|
ADENOIDECTOMY PRIMARY <AGE 12
|
Professional
|
Both
|
$913.00
|
|
|
Service Code
|
HCPCS 42830
|
| Min. Negotiated Rate |
$177.80 |
| Max. Negotiated Rate |
$913.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$894.74
|
| Rate for Payer: Aetna of WY Medicare |
$209.18
|
| Rate for Payer: Beech Street Commercial |
$867.35
|
| Rate for Payer: Cash Price |
$639.10
|
| Rate for Payer: Cash Price |
$639.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$885.61
|
| Rate for Payer: Cigna of WY Commercial |
$894.74
|
| Rate for Payer: First Choice Health Commercial |
$821.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$867.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$209.18
|
| Rate for Payer: HealthUtah PPO |
$913.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$885.61
|
| Rate for Payer: Multiplan Medicare/VA |
$177.80
|
| Rate for Payer: One Health Plan of WY PPO |
$894.74
|
| Rate for Payer: PacificSource Commercial |
$821.70
|
| Rate for Payer: PHCS PPO |
$867.35
|
| Rate for Payer: Three Rivers PPO |
$684.75
|
| Rate for Payer: TriWest Veterans Administration |
$209.18
|
| Rate for Payer: United Healthcare Commercial |
$867.35
|
| Rate for Payer: WINHealth Partners Commercial |
$776.05
|
|
|
ADENOIDECTOMY PRIMARY AGE 12/>
|
Professional
|
Both
|
$988.00
|
|
|
Service Code
|
HCPCS 42831
|
| Min. Negotiated Rate |
$193.32 |
| Max. Negotiated Rate |
$988.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$968.24
|
| Rate for Payer: Aetna of WY Medicare |
$227.43
|
| Rate for Payer: Beech Street Commercial |
$938.60
|
| Rate for Payer: Cash Price |
$691.60
|
| Rate for Payer: Cash Price |
$691.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$958.36
|
| Rate for Payer: Cigna of WY Commercial |
$968.24
|
| Rate for Payer: First Choice Health Commercial |
$889.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$938.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$227.43
|
| Rate for Payer: HealthUtah PPO |
$988.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$958.36
|
| Rate for Payer: Multiplan Medicare/VA |
$193.32
|
| Rate for Payer: One Health Plan of WY PPO |
$968.24
|
| Rate for Payer: PacificSource Commercial |
$889.20
|
| Rate for Payer: PHCS PPO |
$938.60
|
| Rate for Payer: Three Rivers PPO |
$741.00
|
| Rate for Payer: TriWest Veterans Administration |
$227.43
|
| Rate for Payer: United Healthcare Commercial |
$938.60
|
| Rate for Payer: WINHealth Partners Commercial |
$839.80
|
|
|
ADENOIDECTOMY SECONDARY AGE 12/>
|
Professional
|
Both
|
$1,057.00
|
|
|
Service Code
|
HCPCS 42836
|
| Min. Negotiated Rate |
$204.49 |
| 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 |
$240.58
|
| 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 |
$240.58
|
| Rate for Payer: HealthUtah PPO |
$1,057.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,025.29
|
| Rate for Payer: Multiplan Medicare/VA |
$204.49
|
| 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 |
$240.58
|
| Rate for Payer: United Healthcare Commercial |
$1,004.15
|
| Rate for Payer: WINHealth Partners Commercial |
$898.45
|
|
|
ADENOIDECTOMY SECONDARY<AGE 12
|
Professional
|
Both
|
$846.00
|
|
|
Service Code
|
HCPCS 42835
|
| Min. Negotiated Rate |
$166.12 |
| Max. Negotiated Rate |
$846.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$829.08
|
| Rate for Payer: Aetna of WY Medicare |
$195.44
|
| Rate for Payer: Beech Street Commercial |
$803.70
|
| Rate for Payer: Cash Price |
$592.20
|
| Rate for Payer: Cash Price |
$592.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$820.62
|
| Rate for Payer: Cigna of WY Commercial |
$829.08
|
| Rate for Payer: First Choice Health Commercial |
$761.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$803.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$195.44
|
| Rate for Payer: HealthUtah PPO |
$846.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$820.62
|
| Rate for Payer: Multiplan Medicare/VA |
$166.12
|
| Rate for Payer: One Health Plan of WY PPO |
$829.08
|
| Rate for Payer: PacificSource Commercial |
$761.40
|
| Rate for Payer: PHCS PPO |
$803.70
|
| Rate for Payer: Three Rivers PPO |
$634.50
|
| Rate for Payer: TriWest Veterans Administration |
$195.44
|
| Rate for Payer: United Healthcare Commercial |
$803.70
|
| Rate for Payer: WINHealth Partners Commercial |
$719.10
|
|
|
ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION [12914]
|
Facility
|
IP
|
$26.16
|
|
|
Service Code
|
HCPCS J0153
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.16 |
| Max. Negotiated Rate |
$26.16 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$25.64
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$33.48
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$25.72
|
| Rate for Payer: Aetna of WY Medicare |
$21.86
|
| Rate for Payer: Aetna of WY Medicare |
$16.74
|
| Rate for Payer: Aetna of WY Medicare |
$16.80
|
| Rate for Payer: Altius Commercial |
$25.11
|
| Rate for Payer: Altius Commercial |
$25.20
|
| Rate for Payer: Altius Commercial |
$32.79
|
| Rate for Payer: Beech Street Commercial |
$33.48
|
| Rate for Payer: Beech Street Commercial |
$25.64
|
| Rate for Payer: Beech Street Commercial |
$25.72
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$25.46
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$25.38
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$33.14
|
| Rate for Payer: Cash Price |
$18.38
|
| Rate for Payer: Cash Price |
$18.31
|
| Rate for Payer: Cash Price |
$23.91
|
| Rate for Payer: ChoiceCare Network Commercial |
$25.46
|
| Rate for Payer: ChoiceCare Network Commercial |
$25.38
|
| Rate for Payer: ChoiceCare Network Commercial |
$33.14
|
| Rate for Payer: Cigna of WY Commercial |
$33.48
|
| Rate for Payer: Cigna of WY Commercial |
$25.72
|
| Rate for Payer: Cigna of WY Commercial |
$25.64
|
| Rate for Payer: Entrust Commercial |
$24.85
|
| Rate for Payer: Entrust Commercial |
$32.45
|
| Rate for Payer: Entrust Commercial |
$24.94
|
| Rate for Payer: First Choice Health Commercial |
$24.85
|
| Rate for Payer: First Choice Health Commercial |
$32.45
|
| Rate for Payer: First Choice Health Commercial |
$24.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$32.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$24.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$24.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$15.96
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$20.84
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$16.01
|
| Rate for Payer: HealthUtah PPO |
$34.16
|
| Rate for Payer: HealthUtah PPO |
$26.16
|
| Rate for Payer: HealthUtah PPO |
$26.25
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$33.14
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$25.38
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$25.46
|
| Rate for Payer: Multiplan Medicare/VA |
$15.21
|
| Rate for Payer: Multiplan Medicare/VA |
$19.80
|
| Rate for Payer: Multiplan Medicare/VA |
$15.16
|
| Rate for Payer: One Health Plan of WY PPO |
$33.48
|
| Rate for Payer: One Health Plan of WY PPO |
$25.72
|
| Rate for Payer: One Health Plan of WY PPO |
$25.64
|
| Rate for Payer: PacificSource Commercial |
$23.62
|
| Rate for Payer: PacificSource Commercial |
$30.74
|
| Rate for Payer: PacificSource Commercial |
$23.54
|
| Rate for Payer: PHCS PPO |
$25.64
|
| Rate for Payer: PHCS PPO |
$33.48
|
| Rate for Payer: PHCS PPO |
$25.72
|
| Rate for Payer: Three Rivers PPO |
$19.62
|
| Rate for Payer: Three Rivers PPO |
$25.62
|
| Rate for Payer: Three Rivers PPO |
$19.69
|
| Rate for Payer: TriWest Veterans Administration |
$20.84
|
| Rate for Payer: TriWest Veterans Administration |
$16.01
|
| Rate for Payer: TriWest Veterans Administration |
$15.96
|
| Rate for Payer: United Healthcare Commercial |
$24.98
|
| Rate for Payer: United Healthcare Commercial |
$32.62
|
| Rate for Payer: United Healthcare Commercial |
$25.07
|
| Rate for Payer: United Healthcare Medicare |
$20.84
|
| Rate for Payer: United Healthcare Medicare |
$16.01
|
| Rate for Payer: United Healthcare Medicare |
$15.96
|
| Rate for Payer: WINHealth Partners Commercial |
$24.85
|
| Rate for Payer: WINHealth Partners Commercial |
$24.94
|
| Rate for Payer: WINHealth Partners Commercial |
$32.45
|
| Rate for Payer: Wise Provider Network Commercial |
$24.85
|
| Rate for Payer: Wise Provider Network Commercial |
$24.94
|
| Rate for Payer: Wise Provider Network Commercial |
$32.45
|
|
|
ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION [12914]
|
Facility
|
OP
|
$26.16
|
|
|
Service Code
|
HCPCS J0153
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.17 |
| Max. Negotiated Rate |
$26.16 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$25.64
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$25.72
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$33.48
|
| Rate for Payer: Aetna of WY Medicare |
$17.32
|
| Rate for Payer: Aetna of WY Medicare |
$17.27
|
| Rate for Payer: Aetna of WY Medicare |
$22.55
|
| Rate for Payer: Altius Commercial |
$32.79
|
| Rate for Payer: Altius Commercial |
$25.20
|
| Rate for Payer: Altius Commercial |
$25.11
|
| Rate for Payer: Beech Street Commercial |
$25.72
|
| Rate for Payer: Beech Street Commercial |
$33.48
|
| Rate for Payer: Beech Street Commercial |
$25.64
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$25.46
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$33.14
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$25.38
|
| Rate for Payer: Cash Price |
$18.31
|
| Rate for Payer: Cash Price |
$23.91
|
| Rate for Payer: Cash Price |
$18.38
|
| Rate for Payer: ChoiceCare Network Commercial |
$33.14
|
| Rate for Payer: ChoiceCare Network Commercial |
$25.46
|
| Rate for Payer: ChoiceCare Network Commercial |
$25.38
|
| Rate for Payer: Cigna of WY Commercial |
$33.48
|
| Rate for Payer: Cigna of WY Commercial |
$25.72
|
| Rate for Payer: Cigna of WY Commercial |
$25.64
|
| Rate for Payer: Entrust Commercial |
$24.94
|
| Rate for Payer: Entrust Commercial |
$24.85
|
| Rate for Payer: Entrust Commercial |
$32.45
|
| Rate for Payer: First Choice Health Commercial |
$32.45
|
| Rate for Payer: First Choice Health Commercial |
$24.94
|
| Rate for Payer: First Choice Health Commercial |
$24.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$32.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$24.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$24.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$19.47
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$14.91
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$14.96
|
| Rate for Payer: HealthUtah PPO |
$34.16
|
| Rate for Payer: HealthUtah PPO |
$26.25
|
| Rate for Payer: HealthUtah PPO |
$26.16
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$25.38
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$33.14
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$25.46
|
| Rate for Payer: Multiplan Medicare/VA |
$14.17
|
| Rate for Payer: Multiplan Medicare/VA |
$18.50
|
| Rate for Payer: Multiplan Medicare/VA |
$14.21
|
| Rate for Payer: One Health Plan of WY PPO |
$25.64
|
| Rate for Payer: One Health Plan of WY PPO |
$25.72
|
| Rate for Payer: One Health Plan of WY PPO |
$33.48
|
| Rate for Payer: PacificSource Commercial |
$23.62
|
| Rate for Payer: PacificSource Commercial |
$23.54
|
| Rate for Payer: PacificSource Commercial |
$30.74
|
| Rate for Payer: PHCS PPO |
$33.48
|
| Rate for Payer: PHCS PPO |
$25.64
|
| Rate for Payer: PHCS PPO |
$25.72
|
| Rate for Payer: Three Rivers PPO |
$19.62
|
| Rate for Payer: Three Rivers PPO |
$19.69
|
| Rate for Payer: Three Rivers PPO |
$25.62
|
| Rate for Payer: TriWest Veterans Administration |
$14.96
|
| Rate for Payer: TriWest Veterans Administration |
$19.47
|
| Rate for Payer: TriWest Veterans Administration |
$14.91
|
| Rate for Payer: United Healthcare Commercial |
$32.62
|
| Rate for Payer: United Healthcare Commercial |
$25.07
|
| Rate for Payer: United Healthcare Commercial |
$24.98
|
| Rate for Payer: United Healthcare Medicare |
$14.91
|
| Rate for Payer: United Healthcare Medicare |
$14.96
|
| Rate for Payer: United Healthcare Medicare |
$19.47
|
| Rate for Payer: WINHealth Partners Commercial |
$25.72
|
| Rate for Payer: WINHealth Partners Commercial |
$25.64
|
| Rate for Payer: WINHealth Partners Commercial |
$33.48
|
| Rate for Payer: Wise Provider Network Commercial |
$32.45
|
| Rate for Payer: Wise Provider Network Commercial |
$24.85
|
| Rate for Payer: Wise Provider Network Commercial |
$24.94
|
|
|
ADENOSINE INJ 1MG
|
Professional
|
Both
|
$10.00
|
|
|
Service Code
|
HCPCS J0153
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$10.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$9.80
|
| Rate for Payer: Aetna of WY Medicare |
$0.56
|
| Rate for Payer: Beech Street Commercial |
$9.50
|
| Rate for Payer: Cash Price |
$7.00
|
| Rate for Payer: Cash Price |
$7.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$9.70
|
| Rate for Payer: Cigna of WY Commercial |
$9.80
|
| Rate for Payer: First Choice Health Commercial |
$9.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$9.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.56
|
| Rate for Payer: HealthUtah PPO |
$10.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$9.70
|
| Rate for Payer: Multiplan Medicare/VA |
$0.47
|
| Rate for Payer: One Health Plan of WY PPO |
$9.80
|
| Rate for Payer: PacificSource Commercial |
$9.00
|
| Rate for Payer: PHCS PPO |
$9.50
|
| Rate for Payer: Three Rivers PPO |
$7.50
|
| Rate for Payer: TriWest Veterans Administration |
$0.56
|
| Rate for Payer: United Healthcare Commercial |
$9.50
|
| Rate for Payer: WINHealth Partners Commercial |
$9.50
|
|
|
ADHESIVE FLEECE EDGER 1.25"X15YDS BLUE
|
Facility
|
IP
|
$43.23
|
|
| Hospital Charge Code |
2250138
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$25.05 |
| Max. Negotiated Rate |
$43.23 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$42.37
|
| Rate for Payer: Aetna of WY Medicare |
$27.67
|
| Rate for Payer: Altius Commercial |
$41.50
|
| Rate for Payer: Beech Street Commercial |
$42.37
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$41.93
|
| Rate for Payer: Cash Price |
$30.26
|
| Rate for Payer: ChoiceCare Network Commercial |
$41.93
|
| Rate for Payer: Cigna of WY Commercial |
$42.37
|
| Rate for Payer: Entrust Commercial |
$41.07
|
| Rate for Payer: First Choice Health Commercial |
$41.07
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$41.07
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$26.37
|
| Rate for Payer: HealthUtah PPO |
$43.23
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$41.93
|
| Rate for Payer: Multiplan Medicare/VA |
$25.05
|
| Rate for Payer: One Health Plan of WY PPO |
$42.37
|
| Rate for Payer: PacificSource Commercial |
$38.91
|
| Rate for Payer: PHCS PPO |
$42.37
|
| Rate for Payer: Three Rivers PPO |
$32.42
|
| Rate for Payer: TriWest Veterans Administration |
$26.37
|
| Rate for Payer: United Healthcare Commercial |
$41.28
|
| Rate for Payer: United Healthcare Medicare |
$26.37
|
| Rate for Payer: WINHealth Partners Commercial |
$41.07
|
| Rate for Payer: Wise Provider Network Commercial |
$41.07
|
|
|
ADHESIVE FLEECE EDGER 1.25"X15YDS BLUE
|
Facility
|
OP
|
$43.23
|
|
| Hospital Charge Code |
2250138
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$23.41 |
| Max. Negotiated Rate |
$43.23 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$42.37
|
| Rate for Payer: Aetna of WY Medicare |
$28.53
|
| Rate for Payer: Altius Commercial |
$41.50
|
| Rate for Payer: Beech Street Commercial |
$42.37
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$41.93
|
| Rate for Payer: Cash Price |
$30.26
|
| Rate for Payer: ChoiceCare Network Commercial |
$41.93
|
| Rate for Payer: Cigna of WY Commercial |
$42.37
|
| Rate for Payer: Entrust Commercial |
$41.07
|
| Rate for Payer: First Choice Health Commercial |
$41.07
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$41.07
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$24.64
|
| Rate for Payer: HealthUtah PPO |
$43.23
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$41.93
|
| Rate for Payer: Multiplan Medicare/VA |
$23.41
|
| Rate for Payer: One Health Plan of WY PPO |
$42.37
|
| Rate for Payer: PacificSource Commercial |
$38.91
|
| Rate for Payer: PHCS PPO |
$42.37
|
| Rate for Payer: Three Rivers PPO |
$32.42
|
| Rate for Payer: TriWest Veterans Administration |
$24.64
|
| Rate for Payer: United Healthcare Commercial |
$41.28
|
| Rate for Payer: United Healthcare Medicare |
$24.64
|
| Rate for Payer: WINHealth Partners Commercial |
$42.37
|
| Rate for Payer: Wise Provider Network Commercial |
$41.07
|
|
|
ADHESIVE FLEECE EDGER 1.25"X15YDS WHITE
|
Facility
|
OP
|
$43.23
|
|
| Hospital Charge Code |
2250137
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$23.41 |
| Max. Negotiated Rate |
$43.23 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$42.37
|
| Rate for Payer: Aetna of WY Medicare |
$28.53
|
| Rate for Payer: Altius Commercial |
$41.50
|
| Rate for Payer: Beech Street Commercial |
$42.37
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$41.93
|
| Rate for Payer: Cash Price |
$30.26
|
| Rate for Payer: ChoiceCare Network Commercial |
$41.93
|
| Rate for Payer: Cigna of WY Commercial |
$42.37
|
| Rate for Payer: Entrust Commercial |
$41.07
|
| Rate for Payer: First Choice Health Commercial |
$41.07
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$41.07
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$24.64
|
| Rate for Payer: HealthUtah PPO |
$43.23
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$41.93
|
| Rate for Payer: Multiplan Medicare/VA |
$23.41
|
| Rate for Payer: One Health Plan of WY PPO |
$42.37
|
| Rate for Payer: PacificSource Commercial |
$38.91
|
| Rate for Payer: PHCS PPO |
$42.37
|
| Rate for Payer: Three Rivers PPO |
$32.42
|
| Rate for Payer: TriWest Veterans Administration |
$24.64
|
| Rate for Payer: United Healthcare Commercial |
$41.28
|
| Rate for Payer: United Healthcare Medicare |
$24.64
|
| Rate for Payer: WINHealth Partners Commercial |
$42.37
|
| Rate for Payer: Wise Provider Network Commercial |
$41.07
|
|
|
ADHESIVE FLEECE EDGER 1.25"X15YDS WHITE
|
Facility
|
IP
|
$43.23
|
|
| Hospital Charge Code |
2250137
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$25.05 |
| Max. Negotiated Rate |
$43.23 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$42.37
|
| Rate for Payer: Aetna of WY Medicare |
$27.67
|
| Rate for Payer: Altius Commercial |
$41.50
|
| Rate for Payer: Beech Street Commercial |
$42.37
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$41.93
|
| Rate for Payer: Cash Price |
$30.26
|
| Rate for Payer: ChoiceCare Network Commercial |
$41.93
|
| Rate for Payer: Cigna of WY Commercial |
$42.37
|
| Rate for Payer: Entrust Commercial |
$41.07
|
| Rate for Payer: First Choice Health Commercial |
$41.07
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$41.07
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$26.37
|
| Rate for Payer: HealthUtah PPO |
$43.23
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$41.93
|
| Rate for Payer: Multiplan Medicare/VA |
$25.05
|
| Rate for Payer: One Health Plan of WY PPO |
$42.37
|
| Rate for Payer: PacificSource Commercial |
$38.91
|
| Rate for Payer: PHCS PPO |
$42.37
|
| Rate for Payer: Three Rivers PPO |
$32.42
|
| Rate for Payer: TriWest Veterans Administration |
$26.37
|
| Rate for Payer: United Healthcare Commercial |
$41.28
|
| Rate for Payer: United Healthcare Medicare |
$26.37
|
| Rate for Payer: WINHealth Partners Commercial |
$41.07
|
| Rate for Payer: Wise Provider Network Commercial |
$41.07
|
|
|
ADJ BTB ALLOGRAFT
|
Facility
|
IP
|
$11,550.00
|
|
| Hospital Charge Code |
3000114
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,693.22 |
| Max. Negotiated Rate |
$11,550.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$11,319.00
|
| Rate for Payer: Aetna of WY Medicare |
$7,392.00
|
| Rate for Payer: Altius Commercial |
$11,088.00
|
| Rate for Payer: Beech Street Commercial |
$11,319.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$11,203.50
|
| Rate for Payer: Cash Price |
$8,085.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$11,203.50
|
| Rate for Payer: Cigna of WY Commercial |
$11,319.00
|
| Rate for Payer: Entrust Commercial |
$10,972.50
|
| Rate for Payer: First Choice Health Commercial |
$10,972.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$10,972.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$7,045.50
|
| Rate for Payer: HealthUtah PPO |
$11,550.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$11,203.50
|
| Rate for Payer: Multiplan Medicare/VA |
$6,693.22
|
| Rate for Payer: One Health Plan of WY PPO |
$11,319.00
|
| Rate for Payer: PacificSource Commercial |
$10,395.00
|
| Rate for Payer: PHCS PPO |
$11,319.00
|
| Rate for Payer: Three Rivers PPO |
$8,662.50
|
| Rate for Payer: TriWest Veterans Administration |
$7,045.50
|
| Rate for Payer: United Healthcare Commercial |
$11,030.25
|
| Rate for Payer: United Healthcare Medicare |
$7,045.50
|
| Rate for Payer: WINHealth Partners Commercial |
$10,972.50
|
| Rate for Payer: Wise Provider Network Commercial |
$10,972.50
|
|
|
ADJ BTB ALLOGRAFT
|
Facility
|
OP
|
$11,550.00
|
|
| Hospital Charge Code |
3000114
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,254.32 |
| Max. Negotiated Rate |
$11,550.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$11,319.00
|
| Rate for Payer: Aetna of WY Medicare |
$7,623.00
|
| Rate for Payer: Altius Commercial |
$11,088.00
|
| Rate for Payer: Beech Street Commercial |
$11,319.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$11,203.50
|
| Rate for Payer: Cash Price |
$8,085.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$11,203.50
|
| Rate for Payer: Cigna of WY Commercial |
$11,319.00
|
| Rate for Payer: Entrust Commercial |
$10,972.50
|
| Rate for Payer: First Choice Health Commercial |
$10,972.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$10,972.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$6,583.50
|
| Rate for Payer: HealthUtah PPO |
$11,550.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$11,203.50
|
| Rate for Payer: Multiplan Medicare/VA |
$6,254.32
|
| Rate for Payer: One Health Plan of WY PPO |
$11,319.00
|
| Rate for Payer: PacificSource Commercial |
$10,395.00
|
| Rate for Payer: PHCS PPO |
$11,319.00
|
| Rate for Payer: Three Rivers PPO |
$8,662.50
|
| Rate for Payer: TriWest Veterans Administration |
$6,583.50
|
| Rate for Payer: United Healthcare Commercial |
$11,030.25
|
| Rate for Payer: United Healthcare Medicare |
$6,583.50
|
| Rate for Payer: WINHealth Partners Commercial |
$11,319.00
|
| Rate for Payer: Wise Provider Network Commercial |
$10,972.50
|
|
|
ADJNT TIS TRNSFR/REARGMT ANY AREA 30.1-60 SQ CM
|
Professional
|
Both
|
$3,724.00
|
|
|
Service Code
|
HCPCS 14301
|
| Min. Negotiated Rate |
$710.15 |
| Max. Negotiated Rate |
$3,724.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,649.52
|
| Rate for Payer: Aetna of WY Medicare |
$835.47
|
| Rate for Payer: Beech Street Commercial |
$3,537.80
|
| Rate for Payer: Cash Price |
$2,606.80
|
| Rate for Payer: Cash Price |
$2,606.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,612.28
|
| Rate for Payer: Cigna of WY Commercial |
$3,649.52
|
| Rate for Payer: First Choice Health Commercial |
$3,351.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,537.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$835.47
|
| Rate for Payer: HealthUtah PPO |
$3,724.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,612.28
|
| Rate for Payer: Multiplan Medicare/VA |
$710.15
|
| Rate for Payer: One Health Plan of WY PPO |
$3,649.52
|
| Rate for Payer: PacificSource Commercial |
$3,351.60
|
| Rate for Payer: PHCS PPO |
$3,537.80
|
| Rate for Payer: Three Rivers PPO |
$2,793.00
|
| Rate for Payer: TriWest Veterans Administration |
$835.47
|
| Rate for Payer: United Healthcare Commercial |
$3,537.80
|
| Rate for Payer: WINHealth Partners Commercial |
$3,165.40
|
|
|
ADJT/REARRGMT SCALP/ARM/LEG 10.1-30.0 SQ CM
|
Professional
|
Both
|
$3,027.00
|
|
|
Service Code
|
HCPCS 14021
|
| Min. Negotiated Rate |
$582.12 |
| Max. Negotiated Rate |
$3,027.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,966.46
|
| Rate for Payer: Aetna of WY Medicare |
$684.85
|
| Rate for Payer: Beech Street Commercial |
$2,875.65
|
| Rate for Payer: Cash Price |
$2,118.90
|
| Rate for Payer: Cash Price |
$2,118.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,936.19
|
| Rate for Payer: Cigna of WY Commercial |
$2,966.46
|
| Rate for Payer: First Choice Health Commercial |
$2,724.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,875.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$684.85
|
| Rate for Payer: HealthUtah PPO |
$3,027.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,936.19
|
| Rate for Payer: Multiplan Medicare/VA |
$582.12
|
| Rate for Payer: One Health Plan of WY PPO |
$2,966.46
|
| Rate for Payer: PacificSource Commercial |
$2,724.30
|
| Rate for Payer: PHCS PPO |
$2,875.65
|
| Rate for Payer: Three Rivers PPO |
$2,270.25
|
| Rate for Payer: TriWest Veterans Administration |
$684.85
|
| Rate for Payer: United Healthcare Commercial |
$2,875.65
|
| Rate for Payer: WINHealth Partners Commercial |
$2,572.95
|
|
|
ADJT TIS TRNSFR/REARGMT SCALP/ARM/LEG 10 SQ CM/<
|
Professional
|
Both
|
$2,395.00
|
|
|
Service Code
|
HCPCS 14020
|
| Min. Negotiated Rate |
$467.19 |
| Max. Negotiated Rate |
$2,395.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,347.10
|
| Rate for Payer: Aetna of WY Medicare |
$549.64
|
| Rate for Payer: Beech Street Commercial |
$2,275.25
|
| Rate for Payer: Cash Price |
$1,676.50
|
| Rate for Payer: Cash Price |
$1,676.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,323.15
|
| Rate for Payer: Cigna of WY Commercial |
$2,347.10
|
| Rate for Payer: First Choice Health Commercial |
$2,155.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,275.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$549.64
|
| Rate for Payer: HealthUtah PPO |
$2,395.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,323.15
|
| Rate for Payer: Multiplan Medicare/VA |
$467.19
|
| Rate for Payer: One Health Plan of WY PPO |
$2,347.10
|
| Rate for Payer: PacificSource Commercial |
$2,155.50
|
| Rate for Payer: PHCS PPO |
$2,275.25
|
| Rate for Payer: Three Rivers PPO |
$1,796.25
|
| Rate for Payer: TriWest Veterans Administration |
$549.64
|
| Rate for Payer: United Healthcare Commercial |
$2,275.25
|
| Rate for Payer: WINHealth Partners Commercial |
$2,035.75
|
|
|
ADJT TIS TRNS/REARGMT F/C/C/M/N/A/G/H/F 10SQCM/<
|
Professional
|
Both
|
$2,661.00
|
|
|
Service Code
|
HCPCS 14040
|
| Min. Negotiated Rate |
$513.17 |
| Max. Negotiated Rate |
$2,661.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,607.78
|
| Rate for Payer: Aetna of WY Medicare |
$603.73
|
| Rate for Payer: Beech Street Commercial |
$2,527.95
|
| Rate for Payer: Cash Price |
$1,862.70
|
| Rate for Payer: Cash Price |
$1,862.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,581.17
|
| Rate for Payer: Cigna of WY Commercial |
$2,607.78
|
| Rate for Payer: First Choice Health Commercial |
$2,394.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,527.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$603.73
|
| Rate for Payer: HealthUtah PPO |
$2,661.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,581.17
|
| Rate for Payer: Multiplan Medicare/VA |
$513.17
|
| Rate for Payer: One Health Plan of WY PPO |
$2,607.78
|
| Rate for Payer: PacificSource Commercial |
$2,394.90
|
| Rate for Payer: PHCS PPO |
$2,527.95
|
| Rate for Payer: Three Rivers PPO |
$1,995.75
|
| Rate for Payer: TriWest Veterans Administration |
$603.73
|
| Rate for Payer: United Healthcare Commercial |
$2,527.95
|
| Rate for Payer: WINHealth Partners Commercial |
$2,261.85
|
|
|
ADJUSTMENT GASTRIC BAND
|
Professional
|
Both
|
$166.00
|
|
|
Service Code
|
HCPCS S2083
|
| Min. Negotiated Rate |
$124.50 |
| Max. Negotiated Rate |
$166.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$162.68
|
| Rate for Payer: Beech Street Commercial |
$157.70
|
| Rate for Payer: Cash Price |
$116.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$161.02
|
| Rate for Payer: Cigna of WY Commercial |
$162.68
|
| Rate for Payer: First Choice Health Commercial |
$149.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$157.70
|
| Rate for Payer: HealthUtah PPO |
$166.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$161.02
|
| Rate for Payer: One Health Plan of WY PPO |
$162.68
|
| Rate for Payer: PacificSource Commercial |
$149.40
|
| Rate for Payer: PHCS PPO |
$157.70
|
| Rate for Payer: Three Rivers PPO |
$124.50
|
| Rate for Payer: United Healthcare Commercial |
$157.70
|
| Rate for Payer: WINHealth Partners Commercial |
$157.70
|
|
|
ADMIN HEPATITIS B VACCINE
|
Professional
|
Both
|
$15.00
|
|
|
Service Code
|
HCPCS G0010
|
| Min. Negotiated Rate |
$11.25 |
| Max. Negotiated Rate |
$15.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.70
|
| Rate for Payer: Beech Street Commercial |
$14.25
|
| Rate for Payer: Cash Price |
$10.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.55
|
| Rate for Payer: Cigna of WY Commercial |
$14.70
|
| Rate for Payer: First Choice Health Commercial |
$13.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.25
|
| Rate for Payer: HealthUtah PPO |
$15.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.55
|
| Rate for Payer: One Health Plan of WY PPO |
$14.70
|
| Rate for Payer: PacificSource Commercial |
$13.50
|
| Rate for Payer: PHCS PPO |
$14.25
|
| Rate for Payer: Three Rivers PPO |
$11.25
|
| Rate for Payer: United Healthcare Commercial |
$14.25
|
| Rate for Payer: WINHealth Partners Commercial |
$14.25
|
|
|
ADMIN INFLUENZA VIRUS VAC
|
Professional
|
Both
|
$15.00
|
|
|
Service Code
|
HCPCS G0008
|
| Min. Negotiated Rate |
$11.25 |
| Max. Negotiated Rate |
$20.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.70
|
| Rate for Payer: Beech Street Commercial |
$14.25
|
| Rate for Payer: Cash Price |
$10.50
|
| Rate for Payer: Cash Price |
$10.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.55
|
| Rate for Payer: Cigna of WY Commercial |
$14.70
|
| Rate for Payer: First Choice Health Commercial |
$13.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.25
|
| Rate for Payer: HealthUtah PPO |
$15.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.55
|
| Rate for Payer: One Health Plan of WY PPO |
$14.70
|
| Rate for Payer: PacificSource Commercial |
$13.50
|
| Rate for Payer: PHCS PPO |
$14.25
|
| Rate for Payer: Three Rivers PPO |
$11.25
|
| Rate for Payer: TriWest Veterans Administration |
$20.00
|
| Rate for Payer: United Healthcare Commercial |
$14.25
|
| Rate for Payer: WINHealth Partners Commercial |
$14.25
|
|
|
ADMIN PNEUMOCOCCAL VACCINE
|
Professional
|
Both
|
$15.00
|
|
|
Service Code
|
HCPCS G0009
|
| Min. Negotiated Rate |
$11.25 |
| Max. Negotiated Rate |
$15.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.70
|
| Rate for Payer: Beech Street Commercial |
$14.25
|
| Rate for Payer: Cash Price |
$10.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.55
|
| Rate for Payer: Cigna of WY Commercial |
$14.70
|
| Rate for Payer: First Choice Health Commercial |
$13.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.25
|
| Rate for Payer: HealthUtah PPO |
$15.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.55
|
| Rate for Payer: One Health Plan of WY PPO |
$14.70
|
| Rate for Payer: PacificSource Commercial |
$13.50
|
| Rate for Payer: PHCS PPO |
$14.25
|
| Rate for Payer: Three Rivers PPO |
$11.25
|
| Rate for Payer: United Healthcare Commercial |
$14.25
|
| Rate for Payer: WINHealth Partners Commercial |
$14.25
|
|
|
ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION [126813]
|
Facility
|
IP
|
$3,906.75
|
|
|
Service Code
|
HCPCS J9354
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,263.96 |
| Max. Negotiated Rate |
$3,906.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,828.62
|
| Rate for Payer: Aetna of WY Medicare |
$2,500.32
|
| Rate for Payer: Altius Commercial |
$3,750.48
|
| Rate for Payer: Beech Street Commercial |
$3,828.62
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3,789.55
|
| Rate for Payer: Cash Price |
$2,734.72
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,789.55
|
| Rate for Payer: Cigna of WY Commercial |
$3,828.62
|
| Rate for Payer: Entrust Commercial |
$3,711.41
|
| Rate for Payer: First Choice Health Commercial |
$3,711.41
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,711.41
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2,383.12
|
| Rate for Payer: HealthUtah PPO |
$3,906.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,789.55
|
| Rate for Payer: Multiplan Medicare/VA |
$2,263.96
|
| Rate for Payer: One Health Plan of WY PPO |
$3,828.62
|
| Rate for Payer: PacificSource Commercial |
$3,516.08
|
| Rate for Payer: PHCS PPO |
$3,828.62
|
| Rate for Payer: Three Rivers PPO |
$2,930.06
|
| Rate for Payer: TriWest Veterans Administration |
$2,383.12
|
| Rate for Payer: United Healthcare Commercial |
$3,730.95
|
| Rate for Payer: United Healthcare Medicare |
$2,383.12
|
| Rate for Payer: WINHealth Partners Commercial |
$3,711.41
|
| Rate for Payer: Wise Provider Network Commercial |
$3,711.41
|
|
|
ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION [126813]
|
Facility
|
OP
|
$3,906.75
|
|
|
Service Code
|
HCPCS J9354
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,115.51 |
| Max. Negotiated Rate |
$3,906.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,828.62
|
| Rate for Payer: Aetna of WY Medicare |
$2,578.46
|
| Rate for Payer: Altius Commercial |
$3,750.48
|
| Rate for Payer: Beech Street Commercial |
$3,828.62
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3,789.55
|
| Rate for Payer: Cash Price |
$2,734.72
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,789.55
|
| Rate for Payer: Cigna of WY Commercial |
$3,828.62
|
| Rate for Payer: Entrust Commercial |
$3,711.41
|
| Rate for Payer: First Choice Health Commercial |
$3,711.41
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,711.41
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2,226.85
|
| Rate for Payer: HealthUtah PPO |
$3,906.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,789.55
|
| Rate for Payer: Multiplan Medicare/VA |
$2,115.51
|
| Rate for Payer: One Health Plan of WY PPO |
$3,828.62
|
| Rate for Payer: PacificSource Commercial |
$3,516.08
|
| Rate for Payer: PHCS PPO |
$3,828.62
|
| Rate for Payer: Three Rivers PPO |
$2,930.06
|
| Rate for Payer: TriWest Veterans Administration |
$2,226.85
|
| Rate for Payer: United Healthcare Commercial |
$3,730.95
|
| Rate for Payer: United Healthcare Medicare |
$2,226.85
|
| Rate for Payer: WINHealth Partners Commercial |
$3,828.62
|
| Rate for Payer: Wise Provider Network Commercial |
$3,711.41
|
|
|
ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION [126814]
|
Facility
|
OP
|
$6,761.26
|
|
|
Service Code
|
HCPCS J9354
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,661.22 |
| Max. Negotiated Rate |
$6,761.26 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$6,626.03
|
| Rate for Payer: Aetna of WY Medicare |
$4,462.43
|
| Rate for Payer: Altius Commercial |
$6,490.81
|
| Rate for Payer: Beech Street Commercial |
$6,626.03
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$6,558.42
|
| Rate for Payer: Cash Price |
$4,732.88
|
| Rate for Payer: ChoiceCare Network Commercial |
$6,558.42
|
| Rate for Payer: Cigna of WY Commercial |
$6,626.03
|
| Rate for Payer: Entrust Commercial |
$6,423.20
|
| Rate for Payer: First Choice Health Commercial |
$6,423.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$6,423.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3,853.92
|
| Rate for Payer: HealthUtah PPO |
$6,761.26
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$6,558.42
|
| Rate for Payer: Multiplan Medicare/VA |
$3,661.22
|
| Rate for Payer: One Health Plan of WY PPO |
$6,626.03
|
| Rate for Payer: PacificSource Commercial |
$6,085.13
|
| Rate for Payer: PHCS PPO |
$6,626.03
|
| Rate for Payer: Three Rivers PPO |
$5,070.94
|
| Rate for Payer: TriWest Veterans Administration |
$3,853.92
|
| Rate for Payer: United Healthcare Commercial |
$6,457.00
|
| Rate for Payer: United Healthcare Medicare |
$3,853.92
|
| Rate for Payer: WINHealth Partners Commercial |
$6,626.03
|
| Rate for Payer: Wise Provider Network Commercial |
$6,423.20
|
|
|
ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION [126814]
|
Facility
|
IP
|
$6,761.26
|
|
|
Service Code
|
HCPCS J9354
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,918.15 |
| Max. Negotiated Rate |
$6,761.26 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$6,626.03
|
| Rate for Payer: Aetna of WY Medicare |
$4,327.21
|
| Rate for Payer: Altius Commercial |
$6,490.81
|
| Rate for Payer: Beech Street Commercial |
$6,626.03
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$6,558.42
|
| Rate for Payer: Cash Price |
$4,732.88
|
| Rate for Payer: ChoiceCare Network Commercial |
$6,558.42
|
| Rate for Payer: Cigna of WY Commercial |
$6,626.03
|
| Rate for Payer: Entrust Commercial |
$6,423.20
|
| Rate for Payer: First Choice Health Commercial |
$6,423.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$6,423.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$4,124.37
|
| Rate for Payer: HealthUtah PPO |
$6,761.26
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$6,558.42
|
| Rate for Payer: Multiplan Medicare/VA |
$3,918.15
|
| Rate for Payer: One Health Plan of WY PPO |
$6,626.03
|
| Rate for Payer: PacificSource Commercial |
$6,085.13
|
| Rate for Payer: PHCS PPO |
$6,626.03
|
| Rate for Payer: Three Rivers PPO |
$5,070.94
|
| Rate for Payer: TriWest Veterans Administration |
$4,124.37
|
| Rate for Payer: United Healthcare Commercial |
$6,457.00
|
| Rate for Payer: United Healthcare Medicare |
$4,124.37
|
| Rate for Payer: WINHealth Partners Commercial |
$6,423.20
|
| Rate for Payer: Wise Provider Network Commercial |
$6,423.20
|
|
