|
HC PRO PELVIS/HIP JOINT SURGERY
|
Professional
|
Both
|
$5,882.00
|
|
|
Service Code
|
HCPCS 27299
|
| Hospital Charge Code |
9832729901
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$4,411.50 |
| Max. Negotiated Rate |
$5,882.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5,764.36
|
| Rate for Payer: Beech Street Commercial |
$5,587.90
|
| Rate for Payer: Cash Price |
$4,117.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$5,705.54
|
| Rate for Payer: Cigna of WY Commercial |
$5,764.36
|
| Rate for Payer: First Choice Health Commercial |
$5,293.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5,587.90
|
| Rate for Payer: HealthUtah PPO |
$5,882.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5,705.54
|
| Rate for Payer: One Health Plan of WY PPO |
$5,764.36
|
| Rate for Payer: PacificSource Commercial |
$5,293.80
|
| Rate for Payer: PHCS PPO |
$5,587.90
|
| Rate for Payer: Three Rivers PPO |
$4,411.50
|
| Rate for Payer: United Healthcare Commercial |
$5,117.34
|
| Rate for Payer: WINHealth Partners Commercial |
$4,999.70
|
|
|
HC PRO PERCUT SKELETAL FIX, DISTAL RADIUS FX
|
Professional
|
Both
|
$2,342.00
|
|
|
Service Code
|
HCPCS 25606
|
| Hospital Charge Code |
9832560601
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$557.80 |
| Max. Negotiated Rate |
$2,342.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,295.16
|
| Rate for Payer: Aetna of WY Medicare |
$656.24
|
| Rate for Payer: Beech Street Commercial |
$2,224.90
|
| Rate for Payer: Cash Price |
$1,639.40
|
| Rate for Payer: Cash Price |
$1,639.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,271.74
|
| Rate for Payer: Cigna of WY Commercial |
$2,295.16
|
| Rate for Payer: First Choice Health Commercial |
$2,107.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,224.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$656.24
|
| Rate for Payer: HealthUtah PPO |
$2,342.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,271.74
|
| Rate for Payer: Multiplan Medicare/VA |
$557.80
|
| Rate for Payer: One Health Plan of WY PPO |
$2,295.16
|
| Rate for Payer: PacificSource Commercial |
$2,107.80
|
| Rate for Payer: PHCS PPO |
$2,224.90
|
| Rate for Payer: Three Rivers PPO |
$1,756.50
|
| Rate for Payer: TriWest Veterans Administration |
$656.24
|
| Rate for Payer: United Healthcare Commercial |
$2,037.54
|
| Rate for Payer: United Healthcare Medicare |
$656.24
|
| Rate for Payer: WINHealth Partners Commercial |
$1,990.70
|
|
|
HC PRO PERCUT SKELETAL FIX METACARP FX
|
Professional
|
Both
|
$3,695.00
|
|
|
Service Code
|
HCPCS 26608
|
| Hospital Charge Code |
9832660801
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$405.12 |
| Max. Negotiated Rate |
$3,695.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,621.10
|
| Rate for Payer: Aetna of WY Medicare |
$476.61
|
| Rate for Payer: Beech Street Commercial |
$3,510.25
|
| Rate for Payer: Cash Price |
$2,586.50
|
| Rate for Payer: Cash Price |
$2,586.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,584.15
|
| Rate for Payer: Cigna of WY Commercial |
$3,621.10
|
| Rate for Payer: First Choice Health Commercial |
$3,325.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,510.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$476.61
|
| Rate for Payer: HealthUtah PPO |
$3,695.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,584.15
|
| Rate for Payer: Multiplan Medicare/VA |
$405.12
|
| Rate for Payer: One Health Plan of WY PPO |
$3,621.10
|
| Rate for Payer: PacificSource Commercial |
$3,325.50
|
| Rate for Payer: PHCS PPO |
$3,510.25
|
| Rate for Payer: Three Rivers PPO |
$2,771.25
|
| Rate for Payer: TriWest Veterans Administration |
$476.61
|
| Rate for Payer: United Healthcare Commercial |
$3,214.65
|
| Rate for Payer: United Healthcare Medicare |
$476.61
|
| Rate for Payer: WINHealth Partners Commercial |
$3,140.75
|
|
|
HC PRO PERCUT SKEL FIX SUPRACONDYLAR FX
|
Professional
|
Both
|
$3,938.00
|
|
|
Service Code
|
HCPCS 24538
|
| Hospital Charge Code |
9832453801
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$654.70 |
| Max. Negotiated Rate |
$3,938.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,859.24
|
| Rate for Payer: Aetna of WY Medicare |
$770.23
|
| Rate for Payer: Beech Street Commercial |
$3,741.10
|
| Rate for Payer: Cash Price |
$2,756.60
|
| Rate for Payer: Cash Price |
$2,756.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,819.86
|
| Rate for Payer: Cigna of WY Commercial |
$3,859.24
|
| Rate for Payer: First Choice Health Commercial |
$3,544.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,741.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$770.23
|
| Rate for Payer: HealthUtah PPO |
$3,938.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,819.86
|
| Rate for Payer: Multiplan Medicare/VA |
$654.70
|
| Rate for Payer: One Health Plan of WY PPO |
$3,859.24
|
| Rate for Payer: PacificSource Commercial |
$3,544.20
|
| Rate for Payer: PHCS PPO |
$3,741.10
|
| Rate for Payer: Three Rivers PPO |
$2,953.50
|
| Rate for Payer: TriWest Veterans Administration |
$770.23
|
| Rate for Payer: United Healthcare Commercial |
$3,426.06
|
| Rate for Payer: United Healthcare Medicare |
$770.23
|
| Rate for Payer: WINHealth Partners Commercial |
$3,347.30
|
|
|
HC PRO PERCUT TX PROX/MID FING SHFT FX
|
Professional
|
Both
|
$2,431.00
|
|
|
Service Code
|
HCPCS 26727
|
| Hospital Charge Code |
9832672701
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$399.56 |
| Max. Negotiated Rate |
$2,431.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,382.38
|
| Rate for Payer: Aetna of WY Medicare |
$470.07
|
| Rate for Payer: Beech Street Commercial |
$2,309.45
|
| Rate for Payer: Cash Price |
$1,701.70
|
| Rate for Payer: Cash Price |
$1,701.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,358.07
|
| Rate for Payer: Cigna of WY Commercial |
$2,382.38
|
| Rate for Payer: First Choice Health Commercial |
$2,187.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,309.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$470.07
|
| Rate for Payer: HealthUtah PPO |
$2,431.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,358.07
|
| Rate for Payer: Multiplan Medicare/VA |
$399.56
|
| Rate for Payer: One Health Plan of WY PPO |
$2,382.38
|
| Rate for Payer: PacificSource Commercial |
$2,187.90
|
| Rate for Payer: PHCS PPO |
$2,309.45
|
| Rate for Payer: Three Rivers PPO |
$1,823.25
|
| Rate for Payer: TriWest Veterans Administration |
$470.07
|
| Rate for Payer: United Healthcare Commercial |
$2,114.97
|
| Rate for Payer: United Healthcare Medicare |
$470.07
|
| Rate for Payer: WINHealth Partners Commercial |
$2,066.35
|
|
|
HC PRO PERQ DRAINAGE PLEURA INSERT CATH W/O IMAGING
|
Professional
|
Both
|
$1,217.00
|
|
|
Service Code
|
HCPCS 32556
|
| Hospital Charge Code |
9833255601
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$99.18 |
| Max. Negotiated Rate |
$1,217.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,192.66
|
| Rate for Payer: Aetna of WY Medicare |
$116.68
|
| Rate for Payer: Beech Street Commercial |
$1,156.15
|
| Rate for Payer: Cash Price |
$851.90
|
| Rate for Payer: Cash Price |
$851.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,180.49
|
| Rate for Payer: Cigna of WY Commercial |
$1,192.66
|
| Rate for Payer: First Choice Health Commercial |
$1,095.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,156.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$116.68
|
| Rate for Payer: HealthUtah PPO |
$1,217.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,180.49
|
| Rate for Payer: Multiplan Medicare/VA |
$99.18
|
| Rate for Payer: One Health Plan of WY PPO |
$1,192.66
|
| Rate for Payer: PacificSource Commercial |
$1,095.30
|
| Rate for Payer: PHCS PPO |
$1,156.15
|
| Rate for Payer: Three Rivers PPO |
$912.75
|
| Rate for Payer: TriWest Veterans Administration |
$116.68
|
| Rate for Payer: United Healthcare Commercial |
$1,058.79
|
| Rate for Payer: United Healthcare Medicare |
$116.68
|
| Rate for Payer: WINHealth Partners Commercial |
$1,034.45
|
|
|
HC PRO PERQ DRAINAGE PLEURA INSERT CATH W/O IMAGING
|
Professional
|
Both
|
$1,521.00
|
|
|
Service Code
|
HCPCS 32556 NONPBBPAYER
|
| Hospital Charge Code |
9833255601
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$99.18 |
| Max. Negotiated Rate |
$1,521.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,490.58
|
| Rate for Payer: Aetna of WY Medicare |
$116.68
|
| Rate for Payer: Beech Street Commercial |
$1,444.95
|
| Rate for Payer: Cash Price |
$1,064.70
|
| Rate for Payer: Cash Price |
$1,064.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,475.37
|
| Rate for Payer: Cigna of WY Commercial |
$1,490.58
|
| Rate for Payer: First Choice Health Commercial |
$1,368.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,444.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$116.68
|
| Rate for Payer: HealthUtah PPO |
$1,521.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,475.37
|
| Rate for Payer: Multiplan Medicare/VA |
$99.18
|
| Rate for Payer: One Health Plan of WY PPO |
$1,490.58
|
| Rate for Payer: PacificSource Commercial |
$1,368.90
|
| Rate for Payer: PHCS PPO |
$1,444.95
|
| Rate for Payer: Three Rivers PPO |
$1,140.75
|
| Rate for Payer: TriWest Veterans Administration |
$116.68
|
| Rate for Payer: United Healthcare Commercial |
$1,323.27
|
| Rate for Payer: United Healthcare Medicare |
$116.68
|
| Rate for Payer: WINHealth Partners Commercial |
$1,292.85
|
|
|
HC PRO PERQ VERT AGMNTJ CAVITY CRTJ UNI/BI CANNULATION
|
Professional
|
Both
|
$19,614.00
|
|
|
Service Code
|
HCPCS 22513
|
| Hospital Charge Code |
9832251301
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$411.49 |
| Max. Negotiated Rate |
$19,614.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$19,221.72
|
| Rate for Payer: Aetna of WY Medicare |
$484.11
|
| Rate for Payer: Beech Street Commercial |
$18,633.30
|
| Rate for Payer: Cash Price |
$13,729.80
|
| Rate for Payer: Cash Price |
$13,729.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$19,025.58
|
| Rate for Payer: Cigna of WY Commercial |
$19,221.72
|
| Rate for Payer: First Choice Health Commercial |
$17,652.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$18,633.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$484.11
|
| Rate for Payer: HealthUtah PPO |
$19,614.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$19,025.58
|
| Rate for Payer: Multiplan Medicare/VA |
$411.49
|
| Rate for Payer: One Health Plan of WY PPO |
$19,221.72
|
| Rate for Payer: PacificSource Commercial |
$17,652.60
|
| Rate for Payer: PHCS PPO |
$18,633.30
|
| Rate for Payer: Three Rivers PPO |
$14,710.50
|
| Rate for Payer: TriWest Veterans Administration |
$484.11
|
| Rate for Payer: United Healthcare Commercial |
$17,064.18
|
| Rate for Payer: United Healthcare Medicare |
$484.11
|
| Rate for Payer: WINHealth Partners Commercial |
$16,671.90
|
|
|
HC PRO PERQ VERT AGMNTJ CAVITY CRTJ UNI/BI CANNULJ LMBR
|
Professional
|
Both
|
$19,532.00
|
|
|
Service Code
|
HCPCS 22514
|
| Hospital Charge Code |
9832251401
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$383.77 |
| Max. Negotiated Rate |
$19,532.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$19,141.36
|
| Rate for Payer: Aetna of WY Medicare |
$451.49
|
| Rate for Payer: Beech Street Commercial |
$18,555.40
|
| Rate for Payer: Cash Price |
$13,672.40
|
| Rate for Payer: Cash Price |
$13,672.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$18,946.04
|
| Rate for Payer: Cigna of WY Commercial |
$19,141.36
|
| Rate for Payer: First Choice Health Commercial |
$17,578.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$18,555.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$451.49
|
| Rate for Payer: HealthUtah PPO |
$19,532.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$18,946.04
|
| Rate for Payer: Multiplan Medicare/VA |
$383.77
|
| Rate for Payer: One Health Plan of WY PPO |
$19,141.36
|
| Rate for Payer: PacificSource Commercial |
$17,578.80
|
| Rate for Payer: PHCS PPO |
$18,555.40
|
| Rate for Payer: Three Rivers PPO |
$14,649.00
|
| Rate for Payer: TriWest Veterans Administration |
$451.49
|
| Rate for Payer: United Healthcare Commercial |
$16,992.84
|
| Rate for Payer: United Healthcare Medicare |
$451.49
|
| Rate for Payer: WINHealth Partners Commercial |
$16,602.20
|
|
|
HC PRO PHALANGE MYE
|
Professional
|
Both
|
$2,133.00
|
|
|
Service Code
|
HCPCS 28150
|
| Hospital Charge Code |
9832815001
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$232.69 |
| Max. Negotiated Rate |
$2,133.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,090.34
|
| Rate for Payer: Aetna of WY Medicare |
$273.75
|
| Rate for Payer: Beech Street Commercial |
$2,026.35
|
| Rate for Payer: Cash Price |
$1,493.10
|
| Rate for Payer: Cash Price |
$1,493.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,069.01
|
| Rate for Payer: Cigna of WY Commercial |
$2,090.34
|
| Rate for Payer: First Choice Health Commercial |
$1,919.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,026.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$273.75
|
| Rate for Payer: HealthUtah PPO |
$2,133.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,069.01
|
| Rate for Payer: Multiplan Medicare/VA |
$232.69
|
| Rate for Payer: One Health Plan of WY PPO |
$2,090.34
|
| Rate for Payer: PacificSource Commercial |
$1,919.70
|
| Rate for Payer: PHCS PPO |
$2,026.35
|
| Rate for Payer: Three Rivers PPO |
$1,599.75
|
| Rate for Payer: TriWest Veterans Administration |
$273.75
|
| Rate for Payer: United Healthcare Commercial |
$1,855.71
|
| Rate for Payer: United Healthcare Medicare |
$273.75
|
| Rate for Payer: WINHealth Partners Commercial |
$1,813.05
|
|
|
HC PRO PHLEB VARICOSE VEINS - 1 EXTREM - 10 TO 20
|
Professional
|
Both
|
$1,433.00
|
|
|
Service Code
|
HCPCS 37765
|
| Hospital Charge Code |
9833776501
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$1,074.75 |
| Max. Negotiated Rate |
$1,433.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,404.34
|
| Rate for Payer: Beech Street Commercial |
$1,361.35
|
| Rate for Payer: Cash Price |
$1,003.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,390.01
|
| Rate for Payer: Cigna of WY Commercial |
$1,404.34
|
| Rate for Payer: First Choice Health Commercial |
$1,289.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,361.35
|
| Rate for Payer: HealthUtah PPO |
$1,433.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,390.01
|
| Rate for Payer: One Health Plan of WY PPO |
$1,404.34
|
| Rate for Payer: PacificSource Commercial |
$1,289.70
|
| Rate for Payer: PHCS PPO |
$1,361.35
|
| Rate for Payer: Three Rivers PPO |
$1,074.75
|
| Rate for Payer: United Healthcare Commercial |
$1,246.71
|
| Rate for Payer: WINHealth Partners Commercial |
$1,218.05
|
|
|
HC PRO PHONE E/M PHYS/QHP 5-10 MIN
|
Professional
|
Both
|
$44.00
|
|
|
Service Code
|
HCPCS 99441
|
| Hospital Charge Code |
9839944101
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$28.59 |
| Max. Negotiated Rate |
$44.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$43.12
|
| Rate for Payer: Aetna of WY Medicare |
$33.63
|
| Rate for Payer: Beech Street Commercial |
$41.80
|
| Rate for Payer: Cash Price |
$30.80
|
| Rate for Payer: Cash Price |
$30.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$42.68
|
| Rate for Payer: Cigna of WY Commercial |
$43.12
|
| Rate for Payer: First Choice Health Commercial |
$39.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$41.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$33.63
|
| Rate for Payer: HealthUtah PPO |
$44.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$42.68
|
| Rate for Payer: Multiplan Medicare/VA |
$28.59
|
| Rate for Payer: One Health Plan of WY PPO |
$43.12
|
| Rate for Payer: PacificSource Commercial |
$39.60
|
| Rate for Payer: PHCS PPO |
$41.80
|
| Rate for Payer: Three Rivers PPO |
$33.00
|
| Rate for Payer: TriWest Veterans Administration |
$33.63
|
| Rate for Payer: United Healthcare Commercial |
$38.28
|
| Rate for Payer: United Healthcare Medicare |
$33.63
|
| Rate for Payer: WINHealth Partners Commercial |
$41.80
|
|
|
HC PRO PHYS/ DILATION & CURETTAGE
|
Professional
|
Both
|
$940.00
|
|
|
Service Code
|
HCPCS 58120
|
| Hospital Charge Code |
9835812001
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$192.14 |
| Max. Negotiated Rate |
$940.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$921.20
|
| Rate for Payer: Aetna of WY Medicare |
$226.05
|
| Rate for Payer: Beech Street Commercial |
$893.00
|
| Rate for Payer: Cash Price |
$658.00
|
| Rate for Payer: Cash Price |
$658.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$911.80
|
| Rate for Payer: Cigna of WY Commercial |
$921.20
|
| Rate for Payer: First Choice Health Commercial |
$846.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$893.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$226.05
|
| Rate for Payer: HealthUtah PPO |
$940.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$911.80
|
| Rate for Payer: Multiplan Medicare/VA |
$192.14
|
| Rate for Payer: One Health Plan of WY PPO |
$921.20
|
| Rate for Payer: PacificSource Commercial |
$846.00
|
| Rate for Payer: PHCS PPO |
$893.00
|
| Rate for Payer: Three Rivers PPO |
$705.00
|
| Rate for Payer: TriWest Veterans Administration |
$226.05
|
| Rate for Payer: United Healthcare Commercial |
$817.80
|
| Rate for Payer: United Healthcare Medicare |
$226.05
|
| Rate for Payer: WINHealth Partners Commercial |
$799.00
|
|
|
HC PRO PHYS/ DILATION & CURETTAGE
|
Professional
|
Both
|
$1,175.00
|
|
|
Service Code
|
HCPCS 58120 NONPBBPAYER
|
| Hospital Charge Code |
9835812001
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$192.14 |
| Max. Negotiated Rate |
$1,175.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,151.50
|
| Rate for Payer: Aetna of WY Medicare |
$226.05
|
| Rate for Payer: Beech Street Commercial |
$1,116.25
|
| Rate for Payer: Cash Price |
$822.50
|
| Rate for Payer: Cash Price |
$822.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,139.75
|
| Rate for Payer: Cigna of WY Commercial |
$1,151.50
|
| Rate for Payer: First Choice Health Commercial |
$1,057.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,116.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$226.05
|
| Rate for Payer: HealthUtah PPO |
$1,175.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,139.75
|
| Rate for Payer: Multiplan Medicare/VA |
$192.14
|
| Rate for Payer: One Health Plan of WY PPO |
$1,151.50
|
| Rate for Payer: PacificSource Commercial |
$1,057.50
|
| Rate for Payer: PHCS PPO |
$1,116.25
|
| Rate for Payer: Three Rivers PPO |
$881.25
|
| Rate for Payer: TriWest Veterans Administration |
$226.05
|
| Rate for Payer: United Healthcare Commercial |
$1,022.25
|
| Rate for Payer: United Healthcare Medicare |
$226.05
|
| Rate for Payer: WINHealth Partners Commercial |
$998.75
|
|
|
HC PRO PHYS / DRAIN OVARIAN CYST
|
Professional
|
Both
|
$1,743.00
|
|
|
Service Code
|
HCPCS 58805
|
| Hospital Charge Code |
9835880501
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$353.28 |
| Max. Negotiated Rate |
$1,743.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,708.14
|
| Rate for Payer: Aetna of WY Medicare |
$415.62
|
| Rate for Payer: Beech Street Commercial |
$1,655.85
|
| Rate for Payer: Cash Price |
$1,220.10
|
| Rate for Payer: Cash Price |
$1,220.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,690.71
|
| Rate for Payer: Cigna of WY Commercial |
$1,708.14
|
| Rate for Payer: First Choice Health Commercial |
$1,568.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,655.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$415.62
|
| Rate for Payer: HealthUtah PPO |
$1,743.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,690.71
|
| Rate for Payer: Multiplan Medicare/VA |
$353.28
|
| Rate for Payer: One Health Plan of WY PPO |
$1,708.14
|
| Rate for Payer: PacificSource Commercial |
$1,568.70
|
| Rate for Payer: PHCS PPO |
$1,655.85
|
| Rate for Payer: Three Rivers PPO |
$1,307.25
|
| Rate for Payer: TriWest Veterans Administration |
$415.62
|
| Rate for Payer: United Healthcare Commercial |
$1,516.41
|
| Rate for Payer: United Healthcare Medicare |
$415.62
|
| Rate for Payer: WINHealth Partners Commercial |
$1,481.55
|
|
|
HC PRO PHYS / EXC BACK LESION <3CM
|
Professional
|
Both
|
$1,871.00
|
|
|
Service Code
|
HCPCS 21930
|
| Hospital Charge Code |
9832193001
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$301.10 |
| Max. Negotiated Rate |
$1,871.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,833.58
|
| Rate for Payer: Aetna of WY Medicare |
$354.23
|
| Rate for Payer: Beech Street Commercial |
$1,777.45
|
| Rate for Payer: Cash Price |
$1,309.70
|
| Rate for Payer: Cash Price |
$1,309.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,814.87
|
| Rate for Payer: Cigna of WY Commercial |
$1,833.58
|
| Rate for Payer: First Choice Health Commercial |
$1,683.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,777.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$354.23
|
| Rate for Payer: HealthUtah PPO |
$1,871.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,814.87
|
| Rate for Payer: Multiplan Medicare/VA |
$301.10
|
| Rate for Payer: One Health Plan of WY PPO |
$1,833.58
|
| Rate for Payer: PacificSource Commercial |
$1,683.90
|
| Rate for Payer: PHCS PPO |
$1,777.45
|
| Rate for Payer: Three Rivers PPO |
$1,403.25
|
| Rate for Payer: TriWest Veterans Administration |
$354.23
|
| Rate for Payer: United Healthcare Commercial |
$1,627.77
|
| Rate for Payer: United Healthcare Medicare |
$354.23
|
| Rate for Payer: WINHealth Partners Commercial |
$1,590.35
|
|
|
HC PRO PHYS / EXC BACK TUMOR
|
Professional
|
Both
|
$3,111.00
|
|
|
Service Code
|
HCPCS 21932
|
| Hospital Charge Code |
9832193201
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$541.64 |
| Max. Negotiated Rate |
$3,111.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,048.78
|
| Rate for Payer: Aetna of WY Medicare |
$637.22
|
| Rate for Payer: Beech Street Commercial |
$2,955.45
|
| Rate for Payer: Cash Price |
$2,177.70
|
| Rate for Payer: Cash Price |
$2,177.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,017.67
|
| Rate for Payer: Cigna of WY Commercial |
$3,048.78
|
| Rate for Payer: First Choice Health Commercial |
$2,799.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,955.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$637.22
|
| Rate for Payer: HealthUtah PPO |
$3,111.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,017.67
|
| Rate for Payer: Multiplan Medicare/VA |
$541.64
|
| Rate for Payer: One Health Plan of WY PPO |
$3,048.78
|
| Rate for Payer: PacificSource Commercial |
$2,799.90
|
| Rate for Payer: PHCS PPO |
$2,955.45
|
| Rate for Payer: Three Rivers PPO |
$2,333.25
|
| Rate for Payer: TriWest Veterans Administration |
$637.22
|
| Rate for Payer: United Healthcare Commercial |
$2,706.57
|
| Rate for Payer: United Healthcare Medicare |
$637.22
|
| Rate for Payer: WINHealth Partners Commercial |
$2,644.35
|
|
|
HC PRO PHYS / EXC GANGLION WRIST
|
Professional
|
Both
|
$1,381.00
|
|
|
Service Code
|
HCPCS 25112
|
| Hospital Charge Code |
9832511201
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$328.57 |
| Max. Negotiated Rate |
$1,381.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,353.38
|
| Rate for Payer: Aetna of WY Medicare |
$386.55
|
| Rate for Payer: Beech Street Commercial |
$1,311.95
|
| Rate for Payer: Cash Price |
$966.70
|
| Rate for Payer: Cash Price |
$966.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,339.57
|
| Rate for Payer: Cigna of WY Commercial |
$1,353.38
|
| Rate for Payer: First Choice Health Commercial |
$1,242.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,311.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$386.55
|
| Rate for Payer: HealthUtah PPO |
$1,381.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,339.57
|
| Rate for Payer: Multiplan Medicare/VA |
$328.57
|
| Rate for Payer: One Health Plan of WY PPO |
$1,353.38
|
| Rate for Payer: PacificSource Commercial |
$1,242.90
|
| Rate for Payer: PHCS PPO |
$1,311.95
|
| Rate for Payer: Three Rivers PPO |
$1,035.75
|
| Rate for Payer: TriWest Veterans Administration |
$386.55
|
| Rate for Payer: United Healthcare Commercial |
$1,201.47
|
| Rate for Payer: United Healthcare Medicare |
$386.55
|
| Rate for Payer: WINHealth Partners Commercial |
$1,173.85
|
|
|
HC PRO PHYSIOL SUPPORT HARVEST ORGAN FROM BRAIN-DEAD PT
|
Professional
|
Both
|
$314.00
|
|
|
Service Code
|
HCPCS 01990
|
| Hospital Charge Code |
9640199001
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$235.50 |
| Max. Negotiated Rate |
$314.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$307.72
|
| Rate for Payer: Beech Street Commercial |
$298.30
|
| Rate for Payer: Cash Price |
$219.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$304.58
|
| Rate for Payer: Cigna of WY Commercial |
$307.72
|
| Rate for Payer: First Choice Health Commercial |
$282.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$298.30
|
| Rate for Payer: HealthUtah PPO |
$314.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$304.58
|
| Rate for Payer: One Health Plan of WY PPO |
$307.72
|
| Rate for Payer: PacificSource Commercial |
$282.60
|
| Rate for Payer: PHCS PPO |
$298.30
|
| Rate for Payer: Three Rivers PPO |
$235.50
|
| Rate for Payer: United Healthcare Commercial |
$273.18
|
| Rate for Payer: WINHealth Partners Commercial |
$298.30
|
|
|
HC PRO PHYS/ MYOMECTOMY ABDOM COMPLEX
|
Professional
|
Both
|
$1,970.00
|
|
|
Service Code
|
HCPCS 58146
|
| Hospital Charge Code |
9835814601
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$942.12 |
| Max. Negotiated Rate |
$1,970.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,930.60
|
| Rate for Payer: Aetna of WY Medicare |
$1,108.38
|
| Rate for Payer: Beech Street Commercial |
$1,871.50
|
| Rate for Payer: Cash Price |
$1,379.00
|
| Rate for Payer: Cash Price |
$1,379.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,910.90
|
| Rate for Payer: Cigna of WY Commercial |
$1,930.60
|
| Rate for Payer: First Choice Health Commercial |
$1,773.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,871.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,108.38
|
| Rate for Payer: HealthUtah PPO |
$1,970.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,910.90
|
| Rate for Payer: Multiplan Medicare/VA |
$942.12
|
| Rate for Payer: One Health Plan of WY PPO |
$1,930.60
|
| Rate for Payer: PacificSource Commercial |
$1,773.00
|
| Rate for Payer: PHCS PPO |
$1,871.50
|
| Rate for Payer: Three Rivers PPO |
$1,477.50
|
| Rate for Payer: TriWest Veterans Administration |
$1,108.38
|
| Rate for Payer: United Healthcare Commercial |
$1,713.90
|
| Rate for Payer: United Healthcare Medicare |
$1,108.38
|
| Rate for Payer: WINHealth Partners Commercial |
$1,674.50
|
|
|
HC PRO PHYS/ TREAT ECTOPIC PREGN
|
Professional
|
Both
|
$1,955.00
|
|
|
Service Code
|
HCPCS 59120
|
| Hospital Charge Code |
9835912001
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$660.95 |
| Max. Negotiated Rate |
$1,955.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,915.90
|
| Rate for Payer: Aetna of WY Medicare |
$777.59
|
| Rate for Payer: Beech Street Commercial |
$1,857.25
|
| Rate for Payer: Cash Price |
$1,368.50
|
| Rate for Payer: Cash Price |
$1,368.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,896.35
|
| Rate for Payer: Cigna of WY Commercial |
$1,915.90
|
| Rate for Payer: First Choice Health Commercial |
$1,759.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,857.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$777.59
|
| Rate for Payer: HealthUtah PPO |
$1,955.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,896.35
|
| Rate for Payer: Multiplan Medicare/VA |
$660.95
|
| Rate for Payer: One Health Plan of WY PPO |
$1,915.90
|
| Rate for Payer: PacificSource Commercial |
$1,759.50
|
| Rate for Payer: PHCS PPO |
$1,857.25
|
| Rate for Payer: Three Rivers PPO |
$1,466.25
|
| Rate for Payer: TriWest Veterans Administration |
$777.59
|
| Rate for Payer: United Healthcare Commercial |
$1,700.85
|
| Rate for Payer: United Healthcare Medicare |
$777.59
|
| Rate for Payer: WINHealth Partners Commercial |
$1,661.75
|
|
|
HC PRO PLACE CATH EXTREM ARTERY
|
Professional
|
Both
|
$2,416.00
|
|
|
Service Code
|
HCPCS 36140
|
| Hospital Charge Code |
9833614001
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$69.75 |
| Max. Negotiated Rate |
$2,416.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,367.68
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,942.36
|
| Rate for Payer: Aetna of WY Medicare |
$82.06
|
| Rate for Payer: Aetna of WY Medicare |
$82.06
|
| Rate for Payer: Beech Street Commercial |
$1,882.90
|
| Rate for Payer: Beech Street Commercial |
$2,295.20
|
| Rate for Payer: Cash Price |
$1,387.40
|
| Rate for Payer: Cash Price |
$1,387.40
|
| Rate for Payer: Cash Price |
$1,691.20
|
| Rate for Payer: Cash Price |
$1,691.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,343.52
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,922.54
|
| Rate for Payer: Cigna of WY Commercial |
$1,942.36
|
| Rate for Payer: Cigna of WY Commercial |
$2,367.68
|
| Rate for Payer: First Choice Health Commercial |
$1,783.80
|
| Rate for Payer: First Choice Health Commercial |
$2,174.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,295.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,882.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$82.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$82.06
|
| Rate for Payer: HealthUtah PPO |
$2,416.00
|
| Rate for Payer: HealthUtah PPO |
$1,982.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,343.52
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,922.54
|
| Rate for Payer: Multiplan Medicare/VA |
$69.75
|
| Rate for Payer: Multiplan Medicare/VA |
$69.75
|
| Rate for Payer: One Health Plan of WY PPO |
$2,367.68
|
| Rate for Payer: One Health Plan of WY PPO |
$1,942.36
|
| Rate for Payer: PacificSource Commercial |
$1,783.80
|
| Rate for Payer: PacificSource Commercial |
$2,174.40
|
| Rate for Payer: PHCS PPO |
$2,295.20
|
| Rate for Payer: PHCS PPO |
$1,882.90
|
| Rate for Payer: Three Rivers PPO |
$1,812.00
|
| Rate for Payer: Three Rivers PPO |
$1,486.50
|
| Rate for Payer: TriWest Veterans Administration |
$82.06
|
| Rate for Payer: TriWest Veterans Administration |
$82.06
|
| Rate for Payer: United Healthcare Commercial |
$1,724.34
|
| Rate for Payer: United Healthcare Commercial |
$2,101.92
|
| Rate for Payer: United Healthcare Medicare |
$82.06
|
| Rate for Payer: United Healthcare Medicare |
$82.06
|
| Rate for Payer: WINHealth Partners Commercial |
$2,053.60
|
| Rate for Payer: WINHealth Partners Commercial |
$1,684.70
|
|
|
HC PRO PLACEMENT NG/OG TUBE BY PHYSICIAN
|
Professional
|
Both
|
$213.00
|
|
|
Service Code
|
HCPCS 43752
|
| Hospital Charge Code |
9834375201
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$32.11 |
| Max. Negotiated Rate |
$213.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$208.74
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$146.02
|
| Rate for Payer: Aetna of WY Medicare |
$37.78
|
| Rate for Payer: Aetna of WY Medicare |
$37.78
|
| Rate for Payer: Beech Street Commercial |
$141.55
|
| Rate for Payer: Beech Street Commercial |
$202.35
|
| Rate for Payer: Cash Price |
$104.30
|
| Rate for Payer: Cash Price |
$104.30
|
| Rate for Payer: Cash Price |
$149.10
|
| Rate for Payer: Cash Price |
$149.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$206.61
|
| Rate for Payer: ChoiceCare Network Commercial |
$144.53
|
| Rate for Payer: Cigna of WY Commercial |
$146.02
|
| Rate for Payer: Cigna of WY Commercial |
$208.74
|
| Rate for Payer: First Choice Health Commercial |
$134.10
|
| Rate for Payer: First Choice Health Commercial |
$191.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$202.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$141.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$37.78
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$37.78
|
| Rate for Payer: HealthUtah PPO |
$213.00
|
| Rate for Payer: HealthUtah PPO |
$149.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$206.61
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$144.53
|
| Rate for Payer: Multiplan Medicare/VA |
$32.11
|
| Rate for Payer: Multiplan Medicare/VA |
$32.11
|
| Rate for Payer: One Health Plan of WY PPO |
$208.74
|
| Rate for Payer: One Health Plan of WY PPO |
$146.02
|
| Rate for Payer: PacificSource Commercial |
$134.10
|
| Rate for Payer: PacificSource Commercial |
$191.70
|
| Rate for Payer: PHCS PPO |
$202.35
|
| Rate for Payer: PHCS PPO |
$141.55
|
| Rate for Payer: Three Rivers PPO |
$159.75
|
| Rate for Payer: Three Rivers PPO |
$111.75
|
| Rate for Payer: TriWest Veterans Administration |
$37.78
|
| Rate for Payer: TriWest Veterans Administration |
$37.78
|
| Rate for Payer: United Healthcare Commercial |
$129.63
|
| Rate for Payer: United Healthcare Commercial |
$185.31
|
| Rate for Payer: United Healthcare Medicare |
$37.78
|
| Rate for Payer: United Healthcare Medicare |
$37.78
|
| Rate for Payer: WINHealth Partners Commercial |
$181.05
|
| Rate for Payer: WINHealth Partners Commercial |
$126.65
|
|
|
HC PRO PLACE NEEDLE IN VEIN
|
Professional
|
Both
|
$228.00
|
|
|
Service Code
|
HCPCS 36000
|
| Hospital Charge Code |
9833600001
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$171.00 |
| Max. Negotiated Rate |
$228.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$223.44
|
| Rate for Payer: Beech Street Commercial |
$216.60
|
| Rate for Payer: Cash Price |
$159.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$221.16
|
| Rate for Payer: Cigna of WY Commercial |
$223.44
|
| Rate for Payer: First Choice Health Commercial |
$205.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$216.60
|
| Rate for Payer: HealthUtah PPO |
$228.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$221.16
|
| Rate for Payer: One Health Plan of WY PPO |
$223.44
|
| Rate for Payer: PacificSource Commercial |
$205.20
|
| Rate for Payer: PHCS PPO |
$216.60
|
| Rate for Payer: Three Rivers PPO |
$171.00
|
| Rate for Payer: United Healthcare Commercial |
$198.36
|
| Rate for Payer: WINHealth Partners Commercial |
$193.80
|
|
|
HC PRO POSPARTUM CARE ONLY
|
Professional
|
Both
|
$325.00
|
|
|
Service Code
|
HCPCS 59430
|
| Hospital Charge Code |
9835943001
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$143.48 |
| Max. Negotiated Rate |
$325.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$318.50
|
| Rate for Payer: Aetna of WY Medicare |
$168.80
|
| Rate for Payer: Beech Street Commercial |
$308.75
|
| Rate for Payer: Cash Price |
$227.50
|
| Rate for Payer: Cash Price |
$227.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$315.25
|
| Rate for Payer: Cigna of WY Commercial |
$318.50
|
| Rate for Payer: First Choice Health Commercial |
$292.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$308.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$168.80
|
| Rate for Payer: HealthUtah PPO |
$325.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$315.25
|
| Rate for Payer: Multiplan Medicare/VA |
$143.48
|
| Rate for Payer: One Health Plan of WY PPO |
$318.50
|
| Rate for Payer: PacificSource Commercial |
$292.50
|
| Rate for Payer: PHCS PPO |
$308.75
|
| Rate for Payer: Three Rivers PPO |
$243.75
|
| Rate for Payer: TriWest Veterans Administration |
$168.80
|
| Rate for Payer: United Healthcare Commercial |
$282.75
|
| Rate for Payer: United Healthcare Medicare |
$168.80
|
| Rate for Payer: WINHealth Partners Commercial |
$276.25
|
|
