|
XR Panorex/Orthopantogram
|
Facility
OP
|
$517.00
|
|
|
Service Code
|
CPT 70355
|
| Hospital Charge Code |
1537222
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$82.84 |
| Max. Negotiated Rate |
$475.64 |
| Rate for Payer: Aetna Commercial |
$465.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$444.62
|
| Rate for Payer: Aetna Managed Medicare |
$89.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$336.82
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$269.46
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$255.99
|
| Rate for Payer: Anthem Medicare Advantage |
$89.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$274.01
|
| 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 |
$155.10
|
| Rate for Payer: Cash Price |
$155.10
|
| Rate for Payer: Cash Price |
$155.10
|
| Rate for Payer: Cigna Commercial |
$475.64
|
| 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 |
$460.13
|
| Rate for Payer: HFN Commercial |
$475.64
|
| 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 |
$413.60
|
| Rate for Payer: NAPHCARE Commercial |
$134.73
|
| Rate for Payer: Preferred Network Access Commercial |
$475.64
|
| Rate for Payer: Quartz Beloit One Network |
$253.33
|
| Rate for Payer: Quartz Commercial |
$336.05
|
| Rate for Payer: Quartz Medicare Advantage |
$89.82
|
| Rate for Payer: The Alliance Commercial |
$82.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$89.82
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$284.35
|
| Rate for Payer: Wellcare Medicare |
$89.82
|
| Rate for Payer: WPS Commercial |
$382.94
|
|
|
XR Panorex/Orthopantogram
|
Facility
OP
|
$479.00
|
|
|
Service Code
|
CPT 70355
|
| Hospital Charge Code |
630293
|
| Min. Negotiated Rate |
$82.84 |
| Max. Negotiated Rate |
$440.68 |
| Rate for Payer: Aetna Commercial |
$431.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$411.94
|
| Rate for Payer: Aetna Managed Medicare |
$89.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$311.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$239.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$229.92
|
| Rate for Payer: Anthem Medicare Advantage |
$89.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$253.87
|
| 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 |
$143.70
|
| Rate for Payer: Cash Price |
$143.70
|
| Rate for Payer: Cigna Commercial |
$440.68
|
| 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 |
$426.31
|
| Rate for Payer: HFN Commercial |
$440.68
|
| 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 |
$383.20
|
| Rate for Payer: NAPHCARE Commercial |
$134.73
|
| Rate for Payer: Preferred Network Access Commercial |
$440.68
|
| Rate for Payer: Quartz Beloit One Network |
$234.71
|
| Rate for Payer: Quartz Commercial |
$311.35
|
| Rate for Payer: Quartz Medicare Advantage |
$89.82
|
| Rate for Payer: The Alliance Commercial |
$82.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$89.82
|
| Rate for Payer: WEA Trust Commercial |
$263.45
|
| Rate for Payer: Wellcare Medicare |
$89.82
|
| Rate for Payer: WPS Commercial |
$354.80
|
|
|
XR Panorex/Orthopantogram
|
Professional
|
$479.00
|
|
|
Service Code
|
CPT 70355
|
| Hospital Charge Code |
630293
|
| Min. Negotiated Rate |
$17.29 |
| Max. Negotiated Rate |
$455.05 |
| Rate for Payer: Aetna Commercial |
$455.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$411.94
|
| Rate for Payer: Aetna Managed Medicare |
$17.29
|
| Rate for Payer: Anthem Medicare Advantage |
$17.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.29
|
| Rate for Payer: Cash Price |
$143.70
|
| Rate for Payer: Cash Price |
$143.70
|
| Rate for Payer: Cigna Commercial |
$455.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$239.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17.29
|
| Rate for Payer: Health EOS Commercial |
$435.89
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$62.48
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$62.48
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.29
|
| Rate for Payer: Multiplan Commercial |
$383.20
|
| Rate for Payer: Preferred Network Access Commercial |
$455.05
|
| Rate for Payer: Quartz Beloit One Network |
$210.76
|
| Rate for Payer: Quartz Commercial |
$273.03
|
| Rate for Payer: Quartz Medicare Advantage |
$17.29
|
| Rate for Payer: The Alliance Commercial |
$65.70
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.29
|
| Rate for Payer: WEA Trust Commercial |
$263.45
|
| Rate for Payer: WPS Commercial |
$86.45
|
|
|
XR Panorex/Orthopantogram
|
Facility
IP
|
$479.00
|
|
|
Service Code
|
CPT 70355
|
| Hospital Charge Code |
630293
|
| Min. Negotiated Rate |
$234.71 |
| Max. Negotiated Rate |
$440.68 |
| Rate for Payer: Aetna Commercial |
$431.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$253.87
|
| Rate for Payer: Cash Price |
$143.70
|
| Rate for Payer: Cigna Commercial |
$440.68
|
| Rate for Payer: Health EOS Commercial |
$426.31
|
| Rate for Payer: HFN Commercial |
$440.68
|
| Rate for Payer: Multiplan Commercial |
$383.20
|
| Rate for Payer: NAPHCARE Commercial |
$287.40
|
| Rate for Payer: Preferred Network Access Commercial |
$440.68
|
| Rate for Payer: Quartz Beloit One Network |
$234.71
|
| Rate for Payer: Quartz Commercial |
$287.40
|
| Rate for Payer: WEA Trust Commercial |
$263.45
|
| Rate for Payer: WPS Commercial |
$354.80
|
|
|
XR Panorex/Orthopantogram
|
Professional
|
$517.00
|
|
|
Service Code
|
CPT 70355
|
| Hospital Charge Code |
1537222
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$17.29 |
| Max. Negotiated Rate |
$491.15 |
| Rate for Payer: Aetna Commercial |
$491.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$444.62
|
| Rate for Payer: Aetna Managed Medicare |
$17.29
|
| Rate for Payer: Anthem Medicare Advantage |
$17.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.29
|
| Rate for Payer: Cash Price |
$155.10
|
| Rate for Payer: Cash Price |
$155.10
|
| Rate for Payer: Cigna Commercial |
$491.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$258.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17.29
|
| Rate for Payer: Health EOS Commercial |
$470.47
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$62.48
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$62.48
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.29
|
| Rate for Payer: Multiplan Commercial |
$413.60
|
| Rate for Payer: Preferred Network Access Commercial |
$491.15
|
| Rate for Payer: Quartz Beloit One Network |
$227.48
|
| Rate for Payer: Quartz Commercial |
$294.69
|
| Rate for Payer: Quartz Medicare Advantage |
$17.29
|
| Rate for Payer: The Alliance Commercial |
$65.70
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.29
|
| Rate for Payer: WEA Trust Commercial |
$284.35
|
| Rate for Payer: WPS Commercial |
$86.45
|
|
|
XR Pelvimetry
|
Facility
IP
|
$577.00
|
|
|
Service Code
|
CPT 72170
|
| Hospital Charge Code |
1537224
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$282.73 |
| Max. Negotiated Rate |
$530.84 |
| Rate for Payer: Aetna Commercial |
$519.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$305.81
|
| Rate for Payer: Cash Price |
$173.10
|
| Rate for Payer: Cigna Commercial |
$530.84
|
| Rate for Payer: Health EOS Commercial |
$513.53
|
| Rate for Payer: HFN Commercial |
$530.84
|
| Rate for Payer: Multiplan Commercial |
$461.60
|
| Rate for Payer: NAPHCARE Commercial |
$346.20
|
| Rate for Payer: Preferred Network Access Commercial |
$530.84
|
| Rate for Payer: Quartz Beloit One Network |
$282.73
|
| Rate for Payer: Quartz Commercial |
$346.20
|
| Rate for Payer: WEA Trust Commercial |
$317.35
|
| Rate for Payer: WPS Commercial |
$427.38
|
|
|
XR Pelvimetry
|
Professional
|
$754.00
|
|
|
Service Code
|
CPT 74710
|
| Hospital Charge Code |
630291
|
| Min. Negotiated Rate |
$38.56 |
| Max. Negotiated Rate |
$716.30 |
| Rate for Payer: Aetna Commercial |
$716.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$648.44
|
| Rate for Payer: Aetna Managed Medicare |
$38.56
|
| Rate for Payer: Anthem Medicare Advantage |
$38.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$38.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$38.56
|
| Rate for Payer: Cash Price |
$226.20
|
| Rate for Payer: Cash Price |
$226.20
|
| Rate for Payer: Cigna Commercial |
$716.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$377.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$38.56
|
| Rate for Payer: Health EOS Commercial |
$686.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$135.80
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$135.80
|
| Rate for Payer: Independent Care Health Plan Medicare |
$38.56
|
| Rate for Payer: Multiplan Commercial |
$603.20
|
| Rate for Payer: Preferred Network Access Commercial |
$716.30
|
| Rate for Payer: Quartz Beloit One Network |
$331.76
|
| Rate for Payer: Quartz Commercial |
$429.78
|
| Rate for Payer: Quartz Medicare Advantage |
$38.56
|
| Rate for Payer: The Alliance Commercial |
$146.53
|
| Rate for Payer: United Healthcare Medicare Advantage |
$38.56
|
| Rate for Payer: WEA Trust Commercial |
$414.70
|
| Rate for Payer: WPS Commercial |
$192.80
|
|
|
XR Pelvimetry
|
Facility
OP
|
$754.00
|
|
|
Service Code
|
CPT 74710
|
| Hospital Charge Code |
630291
|
| Min. Negotiated Rate |
$211.12 |
| Max. Negotiated Rate |
$3,016.00 |
| Rate for Payer: Aetna Commercial |
$678.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$648.44
|
| Rate for Payer: Aetna Managed Medicare |
$211.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$490.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$377.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$361.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$399.62
|
| Rate for Payer: Cash Price |
$226.20
|
| Rate for Payer: Cash Price |
$226.20
|
| Rate for Payer: Cigna Commercial |
$693.68
|
| Rate for Payer: Health EOS Commercial |
$671.06
|
| Rate for Payer: HFN Commercial |
$693.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$565.50
|
| Rate for Payer: Multiplan Commercial |
$603.20
|
| Rate for Payer: NAPHCARE Commercial |
$452.40
|
| Rate for Payer: Preferred Network Access Commercial |
$693.68
|
| Rate for Payer: Quartz Beloit One Network |
$369.46
|
| Rate for Payer: Quartz Commercial |
$490.10
|
| Rate for Payer: Quartz Medicare Advantage |
$452.40
|
| Rate for Payer: The Alliance Commercial |
$3,016.00
|
| Rate for Payer: WEA Trust Commercial |
$414.70
|
| Rate for Payer: WPS Commercial |
$558.49
|
|
|
XR Pelvimetry
|
Professional
|
$577.00
|
|
|
Service Code
|
CPT 72170
|
| Hospital Charge Code |
1537224
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$26.90 |
| Max. Negotiated Rate |
$548.15 |
| Rate for Payer: Aetna Commercial |
$548.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$496.22
|
| Rate for Payer: Aetna Managed Medicare |
$26.90
|
| Rate for Payer: Anthem Medicare Advantage |
$26.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$26.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$26.90
|
| Rate for Payer: Cash Price |
$173.10
|
| Rate for Payer: Cash Price |
$173.10
|
| Rate for Payer: Cigna Commercial |
$548.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$288.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$26.90
|
| Rate for Payer: Health EOS Commercial |
$525.07
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$93.62
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$93.62
|
| Rate for Payer: Independent Care Health Plan Medicare |
$26.90
|
| Rate for Payer: Multiplan Commercial |
$461.60
|
| Rate for Payer: Preferred Network Access Commercial |
$548.15
|
| Rate for Payer: Quartz Beloit One Network |
$253.88
|
| Rate for Payer: Quartz Commercial |
$328.89
|
| Rate for Payer: Quartz Medicare Advantage |
$26.90
|
| Rate for Payer: The Alliance Commercial |
$102.22
|
| Rate for Payer: United Healthcare Medicare Advantage |
$26.90
|
| Rate for Payer: WEA Trust Commercial |
$317.35
|
| Rate for Payer: WPS Commercial |
$134.50
|
|
|
XR Pelvimetry
|
Facility
OP
|
$577.00
|
|
|
Service Code
|
CPT 72170
|
| Hospital Charge Code |
1537224
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$108.67 |
| Max. Negotiated Rate |
$530.84 |
| Rate for Payer: Aetna Commercial |
$519.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$496.22
|
| 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 |
$305.81
|
| 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 |
$173.10
|
| Rate for Payer: Cash Price |
$173.10
|
| Rate for Payer: Cash Price |
$173.10
|
| Rate for Payer: Cigna Commercial |
$530.84
|
| 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 |
$513.53
|
| Rate for Payer: HFN Commercial |
$530.84
|
| 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 |
$461.60
|
| Rate for Payer: NAPHCARE Commercial |
$163.00
|
| Rate for Payer: Preferred Network Access Commercial |
$530.84
|
| Rate for Payer: Quartz Beloit One Network |
$282.73
|
| Rate for Payer: Quartz Commercial |
$375.05
|
| Rate for Payer: Quartz Medicare Advantage |
$108.67
|
| Rate for Payer: The Alliance Commercial |
$275.88
|
| Rate for Payer: United Healthcare Medicare Advantage |
$108.67
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$317.35
|
| Rate for Payer: Wellcare Medicare |
$108.67
|
| Rate for Payer: WPS Commercial |
$427.38
|
|
|
XR Pelvimetry
|
Facility
IP
|
$754.00
|
|
|
Service Code
|
CPT 74710
|
| Hospital Charge Code |
630291
|
| Min. Negotiated Rate |
$369.46 |
| Max. Negotiated Rate |
$693.68 |
| Rate for Payer: Aetna Commercial |
$678.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$399.62
|
| Rate for Payer: Cash Price |
$226.20
|
| Rate for Payer: Cigna Commercial |
$693.68
|
| Rate for Payer: Health EOS Commercial |
$671.06
|
| Rate for Payer: HFN Commercial |
$693.68
|
| Rate for Payer: Multiplan Commercial |
$603.20
|
| Rate for Payer: NAPHCARE Commercial |
$452.40
|
| Rate for Payer: Preferred Network Access Commercial |
$693.68
|
| Rate for Payer: Quartz Beloit One Network |
$369.46
|
| Rate for Payer: Quartz Commercial |
$452.40
|
| Rate for Payer: WEA Trust Commercial |
$414.70
|
| Rate for Payer: WPS Commercial |
$558.49
|
|
|
XR Pelvis 1 or 2 Views
|
Facility
IP
|
$535.00
|
|
|
Service Code
|
CPT 72170
|
| Hospital Charge Code |
630285
|
| Min. Negotiated Rate |
$262.15 |
| Max. Negotiated Rate |
$492.20 |
| Rate for Payer: Aetna Commercial |
$481.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$283.55
|
| Rate for Payer: Cash Price |
$160.50
|
| Rate for Payer: Cigna Commercial |
$492.20
|
| Rate for Payer: Health EOS Commercial |
$476.15
|
| Rate for Payer: HFN Commercial |
$492.20
|
| Rate for Payer: Multiplan Commercial |
$428.00
|
| Rate for Payer: NAPHCARE Commercial |
$321.00
|
| Rate for Payer: Preferred Network Access Commercial |
$492.20
|
| Rate for Payer: Quartz Beloit One Network |
$262.15
|
| Rate for Payer: Quartz Commercial |
$321.00
|
| Rate for Payer: WEA Trust Commercial |
$294.25
|
| Rate for Payer: WPS Commercial |
$396.27
|
|
|
XR Pelvis 1 or 2 Views
|
Professional
|
$535.00
|
|
|
Service Code
|
CPT 72170
|
| Hospital Charge Code |
630285
|
| Min. Negotiated Rate |
$26.90 |
| Max. Negotiated Rate |
$508.25 |
| Rate for Payer: Aetna Commercial |
$508.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$460.10
|
| Rate for Payer: Aetna Managed Medicare |
$26.90
|
| Rate for Payer: Anthem Medicare Advantage |
$26.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$26.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$26.90
|
| Rate for Payer: Cash Price |
$160.50
|
| Rate for Payer: Cash Price |
$160.50
|
| Rate for Payer: Cigna Commercial |
$508.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$267.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$26.90
|
| Rate for Payer: Health EOS Commercial |
$486.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$93.62
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$93.62
|
| Rate for Payer: Independent Care Health Plan Medicare |
$26.90
|
| Rate for Payer: Multiplan Commercial |
$428.00
|
| Rate for Payer: Preferred Network Access Commercial |
$508.25
|
| Rate for Payer: Quartz Beloit One Network |
$235.40
|
| Rate for Payer: Quartz Commercial |
$304.95
|
| Rate for Payer: Quartz Medicare Advantage |
$26.90
|
| Rate for Payer: The Alliance Commercial |
$102.22
|
| Rate for Payer: United Healthcare Medicare Advantage |
$26.90
|
| Rate for Payer: WEA Trust Commercial |
$294.25
|
| Rate for Payer: WPS Commercial |
$134.50
|
|
|
XR Pelvis 1 or 2 Views
|
Professional
|
$577.00
|
|
|
Service Code
|
CPT 72170 TC
|
| Hospital Charge Code |
1537228
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$18.78 |
| Max. Negotiated Rate |
$548.15 |
| Rate for Payer: Aetna Commercial |
$548.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$496.22
|
| Rate for Payer: Aetna Managed Medicare |
$18.78
|
| Rate for Payer: Anthem Medicare Advantage |
$18.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$18.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$18.78
|
| Rate for Payer: Cash Price |
$173.10
|
| Rate for Payer: Cash Price |
$173.10
|
| Rate for Payer: Cigna Commercial |
$548.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$288.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$18.78
|
| Rate for Payer: Health EOS Commercial |
$525.07
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$64.18
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$64.18
|
| Rate for Payer: Independent Care Health Plan Medicare |
$18.78
|
| Rate for Payer: Multiplan Commercial |
$461.60
|
| Rate for Payer: Preferred Network Access Commercial |
$548.15
|
| Rate for Payer: Quartz Beloit One Network |
$253.88
|
| Rate for Payer: Quartz Commercial |
$328.89
|
| Rate for Payer: Quartz Medicare Advantage |
$18.78
|
| Rate for Payer: The Alliance Commercial |
$71.36
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.78
|
| Rate for Payer: WEA Trust Commercial |
$317.35
|
| Rate for Payer: WPS Commercial |
$93.90
|
|
|
XR Pelvis 1 or 2 Views
|
Facility
OP
|
$577.00
|
|
|
Service Code
|
CPT 72170 TC
|
| Hospital Charge Code |
1537228
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$161.56 |
| Max. Negotiated Rate |
$2,308.00 |
| Rate for Payer: Aetna Commercial |
$519.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$496.22
|
| Rate for Payer: Aetna Managed Medicare |
$161.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$375.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$288.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$276.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$305.81
|
| Rate for Payer: Cash Price |
$173.10
|
| Rate for Payer: Cash Price |
$173.10
|
| Rate for Payer: Cash Price |
$173.10
|
| Rate for Payer: Cigna Commercial |
$530.84
|
| Rate for Payer: Health EOS Commercial |
$513.53
|
| Rate for Payer: HFN Commercial |
$530.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$432.75
|
| Rate for Payer: Multiplan Commercial |
$461.60
|
| Rate for Payer: NAPHCARE Commercial |
$346.20
|
| Rate for Payer: Preferred Network Access Commercial |
$530.84
|
| Rate for Payer: Quartz Beloit One Network |
$282.73
|
| Rate for Payer: Quartz Commercial |
$375.05
|
| Rate for Payer: Quartz Medicare Advantage |
$346.20
|
| Rate for Payer: The Alliance Commercial |
$2,308.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$317.35
|
| Rate for Payer: WPS Commercial |
$427.38
|
|
|
XR Pelvis 1 or 2 Views
|
Facility
OP
|
$535.00
|
|
|
Service Code
|
CPT 72170
|
| Hospital Charge Code |
630285
|
| Min. Negotiated Rate |
$108.67 |
| Max. Negotiated Rate |
$492.20 |
| Rate for Payer: Aetna Commercial |
$481.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$460.10
|
| Rate for Payer: Aetna Managed Medicare |
$108.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$347.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$267.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$256.80
|
| Rate for Payer: Anthem Medicare Advantage |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$283.55
|
| 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 |
$160.50
|
| Rate for Payer: Cash Price |
$160.50
|
| Rate for Payer: Cigna Commercial |
$492.20
|
| 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 |
$476.15
|
| Rate for Payer: HFN Commercial |
$492.20
|
| 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 |
$428.00
|
| Rate for Payer: NAPHCARE Commercial |
$163.00
|
| Rate for Payer: Preferred Network Access Commercial |
$492.20
|
| Rate for Payer: Quartz Beloit One Network |
$262.15
|
| Rate for Payer: Quartz Commercial |
$347.75
|
| Rate for Payer: Quartz Medicare Advantage |
$108.67
|
| Rate for Payer: The Alliance Commercial |
$275.88
|
| Rate for Payer: United Healthcare Medicare Advantage |
$108.67
|
| Rate for Payer: WEA Trust Commercial |
$294.25
|
| Rate for Payer: Wellcare Medicare |
$108.67
|
| Rate for Payer: WPS Commercial |
$396.27
|
|
|
XR Pelvis 1 or 2 Views
|
Facility
IP
|
$577.00
|
|
|
Service Code
|
CPT 72170 TC
|
| Hospital Charge Code |
1537228
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$282.73 |
| Max. Negotiated Rate |
$530.84 |
| Rate for Payer: Aetna Commercial |
$519.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$305.81
|
| Rate for Payer: Cash Price |
$173.10
|
| Rate for Payer: Cigna Commercial |
$530.84
|
| Rate for Payer: Health EOS Commercial |
$513.53
|
| Rate for Payer: HFN Commercial |
$530.84
|
| Rate for Payer: Multiplan Commercial |
$461.60
|
| Rate for Payer: NAPHCARE Commercial |
$346.20
|
| Rate for Payer: Preferred Network Access Commercial |
$530.84
|
| Rate for Payer: Quartz Beloit One Network |
$282.73
|
| Rate for Payer: Quartz Commercial |
$346.20
|
| Rate for Payer: WEA Trust Commercial |
$317.35
|
| Rate for Payer: WPS Commercial |
$427.38
|
|
|
XR Pelvis 1 View
|
Professional
|
$577.00
|
|
|
Service Code
|
CPT 72170 TC
|
| Hospital Charge Code |
6182059
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$18.78 |
| Max. Negotiated Rate |
$548.15 |
| Rate for Payer: Aetna Commercial |
$548.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$496.22
|
| Rate for Payer: Aetna Managed Medicare |
$18.78
|
| Rate for Payer: Anthem Medicare Advantage |
$18.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$18.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$18.78
|
| Rate for Payer: Cash Price |
$173.10
|
| Rate for Payer: Cash Price |
$173.10
|
| Rate for Payer: Cigna Commercial |
$548.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$288.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$18.78
|
| Rate for Payer: Health EOS Commercial |
$525.07
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$64.18
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$64.18
|
| Rate for Payer: Independent Care Health Plan Medicare |
$18.78
|
| Rate for Payer: Multiplan Commercial |
$461.60
|
| Rate for Payer: Preferred Network Access Commercial |
$548.15
|
| Rate for Payer: Quartz Beloit One Network |
$253.88
|
| Rate for Payer: Quartz Commercial |
$328.89
|
| Rate for Payer: Quartz Medicare Advantage |
$18.78
|
| Rate for Payer: The Alliance Commercial |
$71.36
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.78
|
| Rate for Payer: WEA Trust Commercial |
$317.35
|
| Rate for Payer: WPS Commercial |
$93.90
|
|
|
XR Pelvis 1 View
|
Facility
OP
|
$577.00
|
|
|
Service Code
|
CPT 72170 TC
|
| Hospital Charge Code |
6182059
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$161.56 |
| Max. Negotiated Rate |
$2,308.00 |
| Rate for Payer: Aetna Commercial |
$519.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$496.22
|
| Rate for Payer: Aetna Managed Medicare |
$161.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$375.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$288.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$276.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$305.81
|
| Rate for Payer: Cash Price |
$173.10
|
| Rate for Payer: Cash Price |
$173.10
|
| Rate for Payer: Cash Price |
$173.10
|
| Rate for Payer: Cigna Commercial |
$530.84
|
| Rate for Payer: Health EOS Commercial |
$513.53
|
| Rate for Payer: HFN Commercial |
$530.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$432.75
|
| Rate for Payer: Multiplan Commercial |
$461.60
|
| Rate for Payer: NAPHCARE Commercial |
$346.20
|
| Rate for Payer: Preferred Network Access Commercial |
$530.84
|
| Rate for Payer: Quartz Beloit One Network |
$282.73
|
| Rate for Payer: Quartz Commercial |
$375.05
|
| Rate for Payer: Quartz Medicare Advantage |
$346.20
|
| Rate for Payer: The Alliance Commercial |
$2,308.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$317.35
|
| Rate for Payer: WPS Commercial |
$427.38
|
|
|
XR Pelvis 1 View
|
Facility
IP
|
$577.00
|
|
|
Service Code
|
CPT 72170 TC
|
| Hospital Charge Code |
6182059
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$282.73 |
| Max. Negotiated Rate |
$530.84 |
| Rate for Payer: Aetna Commercial |
$519.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$305.81
|
| Rate for Payer: Cash Price |
$173.10
|
| Rate for Payer: Cigna Commercial |
$530.84
|
| Rate for Payer: Health EOS Commercial |
$513.53
|
| Rate for Payer: HFN Commercial |
$530.84
|
| Rate for Payer: Multiplan Commercial |
$461.60
|
| Rate for Payer: NAPHCARE Commercial |
$346.20
|
| Rate for Payer: Preferred Network Access Commercial |
$530.84
|
| Rate for Payer: Quartz Beloit One Network |
$282.73
|
| Rate for Payer: Quartz Commercial |
$346.20
|
| Rate for Payer: WEA Trust Commercial |
$317.35
|
| Rate for Payer: WPS Commercial |
$427.38
|
|
|
XR Pelvis Complete Minimum 3 Views
|
Professional
|
$684.00
|
|
|
Service Code
|
CPT 72190
|
| Hospital Charge Code |
630281
|
| Min. Negotiated Rate |
$40.88 |
| Max. Negotiated Rate |
$649.80 |
| Rate for Payer: Aetna Commercial |
$649.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$588.24
|
| Rate for Payer: Aetna Managed Medicare |
$40.88
|
| Rate for Payer: Anthem Medicare Advantage |
$40.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$40.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$40.88
|
| Rate for Payer: Cash Price |
$205.20
|
| Rate for Payer: Cash Price |
$205.20
|
| Rate for Payer: Cigna Commercial |
$649.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$342.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$40.88
|
| Rate for Payer: Health EOS Commercial |
$622.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$141.76
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$141.76
|
| Rate for Payer: Independent Care Health Plan Medicare |
$40.88
|
| Rate for Payer: Multiplan Commercial |
$547.20
|
| Rate for Payer: Preferred Network Access Commercial |
$649.80
|
| Rate for Payer: Quartz Beloit One Network |
$300.96
|
| Rate for Payer: Quartz Commercial |
$389.88
|
| Rate for Payer: Quartz Medicare Advantage |
$40.88
|
| Rate for Payer: The Alliance Commercial |
$155.34
|
| Rate for Payer: United Healthcare Medicare Advantage |
$40.88
|
| Rate for Payer: WEA Trust Commercial |
$376.20
|
| Rate for Payer: WPS Commercial |
$204.40
|
|
|
XR Pelvis Complete Minimum 3 Views
|
Professional
|
$711.00
|
|
|
Service Code
|
CPT 72190 TC
|
| Hospital Charge Code |
1537230
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$29.08 |
| Max. Negotiated Rate |
$675.45 |
| Rate for Payer: Aetna Commercial |
$675.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$611.46
|
| Rate for Payer: Aetna Managed Medicare |
$29.08
|
| Rate for Payer: Anthem Medicare Advantage |
$29.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$29.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$29.08
|
| Rate for Payer: Cash Price |
$213.30
|
| Rate for Payer: Cash Price |
$213.30
|
| Rate for Payer: Cigna Commercial |
$675.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$355.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$29.08
|
| Rate for Payer: Health EOS Commercial |
$647.01
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$99.02
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$99.02
|
| Rate for Payer: Independent Care Health Plan Medicare |
$29.08
|
| Rate for Payer: Multiplan Commercial |
$568.80
|
| Rate for Payer: Preferred Network Access Commercial |
$675.45
|
| Rate for Payer: Quartz Beloit One Network |
$312.84
|
| Rate for Payer: Quartz Commercial |
$405.27
|
| Rate for Payer: Quartz Medicare Advantage |
$29.08
|
| Rate for Payer: The Alliance Commercial |
$110.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$29.08
|
| Rate for Payer: WEA Trust Commercial |
$391.05
|
| Rate for Payer: WPS Commercial |
$145.40
|
|
|
XR Pelvis Complete Minimum 3 Views
|
Facility
OP
|
$684.00
|
|
|
Service Code
|
CPT 72190
|
| Hospital Charge Code |
630281
|
| Min. Negotiated Rate |
$108.67 |
| Max. Negotiated Rate |
$629.28 |
| Rate for Payer: Aetna Commercial |
$615.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$588.24
|
| Rate for Payer: Aetna Managed Medicare |
$108.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$444.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$342.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$328.32
|
| Rate for Payer: Anthem Medicare Advantage |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$362.52
|
| 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 |
$205.20
|
| Rate for Payer: Cash Price |
$205.20
|
| Rate for Payer: Cigna Commercial |
$629.28
|
| 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 |
$608.76
|
| Rate for Payer: HFN Commercial |
$629.28
|
| 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 |
$547.20
|
| Rate for Payer: NAPHCARE Commercial |
$163.00
|
| Rate for Payer: Preferred Network Access Commercial |
$629.28
|
| Rate for Payer: Quartz Beloit One Network |
$335.16
|
| Rate for Payer: Quartz Commercial |
$444.60
|
| Rate for Payer: Quartz Medicare Advantage |
$108.67
|
| Rate for Payer: The Alliance Commercial |
$509.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$108.67
|
| Rate for Payer: WEA Trust Commercial |
$376.20
|
| Rate for Payer: Wellcare Medicare |
$108.67
|
| Rate for Payer: WPS Commercial |
$506.64
|
|
|
XR Pelvis Complete Minimum 3 Views
|
Facility
IP
|
$684.00
|
|
|
Service Code
|
CPT 72190
|
| Hospital Charge Code |
630281
|
| Min. Negotiated Rate |
$335.16 |
| Max. Negotiated Rate |
$629.28 |
| Rate for Payer: Aetna Commercial |
$615.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$362.52
|
| Rate for Payer: Cash Price |
$205.20
|
| Rate for Payer: Cigna Commercial |
$629.28
|
| Rate for Payer: Health EOS Commercial |
$608.76
|
| Rate for Payer: HFN Commercial |
$629.28
|
| Rate for Payer: Multiplan Commercial |
$547.20
|
| Rate for Payer: NAPHCARE Commercial |
$410.40
|
| Rate for Payer: Preferred Network Access Commercial |
$629.28
|
| Rate for Payer: Quartz Beloit One Network |
$335.16
|
| Rate for Payer: Quartz Commercial |
$410.40
|
| Rate for Payer: WEA Trust Commercial |
$376.20
|
| Rate for Payer: WPS Commercial |
$506.64
|
|
|
XR Pelvis Complete Minimum 3 Views
|
Facility
IP
|
$711.00
|
|
|
Service Code
|
CPT 72190 TC
|
| Hospital Charge Code |
1537230
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$348.39 |
| Max. Negotiated Rate |
$654.12 |
| Rate for Payer: Aetna Commercial |
$639.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$376.83
|
| Rate for Payer: Cash Price |
$213.30
|
| Rate for Payer: Cigna Commercial |
$654.12
|
| Rate for Payer: Health EOS Commercial |
$632.79
|
| Rate for Payer: HFN Commercial |
$654.12
|
| Rate for Payer: Multiplan Commercial |
$568.80
|
| Rate for Payer: NAPHCARE Commercial |
$426.60
|
| Rate for Payer: Preferred Network Access Commercial |
$654.12
|
| Rate for Payer: Quartz Beloit One Network |
$348.39
|
| Rate for Payer: Quartz Commercial |
$426.60
|
| Rate for Payer: WEA Trust Commercial |
$391.05
|
| Rate for Payer: WPS Commercial |
$526.64
|
|
