|
DROPERIDOL INJECTION
|
Professional
|
Both
|
$25.00
|
|
|
Service Code
|
HCPCS J1790
|
| Hospital Charge Code |
J1790
|
| Min. Negotiated Rate |
$18.75 |
| Max. Negotiated Rate |
$25.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$24.50
|
| Rate for Payer: Beech Street Commercial |
$23.75
|
| Rate for Payer: Cash Price |
$17.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$24.25
|
| Rate for Payer: Cigna of WY Commercial |
$24.50
|
| Rate for Payer: First Choice Health Commercial |
$22.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$23.75
|
| Rate for Payer: HealthUtah PPO |
$25.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.25
|
| Rate for Payer: One Health Plan of WY PPO |
$24.50
|
| Rate for Payer: PacificSource Commercial |
$22.50
|
| Rate for Payer: PHCS PPO |
$23.75
|
| Rate for Payer: Three Rivers PPO |
$18.75
|
| Rate for Payer: United Healthcare Commercial |
$21.75
|
| Rate for Payer: WINHealth Partners Commercial |
$23.75
|
|
|
DRS&/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ LARGE
|
Professional
|
Both
|
$667.00
|
|
|
Service Code
|
HCPCS 16030
|
| Hospital Charge Code |
16030
|
| Min. Negotiated Rate |
$106.89 |
| Max. Negotiated Rate |
$667.00 |
| Rate for Payer: TriWest Veterans Administration |
$125.75
|
| Rate for Payer: United Healthcare Commercial |
$580.29
|
| Rate for Payer: United Healthcare Medicare |
$125.75
|
| Rate for Payer: WINHealth Partners Commercial |
$566.95
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$653.66
|
| Rate for Payer: Aetna of WY Medicare |
$125.75
|
| Rate for Payer: Beech Street Commercial |
$633.65
|
| Rate for Payer: Cash Price |
$466.90
|
| Rate for Payer: Cash Price |
$466.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$646.99
|
| Rate for Payer: Cigna of WY Commercial |
$653.66
|
| Rate for Payer: First Choice Health Commercial |
$600.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$633.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$125.75
|
| Rate for Payer: HealthUtah PPO |
$667.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$646.99
|
| Rate for Payer: Multiplan Medicare/VA |
$106.89
|
| Rate for Payer: One Health Plan of WY PPO |
$653.66
|
| Rate for Payer: PacificSource Commercial |
$600.30
|
| Rate for Payer: PHCS PPO |
$633.65
|
| Rate for Payer: Three Rivers PPO |
$500.25
|
|
|
DRS&/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ MEDIUM
|
Professional
|
Both
|
$553.00
|
|
|
Service Code
|
HCPCS 16025
|
| Hospital Charge Code |
16025
|
| Min. Negotiated Rate |
$90.86 |
| Max. Negotiated Rate |
$553.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$541.94
|
| Rate for Payer: Aetna of WY Medicare |
$106.89
|
| Rate for Payer: Beech Street Commercial |
$525.35
|
| Rate for Payer: Cash Price |
$387.10
|
| Rate for Payer: Cash Price |
$387.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$536.41
|
| Rate for Payer: Cigna of WY Commercial |
$541.94
|
| Rate for Payer: First Choice Health Commercial |
$497.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$525.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$106.89
|
| Rate for Payer: HealthUtah PPO |
$553.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$536.41
|
| Rate for Payer: Multiplan Medicare/VA |
$90.86
|
| Rate for Payer: One Health Plan of WY PPO |
$541.94
|
| Rate for Payer: PacificSource Commercial |
$497.70
|
| Rate for Payer: PHCS PPO |
$525.35
|
| Rate for Payer: Three Rivers PPO |
$414.75
|
| Rate for Payer: TriWest Veterans Administration |
$106.89
|
| Rate for Payer: United Healthcare Commercial |
$481.11
|
| Rate for Payer: United Healthcare Medicare |
$106.89
|
| Rate for Payer: WINHealth Partners Commercial |
$470.05
|
|
|
DRS&/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ SMALL
|
Professional
|
Both
|
$270.00
|
|
|
Service Code
|
HCPCS 16020
|
| Hospital Charge Code |
16020
|
| Min. Negotiated Rate |
$45.88 |
| Max. Negotiated Rate |
$270.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$264.60
|
| Rate for Payer: Aetna of WY Medicare |
$53.98
|
| Rate for Payer: Beech Street Commercial |
$256.50
|
| Rate for Payer: Cash Price |
$189.00
|
| Rate for Payer: Cash Price |
$189.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$261.90
|
| Rate for Payer: Cigna of WY Commercial |
$264.60
|
| Rate for Payer: First Choice Health Commercial |
$243.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$256.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$53.98
|
| Rate for Payer: HealthUtah PPO |
$270.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$261.90
|
| Rate for Payer: Multiplan Medicare/VA |
$45.88
|
| Rate for Payer: One Health Plan of WY PPO |
$264.60
|
| Rate for Payer: PacificSource Commercial |
$243.00
|
| Rate for Payer: PHCS PPO |
$256.50
|
| Rate for Payer: Three Rivers PPO |
$202.50
|
| Rate for Payer: TriWest Veterans Administration |
$53.98
|
| Rate for Payer: United Healthcare Commercial |
$234.90
|
| Rate for Payer: United Healthcare Medicare |
$53.98
|
| Rate for Payer: WINHealth Partners Commercial |
$229.50
|
|
|
DRUG SCREEN LIST A ANY NMBR NON TLC DEVICES
|
Professional
|
Both
|
$30.00
|
|
|
Service Code
|
HCPCS 80300
|
| Hospital Charge Code |
80300
|
| Min. Negotiated Rate |
$22.50 |
| Max. Negotiated Rate |
$30.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$29.40
|
| Rate for Payer: Beech Street Commercial |
$28.50
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$29.10
|
| Rate for Payer: Cigna of WY Commercial |
$29.40
|
| Rate for Payer: First Choice Health Commercial |
$27.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$28.50
|
| Rate for Payer: HealthUtah PPO |
$30.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$29.10
|
| Rate for Payer: One Health Plan of WY PPO |
$29.40
|
| Rate for Payer: PacificSource Commercial |
$27.00
|
| Rate for Payer: PHCS PPO |
$28.50
|
| Rate for Payer: Three Rivers PPO |
$22.50
|
| Rate for Payer: United Healthcare Commercial |
$26.10
|
| Rate for Payer: WINHealth Partners Commercial |
$28.50
|
|
|
DRUG SCREEN MULT CLASSES
|
Professional
|
Both
|
$30.00
|
|
|
Service Code
|
HCPCS 80100
|
| Hospital Charge Code |
80100
|
| Min. Negotiated Rate |
$22.50 |
| Max. Negotiated Rate |
$30.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$29.40
|
| Rate for Payer: Beech Street Commercial |
$28.50
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$29.10
|
| Rate for Payer: Cigna of WY Commercial |
$29.40
|
| Rate for Payer: First Choice Health Commercial |
$27.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$28.50
|
| Rate for Payer: HealthUtah PPO |
$30.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$29.10
|
| Rate for Payer: One Health Plan of WY PPO |
$29.40
|
| Rate for Payer: PacificSource Commercial |
$27.00
|
| Rate for Payer: PHCS PPO |
$28.50
|
| Rate for Payer: Three Rivers PPO |
$22.50
|
| Rate for Payer: United Healthcare Commercial |
$26.10
|
| Rate for Payer: WINHealth Partners Commercial |
$28.50
|
|
|
DRUG SCREEN MULTIPLE CLASS
|
Professional
|
Both
|
$43.00
|
|
|
Service Code
|
HCPCS G0431
|
| Hospital Charge Code |
G0431
|
| Min. Negotiated Rate |
$32.25 |
| Max. Negotiated Rate |
$43.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$42.14
|
| Rate for Payer: Beech Street Commercial |
$40.85
|
| Rate for Payer: Cash Price |
$30.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$41.71
|
| Rate for Payer: Cigna of WY Commercial |
$42.14
|
| Rate for Payer: First Choice Health Commercial |
$38.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$40.85
|
| Rate for Payer: HealthUtah PPO |
$43.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$41.71
|
| Rate for Payer: One Health Plan of WY PPO |
$42.14
|
| Rate for Payer: PacificSource Commercial |
$38.70
|
| Rate for Payer: PHCS PPO |
$40.85
|
| Rate for Payer: Three Rivers PPO |
$32.25
|
| Rate for Payer: United Healthcare Commercial |
$37.41
|
| Rate for Payer: WINHealth Partners Commercial |
$40.85
|
|
|
DRUGS UNCLASSIFIED INJECTION
|
Professional
|
Both
|
$21.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
J3490
|
| Min. Negotiated Rate |
$15.75 |
| Max. Negotiated Rate |
$21.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$20.58
|
| Rate for Payer: Beech Street Commercial |
$19.95
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$20.37
|
| Rate for Payer: Cigna of WY Commercial |
$20.58
|
| Rate for Payer: First Choice Health Commercial |
$18.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$19.95
|
| Rate for Payer: HealthUtah PPO |
$21.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$20.37
|
| Rate for Payer: One Health Plan of WY PPO |
$20.58
|
| Rate for Payer: PacificSource Commercial |
$18.90
|
| Rate for Payer: PHCS PPO |
$19.95
|
| Rate for Payer: Three Rivers PPO |
$15.75
|
| Rate for Payer: United Healthcare Commercial |
$18.27
|
| Rate for Payer: WINHealth Partners Commercial |
$19.95
|
|
|
DRUG TEST PRSMV READ DIRECT OPTICAL OBS PR DATE
|
Professional
|
Both
|
$43.00
|
|
|
Service Code
|
HCPCS 80305
|
| Hospital Charge Code |
80305
|
| Min. Negotiated Rate |
$10.71 |
| Max. Negotiated Rate |
$43.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$42.14
|
| Rate for Payer: Aetna of WY Medicare |
$12.60
|
| Rate for Payer: Beech Street Commercial |
$40.85
|
| Rate for Payer: Cash Price |
$30.10
|
| Rate for Payer: Cash Price |
$30.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$41.71
|
| Rate for Payer: Cigna of WY Commercial |
$42.14
|
| Rate for Payer: First Choice Health Commercial |
$38.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$40.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$12.60
|
| Rate for Payer: HealthUtah PPO |
$43.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$41.71
|
| Rate for Payer: Multiplan Medicare/VA |
$10.71
|
| Rate for Payer: One Health Plan of WY PPO |
$42.14
|
| Rate for Payer: PacificSource Commercial |
$38.70
|
| Rate for Payer: PHCS PPO |
$40.85
|
| Rate for Payer: Three Rivers PPO |
$32.25
|
| Rate for Payer: TriWest Veterans Administration |
$12.60
|
| Rate for Payer: United Healthcare Commercial |
$37.41
|
| Rate for Payer: United Healthcare Medicare |
$12.60
|
| Rate for Payer: WINHealth Partners Commercial |
$40.85
|
|
|
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE
|
Professional
|
Both
|
$459.00
|
|
|
Service Code
|
HCPCS 80307
|
| Hospital Charge Code |
80307
|
| Min. Negotiated Rate |
$52.82 |
| Max. Negotiated Rate |
$459.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$449.82
|
| Rate for Payer: Aetna of WY Medicare |
$62.14
|
| Rate for Payer: Beech Street Commercial |
$436.05
|
| Rate for Payer: Cash Price |
$321.30
|
| Rate for Payer: Cash Price |
$321.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$445.23
|
| Rate for Payer: Cigna of WY Commercial |
$449.82
|
| Rate for Payer: First Choice Health Commercial |
$413.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$436.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$62.14
|
| Rate for Payer: HealthUtah PPO |
$459.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$445.23
|
| Rate for Payer: Multiplan Medicare/VA |
$52.82
|
| Rate for Payer: One Health Plan of WY PPO |
$449.82
|
| Rate for Payer: PacificSource Commercial |
$413.10
|
| Rate for Payer: PHCS PPO |
$436.05
|
| Rate for Payer: Three Rivers PPO |
$344.25
|
| Rate for Payer: TriWest Veterans Administration |
$62.14
|
| Rate for Payer: United Healthcare Commercial |
$399.33
|
| Rate for Payer: United Healthcare Medicare |
$62.14
|
| Rate for Payer: WINHealth Partners Commercial |
$436.05
|
|
|
DSTRJ LESION ANUS SIMPLE CHEMICAL
|
Professional
|
Both
|
$702.00
|
|
|
Service Code
|
HCPCS 46900
|
| Hospital Charge Code |
46900
|
| Min. Negotiated Rate |
$113.62 |
| Max. Negotiated Rate |
$702.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$687.96
|
| Rate for Payer: Aetna of WY Medicare |
$133.67
|
| Rate for Payer: Beech Street Commercial |
$666.90
|
| Rate for Payer: Cash Price |
$491.40
|
| Rate for Payer: Cash Price |
$491.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$680.94
|
| Rate for Payer: Cigna of WY Commercial |
$687.96
|
| Rate for Payer: First Choice Health Commercial |
$631.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$666.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$133.67
|
| Rate for Payer: HealthUtah PPO |
$702.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$680.94
|
| Rate for Payer: Multiplan Medicare/VA |
$113.62
|
| Rate for Payer: One Health Plan of WY PPO |
$687.96
|
| Rate for Payer: PacificSource Commercial |
$631.80
|
| Rate for Payer: PHCS PPO |
$666.90
|
| Rate for Payer: Three Rivers PPO |
$526.50
|
| Rate for Payer: TriWest Veterans Administration |
$133.67
|
| Rate for Payer: United Healthcare Commercial |
$610.74
|
| Rate for Payer: United Healthcare Medicare |
$133.67
|
| Rate for Payer: WINHealth Partners Commercial |
$596.70
|
|
|
DSTRJ NEUROLYTIC AGENT INTERCOSTAL NERVE
|
Professional
|
Both
|
$904.00
|
|
|
Service Code
|
HCPCS 64620
|
| Hospital Charge Code |
64620
|
| Min. Negotiated Rate |
$145.60 |
| Max. Negotiated Rate |
$904.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$885.92
|
| Rate for Payer: Aetna of WY Medicare |
$171.29
|
| Rate for Payer: Beech Street Commercial |
$858.80
|
| Rate for Payer: Cash Price |
$632.80
|
| Rate for Payer: Cash Price |
$632.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$876.88
|
| Rate for Payer: Cigna of WY Commercial |
$885.92
|
| Rate for Payer: First Choice Health Commercial |
$813.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$858.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$171.29
|
| Rate for Payer: HealthUtah PPO |
$904.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$876.88
|
| Rate for Payer: Multiplan Medicare/VA |
$145.60
|
| Rate for Payer: One Health Plan of WY PPO |
$885.92
|
| Rate for Payer: PacificSource Commercial |
$813.60
|
| Rate for Payer: PHCS PPO |
$858.80
|
| Rate for Payer: Three Rivers PPO |
$678.00
|
| Rate for Payer: TriWest Veterans Administration |
$171.29
|
| Rate for Payer: United Healthcare Commercial |
$786.48
|
| Rate for Payer: United Healthcare Medicare |
$171.29
|
| Rate for Payer: WINHealth Partners Commercial |
$768.40
|
|
|
DSTRJ NEUROLYTIC AGENT OTHER PERIPHERAL NERVE
|
Professional
|
Both
|
$1,732.00
|
|
|
Service Code
|
HCPCS 64640 50
|
| Hospital Charge Code |
64640
|
| Min. Negotiated Rate |
$97.55 |
| Max. Negotiated Rate |
$1,732.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,697.36
|
| Rate for Payer: Aetna of WY Medicare |
$114.77
|
| Rate for Payer: Beech Street Commercial |
$1,645.40
|
| Rate for Payer: Cash Price |
$1,212.40
|
| Rate for Payer: Cash Price |
$1,212.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,680.04
|
| Rate for Payer: Cigna of WY Commercial |
$1,697.36
|
| Rate for Payer: First Choice Health Commercial |
$1,558.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,645.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$114.77
|
| Rate for Payer: HealthUtah PPO |
$1,732.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,680.04
|
| Rate for Payer: Multiplan Medicare/VA |
$97.55
|
| Rate for Payer: One Health Plan of WY PPO |
$1,697.36
|
| Rate for Payer: PacificSource Commercial |
$1,558.80
|
| Rate for Payer: PHCS PPO |
$1,645.40
|
| Rate for Payer: Three Rivers PPO |
$1,299.00
|
| Rate for Payer: TriWest Veterans Administration |
$114.77
|
| Rate for Payer: United Healthcare Commercial |
$1,506.84
|
| Rate for Payer: United Healthcare Medicare |
$114.77
|
| Rate for Payer: WINHealth Partners Commercial |
$1,472.20
|
|
|
DSTRJ NEUROLYTIC AGENT OTHER PERIPHERAL NERVE
|
Professional
|
Both
|
$866.00
|
|
|
Service Code
|
HCPCS 64640
|
| Hospital Charge Code |
64640
|
| Min. Negotiated Rate |
$97.55 |
| Max. Negotiated Rate |
$866.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$848.68
|
| Rate for Payer: Aetna of WY Medicare |
$114.77
|
| Rate for Payer: Beech Street Commercial |
$822.70
|
| Rate for Payer: Cash Price |
$606.20
|
| Rate for Payer: Cash Price |
$606.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$840.02
|
| Rate for Payer: Cigna of WY Commercial |
$848.68
|
| Rate for Payer: First Choice Health Commercial |
$779.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$822.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$114.77
|
| Rate for Payer: HealthUtah PPO |
$866.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$840.02
|
| Rate for Payer: Multiplan Medicare/VA |
$97.55
|
| Rate for Payer: One Health Plan of WY PPO |
$848.68
|
| Rate for Payer: PacificSource Commercial |
$779.40
|
| Rate for Payer: PHCS PPO |
$822.70
|
| Rate for Payer: Three Rivers PPO |
$649.50
|
| Rate for Payer: TriWest Veterans Administration |
$114.77
|
| Rate for Payer: United Healthcare Commercial |
$753.42
|
| Rate for Payer: United Healthcare Medicare |
$114.77
|
| Rate for Payer: WINHealth Partners Commercial |
$736.10
|
|
|
DSTRJ NEUROLYTIC W/WO RAD MONITOR CELIAC PLEXUS
|
Professional
|
Both
|
$1,689.00
|
|
|
Service Code
|
HCPCS 64680
|
| Hospital Charge Code |
64680
|
| Min. Negotiated Rate |
$131.43 |
| Max. Negotiated Rate |
$1,689.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,655.22
|
| Rate for Payer: Aetna of WY Medicare |
$154.62
|
| Rate for Payer: Beech Street Commercial |
$1,604.55
|
| Rate for Payer: Cash Price |
$1,182.30
|
| Rate for Payer: Cash Price |
$1,182.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,638.33
|
| Rate for Payer: Cigna of WY Commercial |
$1,655.22
|
| Rate for Payer: First Choice Health Commercial |
$1,520.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,604.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$154.62
|
| Rate for Payer: HealthUtah PPO |
$1,689.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,638.33
|
| Rate for Payer: Multiplan Medicare/VA |
$131.43
|
| Rate for Payer: One Health Plan of WY PPO |
$1,655.22
|
| Rate for Payer: PacificSource Commercial |
$1,520.10
|
| Rate for Payer: PHCS PPO |
$1,604.55
|
| Rate for Payer: Three Rivers PPO |
$1,266.75
|
| Rate for Payer: TriWest Veterans Administration |
$154.62
|
| Rate for Payer: United Healthcare Commercial |
$1,469.43
|
| Rate for Payer: United Healthcare Medicare |
$154.62
|
| Rate for Payer: WINHealth Partners Commercial |
$1,435.65
|
|
|
DSTR NROLYTC AGNT PARVERTEB FCT ADDL CRVCL/THORA
|
Professional
|
Both
|
$893.00
|
|
|
Service Code
|
HCPCS 64634
|
| Hospital Charge Code |
64634
|
| Min. Negotiated Rate |
$54.44 |
| Max. Negotiated Rate |
$893.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$875.14
|
| Rate for Payer: Aetna of WY Medicare |
$64.05
|
| Rate for Payer: Beech Street Commercial |
$848.35
|
| Rate for Payer: Cash Price |
$625.10
|
| Rate for Payer: Cash Price |
$625.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$866.21
|
| Rate for Payer: Cigna of WY Commercial |
$875.14
|
| Rate for Payer: First Choice Health Commercial |
$803.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$848.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$64.05
|
| Rate for Payer: HealthUtah PPO |
$893.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$866.21
|
| Rate for Payer: Multiplan Medicare/VA |
$54.44
|
| Rate for Payer: One Health Plan of WY PPO |
$875.14
|
| Rate for Payer: PacificSource Commercial |
$803.70
|
| Rate for Payer: PHCS PPO |
$848.35
|
| Rate for Payer: Three Rivers PPO |
$669.75
|
| Rate for Payer: TriWest Veterans Administration |
$64.05
|
| Rate for Payer: United Healthcare Commercial |
$776.91
|
| Rate for Payer: United Healthcare Medicare |
$64.05
|
| Rate for Payer: WINHealth Partners Commercial |
$759.05
|
|
|
DSTR NROLYTC AGNT PARVERTEB FCT ADDL CRVCL/THORA
|
Professional
|
Both
|
$1,786.00
|
|
|
Service Code
|
HCPCS 64634 50
|
| Hospital Charge Code |
64634
|
| Min. Negotiated Rate |
$54.44 |
| Max. Negotiated Rate |
$1,786.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,750.28
|
| Rate for Payer: Aetna of WY Medicare |
$64.05
|
| Rate for Payer: Beech Street Commercial |
$1,696.70
|
| Rate for Payer: Cash Price |
$1,250.20
|
| Rate for Payer: Cash Price |
$1,250.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,732.42
|
| Rate for Payer: Cigna of WY Commercial |
$1,750.28
|
| Rate for Payer: First Choice Health Commercial |
$1,607.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,696.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$64.05
|
| Rate for Payer: HealthUtah PPO |
$1,786.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,732.42
|
| Rate for Payer: Multiplan Medicare/VA |
$54.44
|
| Rate for Payer: One Health Plan of WY PPO |
$1,750.28
|
| Rate for Payer: PacificSource Commercial |
$1,607.40
|
| Rate for Payer: PHCS PPO |
$1,696.70
|
| Rate for Payer: Three Rivers PPO |
$1,339.50
|
| Rate for Payer: TriWest Veterans Administration |
$64.05
|
| Rate for Payer: United Healthcare Commercial |
$1,553.82
|
| Rate for Payer: United Healthcare Medicare |
$64.05
|
| Rate for Payer: WINHealth Partners Commercial |
$1,518.10
|
|
|
DSTR NROLYTC AGNT PARVERTEB FCT ADDL LMBR/SACRAL
|
Professional
|
Both
|
$838.00
|
|
|
Service Code
|
HCPCS 64636
|
| Hospital Charge Code |
64636
|
| Min. Negotiated Rate |
$47.63 |
| Max. Negotiated Rate |
$838.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$821.24
|
| Rate for Payer: Aetna of WY Medicare |
$56.03
|
| Rate for Payer: Beech Street Commercial |
$796.10
|
| Rate for Payer: Cash Price |
$586.60
|
| Rate for Payer: Cash Price |
$586.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$812.86
|
| Rate for Payer: Cigna of WY Commercial |
$821.24
|
| Rate for Payer: First Choice Health Commercial |
$754.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$796.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$56.03
|
| Rate for Payer: HealthUtah PPO |
$838.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$812.86
|
| Rate for Payer: Multiplan Medicare/VA |
$47.63
|
| Rate for Payer: One Health Plan of WY PPO |
$821.24
|
| Rate for Payer: PacificSource Commercial |
$754.20
|
| Rate for Payer: PHCS PPO |
$796.10
|
| Rate for Payer: Three Rivers PPO |
$628.50
|
| Rate for Payer: TriWest Veterans Administration |
$56.03
|
| Rate for Payer: United Healthcare Commercial |
$729.06
|
| Rate for Payer: United Healthcare Medicare |
$56.03
|
| Rate for Payer: WINHealth Partners Commercial |
$712.30
|
|
|
DSTR NROLYTC AGNT PARVERTEB FCT ADDL LMBR/SACRAL
|
Professional
|
Both
|
$1,676.00
|
|
|
Service Code
|
HCPCS 64636 50
|
| Hospital Charge Code |
64636
|
| Min. Negotiated Rate |
$47.63 |
| Max. Negotiated Rate |
$1,676.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,642.48
|
| Rate for Payer: Aetna of WY Medicare |
$56.03
|
| Rate for Payer: Beech Street Commercial |
$1,592.20
|
| Rate for Payer: Cash Price |
$1,173.20
|
| Rate for Payer: Cash Price |
$1,173.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,625.72
|
| Rate for Payer: Cigna of WY Commercial |
$1,642.48
|
| Rate for Payer: First Choice Health Commercial |
$1,508.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,592.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$56.03
|
| Rate for Payer: HealthUtah PPO |
$1,676.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,625.72
|
| Rate for Payer: Multiplan Medicare/VA |
$47.63
|
| Rate for Payer: One Health Plan of WY PPO |
$1,642.48
|
| Rate for Payer: PacificSource Commercial |
$1,508.40
|
| Rate for Payer: PHCS PPO |
$1,592.20
|
| Rate for Payer: Three Rivers PPO |
$1,257.00
|
| Rate for Payer: TriWest Veterans Administration |
$56.03
|
| Rate for Payer: United Healthcare Commercial |
$1,458.12
|
| Rate for Payer: United Healthcare Medicare |
$56.03
|
| Rate for Payer: WINHealth Partners Commercial |
$1,424.60
|
|
|
DSTR NROLYTC AGNT PARVERTEB FCT SNGL CRVCL/THORA
|
Professional
|
Both
|
$3,054.00
|
|
|
Service Code
|
HCPCS 64633 50
|
| Hospital Charge Code |
64633
|
| Min. Negotiated Rate |
$157.44 |
| Max. Negotiated Rate |
$3,054.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,992.92
|
| Rate for Payer: Aetna of WY Medicare |
$185.22
|
| Rate for Payer: Beech Street Commercial |
$2,901.30
|
| Rate for Payer: Cash Price |
$2,137.80
|
| Rate for Payer: Cash Price |
$2,137.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,962.38
|
| Rate for Payer: Cigna of WY Commercial |
$2,992.92
|
| Rate for Payer: First Choice Health Commercial |
$2,748.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,901.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$185.22
|
| Rate for Payer: HealthUtah PPO |
$3,054.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,962.38
|
| Rate for Payer: Multiplan Medicare/VA |
$157.44
|
| Rate for Payer: One Health Plan of WY PPO |
$2,992.92
|
| Rate for Payer: PacificSource Commercial |
$2,748.60
|
| Rate for Payer: PHCS PPO |
$2,901.30
|
| Rate for Payer: Three Rivers PPO |
$2,290.50
|
| Rate for Payer: TriWest Veterans Administration |
$185.22
|
| Rate for Payer: United Healthcare Commercial |
$2,656.98
|
| Rate for Payer: United Healthcare Medicare |
$185.22
|
| Rate for Payer: WINHealth Partners Commercial |
$2,595.90
|
|
|
DSTR NROLYTC AGNT PARVERTEB FCT SNGL CRVCL/THORA
|
Professional
|
Both
|
$1,527.00
|
|
|
Service Code
|
HCPCS 64633
|
| Hospital Charge Code |
64633
|
| Min. Negotiated Rate |
$157.44 |
| Max. Negotiated Rate |
$1,527.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,496.46
|
| Rate for Payer: Aetna of WY Medicare |
$185.22
|
| Rate for Payer: Beech Street Commercial |
$1,450.65
|
| Rate for Payer: Cash Price |
$1,068.90
|
| Rate for Payer: Cash Price |
$1,068.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,481.19
|
| Rate for Payer: Cigna of WY Commercial |
$1,496.46
|
| Rate for Payer: First Choice Health Commercial |
$1,374.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,450.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$185.22
|
| Rate for Payer: HealthUtah PPO |
$1,527.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,481.19
|
| Rate for Payer: Multiplan Medicare/VA |
$157.44
|
| Rate for Payer: One Health Plan of WY PPO |
$1,496.46
|
| Rate for Payer: PacificSource Commercial |
$1,374.30
|
| Rate for Payer: PHCS PPO |
$1,450.65
|
| Rate for Payer: Three Rivers PPO |
$1,145.25
|
| Rate for Payer: TriWest Veterans Administration |
$185.22
|
| Rate for Payer: United Healthcare Commercial |
$1,328.49
|
| Rate for Payer: United Healthcare Medicare |
$185.22
|
| Rate for Payer: WINHealth Partners Commercial |
$1,297.95
|
|
|
DSTR NROLYTC AGNT PARVERTEB FCT SNGL LMBR/SACRAL
|
Professional
|
Both
|
$3,080.00
|
|
|
Service Code
|
HCPCS 64635 50
|
| Hospital Charge Code |
64635
|
| Min. Negotiated Rate |
$157.71 |
| Max. Negotiated Rate |
$3,080.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,018.40
|
| Rate for Payer: Aetna of WY Medicare |
$185.54
|
| Rate for Payer: Beech Street Commercial |
$2,926.00
|
| Rate for Payer: Cash Price |
$2,156.00
|
| Rate for Payer: Cash Price |
$2,156.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,987.60
|
| Rate for Payer: Cigna of WY Commercial |
$3,018.40
|
| Rate for Payer: First Choice Health Commercial |
$2,772.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,926.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$185.54
|
| Rate for Payer: HealthUtah PPO |
$3,080.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,987.60
|
| Rate for Payer: Multiplan Medicare/VA |
$157.71
|
| Rate for Payer: One Health Plan of WY PPO |
$3,018.40
|
| Rate for Payer: PacificSource Commercial |
$2,772.00
|
| Rate for Payer: PHCS PPO |
$2,926.00
|
| Rate for Payer: Three Rivers PPO |
$2,310.00
|
| Rate for Payer: TriWest Veterans Administration |
$185.54
|
| Rate for Payer: United Healthcare Commercial |
$2,679.60
|
| Rate for Payer: United Healthcare Medicare |
$185.54
|
| Rate for Payer: WINHealth Partners Commercial |
$2,618.00
|
|
|
DSTR NROLYTC AGNT PARVERTEB FCT SNGL LMBR/SACRAL
|
Professional
|
Both
|
$1,540.00
|
|
|
Service Code
|
HCPCS 64635
|
| Hospital Charge Code |
64635
|
| Min. Negotiated Rate |
$157.71 |
| Max. Negotiated Rate |
$1,540.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,509.20
|
| Rate for Payer: Aetna of WY Medicare |
$185.54
|
| Rate for Payer: Beech Street Commercial |
$1,463.00
|
| Rate for Payer: Cash Price |
$1,078.00
|
| Rate for Payer: Cash Price |
$1,078.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,493.80
|
| Rate for Payer: Cigna of WY Commercial |
$1,509.20
|
| Rate for Payer: First Choice Health Commercial |
$1,386.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,463.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$185.54
|
| Rate for Payer: HealthUtah PPO |
$1,540.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,493.80
|
| Rate for Payer: Multiplan Medicare/VA |
$157.71
|
| Rate for Payer: One Health Plan of WY PPO |
$1,509.20
|
| Rate for Payer: PacificSource Commercial |
$1,386.00
|
| Rate for Payer: PHCS PPO |
$1,463.00
|
| Rate for Payer: Three Rivers PPO |
$1,155.00
|
| Rate for Payer: TriWest Veterans Administration |
$185.54
|
| Rate for Payer: United Healthcare Commercial |
$1,339.80
|
| Rate for Payer: United Healthcare Medicare |
$185.54
|
| Rate for Payer: WINHealth Partners Commercial |
$1,309.00
|
|
|
DTAP-HEPB-IPV VACCINE INTRAMUSCULAR
|
Professional
|
Both
|
$333.00
|
|
|
Service Code
|
HCPCS 90723
|
| Hospital Charge Code |
90723
|
| Min. Negotiated Rate |
$249.75 |
| Max. Negotiated Rate |
$333.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$326.34
|
| Rate for Payer: Beech Street Commercial |
$316.35
|
| Rate for Payer: Cash Price |
$233.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$323.01
|
| Rate for Payer: Cigna of WY Commercial |
$326.34
|
| Rate for Payer: First Choice Health Commercial |
$299.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$316.35
|
| Rate for Payer: HealthUtah PPO |
$333.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$323.01
|
| Rate for Payer: One Health Plan of WY PPO |
$326.34
|
| Rate for Payer: PacificSource Commercial |
$299.70
|
| Rate for Payer: PHCS PPO |
$316.35
|
| Rate for Payer: Three Rivers PPO |
$249.75
|
| Rate for Payer: United Healthcare Commercial |
$289.71
|
| Rate for Payer: WINHealth Partners Commercial |
$333.00
|
|
|
DTAP-IPV COMPONENT 1OF2(PF) 15 LF-48MCG-5 LF-62 DU/0.5ML IM SUSPENSION [158469]
|
Facility
|
IP
|
$268.88
|
|
|
Service Code
|
NDC 4928156101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$168.59 |
| Max. Negotiated Rate |
$268.88 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$263.50
|
| Rate for Payer: Altius Auto/Workers Compensation |
$258.12
|
| Rate for Payer: Altius Commercial |
$258.12
|
| Rate for Payer: Beech Street Commercial |
$263.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$220.75
|
| Rate for Payer: Cash Price |
$188.21
|
| Rate for Payer: ChoiceCare Network Commercial |
$260.81
|
| Rate for Payer: Cigna of WY Commercial |
$263.50
|
| Rate for Payer: Entrust Commercial |
$255.44
|
| Rate for Payer: First Choice Health Commercial |
$255.44
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$255.44
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$177.46
|
| Rate for Payer: HealthUtah PPO |
$268.88
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$260.81
|
| Rate for Payer: Multiplan Medicare/VA |
$168.59
|
| Rate for Payer: One Health Plan of WY PPO |
$263.50
|
| Rate for Payer: PacificSource Commercial |
$241.99
|
| Rate for Payer: PHCS PPO |
$263.50
|
| Rate for Payer: Three Rivers PPO |
$201.66
|
| Rate for Payer: TriWest Veterans Administration |
$177.46
|
| Rate for Payer: United Healthcare Commercial |
$233.93
|
| Rate for Payer: United Healthcare Medicare |
$177.46
|
| Rate for Payer: WINHealth Partners Commercial |
$255.44
|
| Rate for Payer: Wise Provider Network Commercial |
$255.44
|
|
