|
SIMPLEX TOBRAMYCIN CEMENT
|
Facility
|
IP
|
$910.00
|
|
| Hospital Charge Code |
27800000S1
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$570.57 |
| Max. Negotiated Rate |
$910.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$891.80
|
| Rate for Payer: Altius Auto/Workers Compensation |
$873.60
|
| Rate for Payer: Altius Commercial |
$873.60
|
| Rate for Payer: Beech Street Commercial |
$891.80
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$747.11
|
| Rate for Payer: Cash Price |
$637.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$882.70
|
| Rate for Payer: Cigna of WY Commercial |
$891.80
|
| Rate for Payer: Entrust Commercial |
$864.50
|
| Rate for Payer: First Choice Health Commercial |
$864.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$864.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$600.60
|
| Rate for Payer: HealthUtah PPO |
$910.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$882.70
|
| Rate for Payer: Multiplan Medicare/VA |
$570.57
|
| Rate for Payer: One Health Plan of WY PPO |
$891.80
|
| Rate for Payer: PacificSource Commercial |
$819.00
|
| Rate for Payer: PHCS PPO |
$891.80
|
| Rate for Payer: Three Rivers PPO |
$682.50
|
| Rate for Payer: TriWest Veterans Administration |
$600.60
|
| Rate for Payer: United Healthcare Commercial |
$791.70
|
| Rate for Payer: United Healthcare Medicare |
$600.60
|
| Rate for Payer: WINHealth Partners Commercial |
$864.50
|
| Rate for Payer: Wise Provider Network Commercial |
$864.50
|
|
|
SIMPLICITY SET: INCLUDES AT X65L & 014613
|
Facility
|
OP
|
$173.25
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$95.46 |
| Max. Negotiated Rate |
$173.25 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$169.78
|
| Rate for Payer: Aetna of WY Medicare |
$114.34
|
| Rate for Payer: Altius Auto/Workers Compensation |
$166.32
|
| Rate for Payer: Altius Commercial |
$166.32
|
| Rate for Payer: Beech Street Commercial |
$169.78
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$142.24
|
| Rate for Payer: Cash Price |
$121.27
|
| Rate for Payer: ChoiceCare Network Commercial |
$168.05
|
| Rate for Payer: Cigna of WY Commercial |
$169.78
|
| Rate for Payer: Entrust Commercial |
$164.59
|
| Rate for Payer: First Choice Health Commercial |
$164.59
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$164.59
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$100.48
|
| Rate for Payer: HealthUtah PPO |
$173.25
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$168.05
|
| Rate for Payer: Multiplan Medicare/VA |
$95.46
|
| Rate for Payer: One Health Plan of WY PPO |
$169.78
|
| Rate for Payer: PacificSource Commercial |
$155.92
|
| Rate for Payer: PHCS PPO |
$169.78
|
| Rate for Payer: Three Rivers PPO |
$129.94
|
| Rate for Payer: TriWest Veterans Administration |
$100.48
|
| Rate for Payer: United Healthcare Commercial |
$150.73
|
| Rate for Payer: United Healthcare Medicare |
$100.48
|
| Rate for Payer: WINHealth Partners Commercial |
$169.78
|
| Rate for Payer: Wise Provider Network Commercial |
$164.59
|
|
|
SIMPLICITY SET: INCLUDES AT X65L & 014613
|
Facility
|
IP
|
$173.25
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$108.63 |
| Max. Negotiated Rate |
$173.25 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$169.78
|
| Rate for Payer: Altius Auto/Workers Compensation |
$166.32
|
| Rate for Payer: Altius Commercial |
$166.32
|
| Rate for Payer: Beech Street Commercial |
$169.78
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$142.24
|
| Rate for Payer: Cash Price |
$121.27
|
| Rate for Payer: ChoiceCare Network Commercial |
$168.05
|
| Rate for Payer: Cigna of WY Commercial |
$169.78
|
| Rate for Payer: Entrust Commercial |
$164.59
|
| Rate for Payer: First Choice Health Commercial |
$164.59
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$164.59
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$114.34
|
| Rate for Payer: HealthUtah PPO |
$173.25
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$168.05
|
| Rate for Payer: Multiplan Medicare/VA |
$108.63
|
| Rate for Payer: One Health Plan of WY PPO |
$169.78
|
| Rate for Payer: PacificSource Commercial |
$155.92
|
| Rate for Payer: PHCS PPO |
$169.78
|
| Rate for Payer: Three Rivers PPO |
$129.94
|
| Rate for Payer: TriWest Veterans Administration |
$114.34
|
| Rate for Payer: United Healthcare Commercial |
$150.73
|
| Rate for Payer: United Healthcare Medicare |
$114.34
|
| Rate for Payer: WINHealth Partners Commercial |
$164.59
|
| Rate for Payer: Wise Provider Network Commercial |
$164.59
|
|
|
SIMVASTATIN 20 MG TABLET [12178]
|
Facility
|
OP
|
$0.96
|
|
|
Service Code
|
NDC 6808451211
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$0.96 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.94
|
| Rate for Payer: Aetna of WY Medicare |
$0.63
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.92
|
| Rate for Payer: Altius Commercial |
$0.92
|
| Rate for Payer: Beech Street Commercial |
$0.94
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.79
|
| Rate for Payer: Cash Price |
$0.67
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.93
|
| Rate for Payer: Cigna of WY Commercial |
$0.94
|
| Rate for Payer: Entrust Commercial |
$0.91
|
| Rate for Payer: First Choice Health Commercial |
$0.91
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.91
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.56
|
| Rate for Payer: HealthUtah PPO |
$0.96
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.93
|
| Rate for Payer: Multiplan Medicare/VA |
$0.53
|
| Rate for Payer: One Health Plan of WY PPO |
$0.94
|
| Rate for Payer: PacificSource Commercial |
$0.86
|
| Rate for Payer: PHCS PPO |
$0.94
|
| Rate for Payer: Three Rivers PPO |
$0.72
|
| Rate for Payer: TriWest Veterans Administration |
$0.56
|
| Rate for Payer: United Healthcare Commercial |
$0.84
|
| Rate for Payer: United Healthcare Medicare |
$0.56
|
| Rate for Payer: WINHealth Partners Commercial |
$0.94
|
| Rate for Payer: Wise Provider Network Commercial |
$0.91
|
|
|
SIMVASTATIN 20 MG TABLET [12178]
|
Facility
|
IP
|
$0.69
|
|
|
Service Code
|
NDC 6373957210
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$0.69 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.68
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.66
|
| Rate for Payer: Altius Commercial |
$0.66
|
| Rate for Payer: Beech Street Commercial |
$0.68
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.57
|
| Rate for Payer: Cash Price |
$0.48
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.67
|
| Rate for Payer: Cigna of WY Commercial |
$0.68
|
| Rate for Payer: Entrust Commercial |
$0.66
|
| Rate for Payer: First Choice Health Commercial |
$0.66
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.66
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.46
|
| Rate for Payer: HealthUtah PPO |
$0.69
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.67
|
| Rate for Payer: Multiplan Medicare/VA |
$0.43
|
| Rate for Payer: One Health Plan of WY PPO |
$0.68
|
| Rate for Payer: PacificSource Commercial |
$0.62
|
| Rate for Payer: PHCS PPO |
$0.68
|
| Rate for Payer: Three Rivers PPO |
$0.52
|
| Rate for Payer: TriWest Veterans Administration |
$0.46
|
| Rate for Payer: United Healthcare Commercial |
$0.60
|
| Rate for Payer: United Healthcare Medicare |
$0.46
|
| Rate for Payer: WINHealth Partners Commercial |
$0.66
|
| Rate for Payer: Wise Provider Network Commercial |
$0.66
|
|
|
SIMVASTATIN 20 MG TABLET [12178]
|
Facility
|
IP
|
$0.96
|
|
|
Service Code
|
NDC 6808451211
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$0.96 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.94
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.92
|
| Rate for Payer: Altius Commercial |
$0.92
|
| Rate for Payer: Beech Street Commercial |
$0.94
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.79
|
| Rate for Payer: Cash Price |
$0.67
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.93
|
| Rate for Payer: Cigna of WY Commercial |
$0.94
|
| Rate for Payer: Entrust Commercial |
$0.91
|
| Rate for Payer: First Choice Health Commercial |
$0.91
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.91
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.63
|
| Rate for Payer: HealthUtah PPO |
$0.96
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.93
|
| Rate for Payer: Multiplan Medicare/VA |
$0.60
|
| Rate for Payer: One Health Plan of WY PPO |
$0.94
|
| Rate for Payer: PacificSource Commercial |
$0.86
|
| Rate for Payer: PHCS PPO |
$0.94
|
| Rate for Payer: Three Rivers PPO |
$0.72
|
| Rate for Payer: TriWest Veterans Administration |
$0.63
|
| Rate for Payer: United Healthcare Commercial |
$0.84
|
| Rate for Payer: United Healthcare Medicare |
$0.63
|
| Rate for Payer: WINHealth Partners Commercial |
$0.91
|
| Rate for Payer: Wise Provider Network Commercial |
$0.91
|
|
|
SIMVASTATIN 20 MG TABLET [12178]
|
Facility
|
OP
|
$0.69
|
|
|
Service Code
|
NDC 6373957210
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$0.69 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.68
|
| Rate for Payer: Aetna of WY Medicare |
$0.46
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.66
|
| Rate for Payer: Altius Commercial |
$0.66
|
| Rate for Payer: Beech Street Commercial |
$0.68
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.57
|
| Rate for Payer: Cash Price |
$0.48
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.67
|
| Rate for Payer: Cigna of WY Commercial |
$0.68
|
| Rate for Payer: Entrust Commercial |
$0.66
|
| Rate for Payer: First Choice Health Commercial |
$0.66
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.66
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.40
|
| Rate for Payer: HealthUtah PPO |
$0.69
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.67
|
| Rate for Payer: Multiplan Medicare/VA |
$0.38
|
| Rate for Payer: One Health Plan of WY PPO |
$0.68
|
| Rate for Payer: PacificSource Commercial |
$0.62
|
| Rate for Payer: PHCS PPO |
$0.68
|
| Rate for Payer: Three Rivers PPO |
$0.52
|
| Rate for Payer: TriWest Veterans Administration |
$0.40
|
| Rate for Payer: United Healthcare Commercial |
$0.60
|
| Rate for Payer: United Healthcare Medicare |
$0.40
|
| Rate for Payer: WINHealth Partners Commercial |
$0.68
|
| Rate for Payer: Wise Provider Network Commercial |
$0.66
|
|
|
SINCALIDE 5 MCG SOLUTION FOR INJECTION [8064]
|
Facility
|
IP
|
$204.99
|
|
|
Service Code
|
HCPCS J2805
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$128.53 |
| Max. Negotiated Rate |
$204.99 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$200.89
|
| Rate for Payer: Altius Auto/Workers Compensation |
$196.79
|
| Rate for Payer: Altius Commercial |
$196.79
|
| Rate for Payer: Beech Street Commercial |
$200.89
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$168.30
|
| Rate for Payer: Cash Price |
$143.49
|
| Rate for Payer: ChoiceCare Network Commercial |
$198.84
|
| Rate for Payer: Cigna of WY Commercial |
$200.89
|
| Rate for Payer: Entrust Commercial |
$194.74
|
| Rate for Payer: First Choice Health Commercial |
$194.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$194.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$135.29
|
| Rate for Payer: HealthUtah PPO |
$204.99
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$198.84
|
| Rate for Payer: Multiplan Medicare/VA |
$128.53
|
| Rate for Payer: One Health Plan of WY PPO |
$200.89
|
| Rate for Payer: PacificSource Commercial |
$184.49
|
| Rate for Payer: PHCS PPO |
$200.89
|
| Rate for Payer: Three Rivers PPO |
$153.74
|
| Rate for Payer: TriWest Veterans Administration |
$135.29
|
| Rate for Payer: United Healthcare Commercial |
$178.34
|
| Rate for Payer: United Healthcare Medicare |
$135.29
|
| Rate for Payer: WINHealth Partners Commercial |
$194.74
|
| Rate for Payer: Wise Provider Network Commercial |
$194.74
|
|
|
SINCALIDE 5 MCG SOLUTION FOR INJECTION [8064]
|
Facility
|
OP
|
$204.99
|
|
|
Service Code
|
HCPCS J2805
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$112.95 |
| Max. Negotiated Rate |
$204.99 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$200.89
|
| Rate for Payer: Aetna of WY Medicare |
$135.29
|
| Rate for Payer: Altius Auto/Workers Compensation |
$196.79
|
| Rate for Payer: Altius Commercial |
$196.79
|
| Rate for Payer: Beech Street Commercial |
$200.89
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$168.30
|
| Rate for Payer: Cash Price |
$143.49
|
| Rate for Payer: ChoiceCare Network Commercial |
$198.84
|
| Rate for Payer: Cigna of WY Commercial |
$200.89
|
| Rate for Payer: Entrust Commercial |
$194.74
|
| Rate for Payer: First Choice Health Commercial |
$194.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$194.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$118.89
|
| Rate for Payer: HealthUtah PPO |
$204.99
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$198.84
|
| Rate for Payer: Multiplan Medicare/VA |
$112.95
|
| Rate for Payer: One Health Plan of WY PPO |
$200.89
|
| Rate for Payer: PacificSource Commercial |
$184.49
|
| Rate for Payer: PHCS PPO |
$200.89
|
| Rate for Payer: Three Rivers PPO |
$153.74
|
| Rate for Payer: TriWest Veterans Administration |
$118.89
|
| Rate for Payer: United Healthcare Commercial |
$178.34
|
| Rate for Payer: United Healthcare Medicare |
$118.89
|
| Rate for Payer: WINHealth Partners Commercial |
$200.89
|
| Rate for Payer: Wise Provider Network Commercial |
$194.74
|
|
|
SINGLE SENSOR ABDOMINAL CATHETER
|
Facility
|
OP
|
$234.50
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$129.21 |
| Max. Negotiated Rate |
$234.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$229.81
|
| Rate for Payer: Aetna of WY Medicare |
$154.77
|
| Rate for Payer: Altius Auto/Workers Compensation |
$225.12
|
| Rate for Payer: Altius Commercial |
$225.12
|
| Rate for Payer: Beech Street Commercial |
$229.81
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$192.52
|
| Rate for Payer: Cash Price |
$164.15
|
| Rate for Payer: ChoiceCare Network Commercial |
$227.46
|
| Rate for Payer: Cigna of WY Commercial |
$229.81
|
| Rate for Payer: Entrust Commercial |
$222.78
|
| Rate for Payer: First Choice Health Commercial |
$222.78
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$222.78
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$136.01
|
| Rate for Payer: HealthUtah PPO |
$234.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$227.46
|
| Rate for Payer: Multiplan Medicare/VA |
$129.21
|
| Rate for Payer: One Health Plan of WY PPO |
$229.81
|
| Rate for Payer: PacificSource Commercial |
$211.05
|
| Rate for Payer: PHCS PPO |
$229.81
|
| Rate for Payer: Three Rivers PPO |
$175.88
|
| Rate for Payer: TriWest Veterans Administration |
$136.01
|
| Rate for Payer: United Healthcare Commercial |
$204.02
|
| Rate for Payer: United Healthcare Medicare |
$136.01
|
| Rate for Payer: WINHealth Partners Commercial |
$229.81
|
| Rate for Payer: Wise Provider Network Commercial |
$222.78
|
|
|
SINGLE SENSOR ABDOMINAL CATHETER
|
Facility
|
IP
|
$234.50
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$147.03 |
| Max. Negotiated Rate |
$234.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$229.81
|
| Rate for Payer: Altius Auto/Workers Compensation |
$225.12
|
| Rate for Payer: Altius Commercial |
$225.12
|
| Rate for Payer: Beech Street Commercial |
$229.81
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$192.52
|
| Rate for Payer: Cash Price |
$164.15
|
| Rate for Payer: ChoiceCare Network Commercial |
$227.46
|
| Rate for Payer: Cigna of WY Commercial |
$229.81
|
| Rate for Payer: Entrust Commercial |
$222.78
|
| Rate for Payer: First Choice Health Commercial |
$222.78
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$222.78
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$154.77
|
| Rate for Payer: HealthUtah PPO |
$234.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$227.46
|
| Rate for Payer: Multiplan Medicare/VA |
$147.03
|
| Rate for Payer: One Health Plan of WY PPO |
$229.81
|
| Rate for Payer: PacificSource Commercial |
$211.05
|
| Rate for Payer: PHCS PPO |
$229.81
|
| Rate for Payer: Three Rivers PPO |
$175.88
|
| Rate for Payer: TriWest Veterans Administration |
$154.77
|
| Rate for Payer: United Healthcare Commercial |
$204.02
|
| Rate for Payer: United Healthcare Medicare |
$154.77
|
| Rate for Payer: WINHealth Partners Commercial |
$222.78
|
| Rate for Payer: Wise Provider Network Commercial |
$222.78
|
|
|
SINGLE VITAMIN NOS
|
Professional
|
Both
|
$35.00
|
|
|
Service Code
|
HCPCS A9152
|
| Hospital Charge Code |
A9152
|
| Min. Negotiated Rate |
$26.25 |
| Max. Negotiated Rate |
$35.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$34.30
|
| Rate for Payer: Beech Street Commercial |
$33.25
|
| Rate for Payer: Cash Price |
$24.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$33.95
|
| Rate for Payer: Cigna of WY Commercial |
$34.30
|
| Rate for Payer: First Choice Health Commercial |
$31.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$33.25
|
| Rate for Payer: HealthUtah PPO |
$35.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$33.95
|
| Rate for Payer: One Health Plan of WY PPO |
$34.30
|
| Rate for Payer: PacificSource Commercial |
$31.50
|
| Rate for Payer: PHCS PPO |
$33.25
|
| Rate for Payer: Three Rivers PPO |
$26.25
|
| Rate for Payer: United Healthcare Commercial |
$30.45
|
| Rate for Payer: WINHealth Partners Commercial |
$33.25
|
|
|
SINUFOAM RR650
|
Facility
|
IP
|
$306.42
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$192.13 |
| Max. Negotiated Rate |
$306.42 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$300.29
|
| Rate for Payer: Altius Auto/Workers Compensation |
$294.16
|
| Rate for Payer: Altius Commercial |
$294.16
|
| Rate for Payer: Beech Street Commercial |
$300.29
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$251.57
|
| Rate for Payer: Cash Price |
$214.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$297.23
|
| Rate for Payer: Cigna of WY Commercial |
$300.29
|
| Rate for Payer: Entrust Commercial |
$291.10
|
| Rate for Payer: First Choice Health Commercial |
$291.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$291.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$202.24
|
| Rate for Payer: HealthUtah PPO |
$306.42
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$297.23
|
| Rate for Payer: Multiplan Medicare/VA |
$192.13
|
| Rate for Payer: One Health Plan of WY PPO |
$300.29
|
| Rate for Payer: PacificSource Commercial |
$275.78
|
| Rate for Payer: PHCS PPO |
$300.29
|
| Rate for Payer: Three Rivers PPO |
$229.82
|
| Rate for Payer: TriWest Veterans Administration |
$202.24
|
| Rate for Payer: United Healthcare Commercial |
$266.59
|
| Rate for Payer: United Healthcare Medicare |
$202.24
|
| Rate for Payer: WINHealth Partners Commercial |
$291.10
|
| Rate for Payer: Wise Provider Network Commercial |
$291.10
|
|
|
SINUFOAM RR650
|
Facility
|
OP
|
$306.42
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$168.84 |
| Max. Negotiated Rate |
$306.42 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$300.29
|
| Rate for Payer: Aetna of WY Medicare |
$202.24
|
| Rate for Payer: Altius Auto/Workers Compensation |
$294.16
|
| Rate for Payer: Altius Commercial |
$294.16
|
| Rate for Payer: Beech Street Commercial |
$300.29
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$251.57
|
| Rate for Payer: Cash Price |
$214.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$297.23
|
| Rate for Payer: Cigna of WY Commercial |
$300.29
|
| Rate for Payer: Entrust Commercial |
$291.10
|
| Rate for Payer: First Choice Health Commercial |
$291.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$291.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$177.72
|
| Rate for Payer: HealthUtah PPO |
$306.42
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$297.23
|
| Rate for Payer: Multiplan Medicare/VA |
$168.84
|
| Rate for Payer: One Health Plan of WY PPO |
$300.29
|
| Rate for Payer: PacificSource Commercial |
$275.78
|
| Rate for Payer: PHCS PPO |
$300.29
|
| Rate for Payer: Three Rivers PPO |
$229.82
|
| Rate for Payer: TriWest Veterans Administration |
$177.72
|
| Rate for Payer: United Healthcare Commercial |
$266.59
|
| Rate for Payer: United Healthcare Medicare |
$177.72
|
| Rate for Payer: WINHealth Partners Commercial |
$300.29
|
| Rate for Payer: Wise Provider Network Commercial |
$291.10
|
|
|
SINUSOTOMY FRONTAL EXTERNAL SIMPLE
|
Professional
|
Both
|
$1,664.00
|
|
|
Service Code
|
HCPCS 31070
|
| Hospital Charge Code |
31070
|
| Min. Negotiated Rate |
$396.21 |
| Max. Negotiated Rate |
$1,664.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,630.72
|
| Rate for Payer: Aetna of WY Medicare |
$466.13
|
| Rate for Payer: Beech Street Commercial |
$1,580.80
|
| Rate for Payer: Cash Price |
$1,164.80
|
| Rate for Payer: Cash Price |
$1,164.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,614.08
|
| Rate for Payer: Cigna of WY Commercial |
$1,630.72
|
| Rate for Payer: First Choice Health Commercial |
$1,497.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,580.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$466.13
|
| Rate for Payer: HealthUtah PPO |
$1,664.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,614.08
|
| Rate for Payer: Multiplan Medicare/VA |
$396.21
|
| Rate for Payer: One Health Plan of WY PPO |
$1,630.72
|
| Rate for Payer: PacificSource Commercial |
$1,497.60
|
| Rate for Payer: PHCS PPO |
$1,580.80
|
| Rate for Payer: Three Rivers PPO |
$1,248.00
|
| Rate for Payer: TriWest Veterans Administration |
$466.13
|
| Rate for Payer: United Healthcare Commercial |
$1,447.68
|
| Rate for Payer: United Healthcare Medicare |
$466.13
|
| Rate for Payer: WINHealth Partners Commercial |
$1,414.40
|
|
|
SINUSOTOMY FRONTAL TRANSORBITAL UNILATERAL
|
Professional
|
Both
|
$2,881.00
|
|
|
Service Code
|
HCPCS 31075
|
| Hospital Charge Code |
31075
|
| Min. Negotiated Rate |
$686.07 |
| Max. Negotiated Rate |
$2,881.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,823.38
|
| Rate for Payer: Aetna of WY Medicare |
$807.14
|
| Rate for Payer: Beech Street Commercial |
$2,736.95
|
| Rate for Payer: Cash Price |
$2,016.70
|
| Rate for Payer: Cash Price |
$2,016.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,794.57
|
| Rate for Payer: Cigna of WY Commercial |
$2,823.38
|
| Rate for Payer: First Choice Health Commercial |
$2,592.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,736.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$807.14
|
| Rate for Payer: HealthUtah PPO |
$2,881.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,794.57
|
| Rate for Payer: Multiplan Medicare/VA |
$686.07
|
| Rate for Payer: One Health Plan of WY PPO |
$2,823.38
|
| Rate for Payer: PacificSource Commercial |
$2,592.90
|
| Rate for Payer: PHCS PPO |
$2,736.95
|
| Rate for Payer: Three Rivers PPO |
$2,160.75
|
| Rate for Payer: TriWest Veterans Administration |
$807.14
|
| Rate for Payer: United Healthcare Commercial |
$2,506.47
|
| Rate for Payer: United Healthcare Medicare |
$807.14
|
| Rate for Payer: WINHealth Partners Commercial |
$2,448.85
|
|
|
SINUSOTOMY MAXILLARY RAD W/O RMVL ANTROCH POLYPS
|
Professional
|
Both
|
$2,647.00
|
|
|
Service Code
|
HCPCS 31030
|
| Hospital Charge Code |
31030
|
| Min. Negotiated Rate |
$426.25 |
| Max. Negotiated Rate |
$2,647.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,594.06
|
| Rate for Payer: Aetna of WY Medicare |
$501.47
|
| Rate for Payer: Beech Street Commercial |
$2,514.65
|
| Rate for Payer: Cash Price |
$1,852.90
|
| Rate for Payer: Cash Price |
$1,852.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,567.59
|
| Rate for Payer: Cigna of WY Commercial |
$2,594.06
|
| Rate for Payer: First Choice Health Commercial |
$2,382.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,514.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$501.47
|
| Rate for Payer: HealthUtah PPO |
$2,647.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,567.59
|
| Rate for Payer: Multiplan Medicare/VA |
$426.25
|
| Rate for Payer: One Health Plan of WY PPO |
$2,594.06
|
| Rate for Payer: PacificSource Commercial |
$2,382.30
|
| Rate for Payer: PHCS PPO |
$2,514.65
|
| Rate for Payer: Three Rivers PPO |
$1,985.25
|
| Rate for Payer: TriWest Veterans Administration |
$501.47
|
| Rate for Payer: United Healthcare Commercial |
$2,302.89
|
| Rate for Payer: United Healthcare Medicare |
$501.47
|
| Rate for Payer: WINHealth Partners Commercial |
$2,249.95
|
|
|
SINUSOTOMY SPHENOID W/WO BIOPSY
|
Professional
|
Both
|
$3,608.00
|
|
|
Service Code
|
HCPCS 31050 50
|
| Hospital Charge Code |
31050
|
| Min. Negotiated Rate |
$429.63 |
| Max. Negotiated Rate |
$3,608.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,535.84
|
| Rate for Payer: Aetna of WY Medicare |
$505.45
|
| Rate for Payer: Beech Street Commercial |
$3,427.60
|
| Rate for Payer: Cash Price |
$2,525.60
|
| Rate for Payer: Cash Price |
$2,525.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,499.76
|
| Rate for Payer: Cigna of WY Commercial |
$3,535.84
|
| Rate for Payer: First Choice Health Commercial |
$3,247.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,427.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$505.45
|
| Rate for Payer: HealthUtah PPO |
$3,608.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,499.76
|
| Rate for Payer: Multiplan Medicare/VA |
$429.63
|
| Rate for Payer: One Health Plan of WY PPO |
$3,535.84
|
| Rate for Payer: PacificSource Commercial |
$3,247.20
|
| Rate for Payer: PHCS PPO |
$3,427.60
|
| Rate for Payer: Three Rivers PPO |
$2,706.00
|
| Rate for Payer: TriWest Veterans Administration |
$505.45
|
| Rate for Payer: United Healthcare Commercial |
$3,138.96
|
| Rate for Payer: United Healthcare Medicare |
$505.45
|
| Rate for Payer: WINHealth Partners Commercial |
$3,066.80
|
|
|
SITAGLIPTIN PHOSPHATE 50 MG TABLET [42252]
|
Facility
|
IP
|
$33.00
|
|
|
Service Code
|
NDC 0006011228
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.69 |
| Max. Negotiated Rate |
$33.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$32.34
|
| Rate for Payer: Altius Auto/Workers Compensation |
$31.68
|
| Rate for Payer: Altius Commercial |
$31.68
|
| Rate for Payer: Beech Street Commercial |
$32.34
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$27.09
|
| Rate for Payer: Cash Price |
$23.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$32.01
|
| Rate for Payer: Cigna of WY Commercial |
$32.34
|
| Rate for Payer: Entrust Commercial |
$31.35
|
| Rate for Payer: First Choice Health Commercial |
$31.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$31.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$21.78
|
| Rate for Payer: HealthUtah PPO |
$33.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$32.01
|
| Rate for Payer: Multiplan Medicare/VA |
$20.69
|
| Rate for Payer: One Health Plan of WY PPO |
$32.34
|
| Rate for Payer: PacificSource Commercial |
$29.70
|
| Rate for Payer: PHCS PPO |
$32.34
|
| Rate for Payer: Three Rivers PPO |
$24.75
|
| Rate for Payer: TriWest Veterans Administration |
$21.78
|
| Rate for Payer: United Healthcare Commercial |
$28.71
|
| Rate for Payer: United Healthcare Medicare |
$21.78
|
| Rate for Payer: WINHealth Partners Commercial |
$31.35
|
| Rate for Payer: Wise Provider Network Commercial |
$31.35
|
|
|
SITAGLIPTIN PHOSPHATE 50 MG TABLET [42252]
|
Facility
|
OP
|
$33.00
|
|
|
Service Code
|
NDC 0006011228
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.18 |
| Max. Negotiated Rate |
$33.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$32.34
|
| Rate for Payer: Aetna of WY Medicare |
$21.78
|
| Rate for Payer: Altius Auto/Workers Compensation |
$31.68
|
| Rate for Payer: Altius Commercial |
$31.68
|
| Rate for Payer: Beech Street Commercial |
$32.34
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$27.09
|
| Rate for Payer: Cash Price |
$23.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$32.01
|
| Rate for Payer: Cigna of WY Commercial |
$32.34
|
| Rate for Payer: Entrust Commercial |
$31.35
|
| Rate for Payer: First Choice Health Commercial |
$31.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$31.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$19.14
|
| Rate for Payer: HealthUtah PPO |
$33.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$32.01
|
| Rate for Payer: Multiplan Medicare/VA |
$18.18
|
| Rate for Payer: One Health Plan of WY PPO |
$32.34
|
| Rate for Payer: PacificSource Commercial |
$29.70
|
| Rate for Payer: PHCS PPO |
$32.34
|
| Rate for Payer: Three Rivers PPO |
$24.75
|
| Rate for Payer: TriWest Veterans Administration |
$19.14
|
| Rate for Payer: United Healthcare Commercial |
$28.71
|
| Rate for Payer: United Healthcare Medicare |
$19.14
|
| Rate for Payer: WINHealth Partners Commercial |
$32.34
|
| Rate for Payer: Wise Provider Network Commercial |
$31.35
|
|
|
SITAGLIPTIN PHOSPHATE 50 MG TABLET [42252]
|
Facility
|
OP
|
$33.00
|
|
|
Service Code
|
NDC 0006011201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.18 |
| Max. Negotiated Rate |
$33.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$32.34
|
| Rate for Payer: Aetna of WY Medicare |
$21.78
|
| Rate for Payer: Altius Auto/Workers Compensation |
$31.68
|
| Rate for Payer: Altius Commercial |
$31.68
|
| Rate for Payer: Beech Street Commercial |
$32.34
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$27.09
|
| Rate for Payer: Cash Price |
$23.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$32.01
|
| Rate for Payer: Cigna of WY Commercial |
$32.34
|
| Rate for Payer: Entrust Commercial |
$31.35
|
| Rate for Payer: First Choice Health Commercial |
$31.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$31.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$19.14
|
| Rate for Payer: HealthUtah PPO |
$33.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$32.01
|
| Rate for Payer: Multiplan Medicare/VA |
$18.18
|
| Rate for Payer: One Health Plan of WY PPO |
$32.34
|
| Rate for Payer: PacificSource Commercial |
$29.70
|
| Rate for Payer: PHCS PPO |
$32.34
|
| Rate for Payer: Three Rivers PPO |
$24.75
|
| Rate for Payer: TriWest Veterans Administration |
$19.14
|
| Rate for Payer: United Healthcare Commercial |
$28.71
|
| Rate for Payer: United Healthcare Medicare |
$19.14
|
| Rate for Payer: WINHealth Partners Commercial |
$32.34
|
| Rate for Payer: Wise Provider Network Commercial |
$31.35
|
|
|
SITAGLIPTIN PHOSPHATE 50 MG TABLET [42252]
|
Facility
|
IP
|
$33.00
|
|
|
Service Code
|
NDC 0006011201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.69 |
| Max. Negotiated Rate |
$33.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$32.34
|
| Rate for Payer: Altius Auto/Workers Compensation |
$31.68
|
| Rate for Payer: Altius Commercial |
$31.68
|
| Rate for Payer: Beech Street Commercial |
$32.34
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$27.09
|
| Rate for Payer: Cash Price |
$23.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$32.01
|
| Rate for Payer: Cigna of WY Commercial |
$32.34
|
| Rate for Payer: Entrust Commercial |
$31.35
|
| Rate for Payer: First Choice Health Commercial |
$31.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$31.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$21.78
|
| Rate for Payer: HealthUtah PPO |
$33.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$32.01
|
| Rate for Payer: Multiplan Medicare/VA |
$20.69
|
| Rate for Payer: One Health Plan of WY PPO |
$32.34
|
| Rate for Payer: PacificSource Commercial |
$29.70
|
| Rate for Payer: PHCS PPO |
$32.34
|
| Rate for Payer: Three Rivers PPO |
$24.75
|
| Rate for Payer: TriWest Veterans Administration |
$21.78
|
| Rate for Payer: United Healthcare Commercial |
$28.71
|
| Rate for Payer: United Healthcare Medicare |
$21.78
|
| Rate for Payer: WINHealth Partners Commercial |
$31.35
|
| Rate for Payer: Wise Provider Network Commercial |
$31.35
|
|
|
SKIN TEST TUBERCULOSIS INTRADERMAL
|
Professional
|
Both
|
$44.00
|
|
|
Service Code
|
HCPCS 86580
|
| Hospital Charge Code |
86580
|
| Min. Negotiated Rate |
$8.56 |
| Max. Negotiated Rate |
$44.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$43.12
|
| Rate for Payer: Aetna of WY Medicare |
$10.07
|
| 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 |
$10.07
|
| Rate for Payer: HealthUtah PPO |
$44.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$42.68
|
| Rate for Payer: Multiplan Medicare/VA |
$8.56
|
| 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 |
$10.07
|
| Rate for Payer: United Healthcare Commercial |
$38.28
|
| Rate for Payer: United Healthcare Medicare |
$10.07
|
| Rate for Payer: WINHealth Partners Commercial |
$41.80
|
|
|
SKYLA, 13.5 MG
|
Professional
|
Both
|
$1,560.00
|
|
|
Service Code
|
HCPCS J7301
|
| Hospital Charge Code |
J7301
|
| Min. Negotiated Rate |
$1,170.00 |
| Max. Negotiated Rate |
$1,560.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,528.80
|
| Rate for Payer: Beech Street Commercial |
$1,482.00
|
| Rate for Payer: Cash Price |
$1,092.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,513.20
|
| Rate for Payer: Cigna of WY Commercial |
$1,528.80
|
| Rate for Payer: First Choice Health Commercial |
$1,404.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,482.00
|
| Rate for Payer: HealthUtah PPO |
$1,560.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,513.20
|
| Rate for Payer: One Health Plan of WY PPO |
$1,528.80
|
| Rate for Payer: PacificSource Commercial |
$1,404.00
|
| Rate for Payer: PHCS PPO |
$1,482.00
|
| Rate for Payer: Three Rivers PPO |
$1,170.00
|
| Rate for Payer: United Healthcare Commercial |
$1,357.20
|
| Rate for Payer: WINHealth Partners Commercial |
$1,482.00
|
|
|
SLEEP STD AIRFLOW HRT RATE&O2 SAT EFFORT UNATT
|
Professional
|
Both
|
$254.00
|
|
|
Service Code
|
HCPCS 95806 26
|
| Hospital Charge Code |
95806
|
| Min. Negotiated Rate |
$35.68 |
| Max. Negotiated Rate |
$254.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$248.92
|
| Rate for Payer: Aetna of WY Medicare |
$41.98
|
| Rate for Payer: Beech Street Commercial |
$241.30
|
| Rate for Payer: Cash Price |
$177.80
|
| Rate for Payer: Cash Price |
$177.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$246.38
|
| Rate for Payer: Cigna of WY Commercial |
$248.92
|
| Rate for Payer: First Choice Health Commercial |
$228.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$241.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$41.98
|
| Rate for Payer: HealthUtah PPO |
$254.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$246.38
|
| Rate for Payer: Multiplan Medicare/VA |
$35.68
|
| Rate for Payer: One Health Plan of WY PPO |
$248.92
|
| Rate for Payer: PacificSource Commercial |
$228.60
|
| Rate for Payer: PHCS PPO |
$241.30
|
| Rate for Payer: Three Rivers PPO |
$190.50
|
| Rate for Payer: TriWest Veterans Administration |
$41.98
|
| Rate for Payer: United Healthcare Commercial |
$220.98
|
| Rate for Payer: United Healthcare Medicare |
$41.98
|
| Rate for Payer: WINHealth Partners Commercial |
$241.30
|
|
