|
CLOSED TX RADIAL&ULNAR SHAFT FRACTURES W/O MNPJ
|
Professional
|
Both
|
$1,312.00
|
|
|
Service Code
|
HCPCS 25560
|
| Hospital Charge Code |
25560
|
| Min. Negotiated Rate |
$223.13 |
| Max. Negotiated Rate |
$1,312.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,285.76
|
| Rate for Payer: Aetna of WY Medicare |
$262.51
|
| Rate for Payer: Beech Street Commercial |
$1,246.40
|
| Rate for Payer: Cash Price |
$918.40
|
| Rate for Payer: Cash Price |
$918.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,272.64
|
| Rate for Payer: Cigna of WY Commercial |
$1,285.76
|
| Rate for Payer: First Choice Health Commercial |
$1,180.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,246.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$262.51
|
| Rate for Payer: HealthUtah PPO |
$1,312.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,272.64
|
| Rate for Payer: Multiplan Medicare/VA |
$223.13
|
| Rate for Payer: One Health Plan of WY PPO |
$1,285.76
|
| Rate for Payer: PacificSource Commercial |
$1,180.80
|
| Rate for Payer: PHCS PPO |
$1,246.40
|
| Rate for Payer: Three Rivers PPO |
$984.00
|
| Rate for Payer: TriWest Veterans Administration |
$262.51
|
| Rate for Payer: United Healthcare Commercial |
$1,141.44
|
| Rate for Payer: United Healthcare Medicare |
$262.51
|
| Rate for Payer: WINHealth Partners Commercial |
$1,115.20
|
|
|
CLOSED TX SCAPULAR FRACTURE W/O MANIPULATION
|
Professional
|
Both
|
$1,196.00
|
|
|
Service Code
|
HCPCS 23570
|
| Hospital Charge Code |
23570
|
| Min. Negotiated Rate |
$208.67 |
| Max. Negotiated Rate |
$1,196.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,172.08
|
| Rate for Payer: Aetna of WY Medicare |
$245.49
|
| Rate for Payer: Beech Street Commercial |
$1,136.20
|
| Rate for Payer: Cash Price |
$837.20
|
| Rate for Payer: Cash Price |
$837.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,160.12
|
| Rate for Payer: Cigna of WY Commercial |
$1,172.08
|
| Rate for Payer: First Choice Health Commercial |
$1,076.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,136.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$245.49
|
| Rate for Payer: HealthUtah PPO |
$1,196.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,160.12
|
| Rate for Payer: Multiplan Medicare/VA |
$208.67
|
| Rate for Payer: One Health Plan of WY PPO |
$1,172.08
|
| Rate for Payer: PacificSource Commercial |
$1,076.40
|
| Rate for Payer: PHCS PPO |
$1,136.20
|
| Rate for Payer: Three Rivers PPO |
$897.00
|
| Rate for Payer: TriWest Veterans Administration |
$245.49
|
| Rate for Payer: United Healthcare Commercial |
$1,040.52
|
| Rate for Payer: United Healthcare Medicare |
$245.49
|
| Rate for Payer: WINHealth Partners Commercial |
$1,016.60
|
|
|
CLOSED TX TALUS FRACTURE W/O MANIPULATION
|
Professional
|
Both
|
$1,085.00
|
|
|
Service Code
|
HCPCS 28430
|
| Hospital Charge Code |
28430
|
| Min. Negotiated Rate |
$179.69 |
| Max. Negotiated Rate |
$1,085.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,063.30
|
| Rate for Payer: Aetna of WY Medicare |
$211.40
|
| Rate for Payer: Beech Street Commercial |
$1,030.75
|
| Rate for Payer: Cash Price |
$759.50
|
| Rate for Payer: Cash Price |
$759.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,052.45
|
| Rate for Payer: Cigna of WY Commercial |
$1,063.30
|
| Rate for Payer: First Choice Health Commercial |
$976.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,030.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$211.40
|
| Rate for Payer: HealthUtah PPO |
$1,085.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,052.45
|
| Rate for Payer: Multiplan Medicare/VA |
$179.69
|
| Rate for Payer: One Health Plan of WY PPO |
$1,063.30
|
| Rate for Payer: PacificSource Commercial |
$976.50
|
| Rate for Payer: PHCS PPO |
$1,030.75
|
| Rate for Payer: Three Rivers PPO |
$813.75
|
| Rate for Payer: TriWest Veterans Administration |
$211.40
|
| Rate for Payer: United Healthcare Commercial |
$943.95
|
| Rate for Payer: United Healthcare Medicare |
$211.40
|
| Rate for Payer: WINHealth Partners Commercial |
$922.25
|
|
|
CLOSED TX TARSOMETATARSAL DISLOCATION W/ANES
|
Professional
|
Both
|
$1,721.00
|
|
|
Service Code
|
HCPCS 28605
|
| Hospital Charge Code |
28605
|
| Min. Negotiated Rate |
$260.13 |
| Max. Negotiated Rate |
$1,721.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,686.58
|
| Rate for Payer: Aetna of WY Medicare |
$306.03
|
| Rate for Payer: Beech Street Commercial |
$1,634.95
|
| Rate for Payer: Cash Price |
$1,204.70
|
| Rate for Payer: Cash Price |
$1,204.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,669.37
|
| Rate for Payer: Cigna of WY Commercial |
$1,686.58
|
| Rate for Payer: First Choice Health Commercial |
$1,548.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,634.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$306.03
|
| Rate for Payer: HealthUtah PPO |
$1,721.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,669.37
|
| Rate for Payer: Multiplan Medicare/VA |
$260.13
|
| Rate for Payer: One Health Plan of WY PPO |
$1,686.58
|
| Rate for Payer: PacificSource Commercial |
$1,548.90
|
| Rate for Payer: PHCS PPO |
$1,634.95
|
| Rate for Payer: Three Rivers PPO |
$1,290.75
|
| Rate for Payer: TriWest Veterans Administration |
$306.03
|
| Rate for Payer: United Healthcare Commercial |
$1,497.27
|
| Rate for Payer: United Healthcare Medicare |
$306.03
|
| Rate for Payer: WINHealth Partners Commercial |
$1,462.85
|
|
|
CLOSED TX TEMPOROMANDIBULAR DISLC COMP 1ST/SBSQ
|
Professional
|
Both
|
$4,674.00
|
|
|
Service Code
|
HCPCS 21485
|
| Hospital Charge Code |
21485
|
| Min. Negotiated Rate |
$649.74 |
| Max. Negotiated Rate |
$4,674.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4,580.52
|
| Rate for Payer: Aetna of WY Medicare |
$764.40
|
| Rate for Payer: Beech Street Commercial |
$4,440.30
|
| Rate for Payer: Cash Price |
$3,271.80
|
| Rate for Payer: Cash Price |
$3,271.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$4,533.78
|
| Rate for Payer: Cigna of WY Commercial |
$4,580.52
|
| Rate for Payer: First Choice Health Commercial |
$4,206.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,440.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$764.40
|
| Rate for Payer: HealthUtah PPO |
$4,674.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4,533.78
|
| Rate for Payer: Multiplan Medicare/VA |
$649.74
|
| Rate for Payer: One Health Plan of WY PPO |
$4,580.52
|
| Rate for Payer: PacificSource Commercial |
$4,206.60
|
| Rate for Payer: PHCS PPO |
$4,440.30
|
| Rate for Payer: Three Rivers PPO |
$3,505.50
|
| Rate for Payer: TriWest Veterans Administration |
$764.40
|
| Rate for Payer: United Healthcare Commercial |
$4,066.38
|
| Rate for Payer: United Healthcare Medicare |
$764.40
|
| Rate for Payer: WINHealth Partners Commercial |
$3,972.90
|
|
|
CLOSED TX TEMPOROMANDIBULAR DISLOCATION 1ST/SBSQ
|
Professional
|
Both
|
$601.00
|
|
|
Service Code
|
HCPCS 21480
|
| Hospital Charge Code |
21480
|
| Min. Negotiated Rate |
$25.02 |
| Max. Negotiated Rate |
$601.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$588.98
|
| Rate for Payer: Aetna of WY Medicare |
$29.43
|
| Rate for Payer: Beech Street Commercial |
$570.95
|
| Rate for Payer: Cash Price |
$420.70
|
| Rate for Payer: Cash Price |
$420.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$582.97
|
| Rate for Payer: Cigna of WY Commercial |
$588.98
|
| Rate for Payer: First Choice Health Commercial |
$540.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$570.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$29.43
|
| Rate for Payer: HealthUtah PPO |
$601.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$582.97
|
| Rate for Payer: Multiplan Medicare/VA |
$25.02
|
| Rate for Payer: One Health Plan of WY PPO |
$588.98
|
| Rate for Payer: PacificSource Commercial |
$540.90
|
| Rate for Payer: PHCS PPO |
$570.95
|
| Rate for Payer: Three Rivers PPO |
$450.75
|
| Rate for Payer: TriWest Veterans Administration |
$29.43
|
| Rate for Payer: United Healthcare Commercial |
$522.87
|
| Rate for Payer: United Healthcare Medicare |
$29.43
|
| Rate for Payer: WINHealth Partners Commercial |
$510.85
|
|
|
CLOSED TX ULNAR FRACTURE PROXIMAL END W/MANJ
|
Professional
|
Both
|
$2,149.00
|
|
|
Service Code
|
HCPCS 24675
|
| Hospital Charge Code |
24675
|
| Min. Negotiated Rate |
$353.80 |
| Max. Negotiated Rate |
$2,149.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,106.02
|
| Rate for Payer: Aetna of WY Medicare |
$416.23
|
| Rate for Payer: Beech Street Commercial |
$2,041.55
|
| Rate for Payer: Cash Price |
$1,504.30
|
| Rate for Payer: Cash Price |
$1,504.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,084.53
|
| Rate for Payer: Cigna of WY Commercial |
$2,106.02
|
| Rate for Payer: First Choice Health Commercial |
$1,934.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,041.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$416.23
|
| Rate for Payer: HealthUtah PPO |
$2,149.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,084.53
|
| Rate for Payer: Multiplan Medicare/VA |
$353.80
|
| Rate for Payer: One Health Plan of WY PPO |
$2,106.02
|
| Rate for Payer: PacificSource Commercial |
$1,934.10
|
| Rate for Payer: PHCS PPO |
$2,041.55
|
| Rate for Payer: Three Rivers PPO |
$1,611.75
|
| Rate for Payer: TriWest Veterans Administration |
$416.23
|
| Rate for Payer: United Healthcare Commercial |
$1,869.63
|
| Rate for Payer: United Healthcare Medicare |
$416.23
|
| Rate for Payer: WINHealth Partners Commercial |
$1,826.65
|
|
|
CLOSED TX ULNAR FRACTURE PROXIMAL END W/O MANJ
|
Professional
|
Both
|
$1,365.00
|
|
|
Service Code
|
HCPCS 24670
|
| Hospital Charge Code |
24670
|
| Min. Negotiated Rate |
$229.94 |
| Max. Negotiated Rate |
$1,365.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,337.70
|
| Rate for Payer: Aetna of WY Medicare |
$270.52
|
| Rate for Payer: Beech Street Commercial |
$1,296.75
|
| Rate for Payer: Cash Price |
$955.50
|
| Rate for Payer: Cash Price |
$955.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,324.05
|
| Rate for Payer: Cigna of WY Commercial |
$1,337.70
|
| Rate for Payer: First Choice Health Commercial |
$1,228.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,296.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$270.52
|
| Rate for Payer: HealthUtah PPO |
$1,365.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,324.05
|
| Rate for Payer: Multiplan Medicare/VA |
$229.94
|
| Rate for Payer: One Health Plan of WY PPO |
$1,337.70
|
| Rate for Payer: PacificSource Commercial |
$1,228.50
|
| Rate for Payer: PHCS PPO |
$1,296.75
|
| Rate for Payer: Three Rivers PPO |
$1,023.75
|
| Rate for Payer: TriWest Veterans Administration |
$270.52
|
| Rate for Payer: United Healthcare Commercial |
$1,187.55
|
| Rate for Payer: United Healthcare Medicare |
$270.52
|
| Rate for Payer: WINHealth Partners Commercial |
$1,160.25
|
|
|
CLOSED TX ULNAR SHAFT FRACTURE W/MANIPULATION
|
Professional
|
Both
|
$1,057.00
|
|
|
Service Code
|
HCPCS 25535
|
| Hospital Charge Code |
25535
|
| Min. Negotiated Rate |
$387.45 |
| Max. Negotiated Rate |
$1,057.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,035.86
|
| Rate for Payer: Aetna of WY Medicare |
$455.82
|
| Rate for Payer: Beech Street Commercial |
$1,004.15
|
| Rate for Payer: Cash Price |
$739.90
|
| Rate for Payer: Cash Price |
$739.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,025.29
|
| Rate for Payer: Cigna of WY Commercial |
$1,035.86
|
| Rate for Payer: First Choice Health Commercial |
$951.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,004.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$455.82
|
| Rate for Payer: HealthUtah PPO |
$1,057.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,025.29
|
| Rate for Payer: Multiplan Medicare/VA |
$387.45
|
| Rate for Payer: One Health Plan of WY PPO |
$1,035.86
|
| Rate for Payer: PacificSource Commercial |
$951.30
|
| Rate for Payer: PHCS PPO |
$1,004.15
|
| Rate for Payer: Three Rivers PPO |
$792.75
|
| Rate for Payer: TriWest Veterans Administration |
$455.82
|
| Rate for Payer: United Healthcare Commercial |
$919.59
|
| Rate for Payer: United Healthcare Medicare |
$455.82
|
| Rate for Payer: WINHealth Partners Commercial |
$898.45
|
|
|
CLOSED TX ULNAR SHAFT FRACTURE W/O MANIPULATION
|
Professional
|
Both
|
$963.00
|
|
|
Service Code
|
HCPCS 25530
|
| Hospital Charge Code |
25530
|
| Min. Negotiated Rate |
$209.80 |
| Max. Negotiated Rate |
$963.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$943.74
|
| Rate for Payer: Aetna of WY Medicare |
$246.82
|
| Rate for Payer: Beech Street Commercial |
$914.85
|
| Rate for Payer: Cash Price |
$674.10
|
| Rate for Payer: Cash Price |
$674.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$934.11
|
| Rate for Payer: Cigna of WY Commercial |
$943.74
|
| Rate for Payer: First Choice Health Commercial |
$866.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$914.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$246.82
|
| Rate for Payer: HealthUtah PPO |
$963.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$934.11
|
| Rate for Payer: Multiplan Medicare/VA |
$209.80
|
| Rate for Payer: One Health Plan of WY PPO |
$943.74
|
| Rate for Payer: PacificSource Commercial |
$866.70
|
| Rate for Payer: PHCS PPO |
$914.85
|
| Rate for Payer: Three Rivers PPO |
$722.25
|
| Rate for Payer: TriWest Veterans Administration |
$246.82
|
| Rate for Payer: United Healthcare Commercial |
$837.81
|
| Rate for Payer: United Healthcare Medicare |
$246.82
|
| Rate for Payer: WINHealth Partners Commercial |
$818.55
|
|
|
CLOSURE ENTEROSTOMY LG/SMALL INTESTINE
|
Professional
|
Both
|
$4,481.00
|
|
|
Service Code
|
HCPCS 44620 80
|
| Hospital Charge Code |
44620
|
| Min. Negotiated Rate |
$697.45 |
| Max. Negotiated Rate |
$4,481.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4,391.38
|
| Rate for Payer: Aetna of WY Medicare |
$820.53
|
| Rate for Payer: Beech Street Commercial |
$4,256.95
|
| Rate for Payer: Cash Price |
$3,136.70
|
| Rate for Payer: Cash Price |
$3,136.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$4,346.57
|
| Rate for Payer: Cigna of WY Commercial |
$4,391.38
|
| Rate for Payer: First Choice Health Commercial |
$4,032.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,256.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$820.53
|
| Rate for Payer: HealthUtah PPO |
$4,481.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4,346.57
|
| Rate for Payer: Multiplan Medicare/VA |
$697.45
|
| Rate for Payer: One Health Plan of WY PPO |
$4,391.38
|
| Rate for Payer: PacificSource Commercial |
$4,032.90
|
| Rate for Payer: PHCS PPO |
$4,256.95
|
| Rate for Payer: Three Rivers PPO |
$3,360.75
|
| Rate for Payer: TriWest Veterans Administration |
$820.53
|
| Rate for Payer: United Healthcare Commercial |
$3,898.47
|
| Rate for Payer: United Healthcare Medicare |
$820.53
|
| Rate for Payer: WINHealth Partners Commercial |
$3,808.85
|
|
|
CLOSURE ENTEROSTOMY LG/SMALL INTESTINE
|
Professional
|
Both
|
$4,481.00
|
|
|
Service Code
|
HCPCS 44620 AS
|
| Hospital Charge Code |
44620
|
| Min. Negotiated Rate |
$697.45 |
| Max. Negotiated Rate |
$4,481.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4,391.38
|
| Rate for Payer: Aetna of WY Medicare |
$820.53
|
| Rate for Payer: Beech Street Commercial |
$4,256.95
|
| Rate for Payer: Cash Price |
$3,136.70
|
| Rate for Payer: Cash Price |
$3,136.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$4,346.57
|
| Rate for Payer: Cigna of WY Commercial |
$4,391.38
|
| Rate for Payer: First Choice Health Commercial |
$4,032.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,256.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$820.53
|
| Rate for Payer: HealthUtah PPO |
$4,481.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4,346.57
|
| Rate for Payer: Multiplan Medicare/VA |
$697.45
|
| Rate for Payer: One Health Plan of WY PPO |
$4,391.38
|
| Rate for Payer: PacificSource Commercial |
$4,032.90
|
| Rate for Payer: PHCS PPO |
$4,256.95
|
| Rate for Payer: Three Rivers PPO |
$3,360.75
|
| Rate for Payer: TriWest Veterans Administration |
$820.53
|
| Rate for Payer: United Healthcare Commercial |
$3,898.47
|
| Rate for Payer: United Healthcare Medicare |
$820.53
|
| Rate for Payer: WINHealth Partners Commercial |
$3,808.85
|
|
|
CLOSURE ENTEROSTOMY LG/SMALL INTESTINE
|
Professional
|
Both
|
$4,481.00
|
|
|
Service Code
|
HCPCS 44620
|
| Hospital Charge Code |
44620
|
| Min. Negotiated Rate |
$697.45 |
| Max. Negotiated Rate |
$4,481.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4,391.38
|
| Rate for Payer: Aetna of WY Medicare |
$820.53
|
| Rate for Payer: Beech Street Commercial |
$4,256.95
|
| Rate for Payer: Cash Price |
$3,136.70
|
| Rate for Payer: Cash Price |
$3,136.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$4,346.57
|
| Rate for Payer: Cigna of WY Commercial |
$4,391.38
|
| Rate for Payer: First Choice Health Commercial |
$4,032.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,256.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$820.53
|
| Rate for Payer: HealthUtah PPO |
$4,481.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4,346.57
|
| Rate for Payer: Multiplan Medicare/VA |
$697.45
|
| Rate for Payer: One Health Plan of WY PPO |
$4,391.38
|
| Rate for Payer: PacificSource Commercial |
$4,032.90
|
| Rate for Payer: PHCS PPO |
$4,256.95
|
| Rate for Payer: Three Rivers PPO |
$3,360.75
|
| Rate for Payer: TriWest Veterans Administration |
$820.53
|
| Rate for Payer: United Healthcare Commercial |
$3,898.47
|
| Rate for Payer: United Healthcare Medicare |
$820.53
|
| Rate for Payer: WINHealth Partners Commercial |
$3,808.85
|
|
|
CLOTRIMAZOLE 1 % TOPICAL CREAM [18977]
|
Facility
|
IP
|
$0.61
|
|
|
Service Code
|
NDC 4580243411
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$0.61 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.60
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.59
|
| Rate for Payer: Altius Commercial |
$0.59
|
| Rate for Payer: Beech Street Commercial |
$0.60
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.50
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.59
|
| Rate for Payer: Cigna of WY Commercial |
$0.60
|
| Rate for Payer: Entrust Commercial |
$0.58
|
| Rate for Payer: First Choice Health Commercial |
$0.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.40
|
| Rate for Payer: HealthUtah PPO |
$0.61
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.59
|
| Rate for Payer: Multiplan Medicare/VA |
$0.38
|
| Rate for Payer: One Health Plan of WY PPO |
$0.60
|
| Rate for Payer: PacificSource Commercial |
$0.55
|
| Rate for Payer: PHCS PPO |
$0.60
|
| Rate for Payer: Three Rivers PPO |
$0.46
|
| Rate for Payer: TriWest Veterans Administration |
$0.40
|
| Rate for Payer: United Healthcare Commercial |
$0.53
|
| Rate for Payer: United Healthcare Medicare |
$0.40
|
| Rate for Payer: WINHealth Partners Commercial |
$0.58
|
| Rate for Payer: Wise Provider Network Commercial |
$0.58
|
|
|
CLOTRIMAZOLE 1 % TOPICAL CREAM [18977]
|
Facility
|
IP
|
$0.29
|
|
|
Service Code
|
NDC 0536127222
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.28
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.28
|
| Rate for Payer: Altius Commercial |
$0.28
|
| Rate for Payer: Beech Street Commercial |
$0.28
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.24
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.28
|
| Rate for Payer: Cigna of WY Commercial |
$0.28
|
| Rate for Payer: Entrust Commercial |
$0.28
|
| Rate for Payer: First Choice Health Commercial |
$0.28
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.28
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.19
|
| Rate for Payer: HealthUtah PPO |
$0.29
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.28
|
| Rate for Payer: Multiplan Medicare/VA |
$0.18
|
| Rate for Payer: One Health Plan of WY PPO |
$0.28
|
| Rate for Payer: PacificSource Commercial |
$0.26
|
| Rate for Payer: PHCS PPO |
$0.28
|
| Rate for Payer: Three Rivers PPO |
$0.22
|
| Rate for Payer: TriWest Veterans Administration |
$0.19
|
| Rate for Payer: United Healthcare Commercial |
$0.25
|
| Rate for Payer: United Healthcare Medicare |
$0.19
|
| Rate for Payer: WINHealth Partners Commercial |
$0.28
|
| Rate for Payer: Wise Provider Network Commercial |
$0.28
|
|
|
CLOTRIMAZOLE 1 % TOPICAL CREAM [18977]
|
Facility
|
IP
|
$0.88
|
|
|
Service Code
|
NDC 5167220022
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$0.88 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.86
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.84
|
| Rate for Payer: Altius Commercial |
$0.84
|
| Rate for Payer: Beech Street Commercial |
$0.86
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.72
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.85
|
| Rate for Payer: Cigna of WY Commercial |
$0.86
|
| Rate for Payer: Entrust Commercial |
$0.84
|
| Rate for Payer: First Choice Health Commercial |
$0.84
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.84
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.58
|
| Rate for Payer: HealthUtah PPO |
$0.88
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.85
|
| Rate for Payer: Multiplan Medicare/VA |
$0.55
|
| Rate for Payer: One Health Plan of WY PPO |
$0.86
|
| Rate for Payer: PacificSource Commercial |
$0.79
|
| Rate for Payer: PHCS PPO |
$0.86
|
| Rate for Payer: Three Rivers PPO |
$0.66
|
| Rate for Payer: TriWest Veterans Administration |
$0.58
|
| Rate for Payer: United Healthcare Commercial |
$0.77
|
| Rate for Payer: United Healthcare Medicare |
$0.58
|
| Rate for Payer: WINHealth Partners Commercial |
$0.84
|
| Rate for Payer: Wise Provider Network Commercial |
$0.84
|
|
|
CLOTRIMAZOLE 1 % TOPICAL CREAM [18977]
|
Facility
|
OP
|
$0.29
|
|
|
Service Code
|
NDC 0536127222
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.28
|
| Rate for Payer: Aetna of WY Medicare |
$0.19
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.28
|
| Rate for Payer: Altius Commercial |
$0.28
|
| Rate for Payer: Beech Street Commercial |
$0.28
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.24
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.28
|
| Rate for Payer: Cigna of WY Commercial |
$0.28
|
| Rate for Payer: Entrust Commercial |
$0.28
|
| Rate for Payer: First Choice Health Commercial |
$0.28
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.28
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.17
|
| Rate for Payer: HealthUtah PPO |
$0.29
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.28
|
| Rate for Payer: Multiplan Medicare/VA |
$0.16
|
| Rate for Payer: One Health Plan of WY PPO |
$0.28
|
| Rate for Payer: PacificSource Commercial |
$0.26
|
| Rate for Payer: PHCS PPO |
$0.28
|
| Rate for Payer: Three Rivers PPO |
$0.22
|
| Rate for Payer: TriWest Veterans Administration |
$0.17
|
| Rate for Payer: United Healthcare Commercial |
$0.25
|
| Rate for Payer: United Healthcare Medicare |
$0.17
|
| Rate for Payer: WINHealth Partners Commercial |
$0.28
|
| Rate for Payer: Wise Provider Network Commercial |
$0.28
|
|
|
CLOTRIMAZOLE 1 % TOPICAL CREAM [18977]
|
Facility
|
OP
|
$0.61
|
|
|
Service Code
|
NDC 4580243411
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$0.61 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.60
|
| Rate for Payer: Aetna of WY Medicare |
$0.40
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.59
|
| Rate for Payer: Altius Commercial |
$0.59
|
| Rate for Payer: Beech Street Commercial |
$0.60
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.50
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.59
|
| Rate for Payer: Cigna of WY Commercial |
$0.60
|
| Rate for Payer: Entrust Commercial |
$0.58
|
| Rate for Payer: First Choice Health Commercial |
$0.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.35
|
| Rate for Payer: HealthUtah PPO |
$0.61
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.59
|
| Rate for Payer: Multiplan Medicare/VA |
$0.34
|
| Rate for Payer: One Health Plan of WY PPO |
$0.60
|
| Rate for Payer: PacificSource Commercial |
$0.55
|
| Rate for Payer: PHCS PPO |
$0.60
|
| Rate for Payer: Three Rivers PPO |
$0.46
|
| Rate for Payer: TriWest Veterans Administration |
$0.35
|
| Rate for Payer: United Healthcare Commercial |
$0.53
|
| Rate for Payer: United Healthcare Medicare |
$0.35
|
| Rate for Payer: WINHealth Partners Commercial |
$0.60
|
| Rate for Payer: Wise Provider Network Commercial |
$0.58
|
|
|
CLOTRIMAZOLE 1 % TOPICAL CREAM [18977]
|
Facility
|
OP
|
$0.88
|
|
|
Service Code
|
NDC 5167220022
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$0.88 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.86
|
| Rate for Payer: Aetna of WY Medicare |
$0.58
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.84
|
| Rate for Payer: Altius Commercial |
$0.84
|
| Rate for Payer: Beech Street Commercial |
$0.86
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.72
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.85
|
| Rate for Payer: Cigna of WY Commercial |
$0.86
|
| Rate for Payer: Entrust Commercial |
$0.84
|
| Rate for Payer: First Choice Health Commercial |
$0.84
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.84
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.51
|
| Rate for Payer: HealthUtah PPO |
$0.88
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.85
|
| Rate for Payer: Multiplan Medicare/VA |
$0.48
|
| Rate for Payer: One Health Plan of WY PPO |
$0.86
|
| Rate for Payer: PacificSource Commercial |
$0.79
|
| Rate for Payer: PHCS PPO |
$0.86
|
| Rate for Payer: Three Rivers PPO |
$0.66
|
| Rate for Payer: TriWest Veterans Administration |
$0.51
|
| Rate for Payer: United Healthcare Commercial |
$0.77
|
| Rate for Payer: United Healthcare Medicare |
$0.51
|
| Rate for Payer: WINHealth Partners Commercial |
$0.86
|
| Rate for Payer: Wise Provider Network Commercial |
$0.84
|
|
|
CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM [12862]
|
Facility
|
OP
|
$2.70
|
|
|
Service Code
|
NDC 6846229817
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$2.70 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.65
|
| Rate for Payer: Aetna of WY Medicare |
$1.78
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.59
|
| Rate for Payer: Altius Commercial |
$2.59
|
| Rate for Payer: Beech Street Commercial |
$2.65
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.22
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.62
|
| Rate for Payer: Cigna of WY Commercial |
$2.65
|
| Rate for Payer: Entrust Commercial |
$2.56
|
| Rate for Payer: First Choice Health Commercial |
$2.56
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.56
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.57
|
| Rate for Payer: HealthUtah PPO |
$2.70
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.62
|
| Rate for Payer: Multiplan Medicare/VA |
$1.49
|
| Rate for Payer: One Health Plan of WY PPO |
$2.65
|
| Rate for Payer: PacificSource Commercial |
$2.43
|
| Rate for Payer: PHCS PPO |
$2.65
|
| Rate for Payer: Three Rivers PPO |
$2.02
|
| Rate for Payer: TriWest Veterans Administration |
$1.57
|
| Rate for Payer: United Healthcare Commercial |
$2.35
|
| Rate for Payer: United Healthcare Medicare |
$1.57
|
| Rate for Payer: WINHealth Partners Commercial |
$2.65
|
| Rate for Payer: Wise Provider Network Commercial |
$2.56
|
|
|
CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM [12862]
|
Facility
|
OP
|
$4.50
|
|
|
Service Code
|
NDC 0168025815
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.48 |
| Max. Negotiated Rate |
$4.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4.41
|
| Rate for Payer: Aetna of WY Medicare |
$2.97
|
| Rate for Payer: Altius Auto/Workers Compensation |
$4.32
|
| Rate for Payer: Altius Commercial |
$4.32
|
| Rate for Payer: Beech Street Commercial |
$4.41
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3.69
|
| Rate for Payer: Cash Price |
$3.15
|
| Rate for Payer: ChoiceCare Network Commercial |
$4.36
|
| Rate for Payer: Cigna of WY Commercial |
$4.41
|
| Rate for Payer: Entrust Commercial |
$4.28
|
| Rate for Payer: First Choice Health Commercial |
$4.28
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4.28
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2.61
|
| Rate for Payer: HealthUtah PPO |
$4.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4.36
|
| Rate for Payer: Multiplan Medicare/VA |
$2.48
|
| Rate for Payer: One Health Plan of WY PPO |
$4.41
|
| Rate for Payer: PacificSource Commercial |
$4.05
|
| Rate for Payer: PHCS PPO |
$4.41
|
| Rate for Payer: Three Rivers PPO |
$3.38
|
| Rate for Payer: TriWest Veterans Administration |
$2.61
|
| Rate for Payer: United Healthcare Commercial |
$3.92
|
| Rate for Payer: United Healthcare Medicare |
$2.61
|
| Rate for Payer: WINHealth Partners Commercial |
$4.41
|
| Rate for Payer: Wise Provider Network Commercial |
$4.28
|
|
|
CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM [12862]
|
Facility
|
IP
|
$4.50
|
|
|
Service Code
|
NDC 0168025815
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.82 |
| Max. Negotiated Rate |
$4.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4.41
|
| Rate for Payer: Altius Auto/Workers Compensation |
$4.32
|
| Rate for Payer: Altius Commercial |
$4.32
|
| Rate for Payer: Beech Street Commercial |
$4.41
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3.69
|
| Rate for Payer: Cash Price |
$3.15
|
| Rate for Payer: ChoiceCare Network Commercial |
$4.36
|
| Rate for Payer: Cigna of WY Commercial |
$4.41
|
| Rate for Payer: Entrust Commercial |
$4.28
|
| Rate for Payer: First Choice Health Commercial |
$4.28
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4.28
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2.97
|
| Rate for Payer: HealthUtah PPO |
$4.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4.36
|
| Rate for Payer: Multiplan Medicare/VA |
$2.82
|
| Rate for Payer: One Health Plan of WY PPO |
$4.41
|
| Rate for Payer: PacificSource Commercial |
$4.05
|
| Rate for Payer: PHCS PPO |
$4.41
|
| Rate for Payer: Three Rivers PPO |
$3.38
|
| Rate for Payer: TriWest Veterans Administration |
$2.97
|
| Rate for Payer: United Healthcare Commercial |
$3.92
|
| Rate for Payer: United Healthcare Medicare |
$2.97
|
| Rate for Payer: WINHealth Partners Commercial |
$4.28
|
| Rate for Payer: Wise Provider Network Commercial |
$4.28
|
|
|
CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM [12862]
|
Facility
|
IP
|
$2.70
|
|
|
Service Code
|
NDC 6846229817
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.69 |
| Max. Negotiated Rate |
$2.70 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.65
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.59
|
| Rate for Payer: Altius Commercial |
$2.59
|
| Rate for Payer: Beech Street Commercial |
$2.65
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.22
|
| Rate for Payer: Cash Price |
$1.89
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.62
|
| Rate for Payer: Cigna of WY Commercial |
$2.65
|
| Rate for Payer: Entrust Commercial |
$2.56
|
| Rate for Payer: First Choice Health Commercial |
$2.56
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.56
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.78
|
| Rate for Payer: HealthUtah PPO |
$2.70
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.62
|
| Rate for Payer: Multiplan Medicare/VA |
$1.69
|
| Rate for Payer: One Health Plan of WY PPO |
$2.65
|
| Rate for Payer: PacificSource Commercial |
$2.43
|
| Rate for Payer: PHCS PPO |
$2.65
|
| Rate for Payer: Three Rivers PPO |
$2.02
|
| Rate for Payer: TriWest Veterans Administration |
$1.78
|
| Rate for Payer: United Healthcare Commercial |
$2.35
|
| Rate for Payer: United Healthcare Medicare |
$1.78
|
| Rate for Payer: WINHealth Partners Commercial |
$2.56
|
| Rate for Payer: Wise Provider Network Commercial |
$2.56
|
|
|
CLSD TX ACROMIOCLAVICULAR DISLC W/MANIPULATION
|
Professional
|
Both
|
$1,544.00
|
|
|
Service Code
|
HCPCS 23545
|
| Hospital Charge Code |
23545
|
| Min. Negotiated Rate |
$276.56 |
| Max. Negotiated Rate |
$1,544.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,513.12
|
| Rate for Payer: Aetna of WY Medicare |
$325.37
|
| Rate for Payer: Beech Street Commercial |
$1,466.80
|
| Rate for Payer: Cash Price |
$1,080.80
|
| Rate for Payer: Cash Price |
$1,080.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,497.68
|
| Rate for Payer: Cigna of WY Commercial |
$1,513.12
|
| Rate for Payer: First Choice Health Commercial |
$1,389.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,466.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$325.37
|
| Rate for Payer: HealthUtah PPO |
$1,544.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,497.68
|
| Rate for Payer: Multiplan Medicare/VA |
$276.56
|
| Rate for Payer: One Health Plan of WY PPO |
$1,513.12
|
| Rate for Payer: PacificSource Commercial |
$1,389.60
|
| Rate for Payer: PHCS PPO |
$1,466.80
|
| Rate for Payer: Three Rivers PPO |
$1,158.00
|
| Rate for Payer: TriWest Veterans Administration |
$325.37
|
| Rate for Payer: United Healthcare Commercial |
$1,343.28
|
| Rate for Payer: United Healthcare Medicare |
$325.37
|
| Rate for Payer: WINHealth Partners Commercial |
$1,312.40
|
|
|
CLSD TX ACROMIOCLAVICULAR DISLC W/O MANIPULATION
|
Professional
|
Both
|
$1,151.00
|
|
|
Service Code
|
HCPCS 23540
|
| Hospital Charge Code |
23540
|
| Min. Negotiated Rate |
$203.38 |
| Max. Negotiated Rate |
$1,151.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,127.98
|
| Rate for Payer: Aetna of WY Medicare |
$239.27
|
| Rate for Payer: Beech Street Commercial |
$1,093.45
|
| Rate for Payer: Cash Price |
$805.70
|
| Rate for Payer: Cash Price |
$805.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,116.47
|
| Rate for Payer: Cigna of WY Commercial |
$1,127.98
|
| Rate for Payer: First Choice Health Commercial |
$1,035.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,093.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$239.27
|
| Rate for Payer: HealthUtah PPO |
$1,151.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,116.47
|
| Rate for Payer: Multiplan Medicare/VA |
$203.38
|
| Rate for Payer: One Health Plan of WY PPO |
$1,127.98
|
| Rate for Payer: PacificSource Commercial |
$1,035.90
|
| Rate for Payer: PHCS PPO |
$1,093.45
|
| Rate for Payer: Three Rivers PPO |
$863.25
|
| Rate for Payer: TriWest Veterans Administration |
$239.27
|
| Rate for Payer: United Healthcare Commercial |
$1,001.37
|
| Rate for Payer: United Healthcare Medicare |
$239.27
|
| Rate for Payer: WINHealth Partners Commercial |
$978.35
|
|
