|
OJ Autoabs
|
Professional
|
Both
|
$116.00
|
|
|
Service Code
|
CPT 83516
|
| Hospital Charge Code |
4592899
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.99 |
| Max. Negotiated Rate |
$114.61 |
| Rate for Payer: Aetna Commercial |
$114.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$103.75
|
| Rate for Payer: Aetna Managed Medicare |
$11.99
|
| Rate for Payer: Anthem Medicare Advantage |
$11.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$11.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$11.99
|
| Rate for Payer: Cash Price |
$34.80
|
| Rate for Payer: Cash Price |
$34.80
|
| Rate for Payer: Cigna Commercial |
$114.61
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$60.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11.99
|
| Rate for Payer: Health EOS Commercial |
$109.78
|
| Rate for Payer: HFN Commercial |
$114.61
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.33
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$42.33
|
| Rate for Payer: Independent Care Health Plan Medicare |
$11.99
|
| Rate for Payer: Multiplan Commercial |
$96.51
|
| Rate for Payer: NAPHCARE Commercial |
$17.99
|
| Rate for Payer: Preferred Network Access Commercial |
$114.61
|
| Rate for Payer: Quartz Beloit One Network |
$53.08
|
| Rate for Payer: Quartz Commercial |
$68.76
|
| Rate for Payer: Quartz Medicare Advantage |
$11.99
|
| Rate for Payer: The Alliance Commercial |
$47.37
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11.99
|
| Rate for Payer: WEA Trust Commercial |
$66.35
|
| Rate for Payer: WPS Commercial |
$52.76
|
|
|
OJ Autoabs
|
Facility
|
IP
|
$116.00
|
|
|
Service Code
|
CPT 83516
|
| Hospital Charge Code |
4592899
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$59.11 |
| Max. Negotiated Rate |
$110.99 |
| Rate for Payer: Aetna Commercial |
$108.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$103.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$63.94
|
| Rate for Payer: Cash Price |
$34.80
|
| Rate for Payer: Cigna Commercial |
$110.99
|
| Rate for Payer: Health EOS Commercial |
$107.37
|
| Rate for Payer: HFN Commercial |
$110.99
|
| Rate for Payer: Multiplan Commercial |
$96.51
|
| Rate for Payer: Preferred Network Access Commercial |
$110.99
|
| Rate for Payer: Quartz Beloit One Network |
$59.11
|
| Rate for Payer: Quartz Commercial |
$72.38
|
| Rate for Payer: WEA Trust Commercial |
$66.35
|
| Rate for Payer: WPS Commercial |
$89.35
|
|
|
Olanzapine
|
Facility
|
IP
|
$553.00
|
|
|
Service Code
|
CPT 80342
|
| Hospital Charge Code |
983346
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$281.81 |
| Max. Negotiated Rate |
$529.11 |
| Rate for Payer: Aetna Commercial |
$517.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$494.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$304.81
|
| Rate for Payer: Cash Price |
$165.90
|
| Rate for Payer: Cigna Commercial |
$529.11
|
| Rate for Payer: Health EOS Commercial |
$511.86
|
| Rate for Payer: HFN Commercial |
$529.11
|
| Rate for Payer: Multiplan Commercial |
$460.10
|
| Rate for Payer: Preferred Network Access Commercial |
$529.11
|
| Rate for Payer: Quartz Beloit One Network |
$281.81
|
| Rate for Payer: Quartz Commercial |
$345.07
|
| Rate for Payer: WEA Trust Commercial |
$316.32
|
| Rate for Payer: WPS Commercial |
$425.98
|
|
|
Olanzapine
|
Professional
|
Both
|
$553.00
|
|
|
Service Code
|
CPT 80342
|
| Hospital Charge Code |
983346
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$83.26 |
| Max. Negotiated Rate |
$546.36 |
| Rate for Payer: Aetna Commercial |
$546.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$494.60
|
| Rate for Payer: Cash Price |
$165.90
|
| Rate for Payer: Cash Price |
$165.90
|
| Rate for Payer: Cigna Commercial |
$546.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$287.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$345.07
|
| Rate for Payer: Health EOS Commercial |
$523.36
|
| Rate for Payer: HFN Commercial |
$546.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$83.26
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$83.26
|
| Rate for Payer: Multiplan Commercial |
$460.10
|
| Rate for Payer: Preferred Network Access Commercial |
$546.36
|
| Rate for Payer: Quartz Beloit One Network |
$253.05
|
| Rate for Payer: Quartz Commercial |
$327.82
|
| Rate for Payer: The Alliance Commercial |
$287.56
|
| Rate for Payer: WEA Trust Commercial |
$316.32
|
| Rate for Payer: WPS Commercial |
$425.98
|
|
|
Olanzapine
|
Facility
|
OP
|
$553.00
|
|
|
Service Code
|
CPT 80342
|
| Hospital Charge Code |
983346
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$161.03 |
| Max. Negotiated Rate |
$529.11 |
| Rate for Payer: Aetna Commercial |
$517.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$494.60
|
| Rate for Payer: Aetna Managed Medicare |
$161.03
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$373.83
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$287.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$276.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$304.81
|
| Rate for Payer: Cash Price |
$165.90
|
| Rate for Payer: Cigna Commercial |
$529.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$321.85
|
| Rate for Payer: Health EOS Commercial |
$511.86
|
| Rate for Payer: HFN Commercial |
$529.11
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$431.34
|
| Rate for Payer: Multiplan Commercial |
$460.10
|
| Rate for Payer: NAPHCARE Commercial |
$345.07
|
| Rate for Payer: Preferred Network Access Commercial |
$529.11
|
| Rate for Payer: Quartz Beloit One Network |
$281.81
|
| Rate for Payer: Quartz Commercial |
$373.83
|
| Rate for Payer: Quartz Medicare Advantage |
$345.07
|
| Rate for Payer: The Alliance Commercial |
$287.56
|
| Rate for Payer: United Healthcare PPO |
$431.34
|
| Rate for Payer: WEA Trust Commercial |
$316.32
|
| Rate for Payer: WPS Commercial |
$425.98
|
|
|
OLECRANON BURSECTOMY
|
Facility
|
OP
|
$1,337.00
|
|
| Hospital Charge Code |
2959883
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$389.33 |
| Max. Negotiated Rate |
$1,279.24 |
| Rate for Payer: Aetna Commercial |
$1,251.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,195.81
|
| Rate for Payer: Aetna Managed Medicare |
$389.33
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$903.81
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$695.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$667.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$736.95
|
| Rate for Payer: Cash Price |
$401.10
|
| Rate for Payer: Cigna Commercial |
$1,279.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$778.13
|
| Rate for Payer: Health EOS Commercial |
$1,237.53
|
| Rate for Payer: HFN Commercial |
$1,279.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,042.86
|
| Rate for Payer: Multiplan Commercial |
$1,112.38
|
| Rate for Payer: NAPHCARE Commercial |
$834.29
|
| Rate for Payer: Preferred Network Access Commercial |
$1,279.24
|
| Rate for Payer: Quartz Beloit One Network |
$681.34
|
| Rate for Payer: Quartz Commercial |
$903.81
|
| Rate for Payer: Quartz Medicare Advantage |
$834.29
|
| Rate for Payer: The Alliance Commercial |
$695.24
|
| Rate for Payer: WEA Trust Commercial |
$764.76
|
| Rate for Payer: WPS Commercial |
$1,029.89
|
|
|
OLECRANON BURSECTOMY
|
Facility
|
IP
|
$1,337.00
|
|
| Hospital Charge Code |
2959883
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$681.34 |
| Max. Negotiated Rate |
$1,279.24 |
| Rate for Payer: Aetna Commercial |
$1,251.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,195.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$736.95
|
| Rate for Payer: Cash Price |
$401.10
|
| Rate for Payer: Cigna Commercial |
$1,279.24
|
| Rate for Payer: Health EOS Commercial |
$1,237.53
|
| Rate for Payer: HFN Commercial |
$1,279.24
|
| Rate for Payer: Multiplan Commercial |
$1,112.38
|
| Rate for Payer: Preferred Network Access Commercial |
$1,279.24
|
| Rate for Payer: Quartz Beloit One Network |
$681.34
|
| Rate for Payer: Quartz Commercial |
$834.29
|
| Rate for Payer: WEA Trust Commercial |
$764.76
|
| Rate for Payer: WPS Commercial |
$1,029.89
|
|
|
Oligoclonal Bands Cerebrospinal Fluid
|
Facility
|
OP
|
$630.00
|
|
|
Service Code
|
CPT 83916
|
| Hospital Charge Code |
978028
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$28.49 |
| Max. Negotiated Rate |
$602.78 |
| Rate for Payer: Aetna Commercial |
$589.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$563.47
|
| Rate for Payer: Aetna Managed Medicare |
$28.49
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$106.82
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$49.85
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$47.29
|
| Rate for Payer: Anthem Medicare Advantage |
$28.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$347.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$28.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$28.49
|
| Rate for Payer: Cash Price |
$189.00
|
| Rate for Payer: Cash Price |
$189.00
|
| Rate for Payer: Cigna Commercial |
$602.78
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$28.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$366.66
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$28.49
|
| Rate for Payer: Health EOS Commercial |
$583.13
|
| Rate for Payer: HFN Commercial |
$602.78
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$105.97
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$28.49
|
| Rate for Payer: Independent Care Health Plan Medicare |
$28.49
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$28.49
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$28.49
|
| Rate for Payer: Multiplan Commercial |
$524.16
|
| Rate for Payer: NAPHCARE Commercial |
$42.73
|
| Rate for Payer: Preferred Network Access Commercial |
$602.78
|
| Rate for Payer: Quartz Beloit One Network |
$321.05
|
| Rate for Payer: Quartz Commercial |
$425.88
|
| Rate for Payer: Quartz Medicare Advantage |
$28.49
|
| Rate for Payer: The Alliance Commercial |
$113.94
|
| Rate for Payer: United Healthcare Medicare Advantage |
$28.49
|
| Rate for Payer: United Healthcare PPO |
$491.40
|
| Rate for Payer: WEA Trust Commercial |
$360.36
|
| Rate for Payer: Wellcare Medicare |
$28.49
|
| Rate for Payer: WPS Commercial |
$485.29
|
|
|
Oligoclonal Bands Cerebrospinal Fluid
|
Professional
|
Both
|
$630.00
|
|
|
Service Code
|
CPT 83916
|
| Hospital Charge Code |
978028
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$28.49 |
| Max. Negotiated Rate |
$622.44 |
| Rate for Payer: Aetna Commercial |
$622.44
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$563.47
|
| Rate for Payer: Aetna Managed Medicare |
$28.49
|
| Rate for Payer: Anthem Medicare Advantage |
$28.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$28.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$28.49
|
| Rate for Payer: Cash Price |
$189.00
|
| Rate for Payer: Cash Price |
$189.00
|
| Rate for Payer: Cigna Commercial |
$622.44
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$327.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$28.49
|
| Rate for Payer: Health EOS Commercial |
$596.23
|
| Rate for Payer: HFN Commercial |
$622.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$100.56
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$100.56
|
| Rate for Payer: Independent Care Health Plan Medicare |
$28.49
|
| Rate for Payer: Multiplan Commercial |
$524.16
|
| Rate for Payer: NAPHCARE Commercial |
$42.73
|
| Rate for Payer: Preferred Network Access Commercial |
$622.44
|
| Rate for Payer: Quartz Beloit One Network |
$288.29
|
| Rate for Payer: Quartz Commercial |
$373.46
|
| Rate for Payer: Quartz Medicare Advantage |
$28.49
|
| Rate for Payer: The Alliance Commercial |
$112.52
|
| Rate for Payer: United Healthcare Medicare Advantage |
$28.49
|
| Rate for Payer: WEA Trust Commercial |
$360.36
|
| Rate for Payer: WPS Commercial |
$125.34
|
|
|
Oligoclonal Bands Cerebrospinal Fluid
|
Facility
|
IP
|
$630.00
|
|
|
Service Code
|
CPT 83916
|
| Hospital Charge Code |
978028
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$321.05 |
| Max. Negotiated Rate |
$602.78 |
| Rate for Payer: Aetna Commercial |
$589.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$563.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$347.26
|
| Rate for Payer: Cash Price |
$189.00
|
| Rate for Payer: Cigna Commercial |
$602.78
|
| Rate for Payer: Health EOS Commercial |
$583.13
|
| Rate for Payer: HFN Commercial |
$602.78
|
| Rate for Payer: Multiplan Commercial |
$524.16
|
| Rate for Payer: Preferred Network Access Commercial |
$602.78
|
| Rate for Payer: Quartz Beloit One Network |
$321.05
|
| Rate for Payer: Quartz Commercial |
$393.12
|
| Rate for Payer: WEA Trust Commercial |
$360.36
|
| Rate for Payer: WPS Commercial |
$485.29
|
|
|
Oligoclonal Bands CSF
|
Facility
|
IP
|
$391.00
|
|
|
Service Code
|
CPT 83916
|
| Hospital Charge Code |
2958995
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$199.25 |
| Max. Negotiated Rate |
$374.11 |
| Rate for Payer: Aetna Commercial |
$365.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$349.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$215.52
|
| Rate for Payer: Cash Price |
$117.30
|
| Rate for Payer: Cigna Commercial |
$374.11
|
| Rate for Payer: Health EOS Commercial |
$361.91
|
| Rate for Payer: HFN Commercial |
$374.11
|
| Rate for Payer: Multiplan Commercial |
$325.31
|
| Rate for Payer: Preferred Network Access Commercial |
$374.11
|
| Rate for Payer: Quartz Beloit One Network |
$199.25
|
| Rate for Payer: Quartz Commercial |
$243.98
|
| Rate for Payer: WEA Trust Commercial |
$223.65
|
| Rate for Payer: WPS Commercial |
$301.19
|
|
|
Oligoclonal Bands CSF
|
Facility
|
OP
|
$391.00
|
|
|
Service Code
|
CPT 83916
|
| Hospital Charge Code |
2958995
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$28.49 |
| Max. Negotiated Rate |
$374.11 |
| Rate for Payer: Aetna Commercial |
$365.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$349.71
|
| Rate for Payer: Aetna Managed Medicare |
$28.49
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$106.82
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$49.85
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$47.29
|
| Rate for Payer: Anthem Medicare Advantage |
$28.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$215.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$28.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$28.49
|
| Rate for Payer: Cash Price |
$117.30
|
| Rate for Payer: Cash Price |
$117.30
|
| Rate for Payer: Cigna Commercial |
$374.11
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$28.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$227.56
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$28.49
|
| Rate for Payer: Health EOS Commercial |
$361.91
|
| Rate for Payer: HFN Commercial |
$374.11
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$105.97
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$28.49
|
| Rate for Payer: Independent Care Health Plan Medicare |
$28.49
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$28.49
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$28.49
|
| Rate for Payer: Multiplan Commercial |
$325.31
|
| Rate for Payer: NAPHCARE Commercial |
$42.73
|
| Rate for Payer: Preferred Network Access Commercial |
$374.11
|
| Rate for Payer: Quartz Beloit One Network |
$199.25
|
| Rate for Payer: Quartz Commercial |
$264.32
|
| Rate for Payer: Quartz Medicare Advantage |
$28.49
|
| Rate for Payer: The Alliance Commercial |
$113.94
|
| Rate for Payer: United Healthcare Medicare Advantage |
$28.49
|
| Rate for Payer: United Healthcare PPO |
$304.98
|
| Rate for Payer: WEA Trust Commercial |
$223.65
|
| Rate for Payer: Wellcare Medicare |
$28.49
|
| Rate for Payer: WPS Commercial |
$301.19
|
|
|
Oligoclonal Bands CSF
|
Professional
|
Both
|
$391.00
|
|
|
Service Code
|
CPT 83916
|
| Hospital Charge Code |
2958995
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$28.49 |
| Max. Negotiated Rate |
$386.31 |
| Rate for Payer: Aetna Commercial |
$386.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$349.71
|
| Rate for Payer: Aetna Managed Medicare |
$28.49
|
| Rate for Payer: Anthem Medicare Advantage |
$28.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$28.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$28.49
|
| Rate for Payer: Cash Price |
$117.30
|
| Rate for Payer: Cash Price |
$117.30
|
| Rate for Payer: Cigna Commercial |
$386.31
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$203.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$28.49
|
| Rate for Payer: Health EOS Commercial |
$370.04
|
| Rate for Payer: HFN Commercial |
$386.31
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$100.56
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$100.56
|
| Rate for Payer: Independent Care Health Plan Medicare |
$28.49
|
| Rate for Payer: Multiplan Commercial |
$325.31
|
| Rate for Payer: NAPHCARE Commercial |
$42.73
|
| Rate for Payer: Preferred Network Access Commercial |
$386.31
|
| Rate for Payer: Quartz Beloit One Network |
$178.92
|
| Rate for Payer: Quartz Commercial |
$231.78
|
| Rate for Payer: Quartz Medicare Advantage |
$28.49
|
| Rate for Payer: The Alliance Commercial |
$112.52
|
| Rate for Payer: United Healthcare Medicare Advantage |
$28.49
|
| Rate for Payer: WEA Trust Commercial |
$223.65
|
| Rate for Payer: WPS Commercial |
$125.34
|
|
|
Oligosaccharide Screen, Urine
|
Facility
|
IP
|
$339.00
|
|
|
Service Code
|
CPT 84376
|
| Hospital Charge Code |
1124803
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$172.75 |
| Max. Negotiated Rate |
$324.36 |
| Rate for Payer: Aetna Commercial |
$317.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$303.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$186.86
|
| Rate for Payer: Cash Price |
$101.70
|
| Rate for Payer: Cigna Commercial |
$324.36
|
| Rate for Payer: Health EOS Commercial |
$313.78
|
| Rate for Payer: HFN Commercial |
$324.36
|
| Rate for Payer: Multiplan Commercial |
$282.05
|
| Rate for Payer: Preferred Network Access Commercial |
$324.36
|
| Rate for Payer: Quartz Beloit One Network |
$172.75
|
| Rate for Payer: Quartz Commercial |
$211.54
|
| Rate for Payer: WEA Trust Commercial |
$193.91
|
| Rate for Payer: WPS Commercial |
$261.13
|
|
|
Oligosaccharide Screen, Urine
|
Facility
|
OP
|
$339.00
|
|
|
Service Code
|
CPT 84376
|
| Hospital Charge Code |
1124803
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.72 |
| Max. Negotiated Rate |
$324.36 |
| Rate for Payer: Aetna Commercial |
$317.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$303.20
|
| Rate for Payer: Aetna Managed Medicare |
$5.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$21.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10.01
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9.50
|
| Rate for Payer: Anthem Medicare Advantage |
$5.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$186.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5.72
|
| Rate for Payer: Cash Price |
$101.70
|
| Rate for Payer: Cash Price |
$101.70
|
| Rate for Payer: Cigna Commercial |
$324.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$5.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$197.30
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$5.72
|
| Rate for Payer: Health EOS Commercial |
$313.78
|
| Rate for Payer: HFN Commercial |
$324.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$21.28
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$5.72
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5.72
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$5.72
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$5.72
|
| Rate for Payer: Multiplan Commercial |
$282.05
|
| Rate for Payer: NAPHCARE Commercial |
$8.58
|
| Rate for Payer: Preferred Network Access Commercial |
$324.36
|
| Rate for Payer: Quartz Beloit One Network |
$172.75
|
| Rate for Payer: Quartz Commercial |
$229.16
|
| Rate for Payer: Quartz Medicare Advantage |
$5.72
|
| Rate for Payer: The Alliance Commercial |
$22.88
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.72
|
| Rate for Payer: United Healthcare PPO |
$264.42
|
| Rate for Payer: WEA Trust Commercial |
$193.91
|
| Rate for Payer: Wellcare Medicare |
$5.72
|
| Rate for Payer: WPS Commercial |
$261.13
|
|
|
Oligosaccharide Screen, Urine
|
Professional
|
Both
|
$339.00
|
|
|
Service Code
|
CPT 84376
|
| Hospital Charge Code |
1124803
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.72 |
| Max. Negotiated Rate |
$334.93 |
| Rate for Payer: Aetna Commercial |
$334.93
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$303.20
|
| Rate for Payer: Aetna Managed Medicare |
$5.72
|
| Rate for Payer: Anthem Medicare Advantage |
$5.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5.72
|
| Rate for Payer: Cash Price |
$101.70
|
| Rate for Payer: Cash Price |
$101.70
|
| Rate for Payer: Cigna Commercial |
$334.93
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$176.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5.72
|
| Rate for Payer: Health EOS Commercial |
$320.83
|
| Rate for Payer: HFN Commercial |
$334.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$20.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$20.20
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5.72
|
| Rate for Payer: Multiplan Commercial |
$282.05
|
| Rate for Payer: NAPHCARE Commercial |
$8.58
|
| Rate for Payer: Preferred Network Access Commercial |
$334.93
|
| Rate for Payer: Quartz Beloit One Network |
$155.13
|
| Rate for Payer: Quartz Commercial |
$200.96
|
| Rate for Payer: Quartz Medicare Advantage |
$5.72
|
| Rate for Payer: The Alliance Commercial |
$22.59
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.72
|
| Rate for Payer: WEA Trust Commercial |
$193.91
|
| Rate for Payer: WPS Commercial |
$25.17
|
|
|
OLYMPUS 3MM ROLLER BALL 24FR M0068802641
|
Facility
|
IP
|
$1,134.00
|
|
| Hospital Charge Code |
4520042
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$577.89 |
| Max. Negotiated Rate |
$1,085.01 |
| Rate for Payer: Aetna Commercial |
$1,061.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,014.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$625.06
|
| Rate for Payer: Cash Price |
$340.20
|
| Rate for Payer: Cigna Commercial |
$1,085.01
|
| Rate for Payer: Health EOS Commercial |
$1,049.63
|
| Rate for Payer: HFN Commercial |
$1,085.01
|
| Rate for Payer: Multiplan Commercial |
$943.49
|
| Rate for Payer: Preferred Network Access Commercial |
$1,085.01
|
| Rate for Payer: Quartz Beloit One Network |
$577.89
|
| Rate for Payer: Quartz Commercial |
$707.62
|
| Rate for Payer: WEA Trust Commercial |
$648.65
|
| Rate for Payer: WPS Commercial |
$873.52
|
|
|
OLYMPUS 3MM ROLLER BALL 24FR M0068802641
|
Facility
|
OP
|
$1,134.00
|
|
| Hospital Charge Code |
4520042
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$330.22 |
| Max. Negotiated Rate |
$1,085.01 |
| Rate for Payer: Aetna Commercial |
$1,061.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,014.25
|
| Rate for Payer: Aetna Managed Medicare |
$330.22
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$766.58
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$589.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$566.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$625.06
|
| Rate for Payer: Cash Price |
$340.20
|
| Rate for Payer: Cigna Commercial |
$1,085.01
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$659.99
|
| Rate for Payer: Health EOS Commercial |
$1,049.63
|
| Rate for Payer: HFN Commercial |
$1,085.01
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$884.52
|
| Rate for Payer: Multiplan Commercial |
$943.49
|
| Rate for Payer: NAPHCARE Commercial |
$707.62
|
| Rate for Payer: Preferred Network Access Commercial |
$1,085.01
|
| Rate for Payer: Quartz Beloit One Network |
$577.89
|
| Rate for Payer: Quartz Commercial |
$766.58
|
| Rate for Payer: Quartz Medicare Advantage |
$707.62
|
| Rate for Payer: The Alliance Commercial |
$589.68
|
| Rate for Payer: WEA Trust Commercial |
$648.65
|
| Rate for Payer: WPS Commercial |
$873.52
|
|
|
Omalizumab Charge 150 mg/5ml
|
Facility
|
IP
|
$2,434.00
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
4506658
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,240.37 |
| Max. Negotiated Rate |
$2,328.85 |
| Rate for Payer: Aetna Commercial |
$2,278.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,176.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,341.62
|
| Rate for Payer: Cash Price |
$730.20
|
| Rate for Payer: Cigna Commercial |
$2,328.85
|
| Rate for Payer: Health EOS Commercial |
$2,252.91
|
| Rate for Payer: HFN Commercial |
$2,328.85
|
| Rate for Payer: Multiplan Commercial |
$2,025.09
|
| Rate for Payer: Preferred Network Access Commercial |
$2,328.85
|
| Rate for Payer: Quartz Beloit One Network |
$1,240.37
|
| Rate for Payer: Quartz Commercial |
$1,518.82
|
| Rate for Payer: WEA Trust Commercial |
$1,392.25
|
| Rate for Payer: WPS Commercial |
$1,874.91
|
|
|
Omalizumab Charge 150 mg/5ml
|
Facility
|
OP
|
$2,434.00
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
4506658
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.32 |
| Max. Negotiated Rate |
$2,328.85 |
| Rate for Payer: Aetna Commercial |
$2,278.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,176.97
|
| Rate for Payer: Aetna Managed Medicare |
$47.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,645.38
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,265.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,215.05
|
| Rate for Payer: Anthem Medicare Advantage |
$47.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,341.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$47.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$47.32
|
| Rate for Payer: Cash Price |
$730.20
|
| Rate for Payer: Cash Price |
$730.20
|
| Rate for Payer: Cigna Commercial |
$2,328.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$47.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$50.64
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$47.32
|
| Rate for Payer: Health EOS Commercial |
$2,252.91
|
| Rate for Payer: HFN Commercial |
$2,328.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$176.03
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$47.32
|
| Rate for Payer: Independent Care Health Plan Medicare |
$47.32
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$47.32
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$47.32
|
| Rate for Payer: Multiplan Commercial |
$2,025.09
|
| Rate for Payer: NAPHCARE Commercial |
$70.98
|
| Rate for Payer: Preferred Network Access Commercial |
$2,328.85
|
| Rate for Payer: Quartz Beloit One Network |
$1,240.37
|
| Rate for Payer: Quartz Commercial |
$1,645.38
|
| Rate for Payer: Quartz Medicare Advantage |
$47.32
|
| Rate for Payer: The Alliance Commercial |
$189.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$47.32
|
| Rate for Payer: WEA Trust Commercial |
$1,392.25
|
| Rate for Payer: Wellcare Medicare |
$47.32
|
| Rate for Payer: WPS Commercial |
$95.70
|
|
|
Omalizumab Charge 150 mg/5ml
|
Professional
|
Both
|
$2,434.00
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
4506658
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$38.28 |
| Max. Negotiated Rate |
$2,404.79 |
| Rate for Payer: Aetna Commercial |
$2,404.79
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,176.97
|
| Rate for Payer: Aetna Managed Medicare |
$47.32
|
| Rate for Payer: Anthem Medicare Advantage |
$47.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$47.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$47.32
|
| Rate for Payer: Cash Price |
$730.20
|
| Rate for Payer: Cash Price |
$730.20
|
| Rate for Payer: Cigna Commercial |
$2,404.79
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$47.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$38.28
|
| Rate for Payer: Health EOS Commercial |
$2,303.54
|
| Rate for Payer: HFN Commercial |
$2,404.79
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$56.44
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$56.44
|
| Rate for Payer: Independent Care Health Plan Medicare |
$47.32
|
| Rate for Payer: Multiplan Commercial |
$2,025.09
|
| Rate for Payer: NAPHCARE Commercial |
$70.98
|
| Rate for Payer: Preferred Network Access Commercial |
$2,404.79
|
| Rate for Payer: Quartz Beloit One Network |
$1,113.80
|
| Rate for Payer: Quartz Commercial |
$1,442.88
|
| Rate for Payer: Quartz Medicare Advantage |
$47.32
|
| Rate for Payer: The Alliance Commercial |
$130.13
|
| Rate for Payer: United Healthcare Medicaid |
$47.32
|
| Rate for Payer: United Healthcare Medicare Advantage |
$47.32
|
| Rate for Payer: WEA Trust Commercial |
$1,392.25
|
| Rate for Payer: WPS Commercial |
$95.70
|
|
|
Omalizumab injection 5 Mg J2357
|
Facility
|
OP
|
$81.00
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
3382876
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$40.44 |
| Max. Negotiated Rate |
$189.28 |
| Rate for Payer: Aetna Commercial |
$75.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$72.45
|
| Rate for Payer: Aetna Managed Medicare |
$47.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$54.76
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$42.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$40.44
|
| Rate for Payer: Anthem Medicare Advantage |
$47.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$44.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$47.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$47.32
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cigna Commercial |
$77.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$47.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$50.64
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$47.32
|
| Rate for Payer: Health EOS Commercial |
$74.97
|
| Rate for Payer: HFN Commercial |
$77.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$176.03
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$47.32
|
| Rate for Payer: Independent Care Health Plan Medicare |
$47.32
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$47.32
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$47.32
|
| Rate for Payer: Multiplan Commercial |
$67.39
|
| Rate for Payer: NAPHCARE Commercial |
$70.98
|
| Rate for Payer: Preferred Network Access Commercial |
$77.50
|
| Rate for Payer: Quartz Beloit One Network |
$41.28
|
| Rate for Payer: Quartz Commercial |
$54.76
|
| Rate for Payer: Quartz Medicare Advantage |
$47.32
|
| Rate for Payer: The Alliance Commercial |
$189.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$47.32
|
| Rate for Payer: WEA Trust Commercial |
$46.33
|
| Rate for Payer: Wellcare Medicare |
$47.32
|
| Rate for Payer: WPS Commercial |
$95.70
|
|
|
Omalizumab injection 5 Mg J2357
|
Facility
|
IP
|
$81.00
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
3382876
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$41.28 |
| Max. Negotiated Rate |
$77.50 |
| Rate for Payer: Aetna Commercial |
$75.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$72.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$44.65
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cigna Commercial |
$77.50
|
| Rate for Payer: Health EOS Commercial |
$74.97
|
| Rate for Payer: HFN Commercial |
$77.50
|
| Rate for Payer: Multiplan Commercial |
$67.39
|
| Rate for Payer: Preferred Network Access Commercial |
$77.50
|
| Rate for Payer: Quartz Beloit One Network |
$41.28
|
| Rate for Payer: Quartz Commercial |
$50.54
|
| Rate for Payer: WEA Trust Commercial |
$46.33
|
| Rate for Payer: WPS Commercial |
$62.39
|
|
|
Omalizumab injection 5 Mg J2357
|
Professional
|
Both
|
$81.00
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
3382876
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.07 |
| Max. Negotiated Rate |
$130.13 |
| Rate for Payer: Aetna Commercial |
$80.03
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$72.45
|
| Rate for Payer: Aetna Managed Medicare |
$47.32
|
| Rate for Payer: Anthem Medicare Advantage |
$47.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$47.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$47.32
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cigna Commercial |
$80.03
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$47.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$38.28
|
| Rate for Payer: Health EOS Commercial |
$76.66
|
| Rate for Payer: HFN Commercial |
$80.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$56.44
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$56.44
|
| Rate for Payer: Independent Care Health Plan Medicare |
$47.32
|
| Rate for Payer: Multiplan Commercial |
$67.39
|
| Rate for Payer: NAPHCARE Commercial |
$70.98
|
| Rate for Payer: Preferred Network Access Commercial |
$80.03
|
| Rate for Payer: Quartz Beloit One Network |
$37.07
|
| Rate for Payer: Quartz Commercial |
$48.02
|
| Rate for Payer: Quartz Medicare Advantage |
$47.32
|
| Rate for Payer: The Alliance Commercial |
$130.13
|
| Rate for Payer: United Healthcare Medicaid |
$47.32
|
| Rate for Payer: United Healthcare Medicare Advantage |
$47.32
|
| Rate for Payer: WEA Trust Commercial |
$46.33
|
| Rate for Payer: WPS Commercial |
$95.70
|
|
|
OmegaCheck
|
Facility
|
IP
|
$138.00
|
|
|
Service Code
|
CPT 82542
|
| Hospital Charge Code |
5867633
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$70.32 |
| Max. Negotiated Rate |
$132.04 |
| Rate for Payer: Aetna Commercial |
$129.17
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$123.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$76.07
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cigna Commercial |
$132.04
|
| Rate for Payer: Health EOS Commercial |
$127.73
|
| Rate for Payer: HFN Commercial |
$132.04
|
| Rate for Payer: Multiplan Commercial |
$114.82
|
| Rate for Payer: Preferred Network Access Commercial |
$132.04
|
| Rate for Payer: Quartz Beloit One Network |
$70.32
|
| Rate for Payer: Quartz Commercial |
$86.11
|
| Rate for Payer: WEA Trust Commercial |
$78.94
|
| Rate for Payer: WPS Commercial |
$106.30
|
|
