Shoppable Services at Park City Hospital

General Disclosure

The two lists of standard charges displayed represent the pricing information for medical items and services required by the federal Hospital Price Transparency Rule. The pricing information does not necessarily reflect your financial responsibility for your hospital visit, for several reasons, including:

  • The listings reflect prices paid by your insurer for services provided during your hospital visit, which may not reflect your share of the costs for these services under the terms of your health plan.
  • The prices for your insurer are only available if your insurer covers the medical items or services under the terms of your health plan.
  • The actual medical items, including medications, and services that are furnished to you during your visit may vary from what is anticipated.
  • You may receive services or supplies from physicians, practitioners or contractors who are not employed by this hospital; the prices for such services or supplies are not listed here.
  • Your insurer may not be contracted with this hospital for all services. The posted prices will not apply to services for which your insurer has not contracted.

These listings do not guarantee pricing, coverage, benefits, or payments. Your financial liability will be based on the medical items and services billed by the hospital, the terms of your insurance policy, and the status of your benefits (i.e., deductibles, out of pocket maximum, co-insurance, and copays) at the time you receive care. Your eligibility and the amounts covered by your insurance are solely determined by your health insurance provider.

We encourage you to contact a Hospital Cost Estimation Specialist at (855) 442-8601 or INTCostEstimate@R1RCM.com or your insurer to obtain more precise information regarding your potential financial liability.

CDM Bill Item Service Code Service Description Payer Plan Name Inpatient Cash Price Inpatient Min Price Inpatient Max Price Inpatient Negotiated Price Outpatient Cash Price Outpatient Min Price Outpatient Max Price Outpatient Negotiated Price Charge Price
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A SelectHealth SelectHealth Med Network Individual Plan (ACA) $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A SelectHealth SelectHealth Med Network Individual Plan (ACA) $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A SelectHealth SelectHealth Med Network $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A SelectHealth SelectHealth Med Network $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A SelectHealth SelectHealth Med Network CHIP $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A SelectHealth SelectHealth Med Network CHIP $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A SelectHealth SelectHealth Value Network Individual Plan (ACA) $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A SelectHealth SelectHealth Value Network Individual Plan (ACA) $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A SelectHealth SelectHealth Share Network $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A SelectHealth SelectHealth Community Care-Medicaid $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A SelectHealth SelectHealth Share Network $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A SelectHealth SelectHealth Community Care-Medicaid $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A Regence BlueCross BlueShield of Utah Regence Focal Point $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A Regence BlueCross BlueShield of Utah Regence BCBS Traditional Plan $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A Regence BlueCross BlueShield of Utah Regence Bridgespan RealValue $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A Regence BlueCross BlueShield of Utah Regence BCBS Preferred BlueOption (PBO) $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A Regence BlueCross BlueShield of Utah Regence Individual and Family Network $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A Regence BlueCross BlueShield of Utah Regence Individual and Family Network $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A Regence BlueCross BlueShield of Utah Regence BCBS Preferred BlueOption (PBO) $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A Regence BlueCross BlueShield of Utah Regence BCBS Traditional Plan $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A Regence BlueCross BlueShield of Utah Regence Focal Point $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A Regence BlueCross BlueShield of Utah Regence BCBS ValueCare $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A Regence BlueCross BlueShield of Utah Regence BCBS ValueCare $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A Regence BlueCross BlueShield of Utah Regence Bridgespan RealValue $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A Regence BlueCross BlueShield of Utah Regence BCBS Federal (FEHBP) $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A Regence BlueCross BlueShield of Utah Regence BCBS Federal (FEHBP) $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A Provider Networks of America Provider Networks of America (PNOA) $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A Provider Networks of America Provider Networks of America (PNOA) $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A Prodegi Corporate Benefit Services, LLC Prodegi Corporate Benefit Services, LLC $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A Prodegi Corporate Benefit Services, LLC Prodegi Corporate Benefit Services, LLC $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A Petersen, Inc. Petersen, Inc. $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A Petersen, Inc. Petersen, Inc. $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A PEHP PEHP Advantage Care - Non State $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A PEHP PEHP Summit Care $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A PEHP PEHP Capital Care $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A PEHP PEHP Advantage Care State Employees and Advantage Care Exclusive $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A PEHP PEHP Advantage Care State Employees and Advantage Care Exclusive $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A PEHP PEHP Summit Exclusive $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A PEHP PEHP Advantage Care - Non State $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A PEHP PEHP Summit Exclusive $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A PEHP PEHP Preferred Care $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A PEHP PEHP Preferred Care $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A PEHP PEHP Summit Care $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A PEHP PEHP Capital Care $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A MotivHealth MotivHealth $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A MotivHealth MotivHealth $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A MotivHealth MotivHealth $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A MotivHealth MotivHealth $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A Molina Healthcare of Utah Molina Marketplace $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A Molina Healthcare of Utah Molina Healthcare Medicaid HMO $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A Molina Healthcare of Utah Molina Marketplace $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A Molina Healthcare of Utah Molina CHIP $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A Molina Healthcare of Utah Molina Healthcare Medicaid HMO $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A Molina Healthcare of Utah Molina CHIP $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A MedCare International, Inc. MedCare International, Inc. $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A Deseret Mutual DMBA Deseret Value $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A Deseret Mutual DMBA Deseret Select $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A Corporation of the President Corporation of the President $45.00 $40.00 $54.00 $45.00 $45.00 $40.00 $54.00 $45.00 $60.00
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A Corporation of the President Corporation of the President $45.00 $40.00 $54.00 $45.00 $45.00 $40.00 $54.00 $45.00 $60.00
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A CorVel Corporation CorVel Corporation $45.00 $40.00 $54.00 $45.00 $45.00 $40.00 $54.00 $45.00 $60.00
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A CorVel Corporation CorVel Corporation $45.00 $40.00 $54.00 $45.00 $45.00 $40.00 $54.00 $45.00 $60.00
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A Cigna Healthcare CIGNA Utah Connect $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A Cigna Healthcare CIGNA Utah Connect $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A Cigna Healthcare CIGNA PPO and EPO $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A Cigna Healthcare CIGNA PPO and EPO $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A Cigna Healthcare CIGNA Managed Care (HMO or Open Access Plus aka OAP) $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A Cigna Healthcare CIGNA Managed Care (HMO or Open Access Plus aka OAP) $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005292 23978996 0011A Covid-19 Moderna 1st Vaccine Admin 0011A Campbell Scientific Campbell Scientific $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005299 23980995 0012A Covid-19 Moderna 2nd Vaccine Admin 0012A PEHP PEHP Capital Care $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005299 23980995 0012A Covid-19 Moderna 2nd Vaccine Admin 0012A SelectHealth SelectHealth Value Network Individual Plan (ACA) $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005299 23980995 0012A Covid-19 Moderna 2nd Vaccine Admin 0012A SelectHealth SelectHealth Value Network $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005299 23980995 0012A Covid-19 Moderna 2nd Vaccine Admin 0012A SelectHealth SelectHealth Value Network $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005299 23980995 0012A Covid-19 Moderna 2nd Vaccine Admin 0012A SelectHealth SelectHealth Med Network Federal Employee (FEHBP) $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005299 23980995 0012A Covid-19 Moderna 2nd Vaccine Admin 0012A SelectHealth SelectHealth Med Network Federal Employee (FEHBP) $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005299 23980995 0012A Covid-19 Moderna 2nd Vaccine Admin 0012A SelectHealth SelectHealth Community Care-Medicaid $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005299 23980995 0012A Covid-19 Moderna 2nd Vaccine Admin 0012A SelectHealth SelectHealth Care Network $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005299 23980995 0012A Covid-19 Moderna 2nd Vaccine Admin 0012A Regence BlueCross BlueShield of Utah Regence BCBS Federal (FEHBP) $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005299 23980995 0012A Covid-19 Moderna 2nd Vaccine Admin 0012A Regence BlueCross BlueShield of Utah Regence Focal Point $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005299 23980995 0012A Covid-19 Moderna 2nd Vaccine Admin 0012A Regence BlueCross BlueShield of Utah Regence Focal Point $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005299 23980995 0012A Covid-19 Moderna 2nd Vaccine Admin 0012A Regence BlueCross BlueShield of Utah Regence BCBS ValueCare $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005299 23980995 0012A Covid-19 Moderna 2nd Vaccine Admin 0012A Regence BlueCross BlueShield of Utah Regence BCBS ValueCare $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005299 23980995 0012A Covid-19 Moderna 2nd Vaccine Admin 0012A Regence BlueCross BlueShield of Utah Regence Bridgespan RealValue $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005299 23980995 0012A Covid-19 Moderna 2nd Vaccine Admin 0012A Regence BlueCross BlueShield of Utah Regence Bridgespan RealValue $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005299 23980995 0012A Covid-19 Moderna 2nd Vaccine Admin 0012A Regence BlueCross BlueShield of Utah Regence BCBS Preferred BlueOption (PBO) $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005299 23980995 0012A Covid-19 Moderna 2nd Vaccine Admin 0012A Regence BlueCross BlueShield of Utah Regence BCBS Traditional Plan $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005299 23980995 0012A Covid-19 Moderna 2nd Vaccine Admin 0012A Regence BlueCross BlueShield of Utah Regence BCBS Traditional Plan $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005299 23980995 0012A Covid-19 Moderna 2nd Vaccine Admin 0012A Regence BlueCross BlueShield of Utah Regence BCBS Federal (FEHBP) $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005299 23980995 0012A Covid-19 Moderna 2nd Vaccine Admin 0012A Regence BlueCross BlueShield of Utah Regence BCBS Preferred BlueOption (PBO) $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005299 23980995 0012A Covid-19 Moderna 2nd Vaccine Admin 0012A Regence BlueCross BlueShield of Utah Regence Individual and Family Network $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005299 23980995 0012A Covid-19 Moderna 2nd Vaccine Admin 0012A Regence BlueCross BlueShield of Utah Regence Individual and Family Network $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005299 23980995 0012A Covid-19 Moderna 2nd Vaccine Admin 0012A Provider Networks of America Provider Networks of America (PNOA) $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005299 23980995 0012A Covid-19 Moderna 2nd Vaccine Admin 0012A Provider Networks of America Provider Networks of America (PNOA) $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005299 23980995 0012A Covid-19 Moderna 2nd Vaccine Admin 0012A Prodegi Corporate Benefit Services, LLC Prodegi Corporate Benefit Services, LLC $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005299 23980995 0012A Covid-19 Moderna 2nd Vaccine Admin 0012A Prodegi Corporate Benefit Services, LLC Prodegi Corporate Benefit Services, LLC $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005299 23980995 0012A Covid-19 Moderna 2nd Vaccine Admin 0012A Petersen, Inc. Petersen, Inc. $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005299 23980995 0012A Covid-19 Moderna 2nd Vaccine Admin 0012A Petersen, Inc. Petersen, Inc. $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005299 23980995 0012A Covid-19 Moderna 2nd Vaccine Admin 0012A PEHP PEHP Advantage Care State Employees and Advantage Care Exclusive $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005299 23980995 0012A Covid-19 Moderna 2nd Vaccine Admin 0012A PEHP PEHP Summit Exclusive $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00
1900005299 23980995 0012A Covid-19 Moderna 2nd Vaccine Admin 0012A PEHP PEHP Advantage Care - Non State $45.00 $40.00 $54.00 $40.00 $45.00 $40.00 $54.00 $40.00 $60.00