|
CLOSED TX RADIAL HEAD/NECK FX W/O MANIPULATION
|
Professional
|
Both
|
$714.00
|
|
|
Service Code
|
HCPCS 24650
|
| Min. Negotiated Rate |
$212.15 |
| Max. Negotiated Rate |
$714.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$699.72
|
| Rate for Payer: Aetna of WY Medicare |
$249.59
|
| Rate for Payer: Beech Street Commercial |
$678.30
|
| Rate for Payer: Cash Price |
$499.80
|
| Rate for Payer: Cash Price |
$499.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$692.58
|
| Rate for Payer: Cigna of WY Commercial |
$699.72
|
| Rate for Payer: First Choice Health Commercial |
$642.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$678.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$249.59
|
| Rate for Payer: HealthUtah PPO |
$714.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$692.58
|
| Rate for Payer: Multiplan Medicare/VA |
$212.15
|
| Rate for Payer: One Health Plan of WY PPO |
$699.72
|
| Rate for Payer: PacificSource Commercial |
$642.60
|
| Rate for Payer: PHCS PPO |
$678.30
|
| Rate for Payer: Three Rivers PPO |
$535.50
|
| Rate for Payer: TriWest Veterans Administration |
$249.59
|
| Rate for Payer: United Healthcare Commercial |
$678.30
|
| Rate for Payer: WINHealth Partners Commercial |
$606.90
|
|
|
CLOSED TX RADIAL SHAFT FRACTURE W/MANIPULATION
|
Professional
|
Both
|
$1,510.00
|
|
|
Service Code
|
HCPCS 25505
|
| Min. Negotiated Rate |
$390.63 |
| Max. Negotiated Rate |
$1,510.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,479.80
|
| Rate for Payer: Aetna of WY Medicare |
$459.57
|
| Rate for Payer: Beech Street Commercial |
$1,434.50
|
| Rate for Payer: Cash Price |
$1,057.00
|
| Rate for Payer: Cash Price |
$1,057.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,464.70
|
| Rate for Payer: Cigna of WY Commercial |
$1,479.80
|
| Rate for Payer: First Choice Health Commercial |
$1,359.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,434.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$459.57
|
| Rate for Payer: HealthUtah PPO |
$1,510.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,464.70
|
| Rate for Payer: Multiplan Medicare/VA |
$390.63
|
| Rate for Payer: One Health Plan of WY PPO |
$1,479.80
|
| Rate for Payer: PacificSource Commercial |
$1,359.00
|
| Rate for Payer: PHCS PPO |
$1,434.50
|
| Rate for Payer: Three Rivers PPO |
$1,132.50
|
| Rate for Payer: TriWest Veterans Administration |
$459.57
|
| Rate for Payer: United Healthcare Commercial |
$1,434.50
|
| Rate for Payer: WINHealth Partners Commercial |
$1,283.50
|
|
|
CLOSED TX RADIAL SHAFT FRACTURE W/O MANIPULATION
|
Professional
|
Both
|
$773.00
|
|
|
Service Code
|
HCPCS 25500
|
| Min. Negotiated Rate |
$222.09 |
| Max. Negotiated Rate |
$773.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$757.54
|
| Rate for Payer: Aetna of WY Medicare |
$261.28
|
| Rate for Payer: Beech Street Commercial |
$734.35
|
| Rate for Payer: Cash Price |
$541.10
|
| Rate for Payer: Cash Price |
$541.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$749.81
|
| Rate for Payer: Cigna of WY Commercial |
$757.54
|
| Rate for Payer: First Choice Health Commercial |
$695.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$734.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$261.28
|
| Rate for Payer: HealthUtah PPO |
$773.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$749.81
|
| Rate for Payer: Multiplan Medicare/VA |
$222.09
|
| Rate for Payer: One Health Plan of WY PPO |
$757.54
|
| Rate for Payer: PacificSource Commercial |
$695.70
|
| Rate for Payer: PHCS PPO |
$734.35
|
| Rate for Payer: Three Rivers PPO |
$579.75
|
| Rate for Payer: TriWest Veterans Administration |
$261.28
|
| Rate for Payer: United Healthcare Commercial |
$734.35
|
| Rate for Payer: WINHealth Partners Commercial |
$657.05
|
|
|
CLOSED TX RADIAL&ULNAR SHAFT FRACTURES W/MANJ
|
Professional
|
Both
|
$544.00
|
|
|
Service Code
|
HCPCS 25565
|
| Min. Negotiated Rate |
$392.28 |
| Max. Negotiated Rate |
$544.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$533.12
|
| Rate for Payer: Aetna of WY Medicare |
$461.50
|
| Rate for Payer: Beech Street Commercial |
$516.80
|
| Rate for Payer: Cash Price |
$380.80
|
| Rate for Payer: Cash Price |
$380.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$527.68
|
| Rate for Payer: Cigna of WY Commercial |
$533.12
|
| Rate for Payer: First Choice Health Commercial |
$489.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$516.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$461.50
|
| Rate for Payer: HealthUtah PPO |
$544.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$527.68
|
| Rate for Payer: Multiplan Medicare/VA |
$392.28
|
| Rate for Payer: One Health Plan of WY PPO |
$533.12
|
| Rate for Payer: PacificSource Commercial |
$489.60
|
| Rate for Payer: PHCS PPO |
$516.80
|
| Rate for Payer: Three Rivers PPO |
$408.00
|
| Rate for Payer: TriWest Veterans Administration |
$461.50
|
| Rate for Payer: United Healthcare Commercial |
$516.80
|
| Rate for Payer: WINHealth Partners Commercial |
$462.40
|
|
|
CLOSED TX RADIAL&ULNAR SHAFT FRACTURES W/O MAN
|
Professional
|
Both
|
$1,121.00
|
|
|
Service Code
|
HCPCS 25560
|
| Min. Negotiated Rate |
$223.13 |
| Max. Negotiated Rate |
$1,121.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,098.58
|
| Rate for Payer: Aetna of WY Medicare |
$262.51
|
| Rate for Payer: Beech Street Commercial |
$1,064.95
|
| Rate for Payer: Cash Price |
$784.70
|
| Rate for Payer: Cash Price |
$784.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,087.37
|
| Rate for Payer: Cigna of WY Commercial |
$1,098.58
|
| Rate for Payer: First Choice Health Commercial |
$1,008.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,064.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$262.51
|
| Rate for Payer: HealthUtah PPO |
$1,121.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,087.37
|
| Rate for Payer: Multiplan Medicare/VA |
$223.13
|
| Rate for Payer: One Health Plan of WY PPO |
$1,098.58
|
| Rate for Payer: PacificSource Commercial |
$1,008.90
|
| Rate for Payer: PHCS PPO |
$1,064.95
|
| Rate for Payer: Three Rivers PPO |
$840.75
|
| Rate for Payer: TriWest Veterans Administration |
$262.51
|
| Rate for Payer: United Healthcare Commercial |
$1,064.95
|
| Rate for Payer: WINHealth Partners Commercial |
$952.85
|
|
|
CLOSED TX SCAPULAR FRACTURE W/O MANIPULATION
|
Professional
|
Both
|
$1,022.00
|
|
|
Service Code
|
HCPCS 23570
|
| Min. Negotiated Rate |
$208.67 |
| Max. Negotiated Rate |
$1,022.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,001.56
|
| Rate for Payer: Aetna of WY Medicare |
$245.49
|
| Rate for Payer: Beech Street Commercial |
$970.90
|
| Rate for Payer: Cash Price |
$715.40
|
| Rate for Payer: Cash Price |
$715.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$991.34
|
| Rate for Payer: Cigna of WY Commercial |
$1,001.56
|
| Rate for Payer: First Choice Health Commercial |
$919.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$970.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$245.49
|
| Rate for Payer: HealthUtah PPO |
$1,022.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$991.34
|
| Rate for Payer: Multiplan Medicare/VA |
$208.67
|
| Rate for Payer: One Health Plan of WY PPO |
$1,001.56
|
| Rate for Payer: PacificSource Commercial |
$919.80
|
| Rate for Payer: PHCS PPO |
$970.90
|
| Rate for Payer: Three Rivers PPO |
$766.50
|
| Rate for Payer: TriWest Veterans Administration |
$245.49
|
| Rate for Payer: United Healthcare Commercial |
$970.90
|
| Rate for Payer: WINHealth Partners Commercial |
$868.70
|
|
|
CLOSED TX TALUS FRACTURE W/O MANIPULATION
|
Professional
|
Both
|
$927.00
|
|
|
Service Code
|
HCPCS 28430
|
| Min. Negotiated Rate |
$179.69 |
| Max. Negotiated Rate |
$927.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$908.46
|
| Rate for Payer: Aetna of WY Medicare |
$211.40
|
| Rate for Payer: Beech Street Commercial |
$880.65
|
| Rate for Payer: Cash Price |
$648.90
|
| Rate for Payer: Cash Price |
$648.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$899.19
|
| Rate for Payer: Cigna of WY Commercial |
$908.46
|
| Rate for Payer: First Choice Health Commercial |
$834.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$880.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$211.40
|
| Rate for Payer: HealthUtah PPO |
$927.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$899.19
|
| Rate for Payer: Multiplan Medicare/VA |
$179.69
|
| Rate for Payer: One Health Plan of WY PPO |
$908.46
|
| Rate for Payer: PacificSource Commercial |
$834.30
|
| Rate for Payer: PHCS PPO |
$880.65
|
| Rate for Payer: Three Rivers PPO |
$695.25
|
| Rate for Payer: TriWest Veterans Administration |
$211.40
|
| Rate for Payer: United Healthcare Commercial |
$880.65
|
| Rate for Payer: WINHealth Partners Commercial |
$787.95
|
|
|
CLOSED TX TARSOMETATARSAL DISLOCATION W/ANES
|
Professional
|
Both
|
$1,471.00
|
|
|
Service Code
|
HCPCS 28605
|
| Min. Negotiated Rate |
$260.13 |
| Max. Negotiated Rate |
$1,471.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,441.58
|
| Rate for Payer: Aetna of WY Medicare |
$306.03
|
| Rate for Payer: Beech Street Commercial |
$1,397.45
|
| Rate for Payer: Cash Price |
$1,029.70
|
| Rate for Payer: Cash Price |
$1,029.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,426.87
|
| Rate for Payer: Cigna of WY Commercial |
$1,441.58
|
| Rate for Payer: First Choice Health Commercial |
$1,323.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,397.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$306.03
|
| Rate for Payer: HealthUtah PPO |
$1,471.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,426.87
|
| Rate for Payer: Multiplan Medicare/VA |
$260.13
|
| Rate for Payer: One Health Plan of WY PPO |
$1,441.58
|
| Rate for Payer: PacificSource Commercial |
$1,323.90
|
| Rate for Payer: PHCS PPO |
$1,397.45
|
| Rate for Payer: Three Rivers PPO |
$1,103.25
|
| Rate for Payer: TriWest Veterans Administration |
$306.03
|
| Rate for Payer: United Healthcare Commercial |
$1,397.45
|
| Rate for Payer: WINHealth Partners Commercial |
$1,250.35
|
|
|
CLOSED TX TEMPOROMANDIBULAR DISLC COMP 1ST/SBSQ
|
Professional
|
Both
|
$3,995.00
|
|
|
Service Code
|
HCPCS 21485
|
| Min. Negotiated Rate |
$649.74 |
| Max. Negotiated Rate |
$3,995.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,915.10
|
| Rate for Payer: Aetna of WY Medicare |
$764.40
|
| Rate for Payer: Beech Street Commercial |
$3,795.25
|
| Rate for Payer: Cash Price |
$2,796.50
|
| Rate for Payer: Cash Price |
$2,796.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,875.15
|
| Rate for Payer: Cigna of WY Commercial |
$3,915.10
|
| Rate for Payer: First Choice Health Commercial |
$3,595.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,795.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$764.40
|
| Rate for Payer: HealthUtah PPO |
$3,995.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,875.15
|
| Rate for Payer: Multiplan Medicare/VA |
$649.74
|
| Rate for Payer: One Health Plan of WY PPO |
$3,915.10
|
| Rate for Payer: PacificSource Commercial |
$3,595.50
|
| Rate for Payer: PHCS PPO |
$3,795.25
|
| Rate for Payer: Three Rivers PPO |
$2,996.25
|
| Rate for Payer: TriWest Veterans Administration |
$764.40
|
| Rate for Payer: United Healthcare Commercial |
$3,795.25
|
| Rate for Payer: WINHealth Partners Commercial |
$3,395.75
|
|
|
CLOSED TX TEMPOROMANDIBULAR DISLOCATION 1ST/SBSQ
|
Professional
|
Both
|
$514.00
|
|
|
Service Code
|
HCPCS 21480
|
| Min. Negotiated Rate |
$25.02 |
| Max. Negotiated Rate |
$514.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$503.72
|
| Rate for Payer: Aetna of WY Medicare |
$29.43
|
| Rate for Payer: Beech Street Commercial |
$488.30
|
| Rate for Payer: Cash Price |
$359.80
|
| Rate for Payer: Cash Price |
$359.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$498.58
|
| Rate for Payer: Cigna of WY Commercial |
$503.72
|
| Rate for Payer: First Choice Health Commercial |
$462.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$488.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$29.43
|
| Rate for Payer: HealthUtah PPO |
$514.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$498.58
|
| Rate for Payer: Multiplan Medicare/VA |
$25.02
|
| Rate for Payer: One Health Plan of WY PPO |
$503.72
|
| Rate for Payer: PacificSource Commercial |
$462.60
|
| Rate for Payer: PHCS PPO |
$488.30
|
| Rate for Payer: Three Rivers PPO |
$385.50
|
| Rate for Payer: TriWest Veterans Administration |
$29.43
|
| Rate for Payer: United Healthcare Commercial |
$488.30
|
| Rate for Payer: WINHealth Partners Commercial |
$436.90
|
|
|
CLOSED TX ULNAR FRACTURE PROXIMAL END W/MANJ
|
Professional
|
Both
|
$1,837.00
|
|
|
Service Code
|
HCPCS 24675
|
| Min. Negotiated Rate |
$353.80 |
| Max. Negotiated Rate |
$1,837.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,800.26
|
| Rate for Payer: Aetna of WY Medicare |
$416.23
|
| Rate for Payer: Beech Street Commercial |
$1,745.15
|
| Rate for Payer: Cash Price |
$1,285.90
|
| Rate for Payer: Cash Price |
$1,285.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,781.89
|
| Rate for Payer: Cigna of WY Commercial |
$1,800.26
|
| Rate for Payer: First Choice Health Commercial |
$1,653.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,745.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$416.23
|
| Rate for Payer: HealthUtah PPO |
$1,837.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,781.89
|
| Rate for Payer: Multiplan Medicare/VA |
$353.80
|
| Rate for Payer: One Health Plan of WY PPO |
$1,800.26
|
| Rate for Payer: PacificSource Commercial |
$1,653.30
|
| Rate for Payer: PHCS PPO |
$1,745.15
|
| Rate for Payer: Three Rivers PPO |
$1,377.75
|
| Rate for Payer: TriWest Veterans Administration |
$416.23
|
| Rate for Payer: United Healthcare Commercial |
$1,745.15
|
| Rate for Payer: WINHealth Partners Commercial |
$1,561.45
|
|
|
CLOSED TX ULNAR FRACTURE PROXIMAL END W/O MANJ
|
Professional
|
Both
|
$1,167.00
|
|
|
Service Code
|
HCPCS 24670
|
| Min. Negotiated Rate |
$229.94 |
| Max. Negotiated Rate |
$1,167.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,143.66
|
| Rate for Payer: Aetna of WY Medicare |
$270.52
|
| Rate for Payer: Beech Street Commercial |
$1,108.65
|
| Rate for Payer: Cash Price |
$816.90
|
| Rate for Payer: Cash Price |
$816.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,131.99
|
| Rate for Payer: Cigna of WY Commercial |
$1,143.66
|
| Rate for Payer: First Choice Health Commercial |
$1,050.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,108.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$270.52
|
| Rate for Payer: HealthUtah PPO |
$1,167.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,131.99
|
| Rate for Payer: Multiplan Medicare/VA |
$229.94
|
| Rate for Payer: One Health Plan of WY PPO |
$1,143.66
|
| Rate for Payer: PacificSource Commercial |
$1,050.30
|
| Rate for Payer: PHCS PPO |
$1,108.65
|
| Rate for Payer: Three Rivers PPO |
$875.25
|
| Rate for Payer: TriWest Veterans Administration |
$270.52
|
| Rate for Payer: United Healthcare Commercial |
$1,108.65
|
| Rate for Payer: WINHealth Partners Commercial |
$991.95
|
|
|
CLOSED TX ULNAR SHAFT FRACTURE W/MANIPULATION
|
Professional
|
Both
|
$903.00
|
|
|
Service Code
|
HCPCS 25535
|
| Min. Negotiated Rate |
$387.45 |
| Max. Negotiated Rate |
$903.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$884.94
|
| Rate for Payer: Aetna of WY Medicare |
$455.82
|
| Rate for Payer: Beech Street Commercial |
$857.85
|
| Rate for Payer: Cash Price |
$632.10
|
| Rate for Payer: Cash Price |
$632.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$875.91
|
| Rate for Payer: Cigna of WY Commercial |
$884.94
|
| Rate for Payer: First Choice Health Commercial |
$812.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$857.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$455.82
|
| Rate for Payer: HealthUtah PPO |
$903.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$875.91
|
| Rate for Payer: Multiplan Medicare/VA |
$387.45
|
| Rate for Payer: One Health Plan of WY PPO |
$884.94
|
| Rate for Payer: PacificSource Commercial |
$812.70
|
| Rate for Payer: PHCS PPO |
$857.85
|
| Rate for Payer: Three Rivers PPO |
$677.25
|
| Rate for Payer: TriWest Veterans Administration |
$455.82
|
| Rate for Payer: United Healthcare Commercial |
$857.85
|
| Rate for Payer: WINHealth Partners Commercial |
$767.55
|
|
|
CLOSED TX ULNAR SHAFT FRACTURE W/O MANIPULATION
|
Professional
|
Both
|
$823.00
|
|
|
Service Code
|
HCPCS 25530
|
| Min. Negotiated Rate |
$209.80 |
| Max. Negotiated Rate |
$823.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$806.54
|
| Rate for Payer: Aetna of WY Medicare |
$246.82
|
| Rate for Payer: Beech Street Commercial |
$781.85
|
| Rate for Payer: Cash Price |
$576.10
|
| Rate for Payer: Cash Price |
$576.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$798.31
|
| Rate for Payer: Cigna of WY Commercial |
$806.54
|
| Rate for Payer: First Choice Health Commercial |
$740.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$781.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$246.82
|
| Rate for Payer: HealthUtah PPO |
$823.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$798.31
|
| Rate for Payer: Multiplan Medicare/VA |
$209.80
|
| Rate for Payer: One Health Plan of WY PPO |
$806.54
|
| Rate for Payer: PacificSource Commercial |
$740.70
|
| Rate for Payer: PHCS PPO |
$781.85
|
| Rate for Payer: Three Rivers PPO |
$617.25
|
| Rate for Payer: TriWest Veterans Administration |
$246.82
|
| Rate for Payer: United Healthcare Commercial |
$781.85
|
| Rate for Payer: WINHealth Partners Commercial |
$699.55
|
|
|
CLOSURE ENTEROSTOMY LG/SMALL INTESTINE
|
Professional
|
Both
|
$3,830.00
|
|
|
Service Code
|
HCPCS 44620 AS
|
| Min. Negotiated Rate |
$697.45 |
| Max. Negotiated Rate |
$3,830.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,753.40
|
| Rate for Payer: Beech Street Commercial |
$3,638.50
|
| Rate for Payer: Cash Price |
$2,681.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,715.10
|
| Rate for Payer: Cigna of WY Commercial |
$3,753.40
|
| Rate for Payer: First Choice Health Commercial |
$3,447.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,638.50
|
| Rate for Payer: HealthUtah PPO |
$3,830.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,715.10
|
| Rate for Payer: One Health Plan of WY PPO |
$3,753.40
|
| Rate for Payer: PacificSource Commercial |
$3,447.00
|
| Rate for Payer: PHCS PPO |
$3,638.50
|
| Rate for Payer: Three Rivers PPO |
$2,872.50
|
| Rate for Payer: United Healthcare Commercial |
$3,638.50
|
| Rate for Payer: WINHealth Partners Commercial |
$3,255.50
|
|
|
CLOSURE ENTEROSTOMY LG/SMALL INTESTINE
|
Professional
|
Both
|
$3,830.00
|
|
|
Service Code
|
HCPCS 44620 80
|
| Min. Negotiated Rate |
$697.45 |
| Max. Negotiated Rate |
$3,830.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,753.40
|
| Rate for Payer: Beech Street Commercial |
$3,638.50
|
| Rate for Payer: Cash Price |
$2,681.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,715.10
|
| Rate for Payer: Cigna of WY Commercial |
$3,753.40
|
| Rate for Payer: First Choice Health Commercial |
$3,447.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,638.50
|
| Rate for Payer: HealthUtah PPO |
$3,830.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,715.10
|
| Rate for Payer: One Health Plan of WY PPO |
$3,753.40
|
| Rate for Payer: PacificSource Commercial |
$3,447.00
|
| Rate for Payer: PHCS PPO |
$3,638.50
|
| Rate for Payer: Three Rivers PPO |
$2,872.50
|
| Rate for Payer: United Healthcare Commercial |
$3,638.50
|
| Rate for Payer: WINHealth Partners Commercial |
$3,255.50
|
|
|
CLOSURE ENTEROSTOMY LG/SMALL INTESTINE
|
Professional
|
Both
|
$3,830.00
|
|
|
Service Code
|
HCPCS 44620
|
| Min. Negotiated Rate |
$697.45 |
| Max. Negotiated Rate |
$3,830.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,753.40
|
| Rate for Payer: Aetna of WY Medicare |
$820.53
|
| Rate for Payer: Beech Street Commercial |
$3,638.50
|
| Rate for Payer: Cash Price |
$2,681.00
|
| Rate for Payer: Cash Price |
$2,681.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,715.10
|
| Rate for Payer: Cigna of WY Commercial |
$3,753.40
|
| Rate for Payer: First Choice Health Commercial |
$3,447.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,638.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$820.53
|
| Rate for Payer: HealthUtah PPO |
$3,830.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,715.10
|
| Rate for Payer: Multiplan Medicare/VA |
$697.45
|
| Rate for Payer: One Health Plan of WY PPO |
$3,753.40
|
| Rate for Payer: PacificSource Commercial |
$3,447.00
|
| Rate for Payer: PHCS PPO |
$3,638.50
|
| Rate for Payer: Three Rivers PPO |
$2,872.50
|
| Rate for Payer: TriWest Veterans Administration |
$820.53
|
| Rate for Payer: United Healthcare Commercial |
$3,638.50
|
| Rate for Payer: WINHealth Partners Commercial |
$3,255.50
|
|
|
CLOTRIMAZOLE 1 % TOPICAL CREAM [18977]
|
Facility
|
OP
|
$15.88
|
|
|
Service Code
|
NDC 5167220022
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.60 |
| Max. Negotiated Rate |
$15.88 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.56
|
| Rate for Payer: Aetna of WY Medicare |
$10.48
|
| Rate for Payer: Altius Commercial |
$15.24
|
| Rate for Payer: Beech Street Commercial |
$15.56
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.40
|
| Rate for Payer: Cash Price |
$11.12
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.40
|
| Rate for Payer: Cigna of WY Commercial |
$15.56
|
| Rate for Payer: Entrust Commercial |
$15.09
|
| Rate for Payer: First Choice Health Commercial |
$15.09
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.09
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.05
|
| Rate for Payer: HealthUtah PPO |
$15.88
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.40
|
| Rate for Payer: Multiplan Medicare/VA |
$8.60
|
| Rate for Payer: One Health Plan of WY PPO |
$15.56
|
| Rate for Payer: PacificSource Commercial |
$14.29
|
| Rate for Payer: PHCS PPO |
$15.56
|
| Rate for Payer: Three Rivers PPO |
$11.91
|
| Rate for Payer: TriWest Veterans Administration |
$9.05
|
| Rate for Payer: United Healthcare Commercial |
$15.17
|
| Rate for Payer: United Healthcare Medicare |
$9.05
|
| Rate for Payer: WINHealth Partners Commercial |
$15.56
|
| Rate for Payer: Wise Provider Network Commercial |
$15.09
|
|
|
CLOTRIMAZOLE 1 % TOPICAL CREAM [18977]
|
Facility
|
IP
|
$15.88
|
|
|
Service Code
|
NDC 5167220022
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.20 |
| Max. Negotiated Rate |
$15.88 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.56
|
| Rate for Payer: Aetna of WY Medicare |
$10.16
|
| Rate for Payer: Altius Commercial |
$15.24
|
| Rate for Payer: Beech Street Commercial |
$15.56
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.40
|
| Rate for Payer: Cash Price |
$11.12
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.40
|
| Rate for Payer: Cigna of WY Commercial |
$15.56
|
| Rate for Payer: Entrust Commercial |
$15.09
|
| Rate for Payer: First Choice Health Commercial |
$15.09
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.09
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.69
|
| Rate for Payer: HealthUtah PPO |
$15.88
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.40
|
| Rate for Payer: Multiplan Medicare/VA |
$9.20
|
| Rate for Payer: One Health Plan of WY PPO |
$15.56
|
| Rate for Payer: PacificSource Commercial |
$14.29
|
| Rate for Payer: PHCS PPO |
$15.56
|
| Rate for Payer: Three Rivers PPO |
$11.91
|
| Rate for Payer: TriWest Veterans Administration |
$9.69
|
| Rate for Payer: United Healthcare Commercial |
$15.17
|
| Rate for Payer: United Healthcare Medicare |
$9.69
|
| Rate for Payer: WINHealth Partners Commercial |
$15.09
|
| Rate for Payer: Wise Provider Network Commercial |
$15.09
|
|
|
CLOTRIMAZOLE 1 % TOPICAL CREAM [18977]
|
Facility
|
IP
|
$15.29
|
|
|
Service Code
|
NDC 0536127222
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.86 |
| Max. Negotiated Rate |
$15.29 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.98
|
| Rate for Payer: Aetna of WY Medicare |
$9.79
|
| Rate for Payer: Altius Commercial |
$14.68
|
| Rate for Payer: Beech Street Commercial |
$14.98
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.83
|
| Rate for Payer: Cash Price |
$10.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.83
|
| Rate for Payer: Cigna of WY Commercial |
$14.98
|
| Rate for Payer: Entrust Commercial |
$14.53
|
| Rate for Payer: First Choice Health Commercial |
$14.53
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.53
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.33
|
| Rate for Payer: HealthUtah PPO |
$15.29
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.83
|
| Rate for Payer: Multiplan Medicare/VA |
$8.86
|
| Rate for Payer: One Health Plan of WY PPO |
$14.98
|
| Rate for Payer: PacificSource Commercial |
$13.76
|
| Rate for Payer: PHCS PPO |
$14.98
|
| Rate for Payer: Three Rivers PPO |
$11.47
|
| Rate for Payer: TriWest Veterans Administration |
$9.33
|
| Rate for Payer: United Healthcare Commercial |
$14.60
|
| Rate for Payer: United Healthcare Medicare |
$9.33
|
| Rate for Payer: WINHealth Partners Commercial |
$14.53
|
| Rate for Payer: Wise Provider Network Commercial |
$14.53
|
|
|
CLOTRIMAZOLE 1 % TOPICAL CREAM [18977]
|
Facility
|
OP
|
$15.61
|
|
|
Service Code
|
NDC 4580243411
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.45 |
| Max. Negotiated Rate |
$15.61 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.30
|
| Rate for Payer: Aetna of WY Medicare |
$10.30
|
| Rate for Payer: Altius Commercial |
$14.99
|
| Rate for Payer: Beech Street Commercial |
$15.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.14
|
| Rate for Payer: Cash Price |
$10.92
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.14
|
| Rate for Payer: Cigna of WY Commercial |
$15.30
|
| Rate for Payer: Entrust Commercial |
$14.83
|
| Rate for Payer: First Choice Health Commercial |
$14.83
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.83
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.90
|
| Rate for Payer: HealthUtah PPO |
$15.61
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.14
|
| Rate for Payer: Multiplan Medicare/VA |
$8.45
|
| Rate for Payer: One Health Plan of WY PPO |
$15.30
|
| Rate for Payer: PacificSource Commercial |
$14.05
|
| Rate for Payer: PHCS PPO |
$15.30
|
| Rate for Payer: Three Rivers PPO |
$11.71
|
| Rate for Payer: TriWest Veterans Administration |
$8.90
|
| Rate for Payer: United Healthcare Commercial |
$14.91
|
| Rate for Payer: United Healthcare Medicare |
$8.90
|
| Rate for Payer: WINHealth Partners Commercial |
$15.30
|
| Rate for Payer: Wise Provider Network Commercial |
$14.83
|
|
|
CLOTRIMAZOLE 1 % TOPICAL CREAM [18977]
|
Facility
|
IP
|
$15.61
|
|
|
Service Code
|
NDC 4580243411
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.05 |
| Max. Negotiated Rate |
$15.61 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.30
|
| Rate for Payer: Aetna of WY Medicare |
$9.99
|
| Rate for Payer: Altius Commercial |
$14.99
|
| Rate for Payer: Beech Street Commercial |
$15.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.14
|
| Rate for Payer: Cash Price |
$10.92
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.14
|
| Rate for Payer: Cigna of WY Commercial |
$15.30
|
| Rate for Payer: Entrust Commercial |
$14.83
|
| Rate for Payer: First Choice Health Commercial |
$14.83
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.83
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.52
|
| Rate for Payer: HealthUtah PPO |
$15.61
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.14
|
| Rate for Payer: Multiplan Medicare/VA |
$9.05
|
| Rate for Payer: One Health Plan of WY PPO |
$15.30
|
| Rate for Payer: PacificSource Commercial |
$14.05
|
| Rate for Payer: PHCS PPO |
$15.30
|
| Rate for Payer: Three Rivers PPO |
$11.71
|
| Rate for Payer: TriWest Veterans Administration |
$9.52
|
| Rate for Payer: United Healthcare Commercial |
$14.91
|
| Rate for Payer: United Healthcare Medicare |
$9.52
|
| Rate for Payer: WINHealth Partners Commercial |
$14.83
|
| Rate for Payer: Wise Provider Network Commercial |
$14.83
|
|
|
CLOTRIMAZOLE 1 % TOPICAL CREAM [18977]
|
Facility
|
OP
|
$15.29
|
|
|
Service Code
|
NDC 0536127222
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.28 |
| Max. Negotiated Rate |
$15.29 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.98
|
| Rate for Payer: Aetna of WY Medicare |
$10.09
|
| Rate for Payer: Altius Commercial |
$14.68
|
| Rate for Payer: Beech Street Commercial |
$14.98
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.83
|
| Rate for Payer: Cash Price |
$10.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.83
|
| Rate for Payer: Cigna of WY Commercial |
$14.98
|
| Rate for Payer: Entrust Commercial |
$14.53
|
| Rate for Payer: First Choice Health Commercial |
$14.53
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.53
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.72
|
| Rate for Payer: HealthUtah PPO |
$15.29
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.83
|
| Rate for Payer: Multiplan Medicare/VA |
$8.28
|
| Rate for Payer: One Health Plan of WY PPO |
$14.98
|
| Rate for Payer: PacificSource Commercial |
$13.76
|
| Rate for Payer: PHCS PPO |
$14.98
|
| Rate for Payer: Three Rivers PPO |
$11.47
|
| Rate for Payer: TriWest Veterans Administration |
$8.72
|
| Rate for Payer: United Healthcare Commercial |
$14.60
|
| Rate for Payer: United Healthcare Medicare |
$8.72
|
| Rate for Payer: WINHealth Partners Commercial |
$14.98
|
| Rate for Payer: Wise Provider Network Commercial |
$14.53
|
|
|
CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM [12862]
|
Facility
|
OP
|
$17.70
|
|
|
Service Code
|
NDC 6846229817
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.58 |
| Max. Negotiated Rate |
$17.70 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$17.35
|
| Rate for Payer: Aetna of WY Medicare |
$11.68
|
| Rate for Payer: Altius Commercial |
$16.99
|
| Rate for Payer: Beech Street Commercial |
$17.35
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$17.17
|
| Rate for Payer: Cash Price |
$12.39
|
| Rate for Payer: ChoiceCare Network Commercial |
$17.17
|
| Rate for Payer: Cigna of WY Commercial |
$17.35
|
| Rate for Payer: Entrust Commercial |
$16.82
|
| Rate for Payer: First Choice Health Commercial |
$16.82
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.82
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.09
|
| Rate for Payer: HealthUtah PPO |
$17.70
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.17
|
| Rate for Payer: Multiplan Medicare/VA |
$9.58
|
| Rate for Payer: One Health Plan of WY PPO |
$17.35
|
| Rate for Payer: PacificSource Commercial |
$15.93
|
| Rate for Payer: PHCS PPO |
$17.35
|
| Rate for Payer: Three Rivers PPO |
$13.28
|
| Rate for Payer: TriWest Veterans Administration |
$10.09
|
| Rate for Payer: United Healthcare Commercial |
$16.90
|
| Rate for Payer: United Healthcare Medicare |
$10.09
|
| Rate for Payer: WINHealth Partners Commercial |
$17.35
|
| Rate for Payer: Wise Provider Network Commercial |
$16.82
|
|
|
CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM [12862]
|
Facility
|
IP
|
$17.70
|
|
|
Service Code
|
NDC 6846229817
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.26 |
| Max. Negotiated Rate |
$17.70 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$17.35
|
| Rate for Payer: Aetna of WY Medicare |
$11.33
|
| Rate for Payer: Altius Commercial |
$16.99
|
| Rate for Payer: Beech Street Commercial |
$17.35
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$17.17
|
| Rate for Payer: Cash Price |
$12.39
|
| Rate for Payer: ChoiceCare Network Commercial |
$17.17
|
| Rate for Payer: Cigna of WY Commercial |
$17.35
|
| Rate for Payer: Entrust Commercial |
$16.82
|
| Rate for Payer: First Choice Health Commercial |
$16.82
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.82
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.80
|
| Rate for Payer: HealthUtah PPO |
$17.70
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.17
|
| Rate for Payer: Multiplan Medicare/VA |
$10.26
|
| Rate for Payer: One Health Plan of WY PPO |
$17.35
|
| Rate for Payer: PacificSource Commercial |
$15.93
|
| Rate for Payer: PHCS PPO |
$17.35
|
| Rate for Payer: Three Rivers PPO |
$13.28
|
| Rate for Payer: TriWest Veterans Administration |
$10.80
|
| Rate for Payer: United Healthcare Commercial |
$16.90
|
| Rate for Payer: United Healthcare Medicare |
$10.80
|
| Rate for Payer: WINHealth Partners Commercial |
$16.82
|
| Rate for Payer: Wise Provider Network Commercial |
$16.82
|
|
