|
ALLODERM DERMAL RL1518P
|
Facility
|
OP
|
$57,592.50
|
|
| Hospital Charge Code |
2650911
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$31,186.34 |
| Max. Negotiated Rate |
$57,592.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$56,440.65
|
| Rate for Payer: Aetna of WY Medicare |
$38,011.05
|
| Rate for Payer: Altius Commercial |
$55,288.80
|
| Rate for Payer: Beech Street Commercial |
$56,440.65
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$55,864.72
|
| Rate for Payer: Cash Price |
$40,314.75
|
| Rate for Payer: ChoiceCare Network Commercial |
$55,864.72
|
| Rate for Payer: Cigna of WY Commercial |
$56,440.65
|
| Rate for Payer: Entrust Commercial |
$54,712.88
|
| Rate for Payer: First Choice Health Commercial |
$54,712.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$54,712.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$32,827.72
|
| Rate for Payer: HealthUtah PPO |
$57,592.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$55,864.72
|
| Rate for Payer: Multiplan Medicare/VA |
$31,186.34
|
| Rate for Payer: One Health Plan of WY PPO |
$56,440.65
|
| Rate for Payer: PacificSource Commercial |
$51,833.25
|
| Rate for Payer: PHCS PPO |
$56,440.65
|
| Rate for Payer: Three Rivers PPO |
$43,194.38
|
| Rate for Payer: TriWest Veterans Administration |
$32,827.72
|
| Rate for Payer: United Healthcare Commercial |
$55,000.84
|
| Rate for Payer: United Healthcare Medicare |
$32,827.72
|
| Rate for Payer: WINHealth Partners Commercial |
$56,440.65
|
| Rate for Payer: Wise Provider Network Commercial |
$54,712.88
|
|
|
ALLODERM DERMAL RXL1518P
|
Facility
|
IP
|
$70,451.50
|
|
| Hospital Charge Code |
2650913
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$40,826.64 |
| Max. Negotiated Rate |
$70,451.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$69,042.47
|
| Rate for Payer: Aetna of WY Medicare |
$45,088.96
|
| Rate for Payer: Altius Commercial |
$67,633.44
|
| Rate for Payer: Beech Street Commercial |
$69,042.47
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$68,337.96
|
| Rate for Payer: Cash Price |
$49,316.05
|
| Rate for Payer: ChoiceCare Network Commercial |
$68,337.96
|
| Rate for Payer: Cigna of WY Commercial |
$69,042.47
|
| Rate for Payer: Entrust Commercial |
$66,928.92
|
| Rate for Payer: First Choice Health Commercial |
$66,928.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$66,928.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$42,975.42
|
| Rate for Payer: HealthUtah PPO |
$70,451.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$68,337.96
|
| Rate for Payer: Multiplan Medicare/VA |
$40,826.64
|
| Rate for Payer: One Health Plan of WY PPO |
$69,042.47
|
| Rate for Payer: PacificSource Commercial |
$63,406.35
|
| Rate for Payer: PHCS PPO |
$69,042.47
|
| Rate for Payer: Three Rivers PPO |
$52,838.62
|
| Rate for Payer: TriWest Veterans Administration |
$42,975.42
|
| Rate for Payer: United Healthcare Commercial |
$67,281.18
|
| Rate for Payer: United Healthcare Medicare |
$42,975.42
|
| Rate for Payer: WINHealth Partners Commercial |
$66,928.92
|
| Rate for Payer: Wise Provider Network Commercial |
$66,928.92
|
|
|
ALLODERM DERMAL RXL1518P
|
Facility
|
OP
|
$70,451.50
|
|
| Hospital Charge Code |
2650913
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$38,149.49 |
| Max. Negotiated Rate |
$70,451.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$69,042.47
|
| Rate for Payer: Aetna of WY Medicare |
$46,497.99
|
| Rate for Payer: Altius Commercial |
$67,633.44
|
| Rate for Payer: Beech Street Commercial |
$69,042.47
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$68,337.96
|
| Rate for Payer: Cash Price |
$49,316.05
|
| Rate for Payer: ChoiceCare Network Commercial |
$68,337.96
|
| Rate for Payer: Cigna of WY Commercial |
$69,042.47
|
| Rate for Payer: Entrust Commercial |
$66,928.92
|
| Rate for Payer: First Choice Health Commercial |
$66,928.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$66,928.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$40,157.36
|
| Rate for Payer: HealthUtah PPO |
$70,451.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$68,337.96
|
| Rate for Payer: Multiplan Medicare/VA |
$38,149.49
|
| Rate for Payer: One Health Plan of WY PPO |
$69,042.47
|
| Rate for Payer: PacificSource Commercial |
$63,406.35
|
| Rate for Payer: PHCS PPO |
$69,042.47
|
| Rate for Payer: Three Rivers PPO |
$52,838.62
|
| Rate for Payer: TriWest Veterans Administration |
$40,157.36
|
| Rate for Payer: United Healthcare Commercial |
$67,281.18
|
| Rate for Payer: United Healthcare Medicare |
$40,157.36
|
| Rate for Payer: WINHealth Partners Commercial |
$69,042.47
|
| Rate for Payer: Wise Provider Network Commercial |
$66,928.92
|
|
|
ALLOGRAFT BONE LG FROM MTF
|
Facility
|
IP
|
$12,757.50
|
|
| Hospital Charge Code |
3002383
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,392.97 |
| Max. Negotiated Rate |
$12,757.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$12,502.35
|
| Rate for Payer: Aetna of WY Medicare |
$8,164.80
|
| Rate for Payer: Altius Commercial |
$12,247.20
|
| Rate for Payer: Beech Street Commercial |
$12,502.35
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12,374.78
|
| Rate for Payer: Cash Price |
$8,930.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$12,374.78
|
| Rate for Payer: Cigna of WY Commercial |
$12,502.35
|
| Rate for Payer: Entrust Commercial |
$12,119.62
|
| Rate for Payer: First Choice Health Commercial |
$12,119.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$12,119.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$7,782.08
|
| Rate for Payer: HealthUtah PPO |
$12,757.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$12,374.78
|
| Rate for Payer: Multiplan Medicare/VA |
$7,392.97
|
| Rate for Payer: One Health Plan of WY PPO |
$12,502.35
|
| Rate for Payer: PacificSource Commercial |
$11,481.75
|
| Rate for Payer: PHCS PPO |
$12,502.35
|
| Rate for Payer: Three Rivers PPO |
$9,568.12
|
| Rate for Payer: TriWest Veterans Administration |
$7,782.08
|
| Rate for Payer: United Healthcare Commercial |
$12,183.41
|
| Rate for Payer: United Healthcare Medicare |
$7,782.08
|
| Rate for Payer: WINHealth Partners Commercial |
$12,119.62
|
| Rate for Payer: Wise Provider Network Commercial |
$12,119.62
|
|
|
ALLOGRAFT BONE LG FROM MTF
|
Facility
|
OP
|
$12,757.50
|
|
| Hospital Charge Code |
3002383
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,908.19 |
| Max. Negotiated Rate |
$12,757.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$12,502.35
|
| Rate for Payer: Aetna of WY Medicare |
$8,419.95
|
| Rate for Payer: Altius Commercial |
$12,247.20
|
| Rate for Payer: Beech Street Commercial |
$12,502.35
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12,374.78
|
| Rate for Payer: Cash Price |
$8,930.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$12,374.78
|
| Rate for Payer: Cigna of WY Commercial |
$12,502.35
|
| Rate for Payer: Entrust Commercial |
$12,119.62
|
| Rate for Payer: First Choice Health Commercial |
$12,119.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$12,119.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$7,271.78
|
| Rate for Payer: HealthUtah PPO |
$12,757.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$12,374.78
|
| Rate for Payer: Multiplan Medicare/VA |
$6,908.19
|
| Rate for Payer: One Health Plan of WY PPO |
$12,502.35
|
| Rate for Payer: PacificSource Commercial |
$11,481.75
|
| Rate for Payer: PHCS PPO |
$12,502.35
|
| Rate for Payer: Three Rivers PPO |
$9,568.12
|
| Rate for Payer: TriWest Veterans Administration |
$7,271.78
|
| Rate for Payer: United Healthcare Commercial |
$12,183.41
|
| Rate for Payer: United Healthcare Medicare |
$7,271.78
|
| Rate for Payer: WINHealth Partners Commercial |
$12,502.35
|
| Rate for Payer: Wise Provider Network Commercial |
$12,119.62
|
|
|
ALLOGRAFT BONE MED FROM MTF
|
Facility
|
OP
|
$7,070.00
|
|
| Hospital Charge Code |
3002566
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,828.40 |
| Max. Negotiated Rate |
$7,070.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$6,928.60
|
| Rate for Payer: Aetna of WY Medicare |
$4,666.20
|
| Rate for Payer: Altius Commercial |
$6,787.20
|
| Rate for Payer: Beech Street Commercial |
$6,928.60
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$6,857.90
|
| Rate for Payer: Cash Price |
$4,949.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$6,857.90
|
| Rate for Payer: Cigna of WY Commercial |
$6,928.60
|
| Rate for Payer: Entrust Commercial |
$6,716.50
|
| Rate for Payer: First Choice Health Commercial |
$6,716.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$6,716.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$4,029.90
|
| Rate for Payer: HealthUtah PPO |
$7,070.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$6,857.90
|
| Rate for Payer: Multiplan Medicare/VA |
$3,828.40
|
| Rate for Payer: One Health Plan of WY PPO |
$6,928.60
|
| Rate for Payer: PacificSource Commercial |
$6,363.00
|
| Rate for Payer: PHCS PPO |
$6,928.60
|
| Rate for Payer: Three Rivers PPO |
$5,302.50
|
| Rate for Payer: TriWest Veterans Administration |
$4,029.90
|
| Rate for Payer: United Healthcare Commercial |
$6,751.85
|
| Rate for Payer: United Healthcare Medicare |
$4,029.90
|
| Rate for Payer: WINHealth Partners Commercial |
$6,928.60
|
| Rate for Payer: Wise Provider Network Commercial |
$6,716.50
|
|
|
ALLOGRAFT BONE MED FROM MTF
|
Facility
|
IP
|
$7,070.00
|
|
| Hospital Charge Code |
3002566
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,097.06 |
| Max. Negotiated Rate |
$7,070.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$6,928.60
|
| Rate for Payer: Aetna of WY Medicare |
$4,524.80
|
| Rate for Payer: Altius Commercial |
$6,787.20
|
| Rate for Payer: Beech Street Commercial |
$6,928.60
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$6,857.90
|
| Rate for Payer: Cash Price |
$4,949.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$6,857.90
|
| Rate for Payer: Cigna of WY Commercial |
$6,928.60
|
| Rate for Payer: Entrust Commercial |
$6,716.50
|
| Rate for Payer: First Choice Health Commercial |
$6,716.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$6,716.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$4,312.70
|
| Rate for Payer: HealthUtah PPO |
$7,070.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$6,857.90
|
| Rate for Payer: Multiplan Medicare/VA |
$4,097.06
|
| Rate for Payer: One Health Plan of WY PPO |
$6,928.60
|
| Rate for Payer: PacificSource Commercial |
$6,363.00
|
| Rate for Payer: PHCS PPO |
$6,928.60
|
| Rate for Payer: Three Rivers PPO |
$5,302.50
|
| Rate for Payer: TriWest Veterans Administration |
$4,312.70
|
| Rate for Payer: United Healthcare Commercial |
$6,751.85
|
| Rate for Payer: United Healthcare Medicare |
$4,312.70
|
| Rate for Payer: WINHealth Partners Commercial |
$6,716.50
|
| Rate for Payer: Wise Provider Network Commercial |
$6,716.50
|
|
|
ALLOGRAFT BONE SM FROM MTF
|
Facility
|
IP
|
$1,592.50
|
|
| Hospital Charge Code |
3002565
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$922.85 |
| Max. Negotiated Rate |
$1,592.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,560.65
|
| Rate for Payer: Aetna of WY Medicare |
$1,019.20
|
| Rate for Payer: Altius Commercial |
$1,528.80
|
| Rate for Payer: Beech Street Commercial |
$1,560.65
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,544.72
|
| Rate for Payer: Cash Price |
$1,114.75
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,544.72
|
| Rate for Payer: Cigna of WY Commercial |
$1,560.65
|
| Rate for Payer: Entrust Commercial |
$1,512.88
|
| Rate for Payer: First Choice Health Commercial |
$1,512.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,512.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$971.42
|
| Rate for Payer: HealthUtah PPO |
$1,592.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,544.72
|
| Rate for Payer: Multiplan Medicare/VA |
$922.85
|
| Rate for Payer: One Health Plan of WY PPO |
$1,560.65
|
| Rate for Payer: PacificSource Commercial |
$1,433.25
|
| Rate for Payer: PHCS PPO |
$1,560.65
|
| Rate for Payer: Three Rivers PPO |
$1,194.38
|
| Rate for Payer: TriWest Veterans Administration |
$971.42
|
| Rate for Payer: United Healthcare Commercial |
$1,520.84
|
| Rate for Payer: United Healthcare Medicare |
$971.42
|
| Rate for Payer: WINHealth Partners Commercial |
$1,512.88
|
| Rate for Payer: Wise Provider Network Commercial |
$1,512.88
|
|
|
ALLOGRAFT BONE SM FROM MTF
|
Facility
|
OP
|
$1,592.50
|
|
| Hospital Charge Code |
3002565
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$862.34 |
| Max. Negotiated Rate |
$1,592.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,560.65
|
| Rate for Payer: Aetna of WY Medicare |
$1,051.05
|
| Rate for Payer: Altius Commercial |
$1,528.80
|
| Rate for Payer: Beech Street Commercial |
$1,560.65
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,544.72
|
| Rate for Payer: Cash Price |
$1,114.75
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,544.72
|
| Rate for Payer: Cigna of WY Commercial |
$1,560.65
|
| Rate for Payer: Entrust Commercial |
$1,512.88
|
| Rate for Payer: First Choice Health Commercial |
$1,512.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,512.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$907.72
|
| Rate for Payer: HealthUtah PPO |
$1,592.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,544.72
|
| Rate for Payer: Multiplan Medicare/VA |
$862.34
|
| Rate for Payer: One Health Plan of WY PPO |
$1,560.65
|
| Rate for Payer: PacificSource Commercial |
$1,433.25
|
| Rate for Payer: PHCS PPO |
$1,560.65
|
| Rate for Payer: Three Rivers PPO |
$1,194.38
|
| Rate for Payer: TriWest Veterans Administration |
$907.72
|
| Rate for Payer: United Healthcare Commercial |
$1,520.84
|
| Rate for Payer: United Healthcare Medicare |
$907.72
|
| Rate for Payer: WINHealth Partners Commercial |
$1,560.65
|
| Rate for Payer: Wise Provider Network Commercial |
$1,512.88
|
|
|
ALLOGRAFT BONE XL FROM MTF
|
Facility
|
OP
|
$24,594.50
|
|
| Hospital Charge Code |
3002567
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$13,317.92 |
| Max. Negotiated Rate |
$24,594.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$24,102.61
|
| Rate for Payer: Aetna of WY Medicare |
$16,232.37
|
| Rate for Payer: Altius Commercial |
$23,610.72
|
| Rate for Payer: Beech Street Commercial |
$24,102.61
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$23,856.66
|
| Rate for Payer: Cash Price |
$17,216.15
|
| Rate for Payer: ChoiceCare Network Commercial |
$23,856.66
|
| Rate for Payer: Cigna of WY Commercial |
$24,102.61
|
| Rate for Payer: Entrust Commercial |
$23,364.78
|
| Rate for Payer: First Choice Health Commercial |
$23,364.78
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$23,364.78
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$14,018.86
|
| Rate for Payer: HealthUtah PPO |
$24,594.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$23,856.66
|
| Rate for Payer: Multiplan Medicare/VA |
$13,317.92
|
| Rate for Payer: One Health Plan of WY PPO |
$24,102.61
|
| Rate for Payer: PacificSource Commercial |
$22,135.05
|
| Rate for Payer: PHCS PPO |
$24,102.61
|
| Rate for Payer: Three Rivers PPO |
$18,445.88
|
| Rate for Payer: TriWest Veterans Administration |
$14,018.86
|
| Rate for Payer: United Healthcare Commercial |
$23,487.75
|
| Rate for Payer: United Healthcare Medicare |
$14,018.86
|
| Rate for Payer: WINHealth Partners Commercial |
$24,102.61
|
| Rate for Payer: Wise Provider Network Commercial |
$23,364.78
|
|
|
ALLOGRAFT BONE XL FROM MTF
|
Facility
|
IP
|
$24,594.50
|
|
| Hospital Charge Code |
3002567
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$14,252.51 |
| Max. Negotiated Rate |
$24,594.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$24,102.61
|
| Rate for Payer: Aetna of WY Medicare |
$15,740.48
|
| Rate for Payer: Altius Commercial |
$23,610.72
|
| Rate for Payer: Beech Street Commercial |
$24,102.61
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$23,856.66
|
| Rate for Payer: Cash Price |
$17,216.15
|
| Rate for Payer: ChoiceCare Network Commercial |
$23,856.66
|
| Rate for Payer: Cigna of WY Commercial |
$24,102.61
|
| Rate for Payer: Entrust Commercial |
$23,364.78
|
| Rate for Payer: First Choice Health Commercial |
$23,364.78
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$23,364.78
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$15,002.64
|
| Rate for Payer: HealthUtah PPO |
$24,594.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$23,856.66
|
| Rate for Payer: Multiplan Medicare/VA |
$14,252.51
|
| Rate for Payer: One Health Plan of WY PPO |
$24,102.61
|
| Rate for Payer: PacificSource Commercial |
$22,135.05
|
| Rate for Payer: PHCS PPO |
$24,102.61
|
| Rate for Payer: Three Rivers PPO |
$18,445.88
|
| Rate for Payer: TriWest Veterans Administration |
$15,002.64
|
| Rate for Payer: United Healthcare Commercial |
$23,487.75
|
| Rate for Payer: United Healthcare Medicare |
$15,002.64
|
| Rate for Payer: WINHealth Partners Commercial |
$23,364.78
|
| Rate for Payer: Wise Provider Network Commercial |
$23,364.78
|
|
|
ALLOGRAFT DBM 10CC
|
Facility
|
IP
|
$16,432.50
|
|
| Hospital Charge Code |
2800254
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,522.63 |
| Max. Negotiated Rate |
$16,432.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16,103.85
|
| Rate for Payer: Aetna of WY Medicare |
$10,516.80
|
| Rate for Payer: Altius Commercial |
$15,775.20
|
| Rate for Payer: Beech Street Commercial |
$16,103.85
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15,939.52
|
| Rate for Payer: Cash Price |
$11,502.75
|
| Rate for Payer: ChoiceCare Network Commercial |
$15,939.52
|
| Rate for Payer: Cigna of WY Commercial |
$16,103.85
|
| Rate for Payer: Entrust Commercial |
$15,610.88
|
| Rate for Payer: First Choice Health Commercial |
$15,610.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15,610.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10,023.82
|
| Rate for Payer: HealthUtah PPO |
$16,432.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15,939.52
|
| Rate for Payer: Multiplan Medicare/VA |
$9,522.63
|
| Rate for Payer: One Health Plan of WY PPO |
$16,103.85
|
| Rate for Payer: PacificSource Commercial |
$14,789.25
|
| Rate for Payer: PHCS PPO |
$16,103.85
|
| Rate for Payer: Three Rivers PPO |
$12,324.38
|
| Rate for Payer: TriWest Veterans Administration |
$10,023.82
|
| Rate for Payer: United Healthcare Commercial |
$15,693.04
|
| Rate for Payer: United Healthcare Medicare |
$10,023.82
|
| Rate for Payer: WINHealth Partners Commercial |
$15,610.88
|
| Rate for Payer: Wise Provider Network Commercial |
$15,610.88
|
|
|
ALLOGRAFT DBM 10CC
|
Facility
|
OP
|
$16,432.50
|
|
| Hospital Charge Code |
2800254
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,898.20 |
| Max. Negotiated Rate |
$16,432.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16,103.85
|
| Rate for Payer: Aetna of WY Medicare |
$10,845.45
|
| Rate for Payer: Altius Commercial |
$15,775.20
|
| Rate for Payer: Beech Street Commercial |
$16,103.85
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15,939.52
|
| Rate for Payer: Cash Price |
$11,502.75
|
| Rate for Payer: ChoiceCare Network Commercial |
$15,939.52
|
| Rate for Payer: Cigna of WY Commercial |
$16,103.85
|
| Rate for Payer: Entrust Commercial |
$15,610.88
|
| Rate for Payer: First Choice Health Commercial |
$15,610.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15,610.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9,366.52
|
| Rate for Payer: HealthUtah PPO |
$16,432.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15,939.52
|
| Rate for Payer: Multiplan Medicare/VA |
$8,898.20
|
| Rate for Payer: One Health Plan of WY PPO |
$16,103.85
|
| Rate for Payer: PacificSource Commercial |
$14,789.25
|
| Rate for Payer: PHCS PPO |
$16,103.85
|
| Rate for Payer: Three Rivers PPO |
$12,324.38
|
| Rate for Payer: TriWest Veterans Administration |
$9,366.52
|
| Rate for Payer: United Healthcare Commercial |
$15,693.04
|
| Rate for Payer: United Healthcare Medicare |
$9,366.52
|
| Rate for Payer: WINHealth Partners Commercial |
$16,103.85
|
| Rate for Payer: Wise Provider Network Commercial |
$15,610.88
|
|
|
ALLOGRAFT DBM 1CC
|
Facility
|
IP
|
$1,746.50
|
|
| Hospital Charge Code |
2800295
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,012.10 |
| Max. Negotiated Rate |
$1,746.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,711.57
|
| Rate for Payer: Aetna of WY Medicare |
$1,117.76
|
| Rate for Payer: Altius Commercial |
$1,676.64
|
| Rate for Payer: Beech Street Commercial |
$1,711.57
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,694.10
|
| Rate for Payer: Cash Price |
$1,222.55
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,694.10
|
| Rate for Payer: Cigna of WY Commercial |
$1,711.57
|
| Rate for Payer: Entrust Commercial |
$1,659.18
|
| Rate for Payer: First Choice Health Commercial |
$1,659.18
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,659.18
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,065.36
|
| Rate for Payer: HealthUtah PPO |
$1,746.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,694.10
|
| Rate for Payer: Multiplan Medicare/VA |
$1,012.10
|
| Rate for Payer: One Health Plan of WY PPO |
$1,711.57
|
| Rate for Payer: PacificSource Commercial |
$1,571.85
|
| Rate for Payer: PHCS PPO |
$1,711.57
|
| Rate for Payer: Three Rivers PPO |
$1,309.88
|
| Rate for Payer: TriWest Veterans Administration |
$1,065.36
|
| Rate for Payer: United Healthcare Commercial |
$1,667.91
|
| Rate for Payer: United Healthcare Medicare |
$1,065.36
|
| Rate for Payer: WINHealth Partners Commercial |
$1,659.18
|
| Rate for Payer: Wise Provider Network Commercial |
$1,659.18
|
|
|
ALLOGRAFT DBM 1CC
|
Facility
|
OP
|
$1,746.50
|
|
| Hospital Charge Code |
2800295
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$945.73 |
| Max. Negotiated Rate |
$1,746.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,711.57
|
| Rate for Payer: Aetna of WY Medicare |
$1,152.69
|
| Rate for Payer: Altius Commercial |
$1,676.64
|
| Rate for Payer: Beech Street Commercial |
$1,711.57
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,694.10
|
| Rate for Payer: Cash Price |
$1,222.55
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,694.10
|
| Rate for Payer: Cigna of WY Commercial |
$1,711.57
|
| Rate for Payer: Entrust Commercial |
$1,659.18
|
| Rate for Payer: First Choice Health Commercial |
$1,659.18
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,659.18
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$995.50
|
| Rate for Payer: HealthUtah PPO |
$1,746.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,694.10
|
| Rate for Payer: Multiplan Medicare/VA |
$945.73
|
| Rate for Payer: One Health Plan of WY PPO |
$1,711.57
|
| Rate for Payer: PacificSource Commercial |
$1,571.85
|
| Rate for Payer: PHCS PPO |
$1,711.57
|
| Rate for Payer: Three Rivers PPO |
$1,309.88
|
| Rate for Payer: TriWest Veterans Administration |
$995.50
|
| Rate for Payer: United Healthcare Commercial |
$1,667.91
|
| Rate for Payer: United Healthcare Medicare |
$995.50
|
| Rate for Payer: WINHealth Partners Commercial |
$1,711.57
|
| Rate for Payer: Wise Provider Network Commercial |
$1,659.18
|
|
|
ALLOGRAFT DBM 5CC
|
Facility
|
OP
|
$8,837.50
|
|
| Hospital Charge Code |
2800253
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,785.51 |
| Max. Negotiated Rate |
$8,837.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$8,660.75
|
| Rate for Payer: Aetna of WY Medicare |
$5,832.75
|
| Rate for Payer: Altius Commercial |
$8,484.00
|
| Rate for Payer: Beech Street Commercial |
$8,660.75
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$8,572.38
|
| Rate for Payer: Cash Price |
$6,186.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$8,572.38
|
| Rate for Payer: Cigna of WY Commercial |
$8,660.75
|
| Rate for Payer: Entrust Commercial |
$8,395.62
|
| Rate for Payer: First Choice Health Commercial |
$8,395.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$8,395.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$5,037.38
|
| Rate for Payer: HealthUtah PPO |
$8,837.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$8,572.38
|
| Rate for Payer: Multiplan Medicare/VA |
$4,785.51
|
| Rate for Payer: One Health Plan of WY PPO |
$8,660.75
|
| Rate for Payer: PacificSource Commercial |
$7,953.75
|
| Rate for Payer: PHCS PPO |
$8,660.75
|
| Rate for Payer: Three Rivers PPO |
$6,628.12
|
| Rate for Payer: TriWest Veterans Administration |
$5,037.38
|
| Rate for Payer: United Healthcare Commercial |
$8,439.81
|
| Rate for Payer: United Healthcare Medicare |
$5,037.38
|
| Rate for Payer: WINHealth Partners Commercial |
$8,660.75
|
| Rate for Payer: Wise Provider Network Commercial |
$8,395.62
|
|
|
ALLOGRAFT DBM 5CC
|
Facility
|
IP
|
$8,837.50
|
|
| Hospital Charge Code |
2800253
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,121.33 |
| Max. Negotiated Rate |
$8,837.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$8,660.75
|
| Rate for Payer: Aetna of WY Medicare |
$5,656.00
|
| Rate for Payer: Altius Commercial |
$8,484.00
|
| Rate for Payer: Beech Street Commercial |
$8,660.75
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$8,572.38
|
| Rate for Payer: Cash Price |
$6,186.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$8,572.38
|
| Rate for Payer: Cigna of WY Commercial |
$8,660.75
|
| Rate for Payer: Entrust Commercial |
$8,395.62
|
| Rate for Payer: First Choice Health Commercial |
$8,395.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$8,395.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$5,390.88
|
| Rate for Payer: HealthUtah PPO |
$8,837.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$8,572.38
|
| Rate for Payer: Multiplan Medicare/VA |
$5,121.33
|
| Rate for Payer: One Health Plan of WY PPO |
$8,660.75
|
| Rate for Payer: PacificSource Commercial |
$7,953.75
|
| Rate for Payer: PHCS PPO |
$8,660.75
|
| Rate for Payer: Three Rivers PPO |
$6,628.12
|
| Rate for Payer: TriWest Veterans Administration |
$5,390.88
|
| Rate for Payer: United Healthcare Commercial |
$8,439.81
|
| Rate for Payer: United Healthcare Medicare |
$5,390.88
|
| Rate for Payer: WINHealth Partners Commercial |
$8,395.62
|
| Rate for Payer: Wise Provider Network Commercial |
$8,395.62
|
|
|
ALLOGRAFT FOR SPINE SURGERY ONLY MORSELIZED
|
Professional
|
Both
|
$197.00
|
|
|
Service Code
|
HCPCS 20930 AS
|
| Min. Negotiated Rate |
$147.75 |
| Max. Negotiated Rate |
$197.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$193.06
|
| Rate for Payer: Beech Street Commercial |
$187.15
|
| Rate for Payer: Cash Price |
$137.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$191.09
|
| Rate for Payer: Cigna of WY Commercial |
$193.06
|
| Rate for Payer: First Choice Health Commercial |
$177.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$187.15
|
| Rate for Payer: HealthUtah PPO |
$197.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$191.09
|
| Rate for Payer: One Health Plan of WY PPO |
$193.06
|
| Rate for Payer: PacificSource Commercial |
$177.30
|
| Rate for Payer: PHCS PPO |
$187.15
|
| Rate for Payer: Three Rivers PPO |
$147.75
|
| Rate for Payer: United Healthcare Commercial |
$187.15
|
| Rate for Payer: WINHealth Partners Commercial |
$167.45
|
|
|
ALLOGRAFT FOR SPINE SURGERY ONLY MORSELIZED
|
Professional
|
Both
|
$1,114.00
|
|
|
Service Code
|
HCPCS 20930
|
| Min. Negotiated Rate |
$835.50 |
| Max. Negotiated Rate |
$1,114.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,091.72
|
| Rate for Payer: Beech Street Commercial |
$1,058.30
|
| Rate for Payer: Cash Price |
$779.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,080.58
|
| Rate for Payer: Cigna of WY Commercial |
$1,091.72
|
| Rate for Payer: First Choice Health Commercial |
$1,002.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,058.30
|
| Rate for Payer: HealthUtah PPO |
$1,114.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,080.58
|
| Rate for Payer: One Health Plan of WY PPO |
$1,091.72
|
| Rate for Payer: PacificSource Commercial |
$1,002.60
|
| Rate for Payer: PHCS PPO |
$1,058.30
|
| Rate for Payer: Three Rivers PPO |
$835.50
|
| Rate for Payer: United Healthcare Commercial |
$1,058.30
|
| Rate for Payer: WINHealth Partners Commercial |
$946.90
|
|
|
ALLOGRAFT FOR SPINE SURGERY ONLY MORSELIZED
|
Professional
|
Both
|
$197.00
|
|
|
Service Code
|
HCPCS 20930 80
|
| Min. Negotiated Rate |
$147.75 |
| Max. Negotiated Rate |
$197.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$193.06
|
| Rate for Payer: Beech Street Commercial |
$187.15
|
| Rate for Payer: Cash Price |
$137.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$191.09
|
| Rate for Payer: Cigna of WY Commercial |
$193.06
|
| Rate for Payer: First Choice Health Commercial |
$177.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$187.15
|
| Rate for Payer: HealthUtah PPO |
$197.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$191.09
|
| Rate for Payer: One Health Plan of WY PPO |
$193.06
|
| Rate for Payer: PacificSource Commercial |
$177.30
|
| Rate for Payer: PHCS PPO |
$187.15
|
| Rate for Payer: Three Rivers PPO |
$147.75
|
| Rate for Payer: United Healthcare Commercial |
$187.15
|
| Rate for Payer: WINHealth Partners Commercial |
$167.45
|
|
|
ALLOGRAFT FOR SPINE SURGERY ONLY STRUCTURAL
|
Professional
|
Both
|
$239.00
|
|
|
Service Code
|
HCPCS 20931 AS
|
| Min. Negotiated Rate |
$179.25 |
| Max. Negotiated Rate |
$239.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$234.22
|
| Rate for Payer: Beech Street Commercial |
$227.05
|
| Rate for Payer: Cash Price |
$167.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$231.83
|
| Rate for Payer: Cigna of WY Commercial |
$234.22
|
| Rate for Payer: First Choice Health Commercial |
$215.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$227.05
|
| Rate for Payer: HealthUtah PPO |
$239.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$231.83
|
| Rate for Payer: One Health Plan of WY PPO |
$234.22
|
| Rate for Payer: PacificSource Commercial |
$215.10
|
| Rate for Payer: PHCS PPO |
$227.05
|
| Rate for Payer: Three Rivers PPO |
$179.25
|
| Rate for Payer: United Healthcare Commercial |
$227.05
|
| Rate for Payer: WINHealth Partners Commercial |
$203.15
|
|
|
ALLOGRAFT FOR SPINE SURGERY ONLY STRUCTURAL
|
Professional
|
Both
|
$239.00
|
|
|
Service Code
|
HCPCS 20931 80
|
| Min. Negotiated Rate |
$179.25 |
| Max. Negotiated Rate |
$239.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$234.22
|
| Rate for Payer: Beech Street Commercial |
$227.05
|
| Rate for Payer: Cash Price |
$167.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$231.83
|
| Rate for Payer: Cigna of WY Commercial |
$234.22
|
| Rate for Payer: First Choice Health Commercial |
$215.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$227.05
|
| Rate for Payer: HealthUtah PPO |
$239.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$231.83
|
| Rate for Payer: One Health Plan of WY PPO |
$234.22
|
| Rate for Payer: PacificSource Commercial |
$215.10
|
| Rate for Payer: PHCS PPO |
$227.05
|
| Rate for Payer: Three Rivers PPO |
$179.25
|
| Rate for Payer: United Healthcare Commercial |
$227.05
|
| Rate for Payer: WINHealth Partners Commercial |
$203.15
|
|
|
ALLOPURINOL 100 MG TABLET [7409]
|
Facility
|
IP
|
$16.66
|
|
|
Service Code
|
NDC 6068767711
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.65 |
| Max. Negotiated Rate |
$16.66 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.33
|
| Rate for Payer: Aetna of WY Medicare |
$10.66
|
| Rate for Payer: Altius Commercial |
$15.99
|
| Rate for Payer: Beech Street Commercial |
$16.33
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.16
|
| Rate for Payer: Cash Price |
$11.66
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.16
|
| Rate for Payer: Cigna of WY Commercial |
$16.33
|
| Rate for Payer: Entrust Commercial |
$15.83
|
| Rate for Payer: First Choice Health Commercial |
$15.83
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.83
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.16
|
| Rate for Payer: HealthUtah PPO |
$16.66
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.16
|
| Rate for Payer: Multiplan Medicare/VA |
$9.65
|
| Rate for Payer: One Health Plan of WY PPO |
$16.33
|
| Rate for Payer: PacificSource Commercial |
$14.99
|
| Rate for Payer: PHCS PPO |
$16.33
|
| Rate for Payer: Three Rivers PPO |
$12.50
|
| Rate for Payer: TriWest Veterans Administration |
$10.16
|
| Rate for Payer: United Healthcare Commercial |
$15.91
|
| Rate for Payer: United Healthcare Medicare |
$10.16
|
| Rate for Payer: WINHealth Partners Commercial |
$15.83
|
| Rate for Payer: Wise Provider Network Commercial |
$15.83
|
|
|
ALLOPURINOL 100 MG TABLET [7409]
|
Facility
|
OP
|
$16.66
|
|
|
Service Code
|
NDC 6068767711
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.02 |
| Max. Negotiated Rate |
$16.66 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.33
|
| Rate for Payer: Aetna of WY Medicare |
$11.00
|
| Rate for Payer: Altius Commercial |
$15.99
|
| Rate for Payer: Beech Street Commercial |
$16.33
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.16
|
| Rate for Payer: Cash Price |
$11.66
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.16
|
| Rate for Payer: Cigna of WY Commercial |
$16.33
|
| Rate for Payer: Entrust Commercial |
$15.83
|
| Rate for Payer: First Choice Health Commercial |
$15.83
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.83
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.50
|
| Rate for Payer: HealthUtah PPO |
$16.66
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.16
|
| Rate for Payer: Multiplan Medicare/VA |
$9.02
|
| Rate for Payer: One Health Plan of WY PPO |
$16.33
|
| Rate for Payer: PacificSource Commercial |
$14.99
|
| Rate for Payer: PHCS PPO |
$16.33
|
| Rate for Payer: Three Rivers PPO |
$12.50
|
| Rate for Payer: TriWest Veterans Administration |
$9.50
|
| Rate for Payer: United Healthcare Commercial |
$15.91
|
| Rate for Payer: United Healthcare Medicare |
$9.50
|
| Rate for Payer: WINHealth Partners Commercial |
$16.33
|
| Rate for Payer: Wise Provider Network Commercial |
$15.83
|
|
|
ALLOPURINOL 100 MG TABLET [7409]
|
Facility
|
OP
|
$16.66
|
|
|
Service Code
|
NDC 6258498801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.02 |
| Max. Negotiated Rate |
$16.66 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.33
|
| Rate for Payer: Aetna of WY Medicare |
$11.00
|
| Rate for Payer: Altius Commercial |
$15.99
|
| Rate for Payer: Beech Street Commercial |
$16.33
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.16
|
| Rate for Payer: Cash Price |
$11.66
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.16
|
| Rate for Payer: Cigna of WY Commercial |
$16.33
|
| Rate for Payer: Entrust Commercial |
$15.83
|
| Rate for Payer: First Choice Health Commercial |
$15.83
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.83
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.50
|
| Rate for Payer: HealthUtah PPO |
$16.66
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.16
|
| Rate for Payer: Multiplan Medicare/VA |
$9.02
|
| Rate for Payer: One Health Plan of WY PPO |
$16.33
|
| Rate for Payer: PacificSource Commercial |
$14.99
|
| Rate for Payer: PHCS PPO |
$16.33
|
| Rate for Payer: Three Rivers PPO |
$12.50
|
| Rate for Payer: TriWest Veterans Administration |
$9.50
|
| Rate for Payer: United Healthcare Commercial |
$15.91
|
| Rate for Payer: United Healthcare Medicare |
$9.50
|
| Rate for Payer: WINHealth Partners Commercial |
$16.33
|
| Rate for Payer: Wise Provider Network Commercial |
$15.83
|
|
