|
CONFORM 3" BANDAGE GAUZE
|
Facility
|
OP
|
$0.55
|
|
| Hospital Charge Code |
2000012
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$0.55 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.54
|
| Rate for Payer: Aetna of WY Medicare |
$0.36
|
| Rate for Payer: Altius Commercial |
$0.53
|
| Rate for Payer: Beech Street Commercial |
$0.54
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.53
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.53
|
| Rate for Payer: Cigna of WY Commercial |
$0.54
|
| Rate for Payer: Entrust Commercial |
$0.52
|
| Rate for Payer: First Choice Health Commercial |
$0.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.31
|
| Rate for Payer: HealthUtah PPO |
$0.55
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.53
|
| Rate for Payer: Multiplan Medicare/VA |
$0.30
|
| Rate for Payer: One Health Plan of WY PPO |
$0.54
|
| Rate for Payer: PacificSource Commercial |
$0.50
|
| Rate for Payer: PHCS PPO |
$0.54
|
| Rate for Payer: Three Rivers PPO |
$0.41
|
| Rate for Payer: TriWest Veterans Administration |
$0.31
|
| Rate for Payer: United Healthcare Commercial |
$0.53
|
| Rate for Payer: United Healthcare Medicare |
$0.31
|
| Rate for Payer: WINHealth Partners Commercial |
$0.54
|
| Rate for Payer: Wise Provider Network Commercial |
$0.52
|
|
|
CONFORM 3" BANDAGE GAUZE
|
Facility
|
IP
|
$0.55
|
|
| Hospital Charge Code |
2000012
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.55 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.54
|
| Rate for Payer: Aetna of WY Medicare |
$0.35
|
| Rate for Payer: Altius Commercial |
$0.53
|
| Rate for Payer: Beech Street Commercial |
$0.54
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.53
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.53
|
| Rate for Payer: Cigna of WY Commercial |
$0.54
|
| Rate for Payer: Entrust Commercial |
$0.52
|
| Rate for Payer: First Choice Health Commercial |
$0.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.34
|
| Rate for Payer: HealthUtah PPO |
$0.55
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.53
|
| Rate for Payer: Multiplan Medicare/VA |
$0.32
|
| Rate for Payer: One Health Plan of WY PPO |
$0.54
|
| Rate for Payer: PacificSource Commercial |
$0.50
|
| Rate for Payer: PHCS PPO |
$0.54
|
| Rate for Payer: Three Rivers PPO |
$0.41
|
| Rate for Payer: TriWest Veterans Administration |
$0.34
|
| Rate for Payer: United Healthcare Commercial |
$0.53
|
| Rate for Payer: United Healthcare Medicare |
$0.34
|
| Rate for Payer: WINHealth Partners Commercial |
$0.52
|
| Rate for Payer: Wise Provider Network Commercial |
$0.52
|
|
|
CONFORM 4" BANDAGE GAUZE
|
Facility
|
OP
|
$0.69
|
|
| Hospital Charge Code |
2000013
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$0.69 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.68
|
| Rate for Payer: Aetna of WY Medicare |
$0.46
|
| Rate for Payer: Altius Commercial |
$0.66
|
| Rate for Payer: Beech Street Commercial |
$0.68
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.67
|
| Rate for Payer: Cash Price |
$0.48
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.67
|
| Rate for Payer: Cigna of WY Commercial |
$0.68
|
| Rate for Payer: Entrust Commercial |
$0.66
|
| Rate for Payer: First Choice Health Commercial |
$0.66
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.66
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.39
|
| Rate for Payer: HealthUtah PPO |
$0.69
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.67
|
| Rate for Payer: Multiplan Medicare/VA |
$0.37
|
| Rate for Payer: One Health Plan of WY PPO |
$0.68
|
| Rate for Payer: PacificSource Commercial |
$0.62
|
| Rate for Payer: PHCS PPO |
$0.68
|
| Rate for Payer: Three Rivers PPO |
$0.52
|
| Rate for Payer: TriWest Veterans Administration |
$0.39
|
| Rate for Payer: United Healthcare Commercial |
$0.66
|
| Rate for Payer: United Healthcare Medicare |
$0.39
|
| Rate for Payer: WINHealth Partners Commercial |
$0.68
|
| Rate for Payer: Wise Provider Network Commercial |
$0.66
|
|
|
CONFORM 4" BANDAGE GAUZE
|
Facility
|
IP
|
$0.69
|
|
| Hospital Charge Code |
2000013
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$0.69 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.68
|
| Rate for Payer: Aetna of WY Medicare |
$0.44
|
| Rate for Payer: Altius Commercial |
$0.66
|
| Rate for Payer: Beech Street Commercial |
$0.68
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.67
|
| Rate for Payer: Cash Price |
$0.48
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.67
|
| Rate for Payer: Cigna of WY Commercial |
$0.68
|
| Rate for Payer: Entrust Commercial |
$0.66
|
| Rate for Payer: First Choice Health Commercial |
$0.66
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.66
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.42
|
| Rate for Payer: HealthUtah PPO |
$0.69
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.67
|
| Rate for Payer: Multiplan Medicare/VA |
$0.40
|
| Rate for Payer: One Health Plan of WY PPO |
$0.68
|
| Rate for Payer: PacificSource Commercial |
$0.62
|
| Rate for Payer: PHCS PPO |
$0.68
|
| Rate for Payer: Three Rivers PPO |
$0.52
|
| Rate for Payer: TriWest Veterans Administration |
$0.42
|
| Rate for Payer: United Healthcare Commercial |
$0.66
|
| Rate for Payer: United Healthcare Medicare |
$0.42
|
| Rate for Payer: WINHealth Partners Commercial |
$0.66
|
| Rate for Payer: Wise Provider Network Commercial |
$0.66
|
|
|
CONIZATION CERVIX W/WO D&C RPR ELTRD EXC
|
Professional
|
Both
|
$1,921.00
|
|
|
Service Code
|
HCPCS 57522
|
| Min. Negotiated Rate |
$211.00 |
| Max. Negotiated Rate |
$1,921.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,882.58
|
| Rate for Payer: Aetna of WY Medicare |
$248.23
|
| Rate for Payer: Beech Street Commercial |
$1,824.95
|
| Rate for Payer: Cash Price |
$1,344.70
|
| Rate for Payer: Cash Price |
$1,344.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,863.37
|
| Rate for Payer: Cigna of WY Commercial |
$1,882.58
|
| Rate for Payer: First Choice Health Commercial |
$1,728.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,824.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$248.23
|
| Rate for Payer: HealthUtah PPO |
$1,921.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,863.37
|
| Rate for Payer: Multiplan Medicare/VA |
$211.00
|
| Rate for Payer: One Health Plan of WY PPO |
$1,882.58
|
| Rate for Payer: PacificSource Commercial |
$1,728.90
|
| Rate for Payer: PHCS PPO |
$1,824.95
|
| Rate for Payer: Three Rivers PPO |
$1,440.75
|
| Rate for Payer: TriWest Veterans Administration |
$248.23
|
| Rate for Payer: United Healthcare Commercial |
$1,824.95
|
| Rate for Payer: WINHealth Partners Commercial |
$1,632.85
|
|
|
CONIZATION CERVIX W/WO D&C RPR KNIFE/LASER
|
Professional
|
Both
|
$1,716.00
|
|
|
Service Code
|
HCPCS 57520
|
| Min. Negotiated Rate |
$245.41 |
| Max. Negotiated Rate |
$1,716.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,681.68
|
| Rate for Payer: Aetna of WY Medicare |
$288.72
|
| Rate for Payer: Beech Street Commercial |
$1,630.20
|
| Rate for Payer: Cash Price |
$1,201.20
|
| Rate for Payer: Cash Price |
$1,201.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,664.52
|
| Rate for Payer: Cigna of WY Commercial |
$1,681.68
|
| Rate for Payer: First Choice Health Commercial |
$1,544.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,630.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$288.72
|
| Rate for Payer: HealthUtah PPO |
$1,716.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,664.52
|
| Rate for Payer: Multiplan Medicare/VA |
$245.41
|
| Rate for Payer: One Health Plan of WY PPO |
$1,681.68
|
| Rate for Payer: PacificSource Commercial |
$1,544.40
|
| Rate for Payer: PHCS PPO |
$1,630.20
|
| Rate for Payer: Three Rivers PPO |
$1,287.00
|
| Rate for Payer: TriWest Veterans Administration |
$288.72
|
| Rate for Payer: United Healthcare Commercial |
$1,630.20
|
| Rate for Payer: WINHealth Partners Commercial |
$1,458.60
|
|
|
CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION [20300]
|
Facility
|
IP
|
$383.05
|
|
|
Service Code
|
HCPCS J1410
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$221.98 |
| Max. Negotiated Rate |
$383.05 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$375.39
|
| Rate for Payer: Aetna of WY Medicare |
$245.15
|
| Rate for Payer: Altius Commercial |
$367.73
|
| Rate for Payer: Beech Street Commercial |
$375.39
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$371.56
|
| Rate for Payer: Cash Price |
$268.14
|
| Rate for Payer: ChoiceCare Network Commercial |
$371.56
|
| Rate for Payer: Cigna of WY Commercial |
$375.39
|
| Rate for Payer: Entrust Commercial |
$363.90
|
| Rate for Payer: First Choice Health Commercial |
$363.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$363.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$233.66
|
| Rate for Payer: HealthUtah PPO |
$383.05
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$371.56
|
| Rate for Payer: Multiplan Medicare/VA |
$221.98
|
| Rate for Payer: One Health Plan of WY PPO |
$375.39
|
| Rate for Payer: PacificSource Commercial |
$344.74
|
| Rate for Payer: PHCS PPO |
$375.39
|
| Rate for Payer: Three Rivers PPO |
$287.29
|
| Rate for Payer: TriWest Veterans Administration |
$233.66
|
| Rate for Payer: United Healthcare Commercial |
$365.81
|
| Rate for Payer: United Healthcare Medicare |
$233.66
|
| Rate for Payer: WINHealth Partners Commercial |
$363.90
|
| Rate for Payer: Wise Provider Network Commercial |
$363.90
|
|
|
CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION [20300]
|
Facility
|
OP
|
$383.05
|
|
|
Service Code
|
HCPCS J1410
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$207.42 |
| Max. Negotiated Rate |
$383.05 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$375.39
|
| Rate for Payer: Aetna of WY Medicare |
$252.81
|
| Rate for Payer: Altius Commercial |
$367.73
|
| Rate for Payer: Beech Street Commercial |
$375.39
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$371.56
|
| Rate for Payer: Cash Price |
$268.14
|
| Rate for Payer: ChoiceCare Network Commercial |
$371.56
|
| Rate for Payer: Cigna of WY Commercial |
$375.39
|
| Rate for Payer: Entrust Commercial |
$363.90
|
| Rate for Payer: First Choice Health Commercial |
$363.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$363.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$218.34
|
| Rate for Payer: HealthUtah PPO |
$383.05
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$371.56
|
| Rate for Payer: Multiplan Medicare/VA |
$207.42
|
| Rate for Payer: One Health Plan of WY PPO |
$375.39
|
| Rate for Payer: PacificSource Commercial |
$344.74
|
| Rate for Payer: PHCS PPO |
$375.39
|
| Rate for Payer: Three Rivers PPO |
$287.29
|
| Rate for Payer: TriWest Veterans Administration |
$218.34
|
| Rate for Payer: United Healthcare Commercial |
$365.81
|
| Rate for Payer: United Healthcare Medicare |
$218.34
|
| Rate for Payer: WINHealth Partners Commercial |
$375.39
|
| Rate for Payer: Wise Provider Network Commercial |
$363.90
|
|
|
CONNECTOR XIA 105° OFFSET BEND
|
Facility
|
IP
|
$2,869.68
|
|
| Hospital Charge Code |
3004420
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,662.98 |
| Max. Negotiated Rate |
$2,869.68 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,812.29
|
| Rate for Payer: Aetna of WY Medicare |
$1,836.60
|
| Rate for Payer: Altius Commercial |
$2,754.89
|
| Rate for Payer: Beech Street Commercial |
$2,812.29
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,783.59
|
| Rate for Payer: Cash Price |
$2,008.78
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,783.59
|
| Rate for Payer: Cigna of WY Commercial |
$2,812.29
|
| Rate for Payer: Entrust Commercial |
$2,726.20
|
| Rate for Payer: First Choice Health Commercial |
$2,726.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,726.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,750.50
|
| Rate for Payer: HealthUtah PPO |
$2,869.68
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,783.59
|
| Rate for Payer: Multiplan Medicare/VA |
$1,662.98
|
| Rate for Payer: One Health Plan of WY PPO |
$2,812.29
|
| Rate for Payer: PacificSource Commercial |
$2,582.71
|
| Rate for Payer: PHCS PPO |
$2,812.29
|
| Rate for Payer: Three Rivers PPO |
$2,152.26
|
| Rate for Payer: TriWest Veterans Administration |
$1,750.50
|
| Rate for Payer: United Healthcare Commercial |
$2,740.54
|
| Rate for Payer: United Healthcare Medicare |
$1,750.50
|
| Rate for Payer: WINHealth Partners Commercial |
$2,726.20
|
| Rate for Payer: Wise Provider Network Commercial |
$2,726.20
|
|
|
CONNECTOR XIA 105° OFFSET BEND
|
Facility
|
OP
|
$2,869.68
|
|
| Hospital Charge Code |
3004420
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,553.93 |
| Max. Negotiated Rate |
$2,869.68 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,812.29
|
| Rate for Payer: Aetna of WY Medicare |
$1,893.99
|
| Rate for Payer: Altius Commercial |
$2,754.89
|
| Rate for Payer: Beech Street Commercial |
$2,812.29
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,783.59
|
| Rate for Payer: Cash Price |
$2,008.78
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,783.59
|
| Rate for Payer: Cigna of WY Commercial |
$2,812.29
|
| Rate for Payer: Entrust Commercial |
$2,726.20
|
| Rate for Payer: First Choice Health Commercial |
$2,726.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,726.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,635.72
|
| Rate for Payer: HealthUtah PPO |
$2,869.68
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,783.59
|
| Rate for Payer: Multiplan Medicare/VA |
$1,553.93
|
| Rate for Payer: One Health Plan of WY PPO |
$2,812.29
|
| Rate for Payer: PacificSource Commercial |
$2,582.71
|
| Rate for Payer: PHCS PPO |
$2,812.29
|
| Rate for Payer: Three Rivers PPO |
$2,152.26
|
| Rate for Payer: TriWest Veterans Administration |
$1,635.72
|
| Rate for Payer: United Healthcare Commercial |
$2,740.54
|
| Rate for Payer: United Healthcare Medicare |
$1,635.72
|
| Rate for Payer: WINHealth Partners Commercial |
$2,812.29
|
| Rate for Payer: Wise Provider Network Commercial |
$2,726.20
|
|
|
CONNECTOR XIA 75° OFFSET BEND
|
Facility
|
OP
|
$2,869.68
|
|
| Hospital Charge Code |
3004419
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,553.93 |
| Max. Negotiated Rate |
$2,869.68 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,812.29
|
| Rate for Payer: Aetna of WY Medicare |
$1,893.99
|
| Rate for Payer: Altius Commercial |
$2,754.89
|
| Rate for Payer: Beech Street Commercial |
$2,812.29
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,783.59
|
| Rate for Payer: Cash Price |
$2,008.78
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,783.59
|
| Rate for Payer: Cigna of WY Commercial |
$2,812.29
|
| Rate for Payer: Entrust Commercial |
$2,726.20
|
| Rate for Payer: First Choice Health Commercial |
$2,726.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,726.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,635.72
|
| Rate for Payer: HealthUtah PPO |
$2,869.68
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,783.59
|
| Rate for Payer: Multiplan Medicare/VA |
$1,553.93
|
| Rate for Payer: One Health Plan of WY PPO |
$2,812.29
|
| Rate for Payer: PacificSource Commercial |
$2,582.71
|
| Rate for Payer: PHCS PPO |
$2,812.29
|
| Rate for Payer: Three Rivers PPO |
$2,152.26
|
| Rate for Payer: TriWest Veterans Administration |
$1,635.72
|
| Rate for Payer: United Healthcare Commercial |
$2,740.54
|
| Rate for Payer: United Healthcare Medicare |
$1,635.72
|
| Rate for Payer: WINHealth Partners Commercial |
$2,812.29
|
| Rate for Payer: Wise Provider Network Commercial |
$2,726.20
|
|
|
CONNECTOR XIA 75° OFFSET BEND
|
Facility
|
IP
|
$2,869.68
|
|
| Hospital Charge Code |
3004419
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,662.98 |
| Max. Negotiated Rate |
$2,869.68 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,812.29
|
| Rate for Payer: Aetna of WY Medicare |
$1,836.60
|
| Rate for Payer: Altius Commercial |
$2,754.89
|
| Rate for Payer: Beech Street Commercial |
$2,812.29
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,783.59
|
| Rate for Payer: Cash Price |
$2,008.78
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,783.59
|
| Rate for Payer: Cigna of WY Commercial |
$2,812.29
|
| Rate for Payer: Entrust Commercial |
$2,726.20
|
| Rate for Payer: First Choice Health Commercial |
$2,726.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,726.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,750.50
|
| Rate for Payer: HealthUtah PPO |
$2,869.68
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,783.59
|
| Rate for Payer: Multiplan Medicare/VA |
$1,662.98
|
| Rate for Payer: One Health Plan of WY PPO |
$2,812.29
|
| Rate for Payer: PacificSource Commercial |
$2,582.71
|
| Rate for Payer: PHCS PPO |
$2,812.29
|
| Rate for Payer: Three Rivers PPO |
$2,152.26
|
| Rate for Payer: TriWest Veterans Administration |
$1,750.50
|
| Rate for Payer: United Healthcare Commercial |
$2,740.54
|
| Rate for Payer: United Healthcare Medicare |
$1,750.50
|
| Rate for Payer: WINHealth Partners Commercial |
$2,726.20
|
| Rate for Payer: Wise Provider Network Commercial |
$2,726.20
|
|
|
CONNECTOR XIA ROD2ROD TOP/SIDE
|
Facility
|
OP
|
$2,868.64
|
|
| Hospital Charge Code |
3004550
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,553.37 |
| Max. Negotiated Rate |
$2,868.64 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,811.27
|
| Rate for Payer: Aetna of WY Medicare |
$1,893.30
|
| Rate for Payer: Altius Commercial |
$2,753.89
|
| Rate for Payer: Beech Street Commercial |
$2,811.27
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,782.58
|
| Rate for Payer: Cash Price |
$2,008.04
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,782.58
|
| Rate for Payer: Cigna of WY Commercial |
$2,811.27
|
| Rate for Payer: Entrust Commercial |
$2,725.21
|
| Rate for Payer: First Choice Health Commercial |
$2,725.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,725.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,635.12
|
| Rate for Payer: HealthUtah PPO |
$2,868.64
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,782.58
|
| Rate for Payer: Multiplan Medicare/VA |
$1,553.37
|
| Rate for Payer: One Health Plan of WY PPO |
$2,811.27
|
| Rate for Payer: PacificSource Commercial |
$2,581.78
|
| Rate for Payer: PHCS PPO |
$2,811.27
|
| Rate for Payer: Three Rivers PPO |
$2,151.48
|
| Rate for Payer: TriWest Veterans Administration |
$1,635.12
|
| Rate for Payer: United Healthcare Commercial |
$2,739.55
|
| Rate for Payer: United Healthcare Medicare |
$1,635.12
|
| Rate for Payer: WINHealth Partners Commercial |
$2,811.27
|
| Rate for Payer: Wise Provider Network Commercial |
$2,725.21
|
|
|
CONNECTOR XIA ROD2ROD TOP/SIDE
|
Facility
|
IP
|
$2,868.64
|
|
| Hospital Charge Code |
3004550
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,662.38 |
| Max. Negotiated Rate |
$2,868.64 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,811.27
|
| Rate for Payer: Aetna of WY Medicare |
$1,835.93
|
| Rate for Payer: Altius Commercial |
$2,753.89
|
| Rate for Payer: Beech Street Commercial |
$2,811.27
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,782.58
|
| Rate for Payer: Cash Price |
$2,008.04
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,782.58
|
| Rate for Payer: Cigna of WY Commercial |
$2,811.27
|
| Rate for Payer: Entrust Commercial |
$2,725.21
|
| Rate for Payer: First Choice Health Commercial |
$2,725.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,725.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,749.87
|
| Rate for Payer: HealthUtah PPO |
$2,868.64
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,782.58
|
| Rate for Payer: Multiplan Medicare/VA |
$1,662.38
|
| Rate for Payer: One Health Plan of WY PPO |
$2,811.27
|
| Rate for Payer: PacificSource Commercial |
$2,581.78
|
| Rate for Payer: PHCS PPO |
$2,811.27
|
| Rate for Payer: Three Rivers PPO |
$2,151.48
|
| Rate for Payer: TriWest Veterans Administration |
$1,749.87
|
| Rate for Payer: United Healthcare Commercial |
$2,739.55
|
| Rate for Payer: United Healthcare Medicare |
$1,749.87
|
| Rate for Payer: WINHealth Partners Commercial |
$2,725.21
|
| Rate for Payer: Wise Provider Network Commercial |
$2,725.21
|
|
|
CONTRAST 60% BASO4 12OZ EZPQ L
|
Facility
|
OP
|
$6.58
|
|
| Hospital Charge Code |
6550033A
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3.56 |
| Max. Negotiated Rate |
$6.58 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$6.45
|
| Rate for Payer: Aetna of WY Medicare |
$4.34
|
| Rate for Payer: Altius Commercial |
$6.32
|
| Rate for Payer: Beech Street Commercial |
$6.45
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$6.38
|
| Rate for Payer: Cash Price |
$4.61
|
| Rate for Payer: ChoiceCare Network Commercial |
$6.38
|
| Rate for Payer: Cigna of WY Commercial |
$6.45
|
| Rate for Payer: Entrust Commercial |
$6.25
|
| Rate for Payer: First Choice Health Commercial |
$6.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$6.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3.75
|
| Rate for Payer: HealthUtah PPO |
$6.58
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$6.38
|
| Rate for Payer: Multiplan Medicare/VA |
$3.56
|
| Rate for Payer: One Health Plan of WY PPO |
$6.45
|
| Rate for Payer: PacificSource Commercial |
$5.92
|
| Rate for Payer: PHCS PPO |
$6.45
|
| Rate for Payer: Three Rivers PPO |
$4.94
|
| Rate for Payer: TriWest Veterans Administration |
$3.75
|
| Rate for Payer: United Healthcare Commercial |
$6.28
|
| Rate for Payer: United Healthcare Medicare |
$3.75
|
| Rate for Payer: WINHealth Partners Commercial |
$6.45
|
| Rate for Payer: Wise Provider Network Commercial |
$6.25
|
|
|
CONTRAST 60% BASO4 12OZ EZPQ L
|
Facility
|
IP
|
$6.58
|
|
| Hospital Charge Code |
6550033A
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3.81 |
| Max. Negotiated Rate |
$6.58 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$6.45
|
| Rate for Payer: Aetna of WY Medicare |
$4.21
|
| Rate for Payer: Altius Commercial |
$6.32
|
| Rate for Payer: Beech Street Commercial |
$6.45
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$6.38
|
| Rate for Payer: Cash Price |
$4.61
|
| Rate for Payer: ChoiceCare Network Commercial |
$6.38
|
| Rate for Payer: Cigna of WY Commercial |
$6.45
|
| Rate for Payer: Entrust Commercial |
$6.25
|
| Rate for Payer: First Choice Health Commercial |
$6.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$6.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$4.01
|
| Rate for Payer: HealthUtah PPO |
$6.58
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$6.38
|
| Rate for Payer: Multiplan Medicare/VA |
$3.81
|
| Rate for Payer: One Health Plan of WY PPO |
$6.45
|
| Rate for Payer: PacificSource Commercial |
$5.92
|
| Rate for Payer: PHCS PPO |
$6.45
|
| Rate for Payer: Three Rivers PPO |
$4.94
|
| Rate for Payer: TriWest Veterans Administration |
$4.01
|
| Rate for Payer: United Healthcare Commercial |
$6.28
|
| Rate for Payer: United Healthcare Medicare |
$4.01
|
| Rate for Payer: WINHealth Partners Commercial |
$6.25
|
| Rate for Payer: Wise Provider Network Commercial |
$6.25
|
|
|
CONTROL NASAL HEMORRHAGE ANTERIOR COMPLEX
|
Professional
|
Both
|
$347.00
|
|
|
Service Code
|
HCPCS 30903
|
| Min. Negotiated Rate |
$62.13 |
| Max. Negotiated Rate |
$347.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$340.06
|
| Rate for Payer: Aetna of WY Medicare |
$73.09
|
| Rate for Payer: Beech Street Commercial |
$329.65
|
| Rate for Payer: Cash Price |
$242.90
|
| Rate for Payer: Cash Price |
$242.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$336.59
|
| Rate for Payer: Cigna of WY Commercial |
$340.06
|
| Rate for Payer: First Choice Health Commercial |
$312.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$329.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$73.09
|
| Rate for Payer: HealthUtah PPO |
$347.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$336.59
|
| Rate for Payer: Multiplan Medicare/VA |
$62.13
|
| Rate for Payer: One Health Plan of WY PPO |
$340.06
|
| Rate for Payer: PacificSource Commercial |
$312.30
|
| Rate for Payer: PHCS PPO |
$329.65
|
| Rate for Payer: Three Rivers PPO |
$260.25
|
| Rate for Payer: TriWest Veterans Administration |
$73.09
|
| Rate for Payer: United Healthcare Commercial |
$329.65
|
| Rate for Payer: WINHealth Partners Commercial |
$294.95
|
|
|
CONTROL NASAL HEMORRHAGE ANTERIOR COMPLEX
|
Professional
|
Both
|
$696.00
|
|
|
Service Code
|
HCPCS 30903 50
|
| Min. Negotiated Rate |
$522.00 |
| Max. Negotiated Rate |
$696.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$682.08
|
| Rate for Payer: Beech Street Commercial |
$661.20
|
| Rate for Payer: Cash Price |
$487.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$675.12
|
| Rate for Payer: Cigna of WY Commercial |
$682.08
|
| Rate for Payer: First Choice Health Commercial |
$626.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$661.20
|
| Rate for Payer: HealthUtah PPO |
$696.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$675.12
|
| Rate for Payer: One Health Plan of WY PPO |
$682.08
|
| Rate for Payer: PacificSource Commercial |
$626.40
|
| Rate for Payer: PHCS PPO |
$661.20
|
| Rate for Payer: Three Rivers PPO |
$522.00
|
| Rate for Payer: United Healthcare Commercial |
$661.20
|
| Rate for Payer: WINHealth Partners Commercial |
$591.60
|
|
|
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE
|
Professional
|
Both
|
$250.00
|
|
|
Service Code
|
HCPCS 30901
|
| Min. Negotiated Rate |
$45.65 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$245.00
|
| Rate for Payer: Aetna of WY Medicare |
$53.71
|
| Rate for Payer: Beech Street Commercial |
$237.50
|
| Rate for Payer: Cash Price |
$175.00
|
| Rate for Payer: Cash Price |
$175.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$242.50
|
| Rate for Payer: Cigna of WY Commercial |
$245.00
|
| Rate for Payer: First Choice Health Commercial |
$225.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$237.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$53.71
|
| Rate for Payer: HealthUtah PPO |
$250.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$242.50
|
| Rate for Payer: Multiplan Medicare/VA |
$45.65
|
| Rate for Payer: One Health Plan of WY PPO |
$245.00
|
| Rate for Payer: PacificSource Commercial |
$225.00
|
| Rate for Payer: PHCS PPO |
$237.50
|
| Rate for Payer: Three Rivers PPO |
$187.50
|
| Rate for Payer: TriWest Veterans Administration |
$53.71
|
| Rate for Payer: United Healthcare Commercial |
$237.50
|
| Rate for Payer: WINHealth Partners Commercial |
$212.50
|
|
|
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE
|
Professional
|
Both
|
$499.00
|
|
|
Service Code
|
HCPCS 30901 50
|
| Min. Negotiated Rate |
$374.25 |
| Max. Negotiated Rate |
$499.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$489.02
|
| Rate for Payer: Beech Street Commercial |
$474.05
|
| Rate for Payer: Cash Price |
$349.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$484.03
|
| Rate for Payer: Cigna of WY Commercial |
$489.02
|
| Rate for Payer: First Choice Health Commercial |
$449.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$474.05
|
| Rate for Payer: HealthUtah PPO |
$499.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$484.03
|
| Rate for Payer: One Health Plan of WY PPO |
$489.02
|
| Rate for Payer: PacificSource Commercial |
$449.10
|
| Rate for Payer: PHCS PPO |
$474.05
|
| Rate for Payer: Three Rivers PPO |
$374.25
|
| Rate for Payer: United Healthcare Commercial |
$474.05
|
| Rate for Payer: WINHealth Partners Commercial |
$424.15
|
|
|
CONTROL OROPHARYNGEAL HEMORRHAGE SIMPLE
|
Professional
|
Both
|
$690.00
|
|
|
Service Code
|
HCPCS 42960
|
| Min. Negotiated Rate |
$132.93 |
| Max. Negotiated Rate |
$690.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$676.20
|
| Rate for Payer: Aetna of WY Medicare |
$156.39
|
| Rate for Payer: Beech Street Commercial |
$655.50
|
| Rate for Payer: Cash Price |
$483.00
|
| Rate for Payer: Cash Price |
$483.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$669.30
|
| Rate for Payer: Cigna of WY Commercial |
$676.20
|
| Rate for Payer: First Choice Health Commercial |
$621.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$655.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$156.39
|
| Rate for Payer: HealthUtah PPO |
$690.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$669.30
|
| Rate for Payer: Multiplan Medicare/VA |
$132.93
|
| Rate for Payer: One Health Plan of WY PPO |
$676.20
|
| Rate for Payer: PacificSource Commercial |
$621.00
|
| Rate for Payer: PHCS PPO |
$655.50
|
| Rate for Payer: Three Rivers PPO |
$517.50
|
| Rate for Payer: TriWest Veterans Administration |
$156.39
|
| Rate for Payer: United Healthcare Commercial |
$655.50
|
| Rate for Payer: WINHealth Partners Commercial |
$586.50
|
|
|
CONV PREV HIP TOT HIP ARTHRP W/WO AGRFT/ALGRFT
|
Professional
|
Both
|
$7,390.00
|
|
|
Service Code
|
HCPCS 27132 80
|
| Min. Negotiated Rate |
$1,357.72 |
| Max. Negotiated Rate |
$7,390.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$7,242.20
|
| Rate for Payer: Beech Street Commercial |
$7,020.50
|
| Rate for Payer: Cash Price |
$5,173.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$7,168.30
|
| Rate for Payer: Cigna of WY Commercial |
$7,242.20
|
| Rate for Payer: First Choice Health Commercial |
$6,651.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$7,020.50
|
| Rate for Payer: HealthUtah PPO |
$7,390.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$7,168.30
|
| Rate for Payer: One Health Plan of WY PPO |
$7,242.20
|
| Rate for Payer: PacificSource Commercial |
$6,651.00
|
| Rate for Payer: PHCS PPO |
$7,020.50
|
| Rate for Payer: Three Rivers PPO |
$5,542.50
|
| Rate for Payer: United Healthcare Commercial |
$7,020.50
|
| Rate for Payer: WINHealth Partners Commercial |
$6,281.50
|
|
|
CONV PREV HIP TOT HIP ARTHRP W/WO AGRFT/ALGRFT
|
Professional
|
Both
|
$7,390.00
|
|
|
Service Code
|
HCPCS 27132 AS
|
| Min. Negotiated Rate |
$1,357.72 |
| Max. Negotiated Rate |
$7,390.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$7,242.20
|
| Rate for Payer: Beech Street Commercial |
$7,020.50
|
| Rate for Payer: Cash Price |
$5,173.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$7,168.30
|
| Rate for Payer: Cigna of WY Commercial |
$7,242.20
|
| Rate for Payer: First Choice Health Commercial |
$6,651.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$7,020.50
|
| Rate for Payer: HealthUtah PPO |
$7,390.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$7,168.30
|
| Rate for Payer: One Health Plan of WY PPO |
$7,242.20
|
| Rate for Payer: PacificSource Commercial |
$6,651.00
|
| Rate for Payer: PHCS PPO |
$7,020.50
|
| Rate for Payer: Three Rivers PPO |
$5,542.50
|
| Rate for Payer: United Healthcare Commercial |
$7,020.50
|
| Rate for Payer: WINHealth Partners Commercial |
$6,281.50
|
|
|
CONV PREV HIP TOT HIP ARTHRP W/WO AGRFT/ALGRFT
|
Professional
|
Both
|
$7,390.00
|
|
|
Service Code
|
HCPCS 27132
|
| Min. Negotiated Rate |
$1,357.72 |
| Max. Negotiated Rate |
$7,390.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$7,242.20
|
| Rate for Payer: Aetna of WY Medicare |
$1,597.32
|
| Rate for Payer: Beech Street Commercial |
$7,020.50
|
| Rate for Payer: Cash Price |
$5,173.00
|
| Rate for Payer: Cash Price |
$5,173.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$7,168.30
|
| Rate for Payer: Cigna of WY Commercial |
$7,242.20
|
| Rate for Payer: First Choice Health Commercial |
$6,651.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$7,020.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,597.32
|
| Rate for Payer: HealthUtah PPO |
$7,390.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$7,168.30
|
| Rate for Payer: Multiplan Medicare/VA |
$1,357.72
|
| Rate for Payer: One Health Plan of WY PPO |
$7,242.20
|
| Rate for Payer: PacificSource Commercial |
$6,651.00
|
| Rate for Payer: PHCS PPO |
$7,020.50
|
| Rate for Payer: Three Rivers PPO |
$5,542.50
|
| Rate for Payer: TriWest Veterans Administration |
$1,597.32
|
| Rate for Payer: United Healthcare Commercial |
$7,020.50
|
| Rate for Payer: WINHealth Partners Commercial |
$6,281.50
|
|
|
COPE MANDRIL WIRE GUIDE G05822
|
Facility
|
OP
|
$98.00
|
|
| Hospital Charge Code |
6550172
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$53.07 |
| Max. Negotiated Rate |
$98.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$96.04
|
| Rate for Payer: Aetna of WY Medicare |
$64.68
|
| Rate for Payer: Altius Commercial |
$94.08
|
| Rate for Payer: Beech Street Commercial |
$96.04
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$95.06
|
| Rate for Payer: Cash Price |
$68.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$95.06
|
| Rate for Payer: Cigna of WY Commercial |
$96.04
|
| Rate for Payer: Entrust Commercial |
$93.10
|
| Rate for Payer: First Choice Health Commercial |
$93.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$93.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$55.86
|
| Rate for Payer: HealthUtah PPO |
$98.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$95.06
|
| Rate for Payer: Multiplan Medicare/VA |
$53.07
|
| Rate for Payer: One Health Plan of WY PPO |
$96.04
|
| Rate for Payer: PacificSource Commercial |
$88.20
|
| Rate for Payer: PHCS PPO |
$96.04
|
| Rate for Payer: Three Rivers PPO |
$73.50
|
| Rate for Payer: TriWest Veterans Administration |
$55.86
|
| Rate for Payer: United Healthcare Commercial |
$93.59
|
| Rate for Payer: United Healthcare Medicare |
$55.86
|
| Rate for Payer: WINHealth Partners Commercial |
$96.04
|
| Rate for Payer: Wise Provider Network Commercial |
$93.10
|
|
