|
RSV VACC PREF RECOMBINANT ADJUVANTED FOR IM USE
|
Professional
|
Both
|
$335.00
|
|
|
Service Code
|
HCPCS 90679
|
| Hospital Charge Code |
90679
|
| Min. Negotiated Rate |
$251.25 |
| Max. Negotiated Rate |
$335.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$328.30
|
| Rate for Payer: Beech Street Commercial |
$318.25
|
| Rate for Payer: Cash Price |
$234.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$324.95
|
| Rate for Payer: Cigna of WY Commercial |
$328.30
|
| Rate for Payer: First Choice Health Commercial |
$301.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$318.25
|
| Rate for Payer: HealthUtah PPO |
$335.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$324.95
|
| Rate for Payer: One Health Plan of WY PPO |
$328.30
|
| Rate for Payer: PacificSource Commercial |
$301.50
|
| Rate for Payer: PHCS PPO |
$318.25
|
| Rate for Payer: Three Rivers PPO |
$251.25
|
| Rate for Payer: United Healthcare Commercial |
$291.45
|
| Rate for Payer: WINHealth Partners Commercial |
$335.00
|
|
|
RSV VACC PREF RECOMBINANT ADJUVANTED FOR IM USE
|
Facility
|
OP
|
$335.00
|
|
|
Service Code
|
HCPCS 90679
|
| Hospital Charge Code |
6369067901
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$184.58 |
| Max. Negotiated Rate |
$335.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$328.30
|
| Rate for Payer: Aetna of WY Medicare |
$221.10
|
| Rate for Payer: Altius Auto/Workers Compensation |
$321.60
|
| Rate for Payer: Altius Commercial |
$321.60
|
| Rate for Payer: Beech Street Commercial |
$328.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$275.04
|
| Rate for Payer: Cash Price |
$234.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$324.95
|
| Rate for Payer: Cigna of WY Commercial |
$328.30
|
| Rate for Payer: Entrust Commercial |
$318.25
|
| Rate for Payer: First Choice Health Commercial |
$318.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$318.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$194.30
|
| Rate for Payer: HealthUtah PPO |
$335.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$324.95
|
| Rate for Payer: Multiplan Medicare/VA |
$184.58
|
| Rate for Payer: One Health Plan of WY PPO |
$328.30
|
| Rate for Payer: PacificSource Commercial |
$301.50
|
| Rate for Payer: PHCS PPO |
$328.30
|
| Rate for Payer: Three Rivers PPO |
$251.25
|
| Rate for Payer: TriWest Veterans Administration |
$194.30
|
| Rate for Payer: United Healthcare Commercial |
$291.45
|
| Rate for Payer: United Healthcare Medicare |
$194.30
|
| Rate for Payer: WINHealth Partners Commercial |
$328.30
|
| Rate for Payer: Wise Provider Network Commercial |
$318.25
|
|
|
RSV VACC PREF RECOMBINANT ADJUVANTED FOR IM USE
|
Facility
|
IP
|
$335.00
|
|
|
Service Code
|
HCPCS 90679
|
| Hospital Charge Code |
6369067901
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$210.04 |
| Max. Negotiated Rate |
$335.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$328.30
|
| Rate for Payer: Altius Auto/Workers Compensation |
$321.60
|
| Rate for Payer: Altius Commercial |
$321.60
|
| Rate for Payer: Beech Street Commercial |
$328.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$275.04
|
| Rate for Payer: Cash Price |
$234.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$324.95
|
| Rate for Payer: Cigna of WY Commercial |
$328.30
|
| Rate for Payer: Entrust Commercial |
$318.25
|
| Rate for Payer: First Choice Health Commercial |
$318.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$318.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$221.10
|
| Rate for Payer: HealthUtah PPO |
$335.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$324.95
|
| Rate for Payer: Multiplan Medicare/VA |
$210.04
|
| Rate for Payer: One Health Plan of WY PPO |
$328.30
|
| Rate for Payer: PacificSource Commercial |
$301.50
|
| Rate for Payer: PHCS PPO |
$328.30
|
| Rate for Payer: Three Rivers PPO |
$251.25
|
| Rate for Payer: TriWest Veterans Administration |
$221.10
|
| Rate for Payer: United Healthcare Commercial |
$291.45
|
| Rate for Payer: United Healthcare Medicare |
$221.10
|
| Rate for Payer: WINHealth Partners Commercial |
$318.25
|
| Rate for Payer: Wise Provider Network Commercial |
$318.25
|
|
|
RV5 VACCINE 3 DOSE SCHEDULE LIVE FOR ORAL USE
|
Professional
|
Both
|
$119.00
|
|
|
Service Code
|
HCPCS 90680
|
| Hospital Charge Code |
90680
|
| Min. Negotiated Rate |
$89.25 |
| Max. Negotiated Rate |
$119.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$116.62
|
| Rate for Payer: Beech Street Commercial |
$113.05
|
| Rate for Payer: Cash Price |
$83.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$115.43
|
| Rate for Payer: Cigna of WY Commercial |
$116.62
|
| Rate for Payer: First Choice Health Commercial |
$107.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$113.05
|
| Rate for Payer: HealthUtah PPO |
$119.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$115.43
|
| Rate for Payer: One Health Plan of WY PPO |
$116.62
|
| Rate for Payer: PacificSource Commercial |
$107.10
|
| Rate for Payer: PHCS PPO |
$113.05
|
| Rate for Payer: Three Rivers PPO |
$89.25
|
| Rate for Payer: United Healthcare Commercial |
$103.53
|
| Rate for Payer: WINHealth Partners Commercial |
$119.00
|
|
|
SALPINGECTOMY COMPLETE/PARTIAL UNI/BI SPX
|
Professional
|
Both
|
$4,091.00
|
|
|
Service Code
|
HCPCS 58700
|
| Hospital Charge Code |
58700
|
| Min. Negotiated Rate |
$655.49 |
| Max. Negotiated Rate |
$4,091.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4,009.18
|
| Rate for Payer: Aetna of WY Medicare |
$771.16
|
| Rate for Payer: Beech Street Commercial |
$3,886.45
|
| Rate for Payer: Cash Price |
$2,863.70
|
| Rate for Payer: Cash Price |
$2,863.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,968.27
|
| Rate for Payer: Cigna of WY Commercial |
$4,009.18
|
| Rate for Payer: First Choice Health Commercial |
$3,681.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,886.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$771.16
|
| Rate for Payer: HealthUtah PPO |
$4,091.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,968.27
|
| Rate for Payer: Multiplan Medicare/VA |
$655.49
|
| Rate for Payer: One Health Plan of WY PPO |
$4,009.18
|
| Rate for Payer: PacificSource Commercial |
$3,681.90
|
| Rate for Payer: PHCS PPO |
$3,886.45
|
| Rate for Payer: Three Rivers PPO |
$3,068.25
|
| Rate for Payer: TriWest Veterans Administration |
$771.16
|
| Rate for Payer: United Healthcare Commercial |
$3,559.17
|
| Rate for Payer: United Healthcare Medicare |
$771.16
|
| Rate for Payer: WINHealth Partners Commercial |
$3,477.35
|
|
|
SALPINGECTOMY COMPLETE/PARTIAL UNI/BI SPX
|
Professional
|
Both
|
$4,091.00
|
|
|
Service Code
|
HCPCS 58700 80
|
| Hospital Charge Code |
58700
|
| Min. Negotiated Rate |
$655.49 |
| Max. Negotiated Rate |
$4,091.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4,009.18
|
| Rate for Payer: Aetna of WY Medicare |
$771.16
|
| Rate for Payer: Beech Street Commercial |
$3,886.45
|
| Rate for Payer: Cash Price |
$2,863.70
|
| Rate for Payer: Cash Price |
$2,863.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,968.27
|
| Rate for Payer: Cigna of WY Commercial |
$4,009.18
|
| Rate for Payer: First Choice Health Commercial |
$3,681.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,886.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$771.16
|
| Rate for Payer: HealthUtah PPO |
$4,091.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,968.27
|
| Rate for Payer: Multiplan Medicare/VA |
$655.49
|
| Rate for Payer: One Health Plan of WY PPO |
$4,009.18
|
| Rate for Payer: PacificSource Commercial |
$3,681.90
|
| Rate for Payer: PHCS PPO |
$3,886.45
|
| Rate for Payer: Three Rivers PPO |
$3,068.25
|
| Rate for Payer: TriWest Veterans Administration |
$771.16
|
| Rate for Payer: United Healthcare Commercial |
$3,559.17
|
| Rate for Payer: United Healthcare Medicare |
$771.16
|
| Rate for Payer: WINHealth Partners Commercial |
$3,477.35
|
|
|
SALPINGECTOMY COMPLETE/PARTIAL UNI/BI SPX
|
Professional
|
Both
|
$4,091.00
|
|
|
Service Code
|
HCPCS 58700 AS
|
| Hospital Charge Code |
58700
|
| Min. Negotiated Rate |
$655.49 |
| Max. Negotiated Rate |
$4,091.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4,009.18
|
| Rate for Payer: Aetna of WY Medicare |
$771.16
|
| Rate for Payer: Beech Street Commercial |
$3,886.45
|
| Rate for Payer: Cash Price |
$2,863.70
|
| Rate for Payer: Cash Price |
$2,863.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,968.27
|
| Rate for Payer: Cigna of WY Commercial |
$4,009.18
|
| Rate for Payer: First Choice Health Commercial |
$3,681.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,886.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$771.16
|
| Rate for Payer: HealthUtah PPO |
$4,091.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,968.27
|
| Rate for Payer: Multiplan Medicare/VA |
$655.49
|
| Rate for Payer: One Health Plan of WY PPO |
$4,009.18
|
| Rate for Payer: PacificSource Commercial |
$3,681.90
|
| Rate for Payer: PHCS PPO |
$3,886.45
|
| Rate for Payer: Three Rivers PPO |
$3,068.25
|
| Rate for Payer: TriWest Veterans Administration |
$771.16
|
| Rate for Payer: United Healthcare Commercial |
$3,559.17
|
| Rate for Payer: United Healthcare Medicare |
$771.16
|
| Rate for Payer: WINHealth Partners Commercial |
$3,477.35
|
|
|
SALPINGO-OOPHORECTOMY COMPL/PRTL UNI/BI SPX
|
Professional
|
Both
|
$3,102.00
|
|
|
Service Code
|
HCPCS 58720 AS
|
| Hospital Charge Code |
58720
|
| Min. Negotiated Rate |
$623.42 |
| Max. Negotiated Rate |
$3,102.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,039.96
|
| Rate for Payer: Aetna of WY Medicare |
$733.43
|
| Rate for Payer: Beech Street Commercial |
$2,946.90
|
| Rate for Payer: Cash Price |
$2,171.40
|
| Rate for Payer: Cash Price |
$2,171.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,008.94
|
| Rate for Payer: Cigna of WY Commercial |
$3,039.96
|
| Rate for Payer: First Choice Health Commercial |
$2,791.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,946.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$733.43
|
| Rate for Payer: HealthUtah PPO |
$3,102.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,008.94
|
| Rate for Payer: Multiplan Medicare/VA |
$623.42
|
| Rate for Payer: One Health Plan of WY PPO |
$3,039.96
|
| Rate for Payer: PacificSource Commercial |
$2,791.80
|
| Rate for Payer: PHCS PPO |
$2,946.90
|
| Rate for Payer: Three Rivers PPO |
$2,326.50
|
| Rate for Payer: TriWest Veterans Administration |
$733.43
|
| Rate for Payer: United Healthcare Commercial |
$2,698.74
|
| Rate for Payer: United Healthcare Medicare |
$733.43
|
| Rate for Payer: WINHealth Partners Commercial |
$2,636.70
|
|
|
SALPINGO-OOPHORECTOMY COMPL/PRTL UNI/BI SPX
|
Professional
|
Both
|
$3,102.00
|
|
|
Service Code
|
HCPCS 58720 80
|
| Hospital Charge Code |
58720
|
| Min. Negotiated Rate |
$623.42 |
| Max. Negotiated Rate |
$3,102.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,039.96
|
| Rate for Payer: Aetna of WY Medicare |
$733.43
|
| Rate for Payer: Beech Street Commercial |
$2,946.90
|
| Rate for Payer: Cash Price |
$2,171.40
|
| Rate for Payer: Cash Price |
$2,171.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,008.94
|
| Rate for Payer: Cigna of WY Commercial |
$3,039.96
|
| Rate for Payer: First Choice Health Commercial |
$2,791.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,946.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$733.43
|
| Rate for Payer: HealthUtah PPO |
$3,102.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,008.94
|
| Rate for Payer: Multiplan Medicare/VA |
$623.42
|
| Rate for Payer: One Health Plan of WY PPO |
$3,039.96
|
| Rate for Payer: PacificSource Commercial |
$2,791.80
|
| Rate for Payer: PHCS PPO |
$2,946.90
|
| Rate for Payer: Three Rivers PPO |
$2,326.50
|
| Rate for Payer: TriWest Veterans Administration |
$733.43
|
| Rate for Payer: United Healthcare Commercial |
$2,698.74
|
| Rate for Payer: United Healthcare Medicare |
$733.43
|
| Rate for Payer: WINHealth Partners Commercial |
$2,636.70
|
|
|
SALPINGO-OOPHORECTOMY COMPL/PRTL UNI/BI SPX
|
Professional
|
Both
|
$3,856.00
|
|
|
Service Code
|
HCPCS 58720
|
| Hospital Charge Code |
58720
|
| Min. Negotiated Rate |
$623.42 |
| Max. Negotiated Rate |
$3,856.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,778.88
|
| Rate for Payer: Aetna of WY Medicare |
$733.43
|
| Rate for Payer: Beech Street Commercial |
$3,663.20
|
| Rate for Payer: Cash Price |
$2,699.20
|
| Rate for Payer: Cash Price |
$2,699.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,740.32
|
| Rate for Payer: Cigna of WY Commercial |
$3,778.88
|
| Rate for Payer: First Choice Health Commercial |
$3,470.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,663.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$733.43
|
| Rate for Payer: HealthUtah PPO |
$3,856.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,740.32
|
| Rate for Payer: Multiplan Medicare/VA |
$623.42
|
| Rate for Payer: One Health Plan of WY PPO |
$3,778.88
|
| Rate for Payer: PacificSource Commercial |
$3,470.40
|
| Rate for Payer: PHCS PPO |
$3,663.20
|
| Rate for Payer: Three Rivers PPO |
$2,892.00
|
| Rate for Payer: TriWest Veterans Administration |
$733.43
|
| Rate for Payer: United Healthcare Commercial |
$3,354.72
|
| Rate for Payer: United Healthcare Medicare |
$733.43
|
| Rate for Payer: WINHealth Partners Commercial |
$3,277.60
|
|
|
SAMPLE LINE MALE LEUR CAPNOFLEX
|
Facility
|
OP
|
$30.05
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$16.56 |
| Max. Negotiated Rate |
$30.05 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$29.45
|
| Rate for Payer: Aetna of WY Medicare |
$19.83
|
| Rate for Payer: Altius Auto/Workers Compensation |
$28.85
|
| Rate for Payer: Altius Commercial |
$28.85
|
| Rate for Payer: Beech Street Commercial |
$29.45
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$24.67
|
| Rate for Payer: Cash Price |
$21.04
|
| Rate for Payer: ChoiceCare Network Commercial |
$29.15
|
| Rate for Payer: Cigna of WY Commercial |
$29.45
|
| Rate for Payer: Entrust Commercial |
$28.55
|
| Rate for Payer: First Choice Health Commercial |
$28.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$28.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$17.43
|
| Rate for Payer: HealthUtah PPO |
$30.05
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$29.15
|
| Rate for Payer: Multiplan Medicare/VA |
$16.56
|
| Rate for Payer: One Health Plan of WY PPO |
$29.45
|
| Rate for Payer: PacificSource Commercial |
$27.04
|
| Rate for Payer: PHCS PPO |
$29.45
|
| Rate for Payer: Three Rivers PPO |
$22.54
|
| Rate for Payer: TriWest Veterans Administration |
$17.43
|
| Rate for Payer: United Healthcare Commercial |
$26.14
|
| Rate for Payer: United Healthcare Medicare |
$17.43
|
| Rate for Payer: WINHealth Partners Commercial |
$29.45
|
| Rate for Payer: Wise Provider Network Commercial |
$28.55
|
|
|
SAMPLE LINE MALE LEUR CAPNOFLEX
|
Facility
|
IP
|
$30.05
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$18.84 |
| Max. Negotiated Rate |
$30.05 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$29.45
|
| Rate for Payer: Altius Auto/Workers Compensation |
$28.85
|
| Rate for Payer: Altius Commercial |
$28.85
|
| Rate for Payer: Beech Street Commercial |
$29.45
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$24.67
|
| Rate for Payer: Cash Price |
$21.04
|
| Rate for Payer: ChoiceCare Network Commercial |
$29.15
|
| Rate for Payer: Cigna of WY Commercial |
$29.45
|
| Rate for Payer: Entrust Commercial |
$28.55
|
| Rate for Payer: First Choice Health Commercial |
$28.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$28.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$19.83
|
| Rate for Payer: HealthUtah PPO |
$30.05
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$29.15
|
| Rate for Payer: Multiplan Medicare/VA |
$18.84
|
| Rate for Payer: One Health Plan of WY PPO |
$29.45
|
| Rate for Payer: PacificSource Commercial |
$27.04
|
| Rate for Payer: PHCS PPO |
$29.45
|
| Rate for Payer: Three Rivers PPO |
$22.54
|
| Rate for Payer: TriWest Veterans Administration |
$19.83
|
| Rate for Payer: United Healthcare Commercial |
$26.14
|
| Rate for Payer: United Healthcare Medicare |
$19.83
|
| Rate for Payer: WINHealth Partners Commercial |
$28.55
|
| Rate for Payer: Wise Provider Network Commercial |
$28.55
|
|
|
SAM SPLINT STANDARD 4.25 x 36"
|
Facility
|
IP
|
$32.16
|
|
| Hospital Charge Code |
27000000S1
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$20.16 |
| Max. Negotiated Rate |
$32.16 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$31.52
|
| Rate for Payer: Altius Auto/Workers Compensation |
$30.87
|
| Rate for Payer: Altius Commercial |
$30.87
|
| Rate for Payer: Beech Street Commercial |
$31.52
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$26.40
|
| Rate for Payer: Cash Price |
$22.52
|
| Rate for Payer: ChoiceCare Network Commercial |
$31.20
|
| Rate for Payer: Cigna of WY Commercial |
$31.52
|
| Rate for Payer: Entrust Commercial |
$30.55
|
| Rate for Payer: First Choice Health Commercial |
$30.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$30.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$21.23
|
| Rate for Payer: HealthUtah PPO |
$32.16
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$31.20
|
| Rate for Payer: Multiplan Medicare/VA |
$20.16
|
| Rate for Payer: One Health Plan of WY PPO |
$31.52
|
| Rate for Payer: PacificSource Commercial |
$28.94
|
| Rate for Payer: PHCS PPO |
$31.52
|
| Rate for Payer: Three Rivers PPO |
$24.12
|
| Rate for Payer: TriWest Veterans Administration |
$21.23
|
| Rate for Payer: United Healthcare Commercial |
$27.98
|
| Rate for Payer: United Healthcare Medicare |
$21.23
|
| Rate for Payer: WINHealth Partners Commercial |
$30.55
|
| Rate for Payer: Wise Provider Network Commercial |
$30.55
|
|
|
SAM SPLINT STANDARD 4.25 x 36"
|
Facility
|
OP
|
$32.16
|
|
| Hospital Charge Code |
27000000S1
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$17.72 |
| Max. Negotiated Rate |
$32.16 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$31.52
|
| Rate for Payer: Aetna of WY Medicare |
$21.23
|
| Rate for Payer: Altius Auto/Workers Compensation |
$30.87
|
| Rate for Payer: Altius Commercial |
$30.87
|
| Rate for Payer: Beech Street Commercial |
$31.52
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$26.40
|
| Rate for Payer: Cash Price |
$22.52
|
| Rate for Payer: ChoiceCare Network Commercial |
$31.20
|
| Rate for Payer: Cigna of WY Commercial |
$31.52
|
| Rate for Payer: Entrust Commercial |
$30.55
|
| Rate for Payer: First Choice Health Commercial |
$30.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$30.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$18.65
|
| Rate for Payer: HealthUtah PPO |
$32.16
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$31.20
|
| Rate for Payer: Multiplan Medicare/VA |
$17.72
|
| Rate for Payer: One Health Plan of WY PPO |
$31.52
|
| Rate for Payer: PacificSource Commercial |
$28.94
|
| Rate for Payer: PHCS PPO |
$31.52
|
| Rate for Payer: Three Rivers PPO |
$24.12
|
| Rate for Payer: TriWest Veterans Administration |
$18.65
|
| Rate for Payer: United Healthcare Commercial |
$27.98
|
| Rate for Payer: United Healthcare Medicare |
$18.65
|
| Rate for Payer: WINHealth Partners Commercial |
$31.52
|
| Rate for Payer: Wise Provider Network Commercial |
$30.55
|
|
|
SAPPHIRE HALF SET MICROBORE Y-SITE
|
Facility
|
OP
|
$28.22
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$15.55 |
| Max. Negotiated Rate |
$28.22 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$27.66
|
| Rate for Payer: Aetna of WY Medicare |
$18.63
|
| Rate for Payer: Altius Auto/Workers Compensation |
$27.09
|
| Rate for Payer: Altius Commercial |
$27.09
|
| Rate for Payer: Beech Street Commercial |
$27.66
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$23.17
|
| Rate for Payer: Cash Price |
$19.75
|
| Rate for Payer: ChoiceCare Network Commercial |
$27.37
|
| Rate for Payer: Cigna of WY Commercial |
$27.66
|
| Rate for Payer: Entrust Commercial |
$26.81
|
| Rate for Payer: First Choice Health Commercial |
$26.81
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$26.81
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$16.37
|
| Rate for Payer: HealthUtah PPO |
$28.22
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$27.37
|
| Rate for Payer: Multiplan Medicare/VA |
$15.55
|
| Rate for Payer: One Health Plan of WY PPO |
$27.66
|
| Rate for Payer: PacificSource Commercial |
$25.40
|
| Rate for Payer: PHCS PPO |
$27.66
|
| Rate for Payer: Three Rivers PPO |
$21.16
|
| Rate for Payer: TriWest Veterans Administration |
$16.37
|
| Rate for Payer: United Healthcare Commercial |
$24.55
|
| Rate for Payer: United Healthcare Medicare |
$16.37
|
| Rate for Payer: WINHealth Partners Commercial |
$27.66
|
| Rate for Payer: Wise Provider Network Commercial |
$26.81
|
|
|
SAPPHIRE HALF SET MICROBORE Y-SITE
|
Facility
|
IP
|
$28.22
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$17.69 |
| Max. Negotiated Rate |
$28.22 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$27.66
|
| Rate for Payer: Altius Auto/Workers Compensation |
$27.09
|
| Rate for Payer: Altius Commercial |
$27.09
|
| Rate for Payer: Beech Street Commercial |
$27.66
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$23.17
|
| Rate for Payer: Cash Price |
$19.75
|
| Rate for Payer: ChoiceCare Network Commercial |
$27.37
|
| Rate for Payer: Cigna of WY Commercial |
$27.66
|
| Rate for Payer: Entrust Commercial |
$26.81
|
| Rate for Payer: First Choice Health Commercial |
$26.81
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$26.81
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$18.63
|
| Rate for Payer: HealthUtah PPO |
$28.22
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$27.37
|
| Rate for Payer: Multiplan Medicare/VA |
$17.69
|
| Rate for Payer: One Health Plan of WY PPO |
$27.66
|
| Rate for Payer: PacificSource Commercial |
$25.40
|
| Rate for Payer: PHCS PPO |
$27.66
|
| Rate for Payer: Three Rivers PPO |
$21.16
|
| Rate for Payer: TriWest Veterans Administration |
$18.63
|
| Rate for Payer: United Healthcare Commercial |
$24.55
|
| Rate for Payer: United Healthcare Medicare |
$18.63
|
| Rate for Payer: WINHealth Partners Commercial |
$26.81
|
| Rate for Payer: Wise Provider Network Commercial |
$26.81
|
|
|
SARSCOV2 VACCINE 50 MCG/0.5 ML FOR IM USE
|
Professional
|
Both
|
$374.00
|
|
|
Service Code
|
HCPCS 91322
|
| Hospital Charge Code |
91322
|
| Min. Negotiated Rate |
$124.03 |
| Max. Negotiated Rate |
$374.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$366.52
|
| Rate for Payer: Aetna of WY Medicare |
$145.92
|
| Rate for Payer: Beech Street Commercial |
$355.30
|
| Rate for Payer: Cash Price |
$261.80
|
| Rate for Payer: Cash Price |
$261.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$362.78
|
| Rate for Payer: Cigna of WY Commercial |
$366.52
|
| Rate for Payer: First Choice Health Commercial |
$336.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$355.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$145.92
|
| Rate for Payer: HealthUtah PPO |
$374.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$362.78
|
| Rate for Payer: Multiplan Medicare/VA |
$124.03
|
| Rate for Payer: One Health Plan of WY PPO |
$366.52
|
| Rate for Payer: PacificSource Commercial |
$336.60
|
| Rate for Payer: PHCS PPO |
$355.30
|
| Rate for Payer: Three Rivers PPO |
$280.50
|
| Rate for Payer: TriWest Veterans Administration |
$145.92
|
| Rate for Payer: United Healthcare Commercial |
$325.38
|
| Rate for Payer: United Healthcare Medicare |
$145.92
|
| Rate for Payer: WINHealth Partners Commercial |
$355.30
|
|
|
SAW 18x1.27x100 6118-127-100
|
Facility
|
IP
|
$168.94
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$105.93 |
| Max. Negotiated Rate |
$168.94 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$165.56
|
| Rate for Payer: Altius Auto/Workers Compensation |
$162.18
|
| Rate for Payer: Altius Commercial |
$162.18
|
| Rate for Payer: Beech Street Commercial |
$165.56
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$138.70
|
| Rate for Payer: Cash Price |
$118.26
|
| Rate for Payer: ChoiceCare Network Commercial |
$163.87
|
| Rate for Payer: Cigna of WY Commercial |
$165.56
|
| Rate for Payer: Entrust Commercial |
$160.49
|
| Rate for Payer: First Choice Health Commercial |
$160.49
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$160.49
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$111.50
|
| Rate for Payer: HealthUtah PPO |
$168.94
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$163.87
|
| Rate for Payer: Multiplan Medicare/VA |
$105.93
|
| Rate for Payer: One Health Plan of WY PPO |
$165.56
|
| Rate for Payer: PacificSource Commercial |
$152.05
|
| Rate for Payer: PHCS PPO |
$165.56
|
| Rate for Payer: Three Rivers PPO |
$126.70
|
| Rate for Payer: TriWest Veterans Administration |
$111.50
|
| Rate for Payer: United Healthcare Commercial |
$146.98
|
| Rate for Payer: United Healthcare Medicare |
$111.50
|
| Rate for Payer: WINHealth Partners Commercial |
$160.49
|
| Rate for Payer: Wise Provider Network Commercial |
$160.49
|
|
|
SAW 18x1.27x100 6118-127-100
|
Facility
|
OP
|
$168.94
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$93.09 |
| Max. Negotiated Rate |
$168.94 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$165.56
|
| Rate for Payer: Aetna of WY Medicare |
$111.50
|
| Rate for Payer: Altius Auto/Workers Compensation |
$162.18
|
| Rate for Payer: Altius Commercial |
$162.18
|
| Rate for Payer: Beech Street Commercial |
$165.56
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$138.70
|
| Rate for Payer: Cash Price |
$118.26
|
| Rate for Payer: ChoiceCare Network Commercial |
$163.87
|
| Rate for Payer: Cigna of WY Commercial |
$165.56
|
| Rate for Payer: Entrust Commercial |
$160.49
|
| Rate for Payer: First Choice Health Commercial |
$160.49
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$160.49
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$97.99
|
| Rate for Payer: HealthUtah PPO |
$168.94
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$163.87
|
| Rate for Payer: Multiplan Medicare/VA |
$93.09
|
| Rate for Payer: One Health Plan of WY PPO |
$165.56
|
| Rate for Payer: PacificSource Commercial |
$152.05
|
| Rate for Payer: PHCS PPO |
$165.56
|
| Rate for Payer: Three Rivers PPO |
$126.70
|
| Rate for Payer: TriWest Veterans Administration |
$97.99
|
| Rate for Payer: United Healthcare Commercial |
$146.98
|
| Rate for Payer: United Healthcare Medicare |
$97.99
|
| Rate for Payer: WINHealth Partners Commercial |
$165.56
|
| Rate for Payer: Wise Provider Network Commercial |
$160.49
|
|
|
SAW BL 9.0X31.0 2296-3-125
|
Facility
|
OP
|
$74.58
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$41.09 |
| Max. Negotiated Rate |
$74.58 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$73.09
|
| Rate for Payer: Aetna of WY Medicare |
$49.22
|
| Rate for Payer: Altius Auto/Workers Compensation |
$71.60
|
| Rate for Payer: Altius Commercial |
$71.60
|
| Rate for Payer: Beech Street Commercial |
$73.09
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$61.23
|
| Rate for Payer: Cash Price |
$52.21
|
| Rate for Payer: ChoiceCare Network Commercial |
$72.34
|
| Rate for Payer: Cigna of WY Commercial |
$73.09
|
| Rate for Payer: Entrust Commercial |
$70.85
|
| Rate for Payer: First Choice Health Commercial |
$70.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$70.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$43.26
|
| Rate for Payer: HealthUtah PPO |
$74.58
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$72.34
|
| Rate for Payer: Multiplan Medicare/VA |
$41.09
|
| Rate for Payer: One Health Plan of WY PPO |
$73.09
|
| Rate for Payer: PacificSource Commercial |
$67.12
|
| Rate for Payer: PHCS PPO |
$73.09
|
| Rate for Payer: Three Rivers PPO |
$55.94
|
| Rate for Payer: TriWest Veterans Administration |
$43.26
|
| Rate for Payer: United Healthcare Commercial |
$64.88
|
| Rate for Payer: United Healthcare Medicare |
$43.26
|
| Rate for Payer: WINHealth Partners Commercial |
$73.09
|
| Rate for Payer: Wise Provider Network Commercial |
$70.85
|
|
|
SAW BL 9.0X31.0 2296-3-125
|
Facility
|
IP
|
$74.58
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$46.76 |
| Max. Negotiated Rate |
$74.58 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$73.09
|
| Rate for Payer: Altius Auto/Workers Compensation |
$71.60
|
| Rate for Payer: Altius Commercial |
$71.60
|
| Rate for Payer: Beech Street Commercial |
$73.09
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$61.23
|
| Rate for Payer: Cash Price |
$52.21
|
| Rate for Payer: ChoiceCare Network Commercial |
$72.34
|
| Rate for Payer: Cigna of WY Commercial |
$73.09
|
| Rate for Payer: Entrust Commercial |
$70.85
|
| Rate for Payer: First Choice Health Commercial |
$70.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$70.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$49.22
|
| Rate for Payer: HealthUtah PPO |
$74.58
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$72.34
|
| Rate for Payer: Multiplan Medicare/VA |
$46.76
|
| Rate for Payer: One Health Plan of WY PPO |
$73.09
|
| Rate for Payer: PacificSource Commercial |
$67.12
|
| Rate for Payer: PHCS PPO |
$73.09
|
| Rate for Payer: Three Rivers PPO |
$55.94
|
| Rate for Payer: TriWest Veterans Administration |
$49.22
|
| Rate for Payer: United Healthcare Commercial |
$64.88
|
| Rate for Payer: United Healthcare Medicare |
$49.22
|
| Rate for Payer: WINHealth Partners Commercial |
$70.85
|
| Rate for Payer: Wise Provider Network Commercial |
$70.85
|
|
|
SAW BLADE 90X1.27MM 21090127YV
|
Facility
|
IP
|
$157.50
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$98.75 |
| Max. Negotiated Rate |
$157.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$154.35
|
| Rate for Payer: Altius Auto/Workers Compensation |
$151.20
|
| Rate for Payer: Altius Commercial |
$151.20
|
| Rate for Payer: Beech Street Commercial |
$154.35
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$129.31
|
| Rate for Payer: Cash Price |
$110.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$152.78
|
| Rate for Payer: Cigna of WY Commercial |
$154.35
|
| Rate for Payer: Entrust Commercial |
$149.62
|
| Rate for Payer: First Choice Health Commercial |
$149.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$149.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$103.95
|
| Rate for Payer: HealthUtah PPO |
$157.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$152.78
|
| Rate for Payer: Multiplan Medicare/VA |
$98.75
|
| Rate for Payer: One Health Plan of WY PPO |
$154.35
|
| Rate for Payer: PacificSource Commercial |
$141.75
|
| Rate for Payer: PHCS PPO |
$154.35
|
| Rate for Payer: Three Rivers PPO |
$118.12
|
| Rate for Payer: TriWest Veterans Administration |
$103.95
|
| Rate for Payer: United Healthcare Commercial |
$137.02
|
| Rate for Payer: United Healthcare Medicare |
$103.95
|
| Rate for Payer: WINHealth Partners Commercial |
$149.62
|
| Rate for Payer: Wise Provider Network Commercial |
$149.62
|
|
|
SAW BLADE 90X1.27MM 21090127YV
|
Facility
|
OP
|
$157.50
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$86.78 |
| Max. Negotiated Rate |
$157.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$154.35
|
| Rate for Payer: Aetna of WY Medicare |
$103.95
|
| Rate for Payer: Altius Auto/Workers Compensation |
$151.20
|
| Rate for Payer: Altius Commercial |
$151.20
|
| Rate for Payer: Beech Street Commercial |
$154.35
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$129.31
|
| Rate for Payer: Cash Price |
$110.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$152.78
|
| Rate for Payer: Cigna of WY Commercial |
$154.35
|
| Rate for Payer: Entrust Commercial |
$149.62
|
| Rate for Payer: First Choice Health Commercial |
$149.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$149.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$91.35
|
| Rate for Payer: HealthUtah PPO |
$157.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$152.78
|
| Rate for Payer: Multiplan Medicare/VA |
$86.78
|
| Rate for Payer: One Health Plan of WY PPO |
$154.35
|
| Rate for Payer: PacificSource Commercial |
$141.75
|
| Rate for Payer: PHCS PPO |
$154.35
|
| Rate for Payer: Three Rivers PPO |
$118.12
|
| Rate for Payer: TriWest Veterans Administration |
$91.35
|
| Rate for Payer: United Healthcare Commercial |
$137.02
|
| Rate for Payer: United Healthcare Medicare |
$91.35
|
| Rate for Payer: WINHealth Partners Commercial |
$154.35
|
| Rate for Payer: Wise Provider Network Commercial |
$149.62
|
|
|
SAW BLADE SAGITTAL 90X.89X25MM
|
Facility
|
IP
|
$154.00
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$96.56 |
| Max. Negotiated Rate |
$154.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$150.92
|
| Rate for Payer: Altius Auto/Workers Compensation |
$147.84
|
| Rate for Payer: Altius Commercial |
$147.84
|
| Rate for Payer: Beech Street Commercial |
$150.92
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$126.43
|
| Rate for Payer: Cash Price |
$107.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$149.38
|
| Rate for Payer: Cigna of WY Commercial |
$150.92
|
| Rate for Payer: Entrust Commercial |
$146.30
|
| Rate for Payer: First Choice Health Commercial |
$146.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$146.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$101.64
|
| Rate for Payer: HealthUtah PPO |
$154.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$149.38
|
| Rate for Payer: Multiplan Medicare/VA |
$96.56
|
| Rate for Payer: One Health Plan of WY PPO |
$150.92
|
| Rate for Payer: PacificSource Commercial |
$138.60
|
| Rate for Payer: PHCS PPO |
$150.92
|
| Rate for Payer: Three Rivers PPO |
$115.50
|
| Rate for Payer: TriWest Veterans Administration |
$101.64
|
| Rate for Payer: United Healthcare Commercial |
$133.98
|
| Rate for Payer: United Healthcare Medicare |
$101.64
|
| Rate for Payer: WINHealth Partners Commercial |
$146.30
|
| Rate for Payer: Wise Provider Network Commercial |
$146.30
|
|
|
SAW BLADE SAGITTAL 90X.89X25MM
|
Facility
|
OP
|
$154.00
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$84.85 |
| Max. Negotiated Rate |
$154.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$150.92
|
| Rate for Payer: Aetna of WY Medicare |
$101.64
|
| Rate for Payer: Altius Auto/Workers Compensation |
$147.84
|
| Rate for Payer: Altius Commercial |
$147.84
|
| Rate for Payer: Beech Street Commercial |
$150.92
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$126.43
|
| Rate for Payer: Cash Price |
$107.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$149.38
|
| Rate for Payer: Cigna of WY Commercial |
$150.92
|
| Rate for Payer: Entrust Commercial |
$146.30
|
| Rate for Payer: First Choice Health Commercial |
$146.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$146.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$89.32
|
| Rate for Payer: HealthUtah PPO |
$154.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$149.38
|
| Rate for Payer: Multiplan Medicare/VA |
$84.85
|
| Rate for Payer: One Health Plan of WY PPO |
$150.92
|
| Rate for Payer: PacificSource Commercial |
$138.60
|
| Rate for Payer: PHCS PPO |
$150.92
|
| Rate for Payer: Three Rivers PPO |
$115.50
|
| Rate for Payer: TriWest Veterans Administration |
$89.32
|
| Rate for Payer: United Healthcare Commercial |
$133.98
|
| Rate for Payer: United Healthcare Medicare |
$89.32
|
| Rate for Payer: WINHealth Partners Commercial |
$150.92
|
| Rate for Payer: Wise Provider Network Commercial |
$146.30
|
|
