|
XR Scapula Right
|
Facility
|
OP
|
$577.00
|
|
|
Service Code
|
CPT 73010
|
| Hospital Charge Code |
630162
|
| 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 |
$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: 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: Cigna Commercial |
$530.84
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$108.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$322.89
|
| 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 |
$434.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$108.67
|
| Rate for Payer: WEA Trust Commercial |
$317.35
|
| Rate for Payer: Wellcare Medicare |
$108.67
|
| Rate for Payer: WPS Commercial |
$427.38
|
|
|
XR Scapula Right
|
Facility
|
IP
|
$600.00
|
|
|
Service Code
|
CPT 73010 TC,RT
|
| Hospital Charge Code |
2979992
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$294.00 |
| Max. Negotiated Rate |
$552.00 |
| Rate for Payer: Aetna Commercial |
$540.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$516.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$318.00
|
| Rate for Payer: Cash Price |
$180.00
|
| Rate for Payer: Cigna Commercial |
$552.00
|
| Rate for Payer: Health EOS Commercial |
$534.00
|
| Rate for Payer: HFN Commercial |
$552.00
|
| Rate for Payer: Multiplan Commercial |
$480.00
|
| Rate for Payer: NAPHCARE Commercial |
$360.00
|
| Rate for Payer: Preferred Network Access Commercial |
$552.00
|
| Rate for Payer: Quartz Beloit One Network |
$294.00
|
| Rate for Payer: Quartz Commercial |
$360.00
|
| Rate for Payer: WEA Trust Commercial |
$330.00
|
| Rate for Payer: WPS Commercial |
$444.42
|
|
|
XR Scapula Right
|
Professional
|
Both
|
$600.00
|
|
|
Service Code
|
CPT 73010 TC,RT
|
| Hospital Charge Code |
2979992
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$79.67 |
| Max. Negotiated Rate |
$570.00 |
| Rate for Payer: Aetna Commercial |
$570.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$516.00
|
| Rate for Payer: Cash Price |
$180.00
|
| Rate for Payer: Cash Price |
$180.00
|
| Rate for Payer: Cash Price |
$180.00
|
| Rate for Payer: Cigna Commercial |
$570.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$300.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$360.00
|
| Rate for Payer: Health EOS Commercial |
$546.00
|
| Rate for Payer: HFN Commercial |
$570.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$79.67
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$79.67
|
| Rate for Payer: Multiplan Commercial |
$480.00
|
| Rate for Payer: Preferred Network Access Commercial |
$570.00
|
| Rate for Payer: Quartz Beloit One Network |
$264.00
|
| Rate for Payer: Quartz Commercial |
$342.00
|
| Rate for Payer: The Alliance Commercial |
$300.00
|
| Rate for Payer: WEA Trust Commercial |
$330.00
|
| Rate for Payer: WPS Commercial |
$444.42
|
|
|
XR Sella Turcica
|
Professional
|
Both
|
$420.00
|
|
|
Service Code
|
CPT 70240
|
| Hospital Charge Code |
630156
|
| Min. Negotiated Rate |
$112.32 |
| Max. Negotiated Rate |
$399.00 |
| Rate for Payer: Aetna Commercial |
$399.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$361.20
|
| Rate for Payer: Cash Price |
$126.00
|
| Rate for Payer: Cash Price |
$126.00
|
| Rate for Payer: Cash Price |
$126.00
|
| Rate for Payer: Cigna Commercial |
$399.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$210.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$252.00
|
| Rate for Payer: Health EOS Commercial |
$382.20
|
| Rate for Payer: HFN Commercial |
$399.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$112.32
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$112.32
|
| Rate for Payer: Multiplan Commercial |
$336.00
|
| Rate for Payer: Preferred Network Access Commercial |
$399.00
|
| Rate for Payer: Quartz Beloit One Network |
$184.80
|
| Rate for Payer: Quartz Commercial |
$239.40
|
| Rate for Payer: The Alliance Commercial |
$210.00
|
| Rate for Payer: WEA Trust Commercial |
$231.00
|
| Rate for Payer: WPS Commercial |
$311.09
|
|
|
XR Sella Turcica
|
Facility
|
OP
|
$420.00
|
|
|
Service Code
|
CPT 70240
|
| Hospital Charge Code |
630156
|
| Min. Negotiated Rate |
$89.82 |
| Max. Negotiated Rate |
$386.40 |
| Rate for Payer: Aetna Commercial |
$378.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$361.20
|
| Rate for Payer: Aetna Managed Medicare |
$89.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$273.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$210.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$201.60
|
| Rate for Payer: Anthem Medicare Advantage |
$89.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$222.60
|
| 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 |
$126.00
|
| Rate for Payer: Cash Price |
$126.00
|
| Rate for Payer: Cigna Commercial |
$386.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$89.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$235.03
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$89.82
|
| Rate for Payer: Health EOS Commercial |
$373.80
|
| Rate for Payer: HFN Commercial |
$386.40
|
| 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 |
$336.00
|
| Rate for Payer: NAPHCARE Commercial |
$134.73
|
| Rate for Payer: Preferred Network Access Commercial |
$386.40
|
| Rate for Payer: Quartz Beloit One Network |
$205.80
|
| Rate for Payer: Quartz Commercial |
$273.00
|
| Rate for Payer: Quartz Medicare Advantage |
$89.82
|
| Rate for Payer: The Alliance Commercial |
$359.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$89.82
|
| Rate for Payer: WEA Trust Commercial |
$231.00
|
| Rate for Payer: Wellcare Medicare |
$89.82
|
| Rate for Payer: WPS Commercial |
$311.09
|
|
|
XR Sella Turcica
|
Professional
|
Both
|
$437.00
|
|
|
Service Code
|
CPT 70240
|
| Hospital Charge Code |
1537282
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$112.32 |
| Max. Negotiated Rate |
$415.15 |
| Rate for Payer: Aetna Commercial |
$415.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$375.82
|
| Rate for Payer: Cash Price |
$131.10
|
| Rate for Payer: Cash Price |
$131.10
|
| Rate for Payer: Cash Price |
$131.10
|
| Rate for Payer: Cigna Commercial |
$415.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$218.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$262.20
|
| Rate for Payer: Health EOS Commercial |
$397.67
|
| Rate for Payer: HFN Commercial |
$415.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$112.32
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$112.32
|
| Rate for Payer: Multiplan Commercial |
$349.60
|
| Rate for Payer: Preferred Network Access Commercial |
$415.15
|
| Rate for Payer: Quartz Beloit One Network |
$192.28
|
| Rate for Payer: Quartz Commercial |
$249.09
|
| Rate for Payer: The Alliance Commercial |
$218.50
|
| Rate for Payer: WEA Trust Commercial |
$240.35
|
| Rate for Payer: WPS Commercial |
$323.69
|
|
|
XR Sella Turcica
|
Facility
|
OP
|
$437.00
|
|
|
Service Code
|
CPT 70240
|
| Hospital Charge Code |
1537282
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$89.82 |
| Max. Negotiated Rate |
$402.04 |
| Rate for Payer: Aetna Commercial |
$393.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$375.82
|
| 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 |
$231.61
|
| 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 |
$131.10
|
| Rate for Payer: Cash Price |
$131.10
|
| Rate for Payer: Cash Price |
$131.10
|
| Rate for Payer: Cigna Commercial |
$402.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$89.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$244.55
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$89.82
|
| Rate for Payer: Health EOS Commercial |
$388.93
|
| Rate for Payer: HFN Commercial |
$402.04
|
| 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 |
$349.60
|
| Rate for Payer: NAPHCARE Commercial |
$134.73
|
| Rate for Payer: Preferred Network Access Commercial |
$402.04
|
| Rate for Payer: Quartz Beloit One Network |
$214.13
|
| Rate for Payer: Quartz Commercial |
$284.05
|
| Rate for Payer: Quartz Medicare Advantage |
$89.82
|
| Rate for Payer: The Alliance Commercial |
$359.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$89.82
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$240.35
|
| Rate for Payer: Wellcare Medicare |
$89.82
|
| Rate for Payer: WPS Commercial |
$323.69
|
|
|
XR Sella Turcica
|
Facility
|
IP
|
$437.00
|
|
|
Service Code
|
CPT 70240
|
| Hospital Charge Code |
1537282
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$214.13 |
| Max. Negotiated Rate |
$402.04 |
| Rate for Payer: Aetna Commercial |
$393.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$375.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$231.61
|
| Rate for Payer: Cash Price |
$131.10
|
| Rate for Payer: Cigna Commercial |
$402.04
|
| Rate for Payer: Health EOS Commercial |
$388.93
|
| Rate for Payer: HFN Commercial |
$402.04
|
| Rate for Payer: Multiplan Commercial |
$349.60
|
| Rate for Payer: NAPHCARE Commercial |
$262.20
|
| Rate for Payer: Preferred Network Access Commercial |
$402.04
|
| Rate for Payer: Quartz Beloit One Network |
$214.13
|
| Rate for Payer: Quartz Commercial |
$262.20
|
| Rate for Payer: WEA Trust Commercial |
$240.35
|
| Rate for Payer: WPS Commercial |
$323.69
|
|
|
XR Sella Turcica
|
Facility
|
IP
|
$420.00
|
|
|
Service Code
|
CPT 70240
|
| Hospital Charge Code |
630156
|
| Min. Negotiated Rate |
$205.80 |
| Max. Negotiated Rate |
$386.40 |
| Rate for Payer: Aetna Commercial |
$378.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$361.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$222.60
|
| Rate for Payer: Cash Price |
$126.00
|
| Rate for Payer: Cigna Commercial |
$386.40
|
| Rate for Payer: Health EOS Commercial |
$373.80
|
| Rate for Payer: HFN Commercial |
$386.40
|
| Rate for Payer: Multiplan Commercial |
$336.00
|
| Rate for Payer: NAPHCARE Commercial |
$252.00
|
| Rate for Payer: Preferred Network Access Commercial |
$386.40
|
| Rate for Payer: Quartz Beloit One Network |
$205.80
|
| Rate for Payer: Quartz Commercial |
$252.00
|
| Rate for Payer: WEA Trust Commercial |
$231.00
|
| Rate for Payer: WPS Commercial |
$311.09
|
|
|
XR Shoulder 1 View Bilateral
|
Professional
|
Both
|
$498.00
|
|
|
Service Code
|
CPT 73020 LT,TC
|
| Hospital Charge Code |
1537284
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$72.58 |
| Max. Negotiated Rate |
$473.10 |
| Rate for Payer: Aetna Commercial |
$473.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$428.28
|
| Rate for Payer: Cash Price |
$149.40
|
| Rate for Payer: Cash Price |
$149.40
|
| Rate for Payer: Cash Price |
$149.40
|
| Rate for Payer: Cigna Commercial |
$473.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$249.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$298.80
|
| Rate for Payer: Health EOS Commercial |
$453.18
|
| Rate for Payer: HFN Commercial |
$473.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$72.58
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$72.58
|
| Rate for Payer: Multiplan Commercial |
$398.40
|
| Rate for Payer: Preferred Network Access Commercial |
$473.10
|
| Rate for Payer: Quartz Beloit One Network |
$219.12
|
| Rate for Payer: Quartz Commercial |
$283.86
|
| Rate for Payer: The Alliance Commercial |
$249.00
|
| Rate for Payer: WEA Trust Commercial |
$273.90
|
| Rate for Payer: WPS Commercial |
$368.87
|
|
|
XR Shoulder 1 View Bilateral
|
Facility
|
IP
|
$498.00
|
|
|
Service Code
|
CPT 73020 LT,TC
|
| Hospital Charge Code |
1537284
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$244.02 |
| Max. Negotiated Rate |
$458.16 |
| Rate for Payer: Aetna Commercial |
$448.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$428.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$263.94
|
| Rate for Payer: Cash Price |
$149.40
|
| Rate for Payer: Cigna Commercial |
$458.16
|
| Rate for Payer: Health EOS Commercial |
$443.22
|
| Rate for Payer: HFN Commercial |
$458.16
|
| Rate for Payer: Multiplan Commercial |
$398.40
|
| Rate for Payer: NAPHCARE Commercial |
$298.80
|
| Rate for Payer: Preferred Network Access Commercial |
$458.16
|
| Rate for Payer: Quartz Beloit One Network |
$244.02
|
| Rate for Payer: Quartz Commercial |
$298.80
|
| Rate for Payer: WEA Trust Commercial |
$273.90
|
| Rate for Payer: WPS Commercial |
$368.87
|
|
|
XR Shoulder 1 View Bilateral
|
Facility
|
IP
|
$959.00
|
|
|
Service Code
|
CPT 73020
|
| Hospital Charge Code |
630150
|
| Min. Negotiated Rate |
$469.91 |
| Max. Negotiated Rate |
$882.28 |
| Rate for Payer: Aetna Commercial |
$863.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$824.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$508.27
|
| Rate for Payer: Cash Price |
$287.70
|
| Rate for Payer: Cigna Commercial |
$882.28
|
| Rate for Payer: Health EOS Commercial |
$853.51
|
| Rate for Payer: HFN Commercial |
$882.28
|
| Rate for Payer: Multiplan Commercial |
$767.20
|
| Rate for Payer: NAPHCARE Commercial |
$575.40
|
| Rate for Payer: Preferred Network Access Commercial |
$882.28
|
| Rate for Payer: Quartz Beloit One Network |
$469.91
|
| Rate for Payer: Quartz Commercial |
$575.40
|
| Rate for Payer: WEA Trust Commercial |
$527.45
|
| Rate for Payer: WPS Commercial |
$710.33
|
|
|
XR Shoulder 1 View Bilateral
|
Facility
|
OP
|
$959.00
|
|
|
Service Code
|
CPT 73020
|
| Hospital Charge Code |
630150
|
| Min. Negotiated Rate |
$89.82 |
| Max. Negotiated Rate |
$882.28 |
| Rate for Payer: Aetna Commercial |
$863.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$824.74
|
| Rate for Payer: Aetna Managed Medicare |
$89.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$623.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$479.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$460.32
|
| Rate for Payer: Anthem Medicare Advantage |
$89.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$508.27
|
| 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 |
$287.70
|
| Rate for Payer: Cash Price |
$287.70
|
| Rate for Payer: Cigna Commercial |
$882.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$89.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$536.66
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$89.82
|
| Rate for Payer: Health EOS Commercial |
$853.51
|
| Rate for Payer: HFN Commercial |
$882.28
|
| 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 |
$767.20
|
| Rate for Payer: NAPHCARE Commercial |
$134.73
|
| Rate for Payer: Preferred Network Access Commercial |
$882.28
|
| Rate for Payer: Quartz Beloit One Network |
$469.91
|
| Rate for Payer: Quartz Commercial |
$623.35
|
| Rate for Payer: Quartz Medicare Advantage |
$89.82
|
| Rate for Payer: The Alliance Commercial |
$359.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$89.82
|
| Rate for Payer: WEA Trust Commercial |
$527.45
|
| Rate for Payer: Wellcare Medicare |
$89.82
|
| Rate for Payer: WPS Commercial |
$710.33
|
|
|
XR Shoulder 1 View Bilateral
|
Professional
|
Both
|
$959.00
|
|
|
Service Code
|
CPT 73020
|
| Hospital Charge Code |
630150
|
| Min. Negotiated Rate |
$72.58 |
| Max. Negotiated Rate |
$911.05 |
| Rate for Payer: Aetna Commercial |
$911.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$824.74
|
| Rate for Payer: Cash Price |
$287.70
|
| Rate for Payer: Cash Price |
$287.70
|
| Rate for Payer: Cash Price |
$287.70
|
| Rate for Payer: Cigna Commercial |
$911.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$479.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$575.40
|
| Rate for Payer: Health EOS Commercial |
$872.69
|
| Rate for Payer: HFN Commercial |
$911.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$72.58
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$72.58
|
| Rate for Payer: Multiplan Commercial |
$767.20
|
| Rate for Payer: Preferred Network Access Commercial |
$911.05
|
| Rate for Payer: Quartz Beloit One Network |
$421.96
|
| Rate for Payer: Quartz Commercial |
$546.63
|
| Rate for Payer: The Alliance Commercial |
$479.50
|
| Rate for Payer: WEA Trust Commercial |
$527.45
|
| Rate for Payer: WPS Commercial |
$710.33
|
|
|
XR Shoulder 1 View Bilateral
|
Facility
|
OP
|
$498.00
|
|
|
Service Code
|
CPT 73020 LT,TC
|
| Hospital Charge Code |
1537284
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$89.82 |
| Max. Negotiated Rate |
$458.16 |
| Rate for Payer: Aetna Commercial |
$448.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$428.28
|
| 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 |
$263.94
|
| 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 |
$149.40
|
| Rate for Payer: Cash Price |
$149.40
|
| Rate for Payer: Cash Price |
$149.40
|
| Rate for Payer: Cigna Commercial |
$458.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$89.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$278.68
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$89.82
|
| Rate for Payer: Health EOS Commercial |
$443.22
|
| Rate for Payer: HFN Commercial |
$458.16
|
| 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 |
$398.40
|
| Rate for Payer: NAPHCARE Commercial |
$134.73
|
| Rate for Payer: Preferred Network Access Commercial |
$458.16
|
| Rate for Payer: Quartz Beloit One Network |
$244.02
|
| Rate for Payer: Quartz Commercial |
$323.70
|
| Rate for Payer: Quartz Medicare Advantage |
$89.82
|
| Rate for Payer: The Alliance Commercial |
$359.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$89.82
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$273.90
|
| Rate for Payer: Wellcare Medicare |
$89.82
|
| Rate for Payer: WPS Commercial |
$368.87
|
|
|
XR Shoulder 1 View Left
|
Facility
|
OP
|
$479.00
|
|
|
Service Code
|
CPT 73020
|
| Hospital Charge Code |
630146
|
| Min. Negotiated Rate |
$89.82 |
| 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 DHI/DHP/ASO |
$268.05
|
| 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 |
$359.28
|
| 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 Shoulder 1 View Left
|
Facility
|
OP
|
$441.00
|
|
|
Service Code
|
CPT 73020 LT,TC
|
| Hospital Charge Code |
1537286
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$89.82 |
| Max. Negotiated Rate |
$405.72 |
| Rate for Payer: Aetna Commercial |
$396.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$379.26
|
| 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 |
$233.73
|
| 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 |
$132.30
|
| Rate for Payer: Cash Price |
$132.30
|
| Rate for Payer: Cash Price |
$132.30
|
| Rate for Payer: Cigna Commercial |
$405.72
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$89.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$246.78
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$89.82
|
| Rate for Payer: Health EOS Commercial |
$392.49
|
| Rate for Payer: HFN Commercial |
$405.72
|
| 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 |
$352.80
|
| Rate for Payer: NAPHCARE Commercial |
$134.73
|
| Rate for Payer: Preferred Network Access Commercial |
$405.72
|
| Rate for Payer: Quartz Beloit One Network |
$216.09
|
| Rate for Payer: Quartz Commercial |
$286.65
|
| Rate for Payer: Quartz Medicare Advantage |
$89.82
|
| Rate for Payer: The Alliance Commercial |
$359.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$89.82
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$242.55
|
| Rate for Payer: Wellcare Medicare |
$89.82
|
| Rate for Payer: WPS Commercial |
$326.65
|
|
|
XR Shoulder 1 View Left
|
Facility
|
IP
|
$479.00
|
|
|
Service Code
|
CPT 73020
|
| Hospital Charge Code |
630146
|
| Min. Negotiated Rate |
$234.71 |
| Max. Negotiated Rate |
$440.68 |
| Rate for Payer: Aetna Commercial |
$431.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$411.94
|
| 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 Shoulder 1 View Left
|
Facility
|
IP
|
$441.00
|
|
|
Service Code
|
CPT 73020 LT,TC
|
| Hospital Charge Code |
1537286
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$216.09 |
| Max. Negotiated Rate |
$405.72 |
| Rate for Payer: Aetna Commercial |
$396.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$379.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$233.73
|
| Rate for Payer: Cash Price |
$132.30
|
| Rate for Payer: Cigna Commercial |
$405.72
|
| Rate for Payer: Health EOS Commercial |
$392.49
|
| Rate for Payer: HFN Commercial |
$405.72
|
| Rate for Payer: Multiplan Commercial |
$352.80
|
| Rate for Payer: NAPHCARE Commercial |
$264.60
|
| Rate for Payer: Preferred Network Access Commercial |
$405.72
|
| Rate for Payer: Quartz Beloit One Network |
$216.09
|
| Rate for Payer: Quartz Commercial |
$264.60
|
| Rate for Payer: WEA Trust Commercial |
$242.55
|
| Rate for Payer: WPS Commercial |
$326.65
|
|
|
XR Shoulder 1 View Left
|
Professional
|
Both
|
$479.00
|
|
|
Service Code
|
CPT 73020
|
| Hospital Charge Code |
630146
|
| Min. Negotiated Rate |
$72.58 |
| Max. Negotiated Rate |
$455.05 |
| Rate for Payer: Aetna Commercial |
$455.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$411.94
|
| Rate for Payer: Cash Price |
$143.70
|
| 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 |
$287.40
|
| Rate for Payer: Health EOS Commercial |
$435.89
|
| Rate for Payer: HFN Commercial |
$455.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$72.58
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$72.58
|
| 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: The Alliance Commercial |
$239.50
|
| Rate for Payer: WEA Trust Commercial |
$263.45
|
| Rate for Payer: WPS Commercial |
$354.80
|
|
|
XR Shoulder 1 View Left
|
Professional
|
Both
|
$441.00
|
|
|
Service Code
|
CPT 73020 LT,TC
|
| Hospital Charge Code |
1537286
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$72.58 |
| Max. Negotiated Rate |
$418.95 |
| Rate for Payer: Aetna Commercial |
$418.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$379.26
|
| Rate for Payer: Cash Price |
$132.30
|
| Rate for Payer: Cash Price |
$132.30
|
| Rate for Payer: Cash Price |
$132.30
|
| Rate for Payer: Cigna Commercial |
$418.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$220.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$264.60
|
| Rate for Payer: Health EOS Commercial |
$401.31
|
| Rate for Payer: HFN Commercial |
$418.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$72.58
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$72.58
|
| Rate for Payer: Multiplan Commercial |
$352.80
|
| Rate for Payer: Preferred Network Access Commercial |
$418.95
|
| Rate for Payer: Quartz Beloit One Network |
$194.04
|
| Rate for Payer: Quartz Commercial |
$251.37
|
| Rate for Payer: The Alliance Commercial |
$220.50
|
| Rate for Payer: WEA Trust Commercial |
$242.55
|
| Rate for Payer: WPS Commercial |
$326.65
|
|
|
XR Shoulder 1 View Right
|
Facility
|
IP
|
$441.00
|
|
|
Service Code
|
CPT 73020 RT,TC
|
| Hospital Charge Code |
1537288
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$216.09 |
| Max. Negotiated Rate |
$405.72 |
| Rate for Payer: Aetna Commercial |
$396.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$379.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$233.73
|
| Rate for Payer: Cash Price |
$132.30
|
| Rate for Payer: Cigna Commercial |
$405.72
|
| Rate for Payer: Health EOS Commercial |
$392.49
|
| Rate for Payer: HFN Commercial |
$405.72
|
| Rate for Payer: Multiplan Commercial |
$352.80
|
| Rate for Payer: NAPHCARE Commercial |
$264.60
|
| Rate for Payer: Preferred Network Access Commercial |
$405.72
|
| Rate for Payer: Quartz Beloit One Network |
$216.09
|
| Rate for Payer: Quartz Commercial |
$264.60
|
| Rate for Payer: WEA Trust Commercial |
$242.55
|
| Rate for Payer: WPS Commercial |
$326.65
|
|
|
XR Shoulder 1 View Right
|
Facility
|
OP
|
$498.00
|
|
|
Service Code
|
CPT 73020 TC,RT
|
| Hospital Charge Code |
2979993
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$89.82 |
| Max. Negotiated Rate |
$458.16 |
| Rate for Payer: Aetna Commercial |
$448.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$428.28
|
| 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 |
$263.94
|
| 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 |
$149.40
|
| Rate for Payer: Cash Price |
$149.40
|
| Rate for Payer: Cash Price |
$149.40
|
| Rate for Payer: Cigna Commercial |
$458.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$89.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$278.68
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$89.82
|
| Rate for Payer: Health EOS Commercial |
$443.22
|
| Rate for Payer: HFN Commercial |
$458.16
|
| 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 |
$398.40
|
| Rate for Payer: NAPHCARE Commercial |
$134.73
|
| Rate for Payer: Preferred Network Access Commercial |
$458.16
|
| Rate for Payer: Quartz Beloit One Network |
$244.02
|
| Rate for Payer: Quartz Commercial |
$323.70
|
| Rate for Payer: Quartz Medicare Advantage |
$89.82
|
| Rate for Payer: The Alliance Commercial |
$359.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$89.82
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$273.90
|
| Rate for Payer: Wellcare Medicare |
$89.82
|
| Rate for Payer: WPS Commercial |
$368.87
|
|
|
XR Shoulder 1 View Right
|
Facility
|
IP
|
$498.00
|
|
|
Service Code
|
CPT 73020 TC,RT
|
| Hospital Charge Code |
2979993
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$244.02 |
| Max. Negotiated Rate |
$458.16 |
| Rate for Payer: Aetna Commercial |
$448.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$428.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$263.94
|
| Rate for Payer: Cash Price |
$149.40
|
| Rate for Payer: Cigna Commercial |
$458.16
|
| Rate for Payer: Health EOS Commercial |
$443.22
|
| Rate for Payer: HFN Commercial |
$458.16
|
| Rate for Payer: Multiplan Commercial |
$398.40
|
| Rate for Payer: NAPHCARE Commercial |
$298.80
|
| Rate for Payer: Preferred Network Access Commercial |
$458.16
|
| Rate for Payer: Quartz Beloit One Network |
$244.02
|
| Rate for Payer: Quartz Commercial |
$298.80
|
| Rate for Payer: WEA Trust Commercial |
$273.90
|
| Rate for Payer: WPS Commercial |
$368.87
|
|
|
XR Shoulder 1 View Right
|
Professional
|
Both
|
$441.00
|
|
|
Service Code
|
CPT 73020 RT,TC
|
| Hospital Charge Code |
1537288
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$72.58 |
| Max. Negotiated Rate |
$418.95 |
| Rate for Payer: Aetna Commercial |
$418.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$379.26
|
| Rate for Payer: Cash Price |
$132.30
|
| Rate for Payer: Cash Price |
$132.30
|
| Rate for Payer: Cash Price |
$132.30
|
| Rate for Payer: Cigna Commercial |
$418.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$220.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$264.60
|
| Rate for Payer: Health EOS Commercial |
$401.31
|
| Rate for Payer: HFN Commercial |
$418.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$72.58
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$72.58
|
| Rate for Payer: Multiplan Commercial |
$352.80
|
| Rate for Payer: Preferred Network Access Commercial |
$418.95
|
| Rate for Payer: Quartz Beloit One Network |
$194.04
|
| Rate for Payer: Quartz Commercial |
$251.37
|
| Rate for Payer: The Alliance Commercial |
$220.50
|
| Rate for Payer: WEA Trust Commercial |
$242.55
|
| Rate for Payer: WPS Commercial |
$326.65
|
|
