|
COVID VAC 2023-24 (12 YR UP)(ANDUSOMERAN)(PF) 50 MCG/0.5 ML IM SYRINGE [183899]
|
Facility
|
OP
|
$338.75
|
|
|
Service Code
|
NDC 8077710296
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$183.43 |
| Max. Negotiated Rate |
$338.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$331.98
|
| Rate for Payer: Aetna of WY Medicare |
$223.58
|
| Rate for Payer: Altius Commercial |
$325.20
|
| Rate for Payer: Beech Street Commercial |
$331.98
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$328.59
|
| Rate for Payer: Cash Price |
$237.12
|
| Rate for Payer: ChoiceCare Network Commercial |
$328.59
|
| Rate for Payer: Cigna of WY Commercial |
$331.98
|
| Rate for Payer: Entrust Commercial |
$321.81
|
| Rate for Payer: First Choice Health Commercial |
$321.81
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$321.81
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$193.09
|
| Rate for Payer: HealthUtah PPO |
$338.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$328.59
|
| Rate for Payer: Multiplan Medicare/VA |
$183.43
|
| Rate for Payer: One Health Plan of WY PPO |
$331.98
|
| Rate for Payer: PacificSource Commercial |
$304.88
|
| Rate for Payer: PHCS PPO |
$331.98
|
| Rate for Payer: Three Rivers PPO |
$254.06
|
| Rate for Payer: TriWest Veterans Administration |
$193.09
|
| Rate for Payer: United Healthcare Commercial |
$323.51
|
| Rate for Payer: United Healthcare Medicare |
$193.09
|
| Rate for Payer: WINHealth Partners Commercial |
$331.98
|
| Rate for Payer: Wise Provider Network Commercial |
$321.81
|
|
|
CPAP FLOW-SAFE II EZ LG ADULT
|
Facility
|
IP
|
$218.78
|
|
| Hospital Charge Code |
2600053
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$126.78 |
| Max. Negotiated Rate |
$218.78 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$214.40
|
| Rate for Payer: Aetna of WY Medicare |
$140.02
|
| Rate for Payer: Altius Commercial |
$210.03
|
| Rate for Payer: Beech Street Commercial |
$214.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$212.22
|
| Rate for Payer: Cash Price |
$153.15
|
| Rate for Payer: ChoiceCare Network Commercial |
$212.22
|
| Rate for Payer: Cigna of WY Commercial |
$214.40
|
| Rate for Payer: Entrust Commercial |
$207.84
|
| Rate for Payer: First Choice Health Commercial |
$207.84
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$207.84
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$133.46
|
| Rate for Payer: HealthUtah PPO |
$218.78
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$212.22
|
| Rate for Payer: Multiplan Medicare/VA |
$126.78
|
| Rate for Payer: One Health Plan of WY PPO |
$214.40
|
| Rate for Payer: PacificSource Commercial |
$196.90
|
| Rate for Payer: PHCS PPO |
$214.40
|
| Rate for Payer: Three Rivers PPO |
$164.08
|
| Rate for Payer: TriWest Veterans Administration |
$133.46
|
| Rate for Payer: United Healthcare Commercial |
$208.93
|
| Rate for Payer: United Healthcare Medicare |
$133.46
|
| Rate for Payer: WINHealth Partners Commercial |
$207.84
|
| Rate for Payer: Wise Provider Network Commercial |
$207.84
|
|
|
CPAP FLOW-SAFE II EZ LG ADULT
|
Facility
|
OP
|
$218.78
|
|
| Hospital Charge Code |
2600053
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$118.47 |
| Max. Negotiated Rate |
$218.78 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$214.40
|
| Rate for Payer: Aetna of WY Medicare |
$144.39
|
| Rate for Payer: Altius Commercial |
$210.03
|
| Rate for Payer: Beech Street Commercial |
$214.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$212.22
|
| Rate for Payer: Cash Price |
$153.15
|
| Rate for Payer: ChoiceCare Network Commercial |
$212.22
|
| Rate for Payer: Cigna of WY Commercial |
$214.40
|
| Rate for Payer: Entrust Commercial |
$207.84
|
| Rate for Payer: First Choice Health Commercial |
$207.84
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$207.84
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$124.70
|
| Rate for Payer: HealthUtah PPO |
$218.78
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$212.22
|
| Rate for Payer: Multiplan Medicare/VA |
$118.47
|
| Rate for Payer: One Health Plan of WY PPO |
$214.40
|
| Rate for Payer: PacificSource Commercial |
$196.90
|
| Rate for Payer: PHCS PPO |
$214.40
|
| Rate for Payer: Three Rivers PPO |
$164.08
|
| Rate for Payer: TriWest Veterans Administration |
$124.70
|
| Rate for Payer: United Healthcare Commercial |
$208.93
|
| Rate for Payer: United Healthcare Medicare |
$124.70
|
| Rate for Payer: WINHealth Partners Commercial |
$214.40
|
| Rate for Payer: Wise Provider Network Commercial |
$207.84
|
|
|
CPAP FLOW-SAFE II EZ SM ADULT
|
Facility
|
IP
|
$196.14
|
|
| Hospital Charge Code |
2600052
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$113.66 |
| Max. Negotiated Rate |
$196.14 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$192.22
|
| Rate for Payer: Aetna of WY Medicare |
$125.53
|
| Rate for Payer: Altius Commercial |
$188.29
|
| Rate for Payer: Beech Street Commercial |
$192.22
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$190.26
|
| Rate for Payer: Cash Price |
$137.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$190.26
|
| Rate for Payer: Cigna of WY Commercial |
$192.22
|
| Rate for Payer: Entrust Commercial |
$186.33
|
| Rate for Payer: First Choice Health Commercial |
$186.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$186.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$119.65
|
| Rate for Payer: HealthUtah PPO |
$196.14
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$190.26
|
| Rate for Payer: Multiplan Medicare/VA |
$113.66
|
| Rate for Payer: One Health Plan of WY PPO |
$192.22
|
| Rate for Payer: PacificSource Commercial |
$176.53
|
| Rate for Payer: PHCS PPO |
$192.22
|
| Rate for Payer: Three Rivers PPO |
$147.10
|
| Rate for Payer: TriWest Veterans Administration |
$119.65
|
| Rate for Payer: United Healthcare Commercial |
$187.31
|
| Rate for Payer: United Healthcare Medicare |
$119.65
|
| Rate for Payer: WINHealth Partners Commercial |
$186.33
|
| Rate for Payer: Wise Provider Network Commercial |
$186.33
|
|
|
CPAP FLOW-SAFE II EZ SM ADULT
|
Facility
|
OP
|
$196.14
|
|
| Hospital Charge Code |
2600052
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$106.21 |
| Max. Negotiated Rate |
$196.14 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$192.22
|
| Rate for Payer: Aetna of WY Medicare |
$129.45
|
| Rate for Payer: Altius Commercial |
$188.29
|
| Rate for Payer: Beech Street Commercial |
$192.22
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$190.26
|
| Rate for Payer: Cash Price |
$137.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$190.26
|
| Rate for Payer: Cigna of WY Commercial |
$192.22
|
| Rate for Payer: Entrust Commercial |
$186.33
|
| Rate for Payer: First Choice Health Commercial |
$186.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$186.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$111.80
|
| Rate for Payer: HealthUtah PPO |
$196.14
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$190.26
|
| Rate for Payer: Multiplan Medicare/VA |
$106.21
|
| Rate for Payer: One Health Plan of WY PPO |
$192.22
|
| Rate for Payer: PacificSource Commercial |
$176.53
|
| Rate for Payer: PHCS PPO |
$192.22
|
| Rate for Payer: Three Rivers PPO |
$147.10
|
| Rate for Payer: TriWest Veterans Administration |
$111.80
|
| Rate for Payer: United Healthcare Commercial |
$187.31
|
| Rate for Payer: United Healthcare Medicare |
$111.80
|
| Rate for Payer: WINHealth Partners Commercial |
$192.22
|
| Rate for Payer: Wise Provider Network Commercial |
$186.33
|
|
|
CPLX CHRONIC CARE MGMT SVC EA ADDL 30 MIN CAL MO
|
Professional
|
Both
|
$100.00
|
|
|
Service Code
|
HCPCS 99489
|
| Min. Negotiated Rate |
$40.96 |
| Max. Negotiated Rate |
$100.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$98.00
|
| Rate for Payer: Aetna of WY Medicare |
$48.19
|
| Rate for Payer: Beech Street Commercial |
$95.00
|
| Rate for Payer: Cash Price |
$70.00
|
| Rate for Payer: Cash Price |
$70.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$97.00
|
| Rate for Payer: Cigna of WY Commercial |
$98.00
|
| Rate for Payer: First Choice Health Commercial |
$90.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$95.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$48.19
|
| Rate for Payer: HealthUtah PPO |
$100.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$97.00
|
| Rate for Payer: Multiplan Medicare/VA |
$40.96
|
| Rate for Payer: One Health Plan of WY PPO |
$98.00
|
| Rate for Payer: PacificSource Commercial |
$90.00
|
| Rate for Payer: PHCS PPO |
$95.00
|
| Rate for Payer: Three Rivers PPO |
$75.00
|
| Rate for Payer: TriWest Veterans Administration |
$48.19
|
| Rate for Payer: United Healthcare Commercial |
$95.00
|
| Rate for Payer: WINHealth Partners Commercial |
$95.00
|
|
|
CPTR-ASST SURGICAL NAVIGATION IMAGE-LESS
|
Professional
|
Both
|
$646.00
|
|
|
Service Code
|
HCPCS 20985 AS
|
| Min. Negotiated Rate |
$115.97 |
| Max. Negotiated Rate |
$646.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$633.08
|
| Rate for Payer: Beech Street Commercial |
$613.70
|
| Rate for Payer: Cash Price |
$452.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$626.62
|
| Rate for Payer: Cigna of WY Commercial |
$633.08
|
| Rate for Payer: First Choice Health Commercial |
$581.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$613.70
|
| Rate for Payer: HealthUtah PPO |
$646.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$626.62
|
| Rate for Payer: One Health Plan of WY PPO |
$633.08
|
| Rate for Payer: PacificSource Commercial |
$581.40
|
| Rate for Payer: PHCS PPO |
$613.70
|
| Rate for Payer: Three Rivers PPO |
$484.50
|
| Rate for Payer: United Healthcare Commercial |
$613.70
|
| Rate for Payer: WINHealth Partners Commercial |
$549.10
|
|
|
CPTR-ASST SURGICAL NAVIGATION IMAGE-LESS
|
Professional
|
Both
|
$646.00
|
|
|
Service Code
|
HCPCS 20985
|
| Min. Negotiated Rate |
$115.97 |
| Max. Negotiated Rate |
$646.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$633.08
|
| Rate for Payer: Aetna of WY Medicare |
$136.44
|
| Rate for Payer: Beech Street Commercial |
$613.70
|
| Rate for Payer: Cash Price |
$452.20
|
| Rate for Payer: Cash Price |
$452.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$626.62
|
| Rate for Payer: Cigna of WY Commercial |
$633.08
|
| Rate for Payer: First Choice Health Commercial |
$581.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$613.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$136.44
|
| Rate for Payer: HealthUtah PPO |
$646.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$626.62
|
| Rate for Payer: Multiplan Medicare/VA |
$115.97
|
| Rate for Payer: One Health Plan of WY PPO |
$633.08
|
| Rate for Payer: PacificSource Commercial |
$581.40
|
| Rate for Payer: PHCS PPO |
$613.70
|
| Rate for Payer: Three Rivers PPO |
$484.50
|
| Rate for Payer: TriWest Veterans Administration |
$136.44
|
| Rate for Payer: United Healthcare Commercial |
$613.70
|
| Rate for Payer: WINHealth Partners Commercial |
$549.10
|
|
|
CPTR-ASST SURGICAL NAVIGATION IMAGE-LESS
|
Professional
|
Both
|
$646.00
|
|
|
Service Code
|
HCPCS 20985 80
|
| Min. Negotiated Rate |
$115.97 |
| Max. Negotiated Rate |
$646.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$633.08
|
| Rate for Payer: Beech Street Commercial |
$613.70
|
| Rate for Payer: Cash Price |
$452.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$626.62
|
| Rate for Payer: Cigna of WY Commercial |
$633.08
|
| Rate for Payer: First Choice Health Commercial |
$581.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$613.70
|
| Rate for Payer: HealthUtah PPO |
$646.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$626.62
|
| Rate for Payer: One Health Plan of WY PPO |
$633.08
|
| Rate for Payer: PacificSource Commercial |
$581.40
|
| Rate for Payer: PHCS PPO |
$613.70
|
| Rate for Payer: Three Rivers PPO |
$484.50
|
| Rate for Payer: United Healthcare Commercial |
$613.70
|
| Rate for Payer: WINHealth Partners Commercial |
$549.10
|
|
|
CRANBERRY FRUIT 450 MG TABLET [97524]
|
Facility
|
IP
|
$15.14
|
|
|
Service Code
|
NDC 5789684501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.77 |
| Max. Negotiated Rate |
$15.14 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.84
|
| Rate for Payer: Aetna of WY Medicare |
$9.69
|
| Rate for Payer: Altius Commercial |
$14.53
|
| Rate for Payer: Beech Street Commercial |
$14.84
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.69
|
| Rate for Payer: Cash Price |
$10.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.69
|
| Rate for Payer: Cigna of WY Commercial |
$14.84
|
| Rate for Payer: Entrust Commercial |
$14.38
|
| Rate for Payer: First Choice Health Commercial |
$14.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.24
|
| Rate for Payer: HealthUtah PPO |
$15.14
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.69
|
| Rate for Payer: Multiplan Medicare/VA |
$8.77
|
| Rate for Payer: One Health Plan of WY PPO |
$14.84
|
| Rate for Payer: PacificSource Commercial |
$13.63
|
| Rate for Payer: PHCS PPO |
$14.84
|
| Rate for Payer: Three Rivers PPO |
$11.36
|
| Rate for Payer: TriWest Veterans Administration |
$9.24
|
| Rate for Payer: United Healthcare Commercial |
$14.46
|
| Rate for Payer: United Healthcare Medicare |
$9.24
|
| Rate for Payer: WINHealth Partners Commercial |
$14.38
|
| Rate for Payer: Wise Provider Network Commercial |
$14.38
|
|
|
CRANBERRY FRUIT 450 MG TABLET [97524]
|
Facility
|
OP
|
$15.14
|
|
|
Service Code
|
NDC 5789684501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.20 |
| Max. Negotiated Rate |
$15.14 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.84
|
| Rate for Payer: Aetna of WY Medicare |
$9.99
|
| Rate for Payer: Altius Commercial |
$14.53
|
| Rate for Payer: Beech Street Commercial |
$14.84
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.69
|
| Rate for Payer: Cash Price |
$10.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.69
|
| Rate for Payer: Cigna of WY Commercial |
$14.84
|
| Rate for Payer: Entrust Commercial |
$14.38
|
| Rate for Payer: First Choice Health Commercial |
$14.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.63
|
| Rate for Payer: HealthUtah PPO |
$15.14
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.69
|
| Rate for Payer: Multiplan Medicare/VA |
$8.20
|
| Rate for Payer: One Health Plan of WY PPO |
$14.84
|
| Rate for Payer: PacificSource Commercial |
$13.63
|
| Rate for Payer: PHCS PPO |
$14.84
|
| Rate for Payer: Three Rivers PPO |
$11.36
|
| Rate for Payer: TriWest Veterans Administration |
$8.63
|
| Rate for Payer: United Healthcare Commercial |
$14.46
|
| Rate for Payer: United Healthcare Medicare |
$8.63
|
| Rate for Payer: WINHealth Partners Commercial |
$14.84
|
| Rate for Payer: Wise Provider Network Commercial |
$14.38
|
|
|
CREATININE BLOOD
|
Professional
|
Both
|
$53.00
|
|
|
Service Code
|
HCPCS 82565
|
| Min. Negotiated Rate |
$4.35 |
| Max. Negotiated Rate |
$53.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$51.94
|
| Rate for Payer: Aetna of WY Medicare |
$5.12
|
| Rate for Payer: Beech Street Commercial |
$50.35
|
| Rate for Payer: Cash Price |
$37.10
|
| Rate for Payer: Cash Price |
$37.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$51.41
|
| Rate for Payer: Cigna of WY Commercial |
$51.94
|
| Rate for Payer: First Choice Health Commercial |
$47.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$50.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$5.12
|
| Rate for Payer: HealthUtah PPO |
$53.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$51.41
|
| Rate for Payer: Multiplan Medicare/VA |
$4.35
|
| Rate for Payer: One Health Plan of WY PPO |
$51.94
|
| Rate for Payer: PacificSource Commercial |
$47.70
|
| Rate for Payer: PHCS PPO |
$50.35
|
| Rate for Payer: Three Rivers PPO |
$39.75
|
| Rate for Payer: TriWest Veterans Administration |
$5.12
|
| Rate for Payer: United Healthcare Commercial |
$50.35
|
| Rate for Payer: WINHealth Partners Commercial |
$50.35
|
|
|
CRICOPHARYNGEAL MYOTOMY
|
Professional
|
Both
|
$2,280.00
|
|
|
Service Code
|
HCPCS 43030
|
| Min. Negotiated Rate |
$432.14 |
| Max. Negotiated Rate |
$2,280.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,234.40
|
| Rate for Payer: Aetna of WY Medicare |
$508.40
|
| Rate for Payer: Beech Street Commercial |
$2,166.00
|
| Rate for Payer: Cash Price |
$1,596.00
|
| Rate for Payer: Cash Price |
$1,596.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,211.60
|
| Rate for Payer: Cigna of WY Commercial |
$2,234.40
|
| Rate for Payer: First Choice Health Commercial |
$2,052.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,166.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$508.40
|
| Rate for Payer: HealthUtah PPO |
$2,280.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,211.60
|
| Rate for Payer: Multiplan Medicare/VA |
$432.14
|
| Rate for Payer: One Health Plan of WY PPO |
$2,234.40
|
| Rate for Payer: PacificSource Commercial |
$2,052.00
|
| Rate for Payer: PHCS PPO |
$2,166.00
|
| Rate for Payer: Three Rivers PPO |
$1,710.00
|
| Rate for Payer: TriWest Veterans Administration |
$508.40
|
| Rate for Payer: United Healthcare Commercial |
$2,166.00
|
| Rate for Payer: WINHealth Partners Commercial |
$1,938.00
|
|
|
CRICOTHYROTOMY EMERGENCY KIT
|
Facility
|
OP
|
$533.57
|
|
| Hospital Charge Code |
2600050
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$288.93 |
| Max. Negotiated Rate |
$533.57 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$522.90
|
| Rate for Payer: Aetna of WY Medicare |
$352.16
|
| Rate for Payer: Altius Commercial |
$512.23
|
| Rate for Payer: Beech Street Commercial |
$522.90
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$517.56
|
| Rate for Payer: Cash Price |
$373.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$517.56
|
| Rate for Payer: Cigna of WY Commercial |
$522.90
|
| Rate for Payer: Entrust Commercial |
$506.89
|
| Rate for Payer: First Choice Health Commercial |
$506.89
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$506.89
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$304.13
|
| Rate for Payer: HealthUtah PPO |
$533.57
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$517.56
|
| Rate for Payer: Multiplan Medicare/VA |
$288.93
|
| Rate for Payer: One Health Plan of WY PPO |
$522.90
|
| Rate for Payer: PacificSource Commercial |
$480.21
|
| Rate for Payer: PHCS PPO |
$522.90
|
| Rate for Payer: Three Rivers PPO |
$400.18
|
| Rate for Payer: TriWest Veterans Administration |
$304.13
|
| Rate for Payer: United Healthcare Commercial |
$509.56
|
| Rate for Payer: United Healthcare Medicare |
$304.13
|
| Rate for Payer: WINHealth Partners Commercial |
$522.90
|
| Rate for Payer: Wise Provider Network Commercial |
$506.89
|
|
|
CRICOTHYROTOMY EMERGENCY KIT
|
Facility
|
IP
|
$533.57
|
|
| Hospital Charge Code |
2600050
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$309.20 |
| Max. Negotiated Rate |
$533.57 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$522.90
|
| Rate for Payer: Aetna of WY Medicare |
$341.48
|
| Rate for Payer: Altius Commercial |
$512.23
|
| Rate for Payer: Beech Street Commercial |
$522.90
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$517.56
|
| Rate for Payer: Cash Price |
$373.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$517.56
|
| Rate for Payer: Cigna of WY Commercial |
$522.90
|
| Rate for Payer: Entrust Commercial |
$506.89
|
| Rate for Payer: First Choice Health Commercial |
$506.89
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$506.89
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$325.48
|
| Rate for Payer: HealthUtah PPO |
$533.57
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$517.56
|
| Rate for Payer: Multiplan Medicare/VA |
$309.20
|
| Rate for Payer: One Health Plan of WY PPO |
$522.90
|
| Rate for Payer: PacificSource Commercial |
$480.21
|
| Rate for Payer: PHCS PPO |
$522.90
|
| Rate for Payer: Three Rivers PPO |
$400.18
|
| Rate for Payer: TriWest Veterans Administration |
$325.48
|
| Rate for Payer: United Healthcare Commercial |
$509.56
|
| Rate for Payer: United Healthcare Medicare |
$325.48
|
| Rate for Payer: WINHealth Partners Commercial |
$506.89
|
| Rate for Payer: Wise Provider Network Commercial |
$506.89
|
|
|
CRITICAL CARE ILL/INJURED PATIENT ADDL 30 MIN
|
Professional
|
Both
|
$1,112.00
|
|
|
Service Code
|
HCPCS 99292
|
| Min. Negotiated Rate |
$86.84 |
| Max. Negotiated Rate |
$1,112.00 |
| Rate for Payer: Three Rivers PPO |
$834.00
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,089.76
|
| Rate for Payer: Aetna of WY Medicare |
$102.16
|
| Rate for Payer: Beech Street Commercial |
$1,056.40
|
| Rate for Payer: Cash Price |
$778.40
|
| Rate for Payer: Cash Price |
$778.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,078.64
|
| Rate for Payer: Cigna of WY Commercial |
$1,089.76
|
| Rate for Payer: First Choice Health Commercial |
$1,000.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,056.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$102.16
|
| Rate for Payer: HealthUtah PPO |
$1,112.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,078.64
|
| Rate for Payer: Multiplan Medicare/VA |
$86.84
|
| Rate for Payer: One Health Plan of WY PPO |
$1,089.76
|
| Rate for Payer: PacificSource Commercial |
$1,000.80
|
| Rate for Payer: PHCS PPO |
$1,056.40
|
| Rate for Payer: TriWest Veterans Administration |
$102.16
|
| Rate for Payer: United Healthcare Commercial |
$1,056.40
|
| Rate for Payer: WINHealth Partners Commercial |
$1,056.40
|
|
|
CRITICAL CARE ILL/INJURED PATIENT INIT 30-74 MIN
|
Professional
|
Both
|
$1,550.00
|
|
|
Service Code
|
HCPCS 99291
|
| Min. Negotiated Rate |
$172.58 |
| Max. Negotiated Rate |
$1,550.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,519.00
|
| Rate for Payer: Aetna of WY Medicare |
$203.03
|
| Rate for Payer: Beech Street Commercial |
$1,472.50
|
| Rate for Payer: Cash Price |
$1,085.00
|
| Rate for Payer: Cash Price |
$1,085.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,503.50
|
| Rate for Payer: Cigna of WY Commercial |
$1,519.00
|
| Rate for Payer: First Choice Health Commercial |
$1,395.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,472.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$203.03
|
| Rate for Payer: HealthUtah PPO |
$1,550.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,503.50
|
| Rate for Payer: Multiplan Medicare/VA |
$172.58
|
| Rate for Payer: One Health Plan of WY PPO |
$1,519.00
|
| Rate for Payer: PacificSource Commercial |
$1,395.00
|
| Rate for Payer: PHCS PPO |
$1,472.50
|
| Rate for Payer: Three Rivers PPO |
$1,162.50
|
| Rate for Payer: TriWest Veterans Administration |
$203.03
|
| Rate for Payer: United Healthcare Commercial |
$1,472.50
|
| Rate for Payer: WINHealth Partners Commercial |
$1,472.50
|
|
|
CRITICAL CARE INTERFACILITY TRANSPORT 30-74 MIN
|
Professional
|
Both
|
$578.00
|
|
|
Service Code
|
HCPCS 99466
|
| Min. Negotiated Rate |
$188.81 |
| Max. Negotiated Rate |
$578.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$566.44
|
| Rate for Payer: Aetna of WY Medicare |
$222.13
|
| Rate for Payer: Beech Street Commercial |
$549.10
|
| Rate for Payer: Cash Price |
$404.60
|
| Rate for Payer: Cash Price |
$404.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$560.66
|
| Rate for Payer: Cigna of WY Commercial |
$566.44
|
| Rate for Payer: First Choice Health Commercial |
$520.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$549.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$222.13
|
| Rate for Payer: HealthUtah PPO |
$578.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$560.66
|
| Rate for Payer: Multiplan Medicare/VA |
$188.81
|
| Rate for Payer: One Health Plan of WY PPO |
$566.44
|
| Rate for Payer: PacificSource Commercial |
$520.20
|
| Rate for Payer: PHCS PPO |
$549.10
|
| Rate for Payer: Three Rivers PPO |
$433.50
|
| Rate for Payer: TriWest Veterans Administration |
$222.13
|
| Rate for Payer: United Healthcare Commercial |
$549.10
|
| Rate for Payer: WINHealth Partners Commercial |
$549.10
|
|
|
CRITICAL CARE INTERFACILITY TRANSPORT EA 30 MIN
|
Professional
|
Both
|
$420.00
|
|
|
Service Code
|
HCPCS 99467
|
| Min. Negotiated Rate |
$94.78 |
| Max. Negotiated Rate |
$420.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$411.60
|
| Rate for Payer: Aetna of WY Medicare |
$111.51
|
| Rate for Payer: Beech Street Commercial |
$399.00
|
| Rate for Payer: Cash Price |
$294.00
|
| Rate for Payer: Cash Price |
$294.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$407.40
|
| Rate for Payer: Cigna of WY Commercial |
$411.60
|
| Rate for Payer: First Choice Health Commercial |
$378.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$399.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$111.51
|
| Rate for Payer: HealthUtah PPO |
$420.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$407.40
|
| Rate for Payer: Multiplan Medicare/VA |
$94.78
|
| Rate for Payer: One Health Plan of WY PPO |
$411.60
|
| Rate for Payer: PacificSource Commercial |
$378.00
|
| Rate for Payer: PHCS PPO |
$399.00
|
| Rate for Payer: Three Rivers PPO |
$315.00
|
| Rate for Payer: TriWest Veterans Administration |
$111.51
|
| Rate for Payer: United Healthcare Commercial |
$399.00
|
| Rate for Payer: WINHealth Partners Commercial |
$399.00
|
|
|
CROSSFIX II DISP PROCEDURE KIT
|
Facility
|
OP
|
$311.50
|
|
| Hospital Charge Code |
3003857
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$168.68 |
| Max. Negotiated Rate |
$311.50 |
| Rate for Payer: United Healthcare Commercial |
$297.48
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$305.27
|
| Rate for Payer: Aetna of WY Medicare |
$205.59
|
| Rate for Payer: Altius Commercial |
$299.04
|
| Rate for Payer: Beech Street Commercial |
$305.27
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$302.16
|
| Rate for Payer: Cash Price |
$218.05
|
| Rate for Payer: ChoiceCare Network Commercial |
$302.16
|
| Rate for Payer: Cigna of WY Commercial |
$305.27
|
| Rate for Payer: Entrust Commercial |
$295.92
|
| Rate for Payer: First Choice Health Commercial |
$295.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$295.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$177.56
|
| Rate for Payer: HealthUtah PPO |
$311.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$302.16
|
| Rate for Payer: Multiplan Medicare/VA |
$168.68
|
| Rate for Payer: One Health Plan of WY PPO |
$305.27
|
| Rate for Payer: PacificSource Commercial |
$280.35
|
| Rate for Payer: PHCS PPO |
$305.27
|
| Rate for Payer: Three Rivers PPO |
$233.62
|
| Rate for Payer: TriWest Veterans Administration |
$177.56
|
| Rate for Payer: United Healthcare Medicare |
$177.56
|
| Rate for Payer: WINHealth Partners Commercial |
$305.27
|
| Rate for Payer: Wise Provider Network Commercial |
$295.92
|
|
|
CROSSFIX II DISP PROCEDURE KIT
|
Facility
|
IP
|
$311.50
|
|
| Hospital Charge Code |
3003857
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$180.51 |
| Max. Negotiated Rate |
$311.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$305.27
|
| Rate for Payer: Aetna of WY Medicare |
$199.36
|
| Rate for Payer: Altius Commercial |
$299.04
|
| Rate for Payer: Beech Street Commercial |
$305.27
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$302.16
|
| Rate for Payer: Cash Price |
$218.05
|
| Rate for Payer: ChoiceCare Network Commercial |
$302.16
|
| Rate for Payer: Cigna of WY Commercial |
$305.27
|
| Rate for Payer: Entrust Commercial |
$295.92
|
| Rate for Payer: First Choice Health Commercial |
$295.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$295.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$190.02
|
| Rate for Payer: HealthUtah PPO |
$311.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$302.16
|
| Rate for Payer: Multiplan Medicare/VA |
$180.51
|
| Rate for Payer: One Health Plan of WY PPO |
$305.27
|
| Rate for Payer: PacificSource Commercial |
$280.35
|
| Rate for Payer: PHCS PPO |
$305.27
|
| Rate for Payer: Three Rivers PPO |
$233.62
|
| Rate for Payer: TriWest Veterans Administration |
$190.02
|
| Rate for Payer: United Healthcare Commercial |
$297.48
|
| Rate for Payer: United Healthcare Medicare |
$190.02
|
| Rate for Payer: WINHealth Partners Commercial |
$295.92
|
| Rate for Payer: Wise Provider Network Commercial |
$295.92
|
|
|
CROWNDRILL TREPHINE 3.0 MM
|
Facility
|
OP
|
$2,247.00
|
|
| Hospital Charge Code |
3100582
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,216.75 |
| Max. Negotiated Rate |
$2,247.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,202.06
|
| Rate for Payer: Aetna of WY Medicare |
$1,483.02
|
| Rate for Payer: Altius Commercial |
$2,157.12
|
| Rate for Payer: Beech Street Commercial |
$2,202.06
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,179.59
|
| Rate for Payer: Cash Price |
$1,572.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,179.59
|
| Rate for Payer: Cigna of WY Commercial |
$2,202.06
|
| Rate for Payer: Entrust Commercial |
$2,134.65
|
| Rate for Payer: First Choice Health Commercial |
$2,134.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,134.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,280.79
|
| Rate for Payer: HealthUtah PPO |
$2,247.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,179.59
|
| Rate for Payer: Multiplan Medicare/VA |
$1,216.75
|
| Rate for Payer: One Health Plan of WY PPO |
$2,202.06
|
| Rate for Payer: PacificSource Commercial |
$2,022.30
|
| Rate for Payer: PHCS PPO |
$2,202.06
|
| Rate for Payer: Three Rivers PPO |
$1,685.25
|
| Rate for Payer: TriWest Veterans Administration |
$1,280.79
|
| Rate for Payer: United Healthcare Commercial |
$2,145.88
|
| Rate for Payer: United Healthcare Medicare |
$1,280.79
|
| Rate for Payer: WINHealth Partners Commercial |
$2,202.06
|
| Rate for Payer: Wise Provider Network Commercial |
$2,134.65
|
|
|
CROWNDRILL TREPHINE 3.0 MM
|
Facility
|
IP
|
$2,247.00
|
|
| Hospital Charge Code |
3100582
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,302.14 |
| Max. Negotiated Rate |
$2,247.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,202.06
|
| Rate for Payer: Aetna of WY Medicare |
$1,438.08
|
| Rate for Payer: Altius Commercial |
$2,157.12
|
| Rate for Payer: Beech Street Commercial |
$2,202.06
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,179.59
|
| Rate for Payer: Cash Price |
$1,572.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,179.59
|
| Rate for Payer: Cigna of WY Commercial |
$2,202.06
|
| Rate for Payer: Entrust Commercial |
$2,134.65
|
| Rate for Payer: First Choice Health Commercial |
$2,134.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,134.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,370.67
|
| Rate for Payer: HealthUtah PPO |
$2,247.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,179.59
|
| Rate for Payer: Multiplan Medicare/VA |
$1,302.14
|
| Rate for Payer: One Health Plan of WY PPO |
$2,202.06
|
| Rate for Payer: PacificSource Commercial |
$2,022.30
|
| Rate for Payer: PHCS PPO |
$2,202.06
|
| Rate for Payer: Three Rivers PPO |
$1,685.25
|
| Rate for Payer: TriWest Veterans Administration |
$1,370.67
|
| Rate for Payer: United Healthcare Commercial |
$2,145.88
|
| Rate for Payer: United Healthcare Medicare |
$1,370.67
|
| Rate for Payer: WINHealth Partners Commercial |
$2,134.65
|
| Rate for Payer: Wise Provider Network Commercial |
$2,134.65
|
|
|
CRTJ SHUNT VENTRICULO-PERITNEAL-PLEURAL TERMINUS
|
Professional
|
Both
|
$4,543.00
|
|
|
Service Code
|
HCPCS 62223 80
|
| Min. Negotiated Rate |
$3,407.25 |
| Max. Negotiated Rate |
$4,543.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4,452.14
|
| Rate for Payer: Beech Street Commercial |
$4,315.85
|
| Rate for Payer: Cash Price |
$3,180.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$4,406.71
|
| Rate for Payer: Cigna of WY Commercial |
$4,452.14
|
| Rate for Payer: First Choice Health Commercial |
$4,088.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,315.85
|
| Rate for Payer: HealthUtah PPO |
$4,543.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4,406.71
|
| Rate for Payer: One Health Plan of WY PPO |
$4,452.14
|
| Rate for Payer: PacificSource Commercial |
$4,088.70
|
| Rate for Payer: PHCS PPO |
$4,315.85
|
| Rate for Payer: Three Rivers PPO |
$3,407.25
|
| Rate for Payer: United Healthcare Commercial |
$4,315.85
|
| Rate for Payer: WINHealth Partners Commercial |
$3,861.55
|
|
|
CRTJ SHUNT VENTRICULO-PERITNEAL-PLEURAL TERMINUS
|
Professional
|
Both
|
$4,543.00
|
|
|
Service Code
|
HCPCS 62223 AS
|
| Min. Negotiated Rate |
$3,407.25 |
| Max. Negotiated Rate |
$4,543.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4,452.14
|
| Rate for Payer: Beech Street Commercial |
$4,315.85
|
| Rate for Payer: Cash Price |
$3,180.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$4,406.71
|
| Rate for Payer: Cigna of WY Commercial |
$4,452.14
|
| Rate for Payer: First Choice Health Commercial |
$4,088.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,315.85
|
| Rate for Payer: HealthUtah PPO |
$4,543.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4,406.71
|
| Rate for Payer: One Health Plan of WY PPO |
$4,452.14
|
| Rate for Payer: PacificSource Commercial |
$4,088.70
|
| Rate for Payer: PHCS PPO |
$4,315.85
|
| Rate for Payer: Three Rivers PPO |
$3,407.25
|
| Rate for Payer: United Healthcare Commercial |
$4,315.85
|
| Rate for Payer: WINHealth Partners Commercial |
$3,861.55
|
|
