|
HIP STEM ACCOLADE SZ 6 6077-0637
|
Facility
|
IP
|
$7,318.00
|
|
| Hospital Charge Code |
4079275
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,585.82 |
| Max. Negotiated Rate |
$6,732.56 |
| Rate for Payer: Aetna Commercial |
$6,586.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,293.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,878.54
|
| Rate for Payer: Cash Price |
$2,195.40
|
| Rate for Payer: Cigna Commercial |
$6,732.56
|
| Rate for Payer: Health EOS Commercial |
$6,513.02
|
| Rate for Payer: HFN Commercial |
$6,732.56
|
| Rate for Payer: Multiplan Commercial |
$5,854.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,390.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,732.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,585.82
|
| Rate for Payer: Quartz Commercial |
$4,390.80
|
| Rate for Payer: WEA Trust Commercial |
$4,024.90
|
| Rate for Payer: WPS Commercial |
$5,420.44
|
|
|
HIP STEM ACCOLADE SZ 7 6077-0740
|
Facility
|
OP
|
$7,318.00
|
|
| Hospital Charge Code |
4518637
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,049.04 |
| Max. Negotiated Rate |
$29,272.00 |
| Rate for Payer: Aetna Commercial |
$6,586.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,293.48
|
| Rate for Payer: Aetna Managed Medicare |
$2,049.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,756.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,659.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,512.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,878.54
|
| Rate for Payer: Cash Price |
$2,195.40
|
| Rate for Payer: Cigna Commercial |
$6,732.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,095.15
|
| Rate for Payer: Health EOS Commercial |
$6,513.02
|
| Rate for Payer: HFN Commercial |
$6,732.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,488.50
|
| Rate for Payer: Multiplan Commercial |
$5,854.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,390.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,732.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,585.82
|
| Rate for Payer: Quartz Commercial |
$4,756.70
|
| Rate for Payer: Quartz Medicare Advantage |
$4,390.80
|
| Rate for Payer: The Alliance Commercial |
$29,272.00
|
| Rate for Payer: WEA Trust Commercial |
$4,024.90
|
| Rate for Payer: WPS Commercial |
$5,420.44
|
|
|
HIP STEM ACCOLADE SZ 7 6077-0740
|
Facility
|
IP
|
$7,318.00
|
|
| Hospital Charge Code |
4518637
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,585.82 |
| Max. Negotiated Rate |
$6,732.56 |
| Rate for Payer: Aetna Commercial |
$6,586.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,293.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,878.54
|
| Rate for Payer: Cash Price |
$2,195.40
|
| Rate for Payer: Cigna Commercial |
$6,732.56
|
| Rate for Payer: Health EOS Commercial |
$6,513.02
|
| Rate for Payer: HFN Commercial |
$6,732.56
|
| Rate for Payer: Multiplan Commercial |
$5,854.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,390.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,732.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,585.82
|
| Rate for Payer: Quartz Commercial |
$4,390.80
|
| Rate for Payer: WEA Trust Commercial |
$4,024.90
|
| Rate for Payer: WPS Commercial |
$5,420.44
|
|
|
HIP STEM ACCOLADE SZ 8 6077-0840
|
Facility
|
IP
|
$7,318.00
|
|
| Hospital Charge Code |
4518638
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,585.82 |
| Max. Negotiated Rate |
$6,732.56 |
| Rate for Payer: Aetna Commercial |
$6,586.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,293.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,878.54
|
| Rate for Payer: Cash Price |
$2,195.40
|
| Rate for Payer: Cigna Commercial |
$6,732.56
|
| Rate for Payer: Health EOS Commercial |
$6,513.02
|
| Rate for Payer: HFN Commercial |
$6,732.56
|
| Rate for Payer: Multiplan Commercial |
$5,854.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,390.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,732.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,585.82
|
| Rate for Payer: Quartz Commercial |
$4,390.80
|
| Rate for Payer: WEA Trust Commercial |
$4,024.90
|
| Rate for Payer: WPS Commercial |
$5,420.44
|
|
|
HIP STEM ACCOLADE SZ 8 6077-0840
|
Facility
|
OP
|
$7,318.00
|
|
| Hospital Charge Code |
4518638
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,049.04 |
| Max. Negotiated Rate |
$29,272.00 |
| Rate for Payer: Aetna Commercial |
$6,586.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,293.48
|
| Rate for Payer: Aetna Managed Medicare |
$2,049.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,756.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,659.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,512.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,878.54
|
| Rate for Payer: Cash Price |
$2,195.40
|
| Rate for Payer: Cigna Commercial |
$6,732.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,095.15
|
| Rate for Payer: Health EOS Commercial |
$6,513.02
|
| Rate for Payer: HFN Commercial |
$6,732.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,488.50
|
| Rate for Payer: Multiplan Commercial |
$5,854.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,390.80
|
| Rate for Payer: Preferred Network Access Commercial |
$6,732.56
|
| Rate for Payer: Quartz Beloit One Network |
$3,585.82
|
| Rate for Payer: Quartz Commercial |
$4,756.70
|
| Rate for Payer: Quartz Medicare Advantage |
$4,390.80
|
| Rate for Payer: The Alliance Commercial |
$29,272.00
|
| Rate for Payer: WEA Trust Commercial |
$4,024.90
|
| Rate for Payer: WPS Commercial |
$5,420.44
|
|
|
HIP STEM SECUR-FIT SZ 7 6051-0730S
|
Facility
|
IP
|
$17,236.00
|
|
| Hospital Charge Code |
3072550
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,445.64 |
| Max. Negotiated Rate |
$15,857.12 |
| Rate for Payer: Aetna Commercial |
$15,512.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,822.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,135.08
|
| Rate for Payer: Cash Price |
$5,170.80
|
| Rate for Payer: Cigna Commercial |
$15,857.12
|
| Rate for Payer: Health EOS Commercial |
$15,340.04
|
| Rate for Payer: HFN Commercial |
$15,857.12
|
| Rate for Payer: Multiplan Commercial |
$13,788.80
|
| Rate for Payer: NAPHCARE Commercial |
$10,341.60
|
| Rate for Payer: Preferred Network Access Commercial |
$15,857.12
|
| Rate for Payer: Quartz Beloit One Network |
$8,445.64
|
| Rate for Payer: Quartz Commercial |
$10,341.60
|
| Rate for Payer: WEA Trust Commercial |
$9,479.80
|
| Rate for Payer: WPS Commercial |
$12,766.71
|
|
|
HIP STEM SECUR-FIT SZ 7 6051-0730S
|
Facility
|
OP
|
$17,236.00
|
|
| Hospital Charge Code |
3072550
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,826.08 |
| Max. Negotiated Rate |
$68,944.00 |
| Rate for Payer: Aetna Commercial |
$15,512.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,822.96
|
| Rate for Payer: Aetna Managed Medicare |
$4,826.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11,203.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,618.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,273.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,135.08
|
| Rate for Payer: Cash Price |
$5,170.80
|
| Rate for Payer: Cigna Commercial |
$15,857.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,645.27
|
| Rate for Payer: Health EOS Commercial |
$15,340.04
|
| Rate for Payer: HFN Commercial |
$15,857.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,927.00
|
| Rate for Payer: Multiplan Commercial |
$13,788.80
|
| Rate for Payer: NAPHCARE Commercial |
$10,341.60
|
| Rate for Payer: Preferred Network Access Commercial |
$15,857.12
|
| Rate for Payer: Quartz Beloit One Network |
$8,445.64
|
| Rate for Payer: Quartz Commercial |
$11,203.40
|
| Rate for Payer: Quartz Medicare Advantage |
$10,341.60
|
| Rate for Payer: The Alliance Commercial |
$68,944.00
|
| Rate for Payer: WEA Trust Commercial |
$9,479.80
|
| Rate for Payer: WPS Commercial |
$12,766.71
|
|
|
HIP STEM SECUR-FIT SZ 8 6052-0830S
|
Facility
|
OP
|
$17,236.00
|
|
| Hospital Charge Code |
3072477
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,826.08 |
| Max. Negotiated Rate |
$68,944.00 |
| Rate for Payer: Aetna Commercial |
$15,512.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,822.96
|
| Rate for Payer: Aetna Managed Medicare |
$4,826.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11,203.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,618.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,273.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,135.08
|
| Rate for Payer: Cash Price |
$5,170.80
|
| Rate for Payer: Cigna Commercial |
$15,857.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,645.27
|
| Rate for Payer: Health EOS Commercial |
$15,340.04
|
| Rate for Payer: HFN Commercial |
$15,857.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,927.00
|
| Rate for Payer: Multiplan Commercial |
$13,788.80
|
| Rate for Payer: NAPHCARE Commercial |
$10,341.60
|
| Rate for Payer: Preferred Network Access Commercial |
$15,857.12
|
| Rate for Payer: Quartz Beloit One Network |
$8,445.64
|
| Rate for Payer: Quartz Commercial |
$11,203.40
|
| Rate for Payer: Quartz Medicare Advantage |
$10,341.60
|
| Rate for Payer: The Alliance Commercial |
$68,944.00
|
| Rate for Payer: WEA Trust Commercial |
$9,479.80
|
| Rate for Payer: WPS Commercial |
$12,766.71
|
|
|
HIP STEM SECUR-FIT SZ 8 6052-0830S
|
Facility
|
IP
|
$17,236.00
|
|
| Hospital Charge Code |
3072477
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,445.64 |
| Max. Negotiated Rate |
$15,857.12 |
| Rate for Payer: Aetna Commercial |
$15,512.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,822.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,135.08
|
| Rate for Payer: Cash Price |
$5,170.80
|
| Rate for Payer: Cigna Commercial |
$15,857.12
|
| Rate for Payer: Health EOS Commercial |
$15,340.04
|
| Rate for Payer: HFN Commercial |
$15,857.12
|
| Rate for Payer: Multiplan Commercial |
$13,788.80
|
| Rate for Payer: NAPHCARE Commercial |
$10,341.60
|
| Rate for Payer: Preferred Network Access Commercial |
$15,857.12
|
| Rate for Payer: Quartz Beloit One Network |
$8,445.64
|
| Rate for Payer: Quartz Commercial |
$10,341.60
|
| Rate for Payer: WEA Trust Commercial |
$9,479.80
|
| Rate for Payer: WPS Commercial |
$12,766.71
|
|
|
Histamine
|
Facility
|
IP
|
$449.00
|
|
|
Service Code
|
CPT 83088
|
| Hospital Charge Code |
977977
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$220.01 |
| Max. Negotiated Rate |
$413.08 |
| Rate for Payer: Aetna Commercial |
$404.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$386.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$237.97
|
| Rate for Payer: Cash Price |
$134.70
|
| Rate for Payer: Cigna Commercial |
$413.08
|
| Rate for Payer: Health EOS Commercial |
$399.61
|
| Rate for Payer: HFN Commercial |
$413.08
|
| Rate for Payer: Multiplan Commercial |
$359.20
|
| Rate for Payer: NAPHCARE Commercial |
$269.40
|
| Rate for Payer: Preferred Network Access Commercial |
$413.08
|
| Rate for Payer: Quartz Beloit One Network |
$220.01
|
| Rate for Payer: Quartz Commercial |
$269.40
|
| Rate for Payer: WEA Trust Commercial |
$246.95
|
| Rate for Payer: WPS Commercial |
$332.57
|
|
|
Histamine
|
Facility
|
OP
|
$449.00
|
|
|
Service Code
|
CPT 83088
|
| Hospital Charge Code |
977977
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$29.53 |
| Max. Negotiated Rate |
$413.08 |
| Rate for Payer: Aetna Commercial |
$404.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$386.14
|
| Rate for Payer: Aetna Managed Medicare |
$29.53
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$110.74
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$51.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$49.02
|
| Rate for Payer: Anthem Medicaid |
$30.51
|
| Rate for Payer: Anthem Medicare Advantage |
$29.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$237.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$29.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$29.53
|
| Rate for Payer: Cash Price |
$134.70
|
| Rate for Payer: Cash Price |
$134.70
|
| Rate for Payer: Cigna Commercial |
$413.08
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$29.53
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$30.51
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$251.26
|
| Rate for Payer: Dean Health Medicaid |
$30.51
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$29.53
|
| Rate for Payer: Health EOS Commercial |
$399.61
|
| Rate for Payer: HFN Commercial |
$413.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$109.85
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$29.53
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$30.51
|
| Rate for Payer: Independent Care Health Plan Medicare |
$29.53
|
| Rate for Payer: Managed Health Services Medicaid |
$31.73
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$29.53
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$29.53
|
| Rate for Payer: Multiplan Commercial |
$359.20
|
| Rate for Payer: NAPHCARE Commercial |
$44.30
|
| Rate for Payer: Preferred Network Access Commercial |
$413.08
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$30.51
|
| Rate for Payer: Quartz Beloit One Network |
$220.01
|
| Rate for Payer: Quartz Commercial |
$291.85
|
| Rate for Payer: Quartz Medicare Advantage |
$29.53
|
| Rate for Payer: The Alliance Commercial |
$118.12
|
| Rate for Payer: United Healthcare Medicaid |
$30.51
|
| Rate for Payer: United Healthcare Medicare Advantage |
$29.53
|
| Rate for Payer: United Healthcare PPO |
$336.75
|
| Rate for Payer: WEA Trust Commercial |
$246.95
|
| Rate for Payer: Wellcare Medicare |
$29.53
|
| Rate for Payer: WMAP Medicaid |
$30.51
|
| Rate for Payer: WPS Commercial |
$332.57
|
|
|
Histamine
|
Professional
|
Both
|
$449.00
|
|
|
Service Code
|
CPT 83088
|
| Hospital Charge Code |
977977
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$104.24 |
| Max. Negotiated Rate |
$426.55 |
| Rate for Payer: Aetna Commercial |
$426.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$386.14
|
| Rate for Payer: Cash Price |
$134.70
|
| Rate for Payer: Cash Price |
$134.70
|
| Rate for Payer: Cigna Commercial |
$426.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$224.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$269.40
|
| Rate for Payer: Health EOS Commercial |
$408.59
|
| Rate for Payer: HFN Commercial |
$426.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$104.24
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$104.24
|
| Rate for Payer: Multiplan Commercial |
$359.20
|
| Rate for Payer: Preferred Network Access Commercial |
$426.55
|
| Rate for Payer: Quartz Beloit One Network |
$197.56
|
| Rate for Payer: Quartz Commercial |
$255.93
|
| Rate for Payer: The Alliance Commercial |
$224.50
|
| Rate for Payer: WEA Trust Commercial |
$246.95
|
| Rate for Payer: WPS Commercial |
$332.57
|
|
|
Histamine 24 Hour Urine
|
Facility
|
OP
|
$162.00
|
|
|
Service Code
|
CPT 83088
|
| Hospital Charge Code |
4538880
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$29.53 |
| Max. Negotiated Rate |
$149.04 |
| Rate for Payer: Aetna Commercial |
$145.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$139.32
|
| Rate for Payer: Aetna Managed Medicare |
$29.53
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$110.74
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$51.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$49.02
|
| Rate for Payer: Anthem Medicaid |
$30.51
|
| Rate for Payer: Anthem Medicare Advantage |
$29.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$85.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$29.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$29.53
|
| Rate for Payer: Cash Price |
$48.60
|
| Rate for Payer: Cash Price |
$48.60
|
| Rate for Payer: Cigna Commercial |
$149.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$29.53
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$30.51
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$90.66
|
| Rate for Payer: Dean Health Medicaid |
$30.51
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$29.53
|
| Rate for Payer: Health EOS Commercial |
$144.18
|
| Rate for Payer: HFN Commercial |
$149.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$109.85
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$29.53
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$30.51
|
| Rate for Payer: Independent Care Health Plan Medicare |
$29.53
|
| Rate for Payer: Managed Health Services Medicaid |
$31.73
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$29.53
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$29.53
|
| Rate for Payer: Multiplan Commercial |
$129.60
|
| Rate for Payer: NAPHCARE Commercial |
$44.30
|
| Rate for Payer: Preferred Network Access Commercial |
$149.04
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$30.51
|
| Rate for Payer: Quartz Beloit One Network |
$79.38
|
| Rate for Payer: Quartz Commercial |
$105.30
|
| Rate for Payer: Quartz Medicare Advantage |
$29.53
|
| Rate for Payer: The Alliance Commercial |
$118.12
|
| Rate for Payer: United Healthcare Medicaid |
$30.51
|
| Rate for Payer: United Healthcare Medicare Advantage |
$29.53
|
| Rate for Payer: United Healthcare PPO |
$121.50
|
| Rate for Payer: WEA Trust Commercial |
$89.10
|
| Rate for Payer: Wellcare Medicare |
$29.53
|
| Rate for Payer: WMAP Medicaid |
$30.51
|
| Rate for Payer: WPS Commercial |
$119.99
|
|
|
Histamine 24 Hour Urine
|
Professional
|
Both
|
$162.00
|
|
|
Service Code
|
CPT 83088
|
| Hospital Charge Code |
4538880
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$71.28 |
| Max. Negotiated Rate |
$153.90 |
| Rate for Payer: Aetna Commercial |
$153.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$139.32
|
| Rate for Payer: Cash Price |
$48.60
|
| Rate for Payer: Cash Price |
$48.60
|
| Rate for Payer: Cigna Commercial |
$153.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$81.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$97.20
|
| Rate for Payer: Health EOS Commercial |
$147.42
|
| Rate for Payer: HFN Commercial |
$153.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$104.24
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$104.24
|
| Rate for Payer: Multiplan Commercial |
$129.60
|
| Rate for Payer: Preferred Network Access Commercial |
$153.90
|
| Rate for Payer: Quartz Beloit One Network |
$71.28
|
| Rate for Payer: Quartz Commercial |
$92.34
|
| Rate for Payer: The Alliance Commercial |
$81.00
|
| Rate for Payer: WEA Trust Commercial |
$89.10
|
| Rate for Payer: WPS Commercial |
$119.99
|
|
|
Histamine 24 Hour Urine
|
Facility
|
IP
|
$162.00
|
|
|
Service Code
|
CPT 83088
|
| Hospital Charge Code |
4538880
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$79.38 |
| Max. Negotiated Rate |
$149.04 |
| Rate for Payer: Aetna Commercial |
$145.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$139.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$85.86
|
| Rate for Payer: Cash Price |
$48.60
|
| Rate for Payer: Cigna Commercial |
$149.04
|
| Rate for Payer: Health EOS Commercial |
$144.18
|
| Rate for Payer: HFN Commercial |
$149.04
|
| Rate for Payer: Multiplan Commercial |
$129.60
|
| Rate for Payer: NAPHCARE Commercial |
$97.20
|
| Rate for Payer: Preferred Network Access Commercial |
$149.04
|
| Rate for Payer: Quartz Beloit One Network |
$79.38
|
| Rate for Payer: Quartz Commercial |
$97.20
|
| Rate for Payer: WEA Trust Commercial |
$89.10
|
| Rate for Payer: WPS Commercial |
$119.99
|
|
|
Histone Ab / 37056
|
Professional
|
Both
|
$42.00
|
|
|
Service Code
|
CPT 83516
|
| Hospital Charge Code |
4075715
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.48 |
| Max. Negotiated Rate |
$40.70 |
| Rate for Payer: Aetna Commercial |
$39.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$36.12
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna Commercial |
$39.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$21.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$25.20
|
| Rate for Payer: Health EOS Commercial |
$38.22
|
| Rate for Payer: HFN Commercial |
$39.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$40.70
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$40.70
|
| Rate for Payer: Multiplan Commercial |
$33.60
|
| Rate for Payer: Preferred Network Access Commercial |
$39.90
|
| Rate for Payer: Quartz Beloit One Network |
$18.48
|
| Rate for Payer: Quartz Commercial |
$23.94
|
| Rate for Payer: The Alliance Commercial |
$21.00
|
| Rate for Payer: WEA Trust Commercial |
$23.10
|
| Rate for Payer: WPS Commercial |
$31.11
|
|
|
Histone Ab / 37056
|
Facility
|
IP
|
$42.00
|
|
|
Service Code
|
CPT 83516
|
| Hospital Charge Code |
4075715
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$20.58 |
| Max. Negotiated Rate |
$38.64 |
| Rate for Payer: Aetna Commercial |
$37.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$36.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$22.26
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna Commercial |
$38.64
|
| Rate for Payer: Health EOS Commercial |
$37.38
|
| Rate for Payer: HFN Commercial |
$38.64
|
| Rate for Payer: Multiplan Commercial |
$33.60
|
| Rate for Payer: NAPHCARE Commercial |
$25.20
|
| Rate for Payer: Preferred Network Access Commercial |
$38.64
|
| Rate for Payer: Quartz Beloit One Network |
$20.58
|
| Rate for Payer: Quartz Commercial |
$25.20
|
| Rate for Payer: WEA Trust Commercial |
$23.10
|
| Rate for Payer: WPS Commercial |
$31.11
|
|
|
Histone Ab / 37056
|
Facility
|
OP
|
$42.00
|
|
|
Service Code
|
CPT 83516
|
| Hospital Charge Code |
4075715
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.53 |
| Max. Negotiated Rate |
$46.12 |
| Rate for Payer: Aetna Commercial |
$37.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$36.12
|
| Rate for Payer: Aetna Managed Medicare |
$11.53
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$43.24
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$20.18
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$19.14
|
| Rate for Payer: Anthem Medicaid |
$11.91
|
| Rate for Payer: Anthem Medicare Advantage |
$11.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$22.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$11.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$11.53
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna Commercial |
$38.64
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$11.53
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$11.91
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$23.50
|
| Rate for Payer: Dean Health Medicaid |
$11.91
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$11.53
|
| Rate for Payer: Health EOS Commercial |
$37.38
|
| Rate for Payer: HFN Commercial |
$38.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.89
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$11.53
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$11.91
|
| Rate for Payer: Independent Care Health Plan Medicare |
$11.53
|
| Rate for Payer: Managed Health Services Medicaid |
$12.39
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$11.53
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$11.53
|
| Rate for Payer: Multiplan Commercial |
$33.60
|
| Rate for Payer: NAPHCARE Commercial |
$17.30
|
| Rate for Payer: Preferred Network Access Commercial |
$38.64
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$11.91
|
| Rate for Payer: Quartz Beloit One Network |
$20.58
|
| Rate for Payer: Quartz Commercial |
$27.30
|
| Rate for Payer: Quartz Medicare Advantage |
$11.53
|
| Rate for Payer: The Alliance Commercial |
$46.12
|
| Rate for Payer: United Healthcare Medicaid |
$11.91
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11.53
|
| Rate for Payer: United Healthcare PPO |
$31.50
|
| Rate for Payer: WEA Trust Commercial |
$23.10
|
| Rate for Payer: Wellcare Medicare |
$11.53
|
| Rate for Payer: WMAP Medicaid |
$11.91
|
| Rate for Payer: WPS Commercial |
$31.11
|
|
|
Histoplasma Antibody
|
Facility
|
IP
|
$57.00
|
|
|
Service Code
|
CPT 86698
|
| Hospital Charge Code |
5598647
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$27.93 |
| Max. Negotiated Rate |
$52.44 |
| Rate for Payer: Aetna Commercial |
$51.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$49.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$30.21
|
| Rate for Payer: Cash Price |
$17.10
|
| Rate for Payer: Cigna Commercial |
$52.44
|
| Rate for Payer: Health EOS Commercial |
$50.73
|
| Rate for Payer: HFN Commercial |
$52.44
|
| Rate for Payer: Multiplan Commercial |
$45.60
|
| Rate for Payer: NAPHCARE Commercial |
$34.20
|
| Rate for Payer: Preferred Network Access Commercial |
$52.44
|
| Rate for Payer: Quartz Beloit One Network |
$27.93
|
| Rate for Payer: Quartz Commercial |
$34.20
|
| Rate for Payer: WEA Trust Commercial |
$31.35
|
| Rate for Payer: WPS Commercial |
$42.22
|
|
|
Histoplasma Antibody
|
Facility
|
OP
|
$57.00
|
|
|
Service Code
|
CPT 86698
|
| Hospital Charge Code |
5598647
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.79 |
| Max. Negotiated Rate |
$55.16 |
| Rate for Payer: Aetna Commercial |
$51.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$49.02
|
| Rate for Payer: Aetna Managed Medicare |
$13.79
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$51.71
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$24.13
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$22.89
|
| Rate for Payer: Anthem Medicaid |
$14.25
|
| Rate for Payer: Anthem Medicare Advantage |
$13.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$30.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$13.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$13.79
|
| Rate for Payer: Cash Price |
$17.10
|
| Rate for Payer: Cash Price |
$17.10
|
| Rate for Payer: Cigna Commercial |
$52.44
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$13.79
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$14.25
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$31.90
|
| Rate for Payer: Dean Health Medicaid |
$14.25
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$13.79
|
| Rate for Payer: Health EOS Commercial |
$50.73
|
| Rate for Payer: HFN Commercial |
$52.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$51.30
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$13.79
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$14.25
|
| Rate for Payer: Independent Care Health Plan Medicare |
$13.79
|
| Rate for Payer: Managed Health Services Medicaid |
$14.82
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$13.79
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$13.79
|
| Rate for Payer: Multiplan Commercial |
$45.60
|
| Rate for Payer: NAPHCARE Commercial |
$20.68
|
| Rate for Payer: Preferred Network Access Commercial |
$52.44
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$14.25
|
| Rate for Payer: Quartz Beloit One Network |
$27.93
|
| Rate for Payer: Quartz Commercial |
$37.05
|
| Rate for Payer: Quartz Medicare Advantage |
$13.79
|
| Rate for Payer: The Alliance Commercial |
$55.16
|
| Rate for Payer: United Healthcare Medicaid |
$14.25
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.79
|
| Rate for Payer: United Healthcare PPO |
$42.75
|
| Rate for Payer: WEA Trust Commercial |
$31.35
|
| Rate for Payer: Wellcare Medicare |
$13.79
|
| Rate for Payer: WMAP Medicaid |
$14.25
|
| Rate for Payer: WPS Commercial |
$42.22
|
|
|
Histoplasma Antibody
|
Facility
|
IP
|
$150.00
|
|
|
Service Code
|
CPT 86698
|
| Hospital Charge Code |
977978
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$73.50 |
| Max. Negotiated Rate |
$138.00 |
| Rate for Payer: Aetna Commercial |
$135.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$129.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$79.50
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cigna Commercial |
$138.00
|
| Rate for Payer: Health EOS Commercial |
$133.50
|
| Rate for Payer: HFN Commercial |
$138.00
|
| Rate for Payer: Multiplan Commercial |
$120.00
|
| Rate for Payer: NAPHCARE Commercial |
$90.00
|
| Rate for Payer: Preferred Network Access Commercial |
$138.00
|
| Rate for Payer: Quartz Beloit One Network |
$73.50
|
| Rate for Payer: Quartz Commercial |
$90.00
|
| Rate for Payer: WEA Trust Commercial |
$82.50
|
| Rate for Payer: WPS Commercial |
$111.10
|
|
|
Histoplasma Antibody
|
Facility
|
OP
|
$150.00
|
|
|
Service Code
|
CPT 86698
|
| Hospital Charge Code |
977978
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.79 |
| Max. Negotiated Rate |
$138.00 |
| Rate for Payer: Anthem Medicare Advantage |
$13.79
|
| Rate for Payer: Aetna Commercial |
$135.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$129.00
|
| Rate for Payer: Aetna Managed Medicare |
$13.79
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$51.71
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$24.13
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$22.89
|
| Rate for Payer: Anthem Medicaid |
$14.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$79.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$13.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$13.79
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cigna Commercial |
$138.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$13.79
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$14.25
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$83.94
|
| Rate for Payer: Dean Health Medicaid |
$14.25
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$13.79
|
| Rate for Payer: Health EOS Commercial |
$133.50
|
| Rate for Payer: HFN Commercial |
$138.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$51.30
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$13.79
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$14.25
|
| Rate for Payer: Independent Care Health Plan Medicare |
$13.79
|
| Rate for Payer: Managed Health Services Medicaid |
$14.82
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$13.79
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$13.79
|
| Rate for Payer: Multiplan Commercial |
$120.00
|
| Rate for Payer: NAPHCARE Commercial |
$20.68
|
| Rate for Payer: Preferred Network Access Commercial |
$138.00
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$14.25
|
| Rate for Payer: Quartz Beloit One Network |
$73.50
|
| Rate for Payer: Quartz Commercial |
$97.50
|
| Rate for Payer: Quartz Medicare Advantage |
$13.79
|
| Rate for Payer: The Alliance Commercial |
$55.16
|
| Rate for Payer: United Healthcare Medicaid |
$14.25
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.79
|
| Rate for Payer: United Healthcare PPO |
$112.50
|
| Rate for Payer: WEA Trust Commercial |
$82.50
|
| Rate for Payer: Wellcare Medicare |
$13.79
|
| Rate for Payer: WMAP Medicaid |
$14.25
|
| Rate for Payer: WPS Commercial |
$111.10
|
|
|
Histoplasma Antibody
|
Professional
|
Both
|
$150.00
|
|
|
Service Code
|
CPT 86698
|
| Hospital Charge Code |
977978
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$48.68 |
| Max. Negotiated Rate |
$142.50 |
| Rate for Payer: Aetna Commercial |
$142.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$129.00
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cigna Commercial |
$142.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$75.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$90.00
|
| Rate for Payer: Health EOS Commercial |
$136.50
|
| Rate for Payer: HFN Commercial |
$142.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$48.68
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$48.68
|
| Rate for Payer: Multiplan Commercial |
$120.00
|
| Rate for Payer: Preferred Network Access Commercial |
$142.50
|
| Rate for Payer: Quartz Beloit One Network |
$66.00
|
| Rate for Payer: Quartz Commercial |
$85.50
|
| Rate for Payer: The Alliance Commercial |
$75.00
|
| Rate for Payer: WEA Trust Commercial |
$82.50
|
| Rate for Payer: WPS Commercial |
$111.10
|
|
|
Histoplasma Antibody
|
Professional
|
Both
|
$57.00
|
|
|
Service Code
|
CPT 86698
|
| Hospital Charge Code |
5598647
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$25.08 |
| Max. Negotiated Rate |
$54.15 |
| Rate for Payer: Aetna Commercial |
$54.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$49.02
|
| Rate for Payer: Cash Price |
$17.10
|
| Rate for Payer: Cash Price |
$17.10
|
| Rate for Payer: Cigna Commercial |
$54.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$28.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$34.20
|
| Rate for Payer: Health EOS Commercial |
$51.87
|
| Rate for Payer: HFN Commercial |
$54.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$48.68
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$48.68
|
| Rate for Payer: Multiplan Commercial |
$45.60
|
| Rate for Payer: Preferred Network Access Commercial |
$54.15
|
| Rate for Payer: Quartz Beloit One Network |
$25.08
|
| Rate for Payer: Quartz Commercial |
$32.49
|
| Rate for Payer: The Alliance Commercial |
$28.50
|
| Rate for Payer: WEA Trust Commercial |
$31.35
|
| Rate for Payer: WPS Commercial |
$42.22
|
|
|
Histoplasma Antibody ID
|
Facility
|
IP
|
$49.00
|
|
|
Service Code
|
CPT 86698
|
| Hospital Charge Code |
4392614
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$24.01 |
| Max. Negotiated Rate |
$45.08 |
| Rate for Payer: Aetna Commercial |
$44.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$42.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$25.97
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cigna Commercial |
$45.08
|
| Rate for Payer: Health EOS Commercial |
$43.61
|
| Rate for Payer: HFN Commercial |
$45.08
|
| Rate for Payer: Multiplan Commercial |
$39.20
|
| Rate for Payer: NAPHCARE Commercial |
$29.40
|
| Rate for Payer: Preferred Network Access Commercial |
$45.08
|
| Rate for Payer: Quartz Beloit One Network |
$24.01
|
| Rate for Payer: Quartz Commercial |
$29.40
|
| Rate for Payer: WEA Trust Commercial |
$26.95
|
| Rate for Payer: WPS Commercial |
$36.29
|
|
