|
AUGMENT TRIATHLON FEMORAL DISTAL SZ 4 5MM 5540-A-402
|
Facility
IP
|
$4,737.63
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6246165
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,321.44 |
| Max. Negotiated Rate |
$4,358.62 |
| Rate for Payer: Aetna Commercial |
$4,263.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,510.94
|
| Rate for Payer: Cash Price |
$1,421.29
|
| Rate for Payer: Cigna Commercial |
$4,358.62
|
| Rate for Payer: Health EOS Commercial |
$4,216.49
|
| Rate for Payer: HFN Commercial |
$4,358.62
|
| Rate for Payer: Multiplan Commercial |
$3,790.10
|
| Rate for Payer: NAPHCARE Commercial |
$2,842.58
|
| Rate for Payer: Preferred Network Access Commercial |
$4,358.62
|
| Rate for Payer: Quartz Beloit One Network |
$2,321.44
|
| Rate for Payer: Quartz Commercial |
$2,842.58
|
| Rate for Payer: WEA Trust Commercial |
$2,605.70
|
| Rate for Payer: WPS Commercial |
$3,509.16
|
|
|
Aural Rehabilitation
|
Facility
IP
|
$522.00
|
|
|
Service Code
|
CPT 92507
|
| Hospital Charge Code |
3203484
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$255.78 |
| Max. Negotiated Rate |
$480.24 |
| Rate for Payer: Aetna Commercial |
$469.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$276.66
|
| Rate for Payer: Cash Price |
$156.60
|
| Rate for Payer: Cigna Commercial |
$480.24
|
| Rate for Payer: Health EOS Commercial |
$464.58
|
| Rate for Payer: HFN Commercial |
$480.24
|
| Rate for Payer: Multiplan Commercial |
$417.60
|
| Rate for Payer: NAPHCARE Commercial |
$313.20
|
| Rate for Payer: Preferred Network Access Commercial |
$480.24
|
| Rate for Payer: Quartz Beloit One Network |
$255.78
|
| Rate for Payer: Quartz Commercial |
$313.20
|
| Rate for Payer: WEA Trust Commercial |
$287.10
|
| Rate for Payer: WPS Commercial |
$386.65
|
|
|
Aural Rehabilitation
|
Professional
|
$522.00
|
|
|
Service Code
|
CPT 92507
|
| Hospital Charge Code |
3203484
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$74.74 |
| Max. Negotiated Rate |
$495.90 |
| Rate for Payer: Aetna Commercial |
$495.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$448.92
|
| Rate for Payer: Aetna Managed Medicare |
$74.74
|
| Rate for Payer: Anthem Medicare Advantage |
$74.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$74.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$74.74
|
| Rate for Payer: Cash Price |
$156.60
|
| Rate for Payer: Cash Price |
$156.60
|
| Rate for Payer: Cigna Commercial |
$495.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$261.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$74.74
|
| Rate for Payer: Health EOS Commercial |
$475.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$265.21
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$265.21
|
| Rate for Payer: Independent Care Health Plan Medicare |
$74.74
|
| Rate for Payer: Multiplan Commercial |
$417.60
|
| Rate for Payer: Preferred Network Access Commercial |
$495.90
|
| Rate for Payer: Quartz Beloit One Network |
$229.68
|
| Rate for Payer: Quartz Commercial |
$297.54
|
| Rate for Payer: Quartz Medicare Advantage |
$74.74
|
| Rate for Payer: The Alliance Commercial |
$186.85
|
| Rate for Payer: United Healthcare Medicare Advantage |
$74.74
|
| Rate for Payer: WEA Trust Commercial |
$287.10
|
| Rate for Payer: WPS Commercial |
$298.96
|
|
|
Aural Rehabilitation
|
Facility
OP
|
$522.00
|
|
|
Service Code
|
CPT 92507
|
| Hospital Charge Code |
3203484
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$146.16 |
| Max. Negotiated Rate |
$2,088.00 |
| Rate for Payer: Aetna Commercial |
$469.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$448.92
|
| Rate for Payer: Aetna Managed Medicare |
$146.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$339.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$261.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$250.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$276.66
|
| Rate for Payer: Cash Price |
$156.60
|
| Rate for Payer: Cigna Commercial |
$480.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$292.11
|
| Rate for Payer: Health EOS Commercial |
$464.58
|
| Rate for Payer: HFN Commercial |
$480.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$391.50
|
| Rate for Payer: Multiplan Commercial |
$417.60
|
| Rate for Payer: NAPHCARE Commercial |
$313.20
|
| Rate for Payer: Preferred Network Access Commercial |
$480.24
|
| Rate for Payer: Quartz Beloit One Network |
$255.78
|
| Rate for Payer: Quartz Commercial |
$339.30
|
| Rate for Payer: Quartz Medicare Advantage |
$313.20
|
| Rate for Payer: The Alliance Commercial |
$2,088.00
|
| Rate for Payer: United Healthcare PPO |
$391.50
|
| Rate for Payer: WEA Trust Commercial |
$287.10
|
| Rate for Payer: WPS Commercial |
$386.65
|
|
|
Aural Rehabilitation First 60 Min
|
Facility
IP
|
$485.00
|
|
|
Service Code
|
CPT 92626
|
| Hospital Charge Code |
3203485
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$237.65 |
| Max. Negotiated Rate |
$446.20 |
| Rate for Payer: Aetna Commercial |
$436.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$257.05
|
| Rate for Payer: Cash Price |
$145.50
|
| Rate for Payer: Cigna Commercial |
$446.20
|
| Rate for Payer: Health EOS Commercial |
$431.65
|
| Rate for Payer: HFN Commercial |
$446.20
|
| Rate for Payer: Multiplan Commercial |
$388.00
|
| Rate for Payer: NAPHCARE Commercial |
$291.00
|
| Rate for Payer: Preferred Network Access Commercial |
$446.20
|
| Rate for Payer: Quartz Beloit One Network |
$237.65
|
| Rate for Payer: Quartz Commercial |
$291.00
|
| Rate for Payer: WEA Trust Commercial |
$266.75
|
| Rate for Payer: WPS Commercial |
$359.24
|
|
|
Aural Rehabilitation First 60 Min
|
Facility
OP
|
$485.00
|
|
|
Service Code
|
CPT 92626
|
| Hospital Charge Code |
3203485
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$154.39 |
| Max. Negotiated Rate |
$446.20 |
| Rate for Payer: Quartz Beloit One Network |
$237.65
|
| Rate for Payer: Aetna Commercial |
$436.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$417.10
|
| Rate for Payer: Aetna Managed Medicare |
$154.39
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$349.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$287.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$272.00
|
| Rate for Payer: Anthem Medicare Advantage |
$154.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$257.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$154.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$154.39
|
| Rate for Payer: Cash Price |
$145.50
|
| Rate for Payer: Cash Price |
$145.50
|
| Rate for Payer: Cash Price |
$145.50
|
| Rate for Payer: Cigna Commercial |
$446.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$154.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$271.41
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$154.39
|
| Rate for Payer: Health EOS Commercial |
$431.65
|
| Rate for Payer: HFN Commercial |
$446.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$154.39
|
| Rate for Payer: Independent Care Health Plan Medicare |
$154.39
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$154.39
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$154.39
|
| Rate for Payer: Multiplan Commercial |
$388.00
|
| Rate for Payer: NAPHCARE Commercial |
$231.58
|
| Rate for Payer: Preferred Network Access Commercial |
$446.20
|
| Rate for Payer: Quartz Commercial |
$315.25
|
| Rate for Payer: Quartz Medicare Advantage |
$154.39
|
| Rate for Payer: United Healthcare Medicare Advantage |
$154.39
|
| Rate for Payer: United Healthcare PPO |
$363.75
|
| Rate for Payer: WEA Trust Commercial |
$266.75
|
| Rate for Payer: Wellcare Medicare |
$154.39
|
| Rate for Payer: WPS Commercial |
$359.24
|
|
|
Aural Rehabilitation First 60 Min
|
Professional
|
$485.00
|
|
|
Service Code
|
CPT 92626
|
| Hospital Charge Code |
3203485
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$72.66 |
| Max. Negotiated Rate |
$460.75 |
| Rate for Payer: Aetna Commercial |
$460.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$417.10
|
| Rate for Payer: Aetna Managed Medicare |
$72.66
|
| Rate for Payer: Anthem Medicare Advantage |
$72.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$72.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$72.66
|
| Rate for Payer: Cash Price |
$145.50
|
| Rate for Payer: Cash Price |
$145.50
|
| Rate for Payer: Cigna Commercial |
$460.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$242.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$72.66
|
| Rate for Payer: Health EOS Commercial |
$441.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$260.13
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$260.13
|
| Rate for Payer: Independent Care Health Plan Medicare |
$72.66
|
| Rate for Payer: Multiplan Commercial |
$388.00
|
| Rate for Payer: Preferred Network Access Commercial |
$460.75
|
| Rate for Payer: Quartz Beloit One Network |
$213.40
|
| Rate for Payer: Quartz Commercial |
$276.45
|
| Rate for Payer: Quartz Medicare Advantage |
$72.66
|
| Rate for Payer: The Alliance Commercial |
$181.65
|
| Rate for Payer: United Healthcare Medicare Advantage |
$72.66
|
| Rate for Payer: WEA Trust Commercial |
$266.75
|
| Rate for Payer: WPS Commercial |
$290.64
|
|
|
Aural Rehab Next 15 Min
|
Facility
IP
|
$120.00
|
|
|
Service Code
|
CPT 92627
|
| Hospital Charge Code |
3203483
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$58.80 |
| Max. Negotiated Rate |
$110.40 |
| Rate for Payer: Aetna Commercial |
$108.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$63.60
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$110.40
|
| Rate for Payer: Health EOS Commercial |
$106.80
|
| Rate for Payer: HFN Commercial |
$110.40
|
| Rate for Payer: Multiplan Commercial |
$96.00
|
| Rate for Payer: NAPHCARE Commercial |
$72.00
|
| Rate for Payer: Preferred Network Access Commercial |
$110.40
|
| Rate for Payer: Quartz Beloit One Network |
$58.80
|
| Rate for Payer: Quartz Commercial |
$72.00
|
| Rate for Payer: WEA Trust Commercial |
$66.00
|
| Rate for Payer: WPS Commercial |
$88.88
|
|
|
Aural Rehab Next 15 Min
|
Professional
|
$120.00
|
|
|
Service Code
|
CPT 92627
|
| Hospital Charge Code |
3203483
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$17.08 |
| Max. Negotiated Rate |
$114.00 |
| Rate for Payer: Aetna Commercial |
$114.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$103.20
|
| Rate for Payer: Aetna Managed Medicare |
$17.08
|
| Rate for Payer: Anthem Medicare Advantage |
$17.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.08
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$114.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$60.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17.08
|
| Rate for Payer: Health EOS Commercial |
$109.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$61.88
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$61.88
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.08
|
| Rate for Payer: Multiplan Commercial |
$96.00
|
| Rate for Payer: Preferred Network Access Commercial |
$114.00
|
| Rate for Payer: Quartz Beloit One Network |
$52.80
|
| Rate for Payer: Quartz Commercial |
$68.40
|
| Rate for Payer: Quartz Medicare Advantage |
$17.08
|
| Rate for Payer: The Alliance Commercial |
$42.70
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.08
|
| Rate for Payer: WEA Trust Commercial |
$66.00
|
| Rate for Payer: WPS Commercial |
$68.32
|
|
|
Aural Rehab Next 15 Min
|
Facility
OP
|
$120.00
|
|
|
Service Code
|
CPT 92627
|
| Hospital Charge Code |
3203483
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$33.60 |
| Max. Negotiated Rate |
$349.00 |
| Rate for Payer: Aetna Commercial |
$108.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$103.20
|
| Rate for Payer: Aetna Managed Medicare |
$33.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$349.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$287.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$272.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$63.60
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$110.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$67.15
|
| Rate for Payer: Health EOS Commercial |
$106.80
|
| Rate for Payer: HFN Commercial |
$110.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.00
|
| Rate for Payer: Multiplan Commercial |
$96.00
|
| Rate for Payer: NAPHCARE Commercial |
$72.00
|
| Rate for Payer: Preferred Network Access Commercial |
$110.40
|
| Rate for Payer: Quartz Beloit One Network |
$58.80
|
| Rate for Payer: Quartz Commercial |
$78.00
|
| Rate for Payer: Quartz Medicare Advantage |
$72.00
|
| Rate for Payer: United Healthcare PPO |
$90.00
|
| Rate for Payer: WEA Trust Commercial |
$66.00
|
| Rate for Payer: WPS Commercial |
$88.88
|
|
|
.Auto Diff
|
Facility
OP
|
$209.00
|
|
|
Service Code
|
CPT 85025
|
| Hospital Charge Code |
983772
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$7.77 |
| Max. Negotiated Rate |
$836.00 |
| Rate for Payer: Aetna Commercial |
$188.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$179.74
|
| Rate for Payer: Aetna Managed Medicare |
$7.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$29.14
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$13.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$12.90
|
| Rate for Payer: Anthem Medicaid |
$8.03
|
| Rate for Payer: Anthem Medicare Advantage |
$7.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$110.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7.77
|
| Rate for Payer: Cash Price |
$62.70
|
| Rate for Payer: Cash Price |
$62.70
|
| Rate for Payer: Cigna Commercial |
$192.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$7.77
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8.03
|
| Rate for Payer: Dean Health Medicaid |
$8.03
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$7.77
|
| Rate for Payer: Health EOS Commercial |
$186.01
|
| Rate for Payer: HFN Commercial |
$192.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$28.90
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$7.77
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$8.03
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7.77
|
| Rate for Payer: Managed Health Services Medicaid |
$8.35
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$7.77
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$7.77
|
| Rate for Payer: Multiplan Commercial |
$167.20
|
| Rate for Payer: NAPHCARE Commercial |
$11.66
|
| Rate for Payer: Preferred Network Access Commercial |
$192.28
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$8.03
|
| Rate for Payer: Quartz Beloit One Network |
$102.41
|
| Rate for Payer: Quartz Commercial |
$135.85
|
| Rate for Payer: Quartz Medicare Advantage |
$7.77
|
| Rate for Payer: The Alliance Commercial |
$836.00
|
| Rate for Payer: United Healthcare Medicaid |
$8.03
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7.77
|
| Rate for Payer: United Healthcare PPO |
$156.75
|
| Rate for Payer: WEA Trust Commercial |
$114.95
|
| Rate for Payer: Wellcare Medicare |
$7.77
|
| Rate for Payer: WMAP Medicaid |
$8.03
|
| Rate for Payer: WPS Commercial |
$154.81
|
|
|
.Auto Diff
|
Facility
IP
|
$209.00
|
|
|
Service Code
|
CPT 85025
|
| Hospital Charge Code |
983772
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$102.41 |
| Max. Negotiated Rate |
$192.28 |
| Rate for Payer: Aetna Commercial |
$188.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$110.77
|
| Rate for Payer: Cash Price |
$62.70
|
| Rate for Payer: Cigna Commercial |
$192.28
|
| Rate for Payer: Health EOS Commercial |
$186.01
|
| Rate for Payer: HFN Commercial |
$192.28
|
| Rate for Payer: Multiplan Commercial |
$167.20
|
| Rate for Payer: NAPHCARE Commercial |
$125.40
|
| Rate for Payer: Preferred Network Access Commercial |
$192.28
|
| Rate for Payer: Quartz Beloit One Network |
$102.41
|
| Rate for Payer: Quartz Commercial |
$125.40
|
| Rate for Payer: WEA Trust Commercial |
$114.95
|
| Rate for Payer: WPS Commercial |
$154.81
|
|
|
.Auto Diff
|
Professional
|
$209.00
|
|
|
Service Code
|
CPT 85025
|
| Hospital Charge Code |
983772
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$7.77 |
| Max. Negotiated Rate |
$198.55 |
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7.77
|
| Rate for Payer: Aetna Commercial |
$198.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$179.74
|
| Rate for Payer: Aetna Managed Medicare |
$7.77
|
| Rate for Payer: Anthem Medicare Advantage |
$7.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7.77
|
| Rate for Payer: Cash Price |
$62.70
|
| Rate for Payer: Cash Price |
$62.70
|
| Rate for Payer: Cigna Commercial |
$198.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$104.50
|
| Rate for Payer: Health EOS Commercial |
$190.19
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$27.43
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$27.43
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7.77
|
| Rate for Payer: Multiplan Commercial |
$167.20
|
| Rate for Payer: Preferred Network Access Commercial |
$198.55
|
| Rate for Payer: Quartz Beloit One Network |
$91.96
|
| Rate for Payer: Quartz Commercial |
$119.13
|
| Rate for Payer: Quartz Medicare Advantage |
$7.77
|
| Rate for Payer: The Alliance Commercial |
$30.69
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7.77
|
| Rate for Payer: WEA Trust Commercial |
$114.95
|
| Rate for Payer: WPS Commercial |
$34.19
|
|
|
AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC
|
Facility
IP
|
$164,542.00
|
|
|
Service Code
|
MS-DRG 016
|
| Min. Negotiated Rate |
$59,187.73 |
| Max. Negotiated Rate |
$164,542.00 |
| Rate for Payer: Aetna Managed Medicare |
$59,187.73
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$129,656.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$99,380.58
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$94,418.04
|
| Rate for Payer: Anthem Medicare Advantage |
$59,187.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$59,187.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$59,187.73
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$59,187.73
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$104,812.68
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$59,187.73
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$120,451.50
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$59,187.73
|
| Rate for Payer: Independent Care Health Plan Medicare |
$59,187.73
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$59,187.73
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$59,187.73
|
| Rate for Payer: NAPHCARE Commercial |
$88,781.60
|
| Rate for Payer: Quartz Medicare Advantage |
$59,187.73
|
| Rate for Payer: The Alliance Commercial |
$164,542.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$59,187.73
|
| Rate for Payer: Wellcare Medicare |
$59,187.73
|
|
|
AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC
|
Facility
IP
|
$164,542.00
|
|
|
Service Code
|
MS-DRG 017
|
| Min. Negotiated Rate |
$59,187.73 |
| Max. Negotiated Rate |
$164,542.00 |
| Rate for Payer: Aetna Managed Medicare |
$59,187.73
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$129,656.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$99,380.58
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$94,418.04
|
| Rate for Payer: Anthem Medicare Advantage |
$59,187.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$59,187.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$59,187.73
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$59,187.73
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$104,812.68
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$59,187.73
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$120,451.50
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$59,187.73
|
| Rate for Payer: Independent Care Health Plan Medicare |
$59,187.73
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$59,187.73
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$59,187.73
|
| Rate for Payer: NAPHCARE Commercial |
$88,781.60
|
| Rate for Payer: Quartz Medicare Advantage |
$59,187.73
|
| Rate for Payer: The Alliance Commercial |
$164,542.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$59,187.73
|
| Rate for Payer: Wellcare Medicare |
$59,187.73
|
|
|
AUTOLOGOUS CARTILAGE IMPLANTATION PROCEDURE (MACI)
|
Facility
OP
|
$62,498.00
|
|
|
Service Code
|
CPT 27412
|
| Hospital Charge Code |
5416772
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$6,546.14 |
| Max. Negotiated Rate |
$57,498.16 |
| Rate for Payer: Aetna Commercial |
$56,248.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$53,748.28
|
| Rate for Payer: Aetna Managed Medicare |
$7,071.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$17,483.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$16,081.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$15,278.00
|
| Rate for Payer: Anthem Medicare Advantage |
$7,071.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$33,123.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7,071.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7,071.12
|
| Rate for Payer: Cash Price |
$18,749.40
|
| Rate for Payer: Cash Price |
$18,749.40
|
| Rate for Payer: Cash Price |
$18,749.40
|
| Rate for Payer: Cigna Commercial |
$57,498.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$7,071.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,546.14
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$7,071.12
|
| Rate for Payer: Health EOS Commercial |
$55,623.22
|
| Rate for Payer: HFN Commercial |
$57,498.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$26,304.57
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$7,071.12
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7,071.12
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$7,071.12
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$7,071.12
|
| Rate for Payer: Multiplan Commercial |
$49,998.40
|
| Rate for Payer: NAPHCARE Commercial |
$10,606.68
|
| Rate for Payer: Preferred Network Access Commercial |
$57,498.16
|
| Rate for Payer: Quartz Beloit One Network |
$30,624.02
|
| Rate for Payer: Quartz Commercial |
$40,623.70
|
| Rate for Payer: Quartz Medicare Advantage |
$7,071.12
|
| Rate for Payer: The Alliance Commercial |
$27,265.32
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7,071.12
|
| Rate for Payer: United Healthcare PPO |
$8,452.00
|
| Rate for Payer: WEA Trust Commercial |
$34,373.90
|
| Rate for Payer: Wellcare Medicare |
$7,071.12
|
| Rate for Payer: WPS Commercial |
$46,292.27
|
|
|
AUTOLOGOUS CARTILAGE IMPLANTATION PROCEDURE (MACI)
|
Facility
IP
|
$62,498.00
|
|
|
Service Code
|
CPT 27412
|
| Hospital Charge Code |
5416772
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$30,624.02 |
| Max. Negotiated Rate |
$57,498.16 |
| Rate for Payer: Aetna Commercial |
$56,248.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$33,123.94
|
| Rate for Payer: Cash Price |
$18,749.40
|
| Rate for Payer: Cigna Commercial |
$57,498.16
|
| Rate for Payer: Health EOS Commercial |
$55,623.22
|
| Rate for Payer: HFN Commercial |
$57,498.16
|
| Rate for Payer: Multiplan Commercial |
$49,998.40
|
| Rate for Payer: NAPHCARE Commercial |
$37,498.80
|
| Rate for Payer: Preferred Network Access Commercial |
$57,498.16
|
| Rate for Payer: Quartz Beloit One Network |
$30,624.02
|
| Rate for Payer: Quartz Commercial |
$37,498.80
|
| Rate for Payer: WEA Trust Commercial |
$34,373.90
|
| Rate for Payer: WPS Commercial |
$46,292.27
|
|
|
AUTOSCORE TEST FORM
|
Facility
OP
|
$87.00
|
|
| Hospital Charge Code |
2971762
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$24.36 |
| Max. Negotiated Rate |
$348.00 |
| Rate for Payer: Aetna Commercial |
$78.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$74.82
|
| Rate for Payer: Aetna Managed Medicare |
$24.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$56.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$43.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$41.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$46.11
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cigna Commercial |
$80.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$48.69
|
| Rate for Payer: Health EOS Commercial |
$77.43
|
| Rate for Payer: HFN Commercial |
$80.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$65.25
|
| Rate for Payer: Multiplan Commercial |
$69.60
|
| Rate for Payer: NAPHCARE Commercial |
$52.20
|
| Rate for Payer: Preferred Network Access Commercial |
$80.04
|
| Rate for Payer: Quartz Beloit One Network |
$42.63
|
| Rate for Payer: Quartz Commercial |
$56.55
|
| Rate for Payer: Quartz Medicare Advantage |
$52.20
|
| Rate for Payer: The Alliance Commercial |
$348.00
|
| Rate for Payer: WEA Trust Commercial |
$47.85
|
| Rate for Payer: WPS Commercial |
$64.44
|
|
|
AUTOSCORE TEST FORM
|
Facility
IP
|
$87.00
|
|
| Hospital Charge Code |
2971762
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$42.63 |
| Max. Negotiated Rate |
$80.04 |
| Rate for Payer: Aetna Commercial |
$78.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$46.11
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cigna Commercial |
$80.04
|
| Rate for Payer: Health EOS Commercial |
$77.43
|
| Rate for Payer: HFN Commercial |
$80.04
|
| Rate for Payer: Multiplan Commercial |
$69.60
|
| Rate for Payer: NAPHCARE Commercial |
$52.20
|
| Rate for Payer: Preferred Network Access Commercial |
$80.04
|
| Rate for Payer: Quartz Beloit One Network |
$42.63
|
| Rate for Payer: Quartz Commercial |
$52.20
|
| Rate for Payer: WEA Trust Commercial |
$47.85
|
| Rate for Payer: WPS Commercial |
$64.44
|
|
|
Avastin 10 mg Charge
|
Professional
|
$296.00
|
|
|
Service Code
|
HCPCS J9035
|
| Hospital Charge Code |
2958919
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$73.58 |
| Max. Negotiated Rate |
$281.20 |
| Rate for Payer: Aetna Commercial |
$281.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$254.56
|
| Rate for Payer: Aetna Managed Medicare |
$73.58
|
| Rate for Payer: Anthem Medicare Advantage |
$73.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$73.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$73.58
|
| Rate for Payer: Cash Price |
$88.80
|
| Rate for Payer: Cash Price |
$88.80
|
| Rate for Payer: Cigna Commercial |
$281.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$148.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$74.16
|
| Rate for Payer: Health EOS Commercial |
$269.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$105.86
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$105.86
|
| Rate for Payer: Independent Care Health Plan Medicare |
$73.58
|
| Rate for Payer: Multiplan Commercial |
$236.80
|
| Rate for Payer: Preferred Network Access Commercial |
$281.20
|
| Rate for Payer: Quartz Beloit One Network |
$130.24
|
| Rate for Payer: Quartz Commercial |
$168.72
|
| Rate for Payer: Quartz Medicare Advantage |
$73.58
|
| Rate for Payer: The Alliance Commercial |
$202.34
|
| Rate for Payer: United Healthcare Medicaid |
$74.07
|
| Rate for Payer: United Healthcare Medicare Advantage |
$73.58
|
| Rate for Payer: WEA Trust Commercial |
$162.80
|
| Rate for Payer: WPS Commercial |
$185.39
|
|
|
Avastin 10 mg Charge
|
Facility
IP
|
$296.00
|
|
|
Service Code
|
HCPCS J9035
|
| Hospital Charge Code |
2958919
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$145.04 |
| Max. Negotiated Rate |
$272.32 |
| Rate for Payer: Aetna Commercial |
$266.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$156.88
|
| Rate for Payer: Cash Price |
$88.80
|
| Rate for Payer: Cigna Commercial |
$272.32
|
| Rate for Payer: Health EOS Commercial |
$263.44
|
| Rate for Payer: HFN Commercial |
$272.32
|
| Rate for Payer: Multiplan Commercial |
$236.80
|
| Rate for Payer: NAPHCARE Commercial |
$177.60
|
| Rate for Payer: Preferred Network Access Commercial |
$272.32
|
| Rate for Payer: Quartz Beloit One Network |
$145.04
|
| Rate for Payer: Quartz Commercial |
$177.60
|
| Rate for Payer: WEA Trust Commercial |
$162.80
|
| Rate for Payer: WPS Commercial |
$219.25
|
|
|
Avastin 10 mg Charge
|
Facility
OP
|
$296.00
|
|
|
Service Code
|
HCPCS J9035
|
| Hospital Charge Code |
2958919
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$74.07 |
| Max. Negotiated Rate |
$1,571.88 |
| Rate for Payer: Aetna Commercial |
$266.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$254.56
|
| Rate for Payer: Aetna Managed Medicare |
$74.07
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$192.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$148.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$142.08
|
| Rate for Payer: Anthem Medicare Advantage |
$74.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$156.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$74.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$74.07
|
| Rate for Payer: Cash Price |
$88.80
|
| Rate for Payer: Cash Price |
$88.80
|
| Rate for Payer: Cigna Commercial |
$272.32
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$74.07
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$98.11
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$74.07
|
| Rate for Payer: Health EOS Commercial |
$263.44
|
| Rate for Payer: HFN Commercial |
$272.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$275.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$74.07
|
| Rate for Payer: Independent Care Health Plan Medicare |
$74.07
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$74.07
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$74.07
|
| Rate for Payer: Multiplan Commercial |
$236.80
|
| Rate for Payer: NAPHCARE Commercial |
$111.11
|
| Rate for Payer: Preferred Network Access Commercial |
$272.32
|
| Rate for Payer: Quartz Beloit One Network |
$145.04
|
| Rate for Payer: Quartz Commercial |
$192.40
|
| Rate for Payer: Quartz Medicare Advantage |
$74.07
|
| Rate for Payer: The Alliance Commercial |
$1,571.88
|
| Rate for Payer: United Healthcare Medicare Advantage |
$74.07
|
| Rate for Payer: WEA Trust Commercial |
$162.80
|
| Rate for Payer: Wellcare Medicare |
$74.07
|
| Rate for Payer: WPS Commercial |
$185.39
|
|
|
Avastin 1.25 mg Charge
|
Facility
OP
|
$73.00
|
|
|
Service Code
|
HCPCS C9257
|
| Hospital Charge Code |
3002818
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.85 |
| Max. Negotiated Rate |
$67.16 |
| Rate for Payer: Aetna Commercial |
$65.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$62.78
|
| Rate for Payer: Aetna Managed Medicare |
$1.85
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$47.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$36.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$35.04
|
| Rate for Payer: Anthem Medicare Advantage |
$1.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$38.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1.85
|
| Rate for Payer: Cash Price |
$21.90
|
| Rate for Payer: Cash Price |
$21.90
|
| Rate for Payer: Cigna Commercial |
$67.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$1.85
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$40.85
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1.85
|
| Rate for Payer: Health EOS Commercial |
$64.97
|
| Rate for Payer: HFN Commercial |
$67.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6.89
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1.85
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1.85
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$1.85
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$1.85
|
| Rate for Payer: Multiplan Commercial |
$58.40
|
| Rate for Payer: NAPHCARE Commercial |
$2.78
|
| Rate for Payer: Preferred Network Access Commercial |
$67.16
|
| Rate for Payer: Quartz Beloit One Network |
$35.77
|
| Rate for Payer: Quartz Commercial |
$47.45
|
| Rate for Payer: Quartz Medicare Advantage |
$1.85
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1.85
|
| Rate for Payer: WEA Trust Commercial |
$40.15
|
| Rate for Payer: Wellcare Medicare |
$1.85
|
| Rate for Payer: WPS Commercial |
$54.07
|
|
|
Avastin 1.25 mg Charge
|
Professional
|
$73.00
|
|
|
Service Code
|
HCPCS C9257
|
| Hospital Charge Code |
3002818
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.12 |
| Max. Negotiated Rate |
$69.35 |
| Rate for Payer: Aetna Commercial |
$69.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$62.78
|
| Rate for Payer: Cash Price |
$21.90
|
| Rate for Payer: Cigna Commercial |
$69.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$36.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$43.80
|
| Rate for Payer: Health EOS Commercial |
$66.43
|
| Rate for Payer: Multiplan Commercial |
$58.40
|
| Rate for Payer: Preferred Network Access Commercial |
$69.35
|
| Rate for Payer: Quartz Beloit One Network |
$32.12
|
| Rate for Payer: Quartz Commercial |
$41.61
|
| Rate for Payer: The Alliance Commercial |
$36.50
|
| Rate for Payer: WEA Trust Commercial |
$40.15
|
| Rate for Payer: WPS Commercial |
$54.07
|
|
|
Avastin 1.25 mg Charge
|
Facility
IP
|
$73.00
|
|
|
Service Code
|
HCPCS C9257
|
| Hospital Charge Code |
3002818
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.77 |
| Max. Negotiated Rate |
$67.16 |
| Rate for Payer: Aetna Commercial |
$65.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$38.69
|
| Rate for Payer: Cash Price |
$21.90
|
| Rate for Payer: Cigna Commercial |
$67.16
|
| Rate for Payer: Health EOS Commercial |
$64.97
|
| Rate for Payer: HFN Commercial |
$67.16
|
| Rate for Payer: Multiplan Commercial |
$58.40
|
| Rate for Payer: NAPHCARE Commercial |
$43.80
|
| Rate for Payer: Preferred Network Access Commercial |
$67.16
|
| Rate for Payer: Quartz Beloit One Network |
$35.77
|
| Rate for Payer: Quartz Commercial |
$43.80
|
| Rate for Payer: WEA Trust Commercial |
$40.15
|
| Rate for Payer: WPS Commercial |
$54.07
|
|
