |
$7,606.14
|
| Rate for Payer: Preferred Network Access Commercial |
$8,747.07
|
| Rate for Payer: Quartz Beloit One Network |
$4,658.76
|
| Rate for Payer: Quartz Commercial |
$5,704.61
|
| Rate for Payer: WEA Trust Commercial |
$5,229.22
|
| Rate for Payer: WPS Commercial |
$7,042.08
|
|
|
MRI LE Non Joint w/o Contrast Bilat
|
Facility
|
IP
|
$4,282.00
|
|
|
Service Code
|
CPT 73718 TC,LT
|
| Hospital Charge Code |
1611219
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$2,182.11 |
| Max. Negotiated Rate |
$4,097.02 |
| Rate for Payer: Aetna Commercial |
$4,007.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,829.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,360.24
|
| Rate for Payer: Cash Price |
$1,284.60
|
| Rate for Payer: Cigna Commercial |
$4,097.02
|
| Rate for Payer: Health EOS Commercial |
$3,963.42
|
| Rate for Payer: HFN Commercial |
$4,097.02
|
| Rate for Payer: Multiplan Commercial |
$3,562.62
|
| Rate for Payer: Preferred Network Access Commercial |
$4,097.02
|
| Rate for Payer: Quartz Beloit One Network |
$2,182.11
|
| Rate for Payer: Quartz Commercial |
$2,671.97
|
| Rate for Payer: WEA Trust Commercial |
$2,449.30
|
| Rate for Payer: WPS Commercial |
$3,298.42
|
|
|
MRI LE Non Joint w/o Contrast Bilat
|
Facility
|
OP
|
$4,282.00
|
|
|
Service Code
|
CPT 73718 TC,LT
|
| Hospital Charge Code |
1611219
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,246.92 |
| Max. Negotiated Rate |
$4,097.02 |
| Rate for Payer: Aetna Commercial |
$4,007.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,829.82
|
| Rate for Payer: Aetna Managed Medicare |
$1,246.92
|
| 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 |
$2,360.24
|
| Rate for Payer: Cash Price |
$1,284.60
|
| Rate for Payer: Cash Price |
$1,284.60
|
| Rate for Payer: Cash Price |
$1,284.60
|
| Rate for Payer: Cigna Commercial |
$4,097.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,492.12
|
| Rate for Payer: Health EOS Commercial |
$3,963.42
|
| Rate for Payer: HFN Commercial |
$4,097.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,339.96
|
| Rate for Payer: Multiplan Commercial |
$3,562.62
|
| Rate for Payer: NAPHCARE Commercial |
$2,671.97
|
| Rate for Payer: Preferred Network Access Commercial |
$4,097.02
|
| Rate for Payer: Quartz Beloit One Network |
$2,182.11
|
| Rate for Payer: Quartz Commercial |
$2,894.63
|
| Rate for Payer: Quartz Medicare Advantage |
$2,671.97
|
| Rate for Payer: The Alliance Commercial |
$2,226.64
|
| Rate for Payer: United Healthcare PPO |
$3,142.88
|
| Rate for Payer: WEA Trust Commercial |
$2,449.30
|
| Rate for Payer: WPS Commercial |
$3,298.42
|
|
|
MRI LE Non Joint w/o Contrast Bilat
|
Facility
|
OP
|
$9,142.00
|
|
|
Service Code
|
CPT 73718
|
| Hospital Charge Code |
631181
|
| Min. Negotiated Rate |
$251.10 |
| Max. Negotiated Rate |
$8,747.07 |
| Rate for Payer: Aetna Commercial |
$8,556.91
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,176.60
|
| Rate for Payer: Aetna Managed Medicare |
$251.10
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,179.99
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,753.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,563.69
|
| Rate for Payer: Anthem Medicare Advantage |
$251.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,039.07
|
| 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 |
$2,742.60
|
| Rate for Payer: Cash Price |
$2,742.60
|
| Rate for Payer: Cigna Commercial |
$8,747.07
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$251.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,320.64
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$251.10
|
| Rate for Payer: Health EOS Commercial |
$8,461.84
|
| Rate for Payer: HFN Commercial |
$8,747.07
|
| 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 |
$7,606.14
|
| Rate for Payer: NAPHCARE Commercial |
$376.65
|
| Rate for Payer: Preferred Network Access Commercial |
$8,747.07
|
| Rate for Payer: Quartz Beloit One Network |
$4,658.76
|
| Rate for Payer: Quartz Commercial |
$6,179.99
|
| 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 |
$5,229.22
|
| Rate for Payer: Wellcare Medicare |
$251.10
|
| Rate for Payer: WPS Commercial |
$7,042.08
|
|
|
MRI LE Non Joint w/o Contrast Bilat
|
Professional
|
Both
|
$9,142.00
|
|
|
Service Code
|
CPT 73718
|
| Hospital Charge Code |
631181
|
| Min. Negotiated Rate |
$221.52 |
| Max. Negotiated Rate |
$9,032.30 |
| Rate for Payer: Aetna Commercial |
$9,032.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,176.60
|
| Rate for Payer: Aetna Managed Medicare |
$221.52
|
| Rate for Payer: Anthem Medicare Advantage |
$221.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$221.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$221.52
|
| Rate for Payer: Cash Price |
$2,742.60
|
| Rate for Payer: Cash Price |
$2,742.60
|
| Rate for Payer: Cash Price |
$2,742.60
|
| Rate for Payer: Cigna Commercial |
$9,032.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4,753.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$221.52
|
| Rate for Payer: Health EOS Commercial |
$8,651.99
|
| Rate for Payer: HFN Commercial |
$9,032.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$891.14
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$891.14
|
| Rate for Payer: Independent Care Health Plan Medicare |
$221.52
|
| Rate for Payer: Multiplan Commercial |
$7,606.14
|
| Rate for Payer: NAPHCARE Commercial |
$332.28
|
| Rate for Payer: Preferred Network Access Commercial |
$9,032.30
|
| Rate for Payer: Quartz Beloit One Network |
$4,183.38
|
| Rate for Payer: Quartz Commercial |
$5,419.38
|
| Rate for Payer: Quartz Medicare Advantage |
$221.52
|
| Rate for Payer: The Alliance Commercial |
$841.78
|
| Rate for Payer: United Healthcare Medicare Advantage |
$221.52
|
| Rate for Payer: WEA Trust Commercial |
$5,229.22
|
| Rate for Payer: WPS Commercial |
$1,107.60
|
|
|
MRI LE Non Joint w/o Contrast Left
|
Facility
|
IP
|
$4,571.00
|
|
|
Service Code
|
CPT 73718
|
| Hospital Charge Code |
631189
|
| Min. Negotiated Rate |
$2,329.38 |
| Max. Negotiated Rate |
$4,373.53 |
| Rate for Payer: Aetna Commercial |
$4,278.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,088.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,519.54
|
| Rate for Payer: Cash Price |
$1,371.30
|
| Rate for Payer: Cigna Commercial |
$4,373.53
|
| Rate for Payer: Health EOS Commercial |
$4,230.92
|
| Rate for Payer: HFN Commercial |
$4,373.53
|
| Rate for Payer: Multiplan Commercial |
$3,803.07
|
| Rate for Payer: Preferred Network Access Commercial |
$4,373.53
|
| Rate for Payer: Quartz Beloit One Network |
$2,329.38
|
| Rate for Payer: Quartz Commercial |
$2,852.30
|
| Rate for Payer: WEA Trust Commercial |
$2,614.61
|
| Rate for Payer: WPS Commercial |
$3,521.04
|
|
|
MRI LE Non Joint w/o Contrast Left
|
Facility
|
OP
|
$4,282.00
|
|
|
Service Code
|
CPT 73718 TC,LT
|
| Hospital Charge Code |
1611221
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,246.92 |
| Max. Negotiated Rate |
$4,097.02 |
| Rate for Payer: Aetna Commercial |
$4,007.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,829.82
|
| Rate for Payer: Aetna Managed Medicare |
$1,246.92
|
| 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 |
$2,360.24
|
| Rate for Payer: Cash Price |
$1,284.60
|
| Rate for Payer: Cash Price |
$1,284.60
|
| Rate for Payer: Cash Price |
$1,284.60
|
| Rate for Payer: Cigna Commercial |
$4,097.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,492.12
|
| Rate for Payer: Health EOS Commercial |
$3,963.42
|
| Rate for Payer: HFN Commercial |
$4,097.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,339.96
|
| Rate for Payer: Multiplan Commercial |
$3,562.62
|
| Rate for Payer: NAPHCARE Commercial |
$2,671.97
|
| Rate for Payer: Preferred Network Access Commercial |
$4,097.02
|
| Rate for Payer: Quartz Beloit One Network |
$2,182.11
|
| Rate for Payer: Quartz Commercial |
$2,894.63
|
| Rate for Payer: Quartz Medicare Advantage |
$2,671.97
|
| Rate for Payer: The Alliance Commercial |
$2,226.64
|
| Rate for Payer: United Healthcare PPO |
$3,142.88
|
| Rate for Payer: WEA Trust Commercial |
$2,449.30
|
| Rate for Payer: WPS Commercial |
$3,298.42
|
|
|
MRI LE Non Joint w/o Contrast Left
|
Facility
|
OP
|
$4,571.00
|
|
|
Service Code
|
CPT 73718
|
| Hospital Charge Code |
631189
|
| Min. Negotiated Rate |
$251.10 |
| Max. Negotiated Rate |
$4,373.53 |
| Rate for Payer: Aetna Commercial |
$4,278.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,088.30
|
| Rate for Payer: Aetna Managed Medicare |
$251.10
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,090.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,376.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,281.84
|
| Rate for Payer: Anthem Medicare Advantage |
$251.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,519.54
|
| 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 |
$1,371.30
|
| Rate for Payer: Cash Price |
$1,371.30
|
| Rate for Payer: Cigna Commercial |
$4,373.53
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$251.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,660.32
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$251.10
|
| Rate for Payer: Health EOS Commercial |
$4,230.92
|
| Rate for Payer: HFN Commercial |
$4,373.53
|
| 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 |
$3,803.07
|
| Rate for Payer: NAPHCARE Commercial |
$376.65
|
| Rate for Payer: Preferred Network Access Commercial |
$4,373.53
|
| Rate for Payer: Quartz Beloit One Network |
$2,329.38
|
| Rate for Payer: Quartz Commercial |
$3,090.00
|
| 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 |
$2,614.61
|
| Rate for Payer: Wellcare Medicare |
$251.10
|
| Rate for Payer: WPS Commercial |
$3,521.04
|
|
|
MRI LE Non Joint w/o Contrast Left
|
Professional
|
Both
|
$4,282.00
|
|
|
Service Code
|
CPT 73718 TC,LT
|
| Hospital Charge Code |
1611221
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$891.14 |
| Max. Negotiated Rate |
$4,230.62 |
| Rate for Payer: Aetna Commercial |
$4,230.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,829.82
|
| Rate for Payer: Cash Price |
$1,284.60
|
| Rate for Payer: Cash Price |
$1,284.60
|
| Rate for Payer: Cash Price |
$1,284.60
|
| Rate for Payer: Cigna Commercial |
$4,230.62
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,226.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,671.97
|
| Rate for Payer: Health EOS Commercial |
$4,052.48
|
| Rate for Payer: HFN Commercial |
$4,230.62
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$891.14
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$891.14
|
| Rate for Payer: Multiplan Commercial |
$3,562.62
|
| Rate for Payer: Preferred Network Access Commercial |
$4,230.62
|
| Rate for Payer: Quartz Beloit One Network |
$1,959.44
|
| Rate for Payer: Quartz Commercial |
$2,538.37
|
| Rate for Payer: The Alliance Commercial |
$2,226.64
|
| Rate for Payer: WEA Trust Commercial |
$2,449.30
|
| Rate for Payer: WPS Commercial |
$3,298.42
|
|
|
MRI LE Non Joint w/o Contrast Left
|
Professional
|
Both
|
$4,571.00
|
|
|
Service Code
|
CPT 73718
|
| Hospital Charge Code |
631189
|
| Min. Negotiated Rate |
$221.52 |
| Max. Negotiated Rate |
$4,516.15 |
| Rate for Payer: Aetna Commercial |
$4,516.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,088.30
|
| Rate for Payer: Aetna Managed Medicare |
$221.52
|
| Rate for Payer: Anthem Medicare Advantage |
$221.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$221.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$221.52
|
| Rate for Payer: Cash Price |
$1,371.30
|
| Rate for Payer: Cash Price |
$1,371.30
|
| Rate for Payer: Cash Price |
$1,371.30
|
| Rate for Payer: Cigna Commercial |
$4,516.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,376.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$221.52
|
| Rate for Payer: Health EOS Commercial |
$4,325.99
|
| Rate for Payer: HFN Commercial |
$4,516.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$891.14
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$891.14
|
| Rate for Payer: Independent Care Health Plan Medicare |
$221.52
|
| Rate for Payer: Multiplan Commercial |
$3,803.07
|
| Rate for Payer: NAPHCARE Commercial |
$332.28
|
| Rate for Payer: Preferred Network Access Commercial |
$4,516.15
|
| Rate for Payer: Quartz Beloit One Network |
$2,091.69
|
| Rate for Payer: Quartz Commercial |
$2,709.69
|
| Rate for Payer: Quartz Medicare Advantage |
$221.52
|
| Rate for Payer: The Alliance Commercial |
$841.78
|
| Rate for Payer: United Healthcare Medicare Advantage |
$221.52
|
| Rate for Payer: WEA Trust Commercial |
$2,614.61
|
| Rate for Payer: WPS Commercial |
$1,107.60
|
|
|
MRI LE Non Joint w/o Contrast Left
|
Facility
|
IP
|
$4,282.00
|
|
|
Service Code
|
CPT 73718 TC,LT
|
| Hospital Charge Code |
1611221
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$2,182.11 |
| Max. Negotiated Rate |
$4,097.02 |
| Rate for Payer: Aetna Commercial |
$4,007.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,829.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,360.24
|
| Rate for Payer: Cash Price |
$1,284.60
|
| Rate for Payer: Cigna Commercial |
$4,097.02
|
| Rate for Payer: Health EOS Commercial |
$3,963.42
|
| Rate for Payer: HFN Commercial |
$4,097.02
|
| Rate for Payer: Multiplan Commercial |
$3,562.62
|
| Rate for Payer: Preferred Network Access Commercial |
$4,097.02
|
| Rate for Payer: Quartz Beloit One Network |
$2,182.11
|
| Rate for Payer: Quartz Commercial |
$2,671.97
|
| Rate for Payer: WEA Trust Commercial |
$2,449.30
|
| Rate for Payer: WPS Commercial |
$3,298.42
|
|
|
MRI LE Non Joint w/o Contrast Right
|
Professional
|
Both
|
$4,282.00
|
|
|
Service Code
|
CPT 73718 TC,RT
|
| Hospital Charge Code |
2980093
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$891.14 |
| Max. Negotiated Rate |
$4,230.62 |
| Rate for Payer: Aetna Commercial |
$4,230.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,829.82
|
| Rate for Payer: Cash Price |
$1,284.60
|
| Rate for Payer: Cash Price |
$1,284.60
|
| Rate for Payer: Cash Price |
$1,284.60
|
| Rate for Payer: Cigna Commercial |
$4,230.62
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,226.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,671.97
|
| Rate for Payer: Health EOS Commercial |
$4,052.48
|
| Rate for Payer: HFN Commercial |
$4,230.62
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$891.14
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$891.14
|
| Rate for Payer: Multiplan Commercial |
$3,562.62
|
| Rate for Payer: Preferred Network Access Commercial |
$4,230.62
|
| Rate for Payer: Quartz Beloit One Network |
$1,959.44
|
| Rate for Payer: Quartz Commercial |
$2,538.37
|
| Rate for Payer: The Alliance Commercial |
$2,226.64
|
| Rate for Payer: WEA Trust Commercial |
$2,449.30
|
| Rate for Payer: WPS Commercial |
$3,298.42
|
|
|
MRI LE Non Joint w/o Contrast Right
|
Facility
|
OP
|
$4,571.00
|
|
|
Service Code
|
CPT 73718
|
| Hospital Charge Code |
631195
|
| Min. Negotiated Rate |
$251.10 |
| Max. Negotiated Rate |
$4,373.53 |
| Rate for Payer: Aetna Commercial |
$4,278.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,088.30
|
| Rate for Payer: Aetna Managed Medicare |
$251.10
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,090.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,376.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,281.84
|
| Rate for Payer: Anthem Medicare Advantage |
$251.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,519.54
|
| 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 |
$1,371.30
|
| Rate for Payer: Cash Price |
$1,371.30
|
| Rate for Payer: Cigna Commercial |
$4,373.53
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$251.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,660.32
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$251.10
|
| Rate for Payer: Health EOS Commercial |
$4,230.92
|
| Rate for Payer: HFN Commercial |
$4,373.53
|
| 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 |
$3,803.07
|
| Rate for Payer: NAPHCARE Commercial |
$376.65
|
| Rate for Payer: Preferred Network Access Commercial |
$4,373.53
|
| Rate for Payer: Quartz Beloit One Network |
$2,329.38
|
| Rate for Payer: Quartz Commercial |
$3,090.00
|
| 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 |
$2,614.61
|
| Rate for Payer: Wellcare Medicare |
$251.10
|
| Rate for Payer: WPS Commercial |
$3,521.04
|
|
|
MRI LE Non Joint w/o Contrast Right
|
Facility
|
IP
|
$4,571.00
|
|
|
Service Code
|
CPT 73718
|
| Hospital Charge Code |
631195
|
| Min. Negotiated Rate |
$2,329.38 |
| Max. Negotiated Rate |
$4,373.53 |
| Rate for Payer: Aetna Commercial |
$4,278.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,088.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,519.54
|
| Rate for Payer: Cash Price |
$1,371.30
|
| Rate for Payer: Cigna Commercial |
$4,373.53
|
| Rate for Payer: Health EOS Commercial |
$4,230.92
|
| Rate for Payer: HFN Commercial |
$4,373.53
|
| Rate for Payer: Multiplan Commercial |
$3,803.07
|
| Rate for Payer: Preferred Network Access Commercial |
$4,373.53
|
| Rate for Payer: Quartz Beloit One Network |
$2,329.38
|
| Rate for Payer: Quartz Commercial |
$2,852.30
|
| Rate for Payer: WEA Trust Commercial |
$2,614.61
|
| Rate for Payer: WPS Commercial |
$3,521.04
|
|
|
MRI LE Non Joint w/o Contrast Right
|
Facility
|
OP
|
$4,282.00
|
|
|
Service Code
|
CPT 73718 TC,RT
|
| Hospital Charge Code |
2980093
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,246.92 |
| Max. Negotiated Rate |
$4,097.02 |
| Rate for Payer: Aetna Commercial |
$4,007.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,829.82
|
| Rate for Payer: Aetna Managed Medicare |
$1,246.92
|
| 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 |
$2,360.24
|
| Rate for Payer: Cash Price |
$1,284.60
|
| Rate for Payer: Cash Price |
$1,284.60
|
| Rate for Payer: Cash Price |
$1,284.60
|
| Rate for Payer: Cigna Commercial |
$4,097.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,492.12
|
| Rate for Payer: Health EOS Commercial |
$3,963.42
|
| Rate for Payer: HFN Commercial |
$4,097.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,339.96
|
| Rate for Payer: Multiplan Commercial |
$3,562.62
|
| Rate for Payer: NAPHCARE Commercial |
$2,671.97
|
| Rate for Payer: Preferred Network Access Commercial |
$4,097.02
|
| Rate for Payer: Quartz Beloit One Network |
$2,182.11
|
| Rate for Payer: Quartz Commercial |
$2,894.63
|
| Rate for Payer: Quartz Medicare Advantage |
$2,671.97
|
| Rate for Payer: The Alliance Commercial |
$2,226.64
|
| Rate for Payer: United Healthcare PPO |
$3,142.88
|
| Rate for Payer: WEA Trust Commercial |
$2,449.30
|
| Rate for Payer: WPS Commercial |
$3,298.42
|
|
|
MRI LE Non Joint w/o Contrast Right
|
Professional
|
Both
|
$4,571.00
|
|
|
Service Code
|
CPT 73718
|
| Hospital Charge Code |
631195
|
| Min. Negotiated Rate |
$221.52 |
| Max. Negotiated Rate |
$4,516.15 |
| Rate for Payer: Aetna Commercial |
$4,516.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,088.30
|
| Rate for Payer: Aetna Managed Medicare |
$221.52
|
| Rate for Payer: Anthem Medicare Advantage |
$221.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$221.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$221.52
|
| Rate for Payer: Cash Price |
$1,371.30
|
| Rate for Payer: Cash Price |
$1,371.30
|
| Rate for Payer: Cash Price |
$1,371.30
|
| Rate for Payer: Cigna Commercial |
$4,516.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,376.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$221.52
|
| Rate for Payer: Health EOS Commercial |
$4,325.99
|
| Rate for Payer: HFN Commercial |
$4,516.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$891.14
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$891.14
|
| Rate for Payer: Independent Care Health Plan Medicare |
$221.52
|
| Rate for Payer: Multiplan Commercial |
$3,803.07
|
| Rate for Payer: NAPHCARE Commercial |
$332.28
|
| Rate for Payer: Preferred Network Access Commercial |
$4,516.15
|
| Rate for Payer: Quartz Beloit One Network |
$2,091.69
|
| Rate for Payer: Quartz Commercial |
$2,709.69
|
| Rate for Payer: Quartz Medicare Advantage |
$221.52
|
| Rate for Payer: The Alliance Commercial |
$841.78
|
| Rate for Payer: United Healthcare Medicare Advantage |
$221.52
|
| Rate for Payer: WEA Trust Commercial |
$2,614.61
|
| Rate for Payer: WPS Commercial |
$1,107.60
|
|
|
MRI LE Non Joint w/o Contrast Right
|
Facility
|
IP
|
$4,282.00
|
|
|
Service Code
|
CPT 73718 TC,RT
|
| Hospital Charge Code |
1611223
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$2,182.11 |
| Max. Negotiated Rate |
$4,097.02 |
| Rate for Payer: Aetna Commercial |
$4,007.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,829.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,360.24
|
| Rate for Payer: Cash Price |
$1,284.60
|
| Rate for Payer: Cigna Commercial |
$4,097.02
|
| Rate for Payer: Health EOS Commercial |
$3,963.42
|
| Rate for Payer: HFN Commercial |
$4,097.02
|
| Rate for Payer: Multiplan Commercial |
$3,562.62
|
| Rate for Payer: Preferred Network Access Commercial |
$4,097.02
|
| Rate for Payer: Quartz Beloit One Network |
$2,182.11
|
| Rate for Payer: Quartz Commercial |
$2,671.97
|
| Rate for Payer: WEA Trust Commercial |
$2,449.30
|
| Rate for Payer: WPS Commercial |
$3,298.42
|
|
|
MRI LE Non Joint w/o Contrast Right
|
Facility
|
OP
|
$4,282.00
|
|
|
Service Code
|
CPT 73718 TC,RT
|
| Hospital Charge Code |
1611223
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,246.92 |
| Max. Negotiated Rate |
$4,097.02 |
| Rate for Payer: Aetna Commercial |
$4,007.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,829.82
|
| Rate for Payer: Aetna Managed Medicare |
$1,246.92
|
| 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 |
$2,360.24
|
| Rate for Payer: Cash Price |
$1,284.60
|
| Rate for Payer: Cash Price |
$1,284.60
|
| Rate for Payer: Cash Price |
$1,284.60
|
| Rate for Payer: Cigna Commercial |
$4,097.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,492.12
|
| Rate for Payer: Health EOS Commercial |
$3,963.42
|
| Rate for Payer: HFN Commercial |
$4,097.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,339.96
|
| Rate for Payer: Multiplan Commercial |
$3,562.62
|
| Rate for Payer: NAPHCARE Commercial |
$2,671.97
|
| Rate for Payer: Preferred Network Access Commercial |
$4,097.02
|
| Rate for Payer: Quartz Beloit One Network |
$2,182.11
|
| Rate for Payer: Quartz Commercial |
$2,894.63
|
| Rate for Payer: Quartz Medicare Advantage |
$2,671.97
|
| Rate for Payer: The Alliance Commercial |
$2,226.64
|
| Rate for Payer: United Healthcare PPO |
$3,142.88
|
| Rate for Payer: WEA Trust Commercial |
$2,449.30
|
| Rate for Payer: WPS Commercial |
$3,298.42
|
|
|
MRI LE Non Joint w/o Contrast Right
|
Facility
|
IP
|
$4,282.00
|
|
|
Service Code
|
CPT 73718 TC,RT
|
| Hospital Charge Code |
2980093
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$2,182.11 |
| Max. Negotiated Rate |
$4,097.02 |
| Rate for Payer: Aetna Commercial |
$4,007.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,829.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,360.24
|
| Rate for Payer: Cash Price |
$1,284.60
|
| Rate for Payer: Cigna Commercial |
$4,097.02
|
| Rate for Payer: Health EOS Commercial |
$3,963.42
|
| Rate for Payer: HFN Commercial |
$4,097.02
|
| Rate for Payer: Multiplan Commercial |
$3,562.62
|
| Rate for Payer: Preferred Network Access Commercial |
$4,097.02
|
| Rate for Payer: Quartz Beloit One Network |
$2,182.11
|
| Rate for Payer: Quartz Commercial |
$2,671.97
|
| Rate for Payer: WEA Trust Commercial |
$2,449.30
|
| Rate for Payer: WPS Commercial |
$3,298.42
|
|
|
MRI LE Non Joint w/o Contrast Right
|
Professional
|
Both
|
$4,282.00
|
|
|
Service Code
|
CPT 73718 TC,RT
|
| Hospital Charge Code |
1611223
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$891.14 |
| Max. Negotiated Rate |
$4,230.62 |
| Rate for Payer: Aetna Commercial |
$4,230.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,829.82
|
| Rate for Payer: Cash Price |
$1,284.60
|
| Rate for Payer: Cash Price |
$1,284.60
|
| Rate for Payer: Cash Price |
$1,284.60
|
| Rate for Payer: Cigna Commercial |
$4,230.62
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,226.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,671.97
|
| Rate for Payer: Health EOS Commercial |
$4,052.48
|
| Rate for Payer: HFN Commercial |
$4,230.62
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$891.14
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$891.14
|
| Rate for Payer: Multiplan Commercial |
$3,562.62
|
| Rate for Payer: Preferred Network Access Commercial |
$4,230.62
|
| Rate for Payer: Quartz Beloit One Network |
$1,959.44
|
| Rate for Payer: Quartz Commercial |
$2,538.37
|
| Rate for Payer: The Alliance Commercial |
$2,226.64
|
| Rate for Payer: WEA Trust Commercial |
$2,449.30
|
| Rate for Payer: WPS Commercial |
$3,298.42
|
|
