|
FENTANYL 75 MCG/HR TRANSDERMAL PATCH [18521]
|
Facility
|
OP
|
$55.04
|
|
|
Service Code
|
NDC 4778142747
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$29.80 |
| Max. Negotiated Rate |
$55.04 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$53.94
|
| Rate for Payer: Aetna of WY Medicare |
$36.33
|
| Rate for Payer: Altius Commercial |
$52.84
|
| Rate for Payer: Beech Street Commercial |
$53.94
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$53.39
|
| Rate for Payer: Cash Price |
$38.53
|
| Rate for Payer: ChoiceCare Network Commercial |
$53.39
|
| Rate for Payer: Cigna of WY Commercial |
$53.94
|
| Rate for Payer: Entrust Commercial |
$52.29
|
| Rate for Payer: First Choice Health Commercial |
$52.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$52.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$31.37
|
| Rate for Payer: HealthUtah PPO |
$55.04
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$53.39
|
| Rate for Payer: Multiplan Medicare/VA |
$29.80
|
| Rate for Payer: One Health Plan of WY PPO |
$53.94
|
| Rate for Payer: PacificSource Commercial |
$49.54
|
| Rate for Payer: PHCS PPO |
$53.94
|
| Rate for Payer: Three Rivers PPO |
$41.28
|
| Rate for Payer: TriWest Veterans Administration |
$31.37
|
| Rate for Payer: United Healthcare Commercial |
$52.56
|
| Rate for Payer: United Healthcare Medicare |
$31.37
|
| Rate for Payer: WINHealth Partners Commercial |
$53.94
|
| Rate for Payer: Wise Provider Network Commercial |
$52.29
|
|
|
FENTANYL 75 MCG/HR TRANSDERMAL PATCH [18521]
|
Facility
|
IP
|
$55.04
|
|
|
Service Code
|
NDC 4778142747
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$31.90 |
| Max. Negotiated Rate |
$55.04 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$53.94
|
| Rate for Payer: Aetna of WY Medicare |
$35.23
|
| Rate for Payer: Altius Commercial |
$52.84
|
| Rate for Payer: Beech Street Commercial |
$53.94
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$53.39
|
| Rate for Payer: Cash Price |
$38.53
|
| Rate for Payer: ChoiceCare Network Commercial |
$53.39
|
| Rate for Payer: Cigna of WY Commercial |
$53.94
|
| Rate for Payer: Entrust Commercial |
$52.29
|
| Rate for Payer: First Choice Health Commercial |
$52.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$52.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$33.57
|
| Rate for Payer: HealthUtah PPO |
$55.04
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$53.39
|
| Rate for Payer: Multiplan Medicare/VA |
$31.90
|
| Rate for Payer: One Health Plan of WY PPO |
$53.94
|
| Rate for Payer: PacificSource Commercial |
$49.54
|
| Rate for Payer: PHCS PPO |
$53.94
|
| Rate for Payer: Three Rivers PPO |
$41.28
|
| Rate for Payer: TriWest Veterans Administration |
$33.57
|
| Rate for Payer: United Healthcare Commercial |
$52.56
|
| Rate for Payer: United Healthcare Medicare |
$33.57
|
| Rate for Payer: WINHealth Partners Commercial |
$52.29
|
| Rate for Payer: Wise Provider Network Commercial |
$52.29
|
|
|
FENTANYL 75 MCG/HR TRANSDERMAL PATCH [18521]
|
Facility
|
OP
|
$55.04
|
|
|
Service Code
|
NDC 0378912316
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$29.80 |
| Max. Negotiated Rate |
$55.04 |
| Rate for Payer: United Healthcare Commercial |
$52.56
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$53.94
|
| Rate for Payer: Aetna of WY Medicare |
$36.33
|
| Rate for Payer: Altius Commercial |
$52.84
|
| Rate for Payer: Beech Street Commercial |
$53.94
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$53.39
|
| Rate for Payer: Cash Price |
$38.53
|
| Rate for Payer: ChoiceCare Network Commercial |
$53.39
|
| Rate for Payer: Cigna of WY Commercial |
$53.94
|
| Rate for Payer: Entrust Commercial |
$52.29
|
| Rate for Payer: First Choice Health Commercial |
$52.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$52.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$31.37
|
| Rate for Payer: HealthUtah PPO |
$55.04
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$53.39
|
| Rate for Payer: Multiplan Medicare/VA |
$29.80
|
| Rate for Payer: One Health Plan of WY PPO |
$53.94
|
| Rate for Payer: PacificSource Commercial |
$49.54
|
| Rate for Payer: PHCS PPO |
$53.94
|
| Rate for Payer: Three Rivers PPO |
$41.28
|
| Rate for Payer: TriWest Veterans Administration |
$31.37
|
| Rate for Payer: United Healthcare Medicare |
$31.37
|
| Rate for Payer: WINHealth Partners Commercial |
$53.94
|
| Rate for Payer: Wise Provider Network Commercial |
$52.29
|
|
|
FENTANYL 75 MCG/HR TRANSDERMAL PATCH [18521]
|
Facility
|
IP
|
$55.04
|
|
|
Service Code
|
NDC 0378912316
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$31.90 |
| Max. Negotiated Rate |
$55.04 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$53.94
|
| Rate for Payer: Aetna of WY Medicare |
$35.23
|
| Rate for Payer: Altius Commercial |
$52.84
|
| Rate for Payer: Beech Street Commercial |
$53.94
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$53.39
|
| Rate for Payer: Cash Price |
$38.53
|
| Rate for Payer: ChoiceCare Network Commercial |
$53.39
|
| Rate for Payer: Cigna of WY Commercial |
$53.94
|
| Rate for Payer: Entrust Commercial |
$52.29
|
| Rate for Payer: First Choice Health Commercial |
$52.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$52.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$33.57
|
| Rate for Payer: HealthUtah PPO |
$55.04
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$53.39
|
| Rate for Payer: Multiplan Medicare/VA |
$31.90
|
| Rate for Payer: One Health Plan of WY PPO |
$53.94
|
| Rate for Payer: PacificSource Commercial |
$49.54
|
| Rate for Payer: PHCS PPO |
$53.94
|
| Rate for Payer: Three Rivers PPO |
$41.28
|
| Rate for Payer: TriWest Veterans Administration |
$33.57
|
| Rate for Payer: United Healthcare Commercial |
$52.56
|
| Rate for Payer: United Healthcare Medicare |
$33.57
|
| Rate for Payer: WINHealth Partners Commercial |
$52.29
|
| Rate for Payer: Wise Provider Network Commercial |
$52.29
|
|
|
FENTANYL CITRATE INJECTION
|
Professional
|
Both
|
$10.00
|
|
|
Service Code
|
HCPCS J3010
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$10.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$9.80
|
| Rate for Payer: Aetna of WY Medicare |
$0.99
|
| Rate for Payer: Beech Street Commercial |
$9.50
|
| Rate for Payer: Cash Price |
$7.00
|
| Rate for Payer: Cash Price |
$7.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$9.70
|
| Rate for Payer: Cigna of WY Commercial |
$9.80
|
| Rate for Payer: First Choice Health Commercial |
$9.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$9.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.99
|
| Rate for Payer: HealthUtah PPO |
$10.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$9.70
|
| Rate for Payer: Multiplan Medicare/VA |
$0.84
|
| Rate for Payer: One Health Plan of WY PPO |
$9.80
|
| Rate for Payer: PacificSource Commercial |
$9.00
|
| Rate for Payer: PHCS PPO |
$9.50
|
| Rate for Payer: Three Rivers PPO |
$7.50
|
| Rate for Payer: TriWest Veterans Administration |
$0.99
|
| Rate for Payer: United Healthcare Commercial |
$9.50
|
| Rate for Payer: WINHealth Partners Commercial |
$9.50
|
|
|
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION [14425]
|
Facility
|
IP
|
$16.85
|
|
|
Service Code
|
HCPCS J3010
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.76 |
| Max. Negotiated Rate |
$16.85 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.51
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$17.72
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$17.05
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18.86
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$19.19
|
| Rate for Payer: Aetna of WY Medicare |
$11.14
|
| Rate for Payer: Aetna of WY Medicare |
$10.78
|
| Rate for Payer: Aetna of WY Medicare |
$11.57
|
| Rate for Payer: Aetna of WY Medicare |
$12.32
|
| Rate for Payer: Aetna of WY Medicare |
$12.53
|
| Rate for Payer: Altius Commercial |
$18.48
|
| Rate for Payer: Altius Commercial |
$18.80
|
| Rate for Payer: Altius Commercial |
$16.18
|
| Rate for Payer: Altius Commercial |
$17.36
|
| Rate for Payer: Altius Commercial |
$16.70
|
| Rate for Payer: Beech Street Commercial |
$17.72
|
| Rate for Payer: Beech Street Commercial |
$18.86
|
| Rate for Payer: Beech Street Commercial |
$19.19
|
| Rate for Payer: Beech Street Commercial |
$16.51
|
| Rate for Payer: Beech Street Commercial |
$17.05
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.88
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$18.67
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$18.99
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.34
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$17.54
|
| Rate for Payer: Cash Price |
$12.66
|
| Rate for Payer: Cash Price |
$11.79
|
| Rate for Payer: Cash Price |
$13.71
|
| Rate for Payer: Cash Price |
$12.18
|
| Rate for Payer: Cash Price |
$13.47
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.88
|
| Rate for Payer: ChoiceCare Network Commercial |
$17.54
|
| Rate for Payer: ChoiceCare Network Commercial |
$18.67
|
| Rate for Payer: ChoiceCare Network Commercial |
$18.99
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.34
|
| Rate for Payer: Cigna of WY Commercial |
$17.72
|
| Rate for Payer: Cigna of WY Commercial |
$19.19
|
| Rate for Payer: Cigna of WY Commercial |
$18.86
|
| Rate for Payer: Cigna of WY Commercial |
$17.05
|
| Rate for Payer: Cigna of WY Commercial |
$16.51
|
| Rate for Payer: Entrust Commercial |
$17.18
|
| Rate for Payer: Entrust Commercial |
$18.29
|
| Rate for Payer: Entrust Commercial |
$18.60
|
| Rate for Payer: Entrust Commercial |
$16.53
|
| Rate for Payer: Entrust Commercial |
$16.01
|
| Rate for Payer: First Choice Health Commercial |
$18.60
|
| Rate for Payer: First Choice Health Commercial |
$16.53
|
| Rate for Payer: First Choice Health Commercial |
$18.29
|
| Rate for Payer: First Choice Health Commercial |
$16.01
|
| Rate for Payer: First Choice Health Commercial |
$17.18
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.01
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.53
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$18.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.18
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$18.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.28
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.61
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.03
|
| Rate for Payer: HealthUtah PPO |
$18.08
|
| Rate for Payer: HealthUtah PPO |
$16.85
|
| Rate for Payer: HealthUtah PPO |
$19.58
|
| Rate for Payer: HealthUtah PPO |
$19.25
|
| Rate for Payer: HealthUtah PPO |
$17.40
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$18.67
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.34
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.88
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.54
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$18.99
|
| Rate for Payer: Multiplan Medicare/VA |
$10.08
|
| Rate for Payer: Multiplan Medicare/VA |
$10.48
|
| Rate for Payer: Multiplan Medicare/VA |
$11.16
|
| Rate for Payer: Multiplan Medicare/VA |
$9.76
|
| Rate for Payer: Multiplan Medicare/VA |
$11.35
|
| Rate for Payer: One Health Plan of WY PPO |
$16.51
|
| Rate for Payer: One Health Plan of WY PPO |
$18.86
|
| Rate for Payer: One Health Plan of WY PPO |
$17.72
|
| Rate for Payer: One Health Plan of WY PPO |
$17.05
|
| Rate for Payer: One Health Plan of WY PPO |
$19.19
|
| Rate for Payer: PacificSource Commercial |
$17.62
|
| Rate for Payer: PacificSource Commercial |
$15.66
|
| Rate for Payer: PacificSource Commercial |
$17.32
|
| Rate for Payer: PacificSource Commercial |
$16.27
|
| Rate for Payer: PacificSource Commercial |
$15.16
|
| Rate for Payer: PHCS PPO |
$16.51
|
| Rate for Payer: PHCS PPO |
$17.72
|
| Rate for Payer: PHCS PPO |
$17.05
|
| Rate for Payer: PHCS PPO |
$18.86
|
| Rate for Payer: PHCS PPO |
$19.19
|
| Rate for Payer: Three Rivers PPO |
$14.44
|
| Rate for Payer: Three Rivers PPO |
$12.64
|
| Rate for Payer: Three Rivers PPO |
$14.68
|
| Rate for Payer: Three Rivers PPO |
$13.56
|
| Rate for Payer: Three Rivers PPO |
$13.05
|
| Rate for Payer: TriWest Veterans Administration |
$10.61
|
| Rate for Payer: TriWest Veterans Administration |
$11.94
|
| Rate for Payer: TriWest Veterans Administration |
$10.28
|
| Rate for Payer: TriWest Veterans Administration |
$11.03
|
| Rate for Payer: TriWest Veterans Administration |
$11.74
|
| Rate for Payer: United Healthcare Commercial |
$18.70
|
| Rate for Payer: United Healthcare Commercial |
$17.27
|
| Rate for Payer: United Healthcare Commercial |
$16.09
|
| Rate for Payer: United Healthcare Commercial |
$16.62
|
| Rate for Payer: United Healthcare Commercial |
$18.38
|
| Rate for Payer: United Healthcare Medicare |
$11.74
|
| Rate for Payer: United Healthcare Medicare |
$10.61
|
| Rate for Payer: United Healthcare Medicare |
$10.28
|
| Rate for Payer: United Healthcare Medicare |
$11.03
|
| Rate for Payer: United Healthcare Medicare |
$11.94
|
| Rate for Payer: WINHealth Partners Commercial |
$18.29
|
| Rate for Payer: WINHealth Partners Commercial |
$17.18
|
| Rate for Payer: WINHealth Partners Commercial |
$18.60
|
| Rate for Payer: WINHealth Partners Commercial |
$16.01
|
| Rate for Payer: WINHealth Partners Commercial |
$16.53
|
| Rate for Payer: Wise Provider Network Commercial |
$16.01
|
| Rate for Payer: Wise Provider Network Commercial |
$18.29
|
| Rate for Payer: Wise Provider Network Commercial |
$16.53
|
| Rate for Payer: Wise Provider Network Commercial |
$18.60
|
| Rate for Payer: Wise Provider Network Commercial |
$17.18
|
|
|
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION [14425]
|
Facility
|
OP
|
$17.40
|
|
|
Service Code
|
HCPCS J3010
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.42 |
| Max. Negotiated Rate |
$17.40 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$17.05
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18.86
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$17.72
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$19.19
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.51
|
| Rate for Payer: Aetna of WY Medicare |
$12.92
|
| Rate for Payer: Aetna of WY Medicare |
$11.12
|
| Rate for Payer: Aetna of WY Medicare |
$12.70
|
| Rate for Payer: Aetna of WY Medicare |
$11.48
|
| Rate for Payer: Aetna of WY Medicare |
$11.93
|
| Rate for Payer: Altius Commercial |
$18.80
|
| Rate for Payer: Altius Commercial |
$16.18
|
| Rate for Payer: Altius Commercial |
$16.70
|
| Rate for Payer: Altius Commercial |
$17.36
|
| Rate for Payer: Altius Commercial |
$18.48
|
| Rate for Payer: Beech Street Commercial |
$17.72
|
| Rate for Payer: Beech Street Commercial |
$18.86
|
| Rate for Payer: Beech Street Commercial |
$16.51
|
| Rate for Payer: Beech Street Commercial |
$17.05
|
| Rate for Payer: Beech Street Commercial |
$19.19
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$18.99
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.34
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$17.54
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$18.67
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.88
|
| Rate for Payer: Cash Price |
$12.18
|
| Rate for Payer: Cash Price |
$13.47
|
| Rate for Payer: Cash Price |
$11.79
|
| Rate for Payer: Cash Price |
$12.66
|
| Rate for Payer: Cash Price |
$13.71
|
| Rate for Payer: ChoiceCare Network Commercial |
$18.99
|
| Rate for Payer: ChoiceCare Network Commercial |
$17.54
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.88
|
| Rate for Payer: ChoiceCare Network Commercial |
$18.67
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.34
|
| Rate for Payer: Cigna of WY Commercial |
$18.86
|
| Rate for Payer: Cigna of WY Commercial |
$16.51
|
| Rate for Payer: Cigna of WY Commercial |
$19.19
|
| Rate for Payer: Cigna of WY Commercial |
$17.72
|
| Rate for Payer: Cigna of WY Commercial |
$17.05
|
| Rate for Payer: Entrust Commercial |
$18.60
|
| Rate for Payer: Entrust Commercial |
$16.53
|
| Rate for Payer: Entrust Commercial |
$16.01
|
| Rate for Payer: Entrust Commercial |
$17.18
|
| Rate for Payer: Entrust Commercial |
$18.29
|
| Rate for Payer: First Choice Health Commercial |
$16.01
|
| Rate for Payer: First Choice Health Commercial |
$17.18
|
| Rate for Payer: First Choice Health Commercial |
$18.29
|
| Rate for Payer: First Choice Health Commercial |
$18.60
|
| Rate for Payer: First Choice Health Commercial |
$16.53
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$18.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$18.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.18
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.01
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.53
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.31
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.97
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.92
|
| Rate for Payer: HealthUtah PPO |
$17.40
|
| Rate for Payer: HealthUtah PPO |
$18.08
|
| Rate for Payer: HealthUtah PPO |
$19.58
|
| Rate for Payer: HealthUtah PPO |
$19.25
|
| Rate for Payer: HealthUtah PPO |
$16.85
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$18.67
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.54
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.34
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$18.99
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.88
|
| Rate for Payer: Multiplan Medicare/VA |
$9.42
|
| Rate for Payer: Multiplan Medicare/VA |
$10.60
|
| Rate for Payer: Multiplan Medicare/VA |
$9.79
|
| Rate for Payer: Multiplan Medicare/VA |
$10.42
|
| Rate for Payer: Multiplan Medicare/VA |
$9.12
|
| Rate for Payer: One Health Plan of WY PPO |
$17.72
|
| Rate for Payer: One Health Plan of WY PPO |
$16.51
|
| Rate for Payer: One Health Plan of WY PPO |
$17.05
|
| Rate for Payer: One Health Plan of WY PPO |
$18.86
|
| Rate for Payer: One Health Plan of WY PPO |
$19.19
|
| Rate for Payer: PacificSource Commercial |
$15.66
|
| Rate for Payer: PacificSource Commercial |
$16.27
|
| Rate for Payer: PacificSource Commercial |
$17.62
|
| Rate for Payer: PacificSource Commercial |
$17.32
|
| Rate for Payer: PacificSource Commercial |
$15.16
|
| Rate for Payer: PHCS PPO |
$19.19
|
| Rate for Payer: PHCS PPO |
$17.05
|
| Rate for Payer: PHCS PPO |
$16.51
|
| Rate for Payer: PHCS PPO |
$18.86
|
| Rate for Payer: PHCS PPO |
$17.72
|
| Rate for Payer: Three Rivers PPO |
$14.44
|
| Rate for Payer: Three Rivers PPO |
$12.64
|
| Rate for Payer: Three Rivers PPO |
$14.68
|
| Rate for Payer: Three Rivers PPO |
$13.05
|
| Rate for Payer: Three Rivers PPO |
$13.56
|
| Rate for Payer: TriWest Veterans Administration |
$9.60
|
| Rate for Payer: TriWest Veterans Administration |
$10.31
|
| Rate for Payer: TriWest Veterans Administration |
$10.97
|
| Rate for Payer: TriWest Veterans Administration |
$9.92
|
| Rate for Payer: TriWest Veterans Administration |
$11.16
|
| Rate for Payer: United Healthcare Commercial |
$18.70
|
| Rate for Payer: United Healthcare Commercial |
$16.09
|
| Rate for Payer: United Healthcare Commercial |
$17.27
|
| Rate for Payer: United Healthcare Commercial |
$16.62
|
| Rate for Payer: United Healthcare Commercial |
$18.38
|
| Rate for Payer: United Healthcare Medicare |
$10.97
|
| Rate for Payer: United Healthcare Medicare |
$9.92
|
| Rate for Payer: United Healthcare Medicare |
$9.60
|
| Rate for Payer: United Healthcare Medicare |
$11.16
|
| Rate for Payer: United Healthcare Medicare |
$10.31
|
| Rate for Payer: WINHealth Partners Commercial |
$17.72
|
| Rate for Payer: WINHealth Partners Commercial |
$17.05
|
| Rate for Payer: WINHealth Partners Commercial |
$16.51
|
| Rate for Payer: WINHealth Partners Commercial |
$18.86
|
| Rate for Payer: WINHealth Partners Commercial |
$19.19
|
| Rate for Payer: Wise Provider Network Commercial |
$16.01
|
| Rate for Payer: Wise Provider Network Commercial |
$17.18
|
| Rate for Payer: Wise Provider Network Commercial |
$16.53
|
| Rate for Payer: Wise Provider Network Commercial |
$18.60
|
| Rate for Payer: Wise Provider Network Commercial |
$18.29
|
|
|
FERN TEST
|
Professional
|
Both
|
$89.00
|
|
|
Service Code
|
HCPCS Q0114
|
| Min. Negotiated Rate |
$8.28 |
| Max. Negotiated Rate |
$89.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$87.22
|
| Rate for Payer: Aetna of WY Medicare |
$9.74
|
| Rate for Payer: Beech Street Commercial |
$84.55
|
| Rate for Payer: Cash Price |
$62.30
|
| Rate for Payer: Cash Price |
$62.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$86.33
|
| Rate for Payer: Cigna of WY Commercial |
$87.22
|
| Rate for Payer: First Choice Health Commercial |
$80.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$84.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.74
|
| Rate for Payer: HealthUtah PPO |
$89.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$86.33
|
| Rate for Payer: Multiplan Medicare/VA |
$8.28
|
| Rate for Payer: One Health Plan of WY PPO |
$87.22
|
| Rate for Payer: PacificSource Commercial |
$80.10
|
| Rate for Payer: PHCS PPO |
$84.55
|
| Rate for Payer: Three Rivers PPO |
$66.75
|
| Rate for Payer: TriWest Veterans Administration |
$9.74
|
| Rate for Payer: United Healthcare Commercial |
$84.55
|
| Rate for Payer: WINHealth Partners Commercial |
$84.55
|
|
|
FERRIC CARBOXYMALTOSE 50 MG IRON/ML INTRAVENOUS SOLUTION [129037]
|
Facility
|
OP
|
$176.94
|
|
|
Service Code
|
HCPCS J1439
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$95.81 |
| Max. Negotiated Rate |
$176.94 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$173.40
|
| Rate for Payer: Aetna of WY Medicare |
$116.78
|
| Rate for Payer: Altius Commercial |
$169.86
|
| Rate for Payer: Beech Street Commercial |
$173.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$171.63
|
| Rate for Payer: Cash Price |
$123.86
|
| Rate for Payer: ChoiceCare Network Commercial |
$171.63
|
| Rate for Payer: Cigna of WY Commercial |
$173.40
|
| Rate for Payer: Entrust Commercial |
$168.09
|
| Rate for Payer: First Choice Health Commercial |
$168.09
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$168.09
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$100.86
|
| Rate for Payer: HealthUtah PPO |
$176.94
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$171.63
|
| Rate for Payer: Multiplan Medicare/VA |
$95.81
|
| Rate for Payer: One Health Plan of WY PPO |
$173.40
|
| Rate for Payer: PacificSource Commercial |
$159.25
|
| Rate for Payer: PHCS PPO |
$173.40
|
| Rate for Payer: Three Rivers PPO |
$132.70
|
| Rate for Payer: TriWest Veterans Administration |
$100.86
|
| Rate for Payer: United Healthcare Commercial |
$168.98
|
| Rate for Payer: United Healthcare Medicare |
$100.86
|
| Rate for Payer: WINHealth Partners Commercial |
$173.40
|
| Rate for Payer: Wise Provider Network Commercial |
$168.09
|
|
|
FERRIC CARBOXYMALTOSE 50 MG IRON/ML INTRAVENOUS SOLUTION [129037]
|
Facility
|
IP
|
$176.94
|
|
|
Service Code
|
HCPCS J1439
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$102.54 |
| Max. Negotiated Rate |
$176.94 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$173.40
|
| Rate for Payer: Aetna of WY Medicare |
$113.24
|
| Rate for Payer: Altius Commercial |
$169.86
|
| Rate for Payer: Beech Street Commercial |
$173.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$171.63
|
| Rate for Payer: Cash Price |
$123.86
|
| Rate for Payer: ChoiceCare Network Commercial |
$171.63
|
| Rate for Payer: Cigna of WY Commercial |
$173.40
|
| Rate for Payer: Entrust Commercial |
$168.09
|
| Rate for Payer: First Choice Health Commercial |
$168.09
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$168.09
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$107.93
|
| Rate for Payer: HealthUtah PPO |
$176.94
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$171.63
|
| Rate for Payer: Multiplan Medicare/VA |
$102.54
|
| Rate for Payer: One Health Plan of WY PPO |
$173.40
|
| Rate for Payer: PacificSource Commercial |
$159.25
|
| Rate for Payer: PHCS PPO |
$173.40
|
| Rate for Payer: Three Rivers PPO |
$132.70
|
| Rate for Payer: TriWest Veterans Administration |
$107.93
|
| Rate for Payer: United Healthcare Commercial |
$168.98
|
| Rate for Payer: United Healthcare Medicare |
$107.93
|
| Rate for Payer: WINHealth Partners Commercial |
$168.09
|
| Rate for Payer: Wise Provider Network Commercial |
$168.09
|
|
|
FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION [87295]
|
Facility
|
IP
|
$137.87
|
|
|
Service Code
|
HCPCS Q0139
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$79.90 |
| Max. Negotiated Rate |
$137.87 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$135.11
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$102.38
|
| Rate for Payer: Aetna of WY Medicare |
$88.24
|
| Rate for Payer: Aetna of WY Medicare |
$66.86
|
| Rate for Payer: Altius Commercial |
$100.29
|
| Rate for Payer: Altius Commercial |
$132.36
|
| Rate for Payer: Beech Street Commercial |
$135.11
|
| Rate for Payer: Beech Street Commercial |
$102.38
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$101.34
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$133.73
|
| Rate for Payer: Cash Price |
$73.13
|
| Rate for Payer: Cash Price |
$96.51
|
| Rate for Payer: ChoiceCare Network Commercial |
$133.73
|
| Rate for Payer: ChoiceCare Network Commercial |
$101.34
|
| Rate for Payer: Cigna of WY Commercial |
$135.11
|
| Rate for Payer: Cigna of WY Commercial |
$102.38
|
| Rate for Payer: Entrust Commercial |
$99.25
|
| Rate for Payer: Entrust Commercial |
$130.98
|
| Rate for Payer: First Choice Health Commercial |
$99.25
|
| Rate for Payer: First Choice Health Commercial |
$130.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$99.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$130.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$63.73
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$84.10
|
| Rate for Payer: HealthUtah PPO |
$137.87
|
| Rate for Payer: HealthUtah PPO |
$104.47
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$133.73
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$101.34
|
| Rate for Payer: Multiplan Medicare/VA |
$60.54
|
| Rate for Payer: Multiplan Medicare/VA |
$79.90
|
| Rate for Payer: One Health Plan of WY PPO |
$102.38
|
| Rate for Payer: One Health Plan of WY PPO |
$135.11
|
| Rate for Payer: PacificSource Commercial |
$94.02
|
| Rate for Payer: PacificSource Commercial |
$124.08
|
| Rate for Payer: PHCS PPO |
$135.11
|
| Rate for Payer: PHCS PPO |
$102.38
|
| Rate for Payer: Three Rivers PPO |
$78.35
|
| Rate for Payer: Three Rivers PPO |
$103.40
|
| Rate for Payer: TriWest Veterans Administration |
$84.10
|
| Rate for Payer: TriWest Veterans Administration |
$63.73
|
| Rate for Payer: United Healthcare Commercial |
$99.77
|
| Rate for Payer: United Healthcare Commercial |
$131.67
|
| Rate for Payer: United Healthcare Medicare |
$63.73
|
| Rate for Payer: United Healthcare Medicare |
$84.10
|
| Rate for Payer: WINHealth Partners Commercial |
$130.98
|
| Rate for Payer: WINHealth Partners Commercial |
$99.25
|
| Rate for Payer: Wise Provider Network Commercial |
$99.25
|
| Rate for Payer: Wise Provider Network Commercial |
$130.98
|
|
|
FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION [87295]
|
Facility
|
OP
|
$104.47
|
|
|
Service Code
|
HCPCS Q0139
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$56.57 |
| Max. Negotiated Rate |
$104.47 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$102.38
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$135.11
|
| Rate for Payer: Aetna of WY Medicare |
$68.95
|
| Rate for Payer: Aetna of WY Medicare |
$90.99
|
| Rate for Payer: Altius Commercial |
$132.36
|
| Rate for Payer: Altius Commercial |
$100.29
|
| Rate for Payer: Beech Street Commercial |
$102.38
|
| Rate for Payer: Beech Street Commercial |
$135.11
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$133.73
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$101.34
|
| Rate for Payer: Cash Price |
$96.51
|
| Rate for Payer: Cash Price |
$73.13
|
| Rate for Payer: ChoiceCare Network Commercial |
$101.34
|
| Rate for Payer: ChoiceCare Network Commercial |
$133.73
|
| Rate for Payer: Cigna of WY Commercial |
$135.11
|
| Rate for Payer: Cigna of WY Commercial |
$102.38
|
| Rate for Payer: Entrust Commercial |
$99.25
|
| Rate for Payer: Entrust Commercial |
$130.98
|
| Rate for Payer: First Choice Health Commercial |
$130.98
|
| Rate for Payer: First Choice Health Commercial |
$99.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$130.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$99.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$78.59
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$59.55
|
| Rate for Payer: HealthUtah PPO |
$137.87
|
| Rate for Payer: HealthUtah PPO |
$104.47
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$101.34
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$133.73
|
| Rate for Payer: Multiplan Medicare/VA |
$74.66
|
| Rate for Payer: Multiplan Medicare/VA |
$56.57
|
| Rate for Payer: One Health Plan of WY PPO |
$102.38
|
| Rate for Payer: One Health Plan of WY PPO |
$135.11
|
| Rate for Payer: PacificSource Commercial |
$94.02
|
| Rate for Payer: PacificSource Commercial |
$124.08
|
| Rate for Payer: PHCS PPO |
$102.38
|
| Rate for Payer: PHCS PPO |
$135.11
|
| Rate for Payer: Three Rivers PPO |
$103.40
|
| Rate for Payer: Three Rivers PPO |
$78.35
|
| Rate for Payer: TriWest Veterans Administration |
$78.59
|
| Rate for Payer: TriWest Veterans Administration |
$59.55
|
| Rate for Payer: United Healthcare Commercial |
$99.77
|
| Rate for Payer: United Healthcare Commercial |
$131.67
|
| Rate for Payer: United Healthcare Medicare |
$59.55
|
| Rate for Payer: United Healthcare Medicare |
$78.59
|
| Rate for Payer: WINHealth Partners Commercial |
$102.38
|
| Rate for Payer: WINHealth Partners Commercial |
$135.11
|
| Rate for Payer: Wise Provider Network Commercial |
$130.98
|
| Rate for Payer: Wise Provider Network Commercial |
$99.25
|
|
|
FETAL BIOPHYSICAL PROFILE NON-STRESS TESTING
|
Professional
|
Both
|
$664.00
|
|
|
Service Code
|
HCPCS 76818
|
| Min. Negotiated Rate |
$98.72 |
| Max. Negotiated Rate |
$664.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$650.72
|
| Rate for Payer: Aetna of WY Medicare |
$116.14
|
| Rate for Payer: Beech Street Commercial |
$630.80
|
| Rate for Payer: Cash Price |
$464.80
|
| Rate for Payer: Cash Price |
$464.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$644.08
|
| Rate for Payer: Cigna of WY Commercial |
$650.72
|
| Rate for Payer: First Choice Health Commercial |
$597.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$630.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$116.14
|
| Rate for Payer: HealthUtah PPO |
$664.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$644.08
|
| Rate for Payer: Multiplan Medicare/VA |
$98.72
|
| Rate for Payer: One Health Plan of WY PPO |
$650.72
|
| Rate for Payer: PacificSource Commercial |
$597.60
|
| Rate for Payer: PHCS PPO |
$630.80
|
| Rate for Payer: Three Rivers PPO |
$498.00
|
| Rate for Payer: TriWest Veterans Administration |
$116.14
|
| Rate for Payer: United Healthcare Commercial |
$630.80
|
| Rate for Payer: WINHealth Partners Commercial |
$630.80
|
|
|
FETAL CONTRACTION STRESS TEST
|
Professional
|
Both
|
$179.00
|
|
|
Service Code
|
HCPCS 59020
|
| Min. Negotiated Rate |
$58.46 |
| Max. Negotiated Rate |
$179.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$175.42
|
| Rate for Payer: Aetna of WY Medicare |
$68.78
|
| Rate for Payer: Beech Street Commercial |
$170.05
|
| Rate for Payer: Cash Price |
$125.30
|
| Rate for Payer: Cash Price |
$125.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$173.63
|
| Rate for Payer: Cigna of WY Commercial |
$175.42
|
| Rate for Payer: First Choice Health Commercial |
$161.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$170.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$68.78
|
| Rate for Payer: HealthUtah PPO |
$179.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$173.63
|
| Rate for Payer: Multiplan Medicare/VA |
$58.46
|
| Rate for Payer: One Health Plan of WY PPO |
$175.42
|
| Rate for Payer: PacificSource Commercial |
$161.10
|
| Rate for Payer: PHCS PPO |
$170.05
|
| Rate for Payer: Three Rivers PPO |
$134.25
|
| Rate for Payer: TriWest Veterans Administration |
$68.78
|
| Rate for Payer: United Healthcare Commercial |
$170.05
|
| Rate for Payer: WINHealth Partners Commercial |
$152.15
|
|
|
FETAL NONSTRESS TEST
|
Professional
|
Both
|
$122.00
|
|
|
Service Code
|
HCPCS 59025
|
| Min. Negotiated Rate |
$40.17 |
| Max. Negotiated Rate |
$122.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$119.56
|
| Rate for Payer: Aetna of WY Medicare |
$47.26
|
| Rate for Payer: Beech Street Commercial |
$115.90
|
| Rate for Payer: Cash Price |
$85.40
|
| Rate for Payer: Cash Price |
$85.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$118.34
|
| Rate for Payer: Cigna of WY Commercial |
$119.56
|
| Rate for Payer: First Choice Health Commercial |
$109.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$115.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$47.26
|
| Rate for Payer: HealthUtah PPO |
$122.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$118.34
|
| Rate for Payer: Multiplan Medicare/VA |
$40.17
|
| Rate for Payer: One Health Plan of WY PPO |
$119.56
|
| Rate for Payer: PacificSource Commercial |
$109.80
|
| Rate for Payer: PHCS PPO |
$115.90
|
| Rate for Payer: Three Rivers PPO |
$91.50
|
| Rate for Payer: TriWest Veterans Administration |
$47.26
|
| Rate for Payer: United Healthcare Commercial |
$115.90
|
| Rate for Payer: WINHealth Partners Commercial |
$103.70
|
|
|
FIBERLOOP 4-0 10" AR-7249-20
|
Facility
|
OP
|
$175.00
|
|
| Hospital Charge Code |
3002256
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$94.76 |
| Max. Negotiated Rate |
$175.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$171.50
|
| Rate for Payer: Aetna of WY Medicare |
$115.50
|
| Rate for Payer: Altius Commercial |
$168.00
|
| Rate for Payer: Beech Street Commercial |
$171.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$169.75
|
| Rate for Payer: Cash Price |
$122.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$169.75
|
| Rate for Payer: Cigna of WY Commercial |
$171.50
|
| Rate for Payer: Entrust Commercial |
$166.25
|
| Rate for Payer: First Choice Health Commercial |
$166.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$166.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$99.75
|
| Rate for Payer: HealthUtah PPO |
$175.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$169.75
|
| Rate for Payer: Multiplan Medicare/VA |
$94.76
|
| Rate for Payer: One Health Plan of WY PPO |
$171.50
|
| Rate for Payer: PacificSource Commercial |
$157.50
|
| Rate for Payer: PHCS PPO |
$171.50
|
| Rate for Payer: Three Rivers PPO |
$131.25
|
| Rate for Payer: TriWest Veterans Administration |
$99.75
|
| Rate for Payer: United Healthcare Commercial |
$167.12
|
| Rate for Payer: United Healthcare Medicare |
$99.75
|
| Rate for Payer: WINHealth Partners Commercial |
$171.50
|
| Rate for Payer: Wise Provider Network Commercial |
$166.25
|
|
|
FIBERLOOP 4-0 10" AR-7249-20
|
Facility
|
IP
|
$175.00
|
|
| Hospital Charge Code |
3002256
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$101.41 |
| Max. Negotiated Rate |
$175.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$171.50
|
| Rate for Payer: Aetna of WY Medicare |
$112.00
|
| Rate for Payer: Altius Commercial |
$168.00
|
| Rate for Payer: Beech Street Commercial |
$171.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$169.75
|
| Rate for Payer: Cash Price |
$122.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$169.75
|
| Rate for Payer: Cigna of WY Commercial |
$171.50
|
| Rate for Payer: Entrust Commercial |
$166.25
|
| Rate for Payer: First Choice Health Commercial |
$166.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$166.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$106.75
|
| Rate for Payer: HealthUtah PPO |
$175.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$169.75
|
| Rate for Payer: Multiplan Medicare/VA |
$101.41
|
| Rate for Payer: One Health Plan of WY PPO |
$171.50
|
| Rate for Payer: PacificSource Commercial |
$157.50
|
| Rate for Payer: PHCS PPO |
$171.50
|
| Rate for Payer: Three Rivers PPO |
$131.25
|
| Rate for Payer: TriWest Veterans Administration |
$106.75
|
| Rate for Payer: United Healthcare Commercial |
$167.12
|
| Rate for Payer: United Healthcare Medicare |
$106.75
|
| Rate for Payer: WINHealth Partners Commercial |
$166.25
|
| Rate for Payer: Wise Provider Network Commercial |
$166.25
|
|
|
FIBERSTITCH 1.5 24° CURVED IMPLANT
|
Facility
|
OP
|
$1,925.00
|
|
| Hospital Charge Code |
3004756
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,042.39 |
| Max. Negotiated Rate |
$1,925.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,886.50
|
| Rate for Payer: Aetna of WY Medicare |
$1,270.50
|
| Rate for Payer: Altius Commercial |
$1,848.00
|
| Rate for Payer: Beech Street Commercial |
$1,886.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,867.25
|
| Rate for Payer: Cash Price |
$1,347.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,867.25
|
| Rate for Payer: Cigna of WY Commercial |
$1,886.50
|
| Rate for Payer: Entrust Commercial |
$1,828.75
|
| Rate for Payer: First Choice Health Commercial |
$1,828.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,828.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,097.25
|
| Rate for Payer: HealthUtah PPO |
$1,925.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,867.25
|
| Rate for Payer: Multiplan Medicare/VA |
$1,042.39
|
| Rate for Payer: One Health Plan of WY PPO |
$1,886.50
|
| Rate for Payer: PacificSource Commercial |
$1,732.50
|
| Rate for Payer: PHCS PPO |
$1,886.50
|
| Rate for Payer: Three Rivers PPO |
$1,443.75
|
| Rate for Payer: TriWest Veterans Administration |
$1,097.25
|
| Rate for Payer: United Healthcare Commercial |
$1,838.38
|
| Rate for Payer: United Healthcare Medicare |
$1,097.25
|
| Rate for Payer: WINHealth Partners Commercial |
$1,886.50
|
| Rate for Payer: Wise Provider Network Commercial |
$1,828.75
|
|
|
FIBERSTITCH 1.5 24° CURVED IMPLANT
|
Facility
|
IP
|
$1,925.00
|
|
| Hospital Charge Code |
3004756
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,115.54 |
| Max. Negotiated Rate |
$1,925.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,886.50
|
| Rate for Payer: Aetna of WY Medicare |
$1,232.00
|
| Rate for Payer: Altius Commercial |
$1,848.00
|
| Rate for Payer: Beech Street Commercial |
$1,886.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,867.25
|
| Rate for Payer: Cash Price |
$1,347.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,867.25
|
| Rate for Payer: Cigna of WY Commercial |
$1,886.50
|
| Rate for Payer: Entrust Commercial |
$1,828.75
|
| Rate for Payer: First Choice Health Commercial |
$1,828.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,828.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,174.25
|
| Rate for Payer: HealthUtah PPO |
$1,925.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,867.25
|
| Rate for Payer: Multiplan Medicare/VA |
$1,115.54
|
| Rate for Payer: One Health Plan of WY PPO |
$1,886.50
|
| Rate for Payer: PacificSource Commercial |
$1,732.50
|
| Rate for Payer: PHCS PPO |
$1,886.50
|
| Rate for Payer: Three Rivers PPO |
$1,443.75
|
| Rate for Payer: TriWest Veterans Administration |
$1,174.25
|
| Rate for Payer: United Healthcare Commercial |
$1,838.38
|
| Rate for Payer: United Healthcare Medicare |
$1,174.25
|
| Rate for Payer: WINHealth Partners Commercial |
$1,828.75
|
| Rate for Payer: Wise Provider Network Commercial |
$1,828.75
|
|
|
FIBERSTITCH 1.5 REVERSE CURVED IMPLANT
|
Facility
|
OP
|
$1,925.00
|
|
| Hospital Charge Code |
3004757
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,042.39 |
| Max. Negotiated Rate |
$1,925.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,886.50
|
| Rate for Payer: Aetna of WY Medicare |
$1,270.50
|
| Rate for Payer: Altius Commercial |
$1,848.00
|
| Rate for Payer: Beech Street Commercial |
$1,886.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,867.25
|
| Rate for Payer: Cash Price |
$1,347.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,867.25
|
| Rate for Payer: Cigna of WY Commercial |
$1,886.50
|
| Rate for Payer: Entrust Commercial |
$1,828.75
|
| Rate for Payer: First Choice Health Commercial |
$1,828.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,828.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,097.25
|
| Rate for Payer: HealthUtah PPO |
$1,925.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,867.25
|
| Rate for Payer: Multiplan Medicare/VA |
$1,042.39
|
| Rate for Payer: One Health Plan of WY PPO |
$1,886.50
|
| Rate for Payer: PacificSource Commercial |
$1,732.50
|
| Rate for Payer: PHCS PPO |
$1,886.50
|
| Rate for Payer: Three Rivers PPO |
$1,443.75
|
| Rate for Payer: TriWest Veterans Administration |
$1,097.25
|
| Rate for Payer: United Healthcare Commercial |
$1,838.38
|
| Rate for Payer: United Healthcare Medicare |
$1,097.25
|
| Rate for Payer: WINHealth Partners Commercial |
$1,886.50
|
| Rate for Payer: Wise Provider Network Commercial |
$1,828.75
|
|
|
FIBERSTITCH 1.5 REVERSE CURVED IMPLANT
|
Facility
|
IP
|
$1,925.00
|
|
| Hospital Charge Code |
3004757
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,115.54 |
| Max. Negotiated Rate |
$1,925.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,886.50
|
| Rate for Payer: Aetna of WY Medicare |
$1,232.00
|
| Rate for Payer: Altius Commercial |
$1,848.00
|
| Rate for Payer: Beech Street Commercial |
$1,886.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,867.25
|
| Rate for Payer: Cash Price |
$1,347.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,867.25
|
| Rate for Payer: Cigna of WY Commercial |
$1,886.50
|
| Rate for Payer: Entrust Commercial |
$1,828.75
|
| Rate for Payer: First Choice Health Commercial |
$1,828.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,828.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,174.25
|
| Rate for Payer: HealthUtah PPO |
$1,925.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,867.25
|
| Rate for Payer: Multiplan Medicare/VA |
$1,115.54
|
| Rate for Payer: One Health Plan of WY PPO |
$1,886.50
|
| Rate for Payer: PacificSource Commercial |
$1,732.50
|
| Rate for Payer: PHCS PPO |
$1,886.50
|
| Rate for Payer: Three Rivers PPO |
$1,443.75
|
| Rate for Payer: TriWest Veterans Administration |
$1,174.25
|
| Rate for Payer: United Healthcare Commercial |
$1,838.38
|
| Rate for Payer: United Healthcare Medicare |
$1,174.25
|
| Rate for Payer: WINHealth Partners Commercial |
$1,828.75
|
| Rate for Payer: Wise Provider Network Commercial |
$1,828.75
|
|
|
FIBERSTITCH 24° CURVE 4570-24
|
Facility
|
IP
|
$2,023.56
|
|
| Hospital Charge Code |
3004110
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,172.65 |
| Max. Negotiated Rate |
$2,023.56 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,983.09
|
| Rate for Payer: Aetna of WY Medicare |
$1,295.08
|
| Rate for Payer: Altius Commercial |
$1,942.62
|
| Rate for Payer: Beech Street Commercial |
$1,983.09
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,962.85
|
| Rate for Payer: Cash Price |
$1,416.49
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,962.85
|
| Rate for Payer: Cigna of WY Commercial |
$1,983.09
|
| Rate for Payer: Entrust Commercial |
$1,922.38
|
| Rate for Payer: First Choice Health Commercial |
$1,922.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,922.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,234.37
|
| Rate for Payer: HealthUtah PPO |
$2,023.56
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,962.85
|
| Rate for Payer: Multiplan Medicare/VA |
$1,172.65
|
| Rate for Payer: One Health Plan of WY PPO |
$1,983.09
|
| Rate for Payer: PacificSource Commercial |
$1,821.20
|
| Rate for Payer: PHCS PPO |
$1,983.09
|
| Rate for Payer: Three Rivers PPO |
$1,517.67
|
| Rate for Payer: TriWest Veterans Administration |
$1,234.37
|
| Rate for Payer: United Healthcare Commercial |
$1,932.50
|
| Rate for Payer: United Healthcare Medicare |
$1,234.37
|
| Rate for Payer: WINHealth Partners Commercial |
$1,922.38
|
| Rate for Payer: Wise Provider Network Commercial |
$1,922.38
|
|
|
FIBERSTITCH 24° CURVE 4570-24
|
Facility
|
OP
|
$2,023.56
|
|
| Hospital Charge Code |
3004110
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,095.76 |
| Max. Negotiated Rate |
$2,023.56 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,983.09
|
| Rate for Payer: Aetna of WY Medicare |
$1,335.55
|
| Rate for Payer: Altius Commercial |
$1,942.62
|
| Rate for Payer: Beech Street Commercial |
$1,983.09
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,962.85
|
| Rate for Payer: Cash Price |
$1,416.49
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,962.85
|
| Rate for Payer: Cigna of WY Commercial |
$1,983.09
|
| Rate for Payer: Entrust Commercial |
$1,922.38
|
| Rate for Payer: First Choice Health Commercial |
$1,922.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,922.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,153.43
|
| Rate for Payer: HealthUtah PPO |
$2,023.56
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,962.85
|
| Rate for Payer: Multiplan Medicare/VA |
$1,095.76
|
| Rate for Payer: One Health Plan of WY PPO |
$1,983.09
|
| Rate for Payer: PacificSource Commercial |
$1,821.20
|
| Rate for Payer: PHCS PPO |
$1,983.09
|
| Rate for Payer: Three Rivers PPO |
$1,517.67
|
| Rate for Payer: TriWest Veterans Administration |
$1,153.43
|
| Rate for Payer: United Healthcare Commercial |
$1,932.50
|
| Rate for Payer: United Healthcare Medicare |
$1,153.43
|
| Rate for Payer: WINHealth Partners Commercial |
$1,983.09
|
| Rate for Payer: Wise Provider Network Commercial |
$1,922.38
|
|
|
FIBERSTITCH CURV 2 POLY 2-0 FW
|
Facility
|
OP
|
$2,023.56
|
|
| Hospital Charge Code |
3003981
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,095.76 |
| Max. Negotiated Rate |
$2,023.56 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,983.09
|
| Rate for Payer: Aetna of WY Medicare |
$1,335.55
|
| Rate for Payer: Altius Commercial |
$1,942.62
|
| Rate for Payer: Beech Street Commercial |
$1,983.09
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,962.85
|
| Rate for Payer: Cash Price |
$1,416.49
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,962.85
|
| Rate for Payer: Cigna of WY Commercial |
$1,983.09
|
| Rate for Payer: Entrust Commercial |
$1,922.38
|
| Rate for Payer: First Choice Health Commercial |
$1,922.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,922.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,153.43
|
| Rate for Payer: HealthUtah PPO |
$2,023.56
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,962.85
|
| Rate for Payer: Multiplan Medicare/VA |
$1,095.76
|
| Rate for Payer: One Health Plan of WY PPO |
$1,983.09
|
| Rate for Payer: PacificSource Commercial |
$1,821.20
|
| Rate for Payer: PHCS PPO |
$1,983.09
|
| Rate for Payer: Three Rivers PPO |
$1,517.67
|
| Rate for Payer: TriWest Veterans Administration |
$1,153.43
|
| Rate for Payer: United Healthcare Commercial |
$1,932.50
|
| Rate for Payer: United Healthcare Medicare |
$1,153.43
|
| Rate for Payer: WINHealth Partners Commercial |
$1,983.09
|
| Rate for Payer: Wise Provider Network Commercial |
$1,922.38
|
|
|
FIBERSTITCH CURV 2 POLY 2-0 FW
|
Facility
|
IP
|
$2,023.56
|
|
| Hospital Charge Code |
3003981
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,172.65 |
| Max. Negotiated Rate |
$2,023.56 |
| Rate for Payer: United Healthcare Commercial |
$1,932.50
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,983.09
|
| Rate for Payer: Aetna of WY Medicare |
$1,295.08
|
| Rate for Payer: Altius Commercial |
$1,942.62
|
| Rate for Payer: Beech Street Commercial |
$1,983.09
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,962.85
|
| Rate for Payer: Cash Price |
$1,416.49
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,962.85
|
| Rate for Payer: Cigna of WY Commercial |
$1,983.09
|
| Rate for Payer: Entrust Commercial |
$1,922.38
|
| Rate for Payer: First Choice Health Commercial |
$1,922.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,922.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,234.37
|
| Rate for Payer: HealthUtah PPO |
$2,023.56
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,962.85
|
| Rate for Payer: Multiplan Medicare/VA |
$1,172.65
|
| Rate for Payer: One Health Plan of WY PPO |
$1,983.09
|
| Rate for Payer: PacificSource Commercial |
$1,821.20
|
| Rate for Payer: PHCS PPO |
$1,983.09
|
| Rate for Payer: Three Rivers PPO |
$1,517.67
|
| Rate for Payer: TriWest Veterans Administration |
$1,234.37
|
| Rate for Payer: United Healthcare Medicare |
$1,234.37
|
| Rate for Payer: WINHealth Partners Commercial |
$1,922.38
|
| Rate for Payer: Wise Provider Network Commercial |
$1,922.38
|
|
