|
VL LE Arterial Graft Patency Right
|
Facility
|
OP
|
$1,227.00
|
|
|
Service Code
|
CPT 93926 TC
|
| Hospital Charge Code |
5238994
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$357.30 |
| Max. Negotiated Rate |
$1,173.99 |
| Rate for Payer: Aetna Commercial |
$1,148.47
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,097.43
|
| Rate for Payer: Aetna Managed Medicare |
$357.30
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$829.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$638.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$612.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$676.32
|
| Rate for Payer: Cash Price |
$368.10
|
| Rate for Payer: Cash Price |
$368.10
|
| Rate for Payer: Cigna Commercial |
$1,173.99
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$714.11
|
| Rate for Payer: Health EOS Commercial |
$1,135.71
|
| Rate for Payer: HFN Commercial |
$1,173.99
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$957.06
|
| Rate for Payer: Multiplan Commercial |
$1,020.86
|
| Rate for Payer: NAPHCARE Commercial |
$765.65
|
| Rate for Payer: Preferred Network Access Commercial |
$1,173.99
|
| Rate for Payer: Quartz Beloit One Network |
$625.28
|
| Rate for Payer: Quartz Commercial |
$829.45
|
| Rate for Payer: Quartz Medicare Advantage |
$765.65
|
| Rate for Payer: The Alliance Commercial |
$465.84
|
| Rate for Payer: United Healthcare PPO |
$957.06
|
| Rate for Payer: WEA Trust Commercial |
$701.84
|
| Rate for Payer: WPS Commercial |
$945.16
|
|
|
VL LE Arterial Graft Patency Right
|
Facility
|
IP
|
$1,227.00
|
|
|
Service Code
|
CPT 93926 TC
|
| Hospital Charge Code |
5238994
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$625.28 |
| Max. Negotiated Rate |
$1,173.99 |
| Rate for Payer: Aetna Commercial |
$1,148.47
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,097.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$676.32
|
| Rate for Payer: Cash Price |
$368.10
|
| Rate for Payer: Cigna Commercial |
$1,173.99
|
| Rate for Payer: Health EOS Commercial |
$1,135.71
|
| Rate for Payer: HFN Commercial |
$1,173.99
|
| Rate for Payer: Multiplan Commercial |
$1,020.86
|
| Rate for Payer: Preferred Network Access Commercial |
$1,173.99
|
| Rate for Payer: Quartz Beloit One Network |
$625.28
|
| Rate for Payer: Quartz Commercial |
$765.65
|
| Rate for Payer: WEA Trust Commercial |
$701.84
|
| Rate for Payer: WPS Commercial |
$945.16
|
|
|
VL LE Venous Duplex Bilateral
|
Facility
|
OP
|
$1,975.00
|
|
|
Service Code
|
CPT 93970 TC
|
| Hospital Charge Code |
1483096
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$575.12 |
| Max. Negotiated Rate |
$1,889.68 |
| Rate for Payer: Aetna Commercial |
$1,848.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,766.44
|
| Rate for Payer: Aetna Managed Medicare |
$575.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,335.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,027.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$985.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,088.62
|
| Rate for Payer: Cash Price |
$592.50
|
| Rate for Payer: Cash Price |
$592.50
|
| Rate for Payer: Cigna Commercial |
$1,889.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,149.45
|
| Rate for Payer: Health EOS Commercial |
$1,828.06
|
| Rate for Payer: HFN Commercial |
$1,889.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,540.50
|
| Rate for Payer: Multiplan Commercial |
$1,643.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,232.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,889.68
|
| Rate for Payer: Quartz Beloit One Network |
$1,006.46
|
| Rate for Payer: Quartz Commercial |
$1,335.10
|
| Rate for Payer: Quartz Medicare Advantage |
$1,232.40
|
| Rate for Payer: The Alliance Commercial |
$602.95
|
| Rate for Payer: United Healthcare PPO |
$1,540.50
|
| Rate for Payer: WEA Trust Commercial |
$1,129.70
|
| Rate for Payer: WPS Commercial |
$1,521.34
|
|
|
VL LE Venous Duplex Bilateral
|
Professional
|
Both
|
$1,975.00
|
|
|
Service Code
|
CPT 93970 TC
|
| Hospital Charge Code |
1483096
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$141.44 |
| Max. Negotiated Rate |
$1,951.30 |
| Rate for Payer: Aetna Commercial |
$1,951.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,766.44
|
| Rate for Payer: Aetna Managed Medicare |
$150.74
|
| Rate for Payer: Anthem Medicare Advantage |
$150.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$150.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$150.74
|
| Rate for Payer: Cash Price |
$592.50
|
| Rate for Payer: Cash Price |
$592.50
|
| Rate for Payer: Cash Price |
$592.50
|
| Rate for Payer: Cigna Commercial |
$1,951.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$141.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$150.74
|
| Rate for Payer: Health EOS Commercial |
$1,869.14
|
| Rate for Payer: HFN Commercial |
$1,951.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$573.96
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$573.96
|
| Rate for Payer: Independent Care Health Plan Medicare |
$150.74
|
| Rate for Payer: Multiplan Commercial |
$1,643.20
|
| Rate for Payer: NAPHCARE Commercial |
$226.11
|
| Rate for Payer: Preferred Network Access Commercial |
$1,951.30
|
| Rate for Payer: Quartz Beloit One Network |
$903.76
|
| Rate for Payer: Quartz Commercial |
$1,170.78
|
| Rate for Payer: Quartz Medicare Advantage |
$150.74
|
| Rate for Payer: The Alliance Commercial |
$376.84
|
| Rate for Payer: United Healthcare Medicaid |
$141.44
|
| Rate for Payer: United Healthcare Medicare Advantage |
$150.74
|
| Rate for Payer: WEA Trust Commercial |
$1,129.70
|
| Rate for Payer: WPS Commercial |
$602.95
|
|
|
VL LE Venous Duplex Bilateral
|
Facility
|
IP
|
$1,975.00
|
|
|
Service Code
|
CPT 93970 TC
|
| Hospital Charge Code |
1483096
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$1,006.46 |
| Max. Negotiated Rate |
$1,889.68 |
| Rate for Payer: Aetna Commercial |
$1,848.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,766.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,088.62
|
| Rate for Payer: Cash Price |
$592.50
|
| Rate for Payer: Cigna Commercial |
$1,889.68
|
| Rate for Payer: Health EOS Commercial |
$1,828.06
|
| Rate for Payer: HFN Commercial |
$1,889.68
|
| Rate for Payer: Multiplan Commercial |
$1,643.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,889.68
|
| Rate for Payer: Quartz Beloit One Network |
$1,006.46
|
| Rate for Payer: Quartz Commercial |
$1,232.40
|
| Rate for Payer: WEA Trust Commercial |
$1,129.70
|
| Rate for Payer: WPS Commercial |
$1,521.34
|
|
|
VL LE Venous Duplex Left
|
Facility
|
IP
|
$1,234.00
|
|
|
Service Code
|
CPT 93971 TC
|
| Hospital Charge Code |
1483099
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$628.85 |
| Max. Negotiated Rate |
$1,180.69 |
| Rate for Payer: Aetna Commercial |
$1,155.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,103.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$680.18
|
| Rate for Payer: Cash Price |
$370.20
|
| Rate for Payer: Cigna Commercial |
$1,180.69
|
| Rate for Payer: Health EOS Commercial |
$1,142.19
|
| Rate for Payer: HFN Commercial |
$1,180.69
|
| Rate for Payer: Multiplan Commercial |
$1,026.69
|
| Rate for Payer: Preferred Network Access Commercial |
$1,180.69
|
| Rate for Payer: Quartz Beloit One Network |
$628.85
|
| Rate for Payer: Quartz Commercial |
$770.02
|
| Rate for Payer: WEA Trust Commercial |
$705.85
|
| Rate for Payer: WPS Commercial |
$950.55
|
|
|
VL LE Venous Duplex Left
|
Facility
|
OP
|
$1,234.00
|
|
|
Service Code
|
CPT 93971 TC
|
| Hospital Charge Code |
1483099
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$359.34 |
| Max. Negotiated Rate |
$1,180.69 |
| Rate for Payer: Aetna Commercial |
$1,155.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,103.69
|
| Rate for Payer: Aetna Managed Medicare |
$359.34
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$834.18
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$641.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$616.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$680.18
|
| Rate for Payer: Cash Price |
$370.20
|
| Rate for Payer: Cash Price |
$370.20
|
| Rate for Payer: Cigna Commercial |
$1,180.69
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$718.19
|
| Rate for Payer: Health EOS Commercial |
$1,142.19
|
| Rate for Payer: HFN Commercial |
$1,180.69
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$962.52
|
| Rate for Payer: Multiplan Commercial |
$1,026.69
|
| Rate for Payer: NAPHCARE Commercial |
$770.02
|
| Rate for Payer: Preferred Network Access Commercial |
$1,180.69
|
| Rate for Payer: Quartz Beloit One Network |
$628.85
|
| Rate for Payer: Quartz Commercial |
$834.18
|
| Rate for Payer: Quartz Medicare Advantage |
$770.02
|
| Rate for Payer: The Alliance Commercial |
$380.22
|
| Rate for Payer: United Healthcare PPO |
$962.52
|
| Rate for Payer: WEA Trust Commercial |
$705.85
|
| Rate for Payer: WPS Commercial |
$950.55
|
|
|
VL LE Venous Duplex Left
|
Professional
|
Both
|
$1,234.00
|
|
|
Service Code
|
CPT 93971 TC
|
| Hospital Charge Code |
1483099
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$90.17 |
| Max. Negotiated Rate |
$1,219.19 |
| Rate for Payer: Aetna Commercial |
$1,219.19
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,103.69
|
| Rate for Payer: Aetna Managed Medicare |
$95.06
|
| Rate for Payer: Anthem Medicare Advantage |
$95.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$95.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$95.06
|
| Rate for Payer: Cash Price |
$370.20
|
| Rate for Payer: Cash Price |
$370.20
|
| Rate for Payer: Cash Price |
$370.20
|
| Rate for Payer: Cigna Commercial |
$1,219.19
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$90.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$95.06
|
| Rate for Payer: Health EOS Commercial |
$1,167.86
|
| Rate for Payer: HFN Commercial |
$1,219.19
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$358.75
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$358.75
|
| Rate for Payer: Independent Care Health Plan Medicare |
$95.06
|
| Rate for Payer: Multiplan Commercial |
$1,026.69
|
| Rate for Payer: NAPHCARE Commercial |
$142.58
|
| Rate for Payer: Preferred Network Access Commercial |
$1,219.19
|
| Rate for Payer: Quartz Beloit One Network |
$564.68
|
| Rate for Payer: Quartz Commercial |
$731.52
|
| Rate for Payer: Quartz Medicare Advantage |
$95.06
|
| Rate for Payer: The Alliance Commercial |
$237.64
|
| Rate for Payer: United Healthcare Medicaid |
$90.17
|
| Rate for Payer: United Healthcare Medicare Advantage |
$95.06
|
| Rate for Payer: WEA Trust Commercial |
$705.85
|
| Rate for Payer: WPS Commercial |
$380.22
|
|
|
VL LE Venous Duplex Right
|
Professional
|
Both
|
$1,234.00
|
|
|
Service Code
|
CPT 93971 TC
|
| Hospital Charge Code |
1483102
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$90.17 |
| Max. Negotiated Rate |
$1,219.19 |
| Rate for Payer: Aetna Commercial |
$1,219.19
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,103.69
|
| Rate for Payer: Aetna Managed Medicare |
$95.06
|
| Rate for Payer: Anthem Medicare Advantage |
$95.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$95.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$95.06
|
| Rate for Payer: Cash Price |
$370.20
|
| Rate for Payer: Cash Price |
$370.20
|
| Rate for Payer: Cash Price |
$370.20
|
| Rate for Payer: Cigna Commercial |
$1,219.19
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$90.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$95.06
|
| Rate for Payer: Health EOS Commercial |
$1,167.86
|
| Rate for Payer: HFN Commercial |
$1,219.19
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$358.75
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$358.75
|
| Rate for Payer: Independent Care Health Plan Medicare |
$95.06
|
| Rate for Payer: Multiplan Commercial |
$1,026.69
|
| Rate for Payer: NAPHCARE Commercial |
$142.58
|
| Rate for Payer: Preferred Network Access Commercial |
$1,219.19
|
| Rate for Payer: Quartz Beloit One Network |
$564.68
|
| Rate for Payer: Quartz Commercial |
$731.52
|
| Rate for Payer: Quartz Medicare Advantage |
$95.06
|
| Rate for Payer: The Alliance Commercial |
$237.64
|
| Rate for Payer: United Healthcare Medicaid |
$90.17
|
| Rate for Payer: United Healthcare Medicare Advantage |
$95.06
|
| Rate for Payer: WEA Trust Commercial |
$705.85
|
| Rate for Payer: WPS Commercial |
$380.22
|
|
|
VL LE Venous Duplex Right
|
Facility
|
IP
|
$1,234.00
|
|
|
Service Code
|
CPT 93971 TC
|
| Hospital Charge Code |
1483102
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$628.85 |
| Max. Negotiated Rate |
$1,180.69 |
| Rate for Payer: Aetna Commercial |
$1,155.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,103.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$680.18
|
| Rate for Payer: Cash Price |
$370.20
|
| Rate for Payer: Cigna Commercial |
$1,180.69
|
| Rate for Payer: Health EOS Commercial |
$1,142.19
|
| Rate for Payer: HFN Commercial |
$1,180.69
|
| Rate for Payer: Multiplan Commercial |
$1,026.69
|
| Rate for Payer: Preferred Network Access Commercial |
$1,180.69
|
| Rate for Payer: Quartz Beloit One Network |
$628.85
|
| Rate for Payer: Quartz Commercial |
$770.02
|
| Rate for Payer: WEA Trust Commercial |
$705.85
|
| Rate for Payer: WPS Commercial |
$950.55
|
|
|
VL LE Venous Duplex Right
|
Facility
|
OP
|
$1,234.00
|
|
|
Service Code
|
CPT 93971 TC
|
| Hospital Charge Code |
1483102
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$359.34 |
| Max. Negotiated Rate |
$1,180.69 |
| Rate for Payer: Aetna Commercial |
$1,155.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,103.69
|
| Rate for Payer: Aetna Managed Medicare |
$359.34
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$834.18
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$641.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$616.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$680.18
|
| Rate for Payer: Cash Price |
$370.20
|
| Rate for Payer: Cash Price |
$370.20
|
| Rate for Payer: Cigna Commercial |
$1,180.69
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$718.19
|
| Rate for Payer: Health EOS Commercial |
$1,142.19
|
| Rate for Payer: HFN Commercial |
$1,180.69
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$962.52
|
| Rate for Payer: Multiplan Commercial |
$1,026.69
|
| Rate for Payer: NAPHCARE Commercial |
$770.02
|
| Rate for Payer: Preferred Network Access Commercial |
$1,180.69
|
| Rate for Payer: Quartz Beloit One Network |
$628.85
|
| Rate for Payer: Quartz Commercial |
$834.18
|
| Rate for Payer: Quartz Medicare Advantage |
$770.02
|
| Rate for Payer: The Alliance Commercial |
$380.22
|
| Rate for Payer: United Healthcare PPO |
$962.52
|
| Rate for Payer: WEA Trust Commercial |
$705.85
|
| Rate for Payer: WPS Commercial |
$950.55
|
|
|
VL Lower Extremity PVR Resting
|
Facility
|
IP
|
$859.00
|
|
|
Service Code
|
CPT 93923 TC
|
| Hospital Charge Code |
2530803
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$437.75 |
| Max. Negotiated Rate |
$821.89 |
| Rate for Payer: Aetna Commercial |
$804.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$768.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$473.48
|
| Rate for Payer: Cash Price |
$257.70
|
| Rate for Payer: Cigna Commercial |
$821.89
|
| Rate for Payer: Health EOS Commercial |
$795.09
|
| Rate for Payer: HFN Commercial |
$821.89
|
| Rate for Payer: Multiplan Commercial |
$714.69
|
| Rate for Payer: Preferred Network Access Commercial |
$821.89
|
| Rate for Payer: Quartz Beloit One Network |
$437.75
|
| Rate for Payer: Quartz Commercial |
$536.02
|
| Rate for Payer: WEA Trust Commercial |
$491.35
|
| Rate for Payer: WPS Commercial |
$661.69
|
|
|
VL Lower Extremity PVR Resting
|
Facility
|
OP
|
$859.00
|
|
|
Service Code
|
CPT 93923 TC
|
| Hospital Charge Code |
2530803
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$250.14 |
| Max. Negotiated Rate |
$821.89 |
| Rate for Payer: Aetna Commercial |
$804.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$768.29
|
| Rate for Payer: Aetna Managed Medicare |
$250.14
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$580.68
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$446.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$428.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$473.48
|
| Rate for Payer: Cash Price |
$257.70
|
| Rate for Payer: Cash Price |
$257.70
|
| Rate for Payer: Cigna Commercial |
$821.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$499.94
|
| Rate for Payer: Health EOS Commercial |
$795.09
|
| Rate for Payer: HFN Commercial |
$821.89
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$670.02
|
| Rate for Payer: Multiplan Commercial |
$714.69
|
| Rate for Payer: NAPHCARE Commercial |
$536.02
|
| Rate for Payer: Preferred Network Access Commercial |
$821.89
|
| Rate for Payer: Quartz Beloit One Network |
$437.75
|
| Rate for Payer: Quartz Commercial |
$580.68
|
| Rate for Payer: Quartz Medicare Advantage |
$536.02
|
| Rate for Payer: The Alliance Commercial |
$444.54
|
| Rate for Payer: United Healthcare PPO |
$670.02
|
| Rate for Payer: WEA Trust Commercial |
$491.35
|
| Rate for Payer: WPS Commercial |
$661.69
|
|
|
VL Lower Extremity PVR Resting
|
Professional
|
Both
|
$859.00
|
|
|
Service Code
|
CPT 93923 TC
|
| Hospital Charge Code |
2530803
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$111.13 |
| Max. Negotiated Rate |
$848.69 |
| Rate for Payer: Aetna Commercial |
$848.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$768.29
|
| Rate for Payer: Aetna Managed Medicare |
$111.13
|
| Rate for Payer: Anthem Medicare Advantage |
$111.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$111.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$111.13
|
| Rate for Payer: Cash Price |
$257.70
|
| Rate for Payer: Cash Price |
$257.70
|
| Rate for Payer: Cash Price |
$257.70
|
| Rate for Payer: Cigna Commercial |
$848.69
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$111.30
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$111.13
|
| Rate for Payer: Health EOS Commercial |
$812.96
|
| Rate for Payer: HFN Commercial |
$848.69
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$389.33
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$389.33
|
| Rate for Payer: Independent Care Health Plan Medicare |
$111.13
|
| Rate for Payer: Multiplan Commercial |
$714.69
|
| Rate for Payer: NAPHCARE Commercial |
$166.70
|
| Rate for Payer: Preferred Network Access Commercial |
$848.69
|
| Rate for Payer: Quartz Beloit One Network |
$393.08
|
| Rate for Payer: Quartz Commercial |
$509.22
|
| Rate for Payer: Quartz Medicare Advantage |
$111.13
|
| Rate for Payer: The Alliance Commercial |
$277.84
|
| Rate for Payer: United Healthcare Medicaid |
$111.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$111.13
|
| Rate for Payer: WEA Trust Commercial |
$491.35
|
| Rate for Payer: WPS Commercial |
$444.54
|
|
|
VL Lower Extremity PVR w Excerise
|
Facility
|
OP
|
$1,924.00
|
|
|
Service Code
|
CPT 93924 TC
|
| Hospital Charge Code |
2530806
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$560.27 |
| Max. Negotiated Rate |
$1,840.88 |
| Rate for Payer: Aetna Commercial |
$1,800.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,720.83
|
| Rate for Payer: Aetna Managed Medicare |
$560.27
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,300.62
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,000.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$960.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,060.51
|
| Rate for Payer: Cash Price |
$577.20
|
| Rate for Payer: Cash Price |
$577.20
|
| Rate for Payer: Cigna Commercial |
$1,840.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,119.77
|
| Rate for Payer: Health EOS Commercial |
$1,780.85
|
| Rate for Payer: HFN Commercial |
$1,840.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,500.72
|
| Rate for Payer: Multiplan Commercial |
$1,600.77
|
| Rate for Payer: NAPHCARE Commercial |
$1,200.58
|
| Rate for Payer: Preferred Network Access Commercial |
$1,840.88
|
| Rate for Payer: Quartz Beloit One Network |
$980.47
|
| Rate for Payer: Quartz Commercial |
$1,300.62
|
| Rate for Payer: Quartz Medicare Advantage |
$1,200.58
|
| Rate for Payer: The Alliance Commercial |
$561.68
|
| Rate for Payer: United Healthcare PPO |
$1,500.72
|
| Rate for Payer: WEA Trust Commercial |
$1,100.53
|
| Rate for Payer: WPS Commercial |
$1,482.06
|
|
|
VL Lower Extremity PVR w Excerise
|
Facility
|
IP
|
$1,924.00
|
|
|
Service Code
|
CPT 93924 TC
|
| Hospital Charge Code |
2530806
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$980.47 |
| Max. Negotiated Rate |
$1,840.88 |
| Rate for Payer: Aetna Commercial |
$1,800.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,720.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,060.51
|
| Rate for Payer: Cash Price |
$577.20
|
| Rate for Payer: Cigna Commercial |
$1,840.88
|
| Rate for Payer: Health EOS Commercial |
$1,780.85
|
| Rate for Payer: HFN Commercial |
$1,840.88
|
| Rate for Payer: Multiplan Commercial |
$1,600.77
|
| Rate for Payer: Preferred Network Access Commercial |
$1,840.88
|
| Rate for Payer: Quartz Beloit One Network |
$980.47
|
| Rate for Payer: Quartz Commercial |
$1,200.58
|
| Rate for Payer: WEA Trust Commercial |
$1,100.53
|
| Rate for Payer: WPS Commercial |
$1,482.06
|
|
|
VL Lower Extremity PVR w Excerise
|
Professional
|
Both
|
$1,924.00
|
|
|
Service Code
|
CPT 93924 TC
|
| Hospital Charge Code |
2530806
|
|
Hospital Revenue Code
|
921
|
| Min. Negotiated Rate |
$139.29 |
| Max. Negotiated Rate |
$1,900.91 |
| Rate for Payer: Health EOS Commercial |
$1,820.87
|
| Rate for Payer: Aetna Commercial |
$1,900.91
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,720.83
|
| Rate for Payer: Aetna Managed Medicare |
$140.42
|
| Rate for Payer: Anthem Medicare Advantage |
$140.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$140.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$140.42
|
| Rate for Payer: Cash Price |
$577.20
|
| Rate for Payer: Cash Price |
$577.20
|
| Rate for Payer: Cash Price |
$577.20
|
| Rate for Payer: Cigna Commercial |
$1,900.91
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$139.29
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$140.42
|
| Rate for Payer: HFN Commercial |
$1,900.91
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$493.12
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$493.12
|
| Rate for Payer: Independent Care Health Plan Medicare |
$140.42
|
| Rate for Payer: Multiplan Commercial |
$1,600.77
|
| Rate for Payer: NAPHCARE Commercial |
$210.63
|
| Rate for Payer: Preferred Network Access Commercial |
$1,900.91
|
| Rate for Payer: Quartz Beloit One Network |
$880.42
|
| Rate for Payer: Quartz Commercial |
$1,140.55
|
| Rate for Payer: Quartz Medicare Advantage |
$140.42
|
| Rate for Payer: The Alliance Commercial |
$351.05
|
| Rate for Payer: United Healthcare Medicaid |
$139.29
|
| Rate for Payer: United Healthcare Medicare Advantage |
$140.42
|
| Rate for Payer: WEA Trust Commercial |
$1,100.53
|
| Rate for Payer: WPS Commercial |
$561.68
|
|
|
VL TEE Adult
|
Professional
|
Both
|
$3,205.00
|
|
|
Service Code
|
CPT 93312
|
| Hospital Charge Code |
1483321
|
|
Hospital Revenue Code
|
483
|
| Min. Negotiated Rate |
$239.62 |
| Max. Negotiated Rate |
$3,166.54 |
| Rate for Payer: Aetna Commercial |
$3,166.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,866.55
|
| Rate for Payer: Aetna Managed Medicare |
$239.62
|
| Rate for Payer: Anthem Medicare Advantage |
$239.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$239.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$239.62
|
| Rate for Payer: Cash Price |
$961.50
|
| Rate for Payer: Cash Price |
$961.50
|
| Rate for Payer: Cash Price |
$961.50
|
| Rate for Payer: Cigna Commercial |
$3,166.54
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$266.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$239.62
|
| Rate for Payer: Health EOS Commercial |
$3,033.21
|
| Rate for Payer: HFN Commercial |
$3,166.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$880.42
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$880.42
|
| Rate for Payer: Independent Care Health Plan Medicare |
$239.62
|
| Rate for Payer: Multiplan Commercial |
$2,666.56
|
| Rate for Payer: NAPHCARE Commercial |
$359.42
|
| Rate for Payer: Preferred Network Access Commercial |
$3,166.54
|
| Rate for Payer: Quartz Beloit One Network |
$1,466.61
|
| Rate for Payer: Quartz Commercial |
$1,899.92
|
| Rate for Payer: Quartz Medicare Advantage |
$239.62
|
| Rate for Payer: The Alliance Commercial |
$910.54
|
| Rate for Payer: United Healthcare Medicaid |
$266.39
|
| Rate for Payer: United Healthcare Medicare Advantage |
$239.62
|
| Rate for Payer: WEA Trust Commercial |
$1,833.26
|
| Rate for Payer: WPS Commercial |
$958.46
|
|
|
VL TEE Adult
|
Facility
|
IP
|
$3,205.00
|
|
|
Service Code
|
CPT 93312
|
| Hospital Charge Code |
1483321
|
|
Hospital Revenue Code
|
483
|
| Min. Negotiated Rate |
$1,633.27 |
| Max. Negotiated Rate |
$3,066.54 |
| Rate for Payer: Aetna Commercial |
$2,999.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,866.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,766.60
|
| Rate for Payer: Cash Price |
$961.50
|
| Rate for Payer: Cigna Commercial |
$3,066.54
|
| Rate for Payer: Health EOS Commercial |
$2,966.55
|
| Rate for Payer: HFN Commercial |
$3,066.54
|
| Rate for Payer: Multiplan Commercial |
$2,666.56
|
| Rate for Payer: Preferred Network Access Commercial |
$3,066.54
|
| Rate for Payer: Quartz Beloit One Network |
$1,633.27
|
| Rate for Payer: Quartz Commercial |
$1,999.92
|
| Rate for Payer: WEA Trust Commercial |
$1,833.26
|
| Rate for Payer: WPS Commercial |
$2,468.81
|
|
|
VL TEE Adult
|
Facility
|
OP
|
$3,205.00
|
|
|
Service Code
|
CPT 93312
|
| Hospital Charge Code |
1483321
|
|
Hospital Revenue Code
|
483
|
| Min. Negotiated Rate |
$575.04 |
| Max. Negotiated Rate |
$3,066.54 |
| Rate for Payer: Aetna Commercial |
$2,999.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,866.55
|
| Rate for Payer: Aetna Managed Medicare |
$575.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,166.58
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,666.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,599.94
|
| Rate for Payer: Anthem Medicare Advantage |
$575.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,766.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$575.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$575.04
|
| Rate for Payer: Cash Price |
$961.50
|
| Rate for Payer: Cash Price |
$961.50
|
| Rate for Payer: Cigna Commercial |
$3,066.54
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$575.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,865.31
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$575.04
|
| Rate for Payer: Health EOS Commercial |
$2,966.55
|
| Rate for Payer: HFN Commercial |
$3,066.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,139.14
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$575.04
|
| Rate for Payer: Independent Care Health Plan Medicare |
$575.04
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$575.04
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$575.04
|
| Rate for Payer: Multiplan Commercial |
$2,666.56
|
| Rate for Payer: NAPHCARE Commercial |
$862.56
|
| Rate for Payer: Preferred Network Access Commercial |
$3,066.54
|
| Rate for Payer: Quartz Beloit One Network |
$1,633.27
|
| Rate for Payer: Quartz Commercial |
$2,166.58
|
| Rate for Payer: Quartz Medicare Advantage |
$575.04
|
| Rate for Payer: The Alliance Commercial |
$2,300.15
|
| Rate for Payer: United Healthcare Medicare Advantage |
$575.04
|
| Rate for Payer: United Healthcare PPO |
$2,499.90
|
| Rate for Payer: WEA Trust Commercial |
$1,833.26
|
| Rate for Payer: Wellcare Medicare |
$575.04
|
| Rate for Payer: WPS Commercial |
$2,468.81
|
|
|
VL TEE Congenital Cardiac Abnormalities
|
Professional
|
Both
|
$4,666.00
|
|
|
Service Code
|
CPT 93315
|
| Hospital Charge Code |
1483324
|
|
Hospital Revenue Code
|
483
|
| Min. Negotiated Rate |
$290.73 |
| Max. Negotiated Rate |
$4,610.01 |
| Rate for Payer: Aetna Commercial |
$4,610.01
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,173.27
|
| Rate for Payer: Cash Price |
$1,399.80
|
| Rate for Payer: Cash Price |
$1,399.80
|
| Rate for Payer: Cash Price |
$1,399.80
|
| Rate for Payer: Cigna Commercial |
$4,610.01
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$290.73
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,911.58
|
| Rate for Payer: Health EOS Commercial |
$4,415.90
|
| Rate for Payer: HFN Commercial |
$4,610.01
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,006.27
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,006.27
|
| Rate for Payer: Multiplan Commercial |
$3,882.11
|
| Rate for Payer: Preferred Network Access Commercial |
$4,610.01
|
| Rate for Payer: Quartz Beloit One Network |
$2,135.16
|
| Rate for Payer: Quartz Commercial |
$2,766.00
|
| Rate for Payer: The Alliance Commercial |
$2,426.32
|
| Rate for Payer: United Healthcare Medicaid |
$290.73
|
| Rate for Payer: WEA Trust Commercial |
$2,668.95
|
| Rate for Payer: WPS Commercial |
$3,594.22
|
|
|
VL TEE Congenital Cardiac Abnormalities
|
Facility
|
OP
|
$4,666.00
|
|
|
Service Code
|
CPT 93315
|
| Hospital Charge Code |
1483324
|
|
Hospital Revenue Code
|
483
|
| Min. Negotiated Rate |
$575.04 |
| Max. Negotiated Rate |
$4,464.43 |
| Rate for Payer: Aetna Commercial |
$4,367.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,173.27
|
| Rate for Payer: Aetna Managed Medicare |
$575.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,154.22
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,426.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,329.27
|
| Rate for Payer: Anthem Medicare Advantage |
$575.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,571.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$575.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$575.04
|
| Rate for Payer: Cash Price |
$1,399.80
|
| Rate for Payer: Cash Price |
$1,399.80
|
| Rate for Payer: Cigna Commercial |
$4,464.43
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$575.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,715.61
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$575.04
|
| Rate for Payer: Health EOS Commercial |
$4,318.85
|
| Rate for Payer: HFN Commercial |
$4,464.43
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,139.14
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$575.04
|
| Rate for Payer: Independent Care Health Plan Medicare |
$575.04
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$575.04
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$575.04
|
| Rate for Payer: Multiplan Commercial |
$3,882.11
|
| Rate for Payer: NAPHCARE Commercial |
$862.56
|
| Rate for Payer: Preferred Network Access Commercial |
$4,464.43
|
| Rate for Payer: Quartz Beloit One Network |
$2,377.79
|
| Rate for Payer: Quartz Commercial |
$3,154.22
|
| Rate for Payer: Quartz Medicare Advantage |
$575.04
|
| Rate for Payer: The Alliance Commercial |
$2,300.15
|
| Rate for Payer: United Healthcare Medicare Advantage |
$575.04
|
| Rate for Payer: United Healthcare PPO |
$3,639.48
|
| Rate for Payer: WEA Trust Commercial |
$2,668.95
|
| Rate for Payer: Wellcare Medicare |
$575.04
|
| Rate for Payer: WPS Commercial |
$3,594.22
|
|
|
VL TEE Congenital Cardiac Abnormalities
|
Facility
|
IP
|
$4,666.00
|
|
|
Service Code
|
CPT 93315
|
| Hospital Charge Code |
1483324
|
|
Hospital Revenue Code
|
483
|
| Min. Negotiated Rate |
$2,377.79 |
| Max. Negotiated Rate |
$4,464.43 |
| Rate for Payer: Aetna Commercial |
$4,367.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,173.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,571.90
|
| Rate for Payer: Cash Price |
$1,399.80
|
| Rate for Payer: Cigna Commercial |
$4,464.43
|
| Rate for Payer: Health EOS Commercial |
$4,318.85
|
| Rate for Payer: HFN Commercial |
$4,464.43
|
| Rate for Payer: Multiplan Commercial |
$3,882.11
|
| Rate for Payer: Preferred Network Access Commercial |
$4,464.43
|
| Rate for Payer: Quartz Beloit One Network |
$2,377.79
|
| Rate for Payer: Quartz Commercial |
$2,911.58
|
| Rate for Payer: WEA Trust Commercial |
$2,668.95
|
| Rate for Payer: WPS Commercial |
$3,594.22
|
|
|
VL TEE Ongoing assess of Cardiac Pump
|
Facility
|
IP
|
$6,012.00
|
|
|
Service Code
|
CPT 93318
|
| Hospital Charge Code |
1483327
|
|
Hospital Revenue Code
|
483
|
| Min. Negotiated Rate |
$3,063.72 |
| Max. Negotiated Rate |
$5,752.28 |
| Rate for Payer: Aetna Commercial |
$5,627.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,377.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,313.81
|
| Rate for Payer: Cash Price |
$1,803.60
|
| Rate for Payer: Cigna Commercial |
$5,752.28
|
| Rate for Payer: Health EOS Commercial |
$5,564.71
|
| Rate for Payer: HFN Commercial |
$5,752.28
|
| Rate for Payer: Multiplan Commercial |
$5,001.98
|
| Rate for Payer: Preferred Network Access Commercial |
$5,752.28
|
| Rate for Payer: Quartz Beloit One Network |
$3,063.72
|
| Rate for Payer: Quartz Commercial |
$3,751.49
|
| Rate for Payer: WEA Trust Commercial |
$3,438.86
|
| Rate for Payer: WPS Commercial |
$4,631.04
|
|
|
VL TEE Ongoing assess of Cardiac Pump
|
Professional
|
Both
|
$6,012.00
|
|
|
Service Code
|
CPT 93318
|
| Hospital Charge Code |
1483327
|
|
Hospital Revenue Code
|
483
|
| Min. Negotiated Rate |
$1,458.79 |
| Max. Negotiated Rate |
$5,939.86 |
| Rate for Payer: Aetna Commercial |
$5,939.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,377.13
|
| Rate for Payer: Cash Price |
$1,803.60
|
| Rate for Payer: Cash Price |
$1,803.60
|
| Rate for Payer: Cash Price |
$1,803.60
|
| Rate for Payer: Cigna Commercial |
$5,939.86
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3,126.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,751.49
|
| Rate for Payer: Health EOS Commercial |
$5,689.76
|
| Rate for Payer: HFN Commercial |
$5,939.86
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,458.79
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,458.79
|
| Rate for Payer: Multiplan Commercial |
$5,001.98
|
| Rate for Payer: Preferred Network Access Commercial |
$5,939.86
|
| Rate for Payer: Quartz Beloit One Network |
$2,751.09
|
| Rate for Payer: Quartz Commercial |
$3,563.91
|
| Rate for Payer: The Alliance Commercial |
$3,126.24
|
| Rate for Payer: WEA Trust Commercial |
$3,438.86
|
| Rate for Payer: WPS Commercial |
$4,631.04
|
|
