|
FOSAPREPITANT 150 MG INTRAVENOUS POWDER FOR SOLUTION [91002]
|
Facility
|
OP
|
$65.00
|
|
|
Service Code
|
HCPCS J1453
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.82 |
| Max. Negotiated Rate |
$65.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$63.70
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$155.64
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$126.18
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$69.58
|
| Rate for Payer: Aetna of WY Medicare |
$104.82
|
| Rate for Payer: Aetna of WY Medicare |
$42.90
|
| Rate for Payer: Aetna of WY Medicare |
$84.98
|
| Rate for Payer: Aetna of WY Medicare |
$46.86
|
| Rate for Payer: Altius Auto/Workers Compensation |
$62.40
|
| Rate for Payer: Altius Auto/Workers Compensation |
$68.16
|
| Rate for Payer: Altius Auto/Workers Compensation |
$152.47
|
| Rate for Payer: Altius Auto/Workers Compensation |
$123.60
|
| Rate for Payer: Altius Commercial |
$62.40
|
| Rate for Payer: Altius Commercial |
$152.47
|
| Rate for Payer: Altius Commercial |
$68.16
|
| Rate for Payer: Altius Commercial |
$123.60
|
| Rate for Payer: Beech Street Commercial |
$155.64
|
| Rate for Payer: Beech Street Commercial |
$63.70
|
| Rate for Payer: Beech Street Commercial |
$126.18
|
| Rate for Payer: Beech Street Commercial |
$69.58
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$105.70
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$53.36
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$130.39
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$58.29
|
| Rate for Payer: Cash Price |
$45.50
|
| Rate for Payer: Cash Price |
$111.17
|
| Rate for Payer: Cash Price |
$49.70
|
| Rate for Payer: Cash Price |
$90.12
|
| Rate for Payer: ChoiceCare Network Commercial |
$124.89
|
| Rate for Payer: ChoiceCare Network Commercial |
$63.05
|
| Rate for Payer: ChoiceCare Network Commercial |
$154.06
|
| Rate for Payer: ChoiceCare Network Commercial |
$68.87
|
| Rate for Payer: Cigna of WY Commercial |
$63.70
|
| Rate for Payer: Cigna of WY Commercial |
$126.18
|
| Rate for Payer: Cigna of WY Commercial |
$155.64
|
| Rate for Payer: Cigna of WY Commercial |
$69.58
|
| Rate for Payer: Entrust Commercial |
$150.88
|
| Rate for Payer: Entrust Commercial |
$122.31
|
| Rate for Payer: Entrust Commercial |
$67.45
|
| Rate for Payer: Entrust Commercial |
$61.75
|
| Rate for Payer: First Choice Health Commercial |
$61.75
|
| Rate for Payer: First Choice Health Commercial |
$122.31
|
| Rate for Payer: First Choice Health Commercial |
$150.88
|
| Rate for Payer: First Choice Health Commercial |
$67.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$150.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$122.31
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$67.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$61.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$41.18
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$74.68
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$92.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$37.70
|
| Rate for Payer: HealthUtah PPO |
$128.75
|
| Rate for Payer: HealthUtah PPO |
$71.00
|
| Rate for Payer: HealthUtah PPO |
$65.00
|
| Rate for Payer: HealthUtah PPO |
$158.82
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$154.06
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$68.87
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$63.05
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$124.89
|
| Rate for Payer: Multiplan Medicare/VA |
$35.82
|
| Rate for Payer: Multiplan Medicare/VA |
$70.94
|
| Rate for Payer: Multiplan Medicare/VA |
$39.12
|
| Rate for Payer: Multiplan Medicare/VA |
$87.51
|
| Rate for Payer: One Health Plan of WY PPO |
$126.18
|
| Rate for Payer: One Health Plan of WY PPO |
$69.58
|
| Rate for Payer: One Health Plan of WY PPO |
$63.70
|
| Rate for Payer: One Health Plan of WY PPO |
$155.64
|
| Rate for Payer: PacificSource Commercial |
$63.90
|
| Rate for Payer: PacificSource Commercial |
$115.88
|
| Rate for Payer: PacificSource Commercial |
$142.94
|
| Rate for Payer: PacificSource Commercial |
$58.50
|
| Rate for Payer: PHCS PPO |
$69.58
|
| Rate for Payer: PHCS PPO |
$63.70
|
| Rate for Payer: PHCS PPO |
$155.64
|
| Rate for Payer: PHCS PPO |
$126.18
|
| Rate for Payer: Three Rivers PPO |
$119.12
|
| Rate for Payer: Three Rivers PPO |
$53.25
|
| Rate for Payer: Three Rivers PPO |
$48.75
|
| Rate for Payer: Three Rivers PPO |
$96.56
|
| Rate for Payer: TriWest Veterans Administration |
$92.12
|
| Rate for Payer: TriWest Veterans Administration |
$41.18
|
| Rate for Payer: TriWest Veterans Administration |
$74.68
|
| Rate for Payer: TriWest Veterans Administration |
$37.70
|
| Rate for Payer: United Healthcare Commercial |
$56.55
|
| Rate for Payer: United Healthcare Commercial |
$138.17
|
| Rate for Payer: United Healthcare Commercial |
$112.01
|
| Rate for Payer: United Healthcare Commercial |
$61.77
|
| Rate for Payer: United Healthcare Medicare |
$37.70
|
| Rate for Payer: United Healthcare Medicare |
$74.68
|
| Rate for Payer: United Healthcare Medicare |
$92.12
|
| Rate for Payer: United Healthcare Medicare |
$41.18
|
| Rate for Payer: WINHealth Partners Commercial |
$69.58
|
| Rate for Payer: WINHealth Partners Commercial |
$155.64
|
| Rate for Payer: WINHealth Partners Commercial |
$126.18
|
| Rate for Payer: WINHealth Partners Commercial |
$63.70
|
| Rate for Payer: Wise Provider Network Commercial |
$150.88
|
| Rate for Payer: Wise Provider Network Commercial |
$122.31
|
| Rate for Payer: Wise Provider Network Commercial |
$61.75
|
| Rate for Payer: Wise Provider Network Commercial |
$67.45
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET [3141]
|
Facility
|
OP
|
$140.56
|
|
|
Service Code
|
NDC 7070026894
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$77.45 |
| Max. Negotiated Rate |
$140.56 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$137.75
|
| Rate for Payer: Aetna of WY Medicare |
$92.77
|
| Rate for Payer: Altius Auto/Workers Compensation |
$134.94
|
| Rate for Payer: Altius Commercial |
$134.94
|
| Rate for Payer: Beech Street Commercial |
$137.75
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$115.40
|
| Rate for Payer: Cash Price |
$98.39
|
| Rate for Payer: ChoiceCare Network Commercial |
$136.34
|
| Rate for Payer: Cigna of WY Commercial |
$137.75
|
| Rate for Payer: Entrust Commercial |
$133.53
|
| Rate for Payer: First Choice Health Commercial |
$133.53
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$133.53
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$81.52
|
| Rate for Payer: HealthUtah PPO |
$140.56
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$136.34
|
| Rate for Payer: Multiplan Medicare/VA |
$77.45
|
| Rate for Payer: One Health Plan of WY PPO |
$137.75
|
| Rate for Payer: PacificSource Commercial |
$126.50
|
| Rate for Payer: PHCS PPO |
$137.75
|
| Rate for Payer: Three Rivers PPO |
$105.42
|
| Rate for Payer: TriWest Veterans Administration |
$81.52
|
| Rate for Payer: United Healthcare Commercial |
$122.29
|
| Rate for Payer: United Healthcare Medicare |
$81.52
|
| Rate for Payer: WINHealth Partners Commercial |
$137.75
|
| Rate for Payer: Wise Provider Network Commercial |
$133.53
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET [3141]
|
Facility
|
IP
|
$140.56
|
|
|
Service Code
|
NDC 7070026899
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$88.13 |
| Max. Negotiated Rate |
$140.56 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$137.75
|
| Rate for Payer: Altius Auto/Workers Compensation |
$134.94
|
| Rate for Payer: Altius Commercial |
$134.94
|
| Rate for Payer: Beech Street Commercial |
$137.75
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$115.40
|
| Rate for Payer: Cash Price |
$98.39
|
| Rate for Payer: ChoiceCare Network Commercial |
$136.34
|
| Rate for Payer: Cigna of WY Commercial |
$137.75
|
| Rate for Payer: Entrust Commercial |
$133.53
|
| Rate for Payer: First Choice Health Commercial |
$133.53
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$133.53
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$92.77
|
| Rate for Payer: HealthUtah PPO |
$140.56
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$136.34
|
| Rate for Payer: Multiplan Medicare/VA |
$88.13
|
| Rate for Payer: One Health Plan of WY PPO |
$137.75
|
| Rate for Payer: PacificSource Commercial |
$126.50
|
| Rate for Payer: PHCS PPO |
$137.75
|
| Rate for Payer: Three Rivers PPO |
$105.42
|
| Rate for Payer: TriWest Veterans Administration |
$92.77
|
| Rate for Payer: United Healthcare Commercial |
$122.29
|
| Rate for Payer: United Healthcare Medicare |
$92.77
|
| Rate for Payer: WINHealth Partners Commercial |
$133.53
|
| Rate for Payer: Wise Provider Network Commercial |
$133.53
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET [3141]
|
Facility
|
IP
|
$140.56
|
|
|
Service Code
|
NDC 7070026894
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$88.13 |
| Max. Negotiated Rate |
$140.56 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$137.75
|
| Rate for Payer: Altius Auto/Workers Compensation |
$134.94
|
| Rate for Payer: Altius Commercial |
$134.94
|
| Rate for Payer: Beech Street Commercial |
$137.75
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$115.40
|
| Rate for Payer: Cash Price |
$98.39
|
| Rate for Payer: ChoiceCare Network Commercial |
$136.34
|
| Rate for Payer: Cigna of WY Commercial |
$137.75
|
| Rate for Payer: Entrust Commercial |
$133.53
|
| Rate for Payer: First Choice Health Commercial |
$133.53
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$133.53
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$92.77
|
| Rate for Payer: HealthUtah PPO |
$140.56
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$136.34
|
| Rate for Payer: Multiplan Medicare/VA |
$88.13
|
| Rate for Payer: One Health Plan of WY PPO |
$137.75
|
| Rate for Payer: PacificSource Commercial |
$126.50
|
| Rate for Payer: PHCS PPO |
$137.75
|
| Rate for Payer: Three Rivers PPO |
$105.42
|
| Rate for Payer: TriWest Veterans Administration |
$92.77
|
| Rate for Payer: United Healthcare Commercial |
$122.29
|
| Rate for Payer: United Healthcare Medicare |
$92.77
|
| Rate for Payer: WINHealth Partners Commercial |
$133.53
|
| Rate for Payer: Wise Provider Network Commercial |
$133.53
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET [3141]
|
Facility
|
OP
|
$140.56
|
|
|
Service Code
|
NDC 7070026899
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$77.45 |
| Max. Negotiated Rate |
$140.56 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$137.75
|
| Rate for Payer: Aetna of WY Medicare |
$92.77
|
| Rate for Payer: Altius Auto/Workers Compensation |
$134.94
|
| Rate for Payer: Altius Commercial |
$134.94
|
| Rate for Payer: Beech Street Commercial |
$137.75
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$115.40
|
| Rate for Payer: Cash Price |
$98.39
|
| Rate for Payer: ChoiceCare Network Commercial |
$136.34
|
| Rate for Payer: Cigna of WY Commercial |
$137.75
|
| Rate for Payer: Entrust Commercial |
$133.53
|
| Rate for Payer: First Choice Health Commercial |
$133.53
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$133.53
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$81.52
|
| Rate for Payer: HealthUtah PPO |
$140.56
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$136.34
|
| Rate for Payer: Multiplan Medicare/VA |
$77.45
|
| Rate for Payer: One Health Plan of WY PPO |
$137.75
|
| Rate for Payer: PacificSource Commercial |
$126.50
|
| Rate for Payer: PHCS PPO |
$137.75
|
| Rate for Payer: Three Rivers PPO |
$105.42
|
| Rate for Payer: TriWest Veterans Administration |
$81.52
|
| Rate for Payer: United Healthcare Commercial |
$122.29
|
| Rate for Payer: United Healthcare Medicare |
$81.52
|
| Rate for Payer: WINHealth Partners Commercial |
$137.75
|
| Rate for Payer: Wise Provider Network Commercial |
$133.53
|
|
|
FO W/O JOINTS CF
|
Professional
|
Both
|
$317.00
|
|
|
Service Code
|
HCPCS L3933
|
| Hospital Charge Code |
L3933
|
| Min. Negotiated Rate |
$196.33 |
| Max. Negotiated Rate |
$317.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$310.66
|
| Rate for Payer: Aetna of WY Medicare |
$230.98
|
| Rate for Payer: Beech Street Commercial |
$301.15
|
| Rate for Payer: Cash Price |
$221.90
|
| Rate for Payer: Cash Price |
$221.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$307.49
|
| Rate for Payer: Cigna of WY Commercial |
$310.66
|
| Rate for Payer: First Choice Health Commercial |
$285.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$301.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$230.98
|
| Rate for Payer: HealthUtah PPO |
$317.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$307.49
|
| Rate for Payer: Multiplan Medicare/VA |
$196.33
|
| Rate for Payer: One Health Plan of WY PPO |
$310.66
|
| Rate for Payer: PacificSource Commercial |
$285.30
|
| Rate for Payer: PHCS PPO |
$301.15
|
| Rate for Payer: Three Rivers PPO |
$237.75
|
| Rate for Payer: TriWest Veterans Administration |
$230.98
|
| Rate for Payer: United Healthcare Commercial |
$275.79
|
| Rate for Payer: United Healthcare Medicare |
$230.98
|
| Rate for Payer: WINHealth Partners Commercial |
$301.15
|
|
|
FRACTURE NASAL INFERIOR TURBINATE THERAPEUTIC
|
Professional
|
Both
|
$606.00
|
|
|
Service Code
|
HCPCS 30930
|
| Hospital Charge Code |
30930
|
| Min. Negotiated Rate |
$98.54 |
| Max. Negotiated Rate |
$606.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$593.88
|
| Rate for Payer: Aetna of WY Medicare |
$115.93
|
| Rate for Payer: Beech Street Commercial |
$575.70
|
| Rate for Payer: Cash Price |
$424.20
|
| Rate for Payer: Cash Price |
$424.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$587.82
|
| Rate for Payer: Cigna of WY Commercial |
$593.88
|
| Rate for Payer: First Choice Health Commercial |
$545.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$575.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$115.93
|
| Rate for Payer: HealthUtah PPO |
$606.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$587.82
|
| Rate for Payer: Multiplan Medicare/VA |
$98.54
|
| Rate for Payer: One Health Plan of WY PPO |
$593.88
|
| Rate for Payer: PacificSource Commercial |
$545.40
|
| Rate for Payer: PHCS PPO |
$575.70
|
| Rate for Payer: Three Rivers PPO |
$454.50
|
| Rate for Payer: TriWest Veterans Administration |
$115.93
|
| Rate for Payer: United Healthcare Commercial |
$527.22
|
| Rate for Payer: United Healthcare Medicare |
$115.93
|
| Rate for Payer: WINHealth Partners Commercial |
$515.10
|
|
|
FREEDOM CMC THUMBFIT LT LG
|
Facility
|
OP
|
$147.88
|
|
| Hospital Charge Code |
27000000S1
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$81.48 |
| Max. Negotiated Rate |
$147.88 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$144.92
|
| Rate for Payer: Aetna of WY Medicare |
$97.60
|
| Rate for Payer: Altius Auto/Workers Compensation |
$141.96
|
| Rate for Payer: Altius Commercial |
$141.96
|
| Rate for Payer: Beech Street Commercial |
$144.92
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$121.41
|
| Rate for Payer: Cash Price |
$103.51
|
| Rate for Payer: ChoiceCare Network Commercial |
$143.44
|
| Rate for Payer: Cigna of WY Commercial |
$144.92
|
| Rate for Payer: Entrust Commercial |
$140.49
|
| Rate for Payer: First Choice Health Commercial |
$140.49
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$140.49
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$85.77
|
| Rate for Payer: HealthUtah PPO |
$147.88
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$143.44
|
| Rate for Payer: Multiplan Medicare/VA |
$81.48
|
| Rate for Payer: One Health Plan of WY PPO |
$144.92
|
| Rate for Payer: PacificSource Commercial |
$133.09
|
| Rate for Payer: PHCS PPO |
$144.92
|
| Rate for Payer: Three Rivers PPO |
$110.91
|
| Rate for Payer: TriWest Veterans Administration |
$85.77
|
| Rate for Payer: United Healthcare Commercial |
$128.66
|
| Rate for Payer: United Healthcare Medicare |
$85.77
|
| Rate for Payer: WINHealth Partners Commercial |
$144.92
|
| Rate for Payer: Wise Provider Network Commercial |
$140.49
|
|
|
FREEDOM CMC THUMBFIT LT LG
|
Facility
|
IP
|
$147.88
|
|
| Hospital Charge Code |
27000000S1
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$92.72 |
| Max. Negotiated Rate |
$147.88 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$144.92
|
| Rate for Payer: Altius Auto/Workers Compensation |
$141.96
|
| Rate for Payer: Altius Commercial |
$141.96
|
| Rate for Payer: Beech Street Commercial |
$144.92
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$121.41
|
| Rate for Payer: Cash Price |
$103.51
|
| Rate for Payer: ChoiceCare Network Commercial |
$143.44
|
| Rate for Payer: Cigna of WY Commercial |
$144.92
|
| Rate for Payer: Entrust Commercial |
$140.49
|
| Rate for Payer: First Choice Health Commercial |
$140.49
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$140.49
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$97.60
|
| Rate for Payer: HealthUtah PPO |
$147.88
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$143.44
|
| Rate for Payer: Multiplan Medicare/VA |
$92.72
|
| Rate for Payer: One Health Plan of WY PPO |
$144.92
|
| Rate for Payer: PacificSource Commercial |
$133.09
|
| Rate for Payer: PHCS PPO |
$144.92
|
| Rate for Payer: Three Rivers PPO |
$110.91
|
| Rate for Payer: TriWest Veterans Administration |
$97.60
|
| Rate for Payer: United Healthcare Commercial |
$128.66
|
| Rate for Payer: United Healthcare Medicare |
$97.60
|
| Rate for Payer: WINHealth Partners Commercial |
$140.49
|
| Rate for Payer: Wise Provider Network Commercial |
$140.49
|
|
|
FREEDOM CMC THUMBFIT LT MED
|
Facility
|
IP
|
$147.88
|
|
| Hospital Charge Code |
27000000S1
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$92.72 |
| Max. Negotiated Rate |
$147.88 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$144.92
|
| Rate for Payer: Altius Auto/Workers Compensation |
$141.96
|
| Rate for Payer: Altius Commercial |
$141.96
|
| Rate for Payer: Beech Street Commercial |
$144.92
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$121.41
|
| Rate for Payer: Cash Price |
$103.51
|
| Rate for Payer: ChoiceCare Network Commercial |
$143.44
|
| Rate for Payer: Cigna of WY Commercial |
$144.92
|
| Rate for Payer: Entrust Commercial |
$140.49
|
| Rate for Payer: First Choice Health Commercial |
$140.49
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$140.49
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$97.60
|
| Rate for Payer: HealthUtah PPO |
$147.88
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$143.44
|
| Rate for Payer: Multiplan Medicare/VA |
$92.72
|
| Rate for Payer: One Health Plan of WY PPO |
$144.92
|
| Rate for Payer: PacificSource Commercial |
$133.09
|
| Rate for Payer: PHCS PPO |
$144.92
|
| Rate for Payer: Three Rivers PPO |
$110.91
|
| Rate for Payer: TriWest Veterans Administration |
$97.60
|
| Rate for Payer: United Healthcare Commercial |
$128.66
|
| Rate for Payer: United Healthcare Medicare |
$97.60
|
| Rate for Payer: WINHealth Partners Commercial |
$140.49
|
| Rate for Payer: Wise Provider Network Commercial |
$140.49
|
|
|
FREEDOM CMC THUMBFIT LT MED
|
Facility
|
OP
|
$147.88
|
|
| Hospital Charge Code |
27000000S1
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$81.48 |
| Max. Negotiated Rate |
$147.88 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$144.92
|
| Rate for Payer: Aetna of WY Medicare |
$97.60
|
| Rate for Payer: Altius Auto/Workers Compensation |
$141.96
|
| Rate for Payer: Altius Commercial |
$141.96
|
| Rate for Payer: Beech Street Commercial |
$144.92
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$121.41
|
| Rate for Payer: Cash Price |
$103.51
|
| Rate for Payer: ChoiceCare Network Commercial |
$143.44
|
| Rate for Payer: Cigna of WY Commercial |
$144.92
|
| Rate for Payer: Entrust Commercial |
$140.49
|
| Rate for Payer: First Choice Health Commercial |
$140.49
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$140.49
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$85.77
|
| Rate for Payer: HealthUtah PPO |
$147.88
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$143.44
|
| Rate for Payer: Multiplan Medicare/VA |
$81.48
|
| Rate for Payer: One Health Plan of WY PPO |
$144.92
|
| Rate for Payer: PacificSource Commercial |
$133.09
|
| Rate for Payer: PHCS PPO |
$144.92
|
| Rate for Payer: Three Rivers PPO |
$110.91
|
| Rate for Payer: TriWest Veterans Administration |
$85.77
|
| Rate for Payer: United Healthcare Commercial |
$128.66
|
| Rate for Payer: United Healthcare Medicare |
$85.77
|
| Rate for Payer: WINHealth Partners Commercial |
$144.92
|
| Rate for Payer: Wise Provider Network Commercial |
$140.49
|
|
|
FREEDOM CMC THUMBFIT LT SM
|
Facility
|
OP
|
$143.50
|
|
| Hospital Charge Code |
27000000S1
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$79.07 |
| Max. Negotiated Rate |
$143.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$140.63
|
| Rate for Payer: Aetna of WY Medicare |
$94.71
|
| Rate for Payer: Altius Auto/Workers Compensation |
$137.76
|
| Rate for Payer: Altius Commercial |
$137.76
|
| Rate for Payer: Beech Street Commercial |
$140.63
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$117.81
|
| Rate for Payer: Cash Price |
$100.45
|
| Rate for Payer: ChoiceCare Network Commercial |
$139.20
|
| Rate for Payer: Cigna of WY Commercial |
$140.63
|
| Rate for Payer: Entrust Commercial |
$136.32
|
| Rate for Payer: First Choice Health Commercial |
$136.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$136.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$83.23
|
| Rate for Payer: HealthUtah PPO |
$143.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$139.20
|
| Rate for Payer: Multiplan Medicare/VA |
$79.07
|
| Rate for Payer: One Health Plan of WY PPO |
$140.63
|
| Rate for Payer: PacificSource Commercial |
$129.15
|
| Rate for Payer: PHCS PPO |
$140.63
|
| Rate for Payer: Three Rivers PPO |
$107.62
|
| Rate for Payer: TriWest Veterans Administration |
$83.23
|
| Rate for Payer: United Healthcare Commercial |
$124.84
|
| Rate for Payer: United Healthcare Medicare |
$83.23
|
| Rate for Payer: WINHealth Partners Commercial |
$140.63
|
| Rate for Payer: Wise Provider Network Commercial |
$136.32
|
|
|
FREEDOM CMC THUMBFIT LT SM
|
Facility
|
IP
|
$143.50
|
|
| Hospital Charge Code |
27000000S1
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$89.97 |
| Max. Negotiated Rate |
$143.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$140.63
|
| Rate for Payer: Altius Auto/Workers Compensation |
$137.76
|
| Rate for Payer: Altius Commercial |
$137.76
|
| Rate for Payer: Beech Street Commercial |
$140.63
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$117.81
|
| Rate for Payer: Cash Price |
$100.45
|
| Rate for Payer: ChoiceCare Network Commercial |
$139.20
|
| Rate for Payer: Cigna of WY Commercial |
$140.63
|
| Rate for Payer: Entrust Commercial |
$136.32
|
| Rate for Payer: First Choice Health Commercial |
$136.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$136.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$94.71
|
| Rate for Payer: HealthUtah PPO |
$143.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$139.20
|
| Rate for Payer: Multiplan Medicare/VA |
$89.97
|
| Rate for Payer: One Health Plan of WY PPO |
$140.63
|
| Rate for Payer: PacificSource Commercial |
$129.15
|
| Rate for Payer: PHCS PPO |
$140.63
|
| Rate for Payer: Three Rivers PPO |
$107.62
|
| Rate for Payer: TriWest Veterans Administration |
$94.71
|
| Rate for Payer: United Healthcare Commercial |
$124.84
|
| Rate for Payer: United Healthcare Medicare |
$94.71
|
| Rate for Payer: WINHealth Partners Commercial |
$136.32
|
| Rate for Payer: Wise Provider Network Commercial |
$136.32
|
|
|
FREEDOM CMC THUMBFIT LT XLG
|
Facility
|
OP
|
$143.50
|
|
| Hospital Charge Code |
27000000S1
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$79.07 |
| Max. Negotiated Rate |
$143.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$140.63
|
| Rate for Payer: Aetna of WY Medicare |
$94.71
|
| Rate for Payer: Altius Auto/Workers Compensation |
$137.76
|
| Rate for Payer: Altius Commercial |
$137.76
|
| Rate for Payer: Beech Street Commercial |
$140.63
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$117.81
|
| Rate for Payer: Cash Price |
$100.45
|
| Rate for Payer: ChoiceCare Network Commercial |
$139.20
|
| Rate for Payer: Cigna of WY Commercial |
$140.63
|
| Rate for Payer: Entrust Commercial |
$136.32
|
| Rate for Payer: First Choice Health Commercial |
$136.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$136.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$83.23
|
| Rate for Payer: HealthUtah PPO |
$143.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$139.20
|
| Rate for Payer: Multiplan Medicare/VA |
$79.07
|
| Rate for Payer: One Health Plan of WY PPO |
$140.63
|
| Rate for Payer: PacificSource Commercial |
$129.15
|
| Rate for Payer: PHCS PPO |
$140.63
|
| Rate for Payer: Three Rivers PPO |
$107.62
|
| Rate for Payer: TriWest Veterans Administration |
$83.23
|
| Rate for Payer: United Healthcare Commercial |
$124.84
|
| Rate for Payer: United Healthcare Medicare |
$83.23
|
| Rate for Payer: WINHealth Partners Commercial |
$140.63
|
| Rate for Payer: Wise Provider Network Commercial |
$136.32
|
|
|
FREEDOM CMC THUMBFIT LT XLG
|
Facility
|
IP
|
$143.50
|
|
| Hospital Charge Code |
27000000S1
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$89.97 |
| Max. Negotiated Rate |
$143.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$140.63
|
| Rate for Payer: Altius Auto/Workers Compensation |
$137.76
|
| Rate for Payer: Altius Commercial |
$137.76
|
| Rate for Payer: Beech Street Commercial |
$140.63
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$117.81
|
| Rate for Payer: Cash Price |
$100.45
|
| Rate for Payer: ChoiceCare Network Commercial |
$139.20
|
| Rate for Payer: Cigna of WY Commercial |
$140.63
|
| Rate for Payer: Entrust Commercial |
$136.32
|
| Rate for Payer: First Choice Health Commercial |
$136.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$136.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$94.71
|
| Rate for Payer: HealthUtah PPO |
$143.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$139.20
|
| Rate for Payer: Multiplan Medicare/VA |
$89.97
|
| Rate for Payer: One Health Plan of WY PPO |
$140.63
|
| Rate for Payer: PacificSource Commercial |
$129.15
|
| Rate for Payer: PHCS PPO |
$140.63
|
| Rate for Payer: Three Rivers PPO |
$107.62
|
| Rate for Payer: TriWest Veterans Administration |
$94.71
|
| Rate for Payer: United Healthcare Commercial |
$124.84
|
| Rate for Payer: United Healthcare Medicare |
$94.71
|
| Rate for Payer: WINHealth Partners Commercial |
$136.32
|
| Rate for Payer: Wise Provider Network Commercial |
$136.32
|
|
|
FREEDOM CMC THUMBFIT RT LG
|
Facility
|
IP
|
$143.50
|
|
| Hospital Charge Code |
27000000S1
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$89.97 |
| Max. Negotiated Rate |
$143.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$140.63
|
| Rate for Payer: Altius Auto/Workers Compensation |
$137.76
|
| Rate for Payer: Altius Commercial |
$137.76
|
| Rate for Payer: Beech Street Commercial |
$140.63
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$117.81
|
| Rate for Payer: Cash Price |
$100.45
|
| Rate for Payer: ChoiceCare Network Commercial |
$139.20
|
| Rate for Payer: Cigna of WY Commercial |
$140.63
|
| Rate for Payer: Entrust Commercial |
$136.32
|
| Rate for Payer: First Choice Health Commercial |
$136.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$136.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$94.71
|
| Rate for Payer: HealthUtah PPO |
$143.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$139.20
|
| Rate for Payer: Multiplan Medicare/VA |
$89.97
|
| Rate for Payer: One Health Plan of WY PPO |
$140.63
|
| Rate for Payer: PacificSource Commercial |
$129.15
|
| Rate for Payer: PHCS PPO |
$140.63
|
| Rate for Payer: Three Rivers PPO |
$107.62
|
| Rate for Payer: TriWest Veterans Administration |
$94.71
|
| Rate for Payer: United Healthcare Commercial |
$124.84
|
| Rate for Payer: United Healthcare Medicare |
$94.71
|
| Rate for Payer: WINHealth Partners Commercial |
$136.32
|
| Rate for Payer: Wise Provider Network Commercial |
$136.32
|
|
|
FREEDOM CMC THUMBFIT RT LG
|
Facility
|
OP
|
$143.50
|
|
| Hospital Charge Code |
27000000S1
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$79.07 |
| Max. Negotiated Rate |
$143.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$140.63
|
| Rate for Payer: Aetna of WY Medicare |
$94.71
|
| Rate for Payer: Altius Auto/Workers Compensation |
$137.76
|
| Rate for Payer: Altius Commercial |
$137.76
|
| Rate for Payer: Beech Street Commercial |
$140.63
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$117.81
|
| Rate for Payer: Cash Price |
$100.45
|
| Rate for Payer: ChoiceCare Network Commercial |
$139.20
|
| Rate for Payer: Cigna of WY Commercial |
$140.63
|
| Rate for Payer: Entrust Commercial |
$136.32
|
| Rate for Payer: First Choice Health Commercial |
$136.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$136.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$83.23
|
| Rate for Payer: HealthUtah PPO |
$143.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$139.20
|
| Rate for Payer: Multiplan Medicare/VA |
$79.07
|
| Rate for Payer: One Health Plan of WY PPO |
$140.63
|
| Rate for Payer: PacificSource Commercial |
$129.15
|
| Rate for Payer: PHCS PPO |
$140.63
|
| Rate for Payer: Three Rivers PPO |
$107.62
|
| Rate for Payer: TriWest Veterans Administration |
$83.23
|
| Rate for Payer: United Healthcare Commercial |
$124.84
|
| Rate for Payer: United Healthcare Medicare |
$83.23
|
| Rate for Payer: WINHealth Partners Commercial |
$140.63
|
| Rate for Payer: Wise Provider Network Commercial |
$136.32
|
|
|
FREEDOM CMC THUMBFIT RT MED
|
Facility
|
OP
|
$143.50
|
|
| Hospital Charge Code |
27000000S1
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$79.07 |
| Max. Negotiated Rate |
$143.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$140.63
|
| Rate for Payer: Aetna of WY Medicare |
$94.71
|
| Rate for Payer: Altius Auto/Workers Compensation |
$137.76
|
| Rate for Payer: Altius Commercial |
$137.76
|
| Rate for Payer: Beech Street Commercial |
$140.63
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$117.81
|
| Rate for Payer: Cash Price |
$100.45
|
| Rate for Payer: ChoiceCare Network Commercial |
$139.20
|
| Rate for Payer: Cigna of WY Commercial |
$140.63
|
| Rate for Payer: Entrust Commercial |
$136.32
|
| Rate for Payer: First Choice Health Commercial |
$136.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$136.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$83.23
|
| Rate for Payer: HealthUtah PPO |
$143.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$139.20
|
| Rate for Payer: Multiplan Medicare/VA |
$79.07
|
| Rate for Payer: One Health Plan of WY PPO |
$140.63
|
| Rate for Payer: PacificSource Commercial |
$129.15
|
| Rate for Payer: PHCS PPO |
$140.63
|
| Rate for Payer: Three Rivers PPO |
$107.62
|
| Rate for Payer: TriWest Veterans Administration |
$83.23
|
| Rate for Payer: United Healthcare Commercial |
$124.84
|
| Rate for Payer: United Healthcare Medicare |
$83.23
|
| Rate for Payer: WINHealth Partners Commercial |
$140.63
|
| Rate for Payer: Wise Provider Network Commercial |
$136.32
|
|
|
FREEDOM CMC THUMBFIT RT MED
|
Facility
|
IP
|
$143.50
|
|
| Hospital Charge Code |
27000000S1
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$89.97 |
| Max. Negotiated Rate |
$143.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$140.63
|
| Rate for Payer: Altius Auto/Workers Compensation |
$137.76
|
| Rate for Payer: Altius Commercial |
$137.76
|
| Rate for Payer: Beech Street Commercial |
$140.63
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$117.81
|
| Rate for Payer: Cash Price |
$100.45
|
| Rate for Payer: ChoiceCare Network Commercial |
$139.20
|
| Rate for Payer: Cigna of WY Commercial |
$140.63
|
| Rate for Payer: Entrust Commercial |
$136.32
|
| Rate for Payer: First Choice Health Commercial |
$136.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$136.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$94.71
|
| Rate for Payer: HealthUtah PPO |
$143.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$139.20
|
| Rate for Payer: Multiplan Medicare/VA |
$89.97
|
| Rate for Payer: One Health Plan of WY PPO |
$140.63
|
| Rate for Payer: PacificSource Commercial |
$129.15
|
| Rate for Payer: PHCS PPO |
$140.63
|
| Rate for Payer: Three Rivers PPO |
$107.62
|
| Rate for Payer: TriWest Veterans Administration |
$94.71
|
| Rate for Payer: United Healthcare Commercial |
$124.84
|
| Rate for Payer: United Healthcare Medicare |
$94.71
|
| Rate for Payer: WINHealth Partners Commercial |
$136.32
|
| Rate for Payer: Wise Provider Network Commercial |
$136.32
|
|
|
FREEDOM CMC THUMBFIT RT SM
|
Facility
|
IP
|
$147.88
|
|
| Hospital Charge Code |
27000000S1
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$92.72 |
| Max. Negotiated Rate |
$147.88 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$144.92
|
| Rate for Payer: Altius Auto/Workers Compensation |
$141.96
|
| Rate for Payer: Altius Commercial |
$141.96
|
| Rate for Payer: Beech Street Commercial |
$144.92
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$121.41
|
| Rate for Payer: Cash Price |
$103.51
|
| Rate for Payer: ChoiceCare Network Commercial |
$143.44
|
| Rate for Payer: Cigna of WY Commercial |
$144.92
|
| Rate for Payer: Entrust Commercial |
$140.49
|
| Rate for Payer: First Choice Health Commercial |
$140.49
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$140.49
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$97.60
|
| Rate for Payer: HealthUtah PPO |
$147.88
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$143.44
|
| Rate for Payer: Multiplan Medicare/VA |
$92.72
|
| Rate for Payer: One Health Plan of WY PPO |
$144.92
|
| Rate for Payer: PacificSource Commercial |
$133.09
|
| Rate for Payer: PHCS PPO |
$144.92
|
| Rate for Payer: Three Rivers PPO |
$110.91
|
| Rate for Payer: TriWest Veterans Administration |
$97.60
|
| Rate for Payer: United Healthcare Commercial |
$128.66
|
| Rate for Payer: United Healthcare Medicare |
$97.60
|
| Rate for Payer: WINHealth Partners Commercial |
$140.49
|
| Rate for Payer: Wise Provider Network Commercial |
$140.49
|
|
|
FREEDOM CMC THUMBFIT RT SM
|
Facility
|
OP
|
$147.88
|
|
| Hospital Charge Code |
27000000S1
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$81.48 |
| Max. Negotiated Rate |
$147.88 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$144.92
|
| Rate for Payer: Aetna of WY Medicare |
$97.60
|
| Rate for Payer: Altius Auto/Workers Compensation |
$141.96
|
| Rate for Payer: Altius Commercial |
$141.96
|
| Rate for Payer: Beech Street Commercial |
$144.92
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$121.41
|
| Rate for Payer: Cash Price |
$103.51
|
| Rate for Payer: ChoiceCare Network Commercial |
$143.44
|
| Rate for Payer: Cigna of WY Commercial |
$144.92
|
| Rate for Payer: Entrust Commercial |
$140.49
|
| Rate for Payer: First Choice Health Commercial |
$140.49
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$140.49
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$85.77
|
| Rate for Payer: HealthUtah PPO |
$147.88
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$143.44
|
| Rate for Payer: Multiplan Medicare/VA |
$81.48
|
| Rate for Payer: One Health Plan of WY PPO |
$144.92
|
| Rate for Payer: PacificSource Commercial |
$133.09
|
| Rate for Payer: PHCS PPO |
$144.92
|
| Rate for Payer: Three Rivers PPO |
$110.91
|
| Rate for Payer: TriWest Veterans Administration |
$85.77
|
| Rate for Payer: United Healthcare Commercial |
$128.66
|
| Rate for Payer: United Healthcare Medicare |
$85.77
|
| Rate for Payer: WINHealth Partners Commercial |
$144.92
|
| Rate for Payer: Wise Provider Network Commercial |
$140.49
|
|
|
FREEDOM CMC THUMBFIT RT XLG
|
Facility
|
IP
|
$143.50
|
|
| Hospital Charge Code |
27000000S1
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$89.97 |
| Max. Negotiated Rate |
$143.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$140.63
|
| Rate for Payer: Altius Auto/Workers Compensation |
$137.76
|
| Rate for Payer: Altius Commercial |
$137.76
|
| Rate for Payer: Beech Street Commercial |
$140.63
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$117.81
|
| Rate for Payer: Cash Price |
$100.45
|
| Rate for Payer: ChoiceCare Network Commercial |
$139.20
|
| Rate for Payer: Cigna of WY Commercial |
$140.63
|
| Rate for Payer: Entrust Commercial |
$136.32
|
| Rate for Payer: First Choice Health Commercial |
$136.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$136.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$94.71
|
| Rate for Payer: HealthUtah PPO |
$143.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$139.20
|
| Rate for Payer: Multiplan Medicare/VA |
$89.97
|
| Rate for Payer: One Health Plan of WY PPO |
$140.63
|
| Rate for Payer: PacificSource Commercial |
$129.15
|
| Rate for Payer: PHCS PPO |
$140.63
|
| Rate for Payer: Three Rivers PPO |
$107.62
|
| Rate for Payer: TriWest Veterans Administration |
$94.71
|
| Rate for Payer: United Healthcare Commercial |
$124.84
|
| Rate for Payer: United Healthcare Medicare |
$94.71
|
| Rate for Payer: WINHealth Partners Commercial |
$136.32
|
| Rate for Payer: Wise Provider Network Commercial |
$136.32
|
|
|
FREEDOM CMC THUMBFIT RT XLG
|
Facility
|
OP
|
$143.50
|
|
| Hospital Charge Code |
27000000S1
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$79.07 |
| Max. Negotiated Rate |
$143.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$140.63
|
| Rate for Payer: Aetna of WY Medicare |
$94.71
|
| Rate for Payer: Altius Auto/Workers Compensation |
$137.76
|
| Rate for Payer: Altius Commercial |
$137.76
|
| Rate for Payer: Beech Street Commercial |
$140.63
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$117.81
|
| Rate for Payer: Cash Price |
$100.45
|
| Rate for Payer: ChoiceCare Network Commercial |
$139.20
|
| Rate for Payer: Cigna of WY Commercial |
$140.63
|
| Rate for Payer: Entrust Commercial |
$136.32
|
| Rate for Payer: First Choice Health Commercial |
$136.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$136.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$83.23
|
| Rate for Payer: HealthUtah PPO |
$143.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$139.20
|
| Rate for Payer: Multiplan Medicare/VA |
$79.07
|
| Rate for Payer: One Health Plan of WY PPO |
$140.63
|
| Rate for Payer: PacificSource Commercial |
$129.15
|
| Rate for Payer: PHCS PPO |
$140.63
|
| Rate for Payer: Three Rivers PPO |
$107.62
|
| Rate for Payer: TriWest Veterans Administration |
$83.23
|
| Rate for Payer: United Healthcare Commercial |
$124.84
|
| Rate for Payer: United Healthcare Medicare |
$83.23
|
| Rate for Payer: WINHealth Partners Commercial |
$140.63
|
| Rate for Payer: Wise Provider Network Commercial |
$136.32
|
|
|
FRENOPLASTY SURG REVJ FRENUM EG W/Z-PLASTY
|
Professional
|
Both
|
$1,280.00
|
|
|
Service Code
|
HCPCS 41520
|
| Hospital Charge Code |
41520
|
| Min. Negotiated Rate |
$208.90 |
| Max. Negotiated Rate |
$1,280.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,254.40
|
| Rate for Payer: Aetna of WY Medicare |
$245.76
|
| Rate for Payer: Beech Street Commercial |
$1,216.00
|
| Rate for Payer: Cash Price |
$896.00
|
| Rate for Payer: Cash Price |
$896.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,241.60
|
| Rate for Payer: Cigna of WY Commercial |
$1,254.40
|
| Rate for Payer: First Choice Health Commercial |
$1,152.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,216.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$245.76
|
| Rate for Payer: HealthUtah PPO |
$1,280.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,241.60
|
| Rate for Payer: Multiplan Medicare/VA |
$208.90
|
| Rate for Payer: One Health Plan of WY PPO |
$1,254.40
|
| Rate for Payer: PacificSource Commercial |
$1,152.00
|
| Rate for Payer: PHCS PPO |
$1,216.00
|
| Rate for Payer: Three Rivers PPO |
$960.00
|
| Rate for Payer: TriWest Veterans Administration |
$245.76
|
| Rate for Payer: United Healthcare Commercial |
$1,113.60
|
| Rate for Payer: United Healthcare Medicare |
$245.76
|
| Rate for Payer: WINHealth Partners Commercial |
$1,088.00
|
|
|
FTH/GFT FR DIR CLSR F/C/C/M/N/AX/G/H/F 20SQCM/<
|
Professional
|
Both
|
$3,971.00
|
|
|
Service Code
|
HCPCS 15240
|
| Hospital Charge Code |
15240
|
| Min. Negotiated Rate |
$655.29 |
| Max. Negotiated Rate |
$3,971.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,891.58
|
| Rate for Payer: Aetna of WY Medicare |
$770.93
|
| Rate for Payer: Beech Street Commercial |
$3,772.45
|
| Rate for Payer: Cash Price |
$2,779.70
|
| Rate for Payer: Cash Price |
$2,779.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,851.87
|
| Rate for Payer: Cigna of WY Commercial |
$3,891.58
|
| Rate for Payer: First Choice Health Commercial |
$3,573.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,772.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$770.93
|
| Rate for Payer: HealthUtah PPO |
$3,971.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,851.87
|
| Rate for Payer: Multiplan Medicare/VA |
$655.29
|
| Rate for Payer: One Health Plan of WY PPO |
$3,891.58
|
| Rate for Payer: PacificSource Commercial |
$3,573.90
|
| Rate for Payer: PHCS PPO |
$3,772.45
|
| Rate for Payer: Three Rivers PPO |
$2,978.25
|
| Rate for Payer: TriWest Veterans Administration |
$770.93
|
| Rate for Payer: United Healthcare Commercial |
$3,454.77
|
| Rate for Payer: United Healthcare Medicare |
$770.93
|
| Rate for Payer: WINHealth Partners Commercial |
$3,375.35
|
|
