|
US Extremity Non-Vascular Bilateral
|
Facility
|
IP
|
$898.00
|
|
|
Service Code
|
CPT 76881 RT,TC
|
| Hospital Charge Code |
2544851
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$440.02 |
| Max. Negotiated Rate |
$826.16 |
| Rate for Payer: Aetna Commercial |
$808.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$772.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$475.94
|
| Rate for Payer: Cash Price |
$269.40
|
| Rate for Payer: Cigna Commercial |
$826.16
|
| Rate for Payer: Health EOS Commercial |
$799.22
|
| Rate for Payer: HFN Commercial |
$826.16
|
| Rate for Payer: Multiplan Commercial |
$718.40
|
| Rate for Payer: NAPHCARE Commercial |
$538.80
|
| Rate for Payer: Preferred Network Access Commercial |
$826.16
|
| Rate for Payer: Quartz Beloit One Network |
$440.02
|
| Rate for Payer: Quartz Commercial |
$538.80
|
| Rate for Payer: WEA Trust Commercial |
$493.90
|
| Rate for Payer: WPS Commercial |
$665.15
|
|
|
US Extremity Non-Vascular Bilateral
|
Professional
|
Both
|
$898.00
|
|
|
Service Code
|
CPT 76881 RT,TC
|
| Hospital Charge Code |
2544851
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$227.23 |
| Max. Negotiated Rate |
$853.10 |
| Rate for Payer: Aetna Commercial |
$853.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$772.28
|
| Rate for Payer: Cash Price |
$269.40
|
| Rate for Payer: Cash Price |
$269.40
|
| Rate for Payer: Cash Price |
$269.40
|
| Rate for Payer: Cigna Commercial |
$853.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$449.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$538.80
|
| Rate for Payer: Health EOS Commercial |
$817.18
|
| Rate for Payer: HFN Commercial |
$853.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$227.23
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$227.23
|
| Rate for Payer: Multiplan Commercial |
$718.40
|
| Rate for Payer: Preferred Network Access Commercial |
$853.10
|
| Rate for Payer: Quartz Beloit One Network |
$395.12
|
| Rate for Payer: Quartz Commercial |
$511.86
|
| Rate for Payer: The Alliance Commercial |
$449.00
|
| Rate for Payer: WEA Trust Commercial |
$493.90
|
| Rate for Payer: WPS Commercial |
$665.15
|
|
|
US Extremity Non-Vascular Left
|
Facility
|
IP
|
$898.00
|
|
|
Service Code
|
CPT 76881 LT,TC
|
| Hospital Charge Code |
2544853
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$440.02 |
| Max. Negotiated Rate |
$826.16 |
| Rate for Payer: Aetna Commercial |
$808.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$772.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$475.94
|
| Rate for Payer: Cash Price |
$269.40
|
| Rate for Payer: Cigna Commercial |
$826.16
|
| Rate for Payer: Health EOS Commercial |
$799.22
|
| Rate for Payer: HFN Commercial |
$826.16
|
| Rate for Payer: Multiplan Commercial |
$718.40
|
| Rate for Payer: NAPHCARE Commercial |
$538.80
|
| Rate for Payer: Preferred Network Access Commercial |
$826.16
|
| Rate for Payer: Quartz Beloit One Network |
$440.02
|
| Rate for Payer: Quartz Commercial |
$538.80
|
| Rate for Payer: WEA Trust Commercial |
$493.90
|
| Rate for Payer: WPS Commercial |
$665.15
|
|
|
US Extremity Non-Vascular Left
|
Facility
|
OP
|
$898.00
|
|
|
Service Code
|
CPT 76881 TC,LT
|
| Hospital Charge Code |
4054117
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$108.67 |
| Max. Negotiated Rate |
$826.16 |
| Rate for Payer: Aetna Commercial |
$808.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$772.28
|
| Rate for Payer: Aetna Managed Medicare |
$108.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$816.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$689.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$655.00
|
| Rate for Payer: Anthem Medicare Advantage |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$475.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$108.67
|
| Rate for Payer: Cash Price |
$269.40
|
| Rate for Payer: Cash Price |
$269.40
|
| Rate for Payer: Cash Price |
$269.40
|
| Rate for Payer: Cigna Commercial |
$826.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$108.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$502.52
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$108.67
|
| Rate for Payer: Health EOS Commercial |
$799.22
|
| Rate for Payer: HFN Commercial |
$826.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$404.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$108.67
|
| Rate for Payer: Independent Care Health Plan Medicare |
$108.67
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$108.67
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$108.67
|
| Rate for Payer: Multiplan Commercial |
$718.40
|
| Rate for Payer: NAPHCARE Commercial |
$163.00
|
| Rate for Payer: Preferred Network Access Commercial |
$826.16
|
| Rate for Payer: Quartz Beloit One Network |
$440.02
|
| Rate for Payer: Quartz Commercial |
$583.70
|
| Rate for Payer: Quartz Medicare Advantage |
$108.67
|
| Rate for Payer: The Alliance Commercial |
$434.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$108.67
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$493.90
|
| Rate for Payer: Wellcare Medicare |
$108.67
|
| Rate for Payer: WPS Commercial |
$665.15
|
|
|
US Extremity Non-Vascular Left
|
Facility
|
IP
|
$934.00
|
|
|
Service Code
|
CPT 76881
|
| Hospital Charge Code |
631085
|
| Min. Negotiated Rate |
$457.66 |
| Max. Negotiated Rate |
$859.28 |
| Rate for Payer: Aetna Commercial |
$840.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$803.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$495.02
|
| Rate for Payer: Cash Price |
$280.20
|
| Rate for Payer: Cigna Commercial |
$859.28
|
| Rate for Payer: Health EOS Commercial |
$831.26
|
| Rate for Payer: HFN Commercial |
$859.28
|
| Rate for Payer: Multiplan Commercial |
$747.20
|
| Rate for Payer: NAPHCARE Commercial |
$560.40
|
| Rate for Payer: Preferred Network Access Commercial |
$859.28
|
| Rate for Payer: Quartz Beloit One Network |
$457.66
|
| Rate for Payer: Quartz Commercial |
$560.40
|
| Rate for Payer: WEA Trust Commercial |
$513.70
|
| Rate for Payer: WPS Commercial |
$691.81
|
|
|
US Extremity Non-Vascular Left
|
Professional
|
Both
|
$898.00
|
|
|
Service Code
|
CPT 76881 TC,LT
|
| Hospital Charge Code |
4054117
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$227.23 |
| Max. Negotiated Rate |
$853.10 |
| Rate for Payer: Aetna Commercial |
$853.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$772.28
|
| Rate for Payer: Cash Price |
$269.40
|
| Rate for Payer: Cash Price |
$269.40
|
| Rate for Payer: Cash Price |
$269.40
|
| Rate for Payer: Cigna Commercial |
$853.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$449.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$538.80
|
| Rate for Payer: Health EOS Commercial |
$817.18
|
| Rate for Payer: HFN Commercial |
$853.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$227.23
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$227.23
|
| Rate for Payer: Multiplan Commercial |
$718.40
|
| Rate for Payer: Preferred Network Access Commercial |
$853.10
|
| Rate for Payer: Quartz Beloit One Network |
$395.12
|
| Rate for Payer: Quartz Commercial |
$511.86
|
| Rate for Payer: The Alliance Commercial |
$449.00
|
| Rate for Payer: WEA Trust Commercial |
$493.90
|
| Rate for Payer: WPS Commercial |
$665.15
|
|
|
US Extremity Non-Vascular Left
|
Facility
|
OP
|
$898.00
|
|
|
Service Code
|
CPT 76881 LT,TC
|
| Hospital Charge Code |
2544853
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$108.67 |
| Max. Negotiated Rate |
$826.16 |
| Rate for Payer: Aetna Commercial |
$808.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$772.28
|
| Rate for Payer: Aetna Managed Medicare |
$108.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$816.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$689.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$655.00
|
| Rate for Payer: Anthem Medicare Advantage |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$475.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$108.67
|
| Rate for Payer: Cash Price |
$269.40
|
| Rate for Payer: Cash Price |
$269.40
|
| Rate for Payer: Cash Price |
$269.40
|
| Rate for Payer: Cigna Commercial |
$826.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$108.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$502.52
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$108.67
|
| Rate for Payer: Health EOS Commercial |
$799.22
|
| Rate for Payer: HFN Commercial |
$826.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$404.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$108.67
|
| Rate for Payer: Independent Care Health Plan Medicare |
$108.67
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$108.67
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$108.67
|
| Rate for Payer: Multiplan Commercial |
$718.40
|
| Rate for Payer: NAPHCARE Commercial |
$163.00
|
| Rate for Payer: Preferred Network Access Commercial |
$826.16
|
| Rate for Payer: Quartz Beloit One Network |
$440.02
|
| Rate for Payer: Quartz Commercial |
$583.70
|
| Rate for Payer: Quartz Medicare Advantage |
$108.67
|
| Rate for Payer: The Alliance Commercial |
$434.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$108.67
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$493.90
|
| Rate for Payer: Wellcare Medicare |
$108.67
|
| Rate for Payer: WPS Commercial |
$665.15
|
|
|
US Extremity Non-Vascular Left
|
Professional
|
Both
|
$898.00
|
|
|
Service Code
|
CPT 76881 LT,TC
|
| Hospital Charge Code |
2544853
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$227.23 |
| Max. Negotiated Rate |
$853.10 |
| Rate for Payer: Aetna Commercial |
$853.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$772.28
|
| Rate for Payer: Cash Price |
$269.40
|
| Rate for Payer: Cash Price |
$269.40
|
| Rate for Payer: Cash Price |
$269.40
|
| Rate for Payer: Cigna Commercial |
$853.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$449.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$538.80
|
| Rate for Payer: Health EOS Commercial |
$817.18
|
| Rate for Payer: HFN Commercial |
$853.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$227.23
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$227.23
|
| Rate for Payer: Multiplan Commercial |
$718.40
|
| Rate for Payer: Preferred Network Access Commercial |
$853.10
|
| Rate for Payer: Quartz Beloit One Network |
$395.12
|
| Rate for Payer: Quartz Commercial |
$511.86
|
| Rate for Payer: The Alliance Commercial |
$449.00
|
| Rate for Payer: WEA Trust Commercial |
$493.90
|
| Rate for Payer: WPS Commercial |
$665.15
|
|
|
US Extremity Non-Vascular Left
|
Professional
|
Both
|
$934.00
|
|
|
Service Code
|
CPT 76881
|
| Hospital Charge Code |
631085
|
| Min. Negotiated Rate |
$227.23 |
| Max. Negotiated Rate |
$887.30 |
| Rate for Payer: Aetna Commercial |
$887.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$803.24
|
| Rate for Payer: Cash Price |
$280.20
|
| Rate for Payer: Cash Price |
$280.20
|
| Rate for Payer: Cash Price |
$280.20
|
| Rate for Payer: Cigna Commercial |
$887.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$467.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$560.40
|
| Rate for Payer: Health EOS Commercial |
$849.94
|
| Rate for Payer: HFN Commercial |
$887.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$227.23
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$227.23
|
| Rate for Payer: Multiplan Commercial |
$747.20
|
| Rate for Payer: Preferred Network Access Commercial |
$887.30
|
| Rate for Payer: Quartz Beloit One Network |
$410.96
|
| Rate for Payer: Quartz Commercial |
$532.38
|
| Rate for Payer: The Alliance Commercial |
$467.00
|
| Rate for Payer: WEA Trust Commercial |
$513.70
|
| Rate for Payer: WPS Commercial |
$691.81
|
|
|
US Extremity Non-Vascular Left
|
Facility
|
OP
|
$934.00
|
|
|
Service Code
|
CPT 76881
|
| Hospital Charge Code |
631085
|
| Min. Negotiated Rate |
$108.67 |
| Max. Negotiated Rate |
$859.28 |
| Rate for Payer: Aetna Commercial |
$840.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$803.24
|
| Rate for Payer: Aetna Managed Medicare |
$108.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$607.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$467.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$448.32
|
| Rate for Payer: Anthem Medicare Advantage |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$495.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$108.67
|
| Rate for Payer: Cash Price |
$280.20
|
| Rate for Payer: Cash Price |
$280.20
|
| Rate for Payer: Cigna Commercial |
$859.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$108.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$522.67
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$108.67
|
| Rate for Payer: Health EOS Commercial |
$831.26
|
| Rate for Payer: HFN Commercial |
$859.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$404.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$108.67
|
| Rate for Payer: Independent Care Health Plan Medicare |
$108.67
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$108.67
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$108.67
|
| Rate for Payer: Multiplan Commercial |
$747.20
|
| Rate for Payer: NAPHCARE Commercial |
$163.00
|
| Rate for Payer: Preferred Network Access Commercial |
$859.28
|
| Rate for Payer: Quartz Beloit One Network |
$457.66
|
| Rate for Payer: Quartz Commercial |
$607.10
|
| Rate for Payer: Quartz Medicare Advantage |
$108.67
|
| Rate for Payer: The Alliance Commercial |
$434.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$108.67
|
| Rate for Payer: WEA Trust Commercial |
$513.70
|
| Rate for Payer: Wellcare Medicare |
$108.67
|
| Rate for Payer: WPS Commercial |
$691.81
|
|
|
US Extremity Non-Vascular Left
|
Facility
|
IP
|
$898.00
|
|
|
Service Code
|
CPT 76881 TC,LT
|
| Hospital Charge Code |
4054117
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$440.02 |
| Max. Negotiated Rate |
$826.16 |
| Rate for Payer: Aetna Commercial |
$808.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$772.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$475.94
|
| Rate for Payer: Cash Price |
$269.40
|
| Rate for Payer: Cigna Commercial |
$826.16
|
| Rate for Payer: Health EOS Commercial |
$799.22
|
| Rate for Payer: HFN Commercial |
$826.16
|
| Rate for Payer: Multiplan Commercial |
$718.40
|
| Rate for Payer: NAPHCARE Commercial |
$538.80
|
| Rate for Payer: Preferred Network Access Commercial |
$826.16
|
| Rate for Payer: Quartz Beloit One Network |
$440.02
|
| Rate for Payer: Quartz Commercial |
$538.80
|
| Rate for Payer: WEA Trust Commercial |
$493.90
|
| Rate for Payer: WPS Commercial |
$665.15
|
|
|
US Extremity, Nonvascular, Realtime Image Complete 76881
|
Professional
|
Both
|
$304.00
|
|
|
Service Code
|
CPT 76881
|
| Hospital Charge Code |
3545508
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$133.76 |
| Max. Negotiated Rate |
$288.80 |
| Rate for Payer: Aetna Commercial |
$288.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$261.44
|
| Rate for Payer: Cash Price |
$91.20
|
| Rate for Payer: Cash Price |
$91.20
|
| Rate for Payer: Cash Price |
$91.20
|
| Rate for Payer: Cigna Commercial |
$288.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$152.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$182.40
|
| Rate for Payer: Health EOS Commercial |
$276.64
|
| Rate for Payer: HFN Commercial |
$288.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$227.23
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$227.23
|
| Rate for Payer: Multiplan Commercial |
$243.20
|
| Rate for Payer: Preferred Network Access Commercial |
$288.80
|
| Rate for Payer: Quartz Beloit One Network |
$133.76
|
| Rate for Payer: Quartz Commercial |
$173.28
|
| Rate for Payer: The Alliance Commercial |
$152.00
|
| Rate for Payer: WEA Trust Commercial |
$167.20
|
| Rate for Payer: WPS Commercial |
$225.17
|
|
|
US Extremity, Nonvascular, Realtime Image Complete 7688126
|
Professional
|
Both
|
$304.00
|
|
|
Service Code
|
CPT 76881 26
|
| Hospital Charge Code |
3015310
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$106.18 |
| Max. Negotiated Rate |
$288.80 |
| Rate for Payer: Aetna Commercial |
$288.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$261.44
|
| Rate for Payer: Cash Price |
$91.20
|
| Rate for Payer: Cash Price |
$91.20
|
| Rate for Payer: Cash Price |
$91.20
|
| Rate for Payer: Cigna Commercial |
$288.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$152.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$182.40
|
| Rate for Payer: Health EOS Commercial |
$276.64
|
| Rate for Payer: HFN Commercial |
$288.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$106.18
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$106.18
|
| Rate for Payer: Multiplan Commercial |
$243.20
|
| Rate for Payer: Preferred Network Access Commercial |
$288.80
|
| Rate for Payer: Quartz Beloit One Network |
$133.76
|
| Rate for Payer: Quartz Commercial |
$173.28
|
| Rate for Payer: The Alliance Commercial |
$152.00
|
| Rate for Payer: WEA Trust Commercial |
$167.20
|
| Rate for Payer: WPS Commercial |
$225.17
|
|
|
US Extremity, Nonvascular, Realtime Image Complete 76881PP
|
Professional
|
Both
|
$1,275.00
|
|
|
Service Code
|
CPT 76881
|
| Hospital Charge Code |
3096893
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$227.23 |
| Max. Negotiated Rate |
$1,211.25 |
| Rate for Payer: Aetna Commercial |
$1,211.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,096.50
|
| Rate for Payer: Cash Price |
$382.50
|
| Rate for Payer: Cash Price |
$382.50
|
| Rate for Payer: Cash Price |
$382.50
|
| Rate for Payer: Cigna Commercial |
$1,211.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$637.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$765.00
|
| Rate for Payer: Health EOS Commercial |
$1,160.25
|
| Rate for Payer: HFN Commercial |
$1,211.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$227.23
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$227.23
|
| Rate for Payer: Multiplan Commercial |
$1,020.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,211.25
|
| Rate for Payer: Quartz Beloit One Network |
$561.00
|
| Rate for Payer: Quartz Commercial |
$726.75
|
| Rate for Payer: The Alliance Commercial |
$637.50
|
| Rate for Payer: WEA Trust Commercial |
$701.25
|
| Rate for Payer: WPS Commercial |
$944.39
|
|
|
US Extremity, Nonvascular, Realtime Image Limited 7688226
|
Professional
|
Both
|
$246.00
|
|
|
Service Code
|
CPT 76882 26
|
| Hospital Charge Code |
3121586
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$80.80 |
| Max. Negotiated Rate |
$233.70 |
| Rate for Payer: Aetna Commercial |
$233.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$211.56
|
| Rate for Payer: Cash Price |
$73.80
|
| Rate for Payer: Cash Price |
$73.80
|
| Rate for Payer: Cash Price |
$73.80
|
| Rate for Payer: Cigna Commercial |
$233.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$123.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$147.60
|
| Rate for Payer: Health EOS Commercial |
$223.86
|
| Rate for Payer: HFN Commercial |
$233.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$80.80
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$80.80
|
| Rate for Payer: Multiplan Commercial |
$196.80
|
| Rate for Payer: Preferred Network Access Commercial |
$233.70
|
| Rate for Payer: Quartz Beloit One Network |
$108.24
|
| Rate for Payer: Quartz Commercial |
$140.22
|
| Rate for Payer: The Alliance Commercial |
$123.00
|
| Rate for Payer: WEA Trust Commercial |
$135.30
|
| Rate for Payer: WPS Commercial |
$182.21
|
|
|
US Extremity Non-Vascular Right
|
Professional
|
Both
|
$971.00
|
|
|
Service Code
|
CPT 76881 RT,TC
|
| Hospital Charge Code |
2544856
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$227.23 |
| Max. Negotiated Rate |
$922.45 |
| Rate for Payer: Aetna Commercial |
$922.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$835.06
|
| Rate for Payer: Cash Price |
$291.30
|
| Rate for Payer: Cash Price |
$291.30
|
| Rate for Payer: Cash Price |
$291.30
|
| Rate for Payer: Cigna Commercial |
$922.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$485.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$582.60
|
| Rate for Payer: Health EOS Commercial |
$883.61
|
| Rate for Payer: HFN Commercial |
$922.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$227.23
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$227.23
|
| Rate for Payer: Multiplan Commercial |
$776.80
|
| Rate for Payer: Preferred Network Access Commercial |
$922.45
|
| Rate for Payer: Quartz Beloit One Network |
$427.24
|
| Rate for Payer: Quartz Commercial |
$553.47
|
| Rate for Payer: The Alliance Commercial |
$485.50
|
| Rate for Payer: WEA Trust Commercial |
$534.05
|
| Rate for Payer: WPS Commercial |
$719.22
|
|
|
US Extremity Non-Vascular Right
|
Professional
|
Both
|
$898.00
|
|
|
Service Code
|
CPT 76881 RT,TC
|
| Hospital Charge Code |
2544855
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$227.23 |
| Max. Negotiated Rate |
$853.10 |
| Rate for Payer: Aetna Commercial |
$853.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$772.28
|
| Rate for Payer: Cash Price |
$269.40
|
| Rate for Payer: Cash Price |
$269.40
|
| Rate for Payer: Cash Price |
$269.40
|
| Rate for Payer: Cigna Commercial |
$853.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$449.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$538.80
|
| Rate for Payer: Health EOS Commercial |
$817.18
|
| Rate for Payer: HFN Commercial |
$853.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$227.23
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$227.23
|
| Rate for Payer: Multiplan Commercial |
$718.40
|
| Rate for Payer: Preferred Network Access Commercial |
$853.10
|
| Rate for Payer: Quartz Beloit One Network |
$395.12
|
| Rate for Payer: Quartz Commercial |
$511.86
|
| Rate for Payer: The Alliance Commercial |
$449.00
|
| Rate for Payer: WEA Trust Commercial |
$493.90
|
| Rate for Payer: WPS Commercial |
$665.15
|
|
|
US Extremity Non-Vascular Right
|
Facility
|
OP
|
$934.00
|
|
|
Service Code
|
CPT 76881
|
| Hospital Charge Code |
631091
|
| Min. Negotiated Rate |
$108.67 |
| Max. Negotiated Rate |
$859.28 |
| Rate for Payer: Aetna Commercial |
$840.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$803.24
|
| Rate for Payer: Aetna Managed Medicare |
$108.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$607.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$467.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$448.32
|
| Rate for Payer: Anthem Medicare Advantage |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$495.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$108.67
|
| Rate for Payer: Cash Price |
$280.20
|
| Rate for Payer: Cash Price |
$280.20
|
| Rate for Payer: Cigna Commercial |
$859.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$108.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$522.67
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$108.67
|
| Rate for Payer: Health EOS Commercial |
$831.26
|
| Rate for Payer: HFN Commercial |
$859.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$404.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$108.67
|
| Rate for Payer: Independent Care Health Plan Medicare |
$108.67
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$108.67
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$108.67
|
| Rate for Payer: Multiplan Commercial |
$747.20
|
| Rate for Payer: NAPHCARE Commercial |
$163.00
|
| Rate for Payer: Preferred Network Access Commercial |
$859.28
|
| Rate for Payer: Quartz Beloit One Network |
$457.66
|
| Rate for Payer: Quartz Commercial |
$607.10
|
| Rate for Payer: Quartz Medicare Advantage |
$108.67
|
| Rate for Payer: The Alliance Commercial |
$434.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$108.67
|
| Rate for Payer: WEA Trust Commercial |
$513.70
|
| Rate for Payer: Wellcare Medicare |
$108.67
|
| Rate for Payer: WPS Commercial |
$691.81
|
|
|
US Extremity Non-Vascular Right
|
Facility
|
IP
|
$971.00
|
|
|
Service Code
|
CPT 76881 RT,TC
|
| Hospital Charge Code |
2544856
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$475.79 |
| Max. Negotiated Rate |
$893.32 |
| Rate for Payer: Aetna Commercial |
$873.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$835.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$514.63
|
| Rate for Payer: Cash Price |
$291.30
|
| Rate for Payer: Cigna Commercial |
$893.32
|
| Rate for Payer: Health EOS Commercial |
$864.19
|
| Rate for Payer: HFN Commercial |
$893.32
|
| Rate for Payer: Multiplan Commercial |
$776.80
|
| Rate for Payer: NAPHCARE Commercial |
$582.60
|
| Rate for Payer: Preferred Network Access Commercial |
$893.32
|
| Rate for Payer: Quartz Beloit One Network |
$475.79
|
| Rate for Payer: Quartz Commercial |
$582.60
|
| Rate for Payer: WEA Trust Commercial |
$534.05
|
| Rate for Payer: WPS Commercial |
$719.22
|
|
|
US Extremity Non-Vascular Right
|
Facility
|
OP
|
$898.00
|
|
|
Service Code
|
CPT 76881 RT,TC
|
| Hospital Charge Code |
2544855
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$108.67 |
| Max. Negotiated Rate |
$826.16 |
| Rate for Payer: Aetna Commercial |
$808.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$772.28
|
| Rate for Payer: Aetna Managed Medicare |
$108.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$816.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$689.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$655.00
|
| Rate for Payer: Anthem Medicare Advantage |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$475.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$108.67
|
| Rate for Payer: Cash Price |
$269.40
|
| Rate for Payer: Cash Price |
$269.40
|
| Rate for Payer: Cash Price |
$269.40
|
| Rate for Payer: Cigna Commercial |
$826.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$108.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$502.52
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$108.67
|
| Rate for Payer: Health EOS Commercial |
$799.22
|
| Rate for Payer: HFN Commercial |
$826.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$404.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$108.67
|
| Rate for Payer: Independent Care Health Plan Medicare |
$108.67
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$108.67
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$108.67
|
| Rate for Payer: Multiplan Commercial |
$718.40
|
| Rate for Payer: NAPHCARE Commercial |
$163.00
|
| Rate for Payer: Preferred Network Access Commercial |
$826.16
|
| Rate for Payer: Quartz Beloit One Network |
$440.02
|
| Rate for Payer: Quartz Commercial |
$583.70
|
| Rate for Payer: Quartz Medicare Advantage |
$108.67
|
| Rate for Payer: The Alliance Commercial |
$434.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$108.67
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$493.90
|
| Rate for Payer: Wellcare Medicare |
$108.67
|
| Rate for Payer: WPS Commercial |
$665.15
|
|
|
US Extremity Non-Vascular Right
|
Facility
|
OP
|
$971.00
|
|
|
Service Code
|
CPT 76881 RT,TC
|
| Hospital Charge Code |
2544856
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$108.67 |
| Max. Negotiated Rate |
$893.32 |
| Rate for Payer: Aetna Commercial |
$873.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$835.06
|
| Rate for Payer: Aetna Managed Medicare |
$108.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$816.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$689.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$655.00
|
| Rate for Payer: Anthem Medicare Advantage |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$514.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$108.67
|
| Rate for Payer: Cash Price |
$291.30
|
| Rate for Payer: Cash Price |
$291.30
|
| Rate for Payer: Cash Price |
$291.30
|
| Rate for Payer: Cigna Commercial |
$893.32
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$108.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$543.37
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$108.67
|
| Rate for Payer: Health EOS Commercial |
$864.19
|
| Rate for Payer: HFN Commercial |
$893.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$404.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$108.67
|
| Rate for Payer: Independent Care Health Plan Medicare |
$108.67
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$108.67
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$108.67
|
| Rate for Payer: Multiplan Commercial |
$776.80
|
| Rate for Payer: NAPHCARE Commercial |
$163.00
|
| Rate for Payer: Preferred Network Access Commercial |
$893.32
|
| Rate for Payer: Quartz Beloit One Network |
$475.79
|
| Rate for Payer: Quartz Commercial |
$631.15
|
| Rate for Payer: Quartz Medicare Advantage |
$108.67
|
| Rate for Payer: The Alliance Commercial |
$434.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$108.67
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$534.05
|
| Rate for Payer: Wellcare Medicare |
$108.67
|
| Rate for Payer: WPS Commercial |
$719.22
|
|
|
US Extremity Non-Vascular Right
|
Facility
|
IP
|
$898.00
|
|
|
Service Code
|
CPT 76881 RT,TC
|
| Hospital Charge Code |
2544855
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$440.02 |
| Max. Negotiated Rate |
$826.16 |
| Rate for Payer: Aetna Commercial |
$808.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$772.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$475.94
|
| Rate for Payer: Cash Price |
$269.40
|
| Rate for Payer: Cigna Commercial |
$826.16
|
| Rate for Payer: Health EOS Commercial |
$799.22
|
| Rate for Payer: HFN Commercial |
$826.16
|
| Rate for Payer: Multiplan Commercial |
$718.40
|
| Rate for Payer: NAPHCARE Commercial |
$538.80
|
| Rate for Payer: Preferred Network Access Commercial |
$826.16
|
| Rate for Payer: Quartz Beloit One Network |
$440.02
|
| Rate for Payer: Quartz Commercial |
$538.80
|
| Rate for Payer: WEA Trust Commercial |
$493.90
|
| Rate for Payer: WPS Commercial |
$665.15
|
|
|
US Extremity Non-Vascular Right
|
Professional
|
Both
|
$934.00
|
|
|
Service Code
|
CPT 76881
|
| Hospital Charge Code |
631091
|
| Min. Negotiated Rate |
$227.23 |
| Max. Negotiated Rate |
$887.30 |
| Rate for Payer: Aetna Commercial |
$887.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$803.24
|
| Rate for Payer: Cash Price |
$280.20
|
| Rate for Payer: Cash Price |
$280.20
|
| Rate for Payer: Cash Price |
$280.20
|
| Rate for Payer: Cigna Commercial |
$887.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$467.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$560.40
|
| Rate for Payer: Health EOS Commercial |
$849.94
|
| Rate for Payer: HFN Commercial |
$887.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$227.23
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$227.23
|
| Rate for Payer: Multiplan Commercial |
$747.20
|
| Rate for Payer: Preferred Network Access Commercial |
$887.30
|
| Rate for Payer: Quartz Beloit One Network |
$410.96
|
| Rate for Payer: Quartz Commercial |
$532.38
|
| Rate for Payer: The Alliance Commercial |
$467.00
|
| Rate for Payer: WEA Trust Commercial |
$513.70
|
| Rate for Payer: WPS Commercial |
$691.81
|
|
|
US Extremity Non-Vascular Right
|
Facility
|
IP
|
$934.00
|
|
|
Service Code
|
CPT 76881
|
| Hospital Charge Code |
631091
|
| Min. Negotiated Rate |
$457.66 |
| Max. Negotiated Rate |
$859.28 |
| Rate for Payer: Aetna Commercial |
$840.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$803.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$495.02
|
| Rate for Payer: Cash Price |
$280.20
|
| Rate for Payer: Cigna Commercial |
$859.28
|
| Rate for Payer: Health EOS Commercial |
$831.26
|
| Rate for Payer: HFN Commercial |
$859.28
|
| Rate for Payer: Multiplan Commercial |
$747.20
|
| Rate for Payer: NAPHCARE Commercial |
$560.40
|
| Rate for Payer: Preferred Network Access Commercial |
$859.28
|
| Rate for Payer: Quartz Beloit One Network |
$457.66
|
| Rate for Payer: Quartz Commercial |
$560.40
|
| Rate for Payer: WEA Trust Commercial |
$513.70
|
| Rate for Payer: WPS Commercial |
$691.81
|
|
|
US Fetal Biophysical Profile w/ Non-St
|
Facility
|
OP
|
$1,567.00
|
|
|
Service Code
|
CPT 76818
|
| Hospital Charge Code |
631102
|
| Min. Negotiated Rate |
$108.67 |
| Max. Negotiated Rate |
$1,441.64 |
| Rate for Payer: Aetna Commercial |
$1,410.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,347.62
|
| Rate for Payer: Aetna Managed Medicare |
$108.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,018.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$783.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$752.16
|
| Rate for Payer: Anthem Medicare Advantage |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$830.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$108.67
|
| Rate for Payer: Cash Price |
$470.10
|
| Rate for Payer: Cash Price |
$470.10
|
| Rate for Payer: Cigna Commercial |
$1,441.64
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$108.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$876.89
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$108.67
|
| Rate for Payer: Health EOS Commercial |
$1,394.63
|
| Rate for Payer: HFN Commercial |
$1,441.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$404.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$108.67
|
| Rate for Payer: Independent Care Health Plan Medicare |
$108.67
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$108.67
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$108.67
|
| Rate for Payer: Multiplan Commercial |
$1,253.60
|
| Rate for Payer: NAPHCARE Commercial |
$163.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,441.64
|
| Rate for Payer: Quartz Beloit One Network |
$767.83
|
| Rate for Payer: Quartz Commercial |
$1,018.55
|
| Rate for Payer: Quartz Medicare Advantage |
$108.67
|
| Rate for Payer: The Alliance Commercial |
$434.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$108.67
|
| Rate for Payer: WEA Trust Commercial |
$861.85
|
| Rate for Payer: Wellcare Medicare |
$108.67
|
| Rate for Payer: WPS Commercial |
$1,160.68
|
|
