|
Biotinidase
|
Facility
|
OP
|
$188.00
|
|
|
Service Code
|
CPT 82261
|
| Hospital Charge Code |
4524639
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.87 |
| Max. Negotiated Rate |
$172.96 |
| Rate for Payer: Aetna Commercial |
$169.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$161.68
|
| Rate for Payer: Aetna Managed Medicare |
$16.87
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$63.26
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$29.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$28.00
|
| Rate for Payer: Anthem Medicaid |
$17.43
|
| Rate for Payer: Anthem Medicare Advantage |
$16.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$99.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$16.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$16.87
|
| Rate for Payer: Cash Price |
$56.40
|
| Rate for Payer: Cash Price |
$56.40
|
| Rate for Payer: Cigna Commercial |
$172.96
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$16.87
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$17.43
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$105.20
|
| Rate for Payer: Dean Health Medicaid |
$17.43
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$16.87
|
| Rate for Payer: Health EOS Commercial |
$167.32
|
| Rate for Payer: HFN Commercial |
$172.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$62.76
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$16.87
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$17.43
|
| Rate for Payer: Independent Care Health Plan Medicare |
$16.87
|
| Rate for Payer: Managed Health Services Medicaid |
$18.13
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$16.87
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$16.87
|
| Rate for Payer: Multiplan Commercial |
$150.40
|
| Rate for Payer: NAPHCARE Commercial |
$25.30
|
| Rate for Payer: Preferred Network Access Commercial |
$172.96
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$17.43
|
| Rate for Payer: Quartz Beloit One Network |
$92.12
|
| Rate for Payer: Quartz Commercial |
$122.20
|
| Rate for Payer: Quartz Medicare Advantage |
$16.87
|
| Rate for Payer: The Alliance Commercial |
$67.48
|
| Rate for Payer: United Healthcare Medicaid |
$17.43
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16.87
|
| Rate for Payer: United Healthcare PPO |
$141.00
|
| Rate for Payer: WEA Trust Commercial |
$103.40
|
| Rate for Payer: Wellcare Medicare |
$16.87
|
| Rate for Payer: WMAP Medicaid |
$17.43
|
| Rate for Payer: WPS Commercial |
$139.25
|
|
|
BIO-TRANSFIX BONE TENDON BONE
|
Facility
|
OP
|
$5,039.00
|
|
| Hospital Charge Code |
2964676
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,410.92 |
| Max. Negotiated Rate |
$20,156.00 |
| Rate for Payer: Aetna Commercial |
$4,535.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,333.54
|
| Rate for Payer: Aetna Managed Medicare |
$1,410.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,275.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,519.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,418.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,670.67
|
| Rate for Payer: Cash Price |
$1,511.70
|
| Rate for Payer: Cigna Commercial |
$4,635.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,819.82
|
| Rate for Payer: Health EOS Commercial |
$4,484.71
|
| Rate for Payer: HFN Commercial |
$4,635.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,779.25
|
| Rate for Payer: Multiplan Commercial |
$4,031.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,023.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,635.88
|
| Rate for Payer: Quartz Beloit One Network |
$2,469.11
|
| Rate for Payer: Quartz Commercial |
$3,275.35
|
| Rate for Payer: Quartz Medicare Advantage |
$3,023.40
|
| Rate for Payer: The Alliance Commercial |
$20,156.00
|
| Rate for Payer: WEA Trust Commercial |
$2,771.45
|
| Rate for Payer: WPS Commercial |
$3,732.39
|
|
|
BIO-TRANSFIX BONE TENDON BONE
|
Facility
|
IP
|
$5,039.00
|
|
| Hospital Charge Code |
2964676
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,469.11 |
| Max. Negotiated Rate |
$4,635.88 |
| Rate for Payer: Aetna Commercial |
$4,535.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,333.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,670.67
|
| Rate for Payer: Cash Price |
$1,511.70
|
| Rate for Payer: Cigna Commercial |
$4,635.88
|
| Rate for Payer: Health EOS Commercial |
$4,484.71
|
| Rate for Payer: HFN Commercial |
$4,635.88
|
| Rate for Payer: Multiplan Commercial |
$4,031.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,023.40
|
| Rate for Payer: Preferred Network Access Commercial |
$4,635.88
|
| Rate for Payer: Quartz Beloit One Network |
$2,469.11
|
| Rate for Payer: Quartz Commercial |
$3,023.40
|
| Rate for Payer: WEA Trust Commercial |
$2,771.45
|
| Rate for Payer: WPS Commercial |
$3,732.39
|
|
|
BIOZORB MARKER 2CM X 2CM F0202
|
Facility
|
OP
|
$5,533.00
|
|
|
Service Code
|
HCPCS C9728
|
| Hospital Charge Code |
5456770
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,369.56 |
| Max. Negotiated Rate |
$5,478.24 |
| Rate for Payer: Aetna Commercial |
$4,979.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,758.38
|
| Rate for Payer: Aetna Managed Medicare |
$1,369.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,596.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,766.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,655.84
|
| Rate for Payer: Anthem Medicare Advantage |
$1,369.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,932.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,369.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,369.56
|
| Rate for Payer: Cash Price |
$1,659.90
|
| Rate for Payer: Cash Price |
$1,659.90
|
| Rate for Payer: Cigna Commercial |
$5,090.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$1,369.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,096.27
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1,369.56
|
| Rate for Payer: Health EOS Commercial |
$4,924.37
|
| Rate for Payer: HFN Commercial |
$5,090.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,094.76
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,369.56
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,369.56
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$1,369.56
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$1,369.56
|
| Rate for Payer: Multiplan Commercial |
$4,426.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,054.34
|
| Rate for Payer: Preferred Network Access Commercial |
$5,090.36
|
| Rate for Payer: Quartz Beloit One Network |
$2,711.17
|
| Rate for Payer: Quartz Commercial |
$3,596.45
|
| Rate for Payer: Quartz Medicare Advantage |
$1,369.56
|
| Rate for Payer: The Alliance Commercial |
$5,478.24
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,369.56
|
| Rate for Payer: WEA Trust Commercial |
$3,043.15
|
| Rate for Payer: Wellcare Medicare |
$1,369.56
|
| Rate for Payer: WPS Commercial |
$4,098.29
|
|
|
BIOZORB MARKER 2CM X 2CM F0202
|
Facility
|
IP
|
$5,533.00
|
|
|
Service Code
|
HCPCS C9728
|
| Hospital Charge Code |
5456770
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,711.17 |
| Max. Negotiated Rate |
$5,090.36 |
| Rate for Payer: Aetna Commercial |
$4,979.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,758.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,932.49
|
| Rate for Payer: Cash Price |
$1,659.90
|
| Rate for Payer: Cigna Commercial |
$5,090.36
|
| Rate for Payer: Health EOS Commercial |
$4,924.37
|
| Rate for Payer: HFN Commercial |
$5,090.36
|
| Rate for Payer: Multiplan Commercial |
$4,426.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,319.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,090.36
|
| Rate for Payer: Quartz Beloit One Network |
$2,711.17
|
| Rate for Payer: Quartz Commercial |
$3,319.80
|
| Rate for Payer: WEA Trust Commercial |
$3,043.15
|
| Rate for Payer: WPS Commercial |
$4,098.29
|
|
|
BIOZORB MARKER 2CM X 3CM F0203
|
Facility
|
IP
|
$5,744.00
|
|
|
Service Code
|
HCPCS C9728
|
| Hospital Charge Code |
5456766
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,814.56 |
| Max. Negotiated Rate |
$5,284.48 |
| Rate for Payer: Aetna Commercial |
$5,169.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,939.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,044.32
|
| Rate for Payer: Cash Price |
$1,723.20
|
| Rate for Payer: Cigna Commercial |
$5,284.48
|
| Rate for Payer: Health EOS Commercial |
$5,112.16
|
| Rate for Payer: HFN Commercial |
$5,284.48
|
| Rate for Payer: Multiplan Commercial |
$4,595.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,446.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,284.48
|
| Rate for Payer: Quartz Beloit One Network |
$2,814.56
|
| Rate for Payer: Quartz Commercial |
$3,446.40
|
| Rate for Payer: WEA Trust Commercial |
$3,159.20
|
| Rate for Payer: WPS Commercial |
$4,254.58
|
|
|
BIOZORB MARKER 2CM X 3CM F0203
|
Facility
|
OP
|
$5,744.00
|
|
|
Service Code
|
HCPCS C9728
|
| Hospital Charge Code |
5456766
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,369.56 |
| Max. Negotiated Rate |
$5,478.24 |
| Rate for Payer: Aetna Commercial |
$5,169.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,939.84
|
| Rate for Payer: Aetna Managed Medicare |
$1,369.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,733.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,872.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,757.12
|
| Rate for Payer: Anthem Medicare Advantage |
$1,369.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,044.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,369.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,369.56
|
| Rate for Payer: Cash Price |
$1,723.20
|
| Rate for Payer: Cash Price |
$1,723.20
|
| Rate for Payer: Cigna Commercial |
$5,284.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$1,369.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,214.34
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1,369.56
|
| Rate for Payer: Health EOS Commercial |
$5,112.16
|
| Rate for Payer: HFN Commercial |
$5,284.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,094.76
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,369.56
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,369.56
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$1,369.56
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$1,369.56
|
| Rate for Payer: Multiplan Commercial |
$4,595.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,054.34
|
| Rate for Payer: Preferred Network Access Commercial |
$5,284.48
|
| Rate for Payer: Quartz Beloit One Network |
$2,814.56
|
| Rate for Payer: Quartz Commercial |
$3,733.60
|
| Rate for Payer: Quartz Medicare Advantage |
$1,369.56
|
| Rate for Payer: The Alliance Commercial |
$5,478.24
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,369.56
|
| Rate for Payer: WEA Trust Commercial |
$3,159.20
|
| Rate for Payer: Wellcare Medicare |
$1,369.56
|
| Rate for Payer: WPS Commercial |
$4,254.58
|
|
|
BIOZORB MARKER 3CM X 3CM F0303
|
Facility
|
OP
|
$5,533.00
|
|
|
Service Code
|
HCPCS C9728
|
| Hospital Charge Code |
5456767
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,369.56 |
| Max. Negotiated Rate |
$5,478.24 |
| Rate for Payer: Aetna Commercial |
$4,979.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,758.38
|
| Rate for Payer: Aetna Managed Medicare |
$1,369.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,596.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,766.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,655.84
|
| Rate for Payer: Anthem Medicare Advantage |
$1,369.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,932.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,369.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,369.56
|
| Rate for Payer: Cash Price |
$1,659.90
|
| Rate for Payer: Cash Price |
$1,659.90
|
| Rate for Payer: Cigna Commercial |
$5,090.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$1,369.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,096.27
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1,369.56
|
| Rate for Payer: Health EOS Commercial |
$4,924.37
|
| Rate for Payer: HFN Commercial |
$5,090.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,094.76
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,369.56
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,369.56
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$1,369.56
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$1,369.56
|
| Rate for Payer: Multiplan Commercial |
$4,426.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,054.34
|
| Rate for Payer: Preferred Network Access Commercial |
$5,090.36
|
| Rate for Payer: Quartz Beloit One Network |
$2,711.17
|
| Rate for Payer: Quartz Commercial |
$3,596.45
|
| Rate for Payer: Quartz Medicare Advantage |
$1,369.56
|
| Rate for Payer: The Alliance Commercial |
$5,478.24
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,369.56
|
| Rate for Payer: WEA Trust Commercial |
$3,043.15
|
| Rate for Payer: Wellcare Medicare |
$1,369.56
|
| Rate for Payer: WPS Commercial |
$4,098.29
|
|
|
BIOZORB MARKER 3CM X 3CM F0303
|
Facility
|
IP
|
$5,533.00
|
|
|
Service Code
|
HCPCS C9728
|
| Hospital Charge Code |
5456767
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,711.17 |
| Max. Negotiated Rate |
$5,090.36 |
| Rate for Payer: Aetna Commercial |
$4,979.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,758.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,932.49
|
| Rate for Payer: Cash Price |
$1,659.90
|
| Rate for Payer: Cigna Commercial |
$5,090.36
|
| Rate for Payer: Health EOS Commercial |
$4,924.37
|
| Rate for Payer: HFN Commercial |
$5,090.36
|
| Rate for Payer: Multiplan Commercial |
$4,426.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,319.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,090.36
|
| Rate for Payer: Quartz Beloit One Network |
$2,711.17
|
| Rate for Payer: Quartz Commercial |
$3,319.80
|
| Rate for Payer: WEA Trust Commercial |
$3,043.15
|
| Rate for Payer: WPS Commercial |
$4,098.29
|
|
|
BIOZORB MARKER 3CM X 4CM F0304
|
Facility
|
IP
|
$5,744.00
|
|
|
Service Code
|
HCPCS A4648
|
| Hospital Charge Code |
5456768
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,814.56 |
| Max. Negotiated Rate |
$5,284.48 |
| Rate for Payer: Aetna Commercial |
$5,169.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,939.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,044.32
|
| Rate for Payer: Cash Price |
$1,723.20
|
| Rate for Payer: Cigna Commercial |
$5,284.48
|
| Rate for Payer: Health EOS Commercial |
$5,112.16
|
| Rate for Payer: HFN Commercial |
$5,284.48
|
| Rate for Payer: Multiplan Commercial |
$4,595.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,446.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,284.48
|
| Rate for Payer: Quartz Beloit One Network |
$2,814.56
|
| Rate for Payer: Quartz Commercial |
$3,446.40
|
| Rate for Payer: WEA Trust Commercial |
$3,159.20
|
| Rate for Payer: WPS Commercial |
$4,254.58
|
|
|
BIOZORB MARKER 3CM X 4CM F0304
|
Facility
|
OP
|
$5,744.00
|
|
|
Service Code
|
HCPCS A4648
|
| Hospital Charge Code |
5456768
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,608.32 |
| Max. Negotiated Rate |
$22,976.00 |
| Rate for Payer: Aetna Commercial |
$5,169.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,939.84
|
| Rate for Payer: Aetna Managed Medicare |
$1,608.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,733.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,872.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,757.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,044.32
|
| Rate for Payer: Cash Price |
$1,723.20
|
| Rate for Payer: Cigna Commercial |
$5,284.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,214.34
|
| Rate for Payer: Health EOS Commercial |
$5,112.16
|
| Rate for Payer: HFN Commercial |
$5,284.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,308.00
|
| Rate for Payer: Multiplan Commercial |
$4,595.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,446.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,284.48
|
| Rate for Payer: Quartz Beloit One Network |
$2,814.56
|
| Rate for Payer: Quartz Commercial |
$3,733.60
|
| Rate for Payer: Quartz Medicare Advantage |
$3,446.40
|
| Rate for Payer: The Alliance Commercial |
$22,976.00
|
| Rate for Payer: WEA Trust Commercial |
$3,159.20
|
| Rate for Payer: WPS Commercial |
$4,254.58
|
|
|
BIOZORB MARKER 4CM X 4CM F0404
|
Facility
|
IP
|
$5,533.00
|
|
|
Service Code
|
HCPCS C9728
|
| Hospital Charge Code |
5456769
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,711.17 |
| Max. Negotiated Rate |
$5,090.36 |
| Rate for Payer: Aetna Commercial |
$4,979.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,758.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,932.49
|
| Rate for Payer: Cash Price |
$1,659.90
|
| Rate for Payer: Cigna Commercial |
$5,090.36
|
| Rate for Payer: Health EOS Commercial |
$4,924.37
|
| Rate for Payer: HFN Commercial |
$5,090.36
|
| Rate for Payer: Multiplan Commercial |
$4,426.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,319.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,090.36
|
| Rate for Payer: Quartz Beloit One Network |
$2,711.17
|
| Rate for Payer: Quartz Commercial |
$3,319.80
|
| Rate for Payer: WEA Trust Commercial |
$3,043.15
|
| Rate for Payer: WPS Commercial |
$4,098.29
|
|
|
BIOZORB MARKER 4CM X 4CM F0404
|
Facility
|
OP
|
$5,533.00
|
|
|
Service Code
|
HCPCS C9728
|
| Hospital Charge Code |
5456769
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,369.56 |
| Max. Negotiated Rate |
$5,478.24 |
| Rate for Payer: Aetna Commercial |
$4,979.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,758.38
|
| Rate for Payer: Aetna Managed Medicare |
$1,369.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,596.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,766.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,655.84
|
| Rate for Payer: Anthem Medicare Advantage |
$1,369.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,932.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,369.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,369.56
|
| Rate for Payer: Cash Price |
$1,659.90
|
| Rate for Payer: Cash Price |
$1,659.90
|
| Rate for Payer: Cigna Commercial |
$5,090.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$1,369.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,096.27
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1,369.56
|
| Rate for Payer: Health EOS Commercial |
$4,924.37
|
| Rate for Payer: HFN Commercial |
$5,090.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,094.76
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,369.56
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,369.56
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$1,369.56
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$1,369.56
|
| Rate for Payer: Multiplan Commercial |
$4,426.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,054.34
|
| Rate for Payer: Preferred Network Access Commercial |
$5,090.36
|
| Rate for Payer: Quartz Beloit One Network |
$2,711.17
|
| Rate for Payer: Quartz Commercial |
$3,596.45
|
| Rate for Payer: Quartz Medicare Advantage |
$1,369.56
|
| Rate for Payer: The Alliance Commercial |
$5,478.24
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,369.56
|
| Rate for Payer: WEA Trust Commercial |
$3,043.15
|
| Rate for Payer: Wellcare Medicare |
$1,369.56
|
| Rate for Payer: WPS Commercial |
$4,098.29
|
|
|
BIPOLAR COMPONENT UHR 51MM 28MM UHR-51-28
|
Facility
|
OP
|
$5,796.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
3072570
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,622.88 |
| Max. Negotiated Rate |
$23,184.00 |
| Rate for Payer: Aetna Commercial |
$5,216.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,984.56
|
| Rate for Payer: Aetna Managed Medicare |
$1,622.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,767.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,898.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,782.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,071.88
|
| Rate for Payer: Cash Price |
$1,738.80
|
| Rate for Payer: Cigna Commercial |
$5,332.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,243.44
|
| Rate for Payer: Health EOS Commercial |
$5,158.44
|
| Rate for Payer: HFN Commercial |
$5,332.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,347.00
|
| Rate for Payer: Multiplan Commercial |
$4,636.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,477.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,332.32
|
| Rate for Payer: Quartz Beloit One Network |
$2,840.04
|
| Rate for Payer: Quartz Commercial |
$3,767.40
|
| Rate for Payer: Quartz Medicare Advantage |
$3,477.60
|
| Rate for Payer: The Alliance Commercial |
$23,184.00
|
| Rate for Payer: WEA Trust Commercial |
$3,187.80
|
| Rate for Payer: WPS Commercial |
$4,293.10
|
|
|
BIPOLAR COMPONENT UHR 51MM 28MM UHR-51-28
|
Facility
|
IP
|
$5,796.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
3072570
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,840.04 |
| Max. Negotiated Rate |
$5,332.32 |
| Rate for Payer: Aetna Commercial |
$5,216.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,984.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,071.88
|
| Rate for Payer: Cash Price |
$1,738.80
|
| Rate for Payer: Cigna Commercial |
$5,332.32
|
| Rate for Payer: Health EOS Commercial |
$5,158.44
|
| Rate for Payer: HFN Commercial |
$5,332.32
|
| Rate for Payer: Multiplan Commercial |
$4,636.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,477.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5,332.32
|
| Rate for Payer: Quartz Beloit One Network |
$2,840.04
|
| Rate for Payer: Quartz Commercial |
$3,477.60
|
| Rate for Payer: WEA Trust Commercial |
$3,187.80
|
| Rate for Payer: WPS Commercial |
$4,293.10
|
|
|
BI-POLAR HEAD SELF-CENTERING 28MM 42MM 1035-42-000
|
Facility
|
OP
|
$3,719.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6217174
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,041.32 |
| Max. Negotiated Rate |
$14,876.00 |
| Rate for Payer: Aetna Commercial |
$3,347.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,198.34
|
| Rate for Payer: Aetna Managed Medicare |
$1,041.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,417.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,859.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,785.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,971.07
|
| Rate for Payer: Cash Price |
$1,115.70
|
| Rate for Payer: Cigna Commercial |
$3,421.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,081.15
|
| Rate for Payer: Health EOS Commercial |
$3,309.91
|
| Rate for Payer: HFN Commercial |
$3,421.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,789.25
|
| Rate for Payer: Multiplan Commercial |
$2,975.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,231.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,421.48
|
| Rate for Payer: Quartz Beloit One Network |
$1,822.31
|
| Rate for Payer: Quartz Commercial |
$2,417.35
|
| Rate for Payer: Quartz Medicare Advantage |
$2,231.40
|
| Rate for Payer: The Alliance Commercial |
$14,876.00
|
| Rate for Payer: WEA Trust Commercial |
$2,045.45
|
| Rate for Payer: WPS Commercial |
$2,754.66
|
|
|
BI-POLAR HEAD SELF-CENTERING 28MM 42MM 1035-42-000
|
Facility
|
IP
|
$3,719.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6217174
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,822.31 |
| Max. Negotiated Rate |
$3,421.48 |
| Rate for Payer: Aetna Commercial |
$3,347.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,198.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,971.07
|
| Rate for Payer: Cash Price |
$1,115.70
|
| Rate for Payer: Cigna Commercial |
$3,421.48
|
| Rate for Payer: Health EOS Commercial |
$3,309.91
|
| Rate for Payer: HFN Commercial |
$3,421.48
|
| Rate for Payer: Multiplan Commercial |
$2,975.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,231.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,421.48
|
| Rate for Payer: Quartz Beloit One Network |
$1,822.31
|
| Rate for Payer: Quartz Commercial |
$2,231.40
|
| Rate for Payer: WEA Trust Commercial |
$2,045.45
|
| Rate for Payer: WPS Commercial |
$2,754.66
|
|
|
BI-POLAR HEAD SELF-CENTERING 28MM 45MM 1035-45-000
|
Facility
|
OP
|
$3,719.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6217175
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,041.32 |
| Max. Negotiated Rate |
$14,876.00 |
| Rate for Payer: Aetna Commercial |
$3,347.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,198.34
|
| Rate for Payer: Aetna Managed Medicare |
$1,041.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,417.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,859.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,785.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,971.07
|
| Rate for Payer: Cash Price |
$1,115.70
|
| Rate for Payer: Cigna Commercial |
$3,421.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,081.15
|
| Rate for Payer: Health EOS Commercial |
$3,309.91
|
| Rate for Payer: HFN Commercial |
$3,421.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,789.25
|
| Rate for Payer: Multiplan Commercial |
$2,975.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,231.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,421.48
|
| Rate for Payer: Quartz Beloit One Network |
$1,822.31
|
| Rate for Payer: Quartz Commercial |
$2,417.35
|
| Rate for Payer: Quartz Medicare Advantage |
$2,231.40
|
| Rate for Payer: The Alliance Commercial |
$14,876.00
|
| Rate for Payer: WEA Trust Commercial |
$2,045.45
|
| Rate for Payer: WPS Commercial |
$2,754.66
|
|
|
BI-POLAR HEAD SELF-CENTERING 28MM 45MM 1035-45-000
|
Facility
|
IP
|
$3,719.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6217175
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,822.31 |
| Max. Negotiated Rate |
$3,421.48 |
| Rate for Payer: Aetna Commercial |
$3,347.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,198.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,971.07
|
| Rate for Payer: Cash Price |
$1,115.70
|
| Rate for Payer: Cigna Commercial |
$3,421.48
|
| Rate for Payer: Health EOS Commercial |
$3,309.91
|
| Rate for Payer: HFN Commercial |
$3,421.48
|
| Rate for Payer: Multiplan Commercial |
$2,975.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,231.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,421.48
|
| Rate for Payer: Quartz Beloit One Network |
$1,822.31
|
| Rate for Payer: Quartz Commercial |
$2,231.40
|
| Rate for Payer: WEA Trust Commercial |
$2,045.45
|
| Rate for Payer: WPS Commercial |
$2,754.66
|
|
|
BIRCH/MARSHALL MARCHETTI KRANZ (MMK) PROCEDURE
|
Facility
|
IP
|
$3,935.00
|
|
| Hospital Charge Code |
2959844
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,928.15 |
| Max. Negotiated Rate |
$3,620.20 |
| Rate for Payer: Aetna Commercial |
$3,541.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,384.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,085.55
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,620.20
|
| Rate for Payer: Health EOS Commercial |
$3,502.15
|
| Rate for Payer: HFN Commercial |
$3,620.20
|
| Rate for Payer: Multiplan Commercial |
$3,148.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,361.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,620.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,928.15
|
| Rate for Payer: Quartz Commercial |
$2,361.00
|
| Rate for Payer: WEA Trust Commercial |
$2,164.25
|
| Rate for Payer: WPS Commercial |
$2,914.65
|
|
|
BIRCH/MARSHALL MARCHETTI KRANZ (MMK) PROCEDURE
|
Facility
|
OP
|
$3,935.00
|
|
| Hospital Charge Code |
2959844
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,101.80 |
| Max. Negotiated Rate |
$15,740.00 |
| Rate for Payer: Aetna Commercial |
$3,541.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,384.10
|
| Rate for Payer: Aetna Managed Medicare |
$1,101.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,557.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,967.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,888.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,085.55
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,620.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,202.03
|
| Rate for Payer: Health EOS Commercial |
$3,502.15
|
| Rate for Payer: HFN Commercial |
$3,620.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,951.25
|
| Rate for Payer: Multiplan Commercial |
$3,148.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,361.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,620.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,928.15
|
| Rate for Payer: Quartz Commercial |
$2,557.75
|
| Rate for Payer: Quartz Medicare Advantage |
$2,361.00
|
| Rate for Payer: The Alliance Commercial |
$15,740.00
|
| Rate for Payer: WEA Trust Commercial |
$2,164.25
|
| Rate for Payer: WPS Commercial |
$2,914.65
|
|
|
Birth Pack
|
Facility
|
IP
|
$30.00
|
|
| Hospital Charge Code |
3040327
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$14.70 |
| Max. Negotiated Rate |
$27.60 |
| Rate for Payer: Aetna Commercial |
$27.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$25.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$15.90
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cigna Commercial |
$27.60
|
| Rate for Payer: Health EOS Commercial |
$26.70
|
| Rate for Payer: HFN Commercial |
$27.60
|
| Rate for Payer: Multiplan Commercial |
$24.00
|
| Rate for Payer: NAPHCARE Commercial |
$18.00
|
| Rate for Payer: Preferred Network Access Commercial |
$27.60
|
| Rate for Payer: Quartz Beloit One Network |
$14.70
|
| Rate for Payer: Quartz Commercial |
$18.00
|
| Rate for Payer: WEA Trust Commercial |
$16.50
|
| Rate for Payer: WPS Commercial |
$22.22
|
|
|
Birth Pack
|
Facility
|
OP
|
$30.00
|
|
| Hospital Charge Code |
3040327
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$8.40 |
| Max. Negotiated Rate |
$120.00 |
| Rate for Payer: Aetna Commercial |
$27.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$25.80
|
| Rate for Payer: Aetna Managed Medicare |
$8.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$19.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$15.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$14.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$15.90
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cigna Commercial |
$27.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$16.79
|
| Rate for Payer: Health EOS Commercial |
$26.70
|
| Rate for Payer: HFN Commercial |
$27.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$22.50
|
| Rate for Payer: Multiplan Commercial |
$24.00
|
| Rate for Payer: NAPHCARE Commercial |
$18.00
|
| Rate for Payer: Preferred Network Access Commercial |
$27.60
|
| Rate for Payer: Quartz Beloit One Network |
$14.70
|
| Rate for Payer: Quartz Commercial |
$19.50
|
| Rate for Payer: Quartz Medicare Advantage |
$18.00
|
| Rate for Payer: The Alliance Commercial |
$120.00
|
| Rate for Payer: WEA Trust Commercial |
$16.50
|
| Rate for Payer: WPS Commercial |
$22.22
|
|
|
Bisphenol A and Creatinine, Random Urine
|
Professional
|
Both
|
$144.00
|
|
|
Service Code
|
CPT 83789
|
| Hospital Charge Code |
3624168
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$63.36 |
| Max. Negotiated Rate |
$136.80 |
| Rate for Payer: Aetna Commercial |
$136.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$123.84
|
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Cigna Commercial |
$136.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$72.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$86.40
|
| Rate for Payer: Health EOS Commercial |
$131.04
|
| Rate for Payer: HFN Commercial |
$136.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$85.11
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$85.11
|
| Rate for Payer: Multiplan Commercial |
$115.20
|
| Rate for Payer: Preferred Network Access Commercial |
$136.80
|
| Rate for Payer: Quartz Beloit One Network |
$63.36
|
| Rate for Payer: Quartz Commercial |
$82.08
|
| Rate for Payer: The Alliance Commercial |
$72.00
|
| Rate for Payer: WEA Trust Commercial |
$79.20
|
| Rate for Payer: WPS Commercial |
$106.66
|
|
|
Bisphenol A and Creatinine, Random Urine
|
Facility
|
IP
|
$144.00
|
|
|
Service Code
|
CPT 83789
|
| Hospital Charge Code |
3624168
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$70.56 |
| Max. Negotiated Rate |
$132.48 |
| Rate for Payer: Aetna Commercial |
$129.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$123.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$76.32
|
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Cigna Commercial |
$132.48
|
| Rate for Payer: Health EOS Commercial |
$128.16
|
| Rate for Payer: HFN Commercial |
$132.48
|
| Rate for Payer: Multiplan Commercial |
$115.20
|
| Rate for Payer: NAPHCARE Commercial |
$86.40
|
| Rate for Payer: Preferred Network Access Commercial |
$132.48
|
| Rate for Payer: Quartz Beloit One Network |
$70.56
|
| Rate for Payer: Quartz Commercial |
$86.40
|
| Rate for Payer: WEA Trust Commercial |
$79.20
|
| Rate for Payer: WPS Commercial |
$106.66
|
|
