|
XR Shoulder Intern/Extern Rotation Right
|
Facility
|
OP
|
$621.00
|
|
|
Service Code
|
CPT 73030
|
| Hospital Charge Code |
711794
|
| Min. Negotiated Rate |
$91.58 |
| Max. Negotiated Rate |
$594.17 |
| Rate for Payer: Aetna Commercial |
$581.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$555.42
|
| Rate for Payer: Aetna Managed Medicare |
$91.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$419.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$322.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$310.00
|
| Rate for Payer: Anthem Medicare Advantage |
$91.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$342.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$91.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$91.58
|
| Rate for Payer: Cash Price |
$186.30
|
| Rate for Payer: Cash Price |
$186.30
|
| Rate for Payer: Cigna Commercial |
$594.17
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$91.58
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$361.42
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$91.58
|
| Rate for Payer: Health EOS Commercial |
$574.80
|
| Rate for Payer: HFN Commercial |
$594.17
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$340.69
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$91.58
|
| Rate for Payer: Independent Care Health Plan Medicare |
$91.58
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$91.58
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$91.58
|
| Rate for Payer: Multiplan Commercial |
$516.67
|
| Rate for Payer: NAPHCARE Commercial |
$137.37
|
| Rate for Payer: Preferred Network Access Commercial |
$594.17
|
| Rate for Payer: Quartz Beloit One Network |
$316.46
|
| Rate for Payer: Quartz Commercial |
$419.80
|
| Rate for Payer: Quartz Medicare Advantage |
$91.58
|
| Rate for Payer: The Alliance Commercial |
$366.33
|
| Rate for Payer: United Healthcare Medicare Advantage |
$91.58
|
| Rate for Payer: WEA Trust Commercial |
$355.21
|
| Rate for Payer: Wellcare Medicare |
$91.58
|
| Rate for Payer: WPS Commercial |
$478.36
|
|
|
XR Shoulder Intern/Extern Rotation Right
|
Facility
|
IP
|
$621.00
|
|
|
Service Code
|
CPT 73030
|
| Hospital Charge Code |
711794
|
| Min. Negotiated Rate |
$316.46 |
| Max. Negotiated Rate |
$594.17 |
| Rate for Payer: Aetna Commercial |
$581.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$555.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$342.30
|
| Rate for Payer: Cash Price |
$186.30
|
| Rate for Payer: Cigna Commercial |
$594.17
|
| Rate for Payer: Health EOS Commercial |
$574.80
|
| Rate for Payer: HFN Commercial |
$594.17
|
| Rate for Payer: Multiplan Commercial |
$516.67
|
| Rate for Payer: Preferred Network Access Commercial |
$594.17
|
| Rate for Payer: Quartz Beloit One Network |
$316.46
|
| Rate for Payer: Quartz Commercial |
$387.50
|
| Rate for Payer: WEA Trust Commercial |
$355.21
|
| Rate for Payer: WPS Commercial |
$478.36
|
|
|
XR Shoulder Intern/Extern Rotation Right
|
Facility
|
OP
|
$671.00
|
|
|
Service Code
|
CPT 73030 RT,TC
|
| Hospital Charge Code |
1537302
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$195.40 |
| Max. Negotiated Rate |
$642.01 |
| Rate for Payer: Aetna Commercial |
$628.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$600.14
|
| Rate for Payer: Aetna Managed Medicare |
$195.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$350.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$280.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$266.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$369.86
|
| Rate for Payer: Cash Price |
$201.30
|
| Rate for Payer: Cash Price |
$201.30
|
| Rate for Payer: Cash Price |
$201.30
|
| Rate for Payer: Cigna Commercial |
$642.01
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$390.52
|
| Rate for Payer: Health EOS Commercial |
$621.08
|
| Rate for Payer: HFN Commercial |
$642.01
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$523.38
|
| Rate for Payer: Multiplan Commercial |
$558.27
|
| Rate for Payer: NAPHCARE Commercial |
$418.70
|
| Rate for Payer: Preferred Network Access Commercial |
$642.01
|
| Rate for Payer: Quartz Beloit One Network |
$341.94
|
| Rate for Payer: Quartz Commercial |
$453.60
|
| Rate for Payer: Quartz Medicare Advantage |
$418.70
|
| Rate for Payer: The Alliance Commercial |
$348.92
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$383.81
|
| Rate for Payer: WPS Commercial |
$516.87
|
|
|
XR Shoulder Intern/Extern Rotation Right
|
Facility
|
IP
|
$646.00
|
|
|
Service Code
|
CPT 73030 TC,RT
|
| Hospital Charge Code |
2979995
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$329.20 |
| Max. Negotiated Rate |
$618.09 |
| Rate for Payer: Aetna Commercial |
$604.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$577.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$356.08
|
| Rate for Payer: Cash Price |
$193.80
|
| Rate for Payer: Cigna Commercial |
$618.09
|
| Rate for Payer: Health EOS Commercial |
$597.94
|
| Rate for Payer: HFN Commercial |
$618.09
|
| Rate for Payer: Multiplan Commercial |
$537.47
|
| Rate for Payer: Preferred Network Access Commercial |
$618.09
|
| Rate for Payer: Quartz Beloit One Network |
$329.20
|
| Rate for Payer: Quartz Commercial |
$403.10
|
| Rate for Payer: WEA Trust Commercial |
$369.51
|
| Rate for Payer: WPS Commercial |
$497.61
|
|
|
XR Shoulder Intern/Extern Rotation Right
|
Facility
|
OP
|
$646.00
|
|
|
Service Code
|
CPT 73030 TC,RT
|
| Hospital Charge Code |
2979995
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$188.12 |
| Max. Negotiated Rate |
$618.09 |
| Rate for Payer: Aetna Commercial |
$604.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$577.78
|
| Rate for Payer: Aetna Managed Medicare |
$188.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$350.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$280.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$266.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$356.08
|
| Rate for Payer: Cash Price |
$193.80
|
| Rate for Payer: Cash Price |
$193.80
|
| Rate for Payer: Cash Price |
$193.80
|
| Rate for Payer: Cigna Commercial |
$618.09
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$375.97
|
| Rate for Payer: Health EOS Commercial |
$597.94
|
| Rate for Payer: HFN Commercial |
$618.09
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$503.88
|
| Rate for Payer: Multiplan Commercial |
$537.47
|
| Rate for Payer: NAPHCARE Commercial |
$403.10
|
| Rate for Payer: Preferred Network Access Commercial |
$618.09
|
| Rate for Payer: Quartz Beloit One Network |
$329.20
|
| Rate for Payer: Quartz Commercial |
$436.70
|
| Rate for Payer: Quartz Medicare Advantage |
$403.10
|
| Rate for Payer: The Alliance Commercial |
$335.92
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$369.51
|
| Rate for Payer: WPS Commercial |
$497.61
|
|
|
XR Shoulder Intern/Extern Rotation Right
|
Facility
|
IP
|
$671.00
|
|
|
Service Code
|
CPT 73030 RT,TC
|
| Hospital Charge Code |
1537302
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$341.94 |
| Max. Negotiated Rate |
$642.01 |
| Rate for Payer: Aetna Commercial |
$628.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$600.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$369.86
|
| Rate for Payer: Cash Price |
$201.30
|
| Rate for Payer: Cigna Commercial |
$642.01
|
| Rate for Payer: Health EOS Commercial |
$621.08
|
| Rate for Payer: HFN Commercial |
$642.01
|
| Rate for Payer: Multiplan Commercial |
$558.27
|
| Rate for Payer: Preferred Network Access Commercial |
$642.01
|
| Rate for Payer: Quartz Beloit One Network |
$341.94
|
| Rate for Payer: Quartz Commercial |
$418.70
|
| Rate for Payer: WEA Trust Commercial |
$383.81
|
| Rate for Payer: WPS Commercial |
$516.87
|
|
|
XR Shoulder Intern/Extern Rotation Right
|
Professional
|
Both
|
$621.00
|
|
|
Service Code
|
CPT 73030
|
| Hospital Charge Code |
711794
|
| Min. Negotiated Rate |
$35.42 |
| Max. Negotiated Rate |
$613.55 |
| Rate for Payer: Aetna Commercial |
$613.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$555.42
|
| Rate for Payer: Aetna Managed Medicare |
$35.42
|
| Rate for Payer: Anthem Medicare Advantage |
$35.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$35.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$35.42
|
| Rate for Payer: Cash Price |
$186.30
|
| Rate for Payer: Cash Price |
$186.30
|
| Rate for Payer: Cash Price |
$186.30
|
| Rate for Payer: Cigna Commercial |
$613.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$322.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$35.42
|
| Rate for Payer: Health EOS Commercial |
$587.71
|
| Rate for Payer: HFN Commercial |
$613.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$120.34
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$120.34
|
| Rate for Payer: Independent Care Health Plan Medicare |
$35.42
|
| Rate for Payer: Multiplan Commercial |
$516.67
|
| Rate for Payer: NAPHCARE Commercial |
$53.13
|
| Rate for Payer: Preferred Network Access Commercial |
$613.55
|
| Rate for Payer: Quartz Beloit One Network |
$284.17
|
| Rate for Payer: Quartz Commercial |
$368.13
|
| Rate for Payer: Quartz Medicare Advantage |
$35.42
|
| Rate for Payer: The Alliance Commercial |
$134.61
|
| Rate for Payer: United Healthcare Medicare Advantage |
$35.42
|
| Rate for Payer: WEA Trust Commercial |
$355.21
|
| Rate for Payer: WPS Commercial |
$177.11
|
|
|
XR Shoulder Therapeutic Injection Lt
|
Facility
|
OP
|
$883.00
|
|
|
Service Code
|
CPT 20610 TC,LT
|
| Hospital Charge Code |
4570658
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$257.13 |
| Max. Negotiated Rate |
$4,386.95 |
| Rate for Payer: Aetna Commercial |
$826.49
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$789.76
|
| Rate for Payer: Aetna Managed Medicare |
$257.13
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$596.91
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$459.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$440.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$486.71
|
| Rate for Payer: Cash Price |
$264.90
|
| Rate for Payer: Cash Price |
$264.90
|
| Rate for Payer: Cigna Commercial |
$844.85
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,386.95
|
| Rate for Payer: Health EOS Commercial |
$817.30
|
| Rate for Payer: HFN Commercial |
$844.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$688.74
|
| Rate for Payer: Multiplan Commercial |
$734.66
|
| Rate for Payer: NAPHCARE Commercial |
$550.99
|
| Rate for Payer: Preferred Network Access Commercial |
$844.85
|
| Rate for Payer: Quartz Beloit One Network |
$449.98
|
| Rate for Payer: Quartz Commercial |
$596.91
|
| Rate for Payer: Quartz Medicare Advantage |
$550.99
|
| Rate for Payer: The Alliance Commercial |
$459.16
|
| Rate for Payer: United Healthcare PPO |
$688.74
|
| Rate for Payer: WEA Trust Commercial |
$505.08
|
| Rate for Payer: WPS Commercial |
$680.17
|
|
|
XR Shoulder Therapeutic Injection Lt
|
Professional
|
Both
|
$883.00
|
|
|
Service Code
|
CPT 20610 TC,LT
|
| Hospital Charge Code |
4570658
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$67.24 |
| Max. Negotiated Rate |
$872.40 |
| Rate for Payer: Aetna Commercial |
$872.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$789.76
|
| Rate for Payer: Cash Price |
$264.90
|
| Rate for Payer: Cash Price |
$264.90
|
| Rate for Payer: Cash Price |
$264.90
|
| Rate for Payer: Cigna Commercial |
$872.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$67.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$550.99
|
| Rate for Payer: Health EOS Commercial |
$835.67
|
| Rate for Payer: HFN Commercial |
$872.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$156.80
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$156.80
|
| Rate for Payer: Multiplan Commercial |
$734.66
|
| Rate for Payer: Preferred Network Access Commercial |
$872.40
|
| Rate for Payer: Quartz Beloit One Network |
$404.06
|
| Rate for Payer: Quartz Commercial |
$523.44
|
| Rate for Payer: The Alliance Commercial |
$459.16
|
| Rate for Payer: United Healthcare Medicaid |
$67.24
|
| Rate for Payer: WEA Trust Commercial |
$505.08
|
| Rate for Payer: WPS Commercial |
$680.17
|
|
|
XR Shoulder Therapeutic Injection Lt
|
Facility
|
IP
|
$883.00
|
|
|
Service Code
|
CPT 20610 TC,LT
|
| Hospital Charge Code |
4570658
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$449.98 |
| Max. Negotiated Rate |
$844.85 |
| Rate for Payer: Aetna Commercial |
$826.49
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$789.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$486.71
|
| Rate for Payer: Cash Price |
$264.90
|
| Rate for Payer: Cigna Commercial |
$844.85
|
| Rate for Payer: Health EOS Commercial |
$817.30
|
| Rate for Payer: HFN Commercial |
$844.85
|
| Rate for Payer: Multiplan Commercial |
$734.66
|
| Rate for Payer: Preferred Network Access Commercial |
$844.85
|
| Rate for Payer: Quartz Beloit One Network |
$449.98
|
| Rate for Payer: Quartz Commercial |
$550.99
|
| Rate for Payer: WEA Trust Commercial |
$505.08
|
| Rate for Payer: WPS Commercial |
$680.17
|
|
|
XR Shoulder Therapeutic Injection Rt
|
Facility
|
OP
|
$883.00
|
|
|
Service Code
|
CPT 20610 TC,RT
|
| Hospital Charge Code |
4570664
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$257.13 |
| Max. Negotiated Rate |
$4,386.95 |
| Rate for Payer: Aetna Commercial |
$826.49
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$789.76
|
| Rate for Payer: Aetna Managed Medicare |
$257.13
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$596.91
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$459.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$440.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$486.71
|
| Rate for Payer: Cash Price |
$264.90
|
| Rate for Payer: Cash Price |
$264.90
|
| Rate for Payer: Cigna Commercial |
$844.85
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,386.95
|
| Rate for Payer: Health EOS Commercial |
$817.30
|
| Rate for Payer: HFN Commercial |
$844.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$688.74
|
| Rate for Payer: Multiplan Commercial |
$734.66
|
| Rate for Payer: NAPHCARE Commercial |
$550.99
|
| Rate for Payer: Preferred Network Access Commercial |
$844.85
|
| Rate for Payer: Quartz Beloit One Network |
$449.98
|
| Rate for Payer: Quartz Commercial |
$596.91
|
| Rate for Payer: Quartz Medicare Advantage |
$550.99
|
| Rate for Payer: The Alliance Commercial |
$459.16
|
| Rate for Payer: United Healthcare PPO |
$688.74
|
| Rate for Payer: WEA Trust Commercial |
$505.08
|
| Rate for Payer: WPS Commercial |
$680.17
|
|
|
XR Shoulder Therapeutic Injection Rt
|
Professional
|
Both
|
$883.00
|
|
|
Service Code
|
CPT 20610 TC,RT
|
| Hospital Charge Code |
4570664
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$67.24 |
| Max. Negotiated Rate |
$872.40 |
| Rate for Payer: Aetna Commercial |
$872.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$789.76
|
| Rate for Payer: Cash Price |
$264.90
|
| Rate for Payer: Cash Price |
$264.90
|
| Rate for Payer: Cash Price |
$264.90
|
| Rate for Payer: Cigna Commercial |
$872.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$67.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$550.99
|
| Rate for Payer: Health EOS Commercial |
$835.67
|
| Rate for Payer: HFN Commercial |
$872.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$156.80
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$156.80
|
| Rate for Payer: Multiplan Commercial |
$734.66
|
| Rate for Payer: Preferred Network Access Commercial |
$872.40
|
| Rate for Payer: Quartz Beloit One Network |
$404.06
|
| Rate for Payer: Quartz Commercial |
$523.44
|
| Rate for Payer: The Alliance Commercial |
$459.16
|
| Rate for Payer: United Healthcare Medicaid |
$67.24
|
| Rate for Payer: WEA Trust Commercial |
$505.08
|
| Rate for Payer: WPS Commercial |
$680.17
|
|
|
XR Shoulder Therapeutic Injection Rt
|
Facility
|
IP
|
$883.00
|
|
|
Service Code
|
CPT 20610 TC,RT
|
| Hospital Charge Code |
4570664
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$449.98 |
| Max. Negotiated Rate |
$844.85 |
| Rate for Payer: Aetna Commercial |
$826.49
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$789.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$486.71
|
| Rate for Payer: Cash Price |
$264.90
|
| Rate for Payer: Cigna Commercial |
$844.85
|
| Rate for Payer: Health EOS Commercial |
$817.30
|
| Rate for Payer: HFN Commercial |
$844.85
|
| Rate for Payer: Multiplan Commercial |
$734.66
|
| Rate for Payer: Preferred Network Access Commercial |
$844.85
|
| Rate for Payer: Quartz Beloit One Network |
$449.98
|
| Rate for Payer: Quartz Commercial |
$550.99
|
| Rate for Payer: WEA Trust Commercial |
$505.08
|
| Rate for Payer: WPS Commercial |
$680.17
|
|
|
XR Sialogram
|
Facility
|
OP
|
$2,416.00
|
|
|
Service Code
|
CPT 70390
|
| Hospital Charge Code |
1537307
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$251.10 |
| Max. Negotiated Rate |
$2,311.63 |
| Rate for Payer: Aetna Commercial |
$2,261.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,160.87
|
| Rate for Payer: Aetna Managed Medicare |
$251.10
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$944.58
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$755.66
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$717.88
|
| Rate for Payer: Anthem Medicare Advantage |
$251.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,331.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$251.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$251.10
|
| Rate for Payer: Cash Price |
$724.80
|
| Rate for Payer: Cash Price |
$724.80
|
| Rate for Payer: Cash Price |
$724.80
|
| Rate for Payer: Cigna Commercial |
$2,311.63
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$251.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,406.11
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$251.10
|
| Rate for Payer: Health EOS Commercial |
$2,236.25
|
| Rate for Payer: HFN Commercial |
$2,311.63
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$934.08
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$251.10
|
| Rate for Payer: Independent Care Health Plan Medicare |
$251.10
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$251.10
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$251.10
|
| Rate for Payer: Multiplan Commercial |
$2,010.11
|
| Rate for Payer: NAPHCARE Commercial |
$376.65
|
| Rate for Payer: Preferred Network Access Commercial |
$2,311.63
|
| Rate for Payer: Quartz Beloit One Network |
$1,231.19
|
| Rate for Payer: Quartz Commercial |
$1,633.22
|
| Rate for Payer: Quartz Medicare Advantage |
$251.10
|
| Rate for Payer: The Alliance Commercial |
$1,004.39
|
| Rate for Payer: United Healthcare Medicare Advantage |
$251.10
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$1,381.95
|
| Rate for Payer: Wellcare Medicare |
$251.10
|
| Rate for Payer: WPS Commercial |
$1,861.04
|
|
|
XR Sialogram
|
Facility
|
IP
|
$2,416.00
|
|
|
Service Code
|
CPT 70390
|
| Hospital Charge Code |
1537307
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1,231.19 |
| Max. Negotiated Rate |
$2,311.63 |
| Rate for Payer: Aetna Commercial |
$2,261.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,160.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,331.70
|
| Rate for Payer: Cash Price |
$724.80
|
| Rate for Payer: Cigna Commercial |
$2,311.63
|
| Rate for Payer: Health EOS Commercial |
$2,236.25
|
| Rate for Payer: HFN Commercial |
$2,311.63
|
| Rate for Payer: Multiplan Commercial |
$2,010.11
|
| Rate for Payer: Preferred Network Access Commercial |
$2,311.63
|
| Rate for Payer: Quartz Beloit One Network |
$1,231.19
|
| Rate for Payer: Quartz Commercial |
$1,507.58
|
| Rate for Payer: WEA Trust Commercial |
$1,381.95
|
| Rate for Payer: WPS Commercial |
$1,861.04
|
|
|
XR Sialogram
|
Facility
|
OP
|
$1,162.00
|
|
|
Service Code
|
CPT 70390
|
| Hospital Charge Code |
630110
|
| Min. Negotiated Rate |
$251.10 |
| Max. Negotiated Rate |
$1,111.80 |
| Rate for Payer: Aetna Commercial |
$1,087.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,039.29
|
| Rate for Payer: Aetna Managed Medicare |
$251.10
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$785.51
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$604.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$580.07
|
| Rate for Payer: Anthem Medicare Advantage |
$251.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$640.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$251.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$251.10
|
| Rate for Payer: Cash Price |
$348.60
|
| Rate for Payer: Cash Price |
$348.60
|
| Rate for Payer: Cigna Commercial |
$1,111.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$251.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$676.28
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$251.10
|
| Rate for Payer: Health EOS Commercial |
$1,075.55
|
| Rate for Payer: HFN Commercial |
$1,111.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$934.08
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$251.10
|
| Rate for Payer: Independent Care Health Plan Medicare |
$251.10
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$251.10
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$251.10
|
| Rate for Payer: Multiplan Commercial |
$966.78
|
| Rate for Payer: NAPHCARE Commercial |
$376.65
|
| Rate for Payer: Preferred Network Access Commercial |
$1,111.80
|
| Rate for Payer: Quartz Beloit One Network |
$592.16
|
| Rate for Payer: Quartz Commercial |
$785.51
|
| Rate for Payer: Quartz Medicare Advantage |
$251.10
|
| Rate for Payer: The Alliance Commercial |
$1,004.39
|
| Rate for Payer: United Healthcare Medicare Advantage |
$251.10
|
| Rate for Payer: WEA Trust Commercial |
$664.66
|
| Rate for Payer: Wellcare Medicare |
$251.10
|
| Rate for Payer: WPS Commercial |
$895.09
|
|
|
XR Sialogram
|
Professional
|
Both
|
$1,162.00
|
|
|
Service Code
|
CPT 70390
|
| Hospital Charge Code |
630110
|
| Min. Negotiated Rate |
$110.01 |
| Max. Negotiated Rate |
$1,148.06 |
| Rate for Payer: Aetna Commercial |
$1,148.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,039.29
|
| Rate for Payer: Aetna Managed Medicare |
$110.01
|
| Rate for Payer: Anthem Medicare Advantage |
$110.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$110.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$110.01
|
| Rate for Payer: Cash Price |
$348.60
|
| Rate for Payer: Cash Price |
$348.60
|
| Rate for Payer: Cash Price |
$348.60
|
| Rate for Payer: Cigna Commercial |
$1,148.06
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$604.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$110.01
|
| Rate for Payer: Health EOS Commercial |
$1,099.72
|
| Rate for Payer: HFN Commercial |
$1,148.06
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$423.87
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$423.87
|
| Rate for Payer: Independent Care Health Plan Medicare |
$110.01
|
| Rate for Payer: Multiplan Commercial |
$966.78
|
| Rate for Payer: NAPHCARE Commercial |
$165.02
|
| Rate for Payer: Preferred Network Access Commercial |
$1,148.06
|
| Rate for Payer: Quartz Beloit One Network |
$531.73
|
| Rate for Payer: Quartz Commercial |
$688.83
|
| Rate for Payer: Quartz Medicare Advantage |
$110.01
|
| Rate for Payer: The Alliance Commercial |
$418.04
|
| Rate for Payer: United Healthcare Medicare Advantage |
$110.01
|
| Rate for Payer: WEA Trust Commercial |
$664.66
|
| Rate for Payer: WPS Commercial |
$550.06
|
|
|
XR Sialogram
|
Facility
|
IP
|
$1,162.00
|
|
|
Service Code
|
CPT 70390
|
| Hospital Charge Code |
630110
|
| Min. Negotiated Rate |
$592.16 |
| Max. Negotiated Rate |
$1,111.80 |
| Rate for Payer: Aetna Commercial |
$1,087.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,039.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$640.49
|
| Rate for Payer: Cash Price |
$348.60
|
| Rate for Payer: Cigna Commercial |
$1,111.80
|
| Rate for Payer: Health EOS Commercial |
$1,075.55
|
| Rate for Payer: HFN Commercial |
$1,111.80
|
| Rate for Payer: Multiplan Commercial |
$966.78
|
| Rate for Payer: Preferred Network Access Commercial |
$1,111.80
|
| Rate for Payer: Quartz Beloit One Network |
$592.16
|
| Rate for Payer: Quartz Commercial |
$725.09
|
| Rate for Payer: WEA Trust Commercial |
$664.66
|
| Rate for Payer: WPS Commercial |
$895.09
|
|
|
XR Sialogram
|
Professional
|
Both
|
$2,416.00
|
|
|
Service Code
|
CPT 70390
|
| Hospital Charge Code |
1537307
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$110.01 |
| Max. Negotiated Rate |
$2,387.01 |
| Rate for Payer: Aetna Commercial |
$2,387.01
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,160.87
|
| Rate for Payer: Aetna Managed Medicare |
$110.01
|
| Rate for Payer: Anthem Medicare Advantage |
$110.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$110.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$110.01
|
| Rate for Payer: Cash Price |
$724.80
|
| Rate for Payer: Cash Price |
$724.80
|
| Rate for Payer: Cash Price |
$724.80
|
| Rate for Payer: Cigna Commercial |
$2,387.01
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,256.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$110.01
|
| Rate for Payer: Health EOS Commercial |
$2,286.50
|
| Rate for Payer: HFN Commercial |
$2,387.01
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$423.87
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$423.87
|
| Rate for Payer: Independent Care Health Plan Medicare |
$110.01
|
| Rate for Payer: Multiplan Commercial |
$2,010.11
|
| Rate for Payer: NAPHCARE Commercial |
$165.02
|
| Rate for Payer: Preferred Network Access Commercial |
$2,387.01
|
| Rate for Payer: Quartz Beloit One Network |
$1,105.56
|
| Rate for Payer: Quartz Commercial |
$1,432.20
|
| Rate for Payer: Quartz Medicare Advantage |
$110.01
|
| Rate for Payer: The Alliance Commercial |
$418.04
|
| Rate for Payer: United Healthcare Medicare Advantage |
$110.01
|
| Rate for Payer: WEA Trust Commercial |
$1,381.95
|
| Rate for Payer: WPS Commercial |
$550.06
|
|
|
XR Sinuses Paranasal < 3 Views
|
Facility
|
IP
|
$404.00
|
|
|
Service Code
|
CPT 70210 TC
|
| Hospital Charge Code |
1537309
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$205.88 |
| Max. Negotiated Rate |
$386.55 |
| Rate for Payer: Aetna Commercial |
$378.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$361.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$222.68
|
| Rate for Payer: Cash Price |
$121.20
|
| Rate for Payer: Cigna Commercial |
$386.55
|
| Rate for Payer: Health EOS Commercial |
$373.94
|
| Rate for Payer: HFN Commercial |
$386.55
|
| Rate for Payer: Multiplan Commercial |
$336.13
|
| Rate for Payer: Preferred Network Access Commercial |
$386.55
|
| Rate for Payer: Quartz Beloit One Network |
$205.88
|
| Rate for Payer: Quartz Commercial |
$252.10
|
| Rate for Payer: WEA Trust Commercial |
$231.09
|
| Rate for Payer: WPS Commercial |
$311.20
|
|
|
XR Sinuses Paranasal < 3 Views
|
Professional
|
Both
|
$404.00
|
|
|
Service Code
|
CPT 70210 TC
|
| Hospital Charge Code |
1537309
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$23.73 |
| Max. Negotiated Rate |
$399.15 |
| Rate for Payer: Aetna Commercial |
$399.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$361.34
|
| Rate for Payer: Aetna Managed Medicare |
$23.73
|
| Rate for Payer: Anthem Medicare Advantage |
$23.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$23.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$23.73
|
| Rate for Payer: Cash Price |
$121.20
|
| Rate for Payer: Cash Price |
$121.20
|
| Rate for Payer: Cash Price |
$121.20
|
| Rate for Payer: Cigna Commercial |
$399.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$210.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$23.73
|
| Rate for Payer: Health EOS Commercial |
$382.35
|
| Rate for Payer: HFN Commercial |
$399.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$82.42
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$82.42
|
| Rate for Payer: Independent Care Health Plan Medicare |
$23.73
|
| Rate for Payer: Multiplan Commercial |
$336.13
|
| Rate for Payer: NAPHCARE Commercial |
$35.60
|
| Rate for Payer: Preferred Network Access Commercial |
$399.15
|
| Rate for Payer: Quartz Beloit One Network |
$184.87
|
| Rate for Payer: Quartz Commercial |
$239.49
|
| Rate for Payer: Quartz Medicare Advantage |
$23.73
|
| Rate for Payer: The Alliance Commercial |
$90.18
|
| Rate for Payer: United Healthcare Medicare Advantage |
$23.73
|
| Rate for Payer: WEA Trust Commercial |
$231.09
|
| Rate for Payer: WPS Commercial |
$118.66
|
|
|
XR Sinuses Paranasal < 3 Views
|
Facility
|
OP
|
$404.00
|
|
|
Service Code
|
CPT 70210 TC
|
| Hospital Charge Code |
1537309
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$94.93 |
| Max. Negotiated Rate |
$386.55 |
| Rate for Payer: Aetna Commercial |
$378.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$361.34
|
| Rate for Payer: Aetna Managed Medicare |
$117.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$350.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$280.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$266.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$222.68
|
| Rate for Payer: Cash Price |
$121.20
|
| Rate for Payer: Cash Price |
$121.20
|
| Rate for Payer: Cash Price |
$121.20
|
| Rate for Payer: Cigna Commercial |
$386.55
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$235.13
|
| Rate for Payer: Health EOS Commercial |
$373.94
|
| Rate for Payer: HFN Commercial |
$386.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$315.12
|
| Rate for Payer: Multiplan Commercial |
$336.13
|
| Rate for Payer: NAPHCARE Commercial |
$252.10
|
| Rate for Payer: Preferred Network Access Commercial |
$386.55
|
| Rate for Payer: Quartz Beloit One Network |
$205.88
|
| Rate for Payer: Quartz Commercial |
$273.10
|
| Rate for Payer: Quartz Medicare Advantage |
$252.10
|
| Rate for Payer: The Alliance Commercial |
$94.93
|
| Rate for Payer: United Healthcare PPO |
$313.04
|
| Rate for Payer: WEA Trust Commercial |
$231.09
|
| Rate for Payer: WPS Commercial |
$311.20
|
|
|
XR Sinuses Paranasal < 3 Views
|
Facility
|
IP
|
$373.00
|
|
|
Service Code
|
CPT 70210
|
| Hospital Charge Code |
630105
|
| Min. Negotiated Rate |
$190.08 |
| Max. Negotiated Rate |
$356.89 |
| Rate for Payer: Aetna Commercial |
$349.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$333.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$205.60
|
| Rate for Payer: Cash Price |
$111.90
|
| Rate for Payer: Cigna Commercial |
$356.89
|
| Rate for Payer: Health EOS Commercial |
$345.25
|
| Rate for Payer: HFN Commercial |
$356.89
|
| Rate for Payer: Multiplan Commercial |
$310.34
|
| Rate for Payer: Preferred Network Access Commercial |
$356.89
|
| Rate for Payer: Quartz Beloit One Network |
$190.08
|
| Rate for Payer: Quartz Commercial |
$232.75
|
| Rate for Payer: WEA Trust Commercial |
$213.36
|
| Rate for Payer: WPS Commercial |
$287.32
|
|
|
XR Sinuses Paranasal < 3 Views
|
Professional
|
Both
|
$373.00
|
|
|
Service Code
|
CPT 70210
|
| Hospital Charge Code |
630105
|
| Min. Negotiated Rate |
$32.07 |
| Max. Negotiated Rate |
$368.52 |
| Rate for Payer: Aetna Commercial |
$368.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$333.61
|
| Rate for Payer: Aetna Managed Medicare |
$32.07
|
| Rate for Payer: Anthem Medicare Advantage |
$32.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$32.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$32.07
|
| Rate for Payer: Cash Price |
$111.90
|
| Rate for Payer: Cash Price |
$111.90
|
| Rate for Payer: Cash Price |
$111.90
|
| Rate for Payer: Cigna Commercial |
$368.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$193.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$32.07
|
| Rate for Payer: Health EOS Commercial |
$353.01
|
| Rate for Payer: HFN Commercial |
$368.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$113.04
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$113.04
|
| Rate for Payer: Independent Care Health Plan Medicare |
$32.07
|
| Rate for Payer: Multiplan Commercial |
$310.34
|
| Rate for Payer: NAPHCARE Commercial |
$48.11
|
| Rate for Payer: Preferred Network Access Commercial |
$368.52
|
| Rate for Payer: Quartz Beloit One Network |
$170.68
|
| Rate for Payer: Quartz Commercial |
$221.11
|
| Rate for Payer: Quartz Medicare Advantage |
$32.07
|
| Rate for Payer: The Alliance Commercial |
$121.88
|
| Rate for Payer: United Healthcare Medicare Advantage |
$32.07
|
| Rate for Payer: WEA Trust Commercial |
$213.36
|
| Rate for Payer: WPS Commercial |
$160.37
|
|
|
XR Sinuses Paranasal < 3 Views
|
Facility
|
OP
|
$373.00
|
|
|
Service Code
|
CPT 70210
|
| Hospital Charge Code |
630105
|
| Min. Negotiated Rate |
$91.58 |
| Max. Negotiated Rate |
$366.33 |
| Rate for Payer: Aetna Commercial |
$349.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$333.61
|
| Rate for Payer: Aetna Managed Medicare |
$91.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$252.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$193.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$186.20
|
| Rate for Payer: Anthem Medicare Advantage |
$91.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$205.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$91.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$91.58
|
| Rate for Payer: Cash Price |
$111.90
|
| Rate for Payer: Cash Price |
$111.90
|
| Rate for Payer: Cigna Commercial |
$356.89
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$91.58
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$217.09
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$91.58
|
| Rate for Payer: Health EOS Commercial |
$345.25
|
| Rate for Payer: HFN Commercial |
$356.89
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$340.69
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$91.58
|
| Rate for Payer: Independent Care Health Plan Medicare |
$91.58
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$91.58
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$91.58
|
| Rate for Payer: Multiplan Commercial |
$310.34
|
| Rate for Payer: NAPHCARE Commercial |
$137.37
|
| Rate for Payer: Preferred Network Access Commercial |
$356.89
|
| Rate for Payer: Quartz Beloit One Network |
$190.08
|
| Rate for Payer: Quartz Commercial |
$252.15
|
| Rate for Payer: Quartz Medicare Advantage |
$91.58
|
| Rate for Payer: The Alliance Commercial |
$366.33
|
| Rate for Payer: United Healthcare Medicare Advantage |
$91.58
|
| Rate for Payer: WEA Trust Commercial |
$213.36
|
| Rate for Payer: Wellcare Medicare |
$91.58
|
| Rate for Payer: WPS Commercial |
$287.32
|
|
