|
Gentamicin
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
4075400
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.92 |
| Max. Negotiated Rate |
$7.36 |
| Rate for Payer: Aetna Commercial |
$7.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4.24
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$7.36
|
| Rate for Payer: Health EOS Commercial |
$7.12
|
| Rate for Payer: HFN Commercial |
$7.36
|
| Rate for Payer: Multiplan Commercial |
$6.40
|
| Rate for Payer: NAPHCARE Commercial |
$4.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7.36
|
| Rate for Payer: Quartz Beloit One Network |
$3.92
|
| Rate for Payer: Quartz Commercial |
$4.80
|
| Rate for Payer: WEA Trust Commercial |
$4.40
|
| Rate for Payer: WPS Commercial |
$5.93
|
|
|
Gentamicin
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
4075400
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.24 |
| Max. Negotiated Rate |
$32.00 |
| Rate for Payer: Aetna Commercial |
$7.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.88
|
| Rate for Payer: Aetna Managed Medicare |
$2.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4.24
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$7.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3.62
|
| Rate for Payer: Health EOS Commercial |
$7.12
|
| Rate for Payer: HFN Commercial |
$7.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6.00
|
| Rate for Payer: Multiplan Commercial |
$6.40
|
| Rate for Payer: NAPHCARE Commercial |
$4.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7.36
|
| Rate for Payer: Quartz Beloit One Network |
$3.92
|
| Rate for Payer: Quartz Commercial |
$5.20
|
| Rate for Payer: Quartz Medicare Advantage |
$4.80
|
| Rate for Payer: The Alliance Commercial |
$32.00
|
| Rate for Payer: WEA Trust Commercial |
$4.40
|
| Rate for Payer: WPS Commercial |
$6.83
|
|
|
Gentamicin 0.3% Ophth Ointment 3.5gm [Med]
|
Facility
|
OP
|
$30.00
|
|
| Hospital Charge Code |
2974941
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.40 |
| Max. Negotiated Rate |
$120.00 |
| Rate for Payer: Aetna Commercial |
$27.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$25.80
|
| Rate for Payer: Aetna Managed Medicare |
$8.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$19.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$15.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$14.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$15.90
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cigna Commercial |
$27.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$16.79
|
| Rate for Payer: Health EOS Commercial |
$26.70
|
| Rate for Payer: HFN Commercial |
$27.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$22.50
|
| Rate for Payer: Multiplan Commercial |
$24.00
|
| Rate for Payer: NAPHCARE Commercial |
$18.00
|
| Rate for Payer: Preferred Network Access Commercial |
$27.60
|
| Rate for Payer: Quartz Beloit One Network |
$14.70
|
| Rate for Payer: Quartz Commercial |
$19.50
|
| Rate for Payer: Quartz Medicare Advantage |
$18.00
|
| Rate for Payer: The Alliance Commercial |
$120.00
|
| Rate for Payer: WEA Trust Commercial |
$16.50
|
| Rate for Payer: WPS Commercial |
$22.22
|
|
|
Gentamicin 0.3% Ophth Ointment 3.5gm [Med]
|
Facility
|
IP
|
$30.00
|
|
| Hospital Charge Code |
2974941
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.70 |
| Max. Negotiated Rate |
$27.60 |
| Rate for Payer: Aetna Commercial |
$27.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$25.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$15.90
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cigna Commercial |
$27.60
|
| Rate for Payer: Health EOS Commercial |
$26.70
|
| Rate for Payer: HFN Commercial |
$27.60
|
| Rate for Payer: Multiplan Commercial |
$24.00
|
| Rate for Payer: NAPHCARE Commercial |
$18.00
|
| Rate for Payer: Preferred Network Access Commercial |
$27.60
|
| Rate for Payer: Quartz Beloit One Network |
$14.70
|
| Rate for Payer: Quartz Commercial |
$18.00
|
| Rate for Payer: WEA Trust Commercial |
$16.50
|
| Rate for Payer: WPS Commercial |
$22.22
|
|
|
Gentamicin 0.3% Ophth Solution 5ml [Med]
|
Facility
|
OP
|
$33.00
|
|
| Hospital Charge Code |
2974942
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.24 |
| Max. Negotiated Rate |
$132.00 |
| Rate for Payer: Aetna Commercial |
$29.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$28.38
|
| Rate for Payer: Aetna Managed Medicare |
$9.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$21.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$16.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$15.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$17.49
|
| Rate for Payer: Cash Price |
$9.90
|
| Rate for Payer: Cigna Commercial |
$30.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$18.47
|
| Rate for Payer: Health EOS Commercial |
$29.37
|
| Rate for Payer: HFN Commercial |
$30.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$24.75
|
| Rate for Payer: Multiplan Commercial |
$26.40
|
| Rate for Payer: NAPHCARE Commercial |
$19.80
|
| Rate for Payer: Preferred Network Access Commercial |
$30.36
|
| Rate for Payer: Quartz Beloit One Network |
$16.17
|
| Rate for Payer: Quartz Commercial |
$21.45
|
| Rate for Payer: Quartz Medicare Advantage |
$19.80
|
| Rate for Payer: The Alliance Commercial |
$132.00
|
| Rate for Payer: WEA Trust Commercial |
$18.15
|
| Rate for Payer: WPS Commercial |
$24.44
|
|
|
Gentamicin 0.3% Ophth Solution 5ml [Med]
|
Facility
|
IP
|
$33.00
|
|
| Hospital Charge Code |
2974942
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.17 |
| Max. Negotiated Rate |
$30.36 |
| Rate for Payer: Aetna Commercial |
$29.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$28.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$17.49
|
| Rate for Payer: Cash Price |
$9.90
|
| Rate for Payer: Cigna Commercial |
$30.36
|
| Rate for Payer: Health EOS Commercial |
$29.37
|
| Rate for Payer: HFN Commercial |
$30.36
|
| Rate for Payer: Multiplan Commercial |
$26.40
|
| Rate for Payer: NAPHCARE Commercial |
$19.80
|
| Rate for Payer: Preferred Network Access Commercial |
$30.36
|
| Rate for Payer: Quartz Beloit One Network |
$16.17
|
| Rate for Payer: Quartz Commercial |
$19.80
|
| Rate for Payer: WEA Trust Commercial |
$18.15
|
| Rate for Payer: WPS Commercial |
$24.44
|
|
|
gentamicin 30 mg Charge
|
Professional
|
Both
|
$9.00
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
2958973
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.69 |
| Max. Negotiated Rate |
$8.55 |
| Rate for Payer: Aetna Commercial |
$8.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7.74
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cigna Commercial |
$8.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2.69
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2.73
|
| Rate for Payer: Health EOS Commercial |
$8.19
|
| Rate for Payer: HFN Commercial |
$8.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2.85
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2.85
|
| Rate for Payer: Multiplan Commercial |
$7.20
|
| Rate for Payer: Preferred Network Access Commercial |
$8.55
|
| Rate for Payer: Quartz Beloit One Network |
$3.96
|
| Rate for Payer: Quartz Commercial |
$5.13
|
| Rate for Payer: The Alliance Commercial |
$4.50
|
| Rate for Payer: United Healthcare Medicaid |
$2.69
|
| Rate for Payer: WEA Trust Commercial |
$4.95
|
| Rate for Payer: WPS Commercial |
$6.83
|
|
|
gentamicin 30 mg Charge
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
2958973
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.52 |
| Max. Negotiated Rate |
$36.00 |
| Rate for Payer: Aetna Commercial |
$8.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7.74
|
| Rate for Payer: Aetna Managed Medicare |
$2.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4.77
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cigna Commercial |
$8.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3.62
|
| Rate for Payer: Health EOS Commercial |
$8.01
|
| Rate for Payer: HFN Commercial |
$8.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6.75
|
| Rate for Payer: Multiplan Commercial |
$7.20
|
| Rate for Payer: NAPHCARE Commercial |
$5.40
|
| Rate for Payer: Preferred Network Access Commercial |
$8.28
|
| Rate for Payer: Quartz Beloit One Network |
$4.41
|
| Rate for Payer: Quartz Commercial |
$5.85
|
| Rate for Payer: Quartz Medicare Advantage |
$5.40
|
| Rate for Payer: The Alliance Commercial |
$36.00
|
| Rate for Payer: WEA Trust Commercial |
$4.95
|
| Rate for Payer: WPS Commercial |
$6.83
|
|
|
gentamicin 30 mg Charge
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
2958973
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.41 |
| Max. Negotiated Rate |
$8.28 |
| Rate for Payer: Aetna Commercial |
$8.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4.77
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cigna Commercial |
$8.28
|
| Rate for Payer: Health EOS Commercial |
$8.01
|
| Rate for Payer: HFN Commercial |
$8.28
|
| Rate for Payer: Multiplan Commercial |
$7.20
|
| Rate for Payer: NAPHCARE Commercial |
$5.40
|
| Rate for Payer: Preferred Network Access Commercial |
$8.28
|
| Rate for Payer: Quartz Beloit One Network |
$4.41
|
| Rate for Payer: Quartz Commercial |
$5.40
|
| Rate for Payer: WEA Trust Commercial |
$4.95
|
| Rate for Payer: WPS Commercial |
$6.67
|
|
|
Gentamicin 80mg/2ml vial [Med]
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
2974943
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.39 |
| Max. Negotiated Rate |
$10.12 |
| Rate for Payer: Aetna Commercial |
$9.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5.83
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cigna Commercial |
$10.12
|
| Rate for Payer: Health EOS Commercial |
$9.79
|
| Rate for Payer: HFN Commercial |
$10.12
|
| Rate for Payer: Multiplan Commercial |
$8.80
|
| Rate for Payer: NAPHCARE Commercial |
$6.60
|
| Rate for Payer: Preferred Network Access Commercial |
$10.12
|
| Rate for Payer: Quartz Beloit One Network |
$5.39
|
| Rate for Payer: Quartz Commercial |
$6.60
|
| Rate for Payer: WEA Trust Commercial |
$6.05
|
| Rate for Payer: WPS Commercial |
$8.15
|
|
|
Gentamicin 80mg/2ml vial [Med]
|
Facility
|
OP
|
$11.00
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
2974943
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.08 |
| Max. Negotiated Rate |
$44.00 |
| Rate for Payer: Aetna Commercial |
$9.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9.46
|
| Rate for Payer: Aetna Managed Medicare |
$3.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5.83
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cigna Commercial |
$10.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3.62
|
| Rate for Payer: Health EOS Commercial |
$9.79
|
| Rate for Payer: HFN Commercial |
$10.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8.25
|
| Rate for Payer: Multiplan Commercial |
$8.80
|
| Rate for Payer: NAPHCARE Commercial |
$6.60
|
| Rate for Payer: Preferred Network Access Commercial |
$10.12
|
| Rate for Payer: Quartz Beloit One Network |
$5.39
|
| Rate for Payer: Quartz Commercial |
$7.15
|
| Rate for Payer: Quartz Medicare Advantage |
$6.60
|
| Rate for Payer: The Alliance Commercial |
$44.00
|
| Rate for Payer: WEA Trust Commercial |
$6.05
|
| Rate for Payer: WPS Commercial |
$6.83
|
|
|
Gentamicin Kinetics
|
Facility
|
IP
|
$272.00
|
|
|
Service Code
|
CPT 80170
|
| Hospital Charge Code |
979890
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$133.28 |
| Max. Negotiated Rate |
$250.24 |
| Rate for Payer: Aetna Commercial |
$244.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$233.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$144.16
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Cigna Commercial |
$250.24
|
| Rate for Payer: Health EOS Commercial |
$242.08
|
| Rate for Payer: HFN Commercial |
$250.24
|
| Rate for Payer: Multiplan Commercial |
$217.60
|
| Rate for Payer: NAPHCARE Commercial |
$163.20
|
| Rate for Payer: Preferred Network Access Commercial |
$250.24
|
| Rate for Payer: Quartz Beloit One Network |
$133.28
|
| Rate for Payer: Quartz Commercial |
$163.20
|
| Rate for Payer: WEA Trust Commercial |
$149.60
|
| Rate for Payer: WPS Commercial |
$201.47
|
|
|
Gentamicin Kinetics
|
Facility
|
OP
|
$272.00
|
|
|
Service Code
|
CPT 80170
|
| Hospital Charge Code |
979890
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.38 |
| Max. Negotiated Rate |
$250.24 |
| Rate for Payer: Aetna Commercial |
$244.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$233.92
|
| Rate for Payer: Aetna Managed Medicare |
$16.38
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$61.42
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$28.66
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$27.19
|
| Rate for Payer: Anthem Medicaid |
$16.93
|
| Rate for Payer: Anthem Medicare Advantage |
$16.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$144.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$16.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$16.38
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Cigna Commercial |
$250.24
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$16.38
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$16.93
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$152.21
|
| Rate for Payer: Dean Health Medicaid |
$16.93
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$16.38
|
| Rate for Payer: Health EOS Commercial |
$242.08
|
| Rate for Payer: HFN Commercial |
$250.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$60.93
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$16.38
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$16.93
|
| Rate for Payer: Independent Care Health Plan Medicare |
$16.38
|
| Rate for Payer: Managed Health Services Medicaid |
$17.61
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$16.38
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$16.38
|
| Rate for Payer: Multiplan Commercial |
$217.60
|
| Rate for Payer: NAPHCARE Commercial |
$24.57
|
| Rate for Payer: Preferred Network Access Commercial |
$250.24
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$16.93
|
| Rate for Payer: Quartz Beloit One Network |
$133.28
|
| Rate for Payer: Quartz Commercial |
$176.80
|
| Rate for Payer: Quartz Medicare Advantage |
$16.38
|
| Rate for Payer: The Alliance Commercial |
$65.52
|
| Rate for Payer: United Healthcare Medicaid |
$16.93
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16.38
|
| Rate for Payer: United Healthcare PPO |
$204.00
|
| Rate for Payer: WEA Trust Commercial |
$149.60
|
| Rate for Payer: Wellcare Medicare |
$16.38
|
| Rate for Payer: WMAP Medicaid |
$16.93
|
| Rate for Payer: WPS Commercial |
$201.47
|
|
|
Gentamicin Kinetics
|
Professional
|
Both
|
$272.00
|
|
|
Service Code
|
CPT 80170
|
| Hospital Charge Code |
979890
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$57.82 |
| Max. Negotiated Rate |
$258.40 |
| Rate for Payer: Aetna Commercial |
$258.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$233.92
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Cigna Commercial |
$258.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$136.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$163.20
|
| Rate for Payer: Health EOS Commercial |
$247.52
|
| Rate for Payer: HFN Commercial |
$258.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$57.82
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$57.82
|
| Rate for Payer: Multiplan Commercial |
$217.60
|
| Rate for Payer: Preferred Network Access Commercial |
$258.40
|
| Rate for Payer: Quartz Beloit One Network |
$119.68
|
| Rate for Payer: Quartz Commercial |
$155.04
|
| Rate for Payer: The Alliance Commercial |
$136.00
|
| Rate for Payer: WEA Trust Commercial |
$149.60
|
| Rate for Payer: WPS Commercial |
$201.47
|
|
|
Gentamicin Level Peak
|
Facility
|
OP
|
$272.00
|
|
|
Service Code
|
CPT 80170
|
| Hospital Charge Code |
633736
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.38 |
| Max. Negotiated Rate |
$250.24 |
| Rate for Payer: Aetna Commercial |
$244.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$233.92
|
| Rate for Payer: Aetna Managed Medicare |
$16.38
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$61.42
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$28.66
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$27.19
|
| Rate for Payer: Anthem Medicaid |
$16.93
|
| Rate for Payer: Anthem Medicare Advantage |
$16.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$144.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$16.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$16.38
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Cigna Commercial |
$250.24
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$16.38
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$16.93
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$152.21
|
| Rate for Payer: Dean Health Medicaid |
$16.93
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$16.38
|
| Rate for Payer: Health EOS Commercial |
$242.08
|
| Rate for Payer: HFN Commercial |
$250.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$60.93
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$16.38
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$16.93
|
| Rate for Payer: Independent Care Health Plan Medicare |
$16.38
|
| Rate for Payer: Managed Health Services Medicaid |
$17.61
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$16.38
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$16.38
|
| Rate for Payer: Multiplan Commercial |
$217.60
|
| Rate for Payer: NAPHCARE Commercial |
$24.57
|
| Rate for Payer: Preferred Network Access Commercial |
$250.24
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$16.93
|
| Rate for Payer: Quartz Beloit One Network |
$133.28
|
| Rate for Payer: Quartz Commercial |
$176.80
|
| Rate for Payer: Quartz Medicare Advantage |
$16.38
|
| Rate for Payer: The Alliance Commercial |
$65.52
|
| Rate for Payer: United Healthcare Medicaid |
$16.93
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16.38
|
| Rate for Payer: United Healthcare PPO |
$204.00
|
| Rate for Payer: WEA Trust Commercial |
$149.60
|
| Rate for Payer: Wellcare Medicare |
$16.38
|
| Rate for Payer: WMAP Medicaid |
$16.93
|
| Rate for Payer: WPS Commercial |
$201.47
|
|
|
Gentamicin Level Peak
|
Facility
|
IP
|
$272.00
|
|
|
Service Code
|
CPT 80170
|
| Hospital Charge Code |
633736
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$133.28 |
| Max. Negotiated Rate |
$250.24 |
| Rate for Payer: Aetna Commercial |
$244.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$233.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$144.16
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Cigna Commercial |
$250.24
|
| Rate for Payer: Health EOS Commercial |
$242.08
|
| Rate for Payer: HFN Commercial |
$250.24
|
| Rate for Payer: Multiplan Commercial |
$217.60
|
| Rate for Payer: NAPHCARE Commercial |
$163.20
|
| Rate for Payer: Preferred Network Access Commercial |
$250.24
|
| Rate for Payer: Quartz Beloit One Network |
$133.28
|
| Rate for Payer: Quartz Commercial |
$163.20
|
| Rate for Payer: WEA Trust Commercial |
$149.60
|
| Rate for Payer: WPS Commercial |
$201.47
|
|
|
Gentamicin Level Peak
|
Professional
|
Both
|
$272.00
|
|
|
Service Code
|
CPT 80170
|
| Hospital Charge Code |
633736
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$57.82 |
| Max. Negotiated Rate |
$258.40 |
| Rate for Payer: Aetna Commercial |
$258.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$233.92
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Cigna Commercial |
$258.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$136.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$163.20
|
| Rate for Payer: Health EOS Commercial |
$247.52
|
| Rate for Payer: HFN Commercial |
$258.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$57.82
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$57.82
|
| Rate for Payer: Multiplan Commercial |
$217.60
|
| Rate for Payer: Preferred Network Access Commercial |
$258.40
|
| Rate for Payer: Quartz Beloit One Network |
$119.68
|
| Rate for Payer: Quartz Commercial |
$155.04
|
| Rate for Payer: The Alliance Commercial |
$136.00
|
| Rate for Payer: WEA Trust Commercial |
$149.60
|
| Rate for Payer: WPS Commercial |
$201.47
|
|
|
Gentamicin Level Trough
|
Professional
|
Both
|
$272.00
|
|
|
Service Code
|
CPT 80170
|
| Hospital Charge Code |
633737
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$57.82 |
| Max. Negotiated Rate |
$258.40 |
| Rate for Payer: Aetna Commercial |
$258.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$233.92
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Cigna Commercial |
$258.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$136.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$163.20
|
| Rate for Payer: Health EOS Commercial |
$247.52
|
| Rate for Payer: HFN Commercial |
$258.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$57.82
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$57.82
|
| Rate for Payer: Multiplan Commercial |
$217.60
|
| Rate for Payer: Preferred Network Access Commercial |
$258.40
|
| Rate for Payer: Quartz Beloit One Network |
$119.68
|
| Rate for Payer: Quartz Commercial |
$155.04
|
| Rate for Payer: The Alliance Commercial |
$136.00
|
| Rate for Payer: WEA Trust Commercial |
$149.60
|
| Rate for Payer: WPS Commercial |
$201.47
|
|
|
Gentamicin Level Trough
|
Facility
|
IP
|
$272.00
|
|
|
Service Code
|
CPT 80170
|
| Hospital Charge Code |
633737
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$133.28 |
| Max. Negotiated Rate |
$250.24 |
| Rate for Payer: Aetna Commercial |
$244.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$233.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$144.16
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Cigna Commercial |
$250.24
|
| Rate for Payer: Health EOS Commercial |
$242.08
|
| Rate for Payer: HFN Commercial |
$250.24
|
| Rate for Payer: Multiplan Commercial |
$217.60
|
| Rate for Payer: NAPHCARE Commercial |
$163.20
|
| Rate for Payer: Preferred Network Access Commercial |
$250.24
|
| Rate for Payer: Quartz Beloit One Network |
$133.28
|
| Rate for Payer: Quartz Commercial |
$163.20
|
| Rate for Payer: WEA Trust Commercial |
$149.60
|
| Rate for Payer: WPS Commercial |
$201.47
|
|
|
Gentamicin Level Trough
|
Facility
|
OP
|
$272.00
|
|
|
Service Code
|
CPT 80170
|
| Hospital Charge Code |
633737
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.38 |
| Max. Negotiated Rate |
$250.24 |
| Rate for Payer: Aetna Commercial |
$244.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$233.92
|
| Rate for Payer: Aetna Managed Medicare |
$16.38
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$61.42
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$28.66
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$27.19
|
| Rate for Payer: Anthem Medicaid |
$16.93
|
| Rate for Payer: Anthem Medicare Advantage |
$16.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$144.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$16.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$16.38
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Cigna Commercial |
$250.24
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$16.38
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$16.93
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$152.21
|
| Rate for Payer: Dean Health Medicaid |
$16.93
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$16.38
|
| Rate for Payer: Health EOS Commercial |
$242.08
|
| Rate for Payer: HFN Commercial |
$250.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$60.93
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$16.38
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$16.93
|
| Rate for Payer: Independent Care Health Plan Medicare |
$16.38
|
| Rate for Payer: Managed Health Services Medicaid |
$17.61
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$16.38
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$16.38
|
| Rate for Payer: Multiplan Commercial |
$217.60
|
| Rate for Payer: NAPHCARE Commercial |
$24.57
|
| Rate for Payer: Preferred Network Access Commercial |
$250.24
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$16.93
|
| Rate for Payer: Quartz Beloit One Network |
$133.28
|
| Rate for Payer: Quartz Commercial |
$176.80
|
| Rate for Payer: Quartz Medicare Advantage |
$16.38
|
| Rate for Payer: The Alliance Commercial |
$65.52
|
| Rate for Payer: United Healthcare Medicaid |
$16.93
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16.38
|
| Rate for Payer: United Healthcare PPO |
$204.00
|
| Rate for Payer: WEA Trust Commercial |
$149.60
|
| Rate for Payer: Wellcare Medicare |
$16.38
|
| Rate for Payer: WMAP Medicaid |
$16.93
|
| Rate for Payer: WPS Commercial |
$201.47
|
|
|
GGT
|
Facility
|
IP
|
$76.00
|
|
|
Service Code
|
CPT 82977
|
| Hospital Charge Code |
4812608
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$37.24 |
| Max. Negotiated Rate |
$69.92 |
| Rate for Payer: Aetna Commercial |
$68.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$65.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$40.28
|
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cigna Commercial |
$69.92
|
| Rate for Payer: Health EOS Commercial |
$67.64
|
| Rate for Payer: HFN Commercial |
$69.92
|
| Rate for Payer: Multiplan Commercial |
$60.80
|
| Rate for Payer: NAPHCARE Commercial |
$45.60
|
| Rate for Payer: Preferred Network Access Commercial |
$69.92
|
| Rate for Payer: Quartz Beloit One Network |
$37.24
|
| Rate for Payer: Quartz Commercial |
$45.60
|
| Rate for Payer: WEA Trust Commercial |
$41.80
|
| Rate for Payer: WPS Commercial |
$56.29
|
|
|
GGT
|
Professional
|
Both
|
$76.00
|
|
|
Service Code
|
CPT 82977
|
| Hospital Charge Code |
4812608
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$25.42 |
| Max. Negotiated Rate |
$72.20 |
| Rate for Payer: Aetna Commercial |
$72.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$65.36
|
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cigna Commercial |
$72.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$38.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$45.60
|
| Rate for Payer: Health EOS Commercial |
$69.16
|
| Rate for Payer: HFN Commercial |
$72.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$25.42
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$25.42
|
| Rate for Payer: Multiplan Commercial |
$60.80
|
| Rate for Payer: Preferred Network Access Commercial |
$72.20
|
| Rate for Payer: Quartz Beloit One Network |
$33.44
|
| Rate for Payer: Quartz Commercial |
$43.32
|
| Rate for Payer: The Alliance Commercial |
$38.00
|
| Rate for Payer: WEA Trust Commercial |
$41.80
|
| Rate for Payer: WPS Commercial |
$56.29
|
|
|
GGT
|
Facility
|
OP
|
$76.00
|
|
|
Service Code
|
CPT 82977
|
| Hospital Charge Code |
4812608
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$7.20 |
| Max. Negotiated Rate |
$69.92 |
| Rate for Payer: Aetna Commercial |
$68.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$65.36
|
| Rate for Payer: Aetna Managed Medicare |
$7.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$27.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$12.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$11.95
|
| Rate for Payer: Anthem Medicaid |
$7.44
|
| Rate for Payer: Anthem Medicare Advantage |
$7.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$40.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7.20
|
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cigna Commercial |
$69.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$7.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$7.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$42.53
|
| Rate for Payer: Dean Health Medicaid |
$7.44
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$7.20
|
| Rate for Payer: Health EOS Commercial |
$67.64
|
| Rate for Payer: HFN Commercial |
$69.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$26.78
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$7.20
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$7.44
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7.20
|
| Rate for Payer: Managed Health Services Medicaid |
$7.74
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$7.20
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$7.20
|
| Rate for Payer: Multiplan Commercial |
$60.80
|
| Rate for Payer: NAPHCARE Commercial |
$10.80
|
| Rate for Payer: Preferred Network Access Commercial |
$69.92
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$7.44
|
| Rate for Payer: Quartz Beloit One Network |
$37.24
|
| Rate for Payer: Quartz Commercial |
$49.40
|
| Rate for Payer: Quartz Medicare Advantage |
$7.20
|
| Rate for Payer: The Alliance Commercial |
$28.80
|
| Rate for Payer: United Healthcare Medicaid |
$7.44
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7.20
|
| Rate for Payer: United Healthcare PPO |
$57.00
|
| Rate for Payer: WEA Trust Commercial |
$41.80
|
| Rate for Payer: Wellcare Medicare |
$7.20
|
| Rate for Payer: WMAP Medicaid |
$7.44
|
| Rate for Payer: WPS Commercial |
$56.29
|
|
|
GGT (FSURE)
|
Facility
|
OP
|
$84.00
|
|
|
Service Code
|
CPT 82977
|
| Hospital Charge Code |
4538812
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$7.20 |
| Max. Negotiated Rate |
$77.28 |
| Rate for Payer: Aetna Commercial |
$75.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$72.24
|
| Rate for Payer: Aetna Managed Medicare |
$7.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$27.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$12.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$11.95
|
| Rate for Payer: Anthem Medicaid |
$7.44
|
| Rate for Payer: Anthem Medicare Advantage |
$7.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$44.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7.20
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna Commercial |
$77.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$7.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$7.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$47.01
|
| Rate for Payer: Dean Health Medicaid |
$7.44
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$7.20
|
| Rate for Payer: Health EOS Commercial |
$74.76
|
| Rate for Payer: HFN Commercial |
$77.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$26.78
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$7.20
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$7.44
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7.20
|
| Rate for Payer: Managed Health Services Medicaid |
$7.74
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$7.20
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$7.20
|
| Rate for Payer: Multiplan Commercial |
$67.20
|
| Rate for Payer: NAPHCARE Commercial |
$10.80
|
| Rate for Payer: Preferred Network Access Commercial |
$77.28
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$7.44
|
| Rate for Payer: Quartz Beloit One Network |
$41.16
|
| Rate for Payer: Quartz Commercial |
$54.60
|
| Rate for Payer: Quartz Medicare Advantage |
$7.20
|
| Rate for Payer: The Alliance Commercial |
$28.80
|
| Rate for Payer: United Healthcare Medicaid |
$7.44
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7.20
|
| Rate for Payer: United Healthcare PPO |
$63.00
|
| Rate for Payer: WEA Trust Commercial |
$46.20
|
| Rate for Payer: Wellcare Medicare |
$7.20
|
| Rate for Payer: WMAP Medicaid |
$7.44
|
| Rate for Payer: WPS Commercial |
$62.22
|
|
|
GGT (FSURE)
|
Facility
|
IP
|
$84.00
|
|
|
Service Code
|
CPT 82977
|
| Hospital Charge Code |
4538812
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$41.16 |
| Max. Negotiated Rate |
$77.28 |
| Rate for Payer: Aetna Commercial |
$75.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$72.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$44.52
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna Commercial |
$77.28
|
| Rate for Payer: Health EOS Commercial |
$74.76
|
| Rate for Payer: HFN Commercial |
$77.28
|
| Rate for Payer: Multiplan Commercial |
$67.20
|
| Rate for Payer: NAPHCARE Commercial |
$50.40
|
| Rate for Payer: Preferred Network Access Commercial |
$77.28
|
| Rate for Payer: Quartz Beloit One Network |
$41.16
|
| Rate for Payer: Quartz Commercial |
$50.40
|
| Rate for Payer: WEA Trust Commercial |
$46.20
|
| Rate for Payer: WPS Commercial |
$62.22
|
|
