|
DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION [30872]
|
Facility
|
OP
|
$75.00
|
|
|
Service Code
|
HCPCS J0877
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$40.61 |
| Max. Negotiated Rate |
$75.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$73.50
|
| Rate for Payer: Aetna of WY Medicare |
$49.50
|
| Rate for Payer: Altius Commercial |
$72.00
|
| Rate for Payer: Beech Street Commercial |
$73.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$72.75
|
| Rate for Payer: Cash Price |
$52.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$72.75
|
| Rate for Payer: Cigna of WY Commercial |
$73.50
|
| Rate for Payer: Entrust Commercial |
$71.25
|
| Rate for Payer: First Choice Health Commercial |
$71.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$71.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$42.75
|
| Rate for Payer: HealthUtah PPO |
$75.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$72.75
|
| Rate for Payer: Multiplan Medicare/VA |
$40.61
|
| Rate for Payer: One Health Plan of WY PPO |
$73.50
|
| Rate for Payer: PacificSource Commercial |
$67.50
|
| Rate for Payer: PHCS PPO |
$73.50
|
| Rate for Payer: Three Rivers PPO |
$56.25
|
| Rate for Payer: TriWest Veterans Administration |
$42.75
|
| Rate for Payer: United Healthcare Commercial |
$71.62
|
| Rate for Payer: United Healthcare Medicare |
$42.75
|
| Rate for Payer: WINHealth Partners Commercial |
$73.50
|
| Rate for Payer: Wise Provider Network Commercial |
$71.25
|
|
|
DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION [30872]
|
Facility
|
IP
|
$75.00
|
|
|
Service Code
|
HCPCS J0877
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$43.46 |
| Max. Negotiated Rate |
$75.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$73.50
|
| Rate for Payer: Aetna of WY Medicare |
$48.00
|
| Rate for Payer: Altius Commercial |
$72.00
|
| Rate for Payer: Beech Street Commercial |
$73.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$72.75
|
| Rate for Payer: Cash Price |
$52.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$72.75
|
| Rate for Payer: Cigna of WY Commercial |
$73.50
|
| Rate for Payer: Entrust Commercial |
$71.25
|
| Rate for Payer: First Choice Health Commercial |
$71.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$71.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$45.75
|
| Rate for Payer: HealthUtah PPO |
$75.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$72.75
|
| Rate for Payer: Multiplan Medicare/VA |
$43.46
|
| Rate for Payer: One Health Plan of WY PPO |
$73.50
|
| Rate for Payer: PacificSource Commercial |
$67.50
|
| Rate for Payer: PHCS PPO |
$73.50
|
| Rate for Payer: Three Rivers PPO |
$56.25
|
| Rate for Payer: TriWest Veterans Administration |
$45.75
|
| Rate for Payer: United Healthcare Commercial |
$71.62
|
| Rate for Payer: United Healthcare Medicare |
$45.75
|
| Rate for Payer: WINHealth Partners Commercial |
$71.25
|
| Rate for Payer: Wise Provider Network Commercial |
$71.25
|
|
|
DARBEPOETIN ALFA 100 MCG/ML IN POLYSORBATE INJECTION [41905]
|
Facility
|
IP
|
$789.00
|
|
|
Service Code
|
HCPCS J0881
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$457.23 |
| Max. Negotiated Rate |
$789.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$773.22
|
| Rate for Payer: Aetna of WY Medicare |
$504.96
|
| Rate for Payer: Altius Commercial |
$757.44
|
| Rate for Payer: Beech Street Commercial |
$773.22
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$765.33
|
| Rate for Payer: Cash Price |
$552.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$765.33
|
| Rate for Payer: Cigna of WY Commercial |
$773.22
|
| Rate for Payer: Entrust Commercial |
$749.55
|
| Rate for Payer: First Choice Health Commercial |
$749.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$749.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$481.29
|
| Rate for Payer: HealthUtah PPO |
$789.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$765.33
|
| Rate for Payer: Multiplan Medicare/VA |
$457.23
|
| Rate for Payer: One Health Plan of WY PPO |
$773.22
|
| Rate for Payer: PacificSource Commercial |
$710.10
|
| Rate for Payer: PHCS PPO |
$773.22
|
| Rate for Payer: Three Rivers PPO |
$591.75
|
| Rate for Payer: TriWest Veterans Administration |
$481.29
|
| Rate for Payer: United Healthcare Commercial |
$753.50
|
| Rate for Payer: United Healthcare Medicare |
$481.29
|
| Rate for Payer: WINHealth Partners Commercial |
$749.55
|
| Rate for Payer: Wise Provider Network Commercial |
$749.55
|
|
|
DARBEPOETIN ALFA 100 MCG/ML IN POLYSORBATE INJECTION [41905]
|
Facility
|
OP
|
$789.00
|
|
|
Service Code
|
HCPCS J0881
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$427.24 |
| Max. Negotiated Rate |
$789.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$773.22
|
| Rate for Payer: Aetna of WY Medicare |
$520.74
|
| Rate for Payer: Altius Commercial |
$757.44
|
| Rate for Payer: Beech Street Commercial |
$773.22
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$765.33
|
| Rate for Payer: Cash Price |
$552.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$765.33
|
| Rate for Payer: Cigna of WY Commercial |
$773.22
|
| Rate for Payer: Entrust Commercial |
$749.55
|
| Rate for Payer: First Choice Health Commercial |
$749.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$749.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$449.73
|
| Rate for Payer: HealthUtah PPO |
$789.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$765.33
|
| Rate for Payer: Multiplan Medicare/VA |
$427.24
|
| Rate for Payer: One Health Plan of WY PPO |
$773.22
|
| Rate for Payer: PacificSource Commercial |
$710.10
|
| Rate for Payer: PHCS PPO |
$773.22
|
| Rate for Payer: Three Rivers PPO |
$591.75
|
| Rate for Payer: TriWest Veterans Administration |
$449.73
|
| Rate for Payer: United Healthcare Commercial |
$753.50
|
| Rate for Payer: United Healthcare Medicare |
$449.73
|
| Rate for Payer: WINHealth Partners Commercial |
$773.22
|
| Rate for Payer: Wise Provider Network Commercial |
$749.55
|
|
|
DARBEPOETIN ALFA 10 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE [140288]
|
Facility
|
OP
|
$305.25
|
|
|
Service Code
|
HCPCS J0881
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$165.29 |
| Max. Negotiated Rate |
$305.25 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$299.14
|
| Rate for Payer: Aetna of WY Medicare |
$201.46
|
| Rate for Payer: Altius Commercial |
$293.04
|
| Rate for Payer: Beech Street Commercial |
$299.14
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$296.09
|
| Rate for Payer: Cash Price |
$213.67
|
| Rate for Payer: ChoiceCare Network Commercial |
$296.09
|
| Rate for Payer: Cigna of WY Commercial |
$299.14
|
| Rate for Payer: Entrust Commercial |
$289.99
|
| Rate for Payer: First Choice Health Commercial |
$289.99
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$289.99
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$173.99
|
| Rate for Payer: HealthUtah PPO |
$305.25
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$296.09
|
| Rate for Payer: Multiplan Medicare/VA |
$165.29
|
| Rate for Payer: One Health Plan of WY PPO |
$299.14
|
| Rate for Payer: PacificSource Commercial |
$274.72
|
| Rate for Payer: PHCS PPO |
$299.14
|
| Rate for Payer: Three Rivers PPO |
$228.94
|
| Rate for Payer: TriWest Veterans Administration |
$173.99
|
| Rate for Payer: United Healthcare Commercial |
$291.51
|
| Rate for Payer: United Healthcare Medicare |
$173.99
|
| Rate for Payer: WINHealth Partners Commercial |
$299.14
|
| Rate for Payer: Wise Provider Network Commercial |
$289.99
|
|
|
DARBEPOETIN ALFA 10 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE [140288]
|
Facility
|
IP
|
$305.25
|
|
|
Service Code
|
HCPCS J0881
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$176.89 |
| Max. Negotiated Rate |
$305.25 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$299.14
|
| Rate for Payer: Aetna of WY Medicare |
$195.36
|
| Rate for Payer: Altius Commercial |
$293.04
|
| Rate for Payer: Beech Street Commercial |
$299.14
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$296.09
|
| Rate for Payer: Cash Price |
$213.67
|
| Rate for Payer: ChoiceCare Network Commercial |
$296.09
|
| Rate for Payer: Cigna of WY Commercial |
$299.14
|
| Rate for Payer: Entrust Commercial |
$289.99
|
| Rate for Payer: First Choice Health Commercial |
$289.99
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$289.99
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$186.20
|
| Rate for Payer: HealthUtah PPO |
$305.25
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$296.09
|
| Rate for Payer: Multiplan Medicare/VA |
$176.89
|
| Rate for Payer: One Health Plan of WY PPO |
$299.14
|
| Rate for Payer: PacificSource Commercial |
$274.72
|
| Rate for Payer: PHCS PPO |
$299.14
|
| Rate for Payer: Three Rivers PPO |
$228.94
|
| Rate for Payer: TriWest Veterans Administration |
$186.20
|
| Rate for Payer: United Healthcare Commercial |
$291.51
|
| Rate for Payer: United Healthcare Medicare |
$186.20
|
| Rate for Payer: WINHealth Partners Commercial |
$289.99
|
| Rate for Payer: Wise Provider Network Commercial |
$289.99
|
|
|
DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE [41766]
|
Facility
|
IP
|
$3,885.00
|
|
|
Service Code
|
HCPCS J0881
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,251.36 |
| Max. Negotiated Rate |
$3,885.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,807.30
|
| Rate for Payer: Aetna of WY Medicare |
$2,486.40
|
| Rate for Payer: Altius Commercial |
$3,729.60
|
| Rate for Payer: Beech Street Commercial |
$3,807.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3,768.45
|
| Rate for Payer: Cash Price |
$2,719.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,768.45
|
| Rate for Payer: Cigna of WY Commercial |
$3,807.30
|
| Rate for Payer: Entrust Commercial |
$3,690.75
|
| Rate for Payer: First Choice Health Commercial |
$3,690.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,690.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2,369.85
|
| Rate for Payer: HealthUtah PPO |
$3,885.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,768.45
|
| Rate for Payer: Multiplan Medicare/VA |
$2,251.36
|
| Rate for Payer: One Health Plan of WY PPO |
$3,807.30
|
| Rate for Payer: PacificSource Commercial |
$3,496.50
|
| Rate for Payer: PHCS PPO |
$3,807.30
|
| Rate for Payer: Three Rivers PPO |
$2,913.75
|
| Rate for Payer: TriWest Veterans Administration |
$2,369.85
|
| Rate for Payer: United Healthcare Commercial |
$3,710.18
|
| Rate for Payer: United Healthcare Medicare |
$2,369.85
|
| Rate for Payer: WINHealth Partners Commercial |
$3,690.75
|
| Rate for Payer: Wise Provider Network Commercial |
$3,690.75
|
|
|
DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE [41766]
|
Facility
|
OP
|
$3,885.00
|
|
|
Service Code
|
HCPCS J0881
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,103.73 |
| Max. Negotiated Rate |
$3,885.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,807.30
|
| Rate for Payer: Aetna of WY Medicare |
$2,564.10
|
| Rate for Payer: Altius Commercial |
$3,729.60
|
| Rate for Payer: Beech Street Commercial |
$3,807.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3,768.45
|
| Rate for Payer: Cash Price |
$2,719.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,768.45
|
| Rate for Payer: Cigna of WY Commercial |
$3,807.30
|
| Rate for Payer: Entrust Commercial |
$3,690.75
|
| Rate for Payer: First Choice Health Commercial |
$3,690.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,690.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2,214.45
|
| Rate for Payer: HealthUtah PPO |
$3,885.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,768.45
|
| Rate for Payer: Multiplan Medicare/VA |
$2,103.73
|
| Rate for Payer: One Health Plan of WY PPO |
$3,807.30
|
| Rate for Payer: PacificSource Commercial |
$3,496.50
|
| Rate for Payer: PHCS PPO |
$3,807.30
|
| Rate for Payer: Three Rivers PPO |
$2,913.75
|
| Rate for Payer: TriWest Veterans Administration |
$2,214.45
|
| Rate for Payer: United Healthcare Commercial |
$3,710.18
|
| Rate for Payer: United Healthcare Medicare |
$2,214.45
|
| Rate for Payer: WINHealth Partners Commercial |
$3,807.30
|
| Rate for Payer: Wise Provider Network Commercial |
$3,690.75
|
|
|
DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE [41764]
|
Facility
|
IP
|
$789.00
|
|
|
Service Code
|
HCPCS J0881
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$457.23 |
| Max. Negotiated Rate |
$789.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$773.22
|
| Rate for Payer: Aetna of WY Medicare |
$504.96
|
| Rate for Payer: Altius Commercial |
$757.44
|
| Rate for Payer: Beech Street Commercial |
$773.22
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$765.33
|
| Rate for Payer: Cash Price |
$552.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$765.33
|
| Rate for Payer: Cigna of WY Commercial |
$773.22
|
| Rate for Payer: Entrust Commercial |
$749.55
|
| Rate for Payer: First Choice Health Commercial |
$749.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$749.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$481.29
|
| Rate for Payer: HealthUtah PPO |
$789.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$765.33
|
| Rate for Payer: Multiplan Medicare/VA |
$457.23
|
| Rate for Payer: One Health Plan of WY PPO |
$773.22
|
| Rate for Payer: PacificSource Commercial |
$710.10
|
| Rate for Payer: PHCS PPO |
$773.22
|
| Rate for Payer: Three Rivers PPO |
$591.75
|
| Rate for Payer: TriWest Veterans Administration |
$481.29
|
| Rate for Payer: United Healthcare Commercial |
$753.50
|
| Rate for Payer: United Healthcare Medicare |
$481.29
|
| Rate for Payer: WINHealth Partners Commercial |
$749.55
|
| Rate for Payer: Wise Provider Network Commercial |
$749.55
|
|
|
DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE [41764]
|
Facility
|
OP
|
$789.00
|
|
|
Service Code
|
HCPCS J0881
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$427.24 |
| Max. Negotiated Rate |
$789.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$773.22
|
| Rate for Payer: Aetna of WY Medicare |
$520.74
|
| Rate for Payer: Altius Commercial |
$757.44
|
| Rate for Payer: Beech Street Commercial |
$773.22
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$765.33
|
| Rate for Payer: Cash Price |
$552.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$765.33
|
| Rate for Payer: Cigna of WY Commercial |
$773.22
|
| Rate for Payer: Entrust Commercial |
$749.55
|
| Rate for Payer: First Choice Health Commercial |
$749.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$749.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$449.73
|
| Rate for Payer: HealthUtah PPO |
$789.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$765.33
|
| Rate for Payer: Multiplan Medicare/VA |
$427.24
|
| Rate for Payer: One Health Plan of WY PPO |
$773.22
|
| Rate for Payer: PacificSource Commercial |
$710.10
|
| Rate for Payer: PHCS PPO |
$773.22
|
| Rate for Payer: Three Rivers PPO |
$591.75
|
| Rate for Payer: TriWest Veterans Administration |
$449.73
|
| Rate for Payer: United Healthcare Commercial |
$753.50
|
| Rate for Payer: United Healthcare Medicare |
$449.73
|
| Rate for Payer: WINHealth Partners Commercial |
$773.22
|
| Rate for Payer: Wise Provider Network Commercial |
$749.55
|
|
|
DARCO TAS SPLINT
|
Facility
|
IP
|
$105.00
|
|
| Hospital Charge Code |
2200248
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$60.85 |
| Max. Negotiated Rate |
$105.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$102.90
|
| Rate for Payer: Aetna of WY Medicare |
$67.20
|
| Rate for Payer: Altius Commercial |
$100.80
|
| Rate for Payer: Beech Street Commercial |
$102.90
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$101.85
|
| Rate for Payer: Cash Price |
$73.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$101.85
|
| Rate for Payer: Cigna of WY Commercial |
$102.90
|
| Rate for Payer: Entrust Commercial |
$99.75
|
| Rate for Payer: First Choice Health Commercial |
$99.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$99.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$64.05
|
| Rate for Payer: HealthUtah PPO |
$105.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$101.85
|
| Rate for Payer: Multiplan Medicare/VA |
$60.85
|
| Rate for Payer: One Health Plan of WY PPO |
$102.90
|
| Rate for Payer: PacificSource Commercial |
$94.50
|
| Rate for Payer: PHCS PPO |
$102.90
|
| Rate for Payer: Three Rivers PPO |
$78.75
|
| Rate for Payer: TriWest Veterans Administration |
$64.05
|
| Rate for Payer: United Healthcare Commercial |
$100.28
|
| Rate for Payer: United Healthcare Medicare |
$64.05
|
| Rate for Payer: WINHealth Partners Commercial |
$99.75
|
| Rate for Payer: Wise Provider Network Commercial |
$99.75
|
|
|
DARCO TAS SPLINT
|
Facility
|
OP
|
$105.00
|
|
| Hospital Charge Code |
2200248
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$56.86 |
| Max. Negotiated Rate |
$105.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$102.90
|
| Rate for Payer: Aetna of WY Medicare |
$69.30
|
| Rate for Payer: Altius Commercial |
$100.80
|
| Rate for Payer: Beech Street Commercial |
$102.90
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$101.85
|
| Rate for Payer: Cash Price |
$73.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$101.85
|
| Rate for Payer: Cigna of WY Commercial |
$102.90
|
| Rate for Payer: Entrust Commercial |
$99.75
|
| Rate for Payer: First Choice Health Commercial |
$99.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$99.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$59.85
|
| Rate for Payer: HealthUtah PPO |
$105.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$101.85
|
| Rate for Payer: Multiplan Medicare/VA |
$56.86
|
| Rate for Payer: One Health Plan of WY PPO |
$102.90
|
| Rate for Payer: PacificSource Commercial |
$94.50
|
| Rate for Payer: PHCS PPO |
$102.90
|
| Rate for Payer: Three Rivers PPO |
$78.75
|
| Rate for Payer: TriWest Veterans Administration |
$59.85
|
| Rate for Payer: United Healthcare Commercial |
$100.28
|
| Rate for Payer: United Healthcare Medicare |
$59.85
|
| Rate for Payer: WINHealth Partners Commercial |
$102.90
|
| Rate for Payer: Wise Provider Network Commercial |
$99.75
|
|
|
DAVINCI 12-8MM REDUCER
|
Facility
|
IP
|
$87.50
|
|
| Hospital Charge Code |
2850006
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$50.71 |
| Max. Negotiated Rate |
$87.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$85.75
|
| Rate for Payer: Aetna of WY Medicare |
$56.00
|
| Rate for Payer: Altius Commercial |
$84.00
|
| Rate for Payer: Beech Street Commercial |
$85.75
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$84.88
|
| Rate for Payer: Cash Price |
$61.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$84.88
|
| Rate for Payer: Cigna of WY Commercial |
$85.75
|
| Rate for Payer: Entrust Commercial |
$83.12
|
| Rate for Payer: First Choice Health Commercial |
$83.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$83.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$53.38
|
| Rate for Payer: HealthUtah PPO |
$87.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$84.88
|
| Rate for Payer: Multiplan Medicare/VA |
$50.71
|
| Rate for Payer: One Health Plan of WY PPO |
$85.75
|
| Rate for Payer: PacificSource Commercial |
$78.75
|
| Rate for Payer: PHCS PPO |
$85.75
|
| Rate for Payer: Three Rivers PPO |
$65.62
|
| Rate for Payer: TriWest Veterans Administration |
$53.38
|
| Rate for Payer: United Healthcare Commercial |
$83.56
|
| Rate for Payer: United Healthcare Medicare |
$53.38
|
| Rate for Payer: WINHealth Partners Commercial |
$83.12
|
| Rate for Payer: Wise Provider Network Commercial |
$83.12
|
|
|
DAVINCI 12-8MM REDUCER
|
Facility
|
OP
|
$87.50
|
|
| Hospital Charge Code |
2850006
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$47.38 |
| Max. Negotiated Rate |
$87.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$85.75
|
| Rate for Payer: Aetna of WY Medicare |
$57.75
|
| Rate for Payer: Altius Commercial |
$84.00
|
| Rate for Payer: Beech Street Commercial |
$85.75
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$84.88
|
| Rate for Payer: Cash Price |
$61.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$84.88
|
| Rate for Payer: Cigna of WY Commercial |
$85.75
|
| Rate for Payer: Entrust Commercial |
$83.12
|
| Rate for Payer: First Choice Health Commercial |
$83.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$83.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$49.88
|
| Rate for Payer: HealthUtah PPO |
$87.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$84.88
|
| Rate for Payer: Multiplan Medicare/VA |
$47.38
|
| Rate for Payer: One Health Plan of WY PPO |
$85.75
|
| Rate for Payer: PacificSource Commercial |
$78.75
|
| Rate for Payer: PHCS PPO |
$85.75
|
| Rate for Payer: Three Rivers PPO |
$65.62
|
| Rate for Payer: TriWest Veterans Administration |
$49.88
|
| Rate for Payer: United Healthcare Commercial |
$83.56
|
| Rate for Payer: United Healthcare Medicare |
$49.88
|
| Rate for Payer: WINHealth Partners Commercial |
$85.75
|
| Rate for Payer: Wise Provider Network Commercial |
$83.12
|
|
|
DAVINCI 12MM & STAPLER SEAL
|
Facility
|
IP
|
$49.00
|
|
| Hospital Charge Code |
2850010
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$28.40 |
| Max. Negotiated Rate |
$49.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$48.02
|
| Rate for Payer: Aetna of WY Medicare |
$31.36
|
| Rate for Payer: Altius Commercial |
$47.04
|
| Rate for Payer: Beech Street Commercial |
$48.02
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$47.53
|
| Rate for Payer: Cash Price |
$34.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$47.53
|
| Rate for Payer: Cigna of WY Commercial |
$48.02
|
| Rate for Payer: Entrust Commercial |
$46.55
|
| Rate for Payer: First Choice Health Commercial |
$46.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$46.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$29.89
|
| Rate for Payer: HealthUtah PPO |
$49.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$47.53
|
| Rate for Payer: Multiplan Medicare/VA |
$28.40
|
| Rate for Payer: One Health Plan of WY PPO |
$48.02
|
| Rate for Payer: PacificSource Commercial |
$44.10
|
| Rate for Payer: PHCS PPO |
$48.02
|
| Rate for Payer: Three Rivers PPO |
$36.75
|
| Rate for Payer: TriWest Veterans Administration |
$29.89
|
| Rate for Payer: United Healthcare Commercial |
$46.80
|
| Rate for Payer: United Healthcare Medicare |
$29.89
|
| Rate for Payer: WINHealth Partners Commercial |
$46.55
|
| Rate for Payer: Wise Provider Network Commercial |
$46.55
|
|
|
DAVINCI 12MM & STAPLER SEAL
|
Facility
|
OP
|
$49.00
|
|
| Hospital Charge Code |
2850010
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$26.53 |
| Max. Negotiated Rate |
$49.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$48.02
|
| Rate for Payer: Aetna of WY Medicare |
$32.34
|
| Rate for Payer: Altius Commercial |
$47.04
|
| Rate for Payer: Beech Street Commercial |
$48.02
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$47.53
|
| Rate for Payer: Cash Price |
$34.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$47.53
|
| Rate for Payer: Cigna of WY Commercial |
$48.02
|
| Rate for Payer: Entrust Commercial |
$46.55
|
| Rate for Payer: First Choice Health Commercial |
$46.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$46.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$27.93
|
| Rate for Payer: HealthUtah PPO |
$49.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$47.53
|
| Rate for Payer: Multiplan Medicare/VA |
$26.53
|
| Rate for Payer: One Health Plan of WY PPO |
$48.02
|
| Rate for Payer: PacificSource Commercial |
$44.10
|
| Rate for Payer: PHCS PPO |
$48.02
|
| Rate for Payer: Three Rivers PPO |
$36.75
|
| Rate for Payer: TriWest Veterans Administration |
$27.93
|
| Rate for Payer: United Healthcare Commercial |
$46.80
|
| Rate for Payer: United Healthcare Medicare |
$27.93
|
| Rate for Payer: WINHealth Partners Commercial |
$48.02
|
| Rate for Payer: Wise Provider Network Commercial |
$46.55
|
|
|
DAVINCI 5-8MM CANNULA SEAL
|
Facility
|
OP
|
$66.15
|
|
| Hospital Charge Code |
2850005
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$35.82 |
| Max. Negotiated Rate |
$66.15 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$64.83
|
| Rate for Payer: Aetna of WY Medicare |
$43.66
|
| Rate for Payer: Altius Commercial |
$63.50
|
| Rate for Payer: Beech Street Commercial |
$64.83
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$64.17
|
| Rate for Payer: Cash Price |
$46.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$64.17
|
| Rate for Payer: Cigna of WY Commercial |
$64.83
|
| Rate for Payer: Entrust Commercial |
$62.84
|
| Rate for Payer: First Choice Health Commercial |
$62.84
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$62.84
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$37.71
|
| Rate for Payer: HealthUtah PPO |
$66.15
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$64.17
|
| Rate for Payer: Multiplan Medicare/VA |
$35.82
|
| Rate for Payer: One Health Plan of WY PPO |
$64.83
|
| Rate for Payer: PacificSource Commercial |
$59.54
|
| Rate for Payer: PHCS PPO |
$64.83
|
| Rate for Payer: Three Rivers PPO |
$49.61
|
| Rate for Payer: TriWest Veterans Administration |
$37.71
|
| Rate for Payer: United Healthcare Commercial |
$63.17
|
| Rate for Payer: United Healthcare Medicare |
$37.71
|
| Rate for Payer: WINHealth Partners Commercial |
$64.83
|
| Rate for Payer: Wise Provider Network Commercial |
$62.84
|
|
|
DAVINCI 5-8MM CANNULA SEAL
|
Facility
|
IP
|
$66.15
|
|
| Hospital Charge Code |
2850005
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$38.33 |
| Max. Negotiated Rate |
$66.15 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$64.83
|
| Rate for Payer: Aetna of WY Medicare |
$42.34
|
| Rate for Payer: Altius Commercial |
$63.50
|
| Rate for Payer: Beech Street Commercial |
$64.83
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$64.17
|
| Rate for Payer: Cash Price |
$46.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$64.17
|
| Rate for Payer: Cigna of WY Commercial |
$64.83
|
| Rate for Payer: Entrust Commercial |
$62.84
|
| Rate for Payer: First Choice Health Commercial |
$62.84
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$62.84
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$40.35
|
| Rate for Payer: HealthUtah PPO |
$66.15
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$64.17
|
| Rate for Payer: Multiplan Medicare/VA |
$38.33
|
| Rate for Payer: One Health Plan of WY PPO |
$64.83
|
| Rate for Payer: PacificSource Commercial |
$59.54
|
| Rate for Payer: PHCS PPO |
$64.83
|
| Rate for Payer: Three Rivers PPO |
$49.61
|
| Rate for Payer: TriWest Veterans Administration |
$40.35
|
| Rate for Payer: United Healthcare Commercial |
$63.17
|
| Rate for Payer: United Healthcare Medicare |
$40.35
|
| Rate for Payer: WINHealth Partners Commercial |
$62.84
|
| Rate for Payer: Wise Provider Network Commercial |
$62.84
|
|
|
DAVINCI 8MM BLADELES OBTURATOR
|
Facility
|
IP
|
$87.50
|
|
| Hospital Charge Code |
2850014
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$50.71 |
| Max. Negotiated Rate |
$87.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$85.75
|
| Rate for Payer: Aetna of WY Medicare |
$56.00
|
| Rate for Payer: Altius Commercial |
$84.00
|
| Rate for Payer: Beech Street Commercial |
$85.75
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$84.88
|
| Rate for Payer: Cash Price |
$61.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$84.88
|
| Rate for Payer: Cigna of WY Commercial |
$85.75
|
| Rate for Payer: Entrust Commercial |
$83.12
|
| Rate for Payer: First Choice Health Commercial |
$83.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$83.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$53.38
|
| Rate for Payer: HealthUtah PPO |
$87.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$84.88
|
| Rate for Payer: Multiplan Medicare/VA |
$50.71
|
| Rate for Payer: One Health Plan of WY PPO |
$85.75
|
| Rate for Payer: PacificSource Commercial |
$78.75
|
| Rate for Payer: PHCS PPO |
$85.75
|
| Rate for Payer: Three Rivers PPO |
$65.62
|
| Rate for Payer: TriWest Veterans Administration |
$53.38
|
| Rate for Payer: United Healthcare Commercial |
$83.56
|
| Rate for Payer: United Healthcare Medicare |
$53.38
|
| Rate for Payer: WINHealth Partners Commercial |
$83.12
|
| Rate for Payer: Wise Provider Network Commercial |
$83.12
|
|
|
DAVINCI 8MM BLADELES OBTURATOR
|
Facility
|
OP
|
$87.50
|
|
| Hospital Charge Code |
2850014
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$47.38 |
| Max. Negotiated Rate |
$87.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$85.75
|
| Rate for Payer: Aetna of WY Medicare |
$57.75
|
| Rate for Payer: Altius Commercial |
$84.00
|
| Rate for Payer: Beech Street Commercial |
$85.75
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$84.88
|
| Rate for Payer: Cash Price |
$61.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$84.88
|
| Rate for Payer: Cigna of WY Commercial |
$85.75
|
| Rate for Payer: Entrust Commercial |
$83.12
|
| Rate for Payer: First Choice Health Commercial |
$83.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$83.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$49.88
|
| Rate for Payer: HealthUtah PPO |
$87.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$84.88
|
| Rate for Payer: Multiplan Medicare/VA |
$47.38
|
| Rate for Payer: One Health Plan of WY PPO |
$85.75
|
| Rate for Payer: PacificSource Commercial |
$78.75
|
| Rate for Payer: PHCS PPO |
$85.75
|
| Rate for Payer: Three Rivers PPO |
$65.62
|
| Rate for Payer: TriWest Veterans Administration |
$49.88
|
| Rate for Payer: United Healthcare Commercial |
$83.56
|
| Rate for Payer: United Healthcare Medicare |
$49.88
|
| Rate for Payer: WINHealth Partners Commercial |
$85.75
|
| Rate for Payer: Wise Provider Network Commercial |
$83.12
|
|
|
DAVINCI DRAPE ARM 4 EXTENSION
|
Facility
|
IP
|
$63.00
|
|
| Hospital Charge Code |
2850015
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$36.51 |
| Max. Negotiated Rate |
$63.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$61.74
|
| Rate for Payer: Aetna of WY Medicare |
$40.32
|
| Rate for Payer: Altius Commercial |
$60.48
|
| Rate for Payer: Beech Street Commercial |
$61.74
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$61.11
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$61.11
|
| Rate for Payer: Cigna of WY Commercial |
$61.74
|
| Rate for Payer: Entrust Commercial |
$59.85
|
| Rate for Payer: First Choice Health Commercial |
$59.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$59.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$38.43
|
| Rate for Payer: HealthUtah PPO |
$63.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$61.11
|
| Rate for Payer: Multiplan Medicare/VA |
$36.51
|
| Rate for Payer: One Health Plan of WY PPO |
$61.74
|
| Rate for Payer: PacificSource Commercial |
$56.70
|
| Rate for Payer: PHCS PPO |
$61.74
|
| Rate for Payer: Three Rivers PPO |
$47.25
|
| Rate for Payer: TriWest Veterans Administration |
$38.43
|
| Rate for Payer: United Healthcare Commercial |
$60.16
|
| Rate for Payer: United Healthcare Medicare |
$38.43
|
| Rate for Payer: WINHealth Partners Commercial |
$59.85
|
| Rate for Payer: Wise Provider Network Commercial |
$59.85
|
|
|
DAVINCI DRAPE ARM 4 EXTENSION
|
Facility
|
OP
|
$63.00
|
|
| Hospital Charge Code |
2850015
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$34.11 |
| Max. Negotiated Rate |
$63.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$61.74
|
| Rate for Payer: Aetna of WY Medicare |
$41.58
|
| Rate for Payer: Altius Commercial |
$60.48
|
| Rate for Payer: Beech Street Commercial |
$61.74
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$61.11
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$61.11
|
| Rate for Payer: Cigna of WY Commercial |
$61.74
|
| Rate for Payer: Entrust Commercial |
$59.85
|
| Rate for Payer: First Choice Health Commercial |
$59.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$59.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$35.91
|
| Rate for Payer: HealthUtah PPO |
$63.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$61.11
|
| Rate for Payer: Multiplan Medicare/VA |
$34.11
|
| Rate for Payer: One Health Plan of WY PPO |
$61.74
|
| Rate for Payer: PacificSource Commercial |
$56.70
|
| Rate for Payer: PHCS PPO |
$61.74
|
| Rate for Payer: Three Rivers PPO |
$47.25
|
| Rate for Payer: TriWest Veterans Administration |
$35.91
|
| Rate for Payer: United Healthcare Commercial |
$60.16
|
| Rate for Payer: United Healthcare Medicare |
$35.91
|
| Rate for Payer: WINHealth Partners Commercial |
$61.74
|
| Rate for Payer: Wise Provider Network Commercial |
$59.85
|
|
|
DAVINCI DRAPE COLUMN
|
Facility
|
OP
|
$43.75
|
|
| Hospital Charge Code |
2850012
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$23.69 |
| Max. Negotiated Rate |
$43.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$42.88
|
| Rate for Payer: Aetna of WY Medicare |
$28.88
|
| Rate for Payer: Altius Commercial |
$42.00
|
| Rate for Payer: Beech Street Commercial |
$42.88
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$42.44
|
| Rate for Payer: Cash Price |
$30.62
|
| Rate for Payer: ChoiceCare Network Commercial |
$42.44
|
| Rate for Payer: Cigna of WY Commercial |
$42.88
|
| Rate for Payer: Entrust Commercial |
$41.56
|
| Rate for Payer: First Choice Health Commercial |
$41.56
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$41.56
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$24.94
|
| Rate for Payer: HealthUtah PPO |
$43.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$42.44
|
| Rate for Payer: Multiplan Medicare/VA |
$23.69
|
| Rate for Payer: One Health Plan of WY PPO |
$42.88
|
| Rate for Payer: PacificSource Commercial |
$39.38
|
| Rate for Payer: PHCS PPO |
$42.88
|
| Rate for Payer: Three Rivers PPO |
$32.81
|
| Rate for Payer: TriWest Veterans Administration |
$24.94
|
| Rate for Payer: United Healthcare Commercial |
$41.78
|
| Rate for Payer: United Healthcare Medicare |
$24.94
|
| Rate for Payer: WINHealth Partners Commercial |
$42.88
|
| Rate for Payer: Wise Provider Network Commercial |
$41.56
|
|
|
DAVINCI DRAPE COLUMN
|
Facility
|
IP
|
$43.75
|
|
| Hospital Charge Code |
2850012
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$25.35 |
| Max. Negotiated Rate |
$43.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$42.88
|
| Rate for Payer: Aetna of WY Medicare |
$28.00
|
| Rate for Payer: Altius Commercial |
$42.00
|
| Rate for Payer: Beech Street Commercial |
$42.88
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$42.44
|
| Rate for Payer: Cash Price |
$30.62
|
| Rate for Payer: ChoiceCare Network Commercial |
$42.44
|
| Rate for Payer: Cigna of WY Commercial |
$42.88
|
| Rate for Payer: Entrust Commercial |
$41.56
|
| Rate for Payer: First Choice Health Commercial |
$41.56
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$41.56
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$26.69
|
| Rate for Payer: HealthUtah PPO |
$43.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$42.44
|
| Rate for Payer: Multiplan Medicare/VA |
$25.35
|
| Rate for Payer: One Health Plan of WY PPO |
$42.88
|
| Rate for Payer: PacificSource Commercial |
$39.38
|
| Rate for Payer: PHCS PPO |
$42.88
|
| Rate for Payer: Three Rivers PPO |
$32.81
|
| Rate for Payer: TriWest Veterans Administration |
$26.69
|
| Rate for Payer: United Healthcare Commercial |
$41.78
|
| Rate for Payer: United Healthcare Medicare |
$26.69
|
| Rate for Payer: WINHealth Partners Commercial |
$41.56
|
| Rate for Payer: Wise Provider Network Commercial |
$41.56
|
|
|
DAVINCI DRAPE INSTRUMENT ARM
|
Facility
|
IP
|
$191.10
|
|
| Hospital Charge Code |
2850011
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$110.74 |
| Max. Negotiated Rate |
$191.10 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$187.28
|
| Rate for Payer: Aetna of WY Medicare |
$122.30
|
| Rate for Payer: Altius Commercial |
$183.46
|
| Rate for Payer: Beech Street Commercial |
$187.28
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$185.37
|
| Rate for Payer: Cash Price |
$133.77
|
| Rate for Payer: ChoiceCare Network Commercial |
$185.37
|
| Rate for Payer: Cigna of WY Commercial |
$187.28
|
| Rate for Payer: Entrust Commercial |
$181.54
|
| Rate for Payer: First Choice Health Commercial |
$181.54
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$181.54
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$116.57
|
| Rate for Payer: HealthUtah PPO |
$191.10
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$185.37
|
| Rate for Payer: Multiplan Medicare/VA |
$110.74
|
| Rate for Payer: One Health Plan of WY PPO |
$187.28
|
| Rate for Payer: PacificSource Commercial |
$171.99
|
| Rate for Payer: PHCS PPO |
$187.28
|
| Rate for Payer: Three Rivers PPO |
$143.32
|
| Rate for Payer: TriWest Veterans Administration |
$116.57
|
| Rate for Payer: United Healthcare Commercial |
$182.50
|
| Rate for Payer: United Healthcare Medicare |
$116.57
|
| Rate for Payer: WINHealth Partners Commercial |
$181.54
|
| Rate for Payer: Wise Provider Network Commercial |
$181.54
|
|
