|
ET TUBE HOLDER ADULT 600-10000
|
Facility
|
IP
|
$8.40
|
|
| Hospital Charge Code |
27000000S1
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$5.27 |
| Max. Negotiated Rate |
$8.40 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$8.23
|
| Rate for Payer: Altius Auto/Workers Compensation |
$8.06
|
| Rate for Payer: Altius Commercial |
$8.06
|
| Rate for Payer: Beech Street Commercial |
$8.23
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$6.90
|
| Rate for Payer: Cash Price |
$5.88
|
| Rate for Payer: ChoiceCare Network Commercial |
$8.15
|
| Rate for Payer: Cigna of WY Commercial |
$8.23
|
| Rate for Payer: Entrust Commercial |
$7.98
|
| Rate for Payer: First Choice Health Commercial |
$7.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$7.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$5.54
|
| Rate for Payer: HealthUtah PPO |
$8.40
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$8.15
|
| Rate for Payer: Multiplan Medicare/VA |
$5.27
|
| Rate for Payer: One Health Plan of WY PPO |
$8.23
|
| Rate for Payer: PacificSource Commercial |
$7.56
|
| Rate for Payer: PHCS PPO |
$8.23
|
| Rate for Payer: Three Rivers PPO |
$6.30
|
| Rate for Payer: TriWest Veterans Administration |
$5.54
|
| Rate for Payer: United Healthcare Commercial |
$7.31
|
| Rate for Payer: United Healthcare Medicare |
$5.54
|
| Rate for Payer: WINHealth Partners Commercial |
$7.98
|
| Rate for Payer: Wise Provider Network Commercial |
$7.98
|
|
|
ET TUBE HOLDER PED
|
Facility
|
IP
|
$11.16
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$7.00 |
| Max. Negotiated Rate |
$11.16 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$10.94
|
| Rate for Payer: Altius Auto/Workers Compensation |
$10.71
|
| Rate for Payer: Altius Commercial |
$10.71
|
| Rate for Payer: Beech Street Commercial |
$10.94
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$9.16
|
| Rate for Payer: Cash Price |
$7.82
|
| Rate for Payer: ChoiceCare Network Commercial |
$10.83
|
| Rate for Payer: Cigna of WY Commercial |
$10.94
|
| Rate for Payer: Entrust Commercial |
$10.60
|
| Rate for Payer: First Choice Health Commercial |
$10.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$10.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$7.37
|
| Rate for Payer: HealthUtah PPO |
$11.16
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$10.83
|
| Rate for Payer: Multiplan Medicare/VA |
$7.00
|
| Rate for Payer: One Health Plan of WY PPO |
$10.94
|
| Rate for Payer: PacificSource Commercial |
$10.04
|
| Rate for Payer: PHCS PPO |
$10.94
|
| Rate for Payer: Three Rivers PPO |
$8.37
|
| Rate for Payer: TriWest Veterans Administration |
$7.37
|
| Rate for Payer: United Healthcare Commercial |
$9.71
|
| Rate for Payer: United Healthcare Medicare |
$7.37
|
| Rate for Payer: WINHealth Partners Commercial |
$10.60
|
| Rate for Payer: Wise Provider Network Commercial |
$10.60
|
|
|
ET TUBE HOLDER PED
|
Facility
|
OP
|
$11.16
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$6.15 |
| Max. Negotiated Rate |
$11.16 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$10.94
|
| Rate for Payer: Aetna of WY Medicare |
$7.37
|
| Rate for Payer: Altius Auto/Workers Compensation |
$10.71
|
| Rate for Payer: Altius Commercial |
$10.71
|
| Rate for Payer: Beech Street Commercial |
$10.94
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$9.16
|
| Rate for Payer: Cash Price |
$7.82
|
| Rate for Payer: ChoiceCare Network Commercial |
$10.83
|
| Rate for Payer: Cigna of WY Commercial |
$10.94
|
| Rate for Payer: Entrust Commercial |
$10.60
|
| Rate for Payer: First Choice Health Commercial |
$10.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$10.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$6.47
|
| Rate for Payer: HealthUtah PPO |
$11.16
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$10.83
|
| Rate for Payer: Multiplan Medicare/VA |
$6.15
|
| Rate for Payer: One Health Plan of WY PPO |
$10.94
|
| Rate for Payer: PacificSource Commercial |
$10.04
|
| Rate for Payer: PHCS PPO |
$10.94
|
| Rate for Payer: Three Rivers PPO |
$8.37
|
| Rate for Payer: TriWest Veterans Administration |
$6.47
|
| Rate for Payer: United Healthcare Commercial |
$9.71
|
| Rate for Payer: United Healthcare Medicare |
$6.47
|
| Rate for Payer: WINHealth Partners Commercial |
$10.94
|
| Rate for Payer: Wise Provider Network Commercial |
$10.60
|
|
|
EUFLEXXA INJ PER DOSE
|
Professional
|
Both
|
$821.00
|
|
|
Service Code
|
HCPCS J7323
|
| Hospital Charge Code |
J7323
|
| Min. Negotiated Rate |
$98.24 |
| Max. Negotiated Rate |
$821.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$804.58
|
| Rate for Payer: Aetna of WY Medicare |
$115.57
|
| Rate for Payer: Beech Street Commercial |
$779.95
|
| Rate for Payer: Cash Price |
$574.70
|
| Rate for Payer: Cash Price |
$574.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$796.37
|
| Rate for Payer: Cigna of WY Commercial |
$804.58
|
| Rate for Payer: First Choice Health Commercial |
$738.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$779.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$115.57
|
| Rate for Payer: HealthUtah PPO |
$821.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$796.37
|
| Rate for Payer: Multiplan Medicare/VA |
$98.24
|
| Rate for Payer: One Health Plan of WY PPO |
$804.58
|
| Rate for Payer: PacificSource Commercial |
$738.90
|
| Rate for Payer: PHCS PPO |
$779.95
|
| Rate for Payer: Three Rivers PPO |
$615.75
|
| Rate for Payer: TriWest Veterans Administration |
$115.57
|
| Rate for Payer: United Healthcare Commercial |
$714.27
|
| Rate for Payer: United Healthcare Medicare |
$115.57
|
| Rate for Payer: WINHealth Partners Commercial |
$779.95
|
|
|
EVAC PVC DRAINAGE BOTTLE 1000M
|
Facility
|
IP
|
$34.83
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$21.84 |
| Max. Negotiated Rate |
$34.83 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$34.13
|
| Rate for Payer: Altius Auto/Workers Compensation |
$33.44
|
| Rate for Payer: Altius Commercial |
$33.44
|
| Rate for Payer: Beech Street Commercial |
$34.13
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$28.60
|
| Rate for Payer: Cash Price |
$24.38
|
| Rate for Payer: ChoiceCare Network Commercial |
$33.79
|
| Rate for Payer: Cigna of WY Commercial |
$34.13
|
| Rate for Payer: Entrust Commercial |
$33.09
|
| Rate for Payer: First Choice Health Commercial |
$33.09
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$33.09
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$22.99
|
| Rate for Payer: HealthUtah PPO |
$34.83
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$33.79
|
| Rate for Payer: Multiplan Medicare/VA |
$21.84
|
| Rate for Payer: One Health Plan of WY PPO |
$34.13
|
| Rate for Payer: PacificSource Commercial |
$31.35
|
| Rate for Payer: PHCS PPO |
$34.13
|
| Rate for Payer: Three Rivers PPO |
$26.12
|
| Rate for Payer: TriWest Veterans Administration |
$22.99
|
| Rate for Payer: United Healthcare Commercial |
$30.30
|
| Rate for Payer: United Healthcare Medicare |
$22.99
|
| Rate for Payer: WINHealth Partners Commercial |
$33.09
|
| Rate for Payer: Wise Provider Network Commercial |
$33.09
|
|
|
EVAC PVC DRAINAGE BOTTLE 1000M
|
Facility
|
OP
|
$34.83
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$19.19 |
| Max. Negotiated Rate |
$34.83 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$34.13
|
| Rate for Payer: Aetna of WY Medicare |
$22.99
|
| Rate for Payer: Altius Auto/Workers Compensation |
$33.44
|
| Rate for Payer: Altius Commercial |
$33.44
|
| Rate for Payer: Beech Street Commercial |
$34.13
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$28.60
|
| Rate for Payer: Cash Price |
$24.38
|
| Rate for Payer: ChoiceCare Network Commercial |
$33.79
|
| Rate for Payer: Cigna of WY Commercial |
$34.13
|
| Rate for Payer: Entrust Commercial |
$33.09
|
| Rate for Payer: First Choice Health Commercial |
$33.09
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$33.09
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$20.20
|
| Rate for Payer: HealthUtah PPO |
$34.83
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$33.79
|
| Rate for Payer: Multiplan Medicare/VA |
$19.19
|
| Rate for Payer: One Health Plan of WY PPO |
$34.13
|
| Rate for Payer: PacificSource Commercial |
$31.35
|
| Rate for Payer: PHCS PPO |
$34.13
|
| Rate for Payer: Three Rivers PPO |
$26.12
|
| Rate for Payer: TriWest Veterans Administration |
$20.20
|
| Rate for Payer: United Healthcare Commercial |
$30.30
|
| Rate for Payer: United Healthcare Medicare |
$20.20
|
| Rate for Payer: WINHealth Partners Commercial |
$34.13
|
| Rate for Payer: Wise Provider Network Commercial |
$33.09
|
|
|
EVACUATION SUBUNGUAL HEMATOMA
|
Professional
|
Both
|
$158.00
|
|
|
Service Code
|
HCPCS 11740
|
| Hospital Charge Code |
11740
|
| Min. Negotiated Rate |
$26.78 |
| Max. Negotiated Rate |
$158.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$154.84
|
| Rate for Payer: Aetna of WY Medicare |
$31.51
|
| Rate for Payer: Beech Street Commercial |
$150.10
|
| Rate for Payer: Cash Price |
$110.60
|
| Rate for Payer: Cash Price |
$110.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$153.26
|
| Rate for Payer: Cigna of WY Commercial |
$154.84
|
| Rate for Payer: First Choice Health Commercial |
$142.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$150.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$31.51
|
| Rate for Payer: HealthUtah PPO |
$158.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$153.26
|
| Rate for Payer: Multiplan Medicare/VA |
$26.78
|
| Rate for Payer: One Health Plan of WY PPO |
$154.84
|
| Rate for Payer: PacificSource Commercial |
$142.20
|
| Rate for Payer: PHCS PPO |
$150.10
|
| Rate for Payer: Three Rivers PPO |
$118.50
|
| Rate for Payer: TriWest Veterans Administration |
$31.51
|
| Rate for Payer: United Healthcare Commercial |
$137.46
|
| Rate for Payer: United Healthcare Medicare |
$31.51
|
| Rate for Payer: WINHealth Partners Commercial |
$134.30
|
|
|
EVAL C/V AMNIOTIC FLUID PROTEIN QUAL EA SPECIMEN
|
Professional
|
Both
|
$281.00
|
|
|
Service Code
|
HCPCS 84112
|
| Hospital Charge Code |
84112
|
| Min. Negotiated Rate |
$83.39 |
| Max. Negotiated Rate |
$281.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$275.38
|
| Rate for Payer: Aetna of WY Medicare |
$98.11
|
| Rate for Payer: Beech Street Commercial |
$266.95
|
| Rate for Payer: Cash Price |
$196.70
|
| Rate for Payer: Cash Price |
$196.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$272.57
|
| Rate for Payer: Cigna of WY Commercial |
$275.38
|
| Rate for Payer: First Choice Health Commercial |
$252.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$266.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$98.11
|
| Rate for Payer: HealthUtah PPO |
$281.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$272.57
|
| Rate for Payer: Multiplan Medicare/VA |
$83.39
|
| Rate for Payer: One Health Plan of WY PPO |
$275.38
|
| Rate for Payer: PacificSource Commercial |
$252.90
|
| Rate for Payer: PHCS PPO |
$266.95
|
| Rate for Payer: Three Rivers PPO |
$210.75
|
| Rate for Payer: TriWest Veterans Administration |
$98.11
|
| Rate for Payer: United Healthcare Commercial |
$244.47
|
| Rate for Payer: United Healthcare Medicare |
$98.11
|
| Rate for Payer: WINHealth Partners Commercial |
$266.95
|
|
|
EVAL ORAL&PHARYNGEAL SWLNG FUNCJ
|
Professional
|
Both
|
$300.00
|
|
|
Service Code
|
HCPCS 92610
|
| Hospital Charge Code |
92610
|
| Min. Negotiated Rate |
$58.16 |
| Max. Negotiated Rate |
$300.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$294.00
|
| Rate for Payer: Aetna of WY Medicare |
$68.42
|
| Rate for Payer: Beech Street Commercial |
$285.00
|
| Rate for Payer: Cash Price |
$210.00
|
| Rate for Payer: Cash Price |
$210.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$291.00
|
| Rate for Payer: Cigna of WY Commercial |
$294.00
|
| Rate for Payer: First Choice Health Commercial |
$270.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$285.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$68.42
|
| Rate for Payer: HealthUtah PPO |
$300.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$291.00
|
| Rate for Payer: Multiplan Medicare/VA |
$58.16
|
| Rate for Payer: One Health Plan of WY PPO |
$294.00
|
| Rate for Payer: PacificSource Commercial |
$270.00
|
| Rate for Payer: PHCS PPO |
$285.00
|
| Rate for Payer: Three Rivers PPO |
$225.00
|
| Rate for Payer: TriWest Veterans Administration |
$68.42
|
| Rate for Payer: United Healthcare Commercial |
$261.00
|
| Rate for Payer: United Healthcare Medicare |
$68.42
|
| Rate for Payer: WINHealth Partners Commercial |
$285.00
|
|
|
EVERLIFT SUBMUCOSAL LIFT AGENT
|
Facility
|
OP
|
$276.50
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$152.35 |
| Max. Negotiated Rate |
$276.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$270.97
|
| Rate for Payer: Aetna of WY Medicare |
$182.49
|
| Rate for Payer: Altius Auto/Workers Compensation |
$265.44
|
| Rate for Payer: Altius Commercial |
$265.44
|
| Rate for Payer: Beech Street Commercial |
$270.97
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$227.01
|
| Rate for Payer: Cash Price |
$193.55
|
| Rate for Payer: ChoiceCare Network Commercial |
$268.20
|
| Rate for Payer: Cigna of WY Commercial |
$270.97
|
| Rate for Payer: Entrust Commercial |
$262.68
|
| Rate for Payer: First Choice Health Commercial |
$262.68
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$262.68
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$160.37
|
| Rate for Payer: HealthUtah PPO |
$276.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$268.20
|
| Rate for Payer: Multiplan Medicare/VA |
$152.35
|
| Rate for Payer: One Health Plan of WY PPO |
$270.97
|
| Rate for Payer: PacificSource Commercial |
$248.85
|
| Rate for Payer: PHCS PPO |
$270.97
|
| Rate for Payer: Three Rivers PPO |
$207.38
|
| Rate for Payer: TriWest Veterans Administration |
$160.37
|
| Rate for Payer: United Healthcare Commercial |
$240.56
|
| Rate for Payer: United Healthcare Medicare |
$160.37
|
| Rate for Payer: WINHealth Partners Commercial |
$270.97
|
| Rate for Payer: Wise Provider Network Commercial |
$262.68
|
|
|
EVERLIFT SUBMUCOSAL LIFT AGENT
|
Facility
|
IP
|
$276.50
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$173.37 |
| Max. Negotiated Rate |
$276.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$270.97
|
| Rate for Payer: Altius Auto/Workers Compensation |
$265.44
|
| Rate for Payer: Altius Commercial |
$265.44
|
| Rate for Payer: Beech Street Commercial |
$270.97
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$227.01
|
| Rate for Payer: Cash Price |
$193.55
|
| Rate for Payer: ChoiceCare Network Commercial |
$268.20
|
| Rate for Payer: Cigna of WY Commercial |
$270.97
|
| Rate for Payer: Entrust Commercial |
$262.68
|
| Rate for Payer: First Choice Health Commercial |
$262.68
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$262.68
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$182.49
|
| Rate for Payer: HealthUtah PPO |
$276.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$268.20
|
| Rate for Payer: Multiplan Medicare/VA |
$173.37
|
| Rate for Payer: One Health Plan of WY PPO |
$270.97
|
| Rate for Payer: PacificSource Commercial |
$248.85
|
| Rate for Payer: PHCS PPO |
$270.97
|
| Rate for Payer: Three Rivers PPO |
$207.38
|
| Rate for Payer: TriWest Veterans Administration |
$182.49
|
| Rate for Payer: United Healthcare Commercial |
$240.56
|
| Rate for Payer: United Healthcare Medicare |
$182.49
|
| Rate for Payer: WINHealth Partners Commercial |
$262.68
|
| Rate for Payer: Wise Provider Network Commercial |
$262.68
|
|
|
EWHFO RIGID W/O JNTS CF
|
Professional
|
Both
|
$1,904.00
|
|
|
Service Code
|
HCPCS L3765
|
| Hospital Charge Code |
L3765
|
| Min. Negotiated Rate |
$1,179.92 |
| Max. Negotiated Rate |
$1,904.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,865.92
|
| Rate for Payer: Aetna of WY Medicare |
$1,388.14
|
| Rate for Payer: Beech Street Commercial |
$1,808.80
|
| Rate for Payer: Cash Price |
$1,332.80
|
| Rate for Payer: Cash Price |
$1,332.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,846.88
|
| Rate for Payer: Cigna of WY Commercial |
$1,865.92
|
| Rate for Payer: First Choice Health Commercial |
$1,713.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,808.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,388.14
|
| Rate for Payer: HealthUtah PPO |
$1,904.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,846.88
|
| Rate for Payer: Multiplan Medicare/VA |
$1,179.92
|
| Rate for Payer: One Health Plan of WY PPO |
$1,865.92
|
| Rate for Payer: PacificSource Commercial |
$1,713.60
|
| Rate for Payer: PHCS PPO |
$1,808.80
|
| Rate for Payer: Three Rivers PPO |
$1,428.00
|
| Rate for Payer: TriWest Veterans Administration |
$1,388.14
|
| Rate for Payer: United Healthcare Commercial |
$1,656.48
|
| Rate for Payer: United Healthcare Medicare |
$1,388.14
|
| Rate for Payer: WINHealth Partners Commercial |
$1,808.80
|
|
|
EWHFO W/JOINT(S) CF
|
Professional
|
Both
|
$2,016.00
|
|
|
Service Code
|
HCPCS L3766
|
| Hospital Charge Code |
L3766
|
| Min. Negotiated Rate |
$1,512.00 |
| Max. Negotiated Rate |
$2,016.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,975.68
|
| Rate for Payer: Beech Street Commercial |
$1,915.20
|
| Rate for Payer: Cash Price |
$1,411.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,955.52
|
| Rate for Payer: Cigna of WY Commercial |
$1,975.68
|
| Rate for Payer: First Choice Health Commercial |
$1,814.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,915.20
|
| Rate for Payer: HealthUtah PPO |
$2,016.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,955.52
|
| Rate for Payer: One Health Plan of WY PPO |
$1,975.68
|
| Rate for Payer: PacificSource Commercial |
$1,814.40
|
| Rate for Payer: PHCS PPO |
$1,915.20
|
| Rate for Payer: Three Rivers PPO |
$1,512.00
|
| Rate for Payer: United Healthcare Commercial |
$1,753.92
|
| Rate for Payer: WINHealth Partners Commercial |
$1,915.20
|
|
|
EWHO RIGID W/O JNTS CF
|
Professional
|
Both
|
$998.00
|
|
|
Service Code
|
HCPCS L3763
|
| Hospital Charge Code |
L3763
|
| Min. Negotiated Rate |
$618.11 |
| Max. Negotiated Rate |
$998.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$978.04
|
| Rate for Payer: Aetna of WY Medicare |
$727.19
|
| Rate for Payer: Beech Street Commercial |
$948.10
|
| Rate for Payer: Cash Price |
$698.60
|
| Rate for Payer: Cash Price |
$698.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$968.06
|
| Rate for Payer: Cigna of WY Commercial |
$978.04
|
| Rate for Payer: First Choice Health Commercial |
$898.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$948.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$727.19
|
| Rate for Payer: HealthUtah PPO |
$998.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$968.06
|
| Rate for Payer: Multiplan Medicare/VA |
$618.11
|
| Rate for Payer: One Health Plan of WY PPO |
$978.04
|
| Rate for Payer: PacificSource Commercial |
$898.20
|
| Rate for Payer: PHCS PPO |
$948.10
|
| Rate for Payer: Three Rivers PPO |
$748.50
|
| Rate for Payer: TriWest Veterans Administration |
$727.19
|
| Rate for Payer: United Healthcare Commercial |
$868.26
|
| Rate for Payer: United Healthcare Medicare |
$727.19
|
| Rate for Payer: WINHealth Partners Commercial |
$948.10
|
|
|
EWHO W/JOINT(S) CF
|
Professional
|
Both
|
$1,138.00
|
|
|
Service Code
|
HCPCS L3764
|
| Hospital Charge Code |
L3764
|
| Min. Negotiated Rate |
$706.58 |
| Max. Negotiated Rate |
$1,138.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,115.24
|
| Rate for Payer: Aetna of WY Medicare |
$831.27
|
| Rate for Payer: Beech Street Commercial |
$1,081.10
|
| Rate for Payer: Cash Price |
$796.60
|
| Rate for Payer: Cash Price |
$796.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,103.86
|
| Rate for Payer: Cigna of WY Commercial |
$1,115.24
|
| Rate for Payer: First Choice Health Commercial |
$1,024.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,081.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$831.27
|
| Rate for Payer: HealthUtah PPO |
$1,138.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,103.86
|
| Rate for Payer: Multiplan Medicare/VA |
$706.58
|
| Rate for Payer: One Health Plan of WY PPO |
$1,115.24
|
| Rate for Payer: PacificSource Commercial |
$1,024.20
|
| Rate for Payer: PHCS PPO |
$1,081.10
|
| Rate for Payer: Three Rivers PPO |
$853.50
|
| Rate for Payer: TriWest Veterans Administration |
$831.27
|
| Rate for Payer: United Healthcare Commercial |
$990.06
|
| Rate for Payer: United Healthcare Medicare |
$831.27
|
| Rate for Payer: WINHealth Partners Commercial |
$1,081.10
|
|
|
EXCALIBUR CURVED 4.0MM 8400CEX
|
Facility
|
IP
|
$269.82
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$169.18 |
| Max. Negotiated Rate |
$269.82 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$264.42
|
| Rate for Payer: Altius Auto/Workers Compensation |
$259.03
|
| Rate for Payer: Altius Commercial |
$259.03
|
| Rate for Payer: Beech Street Commercial |
$264.42
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$221.52
|
| Rate for Payer: Cash Price |
$188.87
|
| Rate for Payer: ChoiceCare Network Commercial |
$261.73
|
| Rate for Payer: Cigna of WY Commercial |
$264.42
|
| Rate for Payer: Entrust Commercial |
$256.33
|
| Rate for Payer: First Choice Health Commercial |
$256.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$256.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$178.08
|
| Rate for Payer: HealthUtah PPO |
$269.82
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$261.73
|
| Rate for Payer: Multiplan Medicare/VA |
$169.18
|
| Rate for Payer: One Health Plan of WY PPO |
$264.42
|
| Rate for Payer: PacificSource Commercial |
$242.84
|
| Rate for Payer: PHCS PPO |
$264.42
|
| Rate for Payer: Three Rivers PPO |
$202.36
|
| Rate for Payer: TriWest Veterans Administration |
$178.08
|
| Rate for Payer: United Healthcare Commercial |
$234.74
|
| Rate for Payer: United Healthcare Medicare |
$178.08
|
| Rate for Payer: WINHealth Partners Commercial |
$256.33
|
| Rate for Payer: Wise Provider Network Commercial |
$256.33
|
|
|
EXCALIBUR CURVED 4.0MM 8400CEX
|
Facility
|
OP
|
$269.82
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$148.67 |
| Max. Negotiated Rate |
$269.82 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$264.42
|
| Rate for Payer: Aetna of WY Medicare |
$178.08
|
| Rate for Payer: Altius Auto/Workers Compensation |
$259.03
|
| Rate for Payer: Altius Commercial |
$259.03
|
| Rate for Payer: Beech Street Commercial |
$264.42
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$221.52
|
| Rate for Payer: Cash Price |
$188.87
|
| Rate for Payer: ChoiceCare Network Commercial |
$261.73
|
| Rate for Payer: Cigna of WY Commercial |
$264.42
|
| Rate for Payer: Entrust Commercial |
$256.33
|
| Rate for Payer: First Choice Health Commercial |
$256.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$256.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$156.50
|
| Rate for Payer: HealthUtah PPO |
$269.82
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$261.73
|
| Rate for Payer: Multiplan Medicare/VA |
$148.67
|
| Rate for Payer: One Health Plan of WY PPO |
$264.42
|
| Rate for Payer: PacificSource Commercial |
$242.84
|
| Rate for Payer: PHCS PPO |
$264.42
|
| Rate for Payer: Three Rivers PPO |
$202.36
|
| Rate for Payer: TriWest Veterans Administration |
$156.50
|
| Rate for Payer: United Healthcare Commercial |
$234.74
|
| Rate for Payer: United Healthcare Medicare |
$156.50
|
| Rate for Payer: WINHealth Partners Commercial |
$264.42
|
| Rate for Payer: Wise Provider Network Commercial |
$256.33
|
|
|
EXCALIBUR SHAVER 4.0MM 8400EX
|
Facility
|
IP
|
$241.18
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$151.22 |
| Max. Negotiated Rate |
$241.18 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$236.36
|
| Rate for Payer: Altius Auto/Workers Compensation |
$231.53
|
| Rate for Payer: Altius Commercial |
$231.53
|
| Rate for Payer: Beech Street Commercial |
$236.36
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$198.01
|
| Rate for Payer: Cash Price |
$168.83
|
| Rate for Payer: ChoiceCare Network Commercial |
$233.94
|
| Rate for Payer: Cigna of WY Commercial |
$236.36
|
| Rate for Payer: Entrust Commercial |
$229.12
|
| Rate for Payer: First Choice Health Commercial |
$229.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$229.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$159.18
|
| Rate for Payer: HealthUtah PPO |
$241.18
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$233.94
|
| Rate for Payer: Multiplan Medicare/VA |
$151.22
|
| Rate for Payer: One Health Plan of WY PPO |
$236.36
|
| Rate for Payer: PacificSource Commercial |
$217.06
|
| Rate for Payer: PHCS PPO |
$236.36
|
| Rate for Payer: Three Rivers PPO |
$180.88
|
| Rate for Payer: TriWest Veterans Administration |
$159.18
|
| Rate for Payer: United Healthcare Commercial |
$209.83
|
| Rate for Payer: United Healthcare Medicare |
$159.18
|
| Rate for Payer: WINHealth Partners Commercial |
$229.12
|
| Rate for Payer: Wise Provider Network Commercial |
$229.12
|
|
|
EXCALIBUR SHAVER 4.0MM 8400EX
|
Facility
|
OP
|
$241.18
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$132.89 |
| Max. Negotiated Rate |
$241.18 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$236.36
|
| Rate for Payer: Aetna of WY Medicare |
$159.18
|
| Rate for Payer: Altius Auto/Workers Compensation |
$231.53
|
| Rate for Payer: Altius Commercial |
$231.53
|
| Rate for Payer: Beech Street Commercial |
$236.36
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$198.01
|
| Rate for Payer: Cash Price |
$168.83
|
| Rate for Payer: ChoiceCare Network Commercial |
$233.94
|
| Rate for Payer: Cigna of WY Commercial |
$236.36
|
| Rate for Payer: Entrust Commercial |
$229.12
|
| Rate for Payer: First Choice Health Commercial |
$229.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$229.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$139.88
|
| Rate for Payer: HealthUtah PPO |
$241.18
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$233.94
|
| Rate for Payer: Multiplan Medicare/VA |
$132.89
|
| Rate for Payer: One Health Plan of WY PPO |
$236.36
|
| Rate for Payer: PacificSource Commercial |
$217.06
|
| Rate for Payer: PHCS PPO |
$236.36
|
| Rate for Payer: Three Rivers PPO |
$180.88
|
| Rate for Payer: TriWest Veterans Administration |
$139.88
|
| Rate for Payer: United Healthcare Commercial |
$209.83
|
| Rate for Payer: United Healthcare Medicare |
$139.88
|
| Rate for Payer: WINHealth Partners Commercial |
$236.36
|
| Rate for Payer: Wise Provider Network Commercial |
$229.12
|
|
|
EXCALIBUR SHAVER 5.5MM 8550EX
|
Facility
|
IP
|
$241.18
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$151.22 |
| Max. Negotiated Rate |
$241.18 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$236.36
|
| Rate for Payer: Altius Auto/Workers Compensation |
$231.53
|
| Rate for Payer: Altius Commercial |
$231.53
|
| Rate for Payer: Beech Street Commercial |
$236.36
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$198.01
|
| Rate for Payer: Cash Price |
$168.83
|
| Rate for Payer: ChoiceCare Network Commercial |
$233.94
|
| Rate for Payer: Cigna of WY Commercial |
$236.36
|
| Rate for Payer: Entrust Commercial |
$229.12
|
| Rate for Payer: First Choice Health Commercial |
$229.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$229.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$159.18
|
| Rate for Payer: HealthUtah PPO |
$241.18
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$233.94
|
| Rate for Payer: Multiplan Medicare/VA |
$151.22
|
| Rate for Payer: One Health Plan of WY PPO |
$236.36
|
| Rate for Payer: PacificSource Commercial |
$217.06
|
| Rate for Payer: PHCS PPO |
$236.36
|
| Rate for Payer: Three Rivers PPO |
$180.88
|
| Rate for Payer: TriWest Veterans Administration |
$159.18
|
| Rate for Payer: United Healthcare Commercial |
$209.83
|
| Rate for Payer: United Healthcare Medicare |
$159.18
|
| Rate for Payer: WINHealth Partners Commercial |
$229.12
|
| Rate for Payer: Wise Provider Network Commercial |
$229.12
|
|
|
EXCALIBUR SHAVER 5.5MM 8550EX
|
Facility
|
OP
|
$241.18
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$132.89 |
| Max. Negotiated Rate |
$241.18 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$236.36
|
| Rate for Payer: Aetna of WY Medicare |
$159.18
|
| Rate for Payer: Altius Auto/Workers Compensation |
$231.53
|
| Rate for Payer: Altius Commercial |
$231.53
|
| Rate for Payer: Beech Street Commercial |
$236.36
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$198.01
|
| Rate for Payer: Cash Price |
$168.83
|
| Rate for Payer: ChoiceCare Network Commercial |
$233.94
|
| Rate for Payer: Cigna of WY Commercial |
$236.36
|
| Rate for Payer: Entrust Commercial |
$229.12
|
| Rate for Payer: First Choice Health Commercial |
$229.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$229.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$139.88
|
| Rate for Payer: HealthUtah PPO |
$241.18
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$233.94
|
| Rate for Payer: Multiplan Medicare/VA |
$132.89
|
| Rate for Payer: One Health Plan of WY PPO |
$236.36
|
| Rate for Payer: PacificSource Commercial |
$217.06
|
| Rate for Payer: PHCS PPO |
$236.36
|
| Rate for Payer: Three Rivers PPO |
$180.88
|
| Rate for Payer: TriWest Veterans Administration |
$139.88
|
| Rate for Payer: United Healthcare Commercial |
$209.83
|
| Rate for Payer: United Healthcare Medicare |
$139.88
|
| Rate for Payer: WINHealth Partners Commercial |
$236.36
|
| Rate for Payer: Wise Provider Network Commercial |
$229.12
|
|
|
EXC B9 LESION MRGN XCP SK TG F/E/E/N/L/M 0.5CM/<
|
Professional
|
Both
|
$515.00
|
|
|
Service Code
|
HCPCS 11440
|
| Hospital Charge Code |
11440
|
| Min. Negotiated Rate |
$89.38 |
| Max. Negotiated Rate |
$515.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$504.70
|
| Rate for Payer: Aetna of WY Medicare |
$105.15
|
| Rate for Payer: Beech Street Commercial |
$489.25
|
| Rate for Payer: Cash Price |
$360.50
|
| Rate for Payer: Cash Price |
$360.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$499.55
|
| Rate for Payer: Cigna of WY Commercial |
$504.70
|
| Rate for Payer: First Choice Health Commercial |
$463.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$489.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$105.15
|
| Rate for Payer: HealthUtah PPO |
$515.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$499.55
|
| Rate for Payer: Multiplan Medicare/VA |
$89.38
|
| Rate for Payer: One Health Plan of WY PPO |
$504.70
|
| Rate for Payer: PacificSource Commercial |
$463.50
|
| Rate for Payer: PHCS PPO |
$489.25
|
| Rate for Payer: Three Rivers PPO |
$386.25
|
| Rate for Payer: TriWest Veterans Administration |
$105.15
|
| Rate for Payer: United Healthcare Commercial |
$448.05
|
| Rate for Payer: United Healthcare Medicare |
$105.15
|
| Rate for Payer: WINHealth Partners Commercial |
$437.75
|
|
|
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 0.5 CM/<
|
Professional
|
Both
|
$411.00
|
|
|
Service Code
|
HCPCS 11420
|
| Hospital Charge Code |
11420
|
| Min. Negotiated Rate |
$68.30 |
| Max. Negotiated Rate |
$411.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$402.78
|
| Rate for Payer: Aetna of WY Medicare |
$80.35
|
| Rate for Payer: Beech Street Commercial |
$390.45
|
| Rate for Payer: Cash Price |
$287.70
|
| Rate for Payer: Cash Price |
$287.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$398.67
|
| Rate for Payer: Cigna of WY Commercial |
$402.78
|
| Rate for Payer: First Choice Health Commercial |
$369.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$390.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$80.35
|
| Rate for Payer: HealthUtah PPO |
$411.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$398.67
|
| Rate for Payer: Multiplan Medicare/VA |
$68.30
|
| Rate for Payer: One Health Plan of WY PPO |
$402.78
|
| Rate for Payer: PacificSource Commercial |
$369.90
|
| Rate for Payer: PHCS PPO |
$390.45
|
| Rate for Payer: Three Rivers PPO |
$308.25
|
| Rate for Payer: TriWest Veterans Administration |
$80.35
|
| Rate for Payer: United Healthcare Commercial |
$357.57
|
| Rate for Payer: United Healthcare Medicare |
$80.35
|
| Rate for Payer: WINHealth Partners Commercial |
$349.35
|
|
|
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 0.6-1.0CM
|
Professional
|
Both
|
$546.00
|
|
|
Service Code
|
HCPCS 11421
|
| Hospital Charge Code |
11421
|
| Min. Negotiated Rate |
$90.34 |
| Max. Negotiated Rate |
$546.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$535.08
|
| Rate for Payer: Aetna of WY Medicare |
$106.28
|
| Rate for Payer: Beech Street Commercial |
$518.70
|
| Rate for Payer: Cash Price |
$382.20
|
| Rate for Payer: Cash Price |
$382.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$529.62
|
| Rate for Payer: Cigna of WY Commercial |
$535.08
|
| Rate for Payer: First Choice Health Commercial |
$491.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$518.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$106.28
|
| Rate for Payer: HealthUtah PPO |
$546.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$529.62
|
| Rate for Payer: Multiplan Medicare/VA |
$90.34
|
| Rate for Payer: One Health Plan of WY PPO |
$535.08
|
| Rate for Payer: PacificSource Commercial |
$491.40
|
| Rate for Payer: PHCS PPO |
$518.70
|
| Rate for Payer: Three Rivers PPO |
$409.50
|
| Rate for Payer: TriWest Veterans Administration |
$106.28
|
| Rate for Payer: United Healthcare Commercial |
$475.02
|
| Rate for Payer: United Healthcare Medicare |
$106.28
|
| Rate for Payer: WINHealth Partners Commercial |
$464.10
|
|
|
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 1.1-2.0CM
|
Professional
|
Both
|
$679.00
|
|
|
Service Code
|
HCPCS 11422
|
| Hospital Charge Code |
11422
|
| Min. Negotiated Rate |
$112.59 |
| Max. Negotiated Rate |
$679.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$665.42
|
| Rate for Payer: Aetna of WY Medicare |
$132.46
|
| Rate for Payer: Beech Street Commercial |
$645.05
|
| Rate for Payer: Cash Price |
$475.30
|
| Rate for Payer: Cash Price |
$475.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$658.63
|
| Rate for Payer: Cigna of WY Commercial |
$665.42
|
| Rate for Payer: First Choice Health Commercial |
$611.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$645.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$132.46
|
| Rate for Payer: HealthUtah PPO |
$679.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$658.63
|
| Rate for Payer: Multiplan Medicare/VA |
$112.59
|
| Rate for Payer: One Health Plan of WY PPO |
$665.42
|
| Rate for Payer: PacificSource Commercial |
$611.10
|
| Rate for Payer: PHCS PPO |
$645.05
|
| Rate for Payer: Three Rivers PPO |
$509.25
|
| Rate for Payer: TriWest Veterans Administration |
$132.46
|
| Rate for Payer: United Healthcare Commercial |
$590.73
|
| Rate for Payer: United Healthcare Medicare |
$132.46
|
| Rate for Payer: WINHealth Partners Commercial |
$577.15
|
|
