|
XR Humerus Right
|
Professional
|
$557.00
|
|
|
Service Code
|
CPT 73060 RT,TC
|
| Hospital Charge Code |
1537124
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$245.08 |
| Max. Negotiated Rate |
$529.15 |
| Rate for Payer: Aetna Commercial |
$529.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$479.02
|
| Rate for Payer: Cash Price |
$167.10
|
| Rate for Payer: Cash Price |
$167.10
|
| Rate for Payer: Cigna Commercial |
$529.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$278.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$334.20
|
| Rate for Payer: Health EOS Commercial |
$506.87
|
| Rate for Payer: Multiplan Commercial |
$445.60
|
| Rate for Payer: Preferred Network Access Commercial |
$529.15
|
| Rate for Payer: Quartz Beloit One Network |
$245.08
|
| Rate for Payer: Quartz Commercial |
$317.49
|
| Rate for Payer: The Alliance Commercial |
$278.50
|
| Rate for Payer: WEA Trust Commercial |
$306.35
|
| Rate for Payer: WPS Commercial |
$412.57
|
|
|
XR Humerus Right
|
Facility
OP
|
$515.00
|
|
|
Service Code
|
CPT 73060
|
| Hospital Charge Code |
630427
|
| Min. Negotiated Rate |
$89.82 |
| Max. Negotiated Rate |
$473.80 |
| Rate for Payer: Aetna Commercial |
$463.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$442.90
|
| Rate for Payer: Aetna Managed Medicare |
$89.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$334.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$257.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$247.20
|
| Rate for Payer: Anthem Medicare Advantage |
$89.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$272.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$89.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$89.82
|
| Rate for Payer: Cash Price |
$154.50
|
| Rate for Payer: Cash Price |
$154.50
|
| Rate for Payer: Cigna Commercial |
$473.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$89.82
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$89.82
|
| Rate for Payer: Health EOS Commercial |
$458.35
|
| Rate for Payer: HFN Commercial |
$473.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$334.13
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$89.82
|
| Rate for Payer: Independent Care Health Plan Medicare |
$89.82
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$89.82
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$89.82
|
| Rate for Payer: Multiplan Commercial |
$412.00
|
| Rate for Payer: NAPHCARE Commercial |
$134.73
|
| Rate for Payer: Preferred Network Access Commercial |
$473.80
|
| Rate for Payer: Quartz Beloit One Network |
$252.35
|
| Rate for Payer: Quartz Commercial |
$334.75
|
| Rate for Payer: Quartz Medicare Advantage |
$89.82
|
| Rate for Payer: The Alliance Commercial |
$364.36
|
| Rate for Payer: United Healthcare Medicare Advantage |
$89.82
|
| Rate for Payer: WEA Trust Commercial |
$283.25
|
| Rate for Payer: Wellcare Medicare |
$89.82
|
| Rate for Payer: WPS Commercial |
$381.46
|
|
|
XR Hysterosalpingography
|
Facility
OP
|
$1,017.00
|
|
|
Service Code
|
CPT 74740 TC
|
| Hospital Charge Code |
3072714
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$284.76 |
| Max. Negotiated Rate |
$4,068.00 |
| Rate for Payer: Aetna Commercial |
$915.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$874.62
|
| Rate for Payer: Aetna Managed Medicare |
$284.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$661.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$508.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$488.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$539.01
|
| Rate for Payer: Cash Price |
$305.10
|
| Rate for Payer: Cash Price |
$305.10
|
| Rate for Payer: Cash Price |
$305.10
|
| Rate for Payer: Cigna Commercial |
$935.64
|
| Rate for Payer: Health EOS Commercial |
$905.13
|
| Rate for Payer: HFN Commercial |
$935.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$762.75
|
| Rate for Payer: Multiplan Commercial |
$813.60
|
| Rate for Payer: NAPHCARE Commercial |
$610.20
|
| Rate for Payer: Preferred Network Access Commercial |
$935.64
|
| Rate for Payer: Quartz Beloit One Network |
$498.33
|
| Rate for Payer: Quartz Commercial |
$661.05
|
| Rate for Payer: Quartz Medicare Advantage |
$610.20
|
| Rate for Payer: The Alliance Commercial |
$4,068.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$559.35
|
| Rate for Payer: WPS Commercial |
$753.29
|
|
|
XR Hysterosalpingography
|
Facility
IP
|
$1,017.00
|
|
|
Service Code
|
CPT 74740 TC
|
| Hospital Charge Code |
3072714
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$498.33 |
| Max. Negotiated Rate |
$935.64 |
| Rate for Payer: Aetna Commercial |
$915.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$539.01
|
| Rate for Payer: Cash Price |
$305.10
|
| Rate for Payer: Cigna Commercial |
$935.64
|
| Rate for Payer: Health EOS Commercial |
$905.13
|
| Rate for Payer: HFN Commercial |
$935.64
|
| Rate for Payer: Multiplan Commercial |
$813.60
|
| Rate for Payer: NAPHCARE Commercial |
$610.20
|
| Rate for Payer: Preferred Network Access Commercial |
$935.64
|
| Rate for Payer: Quartz Beloit One Network |
$498.33
|
| Rate for Payer: Quartz Commercial |
$610.20
|
| Rate for Payer: WEA Trust Commercial |
$559.35
|
| Rate for Payer: WPS Commercial |
$753.29
|
|
|
XR Hysterosalpingography
|
Professional
|
$1,017.00
|
|
|
Service Code
|
CPT 74740 TC
|
| Hospital Charge Code |
3072714
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$75.12 |
| Max. Negotiated Rate |
$966.15 |
| Rate for Payer: Aetna Commercial |
$966.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$874.62
|
| Rate for Payer: Aetna Managed Medicare |
$75.12
|
| Rate for Payer: Anthem Medicare Advantage |
$75.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$75.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$75.12
|
| Rate for Payer: Cash Price |
$305.10
|
| Rate for Payer: Cash Price |
$305.10
|
| Rate for Payer: Cigna Commercial |
$966.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$508.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$75.12
|
| Rate for Payer: Health EOS Commercial |
$925.47
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$268.39
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$268.39
|
| Rate for Payer: Independent Care Health Plan Medicare |
$75.12
|
| Rate for Payer: Multiplan Commercial |
$813.60
|
| Rate for Payer: Preferred Network Access Commercial |
$966.15
|
| Rate for Payer: Quartz Beloit One Network |
$447.48
|
| Rate for Payer: Quartz Commercial |
$579.69
|
| Rate for Payer: Quartz Medicare Advantage |
$75.12
|
| Rate for Payer: The Alliance Commercial |
$285.46
|
| Rate for Payer: United Healthcare Medicare Advantage |
$75.12
|
| Rate for Payer: WEA Trust Commercial |
$559.35
|
| Rate for Payer: WPS Commercial |
$375.60
|
|
|
XR Intro Of Intra Cath Into Renal Pelvis
|
Facility
OP
|
$2,972.00
|
|
|
Service Code
|
CPT 74475 TC
|
| Hospital Charge Code |
3072723
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$832.16 |
| Max. Negotiated Rate |
$11,888.00 |
| Rate for Payer: Aetna Commercial |
$2,674.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,555.92
|
| Rate for Payer: Aetna Managed Medicare |
$832.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,931.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,486.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,426.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,575.16
|
| Rate for Payer: Cash Price |
$891.60
|
| Rate for Payer: Cash Price |
$891.60
|
| Rate for Payer: Cigna Commercial |
$2,734.24
|
| Rate for Payer: Health EOS Commercial |
$2,645.08
|
| Rate for Payer: HFN Commercial |
$2,734.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,229.00
|
| Rate for Payer: Multiplan Commercial |
$2,377.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,783.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,734.24
|
| Rate for Payer: Quartz Beloit One Network |
$1,456.28
|
| Rate for Payer: Quartz Commercial |
$1,931.80
|
| Rate for Payer: Quartz Medicare Advantage |
$1,783.20
|
| Rate for Payer: The Alliance Commercial |
$11,888.00
|
| Rate for Payer: WEA Trust Commercial |
$1,634.60
|
| Rate for Payer: WPS Commercial |
$2,201.36
|
|
|
XR Intro Of Intra Cath Into Renal Pelvis
|
Professional
|
$2,972.00
|
|
|
Service Code
|
CPT 74475 TC
|
| Hospital Charge Code |
3072723
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,307.68 |
| Max. Negotiated Rate |
$2,823.40 |
| Rate for Payer: Aetna Commercial |
$2,823.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,555.92
|
| Rate for Payer: Cash Price |
$891.60
|
| Rate for Payer: Cigna Commercial |
$2,823.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,486.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,783.20
|
| Rate for Payer: Health EOS Commercial |
$2,704.52
|
| Rate for Payer: Multiplan Commercial |
$2,377.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,823.40
|
| Rate for Payer: Quartz Beloit One Network |
$1,307.68
|
| Rate for Payer: Quartz Commercial |
$1,694.04
|
| Rate for Payer: The Alliance Commercial |
$1,486.00
|
| Rate for Payer: WEA Trust Commercial |
$1,634.60
|
| Rate for Payer: WPS Commercial |
$2,201.36
|
|
|
XR Intro Of Intra Cath Into Renal Pelvis
|
Facility
IP
|
$2,972.00
|
|
|
Service Code
|
CPT 74475 TC
|
| Hospital Charge Code |
3072723
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,456.28 |
| Max. Negotiated Rate |
$2,734.24 |
| Rate for Payer: Aetna Commercial |
$2,674.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,575.16
|
| Rate for Payer: Cash Price |
$891.60
|
| Rate for Payer: Cigna Commercial |
$2,734.24
|
| Rate for Payer: Health EOS Commercial |
$2,645.08
|
| Rate for Payer: HFN Commercial |
$2,734.24
|
| Rate for Payer: Multiplan Commercial |
$2,377.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,783.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,734.24
|
| Rate for Payer: Quartz Beloit One Network |
$1,456.28
|
| Rate for Payer: Quartz Commercial |
$1,783.20
|
| Rate for Payer: WEA Trust Commercial |
$1,634.60
|
| Rate for Payer: WPS Commercial |
$2,201.36
|
|
|
XR IVP
|
Facility
OP
|
$1,412.00
|
|
|
Service Code
|
CPT 74400
|
| Hospital Charge Code |
630417
|
| Min. Negotiated Rate |
$135.96 |
| Max. Negotiated Rate |
$1,299.04 |
| Rate for Payer: Aetna Commercial |
$1,270.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,214.32
|
| Rate for Payer: Aetna Managed Medicare |
$181.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$917.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$706.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$677.76
|
| Rate for Payer: Anthem Medicare Advantage |
$181.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$748.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$181.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$181.60
|
| Rate for Payer: Cash Price |
$423.60
|
| Rate for Payer: Cash Price |
$423.60
|
| Rate for Payer: Cigna Commercial |
$1,299.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$181.60
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$181.60
|
| Rate for Payer: Health EOS Commercial |
$1,256.68
|
| Rate for Payer: HFN Commercial |
$1,299.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$675.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$181.60
|
| Rate for Payer: Independent Care Health Plan Medicare |
$181.60
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$181.60
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$181.60
|
| Rate for Payer: Multiplan Commercial |
$1,129.60
|
| Rate for Payer: NAPHCARE Commercial |
$272.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,299.04
|
| Rate for Payer: Quartz Beloit One Network |
$691.88
|
| Rate for Payer: Quartz Commercial |
$917.80
|
| Rate for Payer: Quartz Medicare Advantage |
$181.60
|
| Rate for Payer: The Alliance Commercial |
$135.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$181.60
|
| Rate for Payer: WEA Trust Commercial |
$776.60
|
| Rate for Payer: Wellcare Medicare |
$181.60
|
| Rate for Payer: WPS Commercial |
$1,045.87
|
|
|
XR IVP
|
Facility
IP
|
$1,525.00
|
|
|
Service Code
|
CPT 74400
|
| Hospital Charge Code |
1537128
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$747.25 |
| Max. Negotiated Rate |
$1,403.00 |
| Rate for Payer: Aetna Commercial |
$1,372.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$808.25
|
| Rate for Payer: Cash Price |
$457.50
|
| Rate for Payer: Cigna Commercial |
$1,403.00
|
| Rate for Payer: Health EOS Commercial |
$1,357.25
|
| Rate for Payer: HFN Commercial |
$1,403.00
|
| Rate for Payer: Multiplan Commercial |
$1,220.00
|
| Rate for Payer: NAPHCARE Commercial |
$915.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,403.00
|
| Rate for Payer: Quartz Beloit One Network |
$747.25
|
| Rate for Payer: Quartz Commercial |
$915.00
|
| Rate for Payer: WEA Trust Commercial |
$838.75
|
| Rate for Payer: WPS Commercial |
$1,129.57
|
|
|
XR IVP
|
Facility
OP
|
$1,525.00
|
|
|
Service Code
|
CPT 74400
|
| Hospital Charge Code |
1537128
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$135.96 |
| Max. Negotiated Rate |
$1,403.00 |
| Rate for Payer: Aetna Commercial |
$1,372.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,311.50
|
| Rate for Payer: Aetna Managed Medicare |
$181.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$681.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$544.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$517.56
|
| Rate for Payer: Anthem Medicare Advantage |
$181.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$808.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$181.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$181.60
|
| Rate for Payer: Cash Price |
$457.50
|
| Rate for Payer: Cash Price |
$457.50
|
| Rate for Payer: Cash Price |
$457.50
|
| Rate for Payer: Cigna Commercial |
$1,403.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$181.60
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$181.60
|
| Rate for Payer: Health EOS Commercial |
$1,357.25
|
| Rate for Payer: HFN Commercial |
$1,403.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$675.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$181.60
|
| Rate for Payer: Independent Care Health Plan Medicare |
$181.60
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$181.60
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$181.60
|
| Rate for Payer: Multiplan Commercial |
$1,220.00
|
| Rate for Payer: NAPHCARE Commercial |
$272.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,403.00
|
| Rate for Payer: Quartz Beloit One Network |
$747.25
|
| Rate for Payer: Quartz Commercial |
$991.25
|
| Rate for Payer: Quartz Medicare Advantage |
$181.60
|
| Rate for Payer: The Alliance Commercial |
$135.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$181.60
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$838.75
|
| Rate for Payer: Wellcare Medicare |
$181.60
|
| Rate for Payer: WPS Commercial |
$1,129.57
|
|
|
XR IVP
|
Professional
|
$1,412.00
|
|
|
Service Code
|
CPT 74400
|
| Hospital Charge Code |
630417
|
| Min. Negotiated Rate |
$131.53 |
| Max. Negotiated Rate |
$1,341.40 |
| Rate for Payer: Aetna Commercial |
$1,341.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,214.32
|
| Rate for Payer: Aetna Managed Medicare |
$131.53
|
| Rate for Payer: Anthem Medicare Advantage |
$131.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$131.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$131.53
|
| Rate for Payer: Cash Price |
$423.60
|
| Rate for Payer: Cash Price |
$423.60
|
| Rate for Payer: Cigna Commercial |
$1,341.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$706.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$131.53
|
| Rate for Payer: Health EOS Commercial |
$1,284.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$462.92
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$462.92
|
| Rate for Payer: Independent Care Health Plan Medicare |
$131.53
|
| Rate for Payer: Multiplan Commercial |
$1,129.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,341.40
|
| Rate for Payer: Quartz Beloit One Network |
$621.28
|
| Rate for Payer: Quartz Commercial |
$804.84
|
| Rate for Payer: Quartz Medicare Advantage |
$131.53
|
| Rate for Payer: The Alliance Commercial |
$499.81
|
| Rate for Payer: United Healthcare Medicare Advantage |
$131.53
|
| Rate for Payer: WEA Trust Commercial |
$776.60
|
| Rate for Payer: WPS Commercial |
$657.65
|
|
|
XR IVP
|
Facility
IP
|
$1,412.00
|
|
|
Service Code
|
CPT 74400
|
| Hospital Charge Code |
630417
|
| Min. Negotiated Rate |
$691.88 |
| Max. Negotiated Rate |
$1,299.04 |
| Rate for Payer: Aetna Commercial |
$1,270.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$748.36
|
| Rate for Payer: Cash Price |
$423.60
|
| Rate for Payer: Cigna Commercial |
$1,299.04
|
| Rate for Payer: Health EOS Commercial |
$1,256.68
|
| Rate for Payer: HFN Commercial |
$1,299.04
|
| Rate for Payer: Multiplan Commercial |
$1,129.60
|
| Rate for Payer: NAPHCARE Commercial |
$847.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,299.04
|
| Rate for Payer: Quartz Beloit One Network |
$691.88
|
| Rate for Payer: Quartz Commercial |
$847.20
|
| Rate for Payer: WEA Trust Commercial |
$776.60
|
| Rate for Payer: WPS Commercial |
$1,045.87
|
|
|
XR IVP
|
Professional
|
$1,525.00
|
|
|
Service Code
|
CPT 74400
|
| Hospital Charge Code |
1537128
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$131.53 |
| Max. Negotiated Rate |
$1,448.75 |
| Rate for Payer: Aetna Commercial |
$1,448.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,311.50
|
| Rate for Payer: Aetna Managed Medicare |
$131.53
|
| Rate for Payer: Anthem Medicare Advantage |
$131.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$131.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$131.53
|
| Rate for Payer: Cash Price |
$457.50
|
| Rate for Payer: Cash Price |
$457.50
|
| Rate for Payer: Cigna Commercial |
$1,448.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$762.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$131.53
|
| Rate for Payer: Health EOS Commercial |
$1,387.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$462.92
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$462.92
|
| Rate for Payer: Independent Care Health Plan Medicare |
$131.53
|
| Rate for Payer: Multiplan Commercial |
$1,220.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,448.75
|
| Rate for Payer: Quartz Beloit One Network |
$671.00
|
| Rate for Payer: Quartz Commercial |
$869.25
|
| Rate for Payer: Quartz Medicare Advantage |
$131.53
|
| Rate for Payer: The Alliance Commercial |
$499.81
|
| Rate for Payer: United Healthcare Medicare Advantage |
$131.53
|
| Rate for Payer: WEA Trust Commercial |
$838.75
|
| Rate for Payer: WPS Commercial |
$657.65
|
|
|
XR Joint Survey Single View
|
Professional
|
$685.00
|
|
|
Service Code
|
CPT 77077
|
| Hospital Charge Code |
1537136
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$45.30 |
| Max. Negotiated Rate |
$650.75 |
| Rate for Payer: Aetna Commercial |
$650.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$589.10
|
| Rate for Payer: Aetna Managed Medicare |
$45.30
|
| Rate for Payer: Anthem Medicare Advantage |
$45.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$45.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$45.30
|
| Rate for Payer: Cash Price |
$205.50
|
| Rate for Payer: Cash Price |
$205.50
|
| Rate for Payer: Cigna Commercial |
$650.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$342.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$45.30
|
| Rate for Payer: Health EOS Commercial |
$623.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$158.92
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$158.92
|
| Rate for Payer: Independent Care Health Plan Medicare |
$45.30
|
| Rate for Payer: Multiplan Commercial |
$548.00
|
| Rate for Payer: Preferred Network Access Commercial |
$650.75
|
| Rate for Payer: Quartz Beloit One Network |
$301.40
|
| Rate for Payer: Quartz Commercial |
$390.45
|
| Rate for Payer: Quartz Medicare Advantage |
$45.30
|
| Rate for Payer: The Alliance Commercial |
$172.14
|
| Rate for Payer: United Healthcare Medicare Advantage |
$45.30
|
| Rate for Payer: WEA Trust Commercial |
$376.75
|
| Rate for Payer: WPS Commercial |
$226.50
|
|
|
XR Joint Survey Single View
|
Facility
OP
|
$685.00
|
|
|
Service Code
|
CPT 77077
|
| Hospital Charge Code |
1537136
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$54.84 |
| Max. Negotiated Rate |
$630.20 |
| Rate for Payer: Aetna Commercial |
$616.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$589.10
|
| Rate for Payer: Aetna Managed Medicare |
$108.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$407.51
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$326.01
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$309.71
|
| Rate for Payer: Anthem Medicare Advantage |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$363.05
|
| 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 |
$205.50
|
| Rate for Payer: Cash Price |
$205.50
|
| Rate for Payer: Cash Price |
$205.50
|
| Rate for Payer: Cigna Commercial |
$630.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$108.67
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$108.67
|
| Rate for Payer: Health EOS Commercial |
$609.65
|
| Rate for Payer: HFN Commercial |
$630.20
|
| 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 |
$548.00
|
| Rate for Payer: NAPHCARE Commercial |
$163.00
|
| Rate for Payer: Preferred Network Access Commercial |
$630.20
|
| Rate for Payer: Quartz Beloit One Network |
$335.65
|
| Rate for Payer: Quartz Commercial |
$445.25
|
| Rate for Payer: Quartz Medicare Advantage |
$108.67
|
| Rate for Payer: The Alliance Commercial |
$54.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$108.67
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$376.75
|
| Rate for Payer: Wellcare Medicare |
$108.67
|
| Rate for Payer: WPS Commercial |
$507.38
|
|
|
XR Joint Survey Single View
|
Professional
|
$659.00
|
|
|
Service Code
|
CPT 77077
|
| Hospital Charge Code |
630410
|
| Min. Negotiated Rate |
$45.30 |
| Max. Negotiated Rate |
$626.05 |
| Rate for Payer: Aetna Commercial |
$626.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$566.74
|
| Rate for Payer: Aetna Managed Medicare |
$45.30
|
| Rate for Payer: Anthem Medicare Advantage |
$45.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$45.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$45.30
|
| Rate for Payer: Cash Price |
$197.70
|
| Rate for Payer: Cash Price |
$197.70
|
| Rate for Payer: Cigna Commercial |
$626.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$329.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$45.30
|
| Rate for Payer: Health EOS Commercial |
$599.69
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$158.92
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$158.92
|
| Rate for Payer: Independent Care Health Plan Medicare |
$45.30
|
| Rate for Payer: Multiplan Commercial |
$527.20
|
| Rate for Payer: Preferred Network Access Commercial |
$626.05
|
| Rate for Payer: Quartz Beloit One Network |
$289.96
|
| Rate for Payer: Quartz Commercial |
$375.63
|
| Rate for Payer: Quartz Medicare Advantage |
$45.30
|
| Rate for Payer: The Alliance Commercial |
$172.14
|
| Rate for Payer: United Healthcare Medicare Advantage |
$45.30
|
| Rate for Payer: WEA Trust Commercial |
$362.45
|
| Rate for Payer: WPS Commercial |
$226.50
|
|
|
XR Joint Survey Single View
|
Facility
IP
|
$685.00
|
|
|
Service Code
|
CPT 77077
|
| Hospital Charge Code |
1537136
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$335.65 |
| Max. Negotiated Rate |
$630.20 |
| Rate for Payer: Aetna Commercial |
$616.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$363.05
|
| Rate for Payer: Cash Price |
$205.50
|
| Rate for Payer: Cigna Commercial |
$630.20
|
| Rate for Payer: Health EOS Commercial |
$609.65
|
| Rate for Payer: HFN Commercial |
$630.20
|
| Rate for Payer: Multiplan Commercial |
$548.00
|
| Rate for Payer: NAPHCARE Commercial |
$411.00
|
| Rate for Payer: Preferred Network Access Commercial |
$630.20
|
| Rate for Payer: Quartz Beloit One Network |
$335.65
|
| Rate for Payer: Quartz Commercial |
$411.00
|
| Rate for Payer: WEA Trust Commercial |
$376.75
|
| Rate for Payer: WPS Commercial |
$507.38
|
|
|
XR Joint Survey Single View
|
Facility
OP
|
$659.00
|
|
|
Service Code
|
CPT 77077
|
| Hospital Charge Code |
630410
|
| Min. Negotiated Rate |
$54.84 |
| Max. Negotiated Rate |
$606.28 |
| Rate for Payer: Aetna Commercial |
$593.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$566.74
|
| Rate for Payer: Aetna Managed Medicare |
$108.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$428.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$329.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$316.32
|
| Rate for Payer: Anthem Medicare Advantage |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$349.27
|
| 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 |
$197.70
|
| Rate for Payer: Cash Price |
$197.70
|
| Rate for Payer: Cigna Commercial |
$606.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$108.67
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$108.67
|
| Rate for Payer: Health EOS Commercial |
$586.51
|
| Rate for Payer: HFN Commercial |
$606.28
|
| 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 |
$527.20
|
| Rate for Payer: NAPHCARE Commercial |
$163.00
|
| Rate for Payer: Preferred Network Access Commercial |
$606.28
|
| Rate for Payer: Quartz Beloit One Network |
$322.91
|
| Rate for Payer: Quartz Commercial |
$428.35
|
| Rate for Payer: Quartz Medicare Advantage |
$108.67
|
| Rate for Payer: The Alliance Commercial |
$54.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$108.67
|
| Rate for Payer: WEA Trust Commercial |
$362.45
|
| Rate for Payer: Wellcare Medicare |
$108.67
|
| Rate for Payer: WPS Commercial |
$488.12
|
|
|
XR Joint Survey Single View
|
Facility
IP
|
$659.00
|
|
|
Service Code
|
CPT 77077
|
| Hospital Charge Code |
630410
|
| Min. Negotiated Rate |
$322.91 |
| Max. Negotiated Rate |
$606.28 |
| Rate for Payer: Aetna Commercial |
$593.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$349.27
|
| Rate for Payer: Cash Price |
$197.70
|
| Rate for Payer: Cigna Commercial |
$606.28
|
| Rate for Payer: Health EOS Commercial |
$586.51
|
| Rate for Payer: HFN Commercial |
$606.28
|
| Rate for Payer: Multiplan Commercial |
$527.20
|
| Rate for Payer: NAPHCARE Commercial |
$395.40
|
| Rate for Payer: Preferred Network Access Commercial |
$606.28
|
| Rate for Payer: Quartz Beloit One Network |
$322.91
|
| Rate for Payer: Quartz Commercial |
$395.40
|
| Rate for Payer: WEA Trust Commercial |
$362.45
|
| Rate for Payer: WPS Commercial |
$488.12
|
|
|
XR Knee 1 or 2 Views Bilateral
|
Professional
|
$1,052.00
|
|
|
Service Code
|
CPT 73560
|
| Hospital Charge Code |
630365
|
| Min. Negotiated Rate |
$33.00 |
| Max. Negotiated Rate |
$999.40 |
| Rate for Payer: Aetna Commercial |
$999.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$904.72
|
| Rate for Payer: Aetna Managed Medicare |
$33.00
|
| Rate for Payer: Anthem Medicare Advantage |
$33.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$33.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$33.00
|
| Rate for Payer: Cash Price |
$315.60
|
| Rate for Payer: Cash Price |
$315.60
|
| Rate for Payer: Cigna Commercial |
$999.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$526.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$33.00
|
| Rate for Payer: Health EOS Commercial |
$957.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$115.57
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$115.57
|
| Rate for Payer: Independent Care Health Plan Medicare |
$33.00
|
| Rate for Payer: Multiplan Commercial |
$841.60
|
| Rate for Payer: Preferred Network Access Commercial |
$999.40
|
| Rate for Payer: Quartz Beloit One Network |
$462.88
|
| Rate for Payer: Quartz Commercial |
$599.64
|
| Rate for Payer: Quartz Medicare Advantage |
$33.00
|
| Rate for Payer: The Alliance Commercial |
$125.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$33.00
|
| Rate for Payer: WEA Trust Commercial |
$578.60
|
| Rate for Payer: WPS Commercial |
$165.00
|
|
|
XR Knee 1 or 2 Views Bilateral
|
Facility
OP
|
$1,052.00
|
|
|
Service Code
|
CPT 73560
|
| Hospital Charge Code |
630365
|
| Min. Negotiated Rate |
$51.64 |
| Max. Negotiated Rate |
$967.84 |
| Rate for Payer: Aetna Commercial |
$946.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$904.72
|
| Rate for Payer: Aetna Managed Medicare |
$89.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$683.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$526.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$504.96
|
| Rate for Payer: Anthem Medicare Advantage |
$89.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$557.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$89.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$89.82
|
| Rate for Payer: Cash Price |
$315.60
|
| Rate for Payer: Cash Price |
$315.60
|
| Rate for Payer: Cigna Commercial |
$967.84
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$89.82
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$89.82
|
| Rate for Payer: Health EOS Commercial |
$936.28
|
| Rate for Payer: HFN Commercial |
$967.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$334.13
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$89.82
|
| Rate for Payer: Independent Care Health Plan Medicare |
$89.82
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$89.82
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$89.82
|
| Rate for Payer: Multiplan Commercial |
$841.60
|
| Rate for Payer: NAPHCARE Commercial |
$134.73
|
| Rate for Payer: Preferred Network Access Commercial |
$967.84
|
| Rate for Payer: Quartz Beloit One Network |
$515.48
|
| Rate for Payer: Quartz Commercial |
$683.80
|
| Rate for Payer: Quartz Medicare Advantage |
$89.82
|
| Rate for Payer: The Alliance Commercial |
$51.64
|
| Rate for Payer: United Healthcare Medicare Advantage |
$89.82
|
| Rate for Payer: WEA Trust Commercial |
$578.60
|
| Rate for Payer: Wellcare Medicare |
$89.82
|
| Rate for Payer: WPS Commercial |
$779.22
|
|
|
XR Knee 1 or 2 Views Bilateral
|
Facility
OP
|
$540.00
|
|
|
Service Code
|
CPT 73560 LT,TC
|
| Hospital Charge Code |
1537138
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$151.20 |
| Max. Negotiated Rate |
$2,160.00 |
| Rate for Payer: Quartz Beloit One Network |
$264.60
|
| Rate for Payer: Aetna Commercial |
$486.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$464.40
|
| Rate for Payer: Aetna Managed Medicare |
$151.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$351.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$270.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$259.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$286.20
|
| Rate for Payer: Cash Price |
$162.00
|
| Rate for Payer: Cash Price |
$162.00
|
| Rate for Payer: Cash Price |
$162.00
|
| Rate for Payer: Cigna Commercial |
$496.80
|
| Rate for Payer: Health EOS Commercial |
$480.60
|
| Rate for Payer: HFN Commercial |
$496.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$405.00
|
| Rate for Payer: Multiplan Commercial |
$432.00
|
| Rate for Payer: NAPHCARE Commercial |
$324.00
|
| Rate for Payer: Preferred Network Access Commercial |
$496.80
|
| Rate for Payer: Quartz Commercial |
$351.00
|
| Rate for Payer: Quartz Medicare Advantage |
$324.00
|
| Rate for Payer: The Alliance Commercial |
$2,160.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$297.00
|
| Rate for Payer: WPS Commercial |
$399.98
|
|
|
XR Knee 1 or 2 Views Bilateral
|
Facility
IP
|
$540.00
|
|
|
Service Code
|
CPT 73560 LT,TC
|
| Hospital Charge Code |
1537138
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$264.60 |
| Max. Negotiated Rate |
$496.80 |
| Rate for Payer: Aetna Commercial |
$486.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$286.20
|
| Rate for Payer: Cash Price |
$162.00
|
| Rate for Payer: Cigna Commercial |
$496.80
|
| Rate for Payer: Health EOS Commercial |
$480.60
|
| Rate for Payer: HFN Commercial |
$496.80
|
| Rate for Payer: Multiplan Commercial |
$432.00
|
| Rate for Payer: NAPHCARE Commercial |
$324.00
|
| Rate for Payer: Preferred Network Access Commercial |
$496.80
|
| Rate for Payer: Quartz Beloit One Network |
$264.60
|
| Rate for Payer: Quartz Commercial |
$324.00
|
| Rate for Payer: WEA Trust Commercial |
$297.00
|
| Rate for Payer: WPS Commercial |
$399.98
|
|
|
XR Knee 1 or 2 Views Bilateral
|
Professional
|
$540.00
|
|
|
Service Code
|
CPT 73560 LT,TC
|
| Hospital Charge Code |
1537138
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$237.60 |
| Max. Negotiated Rate |
$513.00 |
| Rate for Payer: Aetna Commercial |
$513.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$464.40
|
| Rate for Payer: Cash Price |
$162.00
|
| Rate for Payer: Cash Price |
$162.00
|
| Rate for Payer: Cigna Commercial |
$513.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$270.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$324.00
|
| Rate for Payer: Health EOS Commercial |
$491.40
|
| Rate for Payer: Multiplan Commercial |
$432.00
|
| Rate for Payer: Preferred Network Access Commercial |
$513.00
|
| Rate for Payer: Quartz Beloit One Network |
$237.60
|
| Rate for Payer: Quartz Commercial |
$307.80
|
| Rate for Payer: The Alliance Commercial |
$270.00
|
| Rate for Payer: WEA Trust Commercial |
$297.00
|
| Rate for Payer: WPS Commercial |
$399.98
|
|
