|
HEART VALVE PERICARDIAL TISSUE
|
Facility
|
IP
|
$45,119.00
|
|
| Hospital Charge Code |
2965104
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$22,108.31 |
| Max. Negotiated Rate |
$41,509.48 |
| Rate for Payer: Aetna Commercial |
$40,607.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$38,802.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$23,913.07
|
| Rate for Payer: Cash Price |
$13,535.70
|
| Rate for Payer: Cigna Commercial |
$41,509.48
|
| Rate for Payer: Health EOS Commercial |
$40,155.91
|
| Rate for Payer: HFN Commercial |
$41,509.48
|
| Rate for Payer: Multiplan Commercial |
$36,095.20
|
| Rate for Payer: NAPHCARE Commercial |
$27,071.40
|
| Rate for Payer: Preferred Network Access Commercial |
$41,509.48
|
| Rate for Payer: Quartz Beloit One Network |
$22,108.31
|
| Rate for Payer: Quartz Commercial |
$27,071.40
|
| Rate for Payer: WEA Trust Commercial |
$24,815.45
|
| Rate for Payer: WPS Commercial |
$33,419.64
|
|
|
HEART VALVE REPLACEMENT
|
Facility
|
OP
|
$15,894.00
|
|
| Hospital Charge Code |
2960492
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,450.32 |
| Max. Negotiated Rate |
$63,576.00 |
| Rate for Payer: Aetna Commercial |
$14,304.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,668.84
|
| Rate for Payer: Aetna Managed Medicare |
$4,450.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,331.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,947.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,629.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,423.82
|
| Rate for Payer: Cash Price |
$4,768.20
|
| Rate for Payer: Cigna Commercial |
$14,622.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,894.28
|
| Rate for Payer: Health EOS Commercial |
$14,145.66
|
| Rate for Payer: HFN Commercial |
$14,622.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$11,920.50
|
| Rate for Payer: Multiplan Commercial |
$12,715.20
|
| Rate for Payer: NAPHCARE Commercial |
$9,536.40
|
| Rate for Payer: Preferred Network Access Commercial |
$14,622.48
|
| Rate for Payer: Quartz Beloit One Network |
$7,788.06
|
| Rate for Payer: Quartz Commercial |
$10,331.10
|
| Rate for Payer: Quartz Medicare Advantage |
$9,536.40
|
| Rate for Payer: The Alliance Commercial |
$63,576.00
|
| Rate for Payer: WEA Trust Commercial |
$8,741.70
|
| Rate for Payer: WPS Commercial |
$11,772.69
|
|
|
HEART VALVE REPLACEMENT
|
Facility
|
IP
|
$15,894.00
|
|
| Hospital Charge Code |
2960492
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$7,788.06 |
| Max. Negotiated Rate |
$14,622.48 |
| Rate for Payer: Aetna Commercial |
$14,304.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$13,668.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$8,423.82
|
| Rate for Payer: Cash Price |
$4,768.20
|
| Rate for Payer: Cigna Commercial |
$14,622.48
|
| Rate for Payer: Health EOS Commercial |
$14,145.66
|
| Rate for Payer: HFN Commercial |
$14,622.48
|
| Rate for Payer: Multiplan Commercial |
$12,715.20
|
| Rate for Payer: NAPHCARE Commercial |
$9,536.40
|
| Rate for Payer: Preferred Network Access Commercial |
$14,622.48
|
| Rate for Payer: Quartz Beloit One Network |
$7,788.06
|
| Rate for Payer: Quartz Commercial |
$9,536.40
|
| Rate for Payer: WEA Trust Commercial |
$8,741.70
|
| Rate for Payer: WPS Commercial |
$11,772.69
|
|
|
Heavy Metal Screen
|
Facility
|
OP
|
$360.00
|
|
|
Service Code
|
CPT 83015
|
| Hospital Charge Code |
977960
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$20.94 |
| Max. Negotiated Rate |
$331.20 |
| Rate for Payer: Anthem Medicare Advantage |
$20.94
|
| Rate for Payer: Aetna Commercial |
$324.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$309.60
|
| Rate for Payer: Aetna Managed Medicare |
$20.94
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$78.52
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$36.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$34.76
|
| Rate for Payer: Anthem Medicaid |
$21.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$190.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$20.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$20.94
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cigna Commercial |
$331.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$20.94
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$21.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$201.46
|
| Rate for Payer: Dean Health Medicaid |
$21.64
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$20.94
|
| Rate for Payer: Health EOS Commercial |
$320.40
|
| Rate for Payer: HFN Commercial |
$331.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$77.90
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$20.94
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$21.64
|
| Rate for Payer: Independent Care Health Plan Medicare |
$20.94
|
| Rate for Payer: Managed Health Services Medicaid |
$22.51
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$20.94
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$20.94
|
| Rate for Payer: Multiplan Commercial |
$288.00
|
| Rate for Payer: NAPHCARE Commercial |
$31.41
|
| Rate for Payer: Preferred Network Access Commercial |
$331.20
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$21.64
|
| Rate for Payer: Quartz Beloit One Network |
$176.40
|
| Rate for Payer: Quartz Commercial |
$234.00
|
| Rate for Payer: Quartz Medicare Advantage |
$20.94
|
| Rate for Payer: The Alliance Commercial |
$83.76
|
| Rate for Payer: United Healthcare Medicaid |
$21.64
|
| Rate for Payer: United Healthcare Medicare Advantage |
$20.94
|
| Rate for Payer: United Healthcare PPO |
$270.00
|
| Rate for Payer: WEA Trust Commercial |
$198.00
|
| Rate for Payer: Wellcare Medicare |
$20.94
|
| Rate for Payer: WMAP Medicaid |
$21.64
|
| Rate for Payer: WPS Commercial |
$266.65
|
|
|
Heavy Metal Screen
|
Professional
|
Both
|
$360.00
|
|
|
Service Code
|
CPT 83015
|
| Hospital Charge Code |
977960
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$73.92 |
| Max. Negotiated Rate |
$342.00 |
| Rate for Payer: Aetna Commercial |
$342.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$309.60
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cigna Commercial |
$342.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$180.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$216.00
|
| Rate for Payer: Health EOS Commercial |
$327.60
|
| Rate for Payer: HFN Commercial |
$342.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$73.92
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$73.92
|
| Rate for Payer: Multiplan Commercial |
$288.00
|
| Rate for Payer: Preferred Network Access Commercial |
$342.00
|
| Rate for Payer: Quartz Beloit One Network |
$158.40
|
| Rate for Payer: Quartz Commercial |
$205.20
|
| Rate for Payer: The Alliance Commercial |
$180.00
|
| Rate for Payer: WEA Trust Commercial |
$198.00
|
| Rate for Payer: WPS Commercial |
$266.65
|
|
|
Heavy Metal Screen
|
Facility
|
IP
|
$360.00
|
|
|
Service Code
|
CPT 83015
|
| Hospital Charge Code |
977960
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$176.40 |
| Max. Negotiated Rate |
$331.20 |
| Rate for Payer: Aetna Commercial |
$324.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$309.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$190.80
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cigna Commercial |
$331.20
|
| Rate for Payer: Health EOS Commercial |
$320.40
|
| Rate for Payer: HFN Commercial |
$331.20
|
| Rate for Payer: Multiplan Commercial |
$288.00
|
| Rate for Payer: NAPHCARE Commercial |
$216.00
|
| Rate for Payer: Preferred Network Access Commercial |
$331.20
|
| Rate for Payer: Quartz Beloit One Network |
$176.40
|
| Rate for Payer: Quartz Commercial |
$216.00
|
| Rate for Payer: WEA Trust Commercial |
$198.00
|
| Rate for Payer: WPS Commercial |
$266.65
|
|
|
Heavy Metals Panel w/ Cadmium, Random Urine
|
Professional
|
Both
|
$240.45
|
|
|
Service Code
|
CPT 82175
|
| Hospital Charge Code |
3986158
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$66.96 |
| Max. Negotiated Rate |
$228.43 |
| Rate for Payer: Aetna Commercial |
$228.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$206.79
|
| Rate for Payer: Cash Price |
$72.13
|
| Rate for Payer: Cash Price |
$72.13
|
| Rate for Payer: Cigna Commercial |
$228.43
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$120.22
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$144.27
|
| Rate for Payer: Health EOS Commercial |
$218.81
|
| Rate for Payer: HFN Commercial |
$228.43
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$66.96
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$66.96
|
| Rate for Payer: Multiplan Commercial |
$192.36
|
| Rate for Payer: Preferred Network Access Commercial |
$228.43
|
| Rate for Payer: Quartz Beloit One Network |
$105.80
|
| Rate for Payer: Quartz Commercial |
$137.06
|
| Rate for Payer: The Alliance Commercial |
$120.22
|
| Rate for Payer: WEA Trust Commercial |
$132.25
|
| Rate for Payer: WPS Commercial |
$178.10
|
|
|
Heavy Metals Panel w/ Cadmium, Random Urine
|
Facility
|
OP
|
$240.45
|
|
|
Service Code
|
CPT 82175
|
| Hospital Charge Code |
3986158
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.97 |
| Max. Negotiated Rate |
$221.21 |
| Rate for Payer: Aetna Commercial |
$216.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$206.79
|
| Rate for Payer: Aetna Managed Medicare |
$18.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$71.14
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$33.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$31.49
|
| Rate for Payer: Anthem Medicaid |
$19.60
|
| Rate for Payer: Anthem Medicare Advantage |
$18.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$127.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$18.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$18.97
|
| Rate for Payer: Cash Price |
$72.13
|
| Rate for Payer: Cash Price |
$72.13
|
| Rate for Payer: Cigna Commercial |
$221.21
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$18.97
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$19.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$134.56
|
| Rate for Payer: Dean Health Medicaid |
$19.60
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$18.97
|
| Rate for Payer: Health EOS Commercial |
$214.00
|
| Rate for Payer: HFN Commercial |
$221.21
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$70.57
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$18.97
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$19.60
|
| Rate for Payer: Independent Care Health Plan Medicare |
$18.97
|
| Rate for Payer: Managed Health Services Medicaid |
$20.38
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$18.97
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$18.97
|
| Rate for Payer: Multiplan Commercial |
$192.36
|
| Rate for Payer: NAPHCARE Commercial |
$28.46
|
| Rate for Payer: Preferred Network Access Commercial |
$221.21
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$19.60
|
| Rate for Payer: Quartz Beloit One Network |
$117.82
|
| Rate for Payer: Quartz Commercial |
$156.29
|
| Rate for Payer: Quartz Medicare Advantage |
$18.97
|
| Rate for Payer: The Alliance Commercial |
$75.88
|
| Rate for Payer: United Healthcare Medicaid |
$19.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.97
|
| Rate for Payer: United Healthcare PPO |
$180.34
|
| Rate for Payer: WEA Trust Commercial |
$132.25
|
| Rate for Payer: Wellcare Medicare |
$18.97
|
| Rate for Payer: WMAP Medicaid |
$19.60
|
| Rate for Payer: WPS Commercial |
$178.10
|
|
|
Heavy Metals Panel w/ Cadmium, Random Urine
|
Facility
|
IP
|
$240.45
|
|
|
Service Code
|
CPT 82175
|
| Hospital Charge Code |
3986158
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$117.82 |
| Max. Negotiated Rate |
$221.21 |
| Rate for Payer: Aetna Commercial |
$216.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$206.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$127.44
|
| Rate for Payer: Cash Price |
$72.13
|
| Rate for Payer: Cigna Commercial |
$221.21
|
| Rate for Payer: Health EOS Commercial |
$214.00
|
| Rate for Payer: HFN Commercial |
$221.21
|
| Rate for Payer: Multiplan Commercial |
$192.36
|
| Rate for Payer: NAPHCARE Commercial |
$144.27
|
| Rate for Payer: Preferred Network Access Commercial |
$221.21
|
| Rate for Payer: Quartz Beloit One Network |
$117.82
|
| Rate for Payer: Quartz Commercial |
$144.27
|
| Rate for Payer: WEA Trust Commercial |
$132.25
|
| Rate for Payer: WPS Commercial |
$178.10
|
|
|
Hectoral 1mcg
|
Facility
|
OP
|
$55.00
|
|
|
Service Code
|
HCPCS J1270
|
| Hospital Charge Code |
3005562
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.10 |
| Max. Negotiated Rate |
$220.00 |
| Rate for Payer: Aetna Commercial |
$49.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$47.30
|
| Rate for Payer: Aetna Managed Medicare |
$15.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$35.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$27.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$26.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.15
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Cigna Commercial |
$50.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.10
|
| Rate for Payer: Health EOS Commercial |
$48.95
|
| Rate for Payer: HFN Commercial |
$50.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$41.25
|
| Rate for Payer: Multiplan Commercial |
$44.00
|
| Rate for Payer: NAPHCARE Commercial |
$33.00
|
| Rate for Payer: Preferred Network Access Commercial |
$50.60
|
| Rate for Payer: Quartz Beloit One Network |
$26.95
|
| Rate for Payer: Quartz Commercial |
$35.75
|
| Rate for Payer: Quartz Medicare Advantage |
$33.00
|
| Rate for Payer: The Alliance Commercial |
$220.00
|
| Rate for Payer: WEA Trust Commercial |
$30.25
|
| Rate for Payer: WPS Commercial |
$2.09
|
|
|
Hectoral 1mcg
|
Facility
|
IP
|
$55.00
|
|
|
Service Code
|
HCPCS J1270
|
| Hospital Charge Code |
3005562
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.95 |
| Max. Negotiated Rate |
$50.60 |
| Rate for Payer: Aetna Commercial |
$49.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$47.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.15
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Cigna Commercial |
$50.60
|
| Rate for Payer: Health EOS Commercial |
$48.95
|
| Rate for Payer: HFN Commercial |
$50.60
|
| Rate for Payer: Multiplan Commercial |
$44.00
|
| Rate for Payer: NAPHCARE Commercial |
$33.00
|
| Rate for Payer: Preferred Network Access Commercial |
$50.60
|
| Rate for Payer: Quartz Beloit One Network |
$26.95
|
| Rate for Payer: Quartz Commercial |
$33.00
|
| Rate for Payer: WEA Trust Commercial |
$30.25
|
| Rate for Payer: WPS Commercial |
$40.74
|
|
|
HEEL CUP LARGE #TU10020
|
Facility
|
OP
|
$194.00
|
|
| Hospital Charge Code |
2974296
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$54.32 |
| Max. Negotiated Rate |
$776.00 |
| Rate for Payer: Aetna Commercial |
$174.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$166.84
|
| Rate for Payer: Aetna Managed Medicare |
$54.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$126.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$97.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$93.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$102.82
|
| Rate for Payer: Cash Price |
$58.20
|
| Rate for Payer: Cigna Commercial |
$178.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$108.56
|
| Rate for Payer: Health EOS Commercial |
$172.66
|
| Rate for Payer: HFN Commercial |
$178.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$145.50
|
| Rate for Payer: Multiplan Commercial |
$155.20
|
| Rate for Payer: NAPHCARE Commercial |
$116.40
|
| Rate for Payer: Preferred Network Access Commercial |
$178.48
|
| Rate for Payer: Quartz Beloit One Network |
$95.06
|
| Rate for Payer: Quartz Commercial |
$126.10
|
| Rate for Payer: Quartz Medicare Advantage |
$116.40
|
| Rate for Payer: The Alliance Commercial |
$776.00
|
| Rate for Payer: WEA Trust Commercial |
$106.70
|
| Rate for Payer: WPS Commercial |
$143.70
|
|
|
HEEL CUP LARGE #TU10020
|
Facility
|
IP
|
$194.00
|
|
| Hospital Charge Code |
2974296
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$95.06 |
| Max. Negotiated Rate |
$178.48 |
| Rate for Payer: Aetna Commercial |
$174.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$166.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$102.82
|
| Rate for Payer: Cash Price |
$58.20
|
| Rate for Payer: Cigna Commercial |
$178.48
|
| Rate for Payer: Health EOS Commercial |
$172.66
|
| Rate for Payer: HFN Commercial |
$178.48
|
| Rate for Payer: Multiplan Commercial |
$155.20
|
| Rate for Payer: NAPHCARE Commercial |
$116.40
|
| Rate for Payer: Preferred Network Access Commercial |
$178.48
|
| Rate for Payer: Quartz Beloit One Network |
$95.06
|
| Rate for Payer: Quartz Commercial |
$116.40
|
| Rate for Payer: WEA Trust Commercial |
$106.70
|
| Rate for Payer: WPS Commercial |
$143.70
|
|
|
HEEL CUP REGULAR #TU10010
|
Facility
|
IP
|
$194.00
|
|
| Hospital Charge Code |
2974295
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$95.06 |
| Max. Negotiated Rate |
$178.48 |
| Rate for Payer: Aetna Commercial |
$174.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$166.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$102.82
|
| Rate for Payer: Cash Price |
$58.20
|
| Rate for Payer: Cigna Commercial |
$178.48
|
| Rate for Payer: Health EOS Commercial |
$172.66
|
| Rate for Payer: HFN Commercial |
$178.48
|
| Rate for Payer: Multiplan Commercial |
$155.20
|
| Rate for Payer: NAPHCARE Commercial |
$116.40
|
| Rate for Payer: Preferred Network Access Commercial |
$178.48
|
| Rate for Payer: Quartz Beloit One Network |
$95.06
|
| Rate for Payer: Quartz Commercial |
$116.40
|
| Rate for Payer: WEA Trust Commercial |
$106.70
|
| Rate for Payer: WPS Commercial |
$143.70
|
|
|
HEEL CUP REGULAR #TU10010
|
Facility
|
OP
|
$194.00
|
|
| Hospital Charge Code |
2974295
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$54.32 |
| Max. Negotiated Rate |
$776.00 |
| Rate for Payer: Aetna Commercial |
$174.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$166.84
|
| Rate for Payer: Aetna Managed Medicare |
$54.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$126.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$97.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$93.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$102.82
|
| Rate for Payer: Cash Price |
$58.20
|
| Rate for Payer: Cigna Commercial |
$178.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$108.56
|
| Rate for Payer: Health EOS Commercial |
$172.66
|
| Rate for Payer: HFN Commercial |
$178.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$145.50
|
| Rate for Payer: Multiplan Commercial |
$155.20
|
| Rate for Payer: NAPHCARE Commercial |
$116.40
|
| Rate for Payer: Preferred Network Access Commercial |
$178.48
|
| Rate for Payer: Quartz Beloit One Network |
$95.06
|
| Rate for Payer: Quartz Commercial |
$126.10
|
| Rate for Payer: Quartz Medicare Advantage |
$116.40
|
| Rate for Payer: The Alliance Commercial |
$776.00
|
| Rate for Payer: WEA Trust Commercial |
$106.70
|
| Rate for Payer: WPS Commercial |
$143.70
|
|
|
HEEL SPUR, REMOVAL
|
Facility
|
IP
|
$1,757.00
|
|
| Hospital Charge Code |
2960102
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$860.93 |
| Max. Negotiated Rate |
$1,616.44 |
| Rate for Payer: Aetna Commercial |
$1,581.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,511.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$931.21
|
| Rate for Payer: Cash Price |
$527.10
|
| Rate for Payer: Cigna Commercial |
$1,616.44
|
| Rate for Payer: Health EOS Commercial |
$1,563.73
|
| Rate for Payer: HFN Commercial |
$1,616.44
|
| Rate for Payer: Multiplan Commercial |
$1,405.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,054.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,616.44
|
| Rate for Payer: Quartz Beloit One Network |
$860.93
|
| Rate for Payer: Quartz Commercial |
$1,054.20
|
| Rate for Payer: WEA Trust Commercial |
$966.35
|
| Rate for Payer: WPS Commercial |
$1,301.41
|
|
|
HEEL SPUR, REMOVAL
|
Facility
|
OP
|
$1,757.00
|
|
| Hospital Charge Code |
2960102
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$491.96 |
| Max. Negotiated Rate |
$7,028.00 |
| Rate for Payer: Aetna Commercial |
$1,581.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,511.02
|
| Rate for Payer: Aetna Managed Medicare |
$491.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,142.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$878.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$843.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$931.21
|
| Rate for Payer: Cash Price |
$527.10
|
| Rate for Payer: Cigna Commercial |
$1,616.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$983.22
|
| Rate for Payer: Health EOS Commercial |
$1,563.73
|
| Rate for Payer: HFN Commercial |
$1,616.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,317.75
|
| Rate for Payer: Multiplan Commercial |
$1,405.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,054.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,616.44
|
| Rate for Payer: Quartz Beloit One Network |
$860.93
|
| Rate for Payer: Quartz Commercial |
$1,142.05
|
| Rate for Payer: Quartz Medicare Advantage |
$1,054.20
|
| Rate for Payer: The Alliance Commercial |
$7,028.00
|
| Rate for Payer: WEA Trust Commercial |
$966.35
|
| Rate for Payer: WPS Commercial |
$1,301.41
|
|
|
Helicobacter pylori Antigen, Stool
|
Professional
|
Both
|
$187.00
|
|
|
Service Code
|
CPT 87338
|
| Hospital Charge Code |
5575230
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$50.76 |
| Max. Negotiated Rate |
$177.65 |
| Rate for Payer: Aetna Commercial |
$177.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$160.82
|
| Rate for Payer: Cash Price |
$56.10
|
| Rate for Payer: Cash Price |
$56.10
|
| Rate for Payer: Cigna Commercial |
$177.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$93.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$112.20
|
| Rate for Payer: Health EOS Commercial |
$170.17
|
| Rate for Payer: HFN Commercial |
$177.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$50.76
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$50.76
|
| Rate for Payer: Multiplan Commercial |
$149.60
|
| Rate for Payer: Preferred Network Access Commercial |
$177.65
|
| Rate for Payer: Quartz Beloit One Network |
$82.28
|
| Rate for Payer: Quartz Commercial |
$106.59
|
| Rate for Payer: The Alliance Commercial |
$93.50
|
| Rate for Payer: WEA Trust Commercial |
$102.85
|
| Rate for Payer: WPS Commercial |
$138.51
|
|
|
Helicobacter pylori Antigen, Stool
|
Facility
|
OP
|
$187.00
|
|
|
Service Code
|
CPT 87338
|
| Hospital Charge Code |
5575230
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.38 |
| Max. Negotiated Rate |
$172.04 |
| Rate for Payer: Aetna Commercial |
$168.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$160.82
|
| Rate for Payer: Aetna Managed Medicare |
$14.38
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$53.92
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$25.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$23.87
|
| Rate for Payer: Anthem Medicaid |
$14.86
|
| Rate for Payer: Anthem Medicare Advantage |
$14.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$99.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$14.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$14.38
|
| Rate for Payer: Cash Price |
$56.10
|
| Rate for Payer: Cash Price |
$56.10
|
| Rate for Payer: Cigna Commercial |
$172.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$14.38
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$14.86
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$104.65
|
| Rate for Payer: Dean Health Medicaid |
$14.86
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$14.38
|
| Rate for Payer: Health EOS Commercial |
$166.43
|
| Rate for Payer: HFN Commercial |
$172.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$53.49
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$14.38
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$14.86
|
| Rate for Payer: Independent Care Health Plan Medicare |
$14.38
|
| Rate for Payer: Managed Health Services Medicaid |
$15.45
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$14.38
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$14.38
|
| Rate for Payer: Multiplan Commercial |
$149.60
|
| Rate for Payer: NAPHCARE Commercial |
$21.57
|
| Rate for Payer: Preferred Network Access Commercial |
$172.04
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$14.86
|
| Rate for Payer: Quartz Beloit One Network |
$91.63
|
| Rate for Payer: Quartz Commercial |
$121.55
|
| Rate for Payer: Quartz Medicare Advantage |
$14.38
|
| Rate for Payer: The Alliance Commercial |
$57.52
|
| Rate for Payer: United Healthcare Medicaid |
$14.86
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.38
|
| Rate for Payer: United Healthcare PPO |
$140.25
|
| Rate for Payer: WEA Trust Commercial |
$102.85
|
| Rate for Payer: Wellcare Medicare |
$14.38
|
| Rate for Payer: WMAP Medicaid |
$14.86
|
| Rate for Payer: WPS Commercial |
$138.51
|
|
|
Helicobacter pylori Antigen, Stool
|
Facility
|
IP
|
$187.00
|
|
|
Service Code
|
CPT 87338
|
| Hospital Charge Code |
5575230
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$91.63 |
| Max. Negotiated Rate |
$172.04 |
| Rate for Payer: Aetna Commercial |
$168.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$160.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$99.11
|
| Rate for Payer: Cash Price |
$56.10
|
| Rate for Payer: Cigna Commercial |
$172.04
|
| Rate for Payer: Health EOS Commercial |
$166.43
|
| Rate for Payer: HFN Commercial |
$172.04
|
| Rate for Payer: Multiplan Commercial |
$149.60
|
| Rate for Payer: NAPHCARE Commercial |
$112.20
|
| Rate for Payer: Preferred Network Access Commercial |
$172.04
|
| Rate for Payer: Quartz Beloit One Network |
$91.63
|
| Rate for Payer: Quartz Commercial |
$112.20
|
| Rate for Payer: WEA Trust Commercial |
$102.85
|
| Rate for Payer: WPS Commercial |
$138.51
|
|
|
Helicobacter pylori Breath Test
|
Facility
|
OP
|
$374.00
|
|
|
Service Code
|
CPT 83013
|
| Hospital Charge Code |
978118
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$67.36 |
| Max. Negotiated Rate |
$344.08 |
| Rate for Payer: WMAP Medicaid |
$69.60
|
| Rate for Payer: WPS Commercial |
$277.02
|
| Rate for Payer: Aetna Commercial |
$336.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$321.64
|
| Rate for Payer: Aetna Managed Medicare |
$67.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$252.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$117.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$111.82
|
| Rate for Payer: Anthem Medicaid |
$69.60
|
| Rate for Payer: Anthem Medicare Advantage |
$67.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$198.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$67.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$67.36
|
| Rate for Payer: Cash Price |
$112.20
|
| Rate for Payer: Cash Price |
$112.20
|
| Rate for Payer: Cigna Commercial |
$344.08
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$67.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$69.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$209.29
|
| Rate for Payer: Dean Health Medicaid |
$69.60
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$67.36
|
| Rate for Payer: Health EOS Commercial |
$332.86
|
| Rate for Payer: HFN Commercial |
$344.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$250.58
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$67.36
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$69.60
|
| Rate for Payer: Independent Care Health Plan Medicare |
$67.36
|
| Rate for Payer: Managed Health Services Medicaid |
$72.38
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$67.36
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$67.36
|
| Rate for Payer: Multiplan Commercial |
$299.20
|
| Rate for Payer: NAPHCARE Commercial |
$101.04
|
| Rate for Payer: Preferred Network Access Commercial |
$344.08
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$69.60
|
| Rate for Payer: Quartz Beloit One Network |
$183.26
|
| Rate for Payer: Quartz Commercial |
$243.10
|
| Rate for Payer: Quartz Medicare Advantage |
$67.36
|
| Rate for Payer: The Alliance Commercial |
$269.44
|
| Rate for Payer: United Healthcare Medicaid |
$69.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$67.36
|
| Rate for Payer: United Healthcare PPO |
$280.50
|
| Rate for Payer: WEA Trust Commercial |
$205.70
|
| Rate for Payer: Wellcare Medicare |
$67.36
|
|
|
Helicobacter pylori Breath Test
|
Professional
|
Both
|
$374.00
|
|
|
Service Code
|
CPT 83013
|
| Hospital Charge Code |
978118
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$164.56 |
| Max. Negotiated Rate |
$355.30 |
| Rate for Payer: Aetna Commercial |
$355.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$321.64
|
| Rate for Payer: Cash Price |
$112.20
|
| Rate for Payer: Cash Price |
$112.20
|
| Rate for Payer: Cigna Commercial |
$355.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$187.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$224.40
|
| Rate for Payer: Health EOS Commercial |
$340.34
|
| Rate for Payer: HFN Commercial |
$355.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$237.78
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$237.78
|
| Rate for Payer: Multiplan Commercial |
$299.20
|
| Rate for Payer: Preferred Network Access Commercial |
$355.30
|
| Rate for Payer: Quartz Beloit One Network |
$164.56
|
| Rate for Payer: Quartz Commercial |
$213.18
|
| Rate for Payer: The Alliance Commercial |
$187.00
|
| Rate for Payer: WEA Trust Commercial |
$205.70
|
| Rate for Payer: WPS Commercial |
$277.02
|
|
|
Helicobacter pylori Breath Test
|
Facility
|
IP
|
$374.00
|
|
|
Service Code
|
CPT 83013
|
| Hospital Charge Code |
978118
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$183.26 |
| Max. Negotiated Rate |
$344.08 |
| Rate for Payer: Aetna Commercial |
$336.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$321.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$198.22
|
| Rate for Payer: Cash Price |
$112.20
|
| Rate for Payer: Cigna Commercial |
$344.08
|
| Rate for Payer: Health EOS Commercial |
$332.86
|
| Rate for Payer: HFN Commercial |
$344.08
|
| Rate for Payer: Multiplan Commercial |
$299.20
|
| Rate for Payer: NAPHCARE Commercial |
$224.40
|
| Rate for Payer: Preferred Network Access Commercial |
$344.08
|
| Rate for Payer: Quartz Beloit One Network |
$183.26
|
| Rate for Payer: Quartz Commercial |
$224.40
|
| Rate for Payer: WEA Trust Commercial |
$205.70
|
| Rate for Payer: WPS Commercial |
$277.02
|
|
|
Helicobacter pylori Culture
|
Facility
|
IP
|
$237.00
|
|
|
Service Code
|
CPT 87081
|
| Hospital Charge Code |
3811600
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$116.13 |
| Max. Negotiated Rate |
$218.04 |
| Rate for Payer: Aetna Commercial |
$213.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$203.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$125.61
|
| Rate for Payer: Cash Price |
$71.10
|
| Rate for Payer: Cigna Commercial |
$218.04
|
| Rate for Payer: Health EOS Commercial |
$210.93
|
| Rate for Payer: HFN Commercial |
$218.04
|
| Rate for Payer: Multiplan Commercial |
$189.60
|
| Rate for Payer: NAPHCARE Commercial |
$142.20
|
| Rate for Payer: Preferred Network Access Commercial |
$218.04
|
| Rate for Payer: Quartz Beloit One Network |
$116.13
|
| Rate for Payer: Quartz Commercial |
$142.20
|
| Rate for Payer: WEA Trust Commercial |
$130.35
|
| Rate for Payer: WPS Commercial |
$175.55
|
|
|
Helicobacter pylori Culture
|
Facility
|
OP
|
$237.00
|
|
|
Service Code
|
CPT 87081
|
| Hospital Charge Code |
3811600
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.63 |
| Max. Negotiated Rate |
$218.04 |
| Rate for Payer: Aetna Commercial |
$213.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$203.82
|
| Rate for Payer: Aetna Managed Medicare |
$6.63
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$24.86
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$11.01
|
| Rate for Payer: Anthem Medicaid |
$6.85
|
| Rate for Payer: Anthem Medicare Advantage |
$6.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$125.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$6.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$6.63
|
| Rate for Payer: Cash Price |
$71.10
|
| Rate for Payer: Cash Price |
$71.10
|
| Rate for Payer: Cigna Commercial |
$218.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$6.63
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$6.85
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$132.63
|
| Rate for Payer: Dean Health Medicaid |
$6.85
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$6.63
|
| Rate for Payer: Health EOS Commercial |
$210.93
|
| Rate for Payer: HFN Commercial |
$218.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$24.66
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$6.63
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$6.85
|
| Rate for Payer: Independent Care Health Plan Medicare |
$6.63
|
| Rate for Payer: Managed Health Services Medicaid |
$7.12
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$6.63
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$6.63
|
| Rate for Payer: Multiplan Commercial |
$189.60
|
| Rate for Payer: NAPHCARE Commercial |
$9.94
|
| Rate for Payer: Preferred Network Access Commercial |
$218.04
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$6.85
|
| Rate for Payer: Quartz Beloit One Network |
$116.13
|
| Rate for Payer: Quartz Commercial |
$154.05
|
| Rate for Payer: Quartz Medicare Advantage |
$6.63
|
| Rate for Payer: The Alliance Commercial |
$26.52
|
| Rate for Payer: United Healthcare Medicaid |
$6.85
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6.63
|
| Rate for Payer: United Healthcare PPO |
$177.75
|
| Rate for Payer: WEA Trust Commercial |
$130.35
|
| Rate for Payer: Wellcare Medicare |
$6.63
|
| Rate for Payer: WMAP Medicaid |
$6.85
|
| Rate for Payer: WPS Commercial |
$175.55
|
|
