|
DECOMPRESSION FASCT F/ARM W/BRACH ART EXPL
|
Professional
|
Both
|
$3,519.00
|
|
|
Service Code
|
HCPCS 24495 80
|
| Min. Negotiated Rate |
$763.76 |
| Max. Negotiated Rate |
$3,519.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,448.62
|
| Rate for Payer: Beech Street Commercial |
$3,343.05
|
| Rate for Payer: Cash Price |
$2,463.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,413.43
|
| Rate for Payer: Cigna of WY Commercial |
$3,448.62
|
| Rate for Payer: First Choice Health Commercial |
$3,167.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,343.05
|
| Rate for Payer: HealthUtah PPO |
$3,519.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,413.43
|
| Rate for Payer: One Health Plan of WY PPO |
$3,448.62
|
| Rate for Payer: PacificSource Commercial |
$3,167.10
|
| Rate for Payer: PHCS PPO |
$3,343.05
|
| Rate for Payer: Three Rivers PPO |
$2,639.25
|
| Rate for Payer: United Healthcare Commercial |
$3,343.05
|
| Rate for Payer: WINHealth Partners Commercial |
$2,991.15
|
|
|
DECOMPRESSION FASCT F/ARM W/BRACH ART EXPL
|
Professional
|
Both
|
$3,519.00
|
|
|
Service Code
|
HCPCS 24495
|
| Min. Negotiated Rate |
$763.76 |
| Max. Negotiated Rate |
$3,519.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,448.62
|
| Rate for Payer: Aetna of WY Medicare |
$898.54
|
| Rate for Payer: Beech Street Commercial |
$3,343.05
|
| Rate for Payer: Cash Price |
$2,463.30
|
| Rate for Payer: Cash Price |
$2,463.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,413.43
|
| Rate for Payer: Cigna of WY Commercial |
$3,448.62
|
| Rate for Payer: First Choice Health Commercial |
$3,167.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,343.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$898.54
|
| Rate for Payer: HealthUtah PPO |
$3,519.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,413.43
|
| Rate for Payer: Multiplan Medicare/VA |
$763.76
|
| Rate for Payer: One Health Plan of WY PPO |
$3,448.62
|
| Rate for Payer: PacificSource Commercial |
$3,167.10
|
| Rate for Payer: PHCS PPO |
$3,343.05
|
| Rate for Payer: Three Rivers PPO |
$2,639.25
|
| Rate for Payer: TriWest Veterans Administration |
$898.54
|
| Rate for Payer: United Healthcare Commercial |
$3,343.05
|
| Rate for Payer: WINHealth Partners Commercial |
$2,991.15
|
|
|
DECOMPRESSION UNSPECIFIED NERVE
|
Professional
|
Both
|
$1,585.00
|
|
|
Service Code
|
HCPCS 64722 80
|
| Min. Negotiated Rate |
$306.81 |
| Max. Negotiated Rate |
$1,585.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,553.30
|
| Rate for Payer: Beech Street Commercial |
$1,505.75
|
| Rate for Payer: Cash Price |
$1,109.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,537.45
|
| Rate for Payer: Cigna of WY Commercial |
$1,553.30
|
| Rate for Payer: First Choice Health Commercial |
$1,426.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,505.75
|
| Rate for Payer: HealthUtah PPO |
$1,585.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,537.45
|
| Rate for Payer: One Health Plan of WY PPO |
$1,553.30
|
| Rate for Payer: PacificSource Commercial |
$1,426.50
|
| Rate for Payer: PHCS PPO |
$1,505.75
|
| Rate for Payer: Three Rivers PPO |
$1,188.75
|
| Rate for Payer: United Healthcare Commercial |
$1,505.75
|
| Rate for Payer: WINHealth Partners Commercial |
$1,347.25
|
|
|
DECOMPRESSION UNSPECIFIED NERVE
|
Professional
|
Both
|
$1,585.00
|
|
|
Service Code
|
HCPCS 64722 AS
|
| Min. Negotiated Rate |
$306.81 |
| Max. Negotiated Rate |
$1,585.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,553.30
|
| Rate for Payer: Beech Street Commercial |
$1,505.75
|
| Rate for Payer: Cash Price |
$1,109.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,537.45
|
| Rate for Payer: Cigna of WY Commercial |
$1,553.30
|
| Rate for Payer: First Choice Health Commercial |
$1,426.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,505.75
|
| Rate for Payer: HealthUtah PPO |
$1,585.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,537.45
|
| Rate for Payer: One Health Plan of WY PPO |
$1,553.30
|
| Rate for Payer: PacificSource Commercial |
$1,426.50
|
| Rate for Payer: PHCS PPO |
$1,505.75
|
| Rate for Payer: Three Rivers PPO |
$1,188.75
|
| Rate for Payer: United Healthcare Commercial |
$1,505.75
|
| Rate for Payer: WINHealth Partners Commercial |
$1,347.25
|
|
|
DECOMPRESSION UNSPECIFIED NERVE
|
Professional
|
Both
|
$1,585.00
|
|
|
Service Code
|
HCPCS 64722
|
| Min. Negotiated Rate |
$306.81 |
| Max. Negotiated Rate |
$1,585.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,553.30
|
| Rate for Payer: Aetna of WY Medicare |
$360.95
|
| Rate for Payer: Beech Street Commercial |
$1,505.75
|
| Rate for Payer: Cash Price |
$1,109.50
|
| Rate for Payer: Cash Price |
$1,109.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,537.45
|
| Rate for Payer: Cigna of WY Commercial |
$1,553.30
|
| Rate for Payer: First Choice Health Commercial |
$1,426.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,505.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$360.95
|
| Rate for Payer: HealthUtah PPO |
$1,585.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,537.45
|
| Rate for Payer: Multiplan Medicare/VA |
$306.81
|
| Rate for Payer: One Health Plan of WY PPO |
$1,553.30
|
| Rate for Payer: PacificSource Commercial |
$1,426.50
|
| Rate for Payer: PHCS PPO |
$1,505.75
|
| Rate for Payer: Three Rivers PPO |
$1,188.75
|
| Rate for Payer: TriWest Veterans Administration |
$360.95
|
| Rate for Payer: United Healthcare Commercial |
$1,505.75
|
| Rate for Payer: WINHealth Partners Commercial |
$1,347.25
|
|
|
DECOMPRESSIVE FASCIOTOMY HAND
|
Professional
|
Both
|
$2,497.00
|
|
|
Service Code
|
HCPCS 26037
|
| Min. Negotiated Rate |
$466.10 |
| Max. Negotiated Rate |
$2,497.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,447.06
|
| Rate for Payer: Aetna of WY Medicare |
$548.35
|
| Rate for Payer: Beech Street Commercial |
$2,372.15
|
| Rate for Payer: Cash Price |
$1,747.90
|
| Rate for Payer: Cash Price |
$1,747.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,422.09
|
| Rate for Payer: Cigna of WY Commercial |
$2,447.06
|
| Rate for Payer: First Choice Health Commercial |
$2,247.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,372.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$548.35
|
| Rate for Payer: HealthUtah PPO |
$2,497.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,422.09
|
| Rate for Payer: Multiplan Medicare/VA |
$466.10
|
| Rate for Payer: One Health Plan of WY PPO |
$2,447.06
|
| Rate for Payer: PacificSource Commercial |
$2,247.30
|
| Rate for Payer: PHCS PPO |
$2,372.15
|
| Rate for Payer: Three Rivers PPO |
$1,872.75
|
| Rate for Payer: TriWest Veterans Administration |
$548.35
|
| Rate for Payer: United Healthcare Commercial |
$2,372.15
|
| Rate for Payer: WINHealth Partners Commercial |
$2,122.45
|
|
|
DELIVERY/BIRTHING ROOM RESUSCITATION
|
Professional
|
Both
|
$499.00
|
|
|
Service Code
|
HCPCS 99465
|
| Min. Negotiated Rate |
$115.72 |
| Max. Negotiated Rate |
$499.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$489.02
|
| Rate for Payer: Aetna of WY Medicare |
$136.14
|
| Rate for Payer: Beech Street Commercial |
$474.05
|
| Rate for Payer: Cash Price |
$349.30
|
| Rate for Payer: Cash Price |
$349.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$484.03
|
| Rate for Payer: Cigna of WY Commercial |
$489.02
|
| Rate for Payer: First Choice Health Commercial |
$449.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$474.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$136.14
|
| Rate for Payer: HealthUtah PPO |
$499.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$484.03
|
| Rate for Payer: Multiplan Medicare/VA |
$115.72
|
| Rate for Payer: One Health Plan of WY PPO |
$489.02
|
| Rate for Payer: PacificSource Commercial |
$449.10
|
| Rate for Payer: PHCS PPO |
$474.05
|
| Rate for Payer: Three Rivers PPO |
$374.25
|
| Rate for Payer: TriWest Veterans Administration |
$136.14
|
| Rate for Payer: United Healthcare Commercial |
$474.05
|
| Rate for Payer: WINHealth Partners Commercial |
$474.05
|
|
|
DELIVERY PLACENTA SEPARATE PROCEDURE
|
Professional
|
Both
|
$235.00
|
|
|
Service Code
|
HCPCS 59414
|
| Min. Negotiated Rate |
$72.15 |
| Max. Negotiated Rate |
$235.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$230.30
|
| Rate for Payer: Aetna of WY Medicare |
$84.88
|
| Rate for Payer: Beech Street Commercial |
$223.25
|
| Rate for Payer: Cash Price |
$164.50
|
| Rate for Payer: Cash Price |
$164.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$227.95
|
| Rate for Payer: Cigna of WY Commercial |
$230.30
|
| Rate for Payer: First Choice Health Commercial |
$211.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$223.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$84.88
|
| Rate for Payer: HealthUtah PPO |
$235.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$227.95
|
| Rate for Payer: Multiplan Medicare/VA |
$72.15
|
| Rate for Payer: One Health Plan of WY PPO |
$230.30
|
| Rate for Payer: PacificSource Commercial |
$211.50
|
| Rate for Payer: PHCS PPO |
$223.25
|
| Rate for Payer: Three Rivers PPO |
$176.25
|
| Rate for Payer: TriWest Veterans Administration |
$84.88
|
| Rate for Payer: United Healthcare Commercial |
$223.25
|
| Rate for Payer: WINHealth Partners Commercial |
$199.75
|
|
|
DELTA ADHS FELT PADDING 23X29
|
Facility
|
OP
|
$119.21
|
|
| Hospital Charge Code |
2250155
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$64.55 |
| Max. Negotiated Rate |
$119.21 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$116.83
|
| Rate for Payer: Aetna of WY Medicare |
$78.68
|
| Rate for Payer: Altius Commercial |
$114.44
|
| Rate for Payer: Beech Street Commercial |
$116.83
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$115.63
|
| Rate for Payer: Cash Price |
$83.45
|
| Rate for Payer: ChoiceCare Network Commercial |
$115.63
|
| Rate for Payer: Cigna of WY Commercial |
$116.83
|
| Rate for Payer: Entrust Commercial |
$113.25
|
| Rate for Payer: First Choice Health Commercial |
$113.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$113.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$67.95
|
| Rate for Payer: HealthUtah PPO |
$119.21
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$115.63
|
| Rate for Payer: Multiplan Medicare/VA |
$64.55
|
| Rate for Payer: One Health Plan of WY PPO |
$116.83
|
| Rate for Payer: PacificSource Commercial |
$107.29
|
| Rate for Payer: PHCS PPO |
$116.83
|
| Rate for Payer: Three Rivers PPO |
$89.41
|
| Rate for Payer: TriWest Veterans Administration |
$67.95
|
| Rate for Payer: United Healthcare Commercial |
$113.85
|
| Rate for Payer: United Healthcare Medicare |
$67.95
|
| Rate for Payer: WINHealth Partners Commercial |
$116.83
|
| Rate for Payer: Wise Provider Network Commercial |
$113.25
|
|
|
DELTA ADHS FELT PADDING 23X29
|
Facility
|
IP
|
$119.21
|
|
| Hospital Charge Code |
2250155
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$69.08 |
| Max. Negotiated Rate |
$119.21 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$116.83
|
| Rate for Payer: Aetna of WY Medicare |
$76.29
|
| Rate for Payer: Altius Commercial |
$114.44
|
| Rate for Payer: Beech Street Commercial |
$116.83
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$115.63
|
| Rate for Payer: Cash Price |
$83.45
|
| Rate for Payer: ChoiceCare Network Commercial |
$115.63
|
| Rate for Payer: Cigna of WY Commercial |
$116.83
|
| Rate for Payer: Entrust Commercial |
$113.25
|
| Rate for Payer: First Choice Health Commercial |
$113.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$113.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$72.72
|
| Rate for Payer: HealthUtah PPO |
$119.21
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$115.63
|
| Rate for Payer: Multiplan Medicare/VA |
$69.08
|
| Rate for Payer: One Health Plan of WY PPO |
$116.83
|
| Rate for Payer: PacificSource Commercial |
$107.29
|
| Rate for Payer: PHCS PPO |
$116.83
|
| Rate for Payer: Three Rivers PPO |
$89.41
|
| Rate for Payer: TriWest Veterans Administration |
$72.72
|
| Rate for Payer: United Healthcare Commercial |
$113.85
|
| Rate for Payer: United Healthcare Medicare |
$72.72
|
| Rate for Payer: WINHealth Partners Commercial |
$113.25
|
| Rate for Payer: Wise Provider Network Commercial |
$113.25
|
|
|
DELTA TERRY ADHES HOOK 1"X10YD
|
Facility
|
OP
|
$44.91
|
|
| Hospital Charge Code |
2250144
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$24.32 |
| Max. Negotiated Rate |
$44.91 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$44.01
|
| Rate for Payer: Aetna of WY Medicare |
$29.64
|
| Rate for Payer: Altius Commercial |
$43.11
|
| Rate for Payer: Beech Street Commercial |
$44.01
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$43.56
|
| Rate for Payer: Cash Price |
$31.43
|
| Rate for Payer: ChoiceCare Network Commercial |
$43.56
|
| Rate for Payer: Cigna of WY Commercial |
$44.01
|
| Rate for Payer: Entrust Commercial |
$42.66
|
| Rate for Payer: First Choice Health Commercial |
$42.66
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$42.66
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$25.60
|
| Rate for Payer: HealthUtah PPO |
$44.91
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$43.56
|
| Rate for Payer: Multiplan Medicare/VA |
$24.32
|
| Rate for Payer: One Health Plan of WY PPO |
$44.01
|
| Rate for Payer: PacificSource Commercial |
$40.42
|
| Rate for Payer: PHCS PPO |
$44.01
|
| Rate for Payer: Three Rivers PPO |
$33.68
|
| Rate for Payer: TriWest Veterans Administration |
$25.60
|
| Rate for Payer: United Healthcare Commercial |
$42.89
|
| Rate for Payer: United Healthcare Medicare |
$25.60
|
| Rate for Payer: WINHealth Partners Commercial |
$44.01
|
| Rate for Payer: Wise Provider Network Commercial |
$42.66
|
|
|
DELTA TERRY ADHES HOOK 1"X10YD
|
Facility
|
IP
|
$44.91
|
|
| Hospital Charge Code |
2250144
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$26.03 |
| Max. Negotiated Rate |
$44.91 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$44.01
|
| Rate for Payer: Aetna of WY Medicare |
$28.74
|
| Rate for Payer: Altius Commercial |
$43.11
|
| Rate for Payer: Beech Street Commercial |
$44.01
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$43.56
|
| Rate for Payer: Cash Price |
$31.43
|
| Rate for Payer: ChoiceCare Network Commercial |
$43.56
|
| Rate for Payer: Cigna of WY Commercial |
$44.01
|
| Rate for Payer: Entrust Commercial |
$42.66
|
| Rate for Payer: First Choice Health Commercial |
$42.66
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$42.66
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$27.40
|
| Rate for Payer: HealthUtah PPO |
$44.91
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$43.56
|
| Rate for Payer: Multiplan Medicare/VA |
$26.03
|
| Rate for Payer: One Health Plan of WY PPO |
$44.01
|
| Rate for Payer: PacificSource Commercial |
$40.42
|
| Rate for Payer: PHCS PPO |
$44.01
|
| Rate for Payer: Three Rivers PPO |
$33.68
|
| Rate for Payer: TriWest Veterans Administration |
$27.40
|
| Rate for Payer: United Healthcare Commercial |
$42.89
|
| Rate for Payer: United Healthcare Medicare |
$27.40
|
| Rate for Payer: WINHealth Partners Commercial |
$42.66
|
| Rate for Payer: Wise Provider Network Commercial |
$42.66
|
|
|
DEMO&/EVAL OF PT UTILIZ AERSL GEN/NEB/INHLR/IP
|
Professional
|
Both
|
$70.00
|
|
|
Service Code
|
HCPCS 94664
|
| Min. Negotiated Rate |
$14.88 |
| Max. Negotiated Rate |
$70.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$68.60
|
| Rate for Payer: Aetna of WY Medicare |
$17.51
|
| Rate for Payer: Beech Street Commercial |
$66.50
|
| Rate for Payer: Cash Price |
$49.00
|
| Rate for Payer: Cash Price |
$49.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$67.90
|
| Rate for Payer: Cigna of WY Commercial |
$68.60
|
| Rate for Payer: First Choice Health Commercial |
$63.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$66.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$17.51
|
| Rate for Payer: HealthUtah PPO |
$70.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$67.90
|
| Rate for Payer: Multiplan Medicare/VA |
$14.88
|
| Rate for Payer: One Health Plan of WY PPO |
$68.60
|
| Rate for Payer: PacificSource Commercial |
$63.00
|
| Rate for Payer: PHCS PPO |
$66.50
|
| Rate for Payer: Three Rivers PPO |
$52.50
|
| Rate for Payer: TriWest Veterans Administration |
$17.51
|
| Rate for Payer: United Healthcare Commercial |
$66.50
|
| Rate for Payer: WINHealth Partners Commercial |
$66.50
|
|
|
DENOSUMAB 120 MG/1.7 ML (70 MG/ML) SUBCUTANEOUS SOLUTION [91054]
|
Facility
|
OP
|
$1,894.08
|
|
|
Service Code
|
HCPCS J0897
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,025.64 |
| Max. Negotiated Rate |
$1,894.08 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,856.20
|
| Rate for Payer: Aetna of WY Medicare |
$1,250.09
|
| Rate for Payer: Altius Commercial |
$1,818.32
|
| Rate for Payer: Beech Street Commercial |
$1,856.20
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,837.26
|
| Rate for Payer: Cash Price |
$1,325.85
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,837.26
|
| Rate for Payer: Cigna of WY Commercial |
$1,856.20
|
| Rate for Payer: Entrust Commercial |
$1,799.38
|
| Rate for Payer: First Choice Health Commercial |
$1,799.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,799.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,079.63
|
| Rate for Payer: HealthUtah PPO |
$1,894.08
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,837.26
|
| Rate for Payer: Multiplan Medicare/VA |
$1,025.64
|
| Rate for Payer: One Health Plan of WY PPO |
$1,856.20
|
| Rate for Payer: PacificSource Commercial |
$1,704.67
|
| Rate for Payer: PHCS PPO |
$1,856.20
|
| Rate for Payer: Three Rivers PPO |
$1,420.56
|
| Rate for Payer: TriWest Veterans Administration |
$1,079.63
|
| Rate for Payer: United Healthcare Commercial |
$1,808.85
|
| Rate for Payer: United Healthcare Medicare |
$1,079.63
|
| Rate for Payer: WINHealth Partners Commercial |
$1,856.20
|
| Rate for Payer: Wise Provider Network Commercial |
$1,799.38
|
|
|
DENOSUMAB 120 MG/1.7 ML (70 MG/ML) SUBCUTANEOUS SOLUTION [91054]
|
Facility
|
IP
|
$1,894.08
|
|
|
Service Code
|
HCPCS J0897
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,097.62 |
| Max. Negotiated Rate |
$1,894.08 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,856.20
|
| Rate for Payer: Aetna of WY Medicare |
$1,212.21
|
| Rate for Payer: Altius Commercial |
$1,818.32
|
| Rate for Payer: Beech Street Commercial |
$1,856.20
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,837.26
|
| Rate for Payer: Cash Price |
$1,325.85
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,837.26
|
| Rate for Payer: Cigna of WY Commercial |
$1,856.20
|
| Rate for Payer: Entrust Commercial |
$1,799.38
|
| Rate for Payer: First Choice Health Commercial |
$1,799.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,799.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,155.39
|
| Rate for Payer: HealthUtah PPO |
$1,894.08
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,837.26
|
| Rate for Payer: Multiplan Medicare/VA |
$1,097.62
|
| Rate for Payer: One Health Plan of WY PPO |
$1,856.20
|
| Rate for Payer: PacificSource Commercial |
$1,704.67
|
| Rate for Payer: PHCS PPO |
$1,856.20
|
| Rate for Payer: Three Rivers PPO |
$1,420.56
|
| Rate for Payer: TriWest Veterans Administration |
$1,155.39
|
| Rate for Payer: United Healthcare Commercial |
$1,808.85
|
| Rate for Payer: United Healthcare Medicare |
$1,155.39
|
| Rate for Payer: WINHealth Partners Commercial |
$1,799.38
|
| Rate for Payer: Wise Provider Network Commercial |
$1,799.38
|
|
|
DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE [89894]
|
Facility
|
IP
|
$1,751.63
|
|
|
Service Code
|
HCPCS J0897
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,015.07 |
| Max. Negotiated Rate |
$1,751.63 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,716.60
|
| Rate for Payer: Aetna of WY Medicare |
$1,121.04
|
| Rate for Payer: Altius Commercial |
$1,681.56
|
| Rate for Payer: Beech Street Commercial |
$1,716.60
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,699.08
|
| Rate for Payer: Cash Price |
$1,226.14
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,699.08
|
| Rate for Payer: Cigna of WY Commercial |
$1,716.60
|
| Rate for Payer: Entrust Commercial |
$1,664.05
|
| Rate for Payer: First Choice Health Commercial |
$1,664.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,664.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,068.49
|
| Rate for Payer: HealthUtah PPO |
$1,751.63
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,699.08
|
| Rate for Payer: Multiplan Medicare/VA |
$1,015.07
|
| Rate for Payer: One Health Plan of WY PPO |
$1,716.60
|
| Rate for Payer: PacificSource Commercial |
$1,576.47
|
| Rate for Payer: PHCS PPO |
$1,716.60
|
| Rate for Payer: Three Rivers PPO |
$1,313.72
|
| Rate for Payer: TriWest Veterans Administration |
$1,068.49
|
| Rate for Payer: United Healthcare Commercial |
$1,672.81
|
| Rate for Payer: United Healthcare Medicare |
$1,068.49
|
| Rate for Payer: WINHealth Partners Commercial |
$1,664.05
|
| Rate for Payer: Wise Provider Network Commercial |
$1,664.05
|
|
|
DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE [89894]
|
Facility
|
OP
|
$1,751.63
|
|
|
Service Code
|
HCPCS J0897
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$948.51 |
| Max. Negotiated Rate |
$1,751.63 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,716.60
|
| Rate for Payer: Aetna of WY Medicare |
$1,156.08
|
| Rate for Payer: Altius Commercial |
$1,681.56
|
| Rate for Payer: Beech Street Commercial |
$1,716.60
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,699.08
|
| Rate for Payer: Cash Price |
$1,226.14
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,699.08
|
| Rate for Payer: Cigna of WY Commercial |
$1,716.60
|
| Rate for Payer: Entrust Commercial |
$1,664.05
|
| Rate for Payer: First Choice Health Commercial |
$1,664.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,664.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$998.43
|
| Rate for Payer: HealthUtah PPO |
$1,751.63
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,699.08
|
| Rate for Payer: Multiplan Medicare/VA |
$948.51
|
| Rate for Payer: One Health Plan of WY PPO |
$1,716.60
|
| Rate for Payer: PacificSource Commercial |
$1,576.47
|
| Rate for Payer: PHCS PPO |
$1,716.60
|
| Rate for Payer: Three Rivers PPO |
$1,313.72
|
| Rate for Payer: TriWest Veterans Administration |
$998.43
|
| Rate for Payer: United Healthcare Commercial |
$1,672.81
|
| Rate for Payer: United Healthcare Medicare |
$998.43
|
| Rate for Payer: WINHealth Partners Commercial |
$1,716.60
|
| Rate for Payer: Wise Provider Network Commercial |
$1,664.05
|
|
|
DENOVO NT TISSUE GRAFT
|
Facility
|
OP
|
$16,345.00
|
|
| Hospital Charge Code |
3003233
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,850.82 |
| Max. Negotiated Rate |
$16,345.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16,018.10
|
| Rate for Payer: Aetna of WY Medicare |
$10,787.70
|
| Rate for Payer: Altius Commercial |
$15,691.20
|
| Rate for Payer: Beech Street Commercial |
$16,018.10
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15,854.65
|
| Rate for Payer: Cash Price |
$11,441.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$15,854.65
|
| Rate for Payer: Cigna of WY Commercial |
$16,018.10
|
| Rate for Payer: Entrust Commercial |
$15,527.75
|
| Rate for Payer: First Choice Health Commercial |
$15,527.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15,527.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9,316.65
|
| Rate for Payer: HealthUtah PPO |
$16,345.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15,854.65
|
| Rate for Payer: Multiplan Medicare/VA |
$8,850.82
|
| Rate for Payer: One Health Plan of WY PPO |
$16,018.10
|
| Rate for Payer: PacificSource Commercial |
$14,710.50
|
| Rate for Payer: PHCS PPO |
$16,018.10
|
| Rate for Payer: Three Rivers PPO |
$12,258.75
|
| Rate for Payer: TriWest Veterans Administration |
$9,316.65
|
| Rate for Payer: United Healthcare Commercial |
$15,609.48
|
| Rate for Payer: United Healthcare Medicare |
$9,316.65
|
| Rate for Payer: WINHealth Partners Commercial |
$16,018.10
|
| Rate for Payer: Wise Provider Network Commercial |
$15,527.75
|
|
|
DENOVO NT TISSUE GRAFT
|
Facility
|
IP
|
$16,345.00
|
|
| Hospital Charge Code |
3003233
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,471.93 |
| Max. Negotiated Rate |
$16,345.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16,018.10
|
| Rate for Payer: Aetna of WY Medicare |
$10,460.80
|
| Rate for Payer: Altius Commercial |
$15,691.20
|
| Rate for Payer: Beech Street Commercial |
$16,018.10
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15,854.65
|
| Rate for Payer: Cash Price |
$11,441.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$15,854.65
|
| Rate for Payer: Cigna of WY Commercial |
$16,018.10
|
| Rate for Payer: Entrust Commercial |
$15,527.75
|
| Rate for Payer: First Choice Health Commercial |
$15,527.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15,527.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9,970.45
|
| Rate for Payer: HealthUtah PPO |
$16,345.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15,854.65
|
| Rate for Payer: Multiplan Medicare/VA |
$9,471.93
|
| Rate for Payer: One Health Plan of WY PPO |
$16,018.10
|
| Rate for Payer: PacificSource Commercial |
$14,710.50
|
| Rate for Payer: PHCS PPO |
$16,018.10
|
| Rate for Payer: Three Rivers PPO |
$12,258.75
|
| Rate for Payer: TriWest Veterans Administration |
$9,970.45
|
| Rate for Payer: United Healthcare Commercial |
$15,609.48
|
| Rate for Payer: United Healthcare Medicare |
$9,970.45
|
| Rate for Payer: WINHealth Partners Commercial |
$15,527.75
|
| Rate for Payer: Wise Provider Network Commercial |
$15,527.75
|
|
|
DENOVO NY GRAFT M1S0893
|
Facility
|
IP
|
$16,317.00
|
|
| Hospital Charge Code |
3002013
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,455.70 |
| Max. Negotiated Rate |
$16,317.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15,990.66
|
| Rate for Payer: Aetna of WY Medicare |
$10,442.88
|
| Rate for Payer: Altius Commercial |
$15,664.32
|
| Rate for Payer: Beech Street Commercial |
$15,990.66
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15,827.49
|
| Rate for Payer: Cash Price |
$11,421.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$15,827.49
|
| Rate for Payer: Cigna of WY Commercial |
$15,990.66
|
| Rate for Payer: Entrust Commercial |
$15,501.15
|
| Rate for Payer: First Choice Health Commercial |
$15,501.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15,501.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9,953.37
|
| Rate for Payer: HealthUtah PPO |
$16,317.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15,827.49
|
| Rate for Payer: Multiplan Medicare/VA |
$9,455.70
|
| Rate for Payer: One Health Plan of WY PPO |
$15,990.66
|
| Rate for Payer: PacificSource Commercial |
$14,685.30
|
| Rate for Payer: PHCS PPO |
$15,990.66
|
| Rate for Payer: Three Rivers PPO |
$12,237.75
|
| Rate for Payer: TriWest Veterans Administration |
$9,953.37
|
| Rate for Payer: United Healthcare Commercial |
$15,582.74
|
| Rate for Payer: United Healthcare Medicare |
$9,953.37
|
| Rate for Payer: WINHealth Partners Commercial |
$15,501.15
|
| Rate for Payer: Wise Provider Network Commercial |
$15,501.15
|
|
|
DENOVO NY GRAFT M1S0893
|
Facility
|
OP
|
$16,317.00
|
|
| Hospital Charge Code |
3002013
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,835.66 |
| Max. Negotiated Rate |
$16,317.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15,990.66
|
| Rate for Payer: Aetna of WY Medicare |
$10,769.22
|
| Rate for Payer: Altius Commercial |
$15,664.32
|
| Rate for Payer: Beech Street Commercial |
$15,990.66
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15,827.49
|
| Rate for Payer: Cash Price |
$11,421.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$15,827.49
|
| Rate for Payer: Cigna of WY Commercial |
$15,990.66
|
| Rate for Payer: Entrust Commercial |
$15,501.15
|
| Rate for Payer: First Choice Health Commercial |
$15,501.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15,501.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9,300.69
|
| Rate for Payer: HealthUtah PPO |
$16,317.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15,827.49
|
| Rate for Payer: Multiplan Medicare/VA |
$8,835.66
|
| Rate for Payer: One Health Plan of WY PPO |
$15,990.66
|
| Rate for Payer: PacificSource Commercial |
$14,685.30
|
| Rate for Payer: PHCS PPO |
$15,990.66
|
| Rate for Payer: Three Rivers PPO |
$12,237.75
|
| Rate for Payer: TriWest Veterans Administration |
$9,300.69
|
| Rate for Payer: United Healthcare Commercial |
$15,582.74
|
| Rate for Payer: United Healthcare Medicare |
$9,300.69
|
| Rate for Payer: WINHealth Partners Commercial |
$15,990.66
|
| Rate for Payer: Wise Provider Network Commercial |
$15,501.15
|
|
|
DEPRESSION SCREEN ANNUAL
|
Professional
|
Both
|
$51.00
|
|
|
Service Code
|
HCPCS G0444
|
| Min. Negotiated Rate |
$7.45 |
| Max. Negotiated Rate |
$51.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$49.98
|
| Rate for Payer: Aetna of WY Medicare |
$8.76
|
| Rate for Payer: Beech Street Commercial |
$48.45
|
| Rate for Payer: Cash Price |
$35.70
|
| Rate for Payer: Cash Price |
$35.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$49.47
|
| Rate for Payer: Cigna of WY Commercial |
$49.98
|
| Rate for Payer: First Choice Health Commercial |
$45.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$48.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.76
|
| Rate for Payer: HealthUtah PPO |
$51.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$49.47
|
| Rate for Payer: Multiplan Medicare/VA |
$7.45
|
| Rate for Payer: One Health Plan of WY PPO |
$49.98
|
| Rate for Payer: PacificSource Commercial |
$45.90
|
| Rate for Payer: PHCS PPO |
$48.45
|
| Rate for Payer: Three Rivers PPO |
$38.25
|
| Rate for Payer: TriWest Veterans Administration |
$8.76
|
| Rate for Payer: United Healthcare Commercial |
$48.45
|
| Rate for Payer: WINHealth Partners Commercial |
$48.45
|
|
|
DERMABOND LIQUIBAND ADHESIVE LARGE
|
Facility
|
OP
|
$54.34
|
|
| Hospital Charge Code |
2150028
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$29.43 |
| Max. Negotiated Rate |
$54.34 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$53.25
|
| Rate for Payer: Aetna of WY Medicare |
$35.86
|
| Rate for Payer: Altius Commercial |
$52.17
|
| Rate for Payer: Beech Street Commercial |
$53.25
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$52.71
|
| Rate for Payer: Cash Price |
$38.04
|
| Rate for Payer: ChoiceCare Network Commercial |
$52.71
|
| Rate for Payer: Cigna of WY Commercial |
$53.25
|
| Rate for Payer: Entrust Commercial |
$51.62
|
| Rate for Payer: First Choice Health Commercial |
$51.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$51.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$30.97
|
| Rate for Payer: HealthUtah PPO |
$54.34
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$52.71
|
| Rate for Payer: Multiplan Medicare/VA |
$29.43
|
| Rate for Payer: One Health Plan of WY PPO |
$53.25
|
| Rate for Payer: PacificSource Commercial |
$48.91
|
| Rate for Payer: PHCS PPO |
$53.25
|
| Rate for Payer: Three Rivers PPO |
$40.76
|
| Rate for Payer: TriWest Veterans Administration |
$30.97
|
| Rate for Payer: United Healthcare Commercial |
$51.89
|
| Rate for Payer: United Healthcare Medicare |
$30.97
|
| Rate for Payer: WINHealth Partners Commercial |
$53.25
|
| Rate for Payer: Wise Provider Network Commercial |
$51.62
|
|
|
DERMABOND LIQUIBAND ADHESIVE LARGE
|
Facility
|
IP
|
$54.34
|
|
| Hospital Charge Code |
2150028
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$31.49 |
| Max. Negotiated Rate |
$54.34 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$53.25
|
| Rate for Payer: Aetna of WY Medicare |
$34.78
|
| Rate for Payer: Altius Commercial |
$52.17
|
| Rate for Payer: Beech Street Commercial |
$53.25
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$52.71
|
| Rate for Payer: Cash Price |
$38.04
|
| Rate for Payer: ChoiceCare Network Commercial |
$52.71
|
| Rate for Payer: Cigna of WY Commercial |
$53.25
|
| Rate for Payer: Entrust Commercial |
$51.62
|
| Rate for Payer: First Choice Health Commercial |
$51.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$51.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$33.15
|
| Rate for Payer: HealthUtah PPO |
$54.34
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$52.71
|
| Rate for Payer: Multiplan Medicare/VA |
$31.49
|
| Rate for Payer: One Health Plan of WY PPO |
$53.25
|
| Rate for Payer: PacificSource Commercial |
$48.91
|
| Rate for Payer: PHCS PPO |
$53.25
|
| Rate for Payer: Three Rivers PPO |
$40.76
|
| Rate for Payer: TriWest Veterans Administration |
$33.15
|
| Rate for Payer: United Healthcare Commercial |
$51.89
|
| Rate for Payer: United Healthcare Medicare |
$33.15
|
| Rate for Payer: WINHealth Partners Commercial |
$51.62
|
| Rate for Payer: Wise Provider Network Commercial |
$51.62
|
|
|
DERMABOND SKIN AFFIX ADHESIVE MINI
|
Facility
|
OP
|
$40.00
|
|
| Hospital Charge Code |
2150349
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$21.66 |
| Max. Negotiated Rate |
$40.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$39.20
|
| Rate for Payer: Aetna of WY Medicare |
$26.40
|
| Rate for Payer: Altius Commercial |
$38.40
|
| Rate for Payer: Beech Street Commercial |
$39.20
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$38.80
|
| Rate for Payer: Cash Price |
$28.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$38.80
|
| Rate for Payer: Cigna of WY Commercial |
$39.20
|
| Rate for Payer: Entrust Commercial |
$38.00
|
| Rate for Payer: First Choice Health Commercial |
$38.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$38.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$22.80
|
| Rate for Payer: HealthUtah PPO |
$40.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$38.80
|
| Rate for Payer: Multiplan Medicare/VA |
$21.66
|
| Rate for Payer: One Health Plan of WY PPO |
$39.20
|
| Rate for Payer: PacificSource Commercial |
$36.00
|
| Rate for Payer: PHCS PPO |
$39.20
|
| Rate for Payer: Three Rivers PPO |
$30.00
|
| Rate for Payer: TriWest Veterans Administration |
$22.80
|
| Rate for Payer: United Healthcare Commercial |
$38.20
|
| Rate for Payer: United Healthcare Medicare |
$22.80
|
| Rate for Payer: WINHealth Partners Commercial |
$39.20
|
| Rate for Payer: Wise Provider Network Commercial |
$38.00
|
|
