|
Dialysis Circuit Peripheral PTA
|
Facility
|
OP
|
$5,559.00
|
|
|
Service Code
|
CPT 36902
|
| Hospital Charge Code |
5218690
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$2,723.91 |
| Max. Negotiated Rate |
$21,015.81 |
| Rate for Payer: Aetna Commercial |
$5,003.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,780.74
|
| Rate for Payer: Aetna Managed Medicare |
$5,649.41
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$16,318.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$13,785.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$13,096.00
|
| Rate for Payer: Anthem Medicare Advantage |
$5,649.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,946.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5,649.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5,649.41
|
| Rate for Payer: Cash Price |
$1,667.70
|
| Rate for Payer: Cash Price |
$1,667.70
|
| Rate for Payer: Cash Price |
$1,667.70
|
| Rate for Payer: Cigna Commercial |
$5,114.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$5,649.41
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,218.22
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$5,649.41
|
| Rate for Payer: Health EOS Commercial |
$4,947.51
|
| Rate for Payer: HFN Commercial |
$5,114.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$21,015.81
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$5,649.41
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5,649.41
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$5,649.41
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$5,649.41
|
| Rate for Payer: Multiplan Commercial |
$4,447.20
|
| Rate for Payer: NAPHCARE Commercial |
$8,474.12
|
| Rate for Payer: Preferred Network Access Commercial |
$5,114.28
|
| Rate for Payer: Quartz Beloit One Network |
$2,723.91
|
| Rate for Payer: Quartz Commercial |
$3,613.35
|
| Rate for Payer: Quartz Medicare Advantage |
$5,649.41
|
| Rate for Payer: The Alliance Commercial |
$9,604.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5,649.41
|
| Rate for Payer: United Healthcare PPO |
$6,154.00
|
| Rate for Payer: WEA Trust Commercial |
$3,057.45
|
| Rate for Payer: Wellcare Medicare |
$5,649.41
|
| Rate for Payer: WPS Commercial |
$4,117.55
|
|
|
Dialysis Circuit Peripheral PTA
|
Facility
|
IP
|
$5,559.00
|
|
|
Service Code
|
CPT 36902
|
| Hospital Charge Code |
5218690
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$2,723.91 |
| Max. Negotiated Rate |
$5,114.28 |
| Rate for Payer: Aetna Commercial |
$5,003.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,780.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,946.27
|
| Rate for Payer: Cash Price |
$1,667.70
|
| Rate for Payer: Cigna Commercial |
$5,114.28
|
| Rate for Payer: Health EOS Commercial |
$4,947.51
|
| Rate for Payer: HFN Commercial |
$5,114.28
|
| Rate for Payer: Multiplan Commercial |
$4,447.20
|
| Rate for Payer: NAPHCARE Commercial |
$3,335.40
|
| Rate for Payer: Preferred Network Access Commercial |
$5,114.28
|
| Rate for Payer: Quartz Beloit One Network |
$2,723.91
|
| Rate for Payer: Quartz Commercial |
$3,335.40
|
| Rate for Payer: WEA Trust Commercial |
$3,057.45
|
| Rate for Payer: WPS Commercial |
$4,117.55
|
|
|
Dialysis Circuit Peripheral Stent
|
Facility
|
OP
|
$12,657.00
|
|
|
Service Code
|
CPT 36903
|
| Hospital Charge Code |
5218691
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$4,218.22 |
| Max. Negotiated Rate |
$40,449.87 |
| Rate for Payer: Aetna Commercial |
$11,391.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,885.02
|
| Rate for Payer: Aetna Managed Medicare |
$10,873.62
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$18,649.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$18,649.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$17,230.00
|
| Rate for Payer: Anthem Medicare Advantage |
$10,873.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,708.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$10,873.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$10,873.62
|
| Rate for Payer: Cash Price |
$3,797.10
|
| Rate for Payer: Cash Price |
$3,797.10
|
| Rate for Payer: Cash Price |
$3,797.10
|
| Rate for Payer: Cigna Commercial |
$11,644.44
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$10,873.62
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,218.22
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$10,873.62
|
| Rate for Payer: Health EOS Commercial |
$11,264.73
|
| Rate for Payer: HFN Commercial |
$11,644.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$40,449.87
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$10,873.62
|
| Rate for Payer: Independent Care Health Plan Medicare |
$10,873.62
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$10,873.62
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$10,873.62
|
| Rate for Payer: Multiplan Commercial |
$10,125.60
|
| Rate for Payer: NAPHCARE Commercial |
$16,310.43
|
| Rate for Payer: Preferred Network Access Commercial |
$11,644.44
|
| Rate for Payer: Quartz Beloit One Network |
$6,201.93
|
| Rate for Payer: Quartz Commercial |
$8,227.05
|
| Rate for Payer: Quartz Medicare Advantage |
$10,873.62
|
| Rate for Payer: The Alliance Commercial |
$18,485.15
|
| Rate for Payer: United Healthcare Medicare Advantage |
$10,873.62
|
| Rate for Payer: United Healthcare PPO |
$9,596.00
|
| Rate for Payer: WEA Trust Commercial |
$6,961.35
|
| Rate for Payer: Wellcare Medicare |
$10,873.62
|
| Rate for Payer: WPS Commercial |
$9,375.04
|
|
|
Dialysis Circuit Peripheral Stent
|
Facility
|
IP
|
$12,657.00
|
|
|
Service Code
|
CPT 36903
|
| Hospital Charge Code |
5218691
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$6,201.93 |
| Max. Negotiated Rate |
$11,644.44 |
| Rate for Payer: Aetna Commercial |
$11,391.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,885.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,708.21
|
| Rate for Payer: Cash Price |
$3,797.10
|
| Rate for Payer: Cigna Commercial |
$11,644.44
|
| Rate for Payer: Health EOS Commercial |
$11,264.73
|
| Rate for Payer: HFN Commercial |
$11,644.44
|
| Rate for Payer: Multiplan Commercial |
$10,125.60
|
| Rate for Payer: NAPHCARE Commercial |
$7,594.20
|
| Rate for Payer: Preferred Network Access Commercial |
$11,644.44
|
| Rate for Payer: Quartz Beloit One Network |
$6,201.93
|
| Rate for Payer: Quartz Commercial |
$7,594.20
|
| Rate for Payer: WEA Trust Commercial |
$6,961.35
|
| Rate for Payer: WPS Commercial |
$9,375.04
|
|
|
Dialysis Circuit Thromb W/PTA
|
Facility
|
IP
|
$5,978.00
|
|
|
Service Code
|
CPT 36905
|
| Hospital Charge Code |
5218693
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$2,929.22 |
| Max. Negotiated Rate |
$5,499.76 |
| Rate for Payer: Aetna Commercial |
$5,380.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,141.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,168.34
|
| Rate for Payer: Cash Price |
$1,793.40
|
| Rate for Payer: Cigna Commercial |
$5,499.76
|
| Rate for Payer: Health EOS Commercial |
$5,320.42
|
| Rate for Payer: HFN Commercial |
$5,499.76
|
| Rate for Payer: Multiplan Commercial |
$4,782.40
|
| Rate for Payer: NAPHCARE Commercial |
$3,586.80
|
| Rate for Payer: Preferred Network Access Commercial |
$5,499.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,929.22
|
| Rate for Payer: Quartz Commercial |
$3,586.80
|
| Rate for Payer: WEA Trust Commercial |
$3,287.90
|
| Rate for Payer: WPS Commercial |
$4,427.90
|
|
|
Dialysis Circuit Thromb W/PTA
|
Facility
|
OP
|
$5,978.00
|
|
|
Service Code
|
CPT 36905
|
| Hospital Charge Code |
5218693
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$2,929.22 |
| Max. Negotiated Rate |
$40,449.87 |
| Rate for Payer: Aetna Commercial |
$5,380.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,141.08
|
| Rate for Payer: Aetna Managed Medicare |
$10,873.62
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$18,649.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$18,649.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$17,230.00
|
| Rate for Payer: Anthem Medicare Advantage |
$10,873.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,168.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$10,873.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$10,873.62
|
| Rate for Payer: Cash Price |
$1,793.40
|
| Rate for Payer: Cash Price |
$1,793.40
|
| Rate for Payer: Cash Price |
$1,793.40
|
| Rate for Payer: Cigna Commercial |
$5,499.76
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$10,873.62
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,874.87
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$10,873.62
|
| Rate for Payer: Health EOS Commercial |
$5,320.42
|
| Rate for Payer: HFN Commercial |
$5,499.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$40,449.87
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$10,873.62
|
| Rate for Payer: Independent Care Health Plan Medicare |
$10,873.62
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$10,873.62
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$10,873.62
|
| Rate for Payer: Multiplan Commercial |
$4,782.40
|
| Rate for Payer: NAPHCARE Commercial |
$16,310.43
|
| Rate for Payer: Preferred Network Access Commercial |
$5,499.76
|
| Rate for Payer: Quartz Beloit One Network |
$2,929.22
|
| Rate for Payer: Quartz Commercial |
$3,885.70
|
| Rate for Payer: Quartz Medicare Advantage |
$10,873.62
|
| Rate for Payer: The Alliance Commercial |
$18,485.15
|
| Rate for Payer: United Healthcare Medicare Advantage |
$10,873.62
|
| Rate for Payer: United Healthcare PPO |
$9,596.00
|
| Rate for Payer: WEA Trust Commercial |
$3,287.90
|
| Rate for Payer: Wellcare Medicare |
$10,873.62
|
| Rate for Payer: WPS Commercial |
$4,427.90
|
|
|
Dialysis Circuit Thromb W/Stent
|
Facility
|
OP
|
$16,248.00
|
|
|
Service Code
|
CPT 36906
|
| Hospital Charge Code |
5218694
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$4,218.22 |
| Max. Negotiated Rate |
$64,474.41 |
| Rate for Payer: Aetna Commercial |
$14,623.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,973.28
|
| Rate for Payer: Aetna Managed Medicare |
$17,331.83
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$19,815.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$18,378.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$17,460.00
|
| Rate for Payer: Anthem Medicare Advantage |
$17,331.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,611.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17,331.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17,331.83
|
| Rate for Payer: Cash Price |
$4,874.40
|
| Rate for Payer: Cash Price |
$4,874.40
|
| Rate for Payer: Cash Price |
$4,874.40
|
| Rate for Payer: Cigna Commercial |
$14,948.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$17,331.83
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,218.22
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$17,331.83
|
| Rate for Payer: Health EOS Commercial |
$14,460.72
|
| Rate for Payer: HFN Commercial |
$14,948.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$64,474.41
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17,331.83
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17,331.83
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$17,331.83
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$17,331.83
|
| Rate for Payer: Multiplan Commercial |
$12,998.40
|
| Rate for Payer: NAPHCARE Commercial |
$25,997.74
|
| Rate for Payer: Preferred Network Access Commercial |
$14,948.16
|
| Rate for Payer: Quartz Beloit One Network |
$7,961.52
|
| Rate for Payer: Quartz Commercial |
$10,561.20
|
| Rate for Payer: Quartz Medicare Advantage |
$17,331.83
|
| Rate for Payer: The Alliance Commercial |
$29,464.11
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17,331.83
|
| Rate for Payer: United Healthcare PPO |
$11,078.00
|
| Rate for Payer: WEA Trust Commercial |
$8,936.40
|
| Rate for Payer: Wellcare Medicare |
$17,331.83
|
| Rate for Payer: WPS Commercial |
$12,034.89
|
|
|
Dialysis Circuit Thromb W/Stent
|
Facility
|
IP
|
$16,248.00
|
|
|
Service Code
|
CPT 36906
|
| Hospital Charge Code |
5218694
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$7,961.52 |
| Max. Negotiated Rate |
$14,948.16 |
| Rate for Payer: Aetna Commercial |
$14,623.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,973.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,611.44
|
| Rate for Payer: Cash Price |
$4,874.40
|
| Rate for Payer: Cigna Commercial |
$14,948.16
|
| Rate for Payer: Health EOS Commercial |
$14,460.72
|
| Rate for Payer: HFN Commercial |
$14,948.16
|
| Rate for Payer: Multiplan Commercial |
$12,998.40
|
| Rate for Payer: NAPHCARE Commercial |
$9,748.80
|
| Rate for Payer: Preferred Network Access Commercial |
$14,948.16
|
| Rate for Payer: Quartz Beloit One Network |
$7,961.52
|
| Rate for Payer: Quartz Commercial |
$9,748.80
|
| Rate for Payer: WEA Trust Commercial |
$8,936.40
|
| Rate for Payer: WPS Commercial |
$12,034.89
|
|
|
Dialysis Water Culture
|
Facility
|
OP
|
$167.00
|
|
|
Service Code
|
CPT 87084
|
| Hospital Charge Code |
979920
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.59 |
| Max. Negotiated Rate |
$153.64 |
| Rate for Payer: Aetna Commercial |
$150.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$143.62
|
| Rate for Payer: Aetna Managed Medicare |
$27.07
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$101.51
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$47.37
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$44.94
|
| Rate for Payer: Anthem Medicaid |
$10.59
|
| Rate for Payer: Anthem Medicare Advantage |
$27.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$88.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$27.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$27.07
|
| Rate for Payer: Cash Price |
$50.10
|
| Rate for Payer: Cash Price |
$50.10
|
| Rate for Payer: Cigna Commercial |
$153.64
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$27.07
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$10.59
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$93.45
|
| Rate for Payer: Dean Health Medicaid |
$10.59
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$27.07
|
| Rate for Payer: Health EOS Commercial |
$148.63
|
| Rate for Payer: HFN Commercial |
$153.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$100.70
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$27.07
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$10.59
|
| Rate for Payer: Independent Care Health Plan Medicare |
$27.07
|
| Rate for Payer: Managed Health Services Medicaid |
$11.01
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$27.07
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$27.07
|
| Rate for Payer: Multiplan Commercial |
$133.60
|
| Rate for Payer: NAPHCARE Commercial |
$40.60
|
| Rate for Payer: Preferred Network Access Commercial |
$153.64
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$10.59
|
| Rate for Payer: Quartz Beloit One Network |
$81.83
|
| Rate for Payer: Quartz Commercial |
$108.55
|
| Rate for Payer: Quartz Medicare Advantage |
$27.07
|
| Rate for Payer: The Alliance Commercial |
$108.28
|
| Rate for Payer: United Healthcare Medicaid |
$10.59
|
| Rate for Payer: United Healthcare Medicare Advantage |
$27.07
|
| Rate for Payer: United Healthcare PPO |
$125.25
|
| Rate for Payer: WEA Trust Commercial |
$91.85
|
| Rate for Payer: Wellcare Medicare |
$27.07
|
| Rate for Payer: WMAP Medicaid |
$10.59
|
| Rate for Payer: WPS Commercial |
$123.70
|
|
|
Dialysis Water Culture
|
Professional
|
Both
|
$167.00
|
|
|
Service Code
|
CPT 87084
|
| Hospital Charge Code |
979920
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$73.48 |
| Max. Negotiated Rate |
$158.65 |
| Rate for Payer: Aetna Commercial |
$158.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$143.62
|
| Rate for Payer: Cash Price |
$50.10
|
| Rate for Payer: Cash Price |
$50.10
|
| Rate for Payer: Cigna Commercial |
$158.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$83.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$100.20
|
| Rate for Payer: Health EOS Commercial |
$151.97
|
| Rate for Payer: HFN Commercial |
$158.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$95.56
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$95.56
|
| Rate for Payer: Multiplan Commercial |
$133.60
|
| Rate for Payer: Preferred Network Access Commercial |
$158.65
|
| Rate for Payer: Quartz Beloit One Network |
$73.48
|
| Rate for Payer: Quartz Commercial |
$95.19
|
| Rate for Payer: The Alliance Commercial |
$83.50
|
| Rate for Payer: WEA Trust Commercial |
$91.85
|
| Rate for Payer: WPS Commercial |
$123.70
|
|
|
Dialysis Water Culture
|
Facility
|
IP
|
$167.00
|
|
|
Service Code
|
CPT 87084
|
| Hospital Charge Code |
979920
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$81.83 |
| Max. Negotiated Rate |
$153.64 |
| Rate for Payer: Aetna Commercial |
$150.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$143.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$88.51
|
| Rate for Payer: Cash Price |
$50.10
|
| Rate for Payer: Cigna Commercial |
$153.64
|
| Rate for Payer: Health EOS Commercial |
$148.63
|
| Rate for Payer: HFN Commercial |
$153.64
|
| Rate for Payer: Multiplan Commercial |
$133.60
|
| Rate for Payer: NAPHCARE Commercial |
$100.20
|
| Rate for Payer: Preferred Network Access Commercial |
$153.64
|
| Rate for Payer: Quartz Beloit One Network |
$81.83
|
| Rate for Payer: Quartz Commercial |
$100.20
|
| Rate for Payer: WEA Trust Commercial |
$91.85
|
| Rate for Payer: WPS Commercial |
$123.70
|
|
|
Diamondback Atherectomy Device
|
Facility
|
IP
|
$12,634.00
|
|
|
Service Code
|
HCPCS C1724
|
| Hospital Charge Code |
5184610
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$6,190.66 |
| Max. Negotiated Rate |
$11,623.28 |
| Rate for Payer: Aetna Commercial |
$11,370.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,865.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,696.02
|
| Rate for Payer: Cash Price |
$3,790.20
|
| Rate for Payer: Cigna Commercial |
$11,623.28
|
| Rate for Payer: Health EOS Commercial |
$11,244.26
|
| Rate for Payer: HFN Commercial |
$11,623.28
|
| Rate for Payer: Multiplan Commercial |
$10,107.20
|
| Rate for Payer: NAPHCARE Commercial |
$7,580.40
|
| Rate for Payer: Preferred Network Access Commercial |
$11,623.28
|
| Rate for Payer: Quartz Beloit One Network |
$6,190.66
|
| Rate for Payer: Quartz Commercial |
$7,580.40
|
| Rate for Payer: WEA Trust Commercial |
$6,948.70
|
| Rate for Payer: WPS Commercial |
$9,358.00
|
|
|
Diamondback Atherectomy Device
|
Facility
|
OP
|
$12,634.00
|
|
|
Service Code
|
HCPCS C1724
|
| Hospital Charge Code |
5184610
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$3,537.52 |
| Max. Negotiated Rate |
$50,536.00 |
| Rate for Payer: Aetna Commercial |
$11,370.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,865.24
|
| Rate for Payer: Aetna Managed Medicare |
$3,537.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$8,212.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6,317.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,064.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,696.02
|
| Rate for Payer: Cash Price |
$3,790.20
|
| Rate for Payer: Cigna Commercial |
$11,623.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7,069.99
|
| Rate for Payer: Health EOS Commercial |
$11,244.26
|
| Rate for Payer: HFN Commercial |
$11,623.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9,475.50
|
| Rate for Payer: Multiplan Commercial |
$10,107.20
|
| Rate for Payer: NAPHCARE Commercial |
$7,580.40
|
| Rate for Payer: Preferred Network Access Commercial |
$11,623.28
|
| Rate for Payer: Quartz Beloit One Network |
$6,190.66
|
| Rate for Payer: Quartz Commercial |
$8,212.10
|
| Rate for Payer: Quartz Medicare Advantage |
$7,580.40
|
| Rate for Payer: The Alliance Commercial |
$50,536.00
|
| Rate for Payer: WEA Trust Commercial |
$6,948.70
|
| Rate for Payer: WPS Commercial |
$9,358.00
|
|
|
DIAMOND BUR 5MM
|
Facility
|
IP
|
$1,738.00
|
|
| Hospital Charge Code |
2964910
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$851.62 |
| Max. Negotiated Rate |
$1,598.96 |
| Rate for Payer: Aetna Commercial |
$1,564.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,494.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$921.14
|
| Rate for Payer: Cash Price |
$521.40
|
| Rate for Payer: Cigna Commercial |
$1,598.96
|
| Rate for Payer: Health EOS Commercial |
$1,546.82
|
| Rate for Payer: HFN Commercial |
$1,598.96
|
| Rate for Payer: Multiplan Commercial |
$1,390.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,042.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,598.96
|
| Rate for Payer: Quartz Beloit One Network |
$851.62
|
| Rate for Payer: Quartz Commercial |
$1,042.80
|
| Rate for Payer: WEA Trust Commercial |
$955.90
|
| Rate for Payer: WPS Commercial |
$1,287.34
|
|
|
DIAMOND BUR 5MM
|
Facility
|
OP
|
$1,738.00
|
|
| Hospital Charge Code |
2964910
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$486.64 |
| Max. Negotiated Rate |
$6,952.00 |
| Rate for Payer: Aetna Commercial |
$1,564.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,494.68
|
| Rate for Payer: Aetna Managed Medicare |
$486.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,129.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$869.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$834.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$921.14
|
| Rate for Payer: Cash Price |
$521.40
|
| Rate for Payer: Cigna Commercial |
$1,598.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$972.58
|
| Rate for Payer: Health EOS Commercial |
$1,546.82
|
| Rate for Payer: HFN Commercial |
$1,598.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,303.50
|
| Rate for Payer: Multiplan Commercial |
$1,390.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,042.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,598.96
|
| Rate for Payer: Quartz Beloit One Network |
$851.62
|
| Rate for Payer: Quartz Commercial |
$1,129.70
|
| Rate for Payer: Quartz Medicare Advantage |
$1,042.80
|
| Rate for Payer: The Alliance Commercial |
$6,952.00
|
| Rate for Payer: WEA Trust Commercial |
$955.90
|
| Rate for Payer: WPS Commercial |
$1,287.34
|
|
|
DIAMOND BUR 6MM
|
Facility
|
OP
|
$1,738.00
|
|
| Hospital Charge Code |
2974041
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$486.64 |
| Max. Negotiated Rate |
$6,952.00 |
| Rate for Payer: Aetna Commercial |
$1,564.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,494.68
|
| Rate for Payer: Aetna Managed Medicare |
$486.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,129.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$869.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$834.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$921.14
|
| Rate for Payer: Cash Price |
$521.40
|
| Rate for Payer: Cigna Commercial |
$1,598.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$972.58
|
| Rate for Payer: Health EOS Commercial |
$1,546.82
|
| Rate for Payer: HFN Commercial |
$1,598.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,303.50
|
| Rate for Payer: Multiplan Commercial |
$1,390.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,042.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,598.96
|
| Rate for Payer: Quartz Beloit One Network |
$851.62
|
| Rate for Payer: Quartz Commercial |
$1,129.70
|
| Rate for Payer: Quartz Medicare Advantage |
$1,042.80
|
| Rate for Payer: The Alliance Commercial |
$6,952.00
|
| Rate for Payer: WEA Trust Commercial |
$955.90
|
| Rate for Payer: WPS Commercial |
$1,287.34
|
|
|
DIAMOND BUR 6MM
|
Facility
|
IP
|
$1,738.00
|
|
| Hospital Charge Code |
2974041
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$851.62 |
| Max. Negotiated Rate |
$1,598.96 |
| Rate for Payer: Aetna Commercial |
$1,564.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,494.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$921.14
|
| Rate for Payer: Cash Price |
$521.40
|
| Rate for Payer: Cigna Commercial |
$1,598.96
|
| Rate for Payer: Health EOS Commercial |
$1,546.82
|
| Rate for Payer: HFN Commercial |
$1,598.96
|
| Rate for Payer: Multiplan Commercial |
$1,390.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,042.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,598.96
|
| Rate for Payer: Quartz Beloit One Network |
$851.62
|
| Rate for Payer: Quartz Commercial |
$1,042.80
|
| Rate for Payer: WEA Trust Commercial |
$955.90
|
| Rate for Payer: WPS Commercial |
$1,287.34
|
|
|
DIAMOND TOOL MIDAS REX 2MM BALL 75BA20D
|
Facility
|
OP
|
$2,024.00
|
|
| Hospital Charge Code |
3613497
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$566.72 |
| Max. Negotiated Rate |
$8,096.00 |
| Rate for Payer: Aetna Commercial |
$1,821.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,740.64
|
| Rate for Payer: Aetna Managed Medicare |
$566.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,315.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,012.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$971.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,072.72
|
| Rate for Payer: Cash Price |
$607.20
|
| Rate for Payer: Cigna Commercial |
$1,862.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,132.63
|
| Rate for Payer: Health EOS Commercial |
$1,801.36
|
| Rate for Payer: HFN Commercial |
$1,862.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,518.00
|
| Rate for Payer: Multiplan Commercial |
$1,619.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,214.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,862.08
|
| Rate for Payer: Quartz Beloit One Network |
$991.76
|
| Rate for Payer: Quartz Commercial |
$1,315.60
|
| Rate for Payer: Quartz Medicare Advantage |
$1,214.40
|
| Rate for Payer: The Alliance Commercial |
$8,096.00
|
| Rate for Payer: WEA Trust Commercial |
$1,113.20
|
| Rate for Payer: WPS Commercial |
$1,499.18
|
|
|
DIAMOND TOOL MIDAS REX 2MM BALL 75BA20D
|
Facility
|
IP
|
$2,024.00
|
|
| Hospital Charge Code |
3613497
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$991.76 |
| Max. Negotiated Rate |
$1,862.08 |
| Rate for Payer: Aetna Commercial |
$1,821.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,740.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,072.72
|
| Rate for Payer: Cash Price |
$607.20
|
| Rate for Payer: Cigna Commercial |
$1,862.08
|
| Rate for Payer: Health EOS Commercial |
$1,801.36
|
| Rate for Payer: HFN Commercial |
$1,862.08
|
| Rate for Payer: Multiplan Commercial |
$1,619.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,214.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,862.08
|
| Rate for Payer: Quartz Beloit One Network |
$991.76
|
| Rate for Payer: Quartz Commercial |
$1,214.40
|
| Rate for Payer: WEA Trust Commercial |
$1,113.20
|
| Rate for Payer: WPS Commercial |
$1,499.18
|
|
|
DIAMOND TOOL MIDAS REX 2MM BALL 75BA20DL
|
Facility
|
IP
|
$2,024.00
|
|
| Hospital Charge Code |
3495516
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$991.76 |
| Max. Negotiated Rate |
$1,862.08 |
| Rate for Payer: Aetna Commercial |
$1,821.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,740.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,072.72
|
| Rate for Payer: Cash Price |
$607.20
|
| Rate for Payer: Cigna Commercial |
$1,862.08
|
| Rate for Payer: Health EOS Commercial |
$1,801.36
|
| Rate for Payer: HFN Commercial |
$1,862.08
|
| Rate for Payer: Multiplan Commercial |
$1,619.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,214.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,862.08
|
| Rate for Payer: Quartz Beloit One Network |
$991.76
|
| Rate for Payer: Quartz Commercial |
$1,214.40
|
| Rate for Payer: WEA Trust Commercial |
$1,113.20
|
| Rate for Payer: WPS Commercial |
$1,499.18
|
|
|
DIAMOND TOOL MIDAS REX 2MM BALL 75BA20DL
|
Facility
|
OP
|
$2,024.00
|
|
| Hospital Charge Code |
3495516
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$566.72 |
| Max. Negotiated Rate |
$8,096.00 |
| Rate for Payer: Aetna Commercial |
$1,821.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,740.64
|
| Rate for Payer: Aetna Managed Medicare |
$566.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,315.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,012.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$971.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,072.72
|
| Rate for Payer: Cash Price |
$607.20
|
| Rate for Payer: Cigna Commercial |
$1,862.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,132.63
|
| Rate for Payer: Health EOS Commercial |
$1,801.36
|
| Rate for Payer: HFN Commercial |
$1,862.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,518.00
|
| Rate for Payer: Multiplan Commercial |
$1,619.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,214.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,862.08
|
| Rate for Payer: Quartz Beloit One Network |
$991.76
|
| Rate for Payer: Quartz Commercial |
$1,315.60
|
| Rate for Payer: Quartz Medicare Advantage |
$1,214.40
|
| Rate for Payer: The Alliance Commercial |
$8,096.00
|
| Rate for Payer: WEA Trust Commercial |
$1,113.20
|
| Rate for Payer: WPS Commercial |
$1,499.18
|
|
|
DIAMOND TOOL MIDAS REX 3MM BALL D 75BA30DL
|
Facility
|
IP
|
$2,024.00
|
|
| Hospital Charge Code |
4519596
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$991.76 |
| Max. Negotiated Rate |
$1,862.08 |
| Rate for Payer: Aetna Commercial |
$1,821.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,740.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,072.72
|
| Rate for Payer: Cash Price |
$607.20
|
| Rate for Payer: Cigna Commercial |
$1,862.08
|
| Rate for Payer: Health EOS Commercial |
$1,801.36
|
| Rate for Payer: HFN Commercial |
$1,862.08
|
| Rate for Payer: Multiplan Commercial |
$1,619.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,214.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,862.08
|
| Rate for Payer: Quartz Beloit One Network |
$991.76
|
| Rate for Payer: Quartz Commercial |
$1,214.40
|
| Rate for Payer: WEA Trust Commercial |
$1,113.20
|
| Rate for Payer: WPS Commercial |
$1,499.18
|
|
|
DIAMOND TOOL MIDAS REX 3MM BALL D 75BA30DL
|
Facility
|
OP
|
$2,024.00
|
|
| Hospital Charge Code |
4519596
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$566.72 |
| Max. Negotiated Rate |
$8,096.00 |
| Rate for Payer: Aetna Commercial |
$1,821.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,740.64
|
| Rate for Payer: Aetna Managed Medicare |
$566.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,315.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,012.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$971.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,072.72
|
| Rate for Payer: Cash Price |
$607.20
|
| Rate for Payer: Cigna Commercial |
$1,862.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,132.63
|
| Rate for Payer: Health EOS Commercial |
$1,801.36
|
| Rate for Payer: HFN Commercial |
$1,862.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,518.00
|
| Rate for Payer: Multiplan Commercial |
$1,619.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,214.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,862.08
|
| Rate for Payer: Quartz Beloit One Network |
$991.76
|
| Rate for Payer: Quartz Commercial |
$1,315.60
|
| Rate for Payer: Quartz Medicare Advantage |
$1,214.40
|
| Rate for Payer: The Alliance Commercial |
$8,096.00
|
| Rate for Payer: WEA Trust Commercial |
$1,113.20
|
| Rate for Payer: WPS Commercial |
$1,499.18
|
|
|
DIAMOND TOOL MIDAS REX 4MM BALL 75BA40D
|
Facility
|
OP
|
$2,024.00
|
|
| Hospital Charge Code |
3495514
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$566.72 |
| Max. Negotiated Rate |
$8,096.00 |
| Rate for Payer: Aetna Commercial |
$1,821.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,740.64
|
| Rate for Payer: Aetna Managed Medicare |
$566.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,315.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,012.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$971.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,072.72
|
| Rate for Payer: Cash Price |
$607.20
|
| Rate for Payer: Cigna Commercial |
$1,862.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,132.63
|
| Rate for Payer: Health EOS Commercial |
$1,801.36
|
| Rate for Payer: HFN Commercial |
$1,862.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,518.00
|
| Rate for Payer: Multiplan Commercial |
$1,619.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,214.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,862.08
|
| Rate for Payer: Quartz Beloit One Network |
$991.76
|
| Rate for Payer: Quartz Commercial |
$1,315.60
|
| Rate for Payer: Quartz Medicare Advantage |
$1,214.40
|
| Rate for Payer: The Alliance Commercial |
$8,096.00
|
| Rate for Payer: WEA Trust Commercial |
$1,113.20
|
| Rate for Payer: WPS Commercial |
$1,499.18
|
|
|
DIAMOND TOOL MIDAS REX 4MM BALL 75BA40D
|
Facility
|
IP
|
$2,024.00
|
|
| Hospital Charge Code |
3495514
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$991.76 |
| Max. Negotiated Rate |
$1,862.08 |
| Rate for Payer: Aetna Commercial |
$1,821.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,740.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,072.72
|
| Rate for Payer: Cash Price |
$607.20
|
| Rate for Payer: Cigna Commercial |
$1,862.08
|
| Rate for Payer: Health EOS Commercial |
$1,801.36
|
| Rate for Payer: HFN Commercial |
$1,862.08
|
| Rate for Payer: Multiplan Commercial |
$1,619.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,214.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,862.08
|
| Rate for Payer: Quartz Beloit One Network |
$991.76
|
| Rate for Payer: Quartz Commercial |
$1,214.40
|
| Rate for Payer: WEA Trust Commercial |
$1,113.20
|
| Rate for Payer: WPS Commercial |
$1,499.18
|
|
