|
DX BRONCHOSCOPE/WASH 31622
|
Professional
|
Both
|
$1,632.00
|
|
|
Service Code
|
CPT 31622
|
| Hospital Charge Code |
3014398
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$116.63 |
| Max. Negotiated Rate |
$1,612.42 |
| Rate for Payer: Aetna Commercial |
$1,612.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,459.66
|
| Rate for Payer: Aetna Managed Medicare |
$116.63
|
| Rate for Payer: Anthem Medicare Advantage |
$116.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$116.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$116.63
|
| Rate for Payer: Cash Price |
$489.60
|
| Rate for Payer: Cash Price |
$489.60
|
| Rate for Payer: Cash Price |
$489.60
|
| Rate for Payer: Cigna Commercial |
$1,612.42
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$288.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$116.63
|
| Rate for Payer: Health EOS Commercial |
$1,544.52
|
| Rate for Payer: HFN Commercial |
$1,612.42
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$458.61
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$458.61
|
| Rate for Payer: Independent Care Health Plan Medicare |
$116.63
|
| Rate for Payer: Multiplan Commercial |
$1,357.82
|
| Rate for Payer: NAPHCARE Commercial |
$174.94
|
| Rate for Payer: Preferred Network Access Commercial |
$1,612.42
|
| Rate for Payer: Quartz Beloit One Network |
$746.80
|
| Rate for Payer: Quartz Commercial |
$967.45
|
| Rate for Payer: Quartz Medicare Advantage |
$116.63
|
| Rate for Payer: The Alliance Commercial |
$495.66
|
| Rate for Payer: United Healthcare Medicaid |
$288.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$116.63
|
| Rate for Payer: WEA Trust Commercial |
$933.50
|
| Rate for Payer: WPS Commercial |
$524.82
|
|
|
DX LARYNGOSCOPY EXCL NB 31525
|
Professional
|
Both
|
$1,145.00
|
|
|
Service Code
|
CPT 31525
|
| Hospital Charge Code |
3014386
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$132.26 |
| Max. Negotiated Rate |
$1,131.26 |
| Rate for Payer: Aetna Commercial |
$1,131.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,024.09
|
| Rate for Payer: Aetna Managed Medicare |
$132.26
|
| Rate for Payer: Anthem Medicare Advantage |
$132.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$132.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$132.26
|
| Rate for Payer: Cash Price |
$343.50
|
| Rate for Payer: Cash Price |
$343.50
|
| Rate for Payer: Cash Price |
$343.50
|
| Rate for Payer: Cigna Commercial |
$1,131.26
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$206.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$132.26
|
| Rate for Payer: Health EOS Commercial |
$1,083.63
|
| Rate for Payer: HFN Commercial |
$1,131.26
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$545.21
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$545.21
|
| Rate for Payer: Independent Care Health Plan Medicare |
$132.26
|
| Rate for Payer: Multiplan Commercial |
$952.64
|
| Rate for Payer: NAPHCARE Commercial |
$198.39
|
| Rate for Payer: Preferred Network Access Commercial |
$1,131.26
|
| Rate for Payer: Quartz Beloit One Network |
$523.95
|
| Rate for Payer: Quartz Commercial |
$678.76
|
| Rate for Payer: Quartz Medicare Advantage |
$132.26
|
| Rate for Payer: The Alliance Commercial |
$562.09
|
| Rate for Payer: United Healthcare Medicaid |
$206.11
|
| Rate for Payer: United Healthcare Medicare Advantage |
$132.26
|
| Rate for Payer: WEA Trust Commercial |
$654.94
|
| Rate for Payer: WPS Commercial |
$595.16
|
|
|
DYNACLIP BONE FIXATION SYSTEM 10MM X 10MM X 10MM 3000-00-101010
|
Facility
|
OP
|
$7,069.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6226162
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,058.49 |
| Max. Negotiated Rate |
$6,763.62 |
| Rate for Payer: Aetna Commercial |
$6,616.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,322.51
|
| Rate for Payer: Aetna Managed Medicare |
$2,058.49
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,778.64
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,675.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,528.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,896.43
|
| Rate for Payer: Cash Price |
$2,120.70
|
| Rate for Payer: Cigna Commercial |
$6,763.62
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,114.16
|
| Rate for Payer: Health EOS Commercial |
$6,543.07
|
| Rate for Payer: HFN Commercial |
$6,763.62
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,513.82
|
| Rate for Payer: Multiplan Commercial |
$5,881.41
|
| Rate for Payer: NAPHCARE Commercial |
$4,411.06
|
| Rate for Payer: Preferred Network Access Commercial |
$6,763.62
|
| Rate for Payer: Quartz Beloit One Network |
$3,602.36
|
| Rate for Payer: Quartz Commercial |
$4,778.64
|
| Rate for Payer: Quartz Medicare Advantage |
$4,411.06
|
| Rate for Payer: The Alliance Commercial |
$3,675.88
|
| Rate for Payer: WEA Trust Commercial |
$4,043.47
|
| Rate for Payer: WPS Commercial |
$5,445.25
|
|
|
DYNACLIP BONE FIXATION SYSTEM 10MM X 10MM X 10MM 3000-00-101010
|
Facility
|
IP
|
$7,069.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6226162
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,602.36 |
| Max. Negotiated Rate |
$6,763.62 |
| Rate for Payer: Aetna Commercial |
$6,616.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,322.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,896.43
|
| Rate for Payer: Cash Price |
$2,120.70
|
| Rate for Payer: Cigna Commercial |
$6,763.62
|
| Rate for Payer: Health EOS Commercial |
$6,543.07
|
| Rate for Payer: HFN Commercial |
$6,763.62
|
| Rate for Payer: Multiplan Commercial |
$5,881.41
|
| Rate for Payer: Preferred Network Access Commercial |
$6,763.62
|
| Rate for Payer: Quartz Beloit One Network |
$3,602.36
|
| Rate for Payer: Quartz Commercial |
$4,411.06
|
| Rate for Payer: WEA Trust Commercial |
$4,043.47
|
| Rate for Payer: WPS Commercial |
$5,445.25
|
|
|
Dynamic Pro/Sup Splint
|
Facility
|
IP
|
$602.00
|
|
|
Service Code
|
HCPCS L3720
|
| Hospital Charge Code |
2989898
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$306.78 |
| Max. Negotiated Rate |
$575.99 |
| Rate for Payer: Aetna Commercial |
$563.47
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$538.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$331.82
|
| Rate for Payer: Cash Price |
$180.60
|
| Rate for Payer: Cigna Commercial |
$575.99
|
| Rate for Payer: Health EOS Commercial |
$557.21
|
| Rate for Payer: HFN Commercial |
$575.99
|
| Rate for Payer: Multiplan Commercial |
$500.86
|
| Rate for Payer: Preferred Network Access Commercial |
$575.99
|
| Rate for Payer: Quartz Beloit One Network |
$306.78
|
| Rate for Payer: Quartz Commercial |
$375.65
|
| Rate for Payer: WEA Trust Commercial |
$344.34
|
| Rate for Payer: WPS Commercial |
$463.72
|
|
|
Dynamic Pro/Sup Splint
|
Facility
|
OP
|
$602.00
|
|
|
Service Code
|
HCPCS L3720
|
| Hospital Charge Code |
2989898
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$175.30 |
| Max. Negotiated Rate |
$3,179.16 |
| Rate for Payer: Aetna Commercial |
$563.47
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$538.43
|
| Rate for Payer: Aetna Managed Medicare |
$175.30
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$301.57
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$301.57
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$301.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$331.82
|
| Rate for Payer: Cash Price |
$180.60
|
| Rate for Payer: Cash Price |
$180.60
|
| Rate for Payer: Cigna Commercial |
$575.99
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$350.36
|
| Rate for Payer: Health EOS Commercial |
$557.21
|
| Rate for Payer: HFN Commercial |
$575.99
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$469.56
|
| Rate for Payer: Multiplan Commercial |
$500.86
|
| Rate for Payer: NAPHCARE Commercial |
$375.65
|
| Rate for Payer: Preferred Network Access Commercial |
$575.99
|
| Rate for Payer: Quartz Beloit One Network |
$306.78
|
| Rate for Payer: Quartz Commercial |
$406.95
|
| Rate for Payer: Quartz Medicare Advantage |
$375.65
|
| Rate for Payer: The Alliance Commercial |
$3,179.16
|
| Rate for Payer: WEA Trust Commercial |
$344.34
|
| Rate for Payer: WPS Commercial |
$463.72
|
|
|
DYNAMIZATION CLIP FOR LARGE COMBINATION CLAMP 390.006
|
Facility
|
IP
|
$1,705.00
|
|
| Hospital Charge Code |
2966164
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$868.87 |
| Max. Negotiated Rate |
$1,631.34 |
| Rate for Payer: Aetna Commercial |
$1,595.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,524.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$939.80
|
| Rate for Payer: Cash Price |
$511.50
|
| Rate for Payer: Cigna Commercial |
$1,631.34
|
| Rate for Payer: Health EOS Commercial |
$1,578.15
|
| Rate for Payer: HFN Commercial |
$1,631.34
|
| Rate for Payer: Multiplan Commercial |
$1,418.56
|
| Rate for Payer: Preferred Network Access Commercial |
$1,631.34
|
| Rate for Payer: Quartz Beloit One Network |
$868.87
|
| Rate for Payer: Quartz Commercial |
$1,063.92
|
| Rate for Payer: WEA Trust Commercial |
$975.26
|
| Rate for Payer: WPS Commercial |
$1,313.36
|
|
|
DYNAMIZATION CLIP FOR LARGE COMBINATION CLAMP 390.006
|
Facility
|
OP
|
$1,705.00
|
|
| Hospital Charge Code |
2966164
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$496.50 |
| Max. Negotiated Rate |
$1,631.34 |
| Rate for Payer: Aetna Commercial |
$1,595.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,524.95
|
| Rate for Payer: Aetna Managed Medicare |
$496.50
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,152.58
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$886.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$851.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$939.80
|
| Rate for Payer: Cash Price |
$511.50
|
| Rate for Payer: Cigna Commercial |
$1,631.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$992.31
|
| Rate for Payer: Health EOS Commercial |
$1,578.15
|
| Rate for Payer: HFN Commercial |
$1,631.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,329.90
|
| Rate for Payer: Multiplan Commercial |
$1,418.56
|
| Rate for Payer: NAPHCARE Commercial |
$1,063.92
|
| Rate for Payer: Preferred Network Access Commercial |
$1,631.34
|
| Rate for Payer: Quartz Beloit One Network |
$868.87
|
| Rate for Payer: Quartz Commercial |
$1,152.58
|
| Rate for Payer: Quartz Medicare Advantage |
$1,063.92
|
| Rate for Payer: The Alliance Commercial |
$886.60
|
| Rate for Payer: WEA Trust Commercial |
$975.26
|
| Rate for Payer: WPS Commercial |
$1,313.36
|
|
|
DYSEQUILIBRIUM
|
Facility
|
IP
|
$20,923.76
|
|
|
Service Code
|
MSDRG 149
|
| Min. Negotiated Rate |
$6,262.68 |
| Max. Negotiated Rate |
$20,923.76 |
| Rate for Payer: Aetna Managed Medicare |
$6,262.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$16,399.31
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$12,569.94
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$11,942.26
|
| Rate for Payer: Anthem Medicare Advantage |
$6,262.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$6,262.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$6,262.68
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$6,262.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13,257.01
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$6,262.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,102.52
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$6,262.68
|
| Rate for Payer: Independent Care Health Plan Medicare |
$6,262.68
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$6,262.68
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$6,262.68
|
| Rate for Payer: NAPHCARE Commercial |
$9,394.02
|
| Rate for Payer: Quartz Medicare Advantage |
$6,262.68
|
| Rate for Payer: The Alliance Commercial |
$20,923.76
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6,262.68
|
| Rate for Payer: United Healthcare PPO |
$11,757.50
|
| Rate for Payer: Wellcare Medicare |
$6,262.68
|
|
|
Each Additional 90472 - Admin Flu ages 3 and up
|
Professional
|
Both
|
$54.00
|
|
|
Service Code
|
CPT 90472
|
| Hospital Charge Code |
3013443
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$15.60 |
| Max. Negotiated Rate |
$63.86 |
| Rate for Payer: Aetna Commercial |
$53.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$48.30
|
| Rate for Payer: Aetna Managed Medicare |
$15.96
|
| Rate for Payer: Anthem Medicare Advantage |
$15.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15.96
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$53.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$15.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15.96
|
| Rate for Payer: Health EOS Commercial |
$51.11
|
| Rate for Payer: HFN Commercial |
$53.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$18.58
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$18.58
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15.96
|
| Rate for Payer: Multiplan Commercial |
$44.93
|
| Rate for Payer: NAPHCARE Commercial |
$23.95
|
| Rate for Payer: Preferred Network Access Commercial |
$53.35
|
| Rate for Payer: Quartz Beloit One Network |
$24.71
|
| Rate for Payer: Quartz Commercial |
$32.01
|
| Rate for Payer: Quartz Medicare Advantage |
$15.96
|
| Rate for Payer: The Alliance Commercial |
$39.91
|
| Rate for Payer: United Healthcare Medicaid |
$15.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.96
|
| Rate for Payer: WEA Trust Commercial |
$30.89
|
| Rate for Payer: WPS Commercial |
$63.86
|
|
|
Each Additional 90472 - Admin Flu ages 3 and up
|
Facility
|
OP
|
$54.00
|
|
|
Service Code
|
CPT 90472
|
| Hospital Charge Code |
3013443
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$15.72 |
| Max. Negotiated Rate |
$63.86 |
| Rate for Payer: Aetna Commercial |
$50.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$48.30
|
| Rate for Payer: Aetna Managed Medicare |
$15.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$36.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$28.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$26.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.76
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$51.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$31.43
|
| Rate for Payer: Health EOS Commercial |
$49.98
|
| Rate for Payer: HFN Commercial |
$51.67
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.12
|
| Rate for Payer: Multiplan Commercial |
$44.93
|
| Rate for Payer: NAPHCARE Commercial |
$33.70
|
| Rate for Payer: Preferred Network Access Commercial |
$51.67
|
| Rate for Payer: Quartz Beloit One Network |
$27.52
|
| Rate for Payer: Quartz Commercial |
$36.50
|
| Rate for Payer: Quartz Medicare Advantage |
$33.70
|
| Rate for Payer: The Alliance Commercial |
$63.86
|
| Rate for Payer: United Healthcare PPO |
$42.12
|
| Rate for Payer: WEA Trust Commercial |
$30.89
|
| Rate for Payer: WPS Commercial |
$41.60
|
|
|
Each Additional 90472 - Admin Flu ages 3 and up
|
Facility
|
IP
|
$54.00
|
|
|
Service Code
|
CPT 90472
|
| Hospital Charge Code |
3013443
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$27.52 |
| Max. Negotiated Rate |
$51.67 |
| Rate for Payer: Aetna Commercial |
$50.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$48.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.76
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$51.67
|
| Rate for Payer: Health EOS Commercial |
$49.98
|
| Rate for Payer: HFN Commercial |
$51.67
|
| Rate for Payer: Multiplan Commercial |
$44.93
|
| Rate for Payer: Preferred Network Access Commercial |
$51.67
|
| Rate for Payer: Quartz Beloit One Network |
$27.52
|
| Rate for Payer: Quartz Commercial |
$33.70
|
| Rate for Payer: WEA Trust Commercial |
$30.89
|
| Rate for Payer: WPS Commercial |
$41.60
|
|
|
Each Additional 90472 - Admin Hep B Charge
|
Professional
|
Both
|
$56.00
|
|
|
Service Code
|
CPT 90472
|
| Hospital Charge Code |
3013440
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$15.60 |
| Max. Negotiated Rate |
$63.86 |
| Rate for Payer: Aetna Commercial |
$55.33
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$50.09
|
| Rate for Payer: Aetna Managed Medicare |
$15.96
|
| Rate for Payer: Anthem Medicare Advantage |
$15.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15.96
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$55.33
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$15.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15.96
|
| Rate for Payer: Health EOS Commercial |
$53.00
|
| Rate for Payer: HFN Commercial |
$55.33
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$18.58
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$18.58
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15.96
|
| Rate for Payer: Multiplan Commercial |
$46.59
|
| Rate for Payer: NAPHCARE Commercial |
$23.95
|
| Rate for Payer: Preferred Network Access Commercial |
$55.33
|
| Rate for Payer: Quartz Beloit One Network |
$25.63
|
| Rate for Payer: Quartz Commercial |
$33.20
|
| Rate for Payer: Quartz Medicare Advantage |
$15.96
|
| Rate for Payer: The Alliance Commercial |
$39.91
|
| Rate for Payer: United Healthcare Medicaid |
$15.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.96
|
| Rate for Payer: WEA Trust Commercial |
$32.03
|
| Rate for Payer: WPS Commercial |
$63.86
|
|
|
Each Additional 90472 - Admin Hep B Charge
|
Facility
|
OP
|
$56.00
|
|
|
Service Code
|
CPT 90472
|
| Hospital Charge Code |
3013440
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$16.31 |
| Max. Negotiated Rate |
$63.86 |
| Rate for Payer: Aetna Commercial |
$52.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$50.09
|
| Rate for Payer: Aetna Managed Medicare |
$16.31
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$37.86
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$29.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$27.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$30.87
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$53.58
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$32.59
|
| Rate for Payer: Health EOS Commercial |
$51.83
|
| Rate for Payer: HFN Commercial |
$53.58
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$43.68
|
| Rate for Payer: Multiplan Commercial |
$46.59
|
| Rate for Payer: NAPHCARE Commercial |
$34.94
|
| Rate for Payer: Preferred Network Access Commercial |
$53.58
|
| Rate for Payer: Quartz Beloit One Network |
$28.54
|
| Rate for Payer: Quartz Commercial |
$37.86
|
| Rate for Payer: Quartz Medicare Advantage |
$34.94
|
| Rate for Payer: The Alliance Commercial |
$63.86
|
| Rate for Payer: United Healthcare PPO |
$43.68
|
| Rate for Payer: WEA Trust Commercial |
$32.03
|
| Rate for Payer: WPS Commercial |
$43.14
|
|
|
Each Additional 90472 - Admin Hep B Charge
|
Facility
|
IP
|
$56.00
|
|
|
Service Code
|
CPT 90472
|
| Hospital Charge Code |
3013440
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$28.54 |
| Max. Negotiated Rate |
$53.58 |
| Rate for Payer: Aetna Commercial |
$52.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$50.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$30.87
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$53.58
|
| Rate for Payer: Health EOS Commercial |
$51.83
|
| Rate for Payer: HFN Commercial |
$53.58
|
| Rate for Payer: Multiplan Commercial |
$46.59
|
| Rate for Payer: Preferred Network Access Commercial |
$53.58
|
| Rate for Payer: Quartz Beloit One Network |
$28.54
|
| Rate for Payer: Quartz Commercial |
$34.94
|
| Rate for Payer: WEA Trust Commercial |
$32.03
|
| Rate for Payer: WPS Commercial |
$43.14
|
|
|
Each Additional 90472 - Admin Immunization Charge
|
Facility
|
IP
|
$56.00
|
|
|
Service Code
|
CPT 90472
|
| Hospital Charge Code |
2473257
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$28.54 |
| Max. Negotiated Rate |
$53.58 |
| Rate for Payer: Aetna Commercial |
$52.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$50.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$30.87
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$53.58
|
| Rate for Payer: Health EOS Commercial |
$51.83
|
| Rate for Payer: HFN Commercial |
$53.58
|
| Rate for Payer: Multiplan Commercial |
$46.59
|
| Rate for Payer: Preferred Network Access Commercial |
$53.58
|
| Rate for Payer: Quartz Beloit One Network |
$28.54
|
| Rate for Payer: Quartz Commercial |
$34.94
|
| Rate for Payer: WEA Trust Commercial |
$32.03
|
| Rate for Payer: WPS Commercial |
$43.14
|
|
|
Each Additional 90472 - Admin Immunization Charge
|
Professional
|
Both
|
$56.00
|
|
|
Service Code
|
CPT 90472
|
| Hospital Charge Code |
2473257
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$15.60 |
| Max. Negotiated Rate |
$63.86 |
| Rate for Payer: Aetna Commercial |
$55.33
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$50.09
|
| Rate for Payer: Aetna Managed Medicare |
$15.96
|
| Rate for Payer: Anthem Medicare Advantage |
$15.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15.96
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$55.33
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$15.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15.96
|
| Rate for Payer: Health EOS Commercial |
$53.00
|
| Rate for Payer: HFN Commercial |
$55.33
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$18.58
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$18.58
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15.96
|
| Rate for Payer: Multiplan Commercial |
$46.59
|
| Rate for Payer: NAPHCARE Commercial |
$23.95
|
| Rate for Payer: Preferred Network Access Commercial |
$55.33
|
| Rate for Payer: Quartz Beloit One Network |
$25.63
|
| Rate for Payer: Quartz Commercial |
$33.20
|
| Rate for Payer: Quartz Medicare Advantage |
$15.96
|
| Rate for Payer: The Alliance Commercial |
$39.91
|
| Rate for Payer: United Healthcare Medicaid |
$15.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.96
|
| Rate for Payer: WEA Trust Commercial |
$32.03
|
| Rate for Payer: WPS Commercial |
$63.86
|
|
|
Each Additional 90472 - Admin Immunization Charge
|
Facility
|
OP
|
$56.00
|
|
|
Service Code
|
CPT 90472
|
| Hospital Charge Code |
2473257
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$16.31 |
| Max. Negotiated Rate |
$63.86 |
| Rate for Payer: Aetna Commercial |
$52.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$50.09
|
| Rate for Payer: Aetna Managed Medicare |
$16.31
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$37.86
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$29.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$27.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$30.87
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$53.58
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$32.59
|
| Rate for Payer: Health EOS Commercial |
$51.83
|
| Rate for Payer: HFN Commercial |
$53.58
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$43.68
|
| Rate for Payer: Multiplan Commercial |
$46.59
|
| Rate for Payer: NAPHCARE Commercial |
$34.94
|
| Rate for Payer: Preferred Network Access Commercial |
$53.58
|
| Rate for Payer: Quartz Beloit One Network |
$28.54
|
| Rate for Payer: Quartz Commercial |
$37.86
|
| Rate for Payer: Quartz Medicare Advantage |
$34.94
|
| Rate for Payer: The Alliance Commercial |
$63.86
|
| Rate for Payer: United Healthcare PPO |
$43.68
|
| Rate for Payer: WEA Trust Commercial |
$32.03
|
| Rate for Payer: WPS Commercial |
$43.14
|
|
|
Each Additional 90472 - Pnuemococcal 23, 2 years+
|
Facility
|
OP
|
$54.00
|
|
|
Service Code
|
CPT 90472
|
| Hospital Charge Code |
3013446
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$15.72 |
| Max. Negotiated Rate |
$63.86 |
| Rate for Payer: Aetna Commercial |
$50.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$48.30
|
| Rate for Payer: Aetna Managed Medicare |
$15.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$36.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$28.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$26.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.76
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$51.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$31.43
|
| Rate for Payer: Health EOS Commercial |
$49.98
|
| Rate for Payer: HFN Commercial |
$51.67
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.12
|
| Rate for Payer: Multiplan Commercial |
$44.93
|
| Rate for Payer: NAPHCARE Commercial |
$33.70
|
| Rate for Payer: Preferred Network Access Commercial |
$51.67
|
| Rate for Payer: Quartz Beloit One Network |
$27.52
|
| Rate for Payer: Quartz Commercial |
$36.50
|
| Rate for Payer: Quartz Medicare Advantage |
$33.70
|
| Rate for Payer: The Alliance Commercial |
$63.86
|
| Rate for Payer: United Healthcare PPO |
$42.12
|
| Rate for Payer: WEA Trust Commercial |
$30.89
|
| Rate for Payer: WPS Commercial |
$41.60
|
|
|
Each Additional 90472 - Pnuemococcal 23, 2 years+
|
Facility
|
IP
|
$54.00
|
|
|
Service Code
|
CPT 90472
|
| Hospital Charge Code |
3013446
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$27.52 |
| Max. Negotiated Rate |
$51.67 |
| Rate for Payer: Aetna Commercial |
$50.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$48.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.76
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$51.67
|
| Rate for Payer: Health EOS Commercial |
$49.98
|
| Rate for Payer: HFN Commercial |
$51.67
|
| Rate for Payer: Multiplan Commercial |
$44.93
|
| Rate for Payer: Preferred Network Access Commercial |
$51.67
|
| Rate for Payer: Quartz Beloit One Network |
$27.52
|
| Rate for Payer: Quartz Commercial |
$33.70
|
| Rate for Payer: WEA Trust Commercial |
$30.89
|
| Rate for Payer: WPS Commercial |
$41.60
|
|
|
Each Additional 90472 - Pnuemococcal 23, 2 years+
|
Professional
|
Both
|
$54.00
|
|
|
Service Code
|
CPT 90472
|
| Hospital Charge Code |
3013446
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$15.60 |
| Max. Negotiated Rate |
$63.86 |
| Rate for Payer: Aetna Commercial |
$53.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$48.30
|
| Rate for Payer: Aetna Managed Medicare |
$15.96
|
| Rate for Payer: Anthem Medicare Advantage |
$15.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15.96
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$53.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$15.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15.96
|
| Rate for Payer: Health EOS Commercial |
$51.11
|
| Rate for Payer: HFN Commercial |
$53.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$18.58
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$18.58
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15.96
|
| Rate for Payer: Multiplan Commercial |
$44.93
|
| Rate for Payer: NAPHCARE Commercial |
$23.95
|
| Rate for Payer: Preferred Network Access Commercial |
$53.35
|
| Rate for Payer: Quartz Beloit One Network |
$24.71
|
| Rate for Payer: Quartz Commercial |
$32.01
|
| Rate for Payer: Quartz Medicare Advantage |
$15.96
|
| Rate for Payer: The Alliance Commercial |
$39.91
|
| Rate for Payer: United Healthcare Medicaid |
$15.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.96
|
| Rate for Payer: WEA Trust Commercial |
$30.89
|
| Rate for Payer: WPS Commercial |
$63.86
|
|
|
EAR AND THROAT EXAMINATION 92502
|
Professional
|
Both
|
$773.00
|
|
|
Service Code
|
CPT 92502
|
| Hospital Charge Code |
3015328
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$85.85 |
| Max. Negotiated Rate |
$763.72 |
| Rate for Payer: Aetna Commercial |
$763.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$691.37
|
| Rate for Payer: Aetna Managed Medicare |
$85.85
|
| Rate for Payer: Anthem Medicare Advantage |
$85.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$85.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$85.85
|
| Rate for Payer: Cash Price |
$231.90
|
| Rate for Payer: Cash Price |
$231.90
|
| Rate for Payer: Cigna Commercial |
$763.72
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$401.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$85.85
|
| Rate for Payer: Health EOS Commercial |
$731.57
|
| Rate for Payer: HFN Commercial |
$763.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$332.39
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$332.39
|
| Rate for Payer: Independent Care Health Plan Medicare |
$85.85
|
| Rate for Payer: Multiplan Commercial |
$643.14
|
| Rate for Payer: NAPHCARE Commercial |
$128.78
|
| Rate for Payer: Preferred Network Access Commercial |
$763.72
|
| Rate for Payer: Quartz Beloit One Network |
$353.72
|
| Rate for Payer: Quartz Commercial |
$458.23
|
| Rate for Payer: Quartz Medicare Advantage |
$85.85
|
| Rate for Payer: The Alliance Commercial |
$214.63
|
| Rate for Payer: United Healthcare Medicare Advantage |
$85.85
|
| Rate for Payer: WEA Trust Commercial |
$442.16
|
| Rate for Payer: WPS Commercial |
$343.41
|
|
|
Ear Culture
|
Facility
|
IP
|
$225.00
|
|
|
Service Code
|
CPT 87070
|
| Hospital Charge Code |
633890
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$114.66 |
| Max. Negotiated Rate |
$215.28 |
| Rate for Payer: Aetna Commercial |
$210.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$201.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$124.02
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cigna Commercial |
$215.28
|
| Rate for Payer: Health EOS Commercial |
$208.26
|
| Rate for Payer: HFN Commercial |
$215.28
|
| Rate for Payer: Multiplan Commercial |
$187.20
|
| Rate for Payer: Preferred Network Access Commercial |
$215.28
|
| Rate for Payer: Quartz Beloit One Network |
$114.66
|
| Rate for Payer: Quartz Commercial |
$140.40
|
| Rate for Payer: WEA Trust Commercial |
$128.70
|
| Rate for Payer: WPS Commercial |
$173.32
|
|
|
Ear Culture
|
Facility
|
OP
|
$225.00
|
|
|
Service Code
|
CPT 87070
|
| Hospital Charge Code |
633890
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.96 |
| Max. Negotiated Rate |
$215.28 |
| Rate for Payer: Aetna Commercial |
$210.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$201.24
|
| Rate for Payer: Aetna Managed Medicare |
$8.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$33.62
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$15.69
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$14.88
|
| Rate for Payer: Anthem Medicare Advantage |
$8.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$124.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8.96
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cigna Commercial |
$215.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$8.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$130.95
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$8.96
|
| Rate for Payer: Health EOS Commercial |
$208.26
|
| Rate for Payer: HFN Commercial |
$215.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$33.35
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$8.96
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8.96
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$8.96
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$8.96
|
| Rate for Payer: Multiplan Commercial |
$187.20
|
| Rate for Payer: NAPHCARE Commercial |
$13.45
|
| Rate for Payer: Preferred Network Access Commercial |
$215.28
|
| Rate for Payer: Quartz Beloit One Network |
$114.66
|
| Rate for Payer: Quartz Commercial |
$152.10
|
| Rate for Payer: Quartz Medicare Advantage |
$8.96
|
| Rate for Payer: The Alliance Commercial |
$35.86
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8.96
|
| Rate for Payer: United Healthcare PPO |
$175.50
|
| Rate for Payer: WEA Trust Commercial |
$128.70
|
| Rate for Payer: Wellcare Medicare |
$8.96
|
| Rate for Payer: WPS Commercial |
$173.32
|
|
|
Ear Culture
|
Professional
|
Both
|
$225.00
|
|
|
Service Code
|
CPT 87070
|
| Hospital Charge Code |
633890
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.96 |
| Max. Negotiated Rate |
$222.30 |
| Rate for Payer: Aetna Commercial |
$222.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$201.24
|
| Rate for Payer: Aetna Managed Medicare |
$8.96
|
| Rate for Payer: Anthem Medicare Advantage |
$8.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8.96
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cigna Commercial |
$222.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$117.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8.96
|
| Rate for Payer: Health EOS Commercial |
$212.94
|
| Rate for Payer: HFN Commercial |
$222.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$31.65
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$31.65
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8.96
|
| Rate for Payer: Multiplan Commercial |
$187.20
|
| Rate for Payer: NAPHCARE Commercial |
$13.45
|
| Rate for Payer: Preferred Network Access Commercial |
$222.30
|
| Rate for Payer: Quartz Beloit One Network |
$102.96
|
| Rate for Payer: Quartz Commercial |
$133.38
|
| Rate for Payer: Quartz Medicare Advantage |
$8.96
|
| Rate for Payer: The Alliance Commercial |
$35.41
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8.96
|
| Rate for Payer: WEA Trust Commercial |
$128.70
|
| Rate for Payer: WPS Commercial |
$39.45
|
|
