|
SIDEPLATE DHHS SYNTHES
|
Facility
IP
|
$5,722.00
|
|
| Hospital Charge Code |
2966583
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,803.78 |
| Max. Negotiated Rate |
$5,264.24 |
| Rate for Payer: Aetna Commercial |
$5,149.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,032.66
|
| Rate for Payer: Cash Price |
$1,716.60
|
| Rate for Payer: Cigna Commercial |
$5,264.24
|
| Rate for Payer: Health EOS Commercial |
$5,092.58
|
| Rate for Payer: HFN Commercial |
$5,264.24
|
| Rate for Payer: Multiplan Commercial |
$4,577.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,433.20
|
| Rate for Payer: Preferred Network Access Commercial |
$5,264.24
|
| Rate for Payer: Quartz Beloit One Network |
$2,803.78
|
| Rate for Payer: Quartz Commercial |
$3,433.20
|
| Rate for Payer: WEA Trust Commercial |
$3,147.10
|
| Rate for Payer: WPS Commercial |
$4,238.29
|
|
|
SIDEPORT 1.2MM 8065921541
|
Facility
OP
|
$236.00
|
|
| Hospital Charge Code |
5415574
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$66.08 |
| Max. Negotiated Rate |
$944.00 |
| Rate for Payer: Aetna Commercial |
$212.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$202.96
|
| Rate for Payer: Aetna Managed Medicare |
$66.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$153.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$118.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$113.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$125.08
|
| Rate for Payer: Cash Price |
$70.80
|
| Rate for Payer: Cigna Commercial |
$217.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$132.07
|
| Rate for Payer: Health EOS Commercial |
$210.04
|
| Rate for Payer: HFN Commercial |
$217.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$177.00
|
| Rate for Payer: Multiplan Commercial |
$188.80
|
| Rate for Payer: NAPHCARE Commercial |
$141.60
|
| Rate for Payer: Preferred Network Access Commercial |
$217.12
|
| Rate for Payer: Quartz Beloit One Network |
$115.64
|
| Rate for Payer: Quartz Commercial |
$153.40
|
| Rate for Payer: Quartz Medicare Advantage |
$141.60
|
| Rate for Payer: The Alliance Commercial |
$944.00
|
| Rate for Payer: WEA Trust Commercial |
$129.80
|
| Rate for Payer: WPS Commercial |
$174.81
|
|
|
SIDEPORT 1.2MM 8065921541
|
Facility
IP
|
$236.00
|
|
| Hospital Charge Code |
5415574
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$115.64 |
| Max. Negotiated Rate |
$217.12 |
| Rate for Payer: Aetna Commercial |
$212.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$125.08
|
| Rate for Payer: Cash Price |
$70.80
|
| Rate for Payer: Cigna Commercial |
$217.12
|
| Rate for Payer: Health EOS Commercial |
$210.04
|
| Rate for Payer: HFN Commercial |
$217.12
|
| Rate for Payer: Multiplan Commercial |
$188.80
|
| Rate for Payer: NAPHCARE Commercial |
$141.60
|
| Rate for Payer: Preferred Network Access Commercial |
$217.12
|
| Rate for Payer: Quartz Beloit One Network |
$115.64
|
| Rate for Payer: Quartz Commercial |
$141.60
|
| Rate for Payer: WEA Trust Commercial |
$129.80
|
| Rate for Payer: WPS Commercial |
$174.81
|
|
|
SIGMOID COLECTOMY/RESECTION/LOW ANTERIOR RESECTION
|
Facility
OP
|
$4,803.00
|
|
| Hospital Charge Code |
2960374
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,344.84 |
| Max. Negotiated Rate |
$19,212.00 |
| Rate for Payer: Aetna Commercial |
$4,322.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,130.58
|
| Rate for Payer: Aetna Managed Medicare |
$1,344.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,121.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,401.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,305.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,545.59
|
| Rate for Payer: Cash Price |
$1,440.90
|
| Rate for Payer: Cigna Commercial |
$4,418.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,687.76
|
| Rate for Payer: Health EOS Commercial |
$4,274.67
|
| Rate for Payer: HFN Commercial |
$4,418.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,602.25
|
| Rate for Payer: Multiplan Commercial |
$3,842.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,881.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,418.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,353.47
|
| Rate for Payer: Quartz Commercial |
$3,121.95
|
| Rate for Payer: Quartz Medicare Advantage |
$2,881.80
|
| Rate for Payer: The Alliance Commercial |
$19,212.00
|
| Rate for Payer: WEA Trust Commercial |
$2,641.65
|
| Rate for Payer: WPS Commercial |
$3,557.58
|
|
|
SIGMOID COLECTOMY/RESECTION/LOW ANTERIOR RESECTION
|
Facility
IP
|
$4,803.00
|
|
| Hospital Charge Code |
2960374
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,353.47 |
| Max. Negotiated Rate |
$4,418.76 |
| Rate for Payer: Aetna Commercial |
$4,322.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,545.59
|
| Rate for Payer: Cash Price |
$1,440.90
|
| Rate for Payer: Cigna Commercial |
$4,418.76
|
| Rate for Payer: Health EOS Commercial |
$4,274.67
|
| Rate for Payer: HFN Commercial |
$4,418.76
|
| Rate for Payer: Multiplan Commercial |
$3,842.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,881.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,418.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,353.47
|
| Rate for Payer: Quartz Commercial |
$2,881.80
|
| Rate for Payer: WEA Trust Commercial |
$2,641.65
|
| Rate for Payer: WPS Commercial |
$3,557.58
|
|
|
SIGMOIDOSCOPE DISPOSABLE 53130
|
Facility
OP
|
$93.00
|
|
| Hospital Charge Code |
2963026
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$26.04 |
| Max. Negotiated Rate |
$372.00 |
| Rate for Payer: Aetna Commercial |
$83.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$79.98
|
| Rate for Payer: Aetna Managed Medicare |
$26.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$60.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$46.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$44.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$49.29
|
| Rate for Payer: Cash Price |
$27.90
|
| Rate for Payer: Cigna Commercial |
$85.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$52.04
|
| Rate for Payer: Health EOS Commercial |
$82.77
|
| Rate for Payer: HFN Commercial |
$85.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$69.75
|
| Rate for Payer: Multiplan Commercial |
$74.40
|
| Rate for Payer: NAPHCARE Commercial |
$55.80
|
| Rate for Payer: Preferred Network Access Commercial |
$85.56
|
| Rate for Payer: Quartz Beloit One Network |
$45.57
|
| Rate for Payer: Quartz Commercial |
$60.45
|
| Rate for Payer: Quartz Medicare Advantage |
$55.80
|
| Rate for Payer: The Alliance Commercial |
$372.00
|
| Rate for Payer: WEA Trust Commercial |
$51.15
|
| Rate for Payer: WPS Commercial |
$68.89
|
|
|
SIGMOIDOSCOPE DISPOSABLE 53130
|
Facility
IP
|
$93.00
|
|
| Hospital Charge Code |
2963026
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$45.57 |
| Max. Negotiated Rate |
$85.56 |
| Rate for Payer: Aetna Commercial |
$83.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$49.29
|
| Rate for Payer: Cash Price |
$27.90
|
| Rate for Payer: Cigna Commercial |
$85.56
|
| Rate for Payer: Health EOS Commercial |
$82.77
|
| Rate for Payer: HFN Commercial |
$85.56
|
| Rate for Payer: Multiplan Commercial |
$74.40
|
| Rate for Payer: NAPHCARE Commercial |
$55.80
|
| Rate for Payer: Preferred Network Access Commercial |
$85.56
|
| Rate for Payer: Quartz Beloit One Network |
$45.57
|
| Rate for Payer: Quartz Commercial |
$55.80
|
| Rate for Payer: WEA Trust Commercial |
$51.15
|
| Rate for Payer: WPS Commercial |
$68.89
|
|
|
SIGMOIDOSCOPE SUCTION TIP 0033050
|
Facility
IP
|
$86.00
|
|
| Hospital Charge Code |
2963604
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$42.14 |
| Max. Negotiated Rate |
$79.12 |
| Rate for Payer: Aetna Commercial |
$77.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$45.58
|
| Rate for Payer: Cash Price |
$25.80
|
| Rate for Payer: Cigna Commercial |
$79.12
|
| Rate for Payer: Health EOS Commercial |
$76.54
|
| Rate for Payer: HFN Commercial |
$79.12
|
| Rate for Payer: Multiplan Commercial |
$68.80
|
| Rate for Payer: NAPHCARE Commercial |
$51.60
|
| Rate for Payer: Preferred Network Access Commercial |
$79.12
|
| Rate for Payer: Quartz Beloit One Network |
$42.14
|
| Rate for Payer: Quartz Commercial |
$51.60
|
| Rate for Payer: WEA Trust Commercial |
$47.30
|
| Rate for Payer: WPS Commercial |
$63.70
|
|
|
SIGMOIDOSCOPE SUCTION TIP 0033050
|
Facility
OP
|
$86.00
|
|
| Hospital Charge Code |
2963604
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$24.08 |
| Max. Negotiated Rate |
$344.00 |
| Rate for Payer: Aetna Commercial |
$77.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$73.96
|
| Rate for Payer: Aetna Managed Medicare |
$24.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$55.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$43.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$41.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$45.58
|
| Rate for Payer: Cash Price |
$25.80
|
| Rate for Payer: Cigna Commercial |
$79.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$48.13
|
| Rate for Payer: Health EOS Commercial |
$76.54
|
| Rate for Payer: HFN Commercial |
$79.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$64.50
|
| Rate for Payer: Multiplan Commercial |
$68.80
|
| Rate for Payer: NAPHCARE Commercial |
$51.60
|
| Rate for Payer: Preferred Network Access Commercial |
$79.12
|
| Rate for Payer: Quartz Beloit One Network |
$42.14
|
| Rate for Payer: Quartz Commercial |
$55.90
|
| Rate for Payer: Quartz Medicare Advantage |
$51.60
|
| Rate for Payer: The Alliance Commercial |
$344.00
|
| Rate for Payer: WEA Trust Commercial |
$47.30
|
| Rate for Payer: WPS Commercial |
$63.70
|
|
|
SIGMOIDOSCOPY AND BIOPSY 45331
|
Professional
|
$275.00
|
|
|
Service Code
|
CPT 45331
|
| Hospital Charge Code |
3014796
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$67.16 |
| Max. Negotiated Rate |
$302.22 |
| Rate for Payer: Aetna Commercial |
$261.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$236.50
|
| Rate for Payer: Aetna Managed Medicare |
$67.16
|
| Rate for Payer: Anthem Medicare Advantage |
$67.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$67.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$67.16
|
| Rate for Payer: Cash Price |
$82.50
|
| Rate for Payer: Cash Price |
$82.50
|
| Rate for Payer: Cigna Commercial |
$261.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$137.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$67.16
|
| Rate for Payer: Health EOS Commercial |
$250.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$239.51
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$239.51
|
| Rate for Payer: Independent Care Health Plan Medicare |
$67.16
|
| Rate for Payer: Multiplan Commercial |
$220.00
|
| Rate for Payer: Preferred Network Access Commercial |
$261.25
|
| Rate for Payer: Quartz Beloit One Network |
$121.00
|
| Rate for Payer: Quartz Commercial |
$156.75
|
| Rate for Payer: Quartz Medicare Advantage |
$67.16
|
| Rate for Payer: The Alliance Commercial |
$285.43
|
| Rate for Payer: United Healthcare Medicaid |
$107.51
|
| Rate for Payer: United Healthcare Medicare Advantage |
$67.16
|
| Rate for Payer: WEA Trust Commercial |
$151.25
|
| Rate for Payer: WPS Commercial |
$302.22
|
|
|
SIGMOIDOSCOPY AND POLYPECTOMY 45333
|
Professional
|
$553.00
|
|
|
Service Code
|
CPT 45333
|
| Hospital Charge Code |
3014798
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$86.52 |
| Max. Negotiated Rate |
$525.35 |
| Rate for Payer: Aetna Commercial |
$525.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$475.58
|
| Rate for Payer: Aetna Managed Medicare |
$86.52
|
| Rate for Payer: Anthem Medicare Advantage |
$86.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$86.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$86.52
|
| Rate for Payer: Cash Price |
$165.90
|
| Rate for Payer: Cash Price |
$165.90
|
| Rate for Payer: Cigna Commercial |
$525.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$276.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$86.52
|
| Rate for Payer: Health EOS Commercial |
$503.23
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$311.13
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$311.13
|
| Rate for Payer: Independent Care Health Plan Medicare |
$86.52
|
| Rate for Payer: Multiplan Commercial |
$442.40
|
| Rate for Payer: Preferred Network Access Commercial |
$525.35
|
| Rate for Payer: Quartz Beloit One Network |
$243.32
|
| Rate for Payer: Quartz Commercial |
$315.21
|
| Rate for Payer: Quartz Medicare Advantage |
$86.52
|
| Rate for Payer: The Alliance Commercial |
$367.71
|
| Rate for Payer: United Healthcare Medicaid |
$106.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$86.52
|
| Rate for Payer: WEA Trust Commercial |
$304.15
|
| Rate for Payer: WPS Commercial |
$389.34
|
|
|
SIGMOIDOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)
|
Facility
OP
|
$13,185.36
|
|
|
Service Code
|
CPT 45330
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$636.03 |
| Max. Negotiated Rate |
$13,185.36 |
| Rate for Payer: Aetna Managed Medicare |
$903.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,914.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,297.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,183.00
|
| Rate for Payer: Anthem Medicare Advantage |
$903.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$903.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$903.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$903.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$636.03
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$903.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,360.50
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$903.36
|
| Rate for Payer: Independent Care Health Plan Medicare |
$903.36
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$903.36
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$903.36
|
| Rate for Payer: NAPHCARE Commercial |
$1,355.04
|
| Rate for Payer: Quartz Medicare Advantage |
$903.36
|
| Rate for Payer: The Alliance Commercial |
$13,185.36
|
| Rate for Payer: United Healthcare Medicare Advantage |
$903.36
|
| Rate for Payer: United Healthcare PPO |
$2,257.00
|
| Rate for Payer: Wellcare Medicare |
$903.36
|
|
|
SIGMOIDOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE
|
Facility
OP
|
$13,185.36
|
|
|
Service Code
|
CPT 45331
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$903.36 |
| Max. Negotiated Rate |
$13,185.36 |
| Rate for Payer: Aetna Managed Medicare |
$903.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,914.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,297.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,183.00
|
| Rate for Payer: Anthem Medicare Advantage |
$903.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$903.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$903.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$903.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,218.22
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$903.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,360.50
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$903.36
|
| Rate for Payer: Independent Care Health Plan Medicare |
$903.36
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$903.36
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$903.36
|
| Rate for Payer: NAPHCARE Commercial |
$1,355.04
|
| Rate for Payer: Quartz Medicare Advantage |
$903.36
|
| Rate for Payer: The Alliance Commercial |
$13,185.36
|
| Rate for Payer: United Healthcare Medicare Advantage |
$903.36
|
| Rate for Payer: United Healthcare PPO |
$2,257.00
|
| Rate for Payer: Wellcare Medicare |
$903.36
|
|
|
SIGMOIDOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE
|
Facility
OP
|
$13,185.36
|
|
|
Service Code
|
CPT 45335
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$903.36 |
| Max. Negotiated Rate |
$13,185.36 |
| Rate for Payer: Aetna Managed Medicare |
$903.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,914.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,297.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,183.00
|
| Rate for Payer: Anthem Medicare Advantage |
$903.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$903.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$903.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$903.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,218.22
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$903.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,360.50
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$903.36
|
| Rate for Payer: Independent Care Health Plan Medicare |
$903.36
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$903.36
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$903.36
|
| Rate for Payer: NAPHCARE Commercial |
$1,355.04
|
| Rate for Payer: Quartz Medicare Advantage |
$903.36
|
| Rate for Payer: The Alliance Commercial |
$13,185.36
|
| Rate for Payer: United Healthcare Medicare Advantage |
$903.36
|
| Rate for Payer: United Healthcare PPO |
$2,257.00
|
| Rate for Payer: Wellcare Medicare |
$903.36
|
|
|
Sigmoidoscopy Flx with Band Ligation(s) 45350
|
Professional
|
$1,518.00
|
|
|
Service Code
|
CPT 45350
|
| Hospital Charge Code |
5430717
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$93.40 |
| Max. Negotiated Rate |
$1,442.10 |
| Rate for Payer: Aetna Commercial |
$1,442.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,305.48
|
| Rate for Payer: Aetna Managed Medicare |
$93.40
|
| Rate for Payer: Anthem Medicare Advantage |
$93.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$93.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$93.40
|
| Rate for Payer: Cash Price |
$455.40
|
| Rate for Payer: Cash Price |
$455.40
|
| Rate for Payer: Cigna Commercial |
$1,442.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$759.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$93.40
|
| Rate for Payer: Health EOS Commercial |
$1,381.38
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$335.24
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$335.24
|
| Rate for Payer: Independent Care Health Plan Medicare |
$93.40
|
| Rate for Payer: Multiplan Commercial |
$1,214.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,442.10
|
| Rate for Payer: Quartz Beloit One Network |
$667.92
|
| Rate for Payer: Quartz Commercial |
$865.26
|
| Rate for Payer: Quartz Medicare Advantage |
$93.40
|
| Rate for Payer: The Alliance Commercial |
$396.95
|
| Rate for Payer: United Healthcare Medicaid |
$131.18
|
| Rate for Payer: United Healthcare Medicare Advantage |
$93.40
|
| Rate for Payer: WEA Trust Commercial |
$834.90
|
| Rate for Payer: WPS Commercial |
$420.30
|
|
|
SIGMOIDOSCOPY W/ABLATE TUMR 45339
|
Professional
|
$1,362.00
|
|
| Hospital Charge Code |
3014802
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$599.28 |
| Max. Negotiated Rate |
$1,293.90 |
| Rate for Payer: Aetna Commercial |
$1,293.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,171.32
|
| Rate for Payer: Cash Price |
$408.60
|
| Rate for Payer: Cigna Commercial |
$1,293.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$681.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$817.20
|
| Rate for Payer: Health EOS Commercial |
$1,239.42
|
| Rate for Payer: Multiplan Commercial |
$1,089.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,293.90
|
| Rate for Payer: Quartz Beloit One Network |
$599.28
|
| Rate for Payer: Quartz Commercial |
$776.34
|
| Rate for Payer: The Alliance Commercial |
$681.00
|
| Rate for Payer: WEA Trust Commercial |
$749.10
|
| Rate for Payer: WPS Commercial |
$1,008.83
|
|
|
SIGMOIDOSCOPY W/FB REMOVAL 45332
|
Professional
|
$616.00
|
|
|
Service Code
|
CPT 45332
|
| Hospital Charge Code |
3014797
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$97.18 |
| Max. Negotiated Rate |
$585.20 |
| Rate for Payer: Aetna Commercial |
$585.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$529.76
|
| Rate for Payer: Aetna Managed Medicare |
$97.18
|
| Rate for Payer: Anthem Medicare Advantage |
$97.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$97.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$97.18
|
| Rate for Payer: Cash Price |
$184.80
|
| Rate for Payer: Cash Price |
$184.80
|
| Rate for Payer: Cigna Commercial |
$585.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$308.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$97.18
|
| Rate for Payer: Health EOS Commercial |
$560.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$348.94
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$348.94
|
| Rate for Payer: Independent Care Health Plan Medicare |
$97.18
|
| Rate for Payer: Multiplan Commercial |
$492.80
|
| Rate for Payer: Preferred Network Access Commercial |
$585.20
|
| Rate for Payer: Quartz Beloit One Network |
$271.04
|
| Rate for Payer: Quartz Commercial |
$351.12
|
| Rate for Payer: Quartz Medicare Advantage |
$97.18
|
| Rate for Payer: The Alliance Commercial |
$413.02
|
| Rate for Payer: United Healthcare Medicaid |
$112.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$97.18
|
| Rate for Payer: WEA Trust Commercial |
$338.80
|
| Rate for Payer: WPS Commercial |
$437.31
|
|
|
SIGMOIDOSCOPY W/SUBMUC INJ 45335
|
Professional
|
$1,627.00
|
|
|
Service Code
|
CPT 45335
|
| Hospital Charge Code |
3014800
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$62.16 |
| Max. Negotiated Rate |
$1,545.65 |
| Rate for Payer: Aetna Commercial |
$1,545.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,399.22
|
| Rate for Payer: Aetna Managed Medicare |
$62.16
|
| Rate for Payer: Anthem Medicare Advantage |
$62.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$62.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$62.16
|
| Rate for Payer: Cash Price |
$488.10
|
| Rate for Payer: Cash Price |
$488.10
|
| Rate for Payer: Cigna Commercial |
$1,545.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$813.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$62.16
|
| Rate for Payer: Health EOS Commercial |
$1,480.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$221.40
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$221.40
|
| Rate for Payer: Independent Care Health Plan Medicare |
$62.16
|
| Rate for Payer: Multiplan Commercial |
$1,301.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,545.65
|
| Rate for Payer: Quartz Beloit One Network |
$715.88
|
| Rate for Payer: Quartz Commercial |
$927.39
|
| Rate for Payer: Quartz Medicare Advantage |
$62.16
|
| Rate for Payer: The Alliance Commercial |
$264.18
|
| Rate for Payer: United Healthcare Medicaid |
$155.47
|
| Rate for Payer: United Healthcare Medicare Advantage |
$62.16
|
| Rate for Payer: WEA Trust Commercial |
$894.85
|
| Rate for Payer: WPS Commercial |
$279.72
|
|
|
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC
|
Facility
IP
|
$37,514.00
|
|
|
Service Code
|
MS-DRG 555
|
| Min. Negotiated Rate |
$13,494.31 |
| Max. Negotiated Rate |
$37,514.00 |
| Rate for Payer: Aetna Managed Medicare |
$13,494.31
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$29,372.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$22,513.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$21,389.20
|
| Rate for Payer: Anthem Medicare Advantage |
$13,494.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$13,494.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$13,494.31
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$13,494.31
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$23,743.97
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$13,494.31
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$27,280.50
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$13,494.31
|
| Rate for Payer: Independent Care Health Plan Medicare |
$13,494.31
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$13,494.31
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$13,494.31
|
| Rate for Payer: NAPHCARE Commercial |
$20,241.46
|
| Rate for Payer: Quartz Medicare Advantage |
$13,494.31
|
| Rate for Payer: The Alliance Commercial |
$37,514.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13,494.31
|
| Rate for Payer: United Healthcare PPO |
$21,238.22
|
| Rate for Payer: Wellcare Medicare |
$13,494.31
|
|
|
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC
|
Facility
IP
|
$22,238.00
|
|
|
Service Code
|
MS-DRG 556
|
| Min. Negotiated Rate |
$7,999.24 |
| Max. Negotiated Rate |
$22,238.00 |
| Rate for Payer: Aetna Managed Medicare |
$7,999.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$17,203.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$13,186.42
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$12,527.96
|
| Rate for Payer: Anthem Medicare Advantage |
$7,999.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7,999.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7,999.24
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$7,999.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13,907.18
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$7,999.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16,075.80
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$7,999.24
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7,999.24
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$7,999.24
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$7,999.24
|
| Rate for Payer: NAPHCARE Commercial |
$11,998.86
|
| Rate for Payer: Quartz Medicare Advantage |
$7,999.24
|
| Rate for Payer: The Alliance Commercial |
$22,238.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7,999.24
|
| Rate for Payer: United Healthcare PPO |
$12,515.22
|
| Rate for Payer: Wellcare Medicare |
$7,999.24
|
|
|
SIGNS AND SYMPTOMS WITH MCC
|
Facility
IP
|
$33,595.00
|
|
|
Service Code
|
MS-DRG 947
|
| Min. Negotiated Rate |
$12,084.69 |
| Max. Negotiated Rate |
$33,595.00 |
| Rate for Payer: Aetna Managed Medicare |
$12,084.69
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$26,225.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$20,101.25
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$19,097.50
|
| Rate for Payer: Anthem Medicare Advantage |
$12,084.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12,084.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12,084.69
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12,084.69
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$21,199.98
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12,084.69
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$24,406.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12,084.69
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12,084.69
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12,084.69
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12,084.69
|
| Rate for Payer: NAPHCARE Commercial |
$18,127.04
|
| Rate for Payer: Quartz Medicare Advantage |
$12,084.69
|
| Rate for Payer: The Alliance Commercial |
$33,595.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12,084.69
|
| Rate for Payer: United Healthcare PPO |
$19,000.54
|
| Rate for Payer: Wellcare Medicare |
$12,084.69
|
|
|
SIGNS AND SYMPTOMS WITHOUT MCC
|
Facility
IP
|
$21,616.00
|
|
|
Service Code
|
MS-DRG 948
|
| Min. Negotiated Rate |
$7,775.47 |
| Max. Negotiated Rate |
$21,616.00 |
| Rate for Payer: Aetna Managed Medicare |
$7,775.47
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$16,784.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$12,864.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$12,222.40
|
| Rate for Payer: Anthem Medicare Advantage |
$7,775.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7,775.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7,775.47
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$7,775.47
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13,567.98
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$7,775.47
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,619.50
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$7,775.47
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7,775.47
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$7,775.47
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$7,775.47
|
| Rate for Payer: NAPHCARE Commercial |
$11,663.20
|
| Rate for Payer: Quartz Medicare Advantage |
$7,775.47
|
| Rate for Payer: The Alliance Commercial |
$21,616.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7,775.47
|
| Rate for Payer: United Healthcare PPO |
$12,159.98
|
| Rate for Payer: Wellcare Medicare |
$7,775.47
|
|
|
SIG W/BALLOON DILATION 45340
|
Professional
|
$742.00
|
|
|
Service Code
|
CPT 45340
|
| Hospital Charge Code |
3014803
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$72.60 |
| Max. Negotiated Rate |
$704.90 |
| Rate for Payer: Aetna Commercial |
$704.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$638.12
|
| Rate for Payer: Aetna Managed Medicare |
$72.60
|
| Rate for Payer: Anthem Medicare Advantage |
$72.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$72.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$72.60
|
| Rate for Payer: Cash Price |
$222.60
|
| Rate for Payer: Cash Price |
$222.60
|
| Rate for Payer: Cigna Commercial |
$704.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$371.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$72.60
|
| Rate for Payer: Health EOS Commercial |
$675.22
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$258.43
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$258.43
|
| Rate for Payer: Independent Care Health Plan Medicare |
$72.60
|
| Rate for Payer: Multiplan Commercial |
$593.60
|
| Rate for Payer: Preferred Network Access Commercial |
$704.90
|
| Rate for Payer: Quartz Beloit One Network |
$326.48
|
| Rate for Payer: Quartz Commercial |
$422.94
|
| Rate for Payer: Quartz Medicare Advantage |
$72.60
|
| Rate for Payer: The Alliance Commercial |
$308.55
|
| Rate for Payer: United Healthcare Medicaid |
$265.58
|
| Rate for Payer: United Healthcare Medicare Advantage |
$72.60
|
| Rate for Payer: WEA Trust Commercial |
$408.10
|
| Rate for Payer: WPS Commercial |
$326.70
|
|
|
Silicon Level to Mayo
|
Facility
OP
|
$173.00
|
|
|
Service Code
|
CPT 84285
|
| Hospital Charge Code |
5198610
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$25.21 |
| Max. Negotiated Rate |
$692.00 |
| Rate for Payer: Aetna Commercial |
$155.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$148.78
|
| Rate for Payer: Aetna Managed Medicare |
$25.21
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$94.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$44.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$41.85
|
| Rate for Payer: Anthem Medicaid |
$26.05
|
| Rate for Payer: Anthem Medicare Advantage |
$25.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$91.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$25.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$25.21
|
| Rate for Payer: Cash Price |
$51.90
|
| Rate for Payer: Cash Price |
$51.90
|
| Rate for Payer: Cigna Commercial |
$159.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$25.21
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$26.05
|
| Rate for Payer: Dean Health Medicaid |
$26.05
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$25.21
|
| Rate for Payer: Health EOS Commercial |
$153.97
|
| Rate for Payer: HFN Commercial |
$159.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$93.78
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$25.21
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$26.05
|
| Rate for Payer: Independent Care Health Plan Medicare |
$25.21
|
| Rate for Payer: Managed Health Services Medicaid |
$27.09
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$25.21
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$25.21
|
| Rate for Payer: Multiplan Commercial |
$138.40
|
| Rate for Payer: NAPHCARE Commercial |
$37.82
|
| Rate for Payer: Preferred Network Access Commercial |
$159.16
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$26.05
|
| Rate for Payer: Quartz Beloit One Network |
$84.77
|
| Rate for Payer: Quartz Commercial |
$112.45
|
| Rate for Payer: Quartz Medicare Advantage |
$25.21
|
| Rate for Payer: The Alliance Commercial |
$692.00
|
| Rate for Payer: United Healthcare Medicaid |
$26.05
|
| Rate for Payer: United Healthcare Medicare Advantage |
$25.21
|
| Rate for Payer: United Healthcare PPO |
$129.75
|
| Rate for Payer: WEA Trust Commercial |
$95.15
|
| Rate for Payer: Wellcare Medicare |
$25.21
|
| Rate for Payer: WMAP Medicaid |
$26.05
|
| Rate for Payer: WPS Commercial |
$128.14
|
|
|
Silicon Level to Mayo
|
Facility
IP
|
$173.00
|
|
|
Service Code
|
CPT 84285
|
| Hospital Charge Code |
5198610
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$84.77 |
| Max. Negotiated Rate |
$159.16 |
| Rate for Payer: Aetna Commercial |
$155.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$91.69
|
| Rate for Payer: Cash Price |
$51.90
|
| Rate for Payer: Cigna Commercial |
$159.16
|
| Rate for Payer: Health EOS Commercial |
$153.97
|
| Rate for Payer: HFN Commercial |
$159.16
|
| Rate for Payer: Multiplan Commercial |
$138.40
|
| Rate for Payer: NAPHCARE Commercial |
$103.80
|
| Rate for Payer: Preferred Network Access Commercial |
$159.16
|
| Rate for Payer: Quartz Beloit One Network |
$84.77
|
| Rate for Payer: Quartz Commercial |
$103.80
|
| Rate for Payer: WEA Trust Commercial |
$95.15
|
| Rate for Payer: WPS Commercial |
$128.14
|
|
