|
FIXATE SUTURING DEVICE
|
Facility
|
IP
|
$2,100.00
|
|
| Hospital Charge Code |
2800250
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,216.95 |
| Max. Negotiated Rate |
$2,100.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,058.00
|
| Rate for Payer: Aetna of WY Medicare |
$1,344.00
|
| Rate for Payer: Altius Commercial |
$2,016.00
|
| Rate for Payer: Beech Street Commercial |
$2,058.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,037.00
|
| Rate for Payer: Cash Price |
$1,470.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,037.00
|
| Rate for Payer: Cigna of WY Commercial |
$2,058.00
|
| Rate for Payer: Entrust Commercial |
$1,995.00
|
| Rate for Payer: First Choice Health Commercial |
$1,995.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,995.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,281.00
|
| Rate for Payer: HealthUtah PPO |
$2,100.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,037.00
|
| Rate for Payer: Multiplan Medicare/VA |
$1,216.95
|
| Rate for Payer: One Health Plan of WY PPO |
$2,058.00
|
| Rate for Payer: PacificSource Commercial |
$1,890.00
|
| Rate for Payer: PHCS PPO |
$2,058.00
|
| Rate for Payer: Three Rivers PPO |
$1,575.00
|
| Rate for Payer: TriWest Veterans Administration |
$1,281.00
|
| Rate for Payer: United Healthcare Commercial |
$2,005.50
|
| Rate for Payer: United Healthcare Medicare |
$1,281.00
|
| Rate for Payer: WINHealth Partners Commercial |
$1,995.00
|
| Rate for Payer: Wise Provider Network Commercial |
$1,995.00
|
|
|
FIXATE TISSUE BAND FB-201-01
|
Facility
|
OP
|
$3,850.00
|
|
| Hospital Charge Code |
2800224
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,084.78 |
| Max. Negotiated Rate |
$3,850.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,773.00
|
| Rate for Payer: Aetna of WY Medicare |
$2,541.00
|
| Rate for Payer: Altius Commercial |
$3,696.00
|
| Rate for Payer: Beech Street Commercial |
$3,773.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3,734.50
|
| Rate for Payer: Cash Price |
$2,695.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,734.50
|
| Rate for Payer: Cigna of WY Commercial |
$3,773.00
|
| Rate for Payer: Entrust Commercial |
$3,657.50
|
| Rate for Payer: First Choice Health Commercial |
$3,657.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,657.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2,194.50
|
| Rate for Payer: HealthUtah PPO |
$3,850.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,734.50
|
| Rate for Payer: Multiplan Medicare/VA |
$2,084.78
|
| Rate for Payer: One Health Plan of WY PPO |
$3,773.00
|
| Rate for Payer: PacificSource Commercial |
$3,465.00
|
| Rate for Payer: PHCS PPO |
$3,773.00
|
| Rate for Payer: Three Rivers PPO |
$2,887.50
|
| Rate for Payer: TriWest Veterans Administration |
$2,194.50
|
| Rate for Payer: United Healthcare Commercial |
$3,676.75
|
| Rate for Payer: United Healthcare Medicare |
$2,194.50
|
| Rate for Payer: WINHealth Partners Commercial |
$3,773.00
|
| Rate for Payer: Wise Provider Network Commercial |
$3,657.50
|
|
|
FIXATE TISSUE BAND FB-201-01
|
Facility
|
IP
|
$3,850.00
|
|
| Hospital Charge Code |
2800224
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,231.08 |
| Max. Negotiated Rate |
$3,850.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,773.00
|
| Rate for Payer: Aetna of WY Medicare |
$2,464.00
|
| Rate for Payer: Altius Commercial |
$3,696.00
|
| Rate for Payer: Beech Street Commercial |
$3,773.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3,734.50
|
| Rate for Payer: Cash Price |
$2,695.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,734.50
|
| Rate for Payer: Cigna of WY Commercial |
$3,773.00
|
| Rate for Payer: Entrust Commercial |
$3,657.50
|
| Rate for Payer: First Choice Health Commercial |
$3,657.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,657.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2,348.50
|
| Rate for Payer: HealthUtah PPO |
$3,850.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,734.50
|
| Rate for Payer: Multiplan Medicare/VA |
$2,231.08
|
| Rate for Payer: One Health Plan of WY PPO |
$3,773.00
|
| Rate for Payer: PacificSource Commercial |
$3,465.00
|
| Rate for Payer: PHCS PPO |
$3,773.00
|
| Rate for Payer: Three Rivers PPO |
$2,887.50
|
| Rate for Payer: TriWest Veterans Administration |
$2,348.50
|
| Rate for Payer: United Healthcare Commercial |
$3,676.75
|
| Rate for Payer: United Healthcare Medicare |
$2,348.50
|
| Rate for Payer: WINHealth Partners Commercial |
$3,657.50
|
| Rate for Payer: Wise Provider Network Commercial |
$3,657.50
|
|
|
FLANGE TIP W/O VENT YANKAUERS
|
Facility
|
IP
|
$0.90
|
|
| Hospital Charge Code |
2650899
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$0.52 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.88
|
| Rate for Payer: Aetna of WY Medicare |
$0.58
|
| Rate for Payer: Altius Commercial |
$0.86
|
| Rate for Payer: Beech Street Commercial |
$0.88
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.87
|
| Rate for Payer: Cash Price |
$0.63
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.87
|
| Rate for Payer: Cigna of WY Commercial |
$0.88
|
| Rate for Payer: Entrust Commercial |
$0.86
|
| Rate for Payer: First Choice Health Commercial |
$0.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.55
|
| Rate for Payer: HealthUtah PPO |
$0.90
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.87
|
| Rate for Payer: Multiplan Medicare/VA |
$0.52
|
| Rate for Payer: One Health Plan of WY PPO |
$0.88
|
| Rate for Payer: PacificSource Commercial |
$0.81
|
| Rate for Payer: PHCS PPO |
$0.88
|
| Rate for Payer: Three Rivers PPO |
$0.68
|
| Rate for Payer: TriWest Veterans Administration |
$0.55
|
| Rate for Payer: United Healthcare Commercial |
$0.86
|
| Rate for Payer: United Healthcare Medicare |
$0.55
|
| Rate for Payer: WINHealth Partners Commercial |
$0.86
|
| Rate for Payer: Wise Provider Network Commercial |
$0.86
|
|
|
FLANGE TIP W/O VENT YANKAUERS
|
Facility
|
OP
|
$0.90
|
|
| Hospital Charge Code |
2650899
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.88
|
| Rate for Payer: Aetna of WY Medicare |
$0.59
|
| Rate for Payer: Altius Commercial |
$0.86
|
| Rate for Payer: Beech Street Commercial |
$0.88
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.87
|
| Rate for Payer: Cash Price |
$0.63
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.87
|
| Rate for Payer: Cigna of WY Commercial |
$0.88
|
| Rate for Payer: Entrust Commercial |
$0.86
|
| Rate for Payer: First Choice Health Commercial |
$0.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.51
|
| Rate for Payer: HealthUtah PPO |
$0.90
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.87
|
| Rate for Payer: Multiplan Medicare/VA |
$0.49
|
| Rate for Payer: One Health Plan of WY PPO |
$0.88
|
| Rate for Payer: PacificSource Commercial |
$0.81
|
| Rate for Payer: PHCS PPO |
$0.88
|
| Rate for Payer: Three Rivers PPO |
$0.68
|
| Rate for Payer: TriWest Veterans Administration |
$0.51
|
| Rate for Payer: United Healthcare Commercial |
$0.86
|
| Rate for Payer: United Healthcare Medicare |
$0.51
|
| Rate for Payer: WINHealth Partners Commercial |
$0.88
|
| Rate for Payer: Wise Provider Network Commercial |
$0.86
|
|
|
FLAP ISLAND PEDICLE ANATOMIC NAMED AXIAL ARTERY
|
Professional
|
Both
|
$3,572.00
|
|
|
Service Code
|
HCPCS 15740
|
| Min. Negotiated Rate |
$690.94 |
| Max. Negotiated Rate |
$3,572.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,500.56
|
| Rate for Payer: Aetna of WY Medicare |
$812.87
|
| Rate for Payer: Beech Street Commercial |
$3,393.40
|
| Rate for Payer: Cash Price |
$2,500.40
|
| Rate for Payer: Cash Price |
$2,500.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,464.84
|
| Rate for Payer: Cigna of WY Commercial |
$3,500.56
|
| Rate for Payer: First Choice Health Commercial |
$3,214.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,393.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$812.87
|
| Rate for Payer: HealthUtah PPO |
$3,572.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,464.84
|
| Rate for Payer: Multiplan Medicare/VA |
$690.94
|
| Rate for Payer: One Health Plan of WY PPO |
$3,500.56
|
| Rate for Payer: PacificSource Commercial |
$3,214.80
|
| Rate for Payer: PHCS PPO |
$3,393.40
|
| Rate for Payer: Three Rivers PPO |
$2,679.00
|
| Rate for Payer: TriWest Veterans Administration |
$812.87
|
| Rate for Payer: United Healthcare Commercial |
$3,393.40
|
| Rate for Payer: WINHealth Partners Commercial |
$3,036.20
|
|
|
FLECAINIDE 100 MG TABLET [14034]
|
Facility
|
IP
|
$15.80
|
|
|
Service Code
|
NDC 5026832111
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.16 |
| Max. Negotiated Rate |
$15.80 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.48
|
| Rate for Payer: Aetna of WY Medicare |
$10.11
|
| Rate for Payer: Altius Commercial |
$15.17
|
| Rate for Payer: Beech Street Commercial |
$15.48
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.33
|
| Rate for Payer: Cash Price |
$11.06
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.33
|
| Rate for Payer: Cigna of WY Commercial |
$15.48
|
| Rate for Payer: Entrust Commercial |
$15.01
|
| Rate for Payer: First Choice Health Commercial |
$15.01
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.01
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.64
|
| Rate for Payer: HealthUtah PPO |
$15.80
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.33
|
| Rate for Payer: Multiplan Medicare/VA |
$9.16
|
| Rate for Payer: One Health Plan of WY PPO |
$15.48
|
| Rate for Payer: PacificSource Commercial |
$14.22
|
| Rate for Payer: PHCS PPO |
$15.48
|
| Rate for Payer: Three Rivers PPO |
$11.85
|
| Rate for Payer: TriWest Veterans Administration |
$9.64
|
| Rate for Payer: United Healthcare Commercial |
$15.09
|
| Rate for Payer: United Healthcare Medicare |
$9.64
|
| Rate for Payer: WINHealth Partners Commercial |
$15.01
|
| Rate for Payer: Wise Provider Network Commercial |
$15.01
|
|
|
FLECAINIDE 100 MG TABLET [14034]
|
Facility
|
OP
|
$18.57
|
|
|
Service Code
|
NDC 6255938101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.06 |
| Max. Negotiated Rate |
$18.57 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18.20
|
| Rate for Payer: Aetna of WY Medicare |
$12.26
|
| Rate for Payer: Altius Commercial |
$17.83
|
| Rate for Payer: Beech Street Commercial |
$18.20
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$18.01
|
| Rate for Payer: Cash Price |
$13.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$18.01
|
| Rate for Payer: Cigna of WY Commercial |
$18.20
|
| Rate for Payer: Entrust Commercial |
$17.64
|
| Rate for Payer: First Choice Health Commercial |
$17.64
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.64
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.58
|
| Rate for Payer: HealthUtah PPO |
$18.57
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$18.01
|
| Rate for Payer: Multiplan Medicare/VA |
$10.06
|
| Rate for Payer: One Health Plan of WY PPO |
$18.20
|
| Rate for Payer: PacificSource Commercial |
$16.71
|
| Rate for Payer: PHCS PPO |
$18.20
|
| Rate for Payer: Three Rivers PPO |
$13.93
|
| Rate for Payer: TriWest Veterans Administration |
$10.58
|
| Rate for Payer: United Healthcare Commercial |
$17.73
|
| Rate for Payer: United Healthcare Medicare |
$10.58
|
| Rate for Payer: WINHealth Partners Commercial |
$18.20
|
| Rate for Payer: Wise Provider Network Commercial |
$17.64
|
|
|
FLECAINIDE 100 MG TABLET [14034]
|
Facility
|
OP
|
$15.80
|
|
|
Service Code
|
NDC 5026832111
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.56 |
| Max. Negotiated Rate |
$15.80 |
| Rate for Payer: ChoiceCare Network Commercial |
$15.33
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.48
|
| Rate for Payer: Aetna of WY Medicare |
$10.43
|
| Rate for Payer: Altius Commercial |
$15.17
|
| Rate for Payer: Beech Street Commercial |
$15.48
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.33
|
| Rate for Payer: Cash Price |
$11.06
|
| Rate for Payer: Cigna of WY Commercial |
$15.48
|
| Rate for Payer: Entrust Commercial |
$15.01
|
| Rate for Payer: First Choice Health Commercial |
$15.01
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.01
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.01
|
| Rate for Payer: HealthUtah PPO |
$15.80
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.33
|
| Rate for Payer: Multiplan Medicare/VA |
$8.56
|
| Rate for Payer: One Health Plan of WY PPO |
$15.48
|
| Rate for Payer: PacificSource Commercial |
$14.22
|
| Rate for Payer: PHCS PPO |
$15.48
|
| Rate for Payer: Three Rivers PPO |
$11.85
|
| Rate for Payer: TriWest Veterans Administration |
$9.01
|
| Rate for Payer: United Healthcare Commercial |
$15.09
|
| Rate for Payer: United Healthcare Medicare |
$9.01
|
| Rate for Payer: WINHealth Partners Commercial |
$15.48
|
| Rate for Payer: Wise Provider Network Commercial |
$15.01
|
|
|
FLECAINIDE 100 MG TABLET [14034]
|
Facility
|
IP
|
$18.57
|
|
|
Service Code
|
NDC 6255938101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.76 |
| Max. Negotiated Rate |
$18.57 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18.20
|
| Rate for Payer: Aetna of WY Medicare |
$11.88
|
| Rate for Payer: Altius Commercial |
$17.83
|
| Rate for Payer: Beech Street Commercial |
$18.20
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$18.01
|
| Rate for Payer: Cash Price |
$13.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$18.01
|
| Rate for Payer: Cigna of WY Commercial |
$18.20
|
| Rate for Payer: Entrust Commercial |
$17.64
|
| Rate for Payer: First Choice Health Commercial |
$17.64
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.64
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.33
|
| Rate for Payer: HealthUtah PPO |
$18.57
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$18.01
|
| Rate for Payer: Multiplan Medicare/VA |
$10.76
|
| Rate for Payer: One Health Plan of WY PPO |
$18.20
|
| Rate for Payer: PacificSource Commercial |
$16.71
|
| Rate for Payer: PHCS PPO |
$18.20
|
| Rate for Payer: Three Rivers PPO |
$13.93
|
| Rate for Payer: TriWest Veterans Administration |
$11.33
|
| Rate for Payer: United Healthcare Commercial |
$17.73
|
| Rate for Payer: United Healthcare Medicare |
$11.33
|
| Rate for Payer: WINHealth Partners Commercial |
$17.64
|
| Rate for Payer: Wise Provider Network Commercial |
$17.64
|
|
|
FLEXBAND 0.3 X 16CM
|
Facility
|
IP
|
$8,750.00
|
|
| Hospital Charge Code |
3004577
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,070.62 |
| Max. Negotiated Rate |
$8,750.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$8,575.00
|
| Rate for Payer: Aetna of WY Medicare |
$5,600.00
|
| Rate for Payer: Altius Commercial |
$8,400.00
|
| Rate for Payer: Beech Street Commercial |
$8,575.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$8,487.50
|
| Rate for Payer: Cash Price |
$6,125.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$8,487.50
|
| Rate for Payer: Cigna of WY Commercial |
$8,575.00
|
| Rate for Payer: Entrust Commercial |
$8,312.50
|
| Rate for Payer: First Choice Health Commercial |
$8,312.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$8,312.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$5,337.50
|
| Rate for Payer: HealthUtah PPO |
$8,750.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$8,487.50
|
| Rate for Payer: Multiplan Medicare/VA |
$5,070.62
|
| Rate for Payer: One Health Plan of WY PPO |
$8,575.00
|
| Rate for Payer: PacificSource Commercial |
$7,875.00
|
| Rate for Payer: PHCS PPO |
$8,575.00
|
| Rate for Payer: Three Rivers PPO |
$6,562.50
|
| Rate for Payer: TriWest Veterans Administration |
$5,337.50
|
| Rate for Payer: United Healthcare Commercial |
$8,356.25
|
| Rate for Payer: United Healthcare Medicare |
$5,337.50
|
| Rate for Payer: WINHealth Partners Commercial |
$8,312.50
|
| Rate for Payer: Wise Provider Network Commercial |
$8,312.50
|
|
|
FLEXBAND 0.3 X 16CM
|
Facility
|
OP
|
$8,750.00
|
|
| Hospital Charge Code |
3004577
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,738.12 |
| Max. Negotiated Rate |
$8,750.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$8,575.00
|
| Rate for Payer: Aetna of WY Medicare |
$5,775.00
|
| Rate for Payer: Altius Commercial |
$8,400.00
|
| Rate for Payer: Beech Street Commercial |
$8,575.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$8,487.50
|
| Rate for Payer: Cash Price |
$6,125.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$8,487.50
|
| Rate for Payer: Cigna of WY Commercial |
$8,575.00
|
| Rate for Payer: Entrust Commercial |
$8,312.50
|
| Rate for Payer: First Choice Health Commercial |
$8,312.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$8,312.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$4,987.50
|
| Rate for Payer: HealthUtah PPO |
$8,750.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$8,487.50
|
| Rate for Payer: Multiplan Medicare/VA |
$4,738.12
|
| Rate for Payer: One Health Plan of WY PPO |
$8,575.00
|
| Rate for Payer: PacificSource Commercial |
$7,875.00
|
| Rate for Payer: PHCS PPO |
$8,575.00
|
| Rate for Payer: Three Rivers PPO |
$6,562.50
|
| Rate for Payer: TriWest Veterans Administration |
$4,987.50
|
| Rate for Payer: United Healthcare Commercial |
$8,356.25
|
| Rate for Payer: United Healthcare Medicare |
$4,987.50
|
| Rate for Payer: WINHealth Partners Commercial |
$8,575.00
|
| Rate for Payer: Wise Provider Network Commercial |
$8,312.50
|
|
|
FLEXBAND 0.5 X 16CM
|
Facility
|
OP
|
$9,625.00
|
|
| Hospital Charge Code |
3004626
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,211.94 |
| Max. Negotiated Rate |
$9,625.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$9,432.50
|
| Rate for Payer: Aetna of WY Medicare |
$6,352.50
|
| Rate for Payer: Altius Commercial |
$9,240.00
|
| Rate for Payer: Beech Street Commercial |
$9,432.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$9,336.25
|
| Rate for Payer: Cash Price |
$6,737.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$9,336.25
|
| Rate for Payer: Cigna of WY Commercial |
$9,432.50
|
| Rate for Payer: Entrust Commercial |
$9,143.75
|
| Rate for Payer: First Choice Health Commercial |
$9,143.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$9,143.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$5,486.25
|
| Rate for Payer: HealthUtah PPO |
$9,625.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$9,336.25
|
| Rate for Payer: Multiplan Medicare/VA |
$5,211.94
|
| Rate for Payer: One Health Plan of WY PPO |
$9,432.50
|
| Rate for Payer: PacificSource Commercial |
$8,662.50
|
| Rate for Payer: PHCS PPO |
$9,432.50
|
| Rate for Payer: Three Rivers PPO |
$7,218.75
|
| Rate for Payer: TriWest Veterans Administration |
$5,486.25
|
| Rate for Payer: United Healthcare Commercial |
$9,191.88
|
| Rate for Payer: United Healthcare Medicare |
$5,486.25
|
| Rate for Payer: WINHealth Partners Commercial |
$9,432.50
|
| Rate for Payer: Wise Provider Network Commercial |
$9,143.75
|
|
|
FLEXBAND 0.5 X 16CM
|
Facility
|
IP
|
$9,625.00
|
|
| Hospital Charge Code |
3004626
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,577.69 |
| Max. Negotiated Rate |
$9,625.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$9,432.50
|
| Rate for Payer: Aetna of WY Medicare |
$6,160.00
|
| Rate for Payer: Altius Commercial |
$9,240.00
|
| Rate for Payer: Beech Street Commercial |
$9,432.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$9,336.25
|
| Rate for Payer: Cash Price |
$6,737.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$9,336.25
|
| Rate for Payer: Cigna of WY Commercial |
$9,432.50
|
| Rate for Payer: Entrust Commercial |
$9,143.75
|
| Rate for Payer: First Choice Health Commercial |
$9,143.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$9,143.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$5,871.25
|
| Rate for Payer: HealthUtah PPO |
$9,625.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$9,336.25
|
| Rate for Payer: Multiplan Medicare/VA |
$5,577.69
|
| Rate for Payer: One Health Plan of WY PPO |
$9,432.50
|
| Rate for Payer: PacificSource Commercial |
$8,662.50
|
| Rate for Payer: PHCS PPO |
$9,432.50
|
| Rate for Payer: Three Rivers PPO |
$7,218.75
|
| Rate for Payer: TriWest Veterans Administration |
$5,871.25
|
| Rate for Payer: United Healthcare Commercial |
$9,191.88
|
| Rate for Payer: United Healthcare Medicare |
$5,871.25
|
| Rate for Payer: WINHealth Partners Commercial |
$9,143.75
|
| Rate for Payer: Wise Provider Network Commercial |
$9,143.75
|
|
|
FLEXBAND 0.7 X 16CM
|
Facility
|
IP
|
$10,500.00
|
|
| Hospital Charge Code |
3004747
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,084.75 |
| Max. Negotiated Rate |
$10,500.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$10,290.00
|
| Rate for Payer: Aetna of WY Medicare |
$6,720.00
|
| Rate for Payer: Altius Commercial |
$10,080.00
|
| Rate for Payer: Beech Street Commercial |
$10,290.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$10,185.00
|
| Rate for Payer: Cash Price |
$7,350.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$10,185.00
|
| Rate for Payer: Cigna of WY Commercial |
$10,290.00
|
| Rate for Payer: Entrust Commercial |
$9,975.00
|
| Rate for Payer: First Choice Health Commercial |
$9,975.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$9,975.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$6,405.00
|
| Rate for Payer: HealthUtah PPO |
$10,500.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$10,185.00
|
| Rate for Payer: Multiplan Medicare/VA |
$6,084.75
|
| Rate for Payer: One Health Plan of WY PPO |
$10,290.00
|
| Rate for Payer: PacificSource Commercial |
$9,450.00
|
| Rate for Payer: PHCS PPO |
$10,290.00
|
| Rate for Payer: Three Rivers PPO |
$7,875.00
|
| Rate for Payer: TriWest Veterans Administration |
$6,405.00
|
| Rate for Payer: United Healthcare Commercial |
$10,027.50
|
| Rate for Payer: United Healthcare Medicare |
$6,405.00
|
| Rate for Payer: WINHealth Partners Commercial |
$9,975.00
|
| Rate for Payer: Wise Provider Network Commercial |
$9,975.00
|
|
|
FLEXBAND 0.7 X 16CM
|
Facility
|
OP
|
$10,500.00
|
|
| Hospital Charge Code |
3004747
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,685.75 |
| Max. Negotiated Rate |
$10,500.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$10,290.00
|
| Rate for Payer: Aetna of WY Medicare |
$6,930.00
|
| Rate for Payer: Altius Commercial |
$10,080.00
|
| Rate for Payer: Beech Street Commercial |
$10,290.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$10,185.00
|
| Rate for Payer: Cash Price |
$7,350.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$10,185.00
|
| Rate for Payer: Cigna of WY Commercial |
$10,290.00
|
| Rate for Payer: Entrust Commercial |
$9,975.00
|
| Rate for Payer: First Choice Health Commercial |
$9,975.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$9,975.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$5,985.00
|
| Rate for Payer: HealthUtah PPO |
$10,500.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$10,185.00
|
| Rate for Payer: Multiplan Medicare/VA |
$5,685.75
|
| Rate for Payer: One Health Plan of WY PPO |
$10,290.00
|
| Rate for Payer: PacificSource Commercial |
$9,450.00
|
| Rate for Payer: PHCS PPO |
$10,290.00
|
| Rate for Payer: Three Rivers PPO |
$7,875.00
|
| Rate for Payer: TriWest Veterans Administration |
$5,985.00
|
| Rate for Payer: United Healthcare Commercial |
$10,027.50
|
| Rate for Payer: United Healthcare Medicare |
$5,985.00
|
| Rate for Payer: WINHealth Partners Commercial |
$10,290.00
|
| Rate for Payer: Wise Provider Network Commercial |
$9,975.00
|
|
|
FLEXBAND 0.7 X 32CM
|
Facility
|
OP
|
$12,425.00
|
|
| Hospital Charge Code |
3004587
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,728.14 |
| Max. Negotiated Rate |
$12,425.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$12,176.50
|
| Rate for Payer: Aetna of WY Medicare |
$8,200.50
|
| Rate for Payer: Altius Commercial |
$11,928.00
|
| Rate for Payer: Beech Street Commercial |
$12,176.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12,052.25
|
| Rate for Payer: Cash Price |
$8,697.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$12,052.25
|
| Rate for Payer: Cigna of WY Commercial |
$12,176.50
|
| Rate for Payer: Entrust Commercial |
$11,803.75
|
| Rate for Payer: First Choice Health Commercial |
$11,803.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$11,803.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$7,082.25
|
| Rate for Payer: HealthUtah PPO |
$12,425.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$12,052.25
|
| Rate for Payer: Multiplan Medicare/VA |
$6,728.14
|
| Rate for Payer: One Health Plan of WY PPO |
$12,176.50
|
| Rate for Payer: PacificSource Commercial |
$11,182.50
|
| Rate for Payer: PHCS PPO |
$12,176.50
|
| Rate for Payer: Three Rivers PPO |
$9,318.75
|
| Rate for Payer: TriWest Veterans Administration |
$7,082.25
|
| Rate for Payer: United Healthcare Commercial |
$11,865.88
|
| Rate for Payer: United Healthcare Medicare |
$7,082.25
|
| Rate for Payer: WINHealth Partners Commercial |
$12,176.50
|
| Rate for Payer: Wise Provider Network Commercial |
$11,803.75
|
|
|
FLEXBAND 0.7 X 32CM
|
Facility
|
IP
|
$12,425.00
|
|
| Hospital Charge Code |
3004587
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,200.29 |
| Max. Negotiated Rate |
$12,425.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$12,176.50
|
| Rate for Payer: Aetna of WY Medicare |
$7,952.00
|
| Rate for Payer: Altius Commercial |
$11,928.00
|
| Rate for Payer: Beech Street Commercial |
$12,176.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12,052.25
|
| Rate for Payer: Cash Price |
$8,697.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$12,052.25
|
| Rate for Payer: Cigna of WY Commercial |
$12,176.50
|
| Rate for Payer: Entrust Commercial |
$11,803.75
|
| Rate for Payer: First Choice Health Commercial |
$11,803.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$11,803.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$7,579.25
|
| Rate for Payer: HealthUtah PPO |
$12,425.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$12,052.25
|
| Rate for Payer: Multiplan Medicare/VA |
$7,200.29
|
| Rate for Payer: One Health Plan of WY PPO |
$12,176.50
|
| Rate for Payer: PacificSource Commercial |
$11,182.50
|
| Rate for Payer: PHCS PPO |
$12,176.50
|
| Rate for Payer: Three Rivers PPO |
$9,318.75
|
| Rate for Payer: TriWest Veterans Administration |
$7,579.25
|
| Rate for Payer: United Healthcare Commercial |
$11,865.88
|
| Rate for Payer: United Healthcare Medicare |
$7,579.25
|
| Rate for Payer: WINHealth Partners Commercial |
$11,803.75
|
| Rate for Payer: Wise Provider Network Commercial |
$11,803.75
|
|
|
FLEX DRILL BIT 3.2 X 30
|
Facility
|
OP
|
$468.20
|
|
| Hospital Charge Code |
3002050
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$253.53 |
| Max. Negotiated Rate |
$468.20 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$458.84
|
| Rate for Payer: Aetna of WY Medicare |
$309.01
|
| Rate for Payer: Altius Commercial |
$449.47
|
| Rate for Payer: Beech Street Commercial |
$458.84
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$454.15
|
| Rate for Payer: Cash Price |
$327.74
|
| Rate for Payer: ChoiceCare Network Commercial |
$454.15
|
| Rate for Payer: Cigna of WY Commercial |
$458.84
|
| Rate for Payer: Entrust Commercial |
$444.79
|
| Rate for Payer: First Choice Health Commercial |
$444.79
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$444.79
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$266.87
|
| Rate for Payer: HealthUtah PPO |
$468.20
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$454.15
|
| Rate for Payer: Multiplan Medicare/VA |
$253.53
|
| Rate for Payer: One Health Plan of WY PPO |
$458.84
|
| Rate for Payer: PacificSource Commercial |
$421.38
|
| Rate for Payer: PHCS PPO |
$458.84
|
| Rate for Payer: Three Rivers PPO |
$351.15
|
| Rate for Payer: TriWest Veterans Administration |
$266.87
|
| Rate for Payer: United Healthcare Commercial |
$447.13
|
| Rate for Payer: United Healthcare Medicare |
$266.87
|
| Rate for Payer: WINHealth Partners Commercial |
$458.84
|
| Rate for Payer: Wise Provider Network Commercial |
$444.79
|
|
|
FLEX DRILL BIT 3.2 X 30
|
Facility
|
IP
|
$468.20
|
|
| Hospital Charge Code |
3002050
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$271.32 |
| Max. Negotiated Rate |
$468.20 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$458.84
|
| Rate for Payer: Aetna of WY Medicare |
$299.65
|
| Rate for Payer: Altius Commercial |
$449.47
|
| Rate for Payer: Beech Street Commercial |
$458.84
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$454.15
|
| Rate for Payer: Cash Price |
$327.74
|
| Rate for Payer: ChoiceCare Network Commercial |
$454.15
|
| Rate for Payer: Cigna of WY Commercial |
$458.84
|
| Rate for Payer: Entrust Commercial |
$444.79
|
| Rate for Payer: First Choice Health Commercial |
$444.79
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$444.79
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$285.60
|
| Rate for Payer: HealthUtah PPO |
$468.20
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$454.15
|
| Rate for Payer: Multiplan Medicare/VA |
$271.32
|
| Rate for Payer: One Health Plan of WY PPO |
$458.84
|
| Rate for Payer: PacificSource Commercial |
$421.38
|
| Rate for Payer: PHCS PPO |
$458.84
|
| Rate for Payer: Three Rivers PPO |
$351.15
|
| Rate for Payer: TriWest Veterans Administration |
$285.60
|
| Rate for Payer: United Healthcare Commercial |
$447.13
|
| Rate for Payer: United Healthcare Medicare |
$285.60
|
| Rate for Payer: WINHealth Partners Commercial |
$444.79
|
| Rate for Payer: Wise Provider Network Commercial |
$444.79
|
|
|
FLEX GUIDE PIN 2.4M AR-1297FLX
|
Facility
|
IP
|
$542.50
|
|
| Hospital Charge Code |
3002398
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$314.38 |
| Max. Negotiated Rate |
$542.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$531.65
|
| Rate for Payer: Aetna of WY Medicare |
$347.20
|
| Rate for Payer: Altius Commercial |
$520.80
|
| Rate for Payer: Beech Street Commercial |
$531.65
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$526.22
|
| Rate for Payer: Cash Price |
$379.75
|
| Rate for Payer: ChoiceCare Network Commercial |
$526.22
|
| Rate for Payer: Cigna of WY Commercial |
$531.65
|
| Rate for Payer: Entrust Commercial |
$515.38
|
| Rate for Payer: First Choice Health Commercial |
$515.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$515.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$330.92
|
| Rate for Payer: HealthUtah PPO |
$542.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$526.22
|
| Rate for Payer: Multiplan Medicare/VA |
$314.38
|
| Rate for Payer: One Health Plan of WY PPO |
$531.65
|
| Rate for Payer: PacificSource Commercial |
$488.25
|
| Rate for Payer: PHCS PPO |
$531.65
|
| Rate for Payer: Three Rivers PPO |
$406.88
|
| Rate for Payer: TriWest Veterans Administration |
$330.92
|
| Rate for Payer: United Healthcare Commercial |
$518.09
|
| Rate for Payer: United Healthcare Medicare |
$330.92
|
| Rate for Payer: WINHealth Partners Commercial |
$515.38
|
| Rate for Payer: Wise Provider Network Commercial |
$515.38
|
|
|
FLEX GUIDE PIN 2.4M AR-1297FLX
|
Facility
|
OP
|
$542.50
|
|
| Hospital Charge Code |
3002398
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$293.76 |
| Max. Negotiated Rate |
$542.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$531.65
|
| Rate for Payer: Aetna of WY Medicare |
$358.05
|
| Rate for Payer: Altius Commercial |
$520.80
|
| Rate for Payer: Beech Street Commercial |
$531.65
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$526.22
|
| Rate for Payer: Cash Price |
$379.75
|
| Rate for Payer: ChoiceCare Network Commercial |
$526.22
|
| Rate for Payer: Cigna of WY Commercial |
$531.65
|
| Rate for Payer: Entrust Commercial |
$515.38
|
| Rate for Payer: First Choice Health Commercial |
$515.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$515.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$309.22
|
| Rate for Payer: HealthUtah PPO |
$542.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$526.22
|
| Rate for Payer: Multiplan Medicare/VA |
$293.76
|
| Rate for Payer: One Health Plan of WY PPO |
$531.65
|
| Rate for Payer: PacificSource Commercial |
$488.25
|
| Rate for Payer: PHCS PPO |
$531.65
|
| Rate for Payer: Three Rivers PPO |
$406.88
|
| Rate for Payer: TriWest Veterans Administration |
$309.22
|
| Rate for Payer: United Healthcare Commercial |
$518.09
|
| Rate for Payer: United Healthcare Medicare |
$309.22
|
| Rate for Payer: WINHealth Partners Commercial |
$531.65
|
| Rate for Payer: Wise Provider Network Commercial |
$515.38
|
|
|
FLIPCUTTER III DRILL AR-1204FF
|
Facility
|
IP
|
$1,696.52
|
|
| Hospital Charge Code |
3003776
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$983.13 |
| Max. Negotiated Rate |
$1,696.52 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,662.59
|
| Rate for Payer: Aetna of WY Medicare |
$1,085.77
|
| Rate for Payer: Altius Commercial |
$1,628.66
|
| Rate for Payer: Beech Street Commercial |
$1,662.59
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,645.62
|
| Rate for Payer: Cash Price |
$1,187.56
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,645.62
|
| Rate for Payer: Cigna of WY Commercial |
$1,662.59
|
| Rate for Payer: Entrust Commercial |
$1,611.69
|
| Rate for Payer: First Choice Health Commercial |
$1,611.69
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,611.69
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,034.88
|
| Rate for Payer: HealthUtah PPO |
$1,696.52
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,645.62
|
| Rate for Payer: Multiplan Medicare/VA |
$983.13
|
| Rate for Payer: One Health Plan of WY PPO |
$1,662.59
|
| Rate for Payer: PacificSource Commercial |
$1,526.87
|
| Rate for Payer: PHCS PPO |
$1,662.59
|
| Rate for Payer: Three Rivers PPO |
$1,272.39
|
| Rate for Payer: TriWest Veterans Administration |
$1,034.88
|
| Rate for Payer: United Healthcare Commercial |
$1,620.18
|
| Rate for Payer: United Healthcare Medicare |
$1,034.88
|
| Rate for Payer: WINHealth Partners Commercial |
$1,611.69
|
| Rate for Payer: Wise Provider Network Commercial |
$1,611.69
|
|
|
FLIPCUTTER III DRILL AR-1204FF
|
Facility
|
OP
|
$1,696.52
|
|
| Hospital Charge Code |
3003776
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$918.67 |
| Max. Negotiated Rate |
$1,696.52 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,662.59
|
| Rate for Payer: Aetna of WY Medicare |
$1,119.70
|
| Rate for Payer: Altius Commercial |
$1,628.66
|
| Rate for Payer: Beech Street Commercial |
$1,662.59
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,645.62
|
| Rate for Payer: Cash Price |
$1,187.56
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,645.62
|
| Rate for Payer: Cigna of WY Commercial |
$1,662.59
|
| Rate for Payer: Entrust Commercial |
$1,611.69
|
| Rate for Payer: First Choice Health Commercial |
$1,611.69
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,611.69
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$967.02
|
| Rate for Payer: HealthUtah PPO |
$1,696.52
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,645.62
|
| Rate for Payer: Multiplan Medicare/VA |
$918.67
|
| Rate for Payer: One Health Plan of WY PPO |
$1,662.59
|
| Rate for Payer: PacificSource Commercial |
$1,526.87
|
| Rate for Payer: PHCS PPO |
$1,662.59
|
| Rate for Payer: Three Rivers PPO |
$1,272.39
|
| Rate for Payer: TriWest Veterans Administration |
$967.02
|
| Rate for Payer: United Healthcare Commercial |
$1,620.18
|
| Rate for Payer: United Healthcare Medicare |
$967.02
|
| Rate for Payer: WINHealth Partners Commercial |
$1,662.59
|
| Rate for Payer: Wise Provider Network Commercial |
$1,611.69
|
|
|
FLOSEAL HEMOSTATIC MATRIX 5ML
|
Facility
|
OP
|
$786.04
|
|
| Hospital Charge Code |
2750037
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$425.64 |
| Max. Negotiated Rate |
$786.04 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$770.32
|
| Rate for Payer: Aetna of WY Medicare |
$518.79
|
| Rate for Payer: Altius Commercial |
$754.60
|
| Rate for Payer: Beech Street Commercial |
$770.32
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$762.46
|
| Rate for Payer: Cash Price |
$550.23
|
| Rate for Payer: ChoiceCare Network Commercial |
$762.46
|
| Rate for Payer: Cigna of WY Commercial |
$770.32
|
| Rate for Payer: Entrust Commercial |
$746.74
|
| Rate for Payer: First Choice Health Commercial |
$746.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$746.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$448.04
|
| Rate for Payer: HealthUtah PPO |
$786.04
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$762.46
|
| Rate for Payer: Multiplan Medicare/VA |
$425.64
|
| Rate for Payer: One Health Plan of WY PPO |
$770.32
|
| Rate for Payer: PacificSource Commercial |
$707.44
|
| Rate for Payer: PHCS PPO |
$770.32
|
| Rate for Payer: Three Rivers PPO |
$589.53
|
| Rate for Payer: TriWest Veterans Administration |
$448.04
|
| Rate for Payer: United Healthcare Commercial |
$750.67
|
| Rate for Payer: United Healthcare Medicare |
$448.04
|
| Rate for Payer: WINHealth Partners Commercial |
$770.32
|
| Rate for Payer: Wise Provider Network Commercial |
$746.74
|
|
