|
Kenalog JW Waste Charge
|
Facility
|
OP
|
$76.00
|
|
|
Service Code
|
HCPCS J3301 JW
|
| Hospital Charge Code |
5246655
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$304.00 |
| Rate for Payer: Aetna Commercial |
$68.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$65.36
|
| Rate for Payer: Aetna Managed Medicare |
$21.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$49.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$38.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$36.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$40.28
|
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cigna Commercial |
$69.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.43
|
| Rate for Payer: Health EOS Commercial |
$67.64
|
| Rate for Payer: HFN Commercial |
$69.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$57.00
|
| 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 |
$49.40
|
| Rate for Payer: Quartz Medicare Advantage |
$45.60
|
| Rate for Payer: The Alliance Commercial |
$304.00
|
| Rate for Payer: WEA Trust Commercial |
$41.80
|
| Rate for Payer: WPS Commercial |
$2.71
|
|
|
Kenalog JW Waste Charge
|
Professional
|
Both
|
$76.00
|
|
|
Service Code
|
HCPCS J3301 JW
|
| Hospital Charge Code |
5246655
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.08 |
| 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 |
$1.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.08
|
| Rate for Payer: Health EOS Commercial |
$69.16
|
| Rate for Payer: HFN Commercial |
$72.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1.88
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1.88
|
| 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: United Healthcare Medicaid |
$1.08
|
| Rate for Payer: WEA Trust Commercial |
$41.80
|
| Rate for Payer: WPS Commercial |
$2.71
|
|
|
Ketorolac tromethamine inj 15 mg J1885 man
|
Professional
|
Both
|
$7.00
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
3373575
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$6.65 |
| Rate for Payer: Aetna Commercial |
$6.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.02
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$0.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.70
|
| Rate for Payer: Health EOS Commercial |
$6.37
|
| Rate for Payer: HFN Commercial |
$6.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$0.95
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$0.95
|
| Rate for Payer: Multiplan Commercial |
$5.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6.65
|
| Rate for Payer: Quartz Beloit One Network |
$3.08
|
| Rate for Payer: Quartz Commercial |
$3.99
|
| Rate for Payer: The Alliance Commercial |
$3.50
|
| Rate for Payer: United Healthcare Medicaid |
$0.49
|
| Rate for Payer: WEA Trust Commercial |
$3.85
|
| Rate for Payer: WPS Commercial |
$1.76
|
|
|
Ketorolac tromethamine inj 15 mg J1885 man
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
3373575
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$28.00 |
| Rate for Payer: Aetna Commercial |
$6.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.02
|
| Rate for Payer: Aetna Managed Medicare |
$1.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.71
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.93
|
| Rate for Payer: Health EOS Commercial |
$6.23
|
| Rate for Payer: HFN Commercial |
$6.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5.25
|
| Rate for Payer: Multiplan Commercial |
$5.60
|
| Rate for Payer: NAPHCARE Commercial |
$4.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6.44
|
| Rate for Payer: Quartz Beloit One Network |
$3.43
|
| Rate for Payer: Quartz Commercial |
$4.55
|
| Rate for Payer: Quartz Medicare Advantage |
$4.20
|
| Rate for Payer: The Alliance Commercial |
$28.00
|
| Rate for Payer: WEA Trust Commercial |
$3.85
|
| Rate for Payer: WPS Commercial |
$1.76
|
|
|
Ketorolac tromethamine inj 15 mg J1885 man
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
3373575
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.43 |
| Max. Negotiated Rate |
$6.44 |
| Rate for Payer: Aetna Commercial |
$6.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.71
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.44
|
| Rate for Payer: Health EOS Commercial |
$6.23
|
| Rate for Payer: HFN Commercial |
$6.44
|
| Rate for Payer: Multiplan Commercial |
$5.60
|
| Rate for Payer: NAPHCARE Commercial |
$4.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6.44
|
| Rate for Payer: Quartz Beloit One Network |
$3.43
|
| Rate for Payer: Quartz Commercial |
$4.20
|
| Rate for Payer: WEA Trust Commercial |
$3.85
|
| Rate for Payer: WPS Commercial |
$5.18
|
|
|
Ketorolac Tromethamine Ophth Solution [Med]
|
Facility
|
OP
|
$26.00
|
|
| Hospital Charge Code |
2974952
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.28 |
| Max. Negotiated Rate |
$104.00 |
| Rate for Payer: Aetna Commercial |
$23.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$22.36
|
| Rate for Payer: Aetna Managed Medicare |
$7.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$16.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$13.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$12.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13.78
|
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Cigna Commercial |
$23.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$14.55
|
| Rate for Payer: Health EOS Commercial |
$23.14
|
| Rate for Payer: HFN Commercial |
$23.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$19.50
|
| Rate for Payer: Multiplan Commercial |
$20.80
|
| Rate for Payer: NAPHCARE Commercial |
$15.60
|
| Rate for Payer: Preferred Network Access Commercial |
$23.92
|
| Rate for Payer: Quartz Beloit One Network |
$12.74
|
| Rate for Payer: Quartz Commercial |
$16.90
|
| Rate for Payer: Quartz Medicare Advantage |
$15.60
|
| Rate for Payer: The Alliance Commercial |
$104.00
|
| Rate for Payer: WEA Trust Commercial |
$14.30
|
| Rate for Payer: WPS Commercial |
$19.26
|
|
|
Ketorolac Tromethamine Ophth Solution [Med]
|
Facility
|
IP
|
$26.00
|
|
| Hospital Charge Code |
2974952
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.74 |
| Max. Negotiated Rate |
$23.92 |
| Rate for Payer: Aetna Commercial |
$23.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$22.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13.78
|
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Cigna Commercial |
$23.92
|
| Rate for Payer: Health EOS Commercial |
$23.14
|
| Rate for Payer: HFN Commercial |
$23.92
|
| Rate for Payer: Multiplan Commercial |
$20.80
|
| Rate for Payer: NAPHCARE Commercial |
$15.60
|
| Rate for Payer: Preferred Network Access Commercial |
$23.92
|
| Rate for Payer: Quartz Beloit One Network |
$12.74
|
| Rate for Payer: Quartz Commercial |
$15.60
|
| Rate for Payer: WEA Trust Commercial |
$14.30
|
| Rate for Payer: WPS Commercial |
$19.26
|
|
|
KEY TRANSONIC KEY314-5
|
Facility
|
OP
|
$2,616.00
|
|
| Hospital Charge Code |
4048790
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$732.48 |
| Max. Negotiated Rate |
$10,464.00 |
| Rate for Payer: Aetna Commercial |
$2,354.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,249.76
|
| Rate for Payer: Aetna Managed Medicare |
$732.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,700.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,308.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,255.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,386.48
|
| Rate for Payer: Cash Price |
$784.80
|
| Rate for Payer: Cigna Commercial |
$2,406.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,463.91
|
| Rate for Payer: Health EOS Commercial |
$2,328.24
|
| Rate for Payer: HFN Commercial |
$2,406.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,962.00
|
| Rate for Payer: Multiplan Commercial |
$2,092.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,569.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,406.72
|
| Rate for Payer: Quartz Beloit One Network |
$1,281.84
|
| Rate for Payer: Quartz Commercial |
$1,700.40
|
| Rate for Payer: Quartz Medicare Advantage |
$1,569.60
|
| Rate for Payer: The Alliance Commercial |
$10,464.00
|
| Rate for Payer: WEA Trust Commercial |
$1,438.80
|
| Rate for Payer: WPS Commercial |
$1,937.67
|
|
|
KEY TRANSONIC KEY314-5
|
Facility
|
IP
|
$2,616.00
|
|
| Hospital Charge Code |
4048790
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,281.84 |
| Max. Negotiated Rate |
$2,406.72 |
| Rate for Payer: Aetna Commercial |
$2,354.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,249.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,386.48
|
| Rate for Payer: Cash Price |
$784.80
|
| Rate for Payer: Cigna Commercial |
$2,406.72
|
| Rate for Payer: Health EOS Commercial |
$2,328.24
|
| Rate for Payer: HFN Commercial |
$2,406.72
|
| Rate for Payer: Multiplan Commercial |
$2,092.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,569.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,406.72
|
| Rate for Payer: Quartz Beloit One Network |
$1,281.84
|
| Rate for Payer: Quartz Commercial |
$1,569.60
|
| Rate for Payer: WEA Trust Commercial |
$1,438.80
|
| Rate for Payer: WPS Commercial |
$1,937.67
|
|
|
KIDNER PROCEDURE
|
Facility
|
IP
|
$1,632.00
|
|
| Hospital Charge Code |
2960164
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$799.68 |
| Max. Negotiated Rate |
$1,501.44 |
| Rate for Payer: Aetna Commercial |
$1,468.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,403.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$864.96
|
| Rate for Payer: Cash Price |
$489.60
|
| Rate for Payer: Cigna Commercial |
$1,501.44
|
| Rate for Payer: Health EOS Commercial |
$1,452.48
|
| Rate for Payer: HFN Commercial |
$1,501.44
|
| Rate for Payer: Multiplan Commercial |
$1,305.60
|
| Rate for Payer: NAPHCARE Commercial |
$979.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,501.44
|
| Rate for Payer: Quartz Beloit One Network |
$799.68
|
| Rate for Payer: Quartz Commercial |
$979.20
|
| Rate for Payer: WEA Trust Commercial |
$897.60
|
| Rate for Payer: WPS Commercial |
$1,208.82
|
|
|
KIDNER PROCEDURE
|
Facility
|
OP
|
$1,632.00
|
|
| Hospital Charge Code |
2960164
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$456.96 |
| Max. Negotiated Rate |
$6,528.00 |
| Rate for Payer: Aetna Commercial |
$1,468.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,403.52
|
| Rate for Payer: Aetna Managed Medicare |
$456.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,060.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$816.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$783.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$864.96
|
| Rate for Payer: Cash Price |
$489.60
|
| Rate for Payer: Cigna Commercial |
$1,501.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$913.27
|
| Rate for Payer: Health EOS Commercial |
$1,452.48
|
| Rate for Payer: HFN Commercial |
$1,501.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,224.00
|
| Rate for Payer: Multiplan Commercial |
$1,305.60
|
| Rate for Payer: NAPHCARE Commercial |
$979.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,501.44
|
| Rate for Payer: Quartz Beloit One Network |
$799.68
|
| Rate for Payer: Quartz Commercial |
$1,060.80
|
| Rate for Payer: Quartz Medicare Advantage |
$979.20
|
| Rate for Payer: The Alliance Commercial |
$6,528.00
|
| Rate for Payer: WEA Trust Commercial |
$897.60
|
| Rate for Payer: WPS Commercial |
$1,208.82
|
|
|
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC
|
Facility
|
IP
|
$49,350.00
|
|
|
Service Code
|
MSDRG 657
|
| Min. Negotiated Rate |
$17,751.88 |
| Max. Negotiated Rate |
$49,350.00 |
| Rate for Payer: Aetna Managed Medicare |
$17,751.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$38,603.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$29,589.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$28,111.52
|
| Rate for Payer: Anthem Medicare Advantage |
$17,751.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17,751.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17,751.88
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$17,751.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$31,206.36
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$17,751.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$35,961.90
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17,751.88
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17,751.88
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$17,751.88
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$17,751.88
|
| Rate for Payer: NAPHCARE Commercial |
$26,627.82
|
| Rate for Payer: Quartz Medicare Advantage |
$17,751.88
|
| Rate for Payer: The Alliance Commercial |
$49,350.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17,751.88
|
| Rate for Payer: United Healthcare PPO |
$27,996.80
|
| Rate for Payer: Wellcare Medicare |
$17,751.88
|
|
|
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC
|
Facility
|
IP
|
$83,737.00
|
|
|
Service Code
|
MSDRG 656
|
| Min. Negotiated Rate |
$30,121.07 |
| Max. Negotiated Rate |
$83,737.00 |
| Rate for Payer: Aetna Managed Medicare |
$30,121.07
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$65,877.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$50,494.34
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$47,972.92
|
| Rate for Payer: Anthem Medicare Advantage |
$30,121.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$30,121.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$30,121.07
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$30,121.07
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$53,254.34
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$30,121.07
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$61,183.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$30,121.07
|
| Rate for Payer: Independent Care Health Plan Medicare |
$30,121.07
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$30,121.07
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$30,121.07
|
| Rate for Payer: NAPHCARE Commercial |
$45,181.60
|
| Rate for Payer: Quartz Medicare Advantage |
$30,121.07
|
| Rate for Payer: The Alliance Commercial |
$83,737.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$30,121.07
|
| Rate for Payer: United Healthcare PPO |
$47,631.91
|
| Rate for Payer: Wellcare Medicare |
$30,121.07
|
|
|
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC
|
Facility
|
IP
|
$39,678.00
|
|
|
Service Code
|
MSDRG 658
|
| Min. Negotiated Rate |
$14,272.77 |
| Max. Negotiated Rate |
$39,678.00 |
| Rate for Payer: Aetna Managed Medicare |
$14,272.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$31,050.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$23,799.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$22,611.44
|
| Rate for Payer: Anthem Medicare Advantage |
$14,272.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$14,272.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$14,272.77
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$14,272.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$25,100.77
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$14,272.77
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$28,867.80
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$14,272.77
|
| Rate for Payer: Independent Care Health Plan Medicare |
$14,272.77
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$14,272.77
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$14,272.77
|
| Rate for Payer: NAPHCARE Commercial |
$21,409.16
|
| Rate for Payer: Quartz Medicare Advantage |
$14,272.77
|
| Rate for Payer: The Alliance Commercial |
$39,678.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14,272.77
|
| Rate for Payer: United Healthcare PPO |
$22,473.95
|
| Rate for Payer: Wellcare Medicare |
$14,272.77
|
|
|
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC
|
Facility
|
IP
|
$36,102.00
|
|
|
Service Code
|
MSDRG 660
|
| Min. Negotiated Rate |
$12,986.50 |
| Max. Negotiated Rate |
$36,102.00 |
| Rate for Payer: Aetna Managed Medicare |
$12,986.50
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$28,323.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21,709.35
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$20,625.30
|
| Rate for Payer: Anthem Medicare Advantage |
$12,986.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12,986.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12,986.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12,986.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$22,895.97
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12,986.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$26,245.05
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12,986.50
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12,986.50
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12,986.50
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12,986.50
|
| Rate for Payer: NAPHCARE Commercial |
$19,479.75
|
| Rate for Payer: Quartz Medicare Advantage |
$12,986.50
|
| Rate for Payer: The Alliance Commercial |
$36,102.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12,986.50
|
| Rate for Payer: United Healthcare PPO |
$20,432.11
|
| Rate for Payer: Wellcare Medicare |
$12,986.50
|
|
|
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC
|
Facility
|
IP
|
$69,149.00
|
|
|
Service Code
|
MSDRG 659
|
| Min. Negotiated Rate |
$24,873.67 |
| Max. Negotiated Rate |
$69,149.00 |
| Rate for Payer: Aetna Managed Medicare |
$24,873.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$54,338.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$41,649.79
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$39,570.02
|
| Rate for Payer: Anthem Medicare Advantage |
$24,873.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$24,873.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$24,873.67
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$24,873.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$43,926.35
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$24,873.67
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$50,483.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$24,873.67
|
| Rate for Payer: Independent Care Health Plan Medicare |
$24,873.67
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$24,873.67
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$24,873.67
|
| Rate for Payer: NAPHCARE Commercial |
$37,310.50
|
| Rate for Payer: Quartz Medicare Advantage |
$24,873.67
|
| Rate for Payer: The Alliance Commercial |
$69,149.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$24,873.67
|
| Rate for Payer: United Healthcare PPO |
$39,302.09
|
| Rate for Payer: Wellcare Medicare |
$24,873.67
|
|
|
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC
|
Facility
|
IP
|
$28,193.00
|
|
|
Service Code
|
MSDRG 661
|
| Min. Negotiated Rate |
$10,141.41 |
| Max. Negotiated Rate |
$28,193.00 |
| Rate for Payer: Aetna Managed Medicare |
$10,141.41
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$22,029.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$16,885.05
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$16,041.90
|
| Rate for Payer: Anthem Medicare Advantage |
$10,141.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$10,141.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$10,141.41
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$10,141.41
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17,807.98
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$10,141.41
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$20,443.80
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$10,141.41
|
| Rate for Payer: Independent Care Health Plan Medicare |
$10,141.41
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$10,141.41
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$10,141.41
|
| Rate for Payer: NAPHCARE Commercial |
$15,212.12
|
| Rate for Payer: Quartz Medicare Advantage |
$10,141.41
|
| Rate for Payer: The Alliance Commercial |
$28,193.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$10,141.41
|
| Rate for Payer: United Healthcare PPO |
$15,915.76
|
| Rate for Payer: Wellcare Medicare |
$10,141.41
|
|
|
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC
|
Facility
|
IP
|
$31,543.00
|
|
|
Service Code
|
MSDRG 689
|
| Min. Negotiated Rate |
$11,346.40 |
| Max. Negotiated Rate |
$31,543.00 |
| Rate for Payer: Aetna Managed Medicare |
$11,346.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$24,546.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$18,814.77
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$17,875.26
|
| Rate for Payer: Anthem Medicare Advantage |
$11,346.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$11,346.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$11,346.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$11,346.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19,843.18
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$11,346.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$22,900.80
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$11,346.40
|
| Rate for Payer: Independent Care Health Plan Medicare |
$11,346.40
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$11,346.40
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$11,346.40
|
| Rate for Payer: NAPHCARE Commercial |
$17,019.60
|
| Rate for Payer: Quartz Medicare Advantage |
$11,346.40
|
| Rate for Payer: The Alliance Commercial |
$31,543.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11,346.40
|
| Rate for Payer: United Healthcare PPO |
$17,828.57
|
| Rate for Payer: Wellcare Medicare |
$11,346.40
|
|
|
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC
|
Facility
|
IP
|
$21,773.00
|
|
|
Service Code
|
MSDRG 690
|
| Min. Negotiated Rate |
$7,831.89 |
| Max. Negotiated Rate |
$21,773.00 |
| Rate for Payer: Aetna Managed Medicare |
$7,831.89
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$16,993.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$13,025.61
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$12,375.18
|
| Rate for Payer: Anthem Medicare Advantage |
$7,831.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7,831.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7,831.89
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$7,831.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13,737.58
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$7,831.89
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,734.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$7,831.89
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7,831.89
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$7,831.89
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$7,831.89
|
| Rate for Payer: NAPHCARE Commercial |
$11,747.84
|
| Rate for Payer: Quartz Medicare Advantage |
$7,831.89
|
| Rate for Payer: The Alliance Commercial |
$21,773.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7,831.89
|
| Rate for Payer: United Healthcare PPO |
$12,249.55
|
| Rate for Payer: Wellcare Medicare |
$7,831.89
|
|
|
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC
|
Facility
|
IP
|
$28,111.00
|
|
|
Service Code
|
MSDRG 687
|
| Min. Negotiated Rate |
$10,111.78 |
| Max. Negotiated Rate |
$28,111.00 |
| Rate for Payer: Aetna Managed Medicare |
$10,111.78
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$22,029.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$16,885.05
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$16,041.90
|
| Rate for Payer: Anthem Medicare Advantage |
$10,111.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$10,111.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$10,111.78
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$10,111.78
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17,807.98
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$10,111.78
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$20,383.35
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$10,111.78
|
| Rate for Payer: Independent Care Health Plan Medicare |
$10,111.78
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$10,111.78
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$10,111.78
|
| Rate for Payer: NAPHCARE Commercial |
$15,167.67
|
| Rate for Payer: Quartz Medicare Advantage |
$10,111.78
|
| Rate for Payer: The Alliance Commercial |
$28,111.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$10,111.78
|
| Rate for Payer: United Healthcare PPO |
$15,868.70
|
| Rate for Payer: Wellcare Medicare |
$10,111.78
|
|
|
KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC
|
Facility
|
IP
|
$49,223.00
|
|
|
Service Code
|
MSDRG 686
|
| Min. Negotiated Rate |
$17,705.98 |
| Max. Negotiated Rate |
$49,223.00 |
| Rate for Payer: Aetna Managed Medicare |
$17,705.98
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$38,603.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$29,589.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$28,111.52
|
| Rate for Payer: Anthem Medicare Advantage |
$17,705.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17,705.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17,705.98
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$17,705.98
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$31,206.36
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$17,705.98
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$35,868.30
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17,705.98
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17,705.98
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$17,705.98
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$17,705.98
|
| Rate for Payer: NAPHCARE Commercial |
$26,558.97
|
| Rate for Payer: Quartz Medicare Advantage |
$17,705.98
|
| Rate for Payer: The Alliance Commercial |
$49,223.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17,705.98
|
| Rate for Payer: United Healthcare PPO |
$27,923.93
|
| Rate for Payer: Wellcare Medicare |
$17,705.98
|
|
|
KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC
|
Facility
|
IP
|
$21,081.00
|
|
|
Service Code
|
MSDRG 688
|
| Min. Negotiated Rate |
$7,583.25 |
| Max. Negotiated Rate |
$21,081.00 |
| Rate for Payer: Aetna Managed Medicare |
$7,583.25
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$16,364.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$12,543.18
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$11,916.84
|
| Rate for Payer: Anthem Medicare Advantage |
$7,583.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7,583.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7,583.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$7,583.25
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13,228.78
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$7,583.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,227.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$7,583.25
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7,583.25
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$7,583.25
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$7,583.25
|
| Rate for Payer: NAPHCARE Commercial |
$11,374.88
|
| Rate for Payer: Quartz Medicare Advantage |
$7,583.25
|
| Rate for Payer: The Alliance Commercial |
$21,081.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7,583.25
|
| Rate for Payer: United Healthcare PPO |
$11,854.84
|
| Rate for Payer: Wellcare Medicare |
$7,583.25
|
|
|
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC
|
Facility
|
IP
|
$32,117.00
|
|
|
Service Code
|
MSDRG 695
|
| Min. Negotiated Rate |
$11,552.97 |
| Max. Negotiated Rate |
$32,117.00 |
| Rate for Payer: Wellcare Medicare |
$11,552.97
|
| Rate for Payer: Aetna Managed Medicare |
$11,552.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$25,176.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$19,297.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$18,333.60
|
| Rate for Payer: Anthem Medicare Advantage |
$11,552.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$11,552.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$11,552.97
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$11,552.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$20,351.98
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$11,552.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$23,322.00
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$11,552.97
|
| Rate for Payer: Independent Care Health Plan Medicare |
$11,552.97
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$11,552.97
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$11,552.97
|
| Rate for Payer: NAPHCARE Commercial |
$17,329.46
|
| Rate for Payer: Quartz Medicare Advantage |
$11,552.97
|
| Rate for Payer: The Alliance Commercial |
$32,117.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11,552.97
|
| Rate for Payer: United Healthcare PPO |
$18,156.48
|
|
|
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC
|
Facility
|
IP
|
$18,721.00
|
|
|
Service Code
|
MSDRG 696
|
| Min. Negotiated Rate |
$6,734.01 |
| Max. Negotiated Rate |
$18,721.00 |
| Rate for Payer: Aetna Managed Medicare |
$6,734.01
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14,476.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11,095.89
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,541.82
|
| Rate for Payer: Anthem Medicare Advantage |
$6,734.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$6,734.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$6,734.01
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$6,734.01
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,702.39
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$6,734.01
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,495.95
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$6,734.01
|
| Rate for Payer: Independent Care Health Plan Medicare |
$6,734.01
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$6,734.01
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$6,734.01
|
| Rate for Payer: NAPHCARE Commercial |
$10,101.02
|
| Rate for Payer: Quartz Medicare Advantage |
$6,734.01
|
| Rate for Payer: The Alliance Commercial |
$18,721.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6,734.01
|
| Rate for Payer: United Healthcare PPO |
$10,506.77
|
| Rate for Payer: Wellcare Medicare |
$6,734.01
|
|
|
KIDNEY ENDOSCOPY AND BIOPSY 50555
|
Professional
|
Both
|
$2,214.00
|
|
|
Service Code
|
CPT 50555
|
| Hospital Charge Code |
3014940
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$219.82 |
| Max. Negotiated Rate |
$2,103.30 |
| Rate for Payer: Aetna Commercial |
$2,103.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,904.04
|
| Rate for Payer: Cash Price |
$664.20
|
| Rate for Payer: Cash Price |
$664.20
|
| Rate for Payer: Cash Price |
$664.20
|
| Rate for Payer: Cigna Commercial |
$2,103.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$219.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,328.40
|
| Rate for Payer: Health EOS Commercial |
$2,014.74
|
| Rate for Payer: HFN Commercial |
$2,103.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,131.75
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,131.75
|
| Rate for Payer: Multiplan Commercial |
$1,771.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,103.30
|
| Rate for Payer: Quartz Beloit One Network |
$974.16
|
| Rate for Payer: Quartz Commercial |
$1,261.98
|
| Rate for Payer: The Alliance Commercial |
$1,107.00
|
| Rate for Payer: United Healthcare Medicaid |
$219.82
|
| Rate for Payer: WEA Trust Commercial |
$1,217.70
|
| Rate for Payer: WPS Commercial |
$1,639.91
|
|
