|
ACHr Ganglionic Neuronal Antibody
|
Facility
IP
|
$140.00
|
|
|
Service Code
|
CPT 83519
|
| Hospital Charge Code |
2942964
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$68.60 |
| Max. Negotiated Rate |
$128.80 |
| Rate for Payer: Aetna Commercial |
$126.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$74.20
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Cigna Commercial |
$128.80
|
| Rate for Payer: Health EOS Commercial |
$124.60
|
| Rate for Payer: HFN Commercial |
$128.80
|
| Rate for Payer: Multiplan Commercial |
$112.00
|
| Rate for Payer: NAPHCARE Commercial |
$84.00
|
| Rate for Payer: Preferred Network Access Commercial |
$128.80
|
| Rate for Payer: Quartz Beloit One Network |
$68.60
|
| Rate for Payer: Quartz Commercial |
$84.00
|
| Rate for Payer: WEA Trust Commercial |
$77.00
|
| Rate for Payer: WPS Commercial |
$103.70
|
|
|
ACHr Ganglionic Neuronal Antibody
|
Professional
|
$140.00
|
|
|
Service Code
|
CPT 83519
|
| Hospital Charge Code |
2942964
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.40 |
| Max. Negotiated Rate |
$133.00 |
| Rate for Payer: Aetna Commercial |
$133.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$120.40
|
| Rate for Payer: Aetna Managed Medicare |
$18.40
|
| Rate for Payer: Anthem Medicare Advantage |
$18.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$18.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$18.40
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Cigna Commercial |
$133.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$70.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$18.40
|
| Rate for Payer: Health EOS Commercial |
$127.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$64.95
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$64.95
|
| Rate for Payer: Independent Care Health Plan Medicare |
$18.40
|
| Rate for Payer: Multiplan Commercial |
$112.00
|
| Rate for Payer: Preferred Network Access Commercial |
$133.00
|
| Rate for Payer: Quartz Beloit One Network |
$61.60
|
| Rate for Payer: Quartz Commercial |
$79.80
|
| Rate for Payer: Quartz Medicare Advantage |
$18.40
|
| Rate for Payer: The Alliance Commercial |
$72.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.40
|
| Rate for Payer: WEA Trust Commercial |
$77.00
|
| Rate for Payer: WPS Commercial |
$80.96
|
|
|
ACHr Mod Ab / 26474
|
Facility
OP
|
$160.00
|
|
|
Service Code
|
CPT 86043
|
| Hospital Charge Code |
977771
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$9.64 |
| Max. Negotiated Rate |
$640.00 |
| Rate for Payer: Aetna Commercial |
$144.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$137.60
|
| Rate for Payer: Aetna Managed Medicare |
$44.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$104.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$80.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$76.80
|
| Rate for Payer: Anthem Medicaid |
$9.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$84.80
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cigna Commercial |
$147.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$9.64
|
| Rate for Payer: Dean Health Medicaid |
$9.64
|
| Rate for Payer: Health EOS Commercial |
$142.40
|
| Rate for Payer: HFN Commercial |
$147.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$120.00
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$9.64
|
| Rate for Payer: Managed Health Services Medicaid |
$10.03
|
| Rate for Payer: Multiplan Commercial |
$128.00
|
| Rate for Payer: NAPHCARE Commercial |
$96.00
|
| Rate for Payer: Preferred Network Access Commercial |
$147.20
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$9.64
|
| Rate for Payer: Quartz Beloit One Network |
$78.40
|
| Rate for Payer: Quartz Commercial |
$104.00
|
| Rate for Payer: Quartz Medicare Advantage |
$96.00
|
| Rate for Payer: The Alliance Commercial |
$640.00
|
| Rate for Payer: United Healthcare Medicaid |
$9.64
|
| Rate for Payer: United Healthcare PPO |
$120.00
|
| Rate for Payer: WEA Trust Commercial |
$88.00
|
| Rate for Payer: WMAP Medicaid |
$9.64
|
| Rate for Payer: WPS Commercial |
$118.51
|
|
|
ACHr Mod Ab / 26474
|
Facility
IP
|
$160.00
|
|
|
Service Code
|
CPT 86043
|
| Hospital Charge Code |
977771
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$78.40 |
| Max. Negotiated Rate |
$147.20 |
| Rate for Payer: Aetna Commercial |
$144.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$84.80
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cigna Commercial |
$147.20
|
| Rate for Payer: Health EOS Commercial |
$142.40
|
| Rate for Payer: HFN Commercial |
$147.20
|
| Rate for Payer: Multiplan Commercial |
$128.00
|
| Rate for Payer: NAPHCARE Commercial |
$96.00
|
| Rate for Payer: Preferred Network Access Commercial |
$147.20
|
| Rate for Payer: Quartz Beloit One Network |
$78.40
|
| Rate for Payer: Quartz Commercial |
$96.00
|
| Rate for Payer: WEA Trust Commercial |
$88.00
|
| Rate for Payer: WPS Commercial |
$118.51
|
|
|
ACHr Mod Ab / 26474
|
Professional
|
$160.00
|
|
|
Service Code
|
CPT 86043
|
| Hospital Charge Code |
977771
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$70.40 |
| Max. Negotiated Rate |
$152.00 |
| Rate for Payer: Aetna Commercial |
$152.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$137.60
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cigna Commercial |
$152.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$80.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$96.00
|
| Rate for Payer: Health EOS Commercial |
$145.60
|
| Rate for Payer: Multiplan Commercial |
$128.00
|
| Rate for Payer: Preferred Network Access Commercial |
$152.00
|
| Rate for Payer: Quartz Beloit One Network |
$70.40
|
| Rate for Payer: Quartz Commercial |
$91.20
|
| Rate for Payer: The Alliance Commercial |
$80.00
|
| Rate for Payer: WEA Trust Commercial |
$88.00
|
| Rate for Payer: WPS Commercial |
$118.51
|
|
|
Acid Fast Bacilli Culture
|
Facility
IP
|
$227.00
|
|
|
Service Code
|
CPT 87116
|
| Hospital Charge Code |
633878
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$111.23 |
| Max. Negotiated Rate |
$208.84 |
| Rate for Payer: Aetna Commercial |
$204.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$120.31
|
| Rate for Payer: Cash Price |
$68.10
|
| Rate for Payer: Cigna Commercial |
$208.84
|
| Rate for Payer: Health EOS Commercial |
$202.03
|
| Rate for Payer: HFN Commercial |
$208.84
|
| Rate for Payer: Multiplan Commercial |
$181.60
|
| Rate for Payer: NAPHCARE Commercial |
$136.20
|
| Rate for Payer: Preferred Network Access Commercial |
$208.84
|
| Rate for Payer: Quartz Beloit One Network |
$111.23
|
| Rate for Payer: Quartz Commercial |
$136.20
|
| Rate for Payer: WEA Trust Commercial |
$124.85
|
| Rate for Payer: WPS Commercial |
$168.14
|
|
|
Acid Fast Bacilli Culture
|
Professional
|
$227.00
|
|
|
Service Code
|
CPT 87116
|
| Hospital Charge Code |
633878
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.80 |
| Max. Negotiated Rate |
$215.65 |
| Rate for Payer: Aetna Commercial |
$215.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$195.22
|
| Rate for Payer: Aetna Managed Medicare |
$10.80
|
| Rate for Payer: Anthem Medicare Advantage |
$10.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$10.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$10.80
|
| Rate for Payer: Cash Price |
$68.10
|
| Rate for Payer: Cash Price |
$68.10
|
| Rate for Payer: Cigna Commercial |
$215.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$113.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10.80
|
| Rate for Payer: Health EOS Commercial |
$206.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$38.12
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$38.12
|
| Rate for Payer: Independent Care Health Plan Medicare |
$10.80
|
| Rate for Payer: Multiplan Commercial |
$181.60
|
| Rate for Payer: Preferred Network Access Commercial |
$215.65
|
| Rate for Payer: Quartz Beloit One Network |
$99.88
|
| Rate for Payer: Quartz Commercial |
$129.39
|
| Rate for Payer: Quartz Medicare Advantage |
$10.80
|
| Rate for Payer: The Alliance Commercial |
$42.66
|
| Rate for Payer: United Healthcare Medicare Advantage |
$10.80
|
| Rate for Payer: WEA Trust Commercial |
$124.85
|
| Rate for Payer: WPS Commercial |
$47.52
|
|
|
Acid Fast Bacilli Culture
|
Facility
OP
|
$227.00
|
|
|
Service Code
|
CPT 87116
|
| Hospital Charge Code |
633878
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.80 |
| Max. Negotiated Rate |
$908.00 |
| Rate for Payer: Aetna Commercial |
$204.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$195.22
|
| Rate for Payer: Aetna Managed Medicare |
$10.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$40.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$18.90
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$17.93
|
| Rate for Payer: Anthem Medicaid |
$11.16
|
| Rate for Payer: Anthem Medicare Advantage |
$10.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$120.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$10.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$10.80
|
| Rate for Payer: Cash Price |
$68.10
|
| Rate for Payer: Cash Price |
$68.10
|
| Rate for Payer: Cigna Commercial |
$208.84
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$10.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$11.16
|
| Rate for Payer: Dean Health Medicaid |
$11.16
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$10.80
|
| Rate for Payer: Health EOS Commercial |
$202.03
|
| Rate for Payer: HFN Commercial |
$208.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$40.18
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$10.80
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$11.16
|
| Rate for Payer: Independent Care Health Plan Medicare |
$10.80
|
| Rate for Payer: Managed Health Services Medicaid |
$11.61
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$10.80
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$10.80
|
| Rate for Payer: Multiplan Commercial |
$181.60
|
| Rate for Payer: NAPHCARE Commercial |
$16.20
|
| Rate for Payer: Preferred Network Access Commercial |
$208.84
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$11.16
|
| Rate for Payer: Quartz Beloit One Network |
$111.23
|
| Rate for Payer: Quartz Commercial |
$147.55
|
| Rate for Payer: Quartz Medicare Advantage |
$10.80
|
| Rate for Payer: The Alliance Commercial |
$908.00
|
| Rate for Payer: United Healthcare Medicaid |
$11.16
|
| Rate for Payer: United Healthcare Medicare Advantage |
$10.80
|
| Rate for Payer: United Healthcare PPO |
$170.25
|
| Rate for Payer: WEA Trust Commercial |
$124.85
|
| Rate for Payer: Wellcare Medicare |
$10.80
|
| Rate for Payer: WMAP Medicaid |
$11.16
|
| Rate for Payer: WPS Commercial |
$168.14
|
|
|
Acid Fast Stain Report
|
Professional
|
$121.00
|
|
|
Service Code
|
CPT 87206
|
| Hospital Charge Code |
634214
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.39 |
| Max. Negotiated Rate |
$114.95 |
| Rate for Payer: Aetna Commercial |
$114.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$104.06
|
| Rate for Payer: Aetna Managed Medicare |
$5.39
|
| Rate for Payer: Anthem Medicare Advantage |
$5.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5.39
|
| Rate for Payer: Cash Price |
$36.30
|
| Rate for Payer: Cash Price |
$36.30
|
| Rate for Payer: Cigna Commercial |
$114.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$60.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5.39
|
| Rate for Payer: Health EOS Commercial |
$110.11
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$19.03
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$19.03
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5.39
|
| Rate for Payer: Multiplan Commercial |
$96.80
|
| Rate for Payer: Preferred Network Access Commercial |
$114.95
|
| Rate for Payer: Quartz Beloit One Network |
$53.24
|
| Rate for Payer: Quartz Commercial |
$68.97
|
| Rate for Payer: Quartz Medicare Advantage |
$5.39
|
| Rate for Payer: The Alliance Commercial |
$21.29
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.39
|
| Rate for Payer: WEA Trust Commercial |
$66.55
|
| Rate for Payer: WPS Commercial |
$23.72
|
|
|
Acid Fast Stain Report
|
Facility
OP
|
$121.00
|
|
|
Service Code
|
CPT 87206
|
| Hospital Charge Code |
634214
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.39 |
| Max. Negotiated Rate |
$484.00 |
| Rate for Payer: Aetna Commercial |
$108.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$104.06
|
| Rate for Payer: Aetna Managed Medicare |
$5.39
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$20.21
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9.43
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8.95
|
| Rate for Payer: Anthem Medicaid |
$5.57
|
| Rate for Payer: Anthem Medicare Advantage |
$5.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$64.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5.39
|
| Rate for Payer: Cash Price |
$36.30
|
| Rate for Payer: Cash Price |
$36.30
|
| Rate for Payer: Cigna Commercial |
$111.32
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$5.39
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5.57
|
| Rate for Payer: Dean Health Medicaid |
$5.57
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$5.39
|
| Rate for Payer: Health EOS Commercial |
$107.69
|
| Rate for Payer: HFN Commercial |
$111.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$20.05
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$5.39
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$5.57
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5.39
|
| Rate for Payer: Managed Health Services Medicaid |
$5.79
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$5.39
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$5.39
|
| Rate for Payer: Multiplan Commercial |
$96.80
|
| Rate for Payer: NAPHCARE Commercial |
$8.08
|
| Rate for Payer: Preferred Network Access Commercial |
$111.32
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$5.57
|
| Rate for Payer: Quartz Beloit One Network |
$59.29
|
| Rate for Payer: Quartz Commercial |
$78.65
|
| Rate for Payer: Quartz Medicare Advantage |
$5.39
|
| Rate for Payer: The Alliance Commercial |
$484.00
|
| Rate for Payer: United Healthcare Medicaid |
$5.57
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.39
|
| Rate for Payer: United Healthcare PPO |
$90.75
|
| Rate for Payer: WEA Trust Commercial |
$66.55
|
| Rate for Payer: Wellcare Medicare |
$5.39
|
| Rate for Payer: WMAP Medicaid |
$5.57
|
| Rate for Payer: WPS Commercial |
$89.62
|
|
|
Acid Fast Stain Report
|
Facility
IP
|
$121.00
|
|
|
Service Code
|
CPT 87206
|
| Hospital Charge Code |
634214
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$59.29 |
| Max. Negotiated Rate |
$111.32 |
| Rate for Payer: Aetna Commercial |
$108.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$64.13
|
| Rate for Payer: Cash Price |
$36.30
|
| Rate for Payer: Cigna Commercial |
$111.32
|
| Rate for Payer: Health EOS Commercial |
$107.69
|
| Rate for Payer: HFN Commercial |
$111.32
|
| Rate for Payer: Multiplan Commercial |
$96.80
|
| Rate for Payer: NAPHCARE Commercial |
$72.60
|
| Rate for Payer: Preferred Network Access Commercial |
$111.32
|
| Rate for Payer: Quartz Beloit One Network |
$59.29
|
| Rate for Payer: Quartz Commercial |
$72.60
|
| Rate for Payer: WEA Trust Commercial |
$66.55
|
| Rate for Payer: WPS Commercial |
$89.62
|
|
|
Acne Surgery 10040
|
Professional
|
$290.00
|
|
|
Service Code
|
CPT 10040
|
| Hospital Charge Code |
1188872
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$22.91 |
| Max. Negotiated Rate |
$275.50 |
| Rate for Payer: Aetna Commercial |
$275.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$249.40
|
| Rate for Payer: Aetna Managed Medicare |
$48.96
|
| Rate for Payer: Anthem Medicare Advantage |
$48.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$48.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$48.96
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Cigna Commercial |
$275.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$145.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$48.96
|
| Rate for Payer: Health EOS Commercial |
$263.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$175.69
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$175.69
|
| Rate for Payer: Independent Care Health Plan Medicare |
$48.96
|
| Rate for Payer: Multiplan Commercial |
$232.00
|
| Rate for Payer: Preferred Network Access Commercial |
$275.50
|
| Rate for Payer: Quartz Beloit One Network |
$127.60
|
| Rate for Payer: Quartz Commercial |
$165.30
|
| Rate for Payer: Quartz Medicare Advantage |
$48.96
|
| Rate for Payer: The Alliance Commercial |
$208.08
|
| Rate for Payer: United Healthcare Medicaid |
$22.91
|
| Rate for Payer: United Healthcare Medicare Advantage |
$48.96
|
| Rate for Payer: WEA Trust Commercial |
$159.50
|
| Rate for Payer: WPS Commercial |
$220.32
|
|
|
Acorn Nebulizer Kit
|
Facility
IP
|
$4.00
|
|
| Hospital Charge Code |
3040339
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1.96 |
| Max. Negotiated Rate |
$3.68 |
| Rate for Payer: Aetna Commercial |
$3.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2.12
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Cigna Commercial |
$3.68
|
| Rate for Payer: Health EOS Commercial |
$3.56
|
| Rate for Payer: HFN Commercial |
$3.68
|
| Rate for Payer: Multiplan Commercial |
$3.20
|
| Rate for Payer: NAPHCARE Commercial |
$2.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3.68
|
| Rate for Payer: Quartz Beloit One Network |
$1.96
|
| Rate for Payer: Quartz Commercial |
$2.40
|
| Rate for Payer: WEA Trust Commercial |
$2.20
|
| Rate for Payer: WPS Commercial |
$2.96
|
|
|
Acorn Nebulizer Kit
|
Facility
OP
|
$4.00
|
|
| Hospital Charge Code |
3040339
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1.12 |
| Max. Negotiated Rate |
$16.00 |
| Rate for Payer: Aetna Commercial |
$3.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3.44
|
| Rate for Payer: Aetna Managed Medicare |
$1.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2.12
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Cigna Commercial |
$3.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2.24
|
| Rate for Payer: Health EOS Commercial |
$3.56
|
| Rate for Payer: HFN Commercial |
$3.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3.00
|
| Rate for Payer: Multiplan Commercial |
$3.20
|
| Rate for Payer: NAPHCARE Commercial |
$2.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3.68
|
| Rate for Payer: Quartz Beloit One Network |
$1.96
|
| Rate for Payer: Quartz Commercial |
$2.60
|
| Rate for Payer: Quartz Medicare Advantage |
$2.40
|
| Rate for Payer: The Alliance Commercial |
$16.00
|
| Rate for Payer: WEA Trust Commercial |
$2.20
|
| Rate for Payer: WPS Commercial |
$2.96
|
|
|
Acoustic Reflex Testing; Threshold
|
Professional
|
$102.00
|
|
|
Service Code
|
CPT 92568
|
| Hospital Charge Code |
1230806
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$14.55 |
| Max. Negotiated Rate |
$96.90 |
| Rate for Payer: Aetna Commercial |
$96.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$87.72
|
| Rate for Payer: Aetna Managed Medicare |
$14.55
|
| Rate for Payer: Anthem Medicare Advantage |
$14.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$14.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$14.55
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cigna Commercial |
$96.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$51.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$14.55
|
| Rate for Payer: Health EOS Commercial |
$92.82
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$52.70
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$52.70
|
| Rate for Payer: Independent Care Health Plan Medicare |
$14.55
|
| Rate for Payer: Multiplan Commercial |
$81.60
|
| Rate for Payer: Preferred Network Access Commercial |
$96.90
|
| Rate for Payer: Quartz Beloit One Network |
$44.88
|
| Rate for Payer: Quartz Commercial |
$58.14
|
| Rate for Payer: Quartz Medicare Advantage |
$14.55
|
| Rate for Payer: The Alliance Commercial |
$36.38
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.55
|
| Rate for Payer: WEA Trust Commercial |
$56.10
|
| Rate for Payer: WPS Commercial |
$58.20
|
|
|
Acoustic Reflex Testing; Threshold
|
Facility
OP
|
$102.00
|
|
|
Service Code
|
CPT 92568
|
| Hospital Charge Code |
1230806
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$39.64 |
| Max. Negotiated Rate |
$147.46 |
| Rate for Payer: Aetna Commercial |
$91.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$87.72
|
| Rate for Payer: Aetna Managed Medicare |
$39.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$66.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$51.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$48.96
|
| Rate for Payer: Anthem Medicare Advantage |
$39.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$54.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$39.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$39.64
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cigna Commercial |
$93.84
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$39.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$57.08
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$39.64
|
| Rate for Payer: Health EOS Commercial |
$90.78
|
| Rate for Payer: HFN Commercial |
$93.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$147.46
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$39.64
|
| Rate for Payer: Independent Care Health Plan Medicare |
$39.64
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$39.64
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$39.64
|
| Rate for Payer: Multiplan Commercial |
$81.60
|
| Rate for Payer: NAPHCARE Commercial |
$59.46
|
| Rate for Payer: Preferred Network Access Commercial |
$93.84
|
| Rate for Payer: Quartz Beloit One Network |
$49.98
|
| Rate for Payer: Quartz Commercial |
$66.30
|
| Rate for Payer: Quartz Medicare Advantage |
$39.64
|
| Rate for Payer: United Healthcare Medicare Advantage |
$39.64
|
| Rate for Payer: United Healthcare PPO |
$76.50
|
| Rate for Payer: WEA Trust Commercial |
$56.10
|
| Rate for Payer: Wellcare Medicare |
$39.64
|
| Rate for Payer: WPS Commercial |
$75.55
|
|
|
Acoustic Reflex Testing; Threshold
|
Facility
IP
|
$102.00
|
|
|
Service Code
|
CPT 92568
|
| Hospital Charge Code |
1230806
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$49.98 |
| Max. Negotiated Rate |
$93.84 |
| Rate for Payer: Aetna Commercial |
$91.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$54.06
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cigna Commercial |
$93.84
|
| Rate for Payer: Health EOS Commercial |
$90.78
|
| Rate for Payer: HFN Commercial |
$93.84
|
| Rate for Payer: Multiplan Commercial |
$81.60
|
| Rate for Payer: NAPHCARE Commercial |
$61.20
|
| Rate for Payer: Preferred Network Access Commercial |
$93.84
|
| Rate for Payer: Quartz Beloit One Network |
$49.98
|
| Rate for Payer: Quartz Commercial |
$61.20
|
| Rate for Payer: WEA Trust Commercial |
$56.10
|
| Rate for Payer: WPS Commercial |
$75.55
|
|
|
Acromio/clavicular canvas&we L3670
|
Professional
|
$223.00
|
|
|
Service Code
|
HCPCS L3670
|
| Hospital Charge Code |
3303498
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$98.12 |
| Max. Negotiated Rate |
$366.63 |
| Rate for Payer: Aetna Commercial |
$211.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$191.78
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cigna Commercial |
$211.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$111.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$133.80
|
| Rate for Payer: Health EOS Commercial |
$202.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$366.63
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$366.63
|
| Rate for Payer: Multiplan Commercial |
$178.40
|
| Rate for Payer: Preferred Network Access Commercial |
$211.85
|
| Rate for Payer: Quartz Beloit One Network |
$98.12
|
| Rate for Payer: Quartz Commercial |
$127.11
|
| Rate for Payer: The Alliance Commercial |
$111.50
|
| Rate for Payer: WEA Trust Commercial |
$122.65
|
| Rate for Payer: WPS Commercial |
$165.18
|
|
|
Acromio/clavicular canvas&we L3670
|
Facility
OP
|
$223.00
|
|
|
Service Code
|
HCPCS L3670
|
| Hospital Charge Code |
3303498
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$62.44 |
| Max. Negotiated Rate |
$892.00 |
| Rate for Payer: Aetna Commercial |
$200.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$191.78
|
| Rate for Payer: Aetna Managed Medicare |
$62.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$77.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$77.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$77.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$118.19
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cigna Commercial |
$205.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$124.79
|
| Rate for Payer: Health EOS Commercial |
$198.47
|
| Rate for Payer: HFN Commercial |
$205.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$167.25
|
| Rate for Payer: Multiplan Commercial |
$178.40
|
| Rate for Payer: NAPHCARE Commercial |
$133.80
|
| Rate for Payer: Preferred Network Access Commercial |
$205.16
|
| Rate for Payer: Quartz Beloit One Network |
$109.27
|
| Rate for Payer: Quartz Commercial |
$144.95
|
| Rate for Payer: Quartz Medicare Advantage |
$133.80
|
| Rate for Payer: The Alliance Commercial |
$892.00
|
| Rate for Payer: WEA Trust Commercial |
$122.65
|
| Rate for Payer: WPS Commercial |
$165.18
|
|
|
Acromio/clavicular canvas&we L3670
|
Facility
IP
|
$223.00
|
|
|
Service Code
|
HCPCS L3670
|
| Hospital Charge Code |
3303498
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$109.27 |
| Max. Negotiated Rate |
$205.16 |
| Rate for Payer: Aetna Commercial |
$200.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$118.19
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cigna Commercial |
$205.16
|
| Rate for Payer: Health EOS Commercial |
$198.47
|
| Rate for Payer: HFN Commercial |
$205.16
|
| Rate for Payer: Multiplan Commercial |
$178.40
|
| Rate for Payer: NAPHCARE Commercial |
$133.80
|
| Rate for Payer: Preferred Network Access Commercial |
$205.16
|
| Rate for Payer: Quartz Beloit One Network |
$109.27
|
| Rate for Payer: Quartz Commercial |
$133.80
|
| Rate for Payer: WEA Trust Commercial |
$122.65
|
| Rate for Payer: WPS Commercial |
$165.18
|
|
|
ACROMIOPLASTY OR ACROMIONECTOMY, PARTIAL, WITH OR WITHOUT CORACOACROMIAL LIGAMENT RELEASE
|
Facility
OP
|
$41,927.24
|
|
|
Service Code
|
CPT 23130
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,199.31 |
| Max. Negotiated Rate |
$41,927.24 |
| Rate for Payer: Aetna Managed Medicare |
$3,199.31
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,907.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,043.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,639.00
|
| Rate for Payer: Anthem Medicare Advantage |
$3,199.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3,199.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3,199.31
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$3,199.31
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,339.76
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$3,199.31
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,901.43
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3,199.31
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3,199.31
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$3,199.31
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$3,199.31
|
| Rate for Payer: NAPHCARE Commercial |
$4,798.96
|
| Rate for Payer: Quartz Medicare Advantage |
$3,199.31
|
| Rate for Payer: The Alliance Commercial |
$41,927.24
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,199.31
|
| Rate for Payer: United Healthcare PPO |
$4,103.00
|
| Rate for Payer: Wellcare Medicare |
$3,199.31
|
|
|
ACTH Stimulation, 2 Specimens
|
Professional
|
$121.00
|
|
|
Service Code
|
CPT 82533
|
| Hospital Charge Code |
980010
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.30 |
| Max. Negotiated Rate |
$114.95 |
| Rate for Payer: Aetna Commercial |
$114.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$104.06
|
| Rate for Payer: Aetna Managed Medicare |
$16.30
|
| Rate for Payer: Anthem Medicare Advantage |
$16.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$16.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$16.30
|
| Rate for Payer: Cash Price |
$36.30
|
| Rate for Payer: Cash Price |
$36.30
|
| Rate for Payer: Cigna Commercial |
$114.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$60.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$16.30
|
| Rate for Payer: Health EOS Commercial |
$110.11
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$57.54
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$57.54
|
| Rate for Payer: Independent Care Health Plan Medicare |
$16.30
|
| Rate for Payer: Multiplan Commercial |
$96.80
|
| Rate for Payer: Preferred Network Access Commercial |
$114.95
|
| Rate for Payer: Quartz Beloit One Network |
$53.24
|
| Rate for Payer: Quartz Commercial |
$68.97
|
| Rate for Payer: Quartz Medicare Advantage |
$16.30
|
| Rate for Payer: The Alliance Commercial |
$64.38
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16.30
|
| Rate for Payer: WEA Trust Commercial |
$66.55
|
| Rate for Payer: WPS Commercial |
$71.72
|
|
|
ACTH Stimulation, 2 Specimens
|
Facility
OP
|
$121.00
|
|
|
Service Code
|
CPT 82533
|
| Hospital Charge Code |
980010
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.30 |
| Max. Negotiated Rate |
$484.00 |
| Rate for Payer: Aetna Commercial |
$108.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$104.06
|
| Rate for Payer: Aetna Managed Medicare |
$16.30
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$61.12
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$28.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$27.06
|
| Rate for Payer: Anthem Medicaid |
$16.84
|
| Rate for Payer: Anthem Medicare Advantage |
$16.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$64.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$16.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$16.30
|
| Rate for Payer: Cash Price |
$36.30
|
| Rate for Payer: Cash Price |
$36.30
|
| Rate for Payer: Cigna Commercial |
$111.32
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$16.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$16.84
|
| Rate for Payer: Dean Health Medicaid |
$16.84
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$16.30
|
| Rate for Payer: Health EOS Commercial |
$107.69
|
| Rate for Payer: HFN Commercial |
$111.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$60.64
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$16.30
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$16.84
|
| Rate for Payer: Independent Care Health Plan Medicare |
$16.30
|
| Rate for Payer: Managed Health Services Medicaid |
$17.51
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$16.30
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$16.30
|
| Rate for Payer: Multiplan Commercial |
$96.80
|
| Rate for Payer: NAPHCARE Commercial |
$24.45
|
| Rate for Payer: Preferred Network Access Commercial |
$111.32
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$16.84
|
| Rate for Payer: Quartz Beloit One Network |
$59.29
|
| Rate for Payer: Quartz Commercial |
$78.65
|
| Rate for Payer: Quartz Medicare Advantage |
$16.30
|
| Rate for Payer: The Alliance Commercial |
$484.00
|
| Rate for Payer: United Healthcare Medicaid |
$16.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16.30
|
| Rate for Payer: United Healthcare PPO |
$90.75
|
| Rate for Payer: WEA Trust Commercial |
$66.55
|
| Rate for Payer: Wellcare Medicare |
$16.30
|
| Rate for Payer: WMAP Medicaid |
$16.84
|
| Rate for Payer: WPS Commercial |
$89.62
|
|
|
ACTH Stimulation, 2 Specimens
|
Facility
IP
|
$121.00
|
|
|
Service Code
|
CPT 82533
|
| Hospital Charge Code |
980010
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$59.29 |
| Max. Negotiated Rate |
$111.32 |
| Rate for Payer: Aetna Commercial |
$108.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$64.13
|
| Rate for Payer: Cash Price |
$36.30
|
| Rate for Payer: Cigna Commercial |
$111.32
|
| Rate for Payer: Health EOS Commercial |
$107.69
|
| Rate for Payer: HFN Commercial |
$111.32
|
| Rate for Payer: Multiplan Commercial |
$96.80
|
| Rate for Payer: NAPHCARE Commercial |
$72.60
|
| Rate for Payer: Preferred Network Access Commercial |
$111.32
|
| Rate for Payer: Quartz Beloit One Network |
$59.29
|
| Rate for Payer: Quartz Commercial |
$72.60
|
| Rate for Payer: WEA Trust Commercial |
$66.55
|
| Rate for Payer: WPS Commercial |
$89.62
|
|
|
ACTH Stimulation, 3 Specimens
|
Facility
IP
|
$114.00
|
|
|
Service Code
|
CPT 82533
|
| Hospital Charge Code |
3162776
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$55.86 |
| Max. Negotiated Rate |
$104.88 |
| Rate for Payer: Aetna Commercial |
$102.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$60.42
|
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Cigna Commercial |
$104.88
|
| Rate for Payer: Health EOS Commercial |
$101.46
|
| Rate for Payer: HFN Commercial |
$104.88
|
| Rate for Payer: Multiplan Commercial |
$91.20
|
| Rate for Payer: NAPHCARE Commercial |
$68.40
|
| Rate for Payer: Preferred Network Access Commercial |
$104.88
|
| Rate for Payer: Quartz Beloit One Network |
$55.86
|
| Rate for Payer: Quartz Commercial |
$68.40
|
| Rate for Payer: WEA Trust Commercial |
$62.70
|
| Rate for Payer: WPS Commercial |
$84.44
|
|
