|
FOLEY TRAY LATEX UM A303316A
|
Facility
|
OP
|
$60.78
|
|
| Hospital Charge Code |
2750120
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$32.91 |
| Max. Negotiated Rate |
$60.78 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$59.56
|
| Rate for Payer: Aetna of WY Medicare |
$40.11
|
| Rate for Payer: Altius Commercial |
$58.35
|
| Rate for Payer: Beech Street Commercial |
$59.56
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$58.96
|
| Rate for Payer: Cash Price |
$42.55
|
| Rate for Payer: ChoiceCare Network Commercial |
$58.96
|
| Rate for Payer: Cigna of WY Commercial |
$59.56
|
| Rate for Payer: Entrust Commercial |
$57.74
|
| Rate for Payer: First Choice Health Commercial |
$57.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$57.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$34.64
|
| Rate for Payer: HealthUtah PPO |
$60.78
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$58.96
|
| Rate for Payer: Multiplan Medicare/VA |
$32.91
|
| Rate for Payer: One Health Plan of WY PPO |
$59.56
|
| Rate for Payer: PacificSource Commercial |
$54.70
|
| Rate for Payer: PHCS PPO |
$59.56
|
| Rate for Payer: Three Rivers PPO |
$45.58
|
| Rate for Payer: TriWest Veterans Administration |
$34.64
|
| Rate for Payer: United Healthcare Commercial |
$58.04
|
| Rate for Payer: United Healthcare Medicare |
$34.64
|
| Rate for Payer: WINHealth Partners Commercial |
$59.56
|
| Rate for Payer: Wise Provider Network Commercial |
$57.74
|
|
|
FOLEY TRAY SILICONE
|
Facility
|
IP
|
$97.87
|
|
| Hospital Charge Code |
2750116
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$56.72 |
| Max. Negotiated Rate |
$97.87 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$95.91
|
| Rate for Payer: Aetna of WY Medicare |
$62.64
|
| Rate for Payer: Altius Commercial |
$93.96
|
| Rate for Payer: Beech Street Commercial |
$95.91
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$94.93
|
| Rate for Payer: Cash Price |
$68.51
|
| Rate for Payer: ChoiceCare Network Commercial |
$94.93
|
| Rate for Payer: Cigna of WY Commercial |
$95.91
|
| Rate for Payer: Entrust Commercial |
$92.98
|
| Rate for Payer: First Choice Health Commercial |
$92.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$92.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$59.70
|
| Rate for Payer: HealthUtah PPO |
$97.87
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$94.93
|
| Rate for Payer: Multiplan Medicare/VA |
$56.72
|
| Rate for Payer: One Health Plan of WY PPO |
$95.91
|
| Rate for Payer: PacificSource Commercial |
$88.08
|
| Rate for Payer: PHCS PPO |
$95.91
|
| Rate for Payer: Three Rivers PPO |
$73.40
|
| Rate for Payer: TriWest Veterans Administration |
$59.70
|
| Rate for Payer: United Healthcare Commercial |
$93.47
|
| Rate for Payer: United Healthcare Medicare |
$59.70
|
| Rate for Payer: WINHealth Partners Commercial |
$92.98
|
| Rate for Payer: Wise Provider Network Commercial |
$92.98
|
|
|
FOLEY TRAY SILICONE
|
Facility
|
OP
|
$97.87
|
|
| Hospital Charge Code |
2750116
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$53.00 |
| Max. Negotiated Rate |
$97.87 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$95.91
|
| Rate for Payer: Aetna of WY Medicare |
$64.59
|
| Rate for Payer: Altius Commercial |
$93.96
|
| Rate for Payer: Beech Street Commercial |
$95.91
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$94.93
|
| Rate for Payer: Cash Price |
$68.51
|
| Rate for Payer: ChoiceCare Network Commercial |
$94.93
|
| Rate for Payer: Cigna of WY Commercial |
$95.91
|
| Rate for Payer: Entrust Commercial |
$92.98
|
| Rate for Payer: First Choice Health Commercial |
$92.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$92.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$55.79
|
| Rate for Payer: HealthUtah PPO |
$97.87
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$94.93
|
| Rate for Payer: Multiplan Medicare/VA |
$53.00
|
| Rate for Payer: One Health Plan of WY PPO |
$95.91
|
| Rate for Payer: PacificSource Commercial |
$88.08
|
| Rate for Payer: PHCS PPO |
$95.91
|
| Rate for Payer: Three Rivers PPO |
$73.40
|
| Rate for Payer: TriWest Veterans Administration |
$55.79
|
| Rate for Payer: United Healthcare Commercial |
$93.47
|
| Rate for Payer: United Healthcare Medicare |
$55.79
|
| Rate for Payer: WINHealth Partners Commercial |
$95.91
|
| Rate for Payer: Wise Provider Network Commercial |
$92.98
|
|
|
FOLIC ACID 1 MG TABLET [15881]
|
Facility
|
IP
|
$15.83
|
|
|
Service Code
|
NDC 6068768111
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.17 |
| Max. Negotiated Rate |
$15.83 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.51
|
| Rate for Payer: Aetna of WY Medicare |
$10.13
|
| Rate for Payer: Altius Commercial |
$15.20
|
| Rate for Payer: Beech Street Commercial |
$15.51
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.36
|
| Rate for Payer: Cash Price |
$11.08
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.36
|
| Rate for Payer: Cigna of WY Commercial |
$15.51
|
| Rate for Payer: Entrust Commercial |
$15.04
|
| Rate for Payer: First Choice Health Commercial |
$15.04
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.04
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.66
|
| Rate for Payer: HealthUtah PPO |
$15.83
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.36
|
| Rate for Payer: Multiplan Medicare/VA |
$9.17
|
| Rate for Payer: One Health Plan of WY PPO |
$15.51
|
| Rate for Payer: PacificSource Commercial |
$14.25
|
| Rate for Payer: PHCS PPO |
$15.51
|
| Rate for Payer: Three Rivers PPO |
$11.87
|
| Rate for Payer: TriWest Veterans Administration |
$9.66
|
| Rate for Payer: United Healthcare Commercial |
$15.12
|
| Rate for Payer: United Healthcare Medicare |
$9.66
|
| Rate for Payer: WINHealth Partners Commercial |
$15.04
|
| Rate for Payer: Wise Provider Network Commercial |
$15.04
|
|
|
FOLIC ACID 1 MG TABLET [15881]
|
Facility
|
OP
|
$15.83
|
|
|
Service Code
|
NDC 6068768111
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.57 |
| Max. Negotiated Rate |
$15.83 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.51
|
| Rate for Payer: Aetna of WY Medicare |
$10.45
|
| Rate for Payer: Altius Commercial |
$15.20
|
| Rate for Payer: Beech Street Commercial |
$15.51
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.36
|
| Rate for Payer: Cash Price |
$11.08
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.36
|
| Rate for Payer: Cigna of WY Commercial |
$15.51
|
| Rate for Payer: Entrust Commercial |
$15.04
|
| Rate for Payer: First Choice Health Commercial |
$15.04
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.04
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.02
|
| Rate for Payer: HealthUtah PPO |
$15.83
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.36
|
| Rate for Payer: Multiplan Medicare/VA |
$8.57
|
| Rate for Payer: One Health Plan of WY PPO |
$15.51
|
| Rate for Payer: PacificSource Commercial |
$14.25
|
| Rate for Payer: PHCS PPO |
$15.51
|
| Rate for Payer: Three Rivers PPO |
$11.87
|
| Rate for Payer: TriWest Veterans Administration |
$9.02
|
| Rate for Payer: United Healthcare Commercial |
$15.12
|
| Rate for Payer: United Healthcare Medicare |
$9.02
|
| Rate for Payer: WINHealth Partners Commercial |
$15.51
|
| Rate for Payer: Wise Provider Network Commercial |
$15.04
|
|
|
FOLIC ACID 5 MG/ML INJECTION SOLUTION [9367]
|
Facility
|
IP
|
$33.44
|
|
|
Service Code
|
NDC 6332318410
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.38 |
| Max. Negotiated Rate |
$33.44 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$32.77
|
| Rate for Payer: Aetna of WY Medicare |
$21.40
|
| Rate for Payer: Altius Commercial |
$32.10
|
| Rate for Payer: Beech Street Commercial |
$32.77
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$32.44
|
| Rate for Payer: Cash Price |
$23.41
|
| Rate for Payer: ChoiceCare Network Commercial |
$32.44
|
| Rate for Payer: Cigna of WY Commercial |
$32.77
|
| Rate for Payer: Entrust Commercial |
$31.77
|
| Rate for Payer: First Choice Health Commercial |
$31.77
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$31.77
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$20.40
|
| Rate for Payer: HealthUtah PPO |
$33.44
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$32.44
|
| Rate for Payer: Multiplan Medicare/VA |
$19.38
|
| Rate for Payer: One Health Plan of WY PPO |
$32.77
|
| Rate for Payer: PacificSource Commercial |
$30.10
|
| Rate for Payer: PHCS PPO |
$32.77
|
| Rate for Payer: Three Rivers PPO |
$25.08
|
| Rate for Payer: TriWest Veterans Administration |
$20.40
|
| Rate for Payer: United Healthcare Commercial |
$31.94
|
| Rate for Payer: United Healthcare Medicare |
$20.40
|
| Rate for Payer: WINHealth Partners Commercial |
$31.77
|
| Rate for Payer: Wise Provider Network Commercial |
$31.77
|
|
|
FOLIC ACID 5 MG/ML INJECTION SOLUTION [9367]
|
Facility
|
OP
|
$33.44
|
|
|
Service Code
|
NDC 6332318410
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.11 |
| Max. Negotiated Rate |
$33.44 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$32.77
|
| Rate for Payer: Aetna of WY Medicare |
$22.07
|
| Rate for Payer: Altius Commercial |
$32.10
|
| Rate for Payer: Beech Street Commercial |
$32.77
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$32.44
|
| Rate for Payer: Cash Price |
$23.41
|
| Rate for Payer: ChoiceCare Network Commercial |
$32.44
|
| Rate for Payer: Cigna of WY Commercial |
$32.77
|
| Rate for Payer: Entrust Commercial |
$31.77
|
| Rate for Payer: First Choice Health Commercial |
$31.77
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$31.77
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$19.06
|
| Rate for Payer: HealthUtah PPO |
$33.44
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$32.44
|
| Rate for Payer: Multiplan Medicare/VA |
$18.11
|
| Rate for Payer: One Health Plan of WY PPO |
$32.77
|
| Rate for Payer: PacificSource Commercial |
$30.10
|
| Rate for Payer: PHCS PPO |
$32.77
|
| Rate for Payer: Three Rivers PPO |
$25.08
|
| Rate for Payer: TriWest Veterans Administration |
$19.06
|
| Rate for Payer: United Healthcare Commercial |
$31.94
|
| Rate for Payer: United Healthcare Medicare |
$19.06
|
| Rate for Payer: WINHealth Partners Commercial |
$32.77
|
| Rate for Payer: Wise Provider Network Commercial |
$31.77
|
|
|
FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION [11540]
|
Facility
|
IP
|
$1,015.00
|
|
|
Service Code
|
NDC 0517071001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$588.19 |
| Max. Negotiated Rate |
$1,015.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$994.70
|
| Rate for Payer: Aetna of WY Medicare |
$649.60
|
| Rate for Payer: Altius Commercial |
$974.40
|
| Rate for Payer: Beech Street Commercial |
$994.70
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$984.55
|
| Rate for Payer: Cash Price |
$710.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$984.55
|
| Rate for Payer: Cigna of WY Commercial |
$994.70
|
| Rate for Payer: Entrust Commercial |
$964.25
|
| Rate for Payer: First Choice Health Commercial |
$964.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$964.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$619.15
|
| Rate for Payer: HealthUtah PPO |
$1,015.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$984.55
|
| Rate for Payer: Multiplan Medicare/VA |
$588.19
|
| Rate for Payer: One Health Plan of WY PPO |
$994.70
|
| Rate for Payer: PacificSource Commercial |
$913.50
|
| Rate for Payer: PHCS PPO |
$994.70
|
| Rate for Payer: Three Rivers PPO |
$761.25
|
| Rate for Payer: TriWest Veterans Administration |
$619.15
|
| Rate for Payer: United Healthcare Commercial |
$969.32
|
| Rate for Payer: United Healthcare Medicare |
$619.15
|
| Rate for Payer: WINHealth Partners Commercial |
$964.25
|
| Rate for Payer: Wise Provider Network Commercial |
$964.25
|
|
|
FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION [11540]
|
Facility
|
OP
|
$1,015.00
|
|
|
Service Code
|
NDC 0517071001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$549.62 |
| Max. Negotiated Rate |
$1,015.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$994.70
|
| Rate for Payer: Aetna of WY Medicare |
$669.90
|
| Rate for Payer: Altius Commercial |
$974.40
|
| Rate for Payer: Beech Street Commercial |
$994.70
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$984.55
|
| Rate for Payer: Cash Price |
$710.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$984.55
|
| Rate for Payer: Cigna of WY Commercial |
$994.70
|
| Rate for Payer: Entrust Commercial |
$964.25
|
| Rate for Payer: First Choice Health Commercial |
$964.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$964.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$578.55
|
| Rate for Payer: HealthUtah PPO |
$1,015.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$984.55
|
| Rate for Payer: Multiplan Medicare/VA |
$549.62
|
| Rate for Payer: One Health Plan of WY PPO |
$994.70
|
| Rate for Payer: PacificSource Commercial |
$913.50
|
| Rate for Payer: PHCS PPO |
$994.70
|
| Rate for Payer: Three Rivers PPO |
$761.25
|
| Rate for Payer: TriWest Veterans Administration |
$578.55
|
| Rate for Payer: United Healthcare Commercial |
$969.32
|
| Rate for Payer: United Healthcare Medicare |
$578.55
|
| Rate for Payer: WINHealth Partners Commercial |
$994.70
|
| Rate for Payer: Wise Provider Network Commercial |
$964.25
|
|
|
FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION [11540]
|
Facility
|
IP
|
$1,169.41
|
|
|
Service Code
|
NDC 7071014781
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$677.67 |
| Max. Negotiated Rate |
$1,169.41 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,146.02
|
| Rate for Payer: Aetna of WY Medicare |
$748.42
|
| Rate for Payer: Altius Commercial |
$1,122.63
|
| Rate for Payer: Beech Street Commercial |
$1,146.02
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,134.33
|
| Rate for Payer: Cash Price |
$818.58
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,134.33
|
| Rate for Payer: Cigna of WY Commercial |
$1,146.02
|
| Rate for Payer: Entrust Commercial |
$1,110.94
|
| Rate for Payer: First Choice Health Commercial |
$1,110.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,110.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$713.34
|
| Rate for Payer: HealthUtah PPO |
$1,169.41
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,134.33
|
| Rate for Payer: Multiplan Medicare/VA |
$677.67
|
| Rate for Payer: One Health Plan of WY PPO |
$1,146.02
|
| Rate for Payer: PacificSource Commercial |
$1,052.47
|
| Rate for Payer: PHCS PPO |
$1,146.02
|
| Rate for Payer: Three Rivers PPO |
$877.06
|
| Rate for Payer: TriWest Veterans Administration |
$713.34
|
| Rate for Payer: United Healthcare Commercial |
$1,116.79
|
| Rate for Payer: United Healthcare Medicare |
$713.34
|
| Rate for Payer: WINHealth Partners Commercial |
$1,110.94
|
| Rate for Payer: Wise Provider Network Commercial |
$1,110.94
|
|
|
FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION [11540]
|
Facility
|
OP
|
$1,169.41
|
|
|
Service Code
|
NDC 7071014781
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$633.24 |
| Max. Negotiated Rate |
$1,169.41 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,146.02
|
| Rate for Payer: Aetna of WY Medicare |
$771.81
|
| Rate for Payer: Altius Commercial |
$1,122.63
|
| Rate for Payer: Beech Street Commercial |
$1,146.02
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,134.33
|
| Rate for Payer: Cash Price |
$818.58
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,134.33
|
| Rate for Payer: Cigna of WY Commercial |
$1,146.02
|
| Rate for Payer: Entrust Commercial |
$1,110.94
|
| Rate for Payer: First Choice Health Commercial |
$1,110.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,110.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$666.56
|
| Rate for Payer: HealthUtah PPO |
$1,169.41
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,134.33
|
| Rate for Payer: Multiplan Medicare/VA |
$633.24
|
| Rate for Payer: One Health Plan of WY PPO |
$1,146.02
|
| Rate for Payer: PacificSource Commercial |
$1,052.47
|
| Rate for Payer: PHCS PPO |
$1,146.02
|
| Rate for Payer: Three Rivers PPO |
$877.06
|
| Rate for Payer: TriWest Veterans Administration |
$666.56
|
| Rate for Payer: United Healthcare Commercial |
$1,116.79
|
| Rate for Payer: United Healthcare Medicare |
$666.56
|
| Rate for Payer: WINHealth Partners Commercial |
$1,146.02
|
| Rate for Payer: Wise Provider Network Commercial |
$1,110.94
|
|
|
FO NONTORSION JOINT CF
|
Professional
|
Both
|
$281.00
|
|
|
Service Code
|
HCPCS L3935
|
| Min. Negotiated Rate |
$210.75 |
| Max. Negotiated Rate |
$281.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$275.38
|
| Rate for Payer: Beech Street Commercial |
$266.95
|
| Rate for Payer: Cash Price |
$196.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$272.57
|
| Rate for Payer: Cigna of WY Commercial |
$275.38
|
| Rate for Payer: First Choice Health Commercial |
$252.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$266.95
|
| Rate for Payer: HealthUtah PPO |
$281.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$272.57
|
| Rate for Payer: One Health Plan of WY PPO |
$275.38
|
| Rate for Payer: PacificSource Commercial |
$252.90
|
| Rate for Payer: PHCS PPO |
$266.95
|
| Rate for Payer: Three Rivers PPO |
$210.75
|
| Rate for Payer: United Healthcare Commercial |
$266.95
|
| Rate for Payer: WINHealth Partners Commercial |
$266.95
|
|
|
FOOT PLAS HEEL STABI PRE OTS
|
Professional
|
Both
|
$83.00
|
|
|
Service Code
|
HCPCS L3170
|
| Min. Negotiated Rate |
$62.25 |
| Max. Negotiated Rate |
$83.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$81.34
|
| Rate for Payer: Beech Street Commercial |
$78.85
|
| Rate for Payer: Cash Price |
$58.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$80.51
|
| Rate for Payer: Cigna of WY Commercial |
$81.34
|
| Rate for Payer: First Choice Health Commercial |
$74.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$78.85
|
| Rate for Payer: HealthUtah PPO |
$83.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$80.51
|
| Rate for Payer: One Health Plan of WY PPO |
$81.34
|
| Rate for Payer: PacificSource Commercial |
$74.70
|
| Rate for Payer: PHCS PPO |
$78.85
|
| Rate for Payer: Three Rivers PPO |
$62.25
|
| Rate for Payer: United Healthcare Commercial |
$78.85
|
| Rate for Payer: WINHealth Partners Commercial |
$78.85
|
|
|
FO PIP DIP JNT/SPRNG PRE OTS
|
Professional
|
Both
|
$37.00
|
|
|
Service Code
|
HCPCS L3925
|
| Min. Negotiated Rate |
$27.75 |
| Max. Negotiated Rate |
$37.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$36.26
|
| Rate for Payer: Beech Street Commercial |
$35.15
|
| Rate for Payer: Cash Price |
$25.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$35.89
|
| Rate for Payer: Cigna of WY Commercial |
$36.26
|
| Rate for Payer: First Choice Health Commercial |
$33.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$35.15
|
| Rate for Payer: HealthUtah PPO |
$37.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$35.89
|
| Rate for Payer: One Health Plan of WY PPO |
$36.26
|
| Rate for Payer: PacificSource Commercial |
$33.30
|
| Rate for Payer: PHCS PPO |
$35.15
|
| Rate for Payer: Three Rivers PPO |
$27.75
|
| Rate for Payer: United Healthcare Commercial |
$35.15
|
| Rate for Payer: WINHealth Partners Commercial |
$35.15
|
|
|
FORCEPS BOEDECKER MAGILL 25CM
|
Facility
|
OP
|
$1,133.44
|
|
| Hospital Charge Code |
2400273
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$613.76 |
| Max. Negotiated Rate |
$1,133.44 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,110.77
|
| Rate for Payer: Aetna of WY Medicare |
$748.07
|
| Rate for Payer: Altius Commercial |
$1,088.10
|
| Rate for Payer: Beech Street Commercial |
$1,110.77
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,099.44
|
| Rate for Payer: Cash Price |
$793.41
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,099.44
|
| Rate for Payer: Cigna of WY Commercial |
$1,110.77
|
| Rate for Payer: Entrust Commercial |
$1,076.77
|
| Rate for Payer: First Choice Health Commercial |
$1,076.77
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,076.77
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$646.06
|
| Rate for Payer: HealthUtah PPO |
$1,133.44
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,099.44
|
| Rate for Payer: Multiplan Medicare/VA |
$613.76
|
| Rate for Payer: One Health Plan of WY PPO |
$1,110.77
|
| Rate for Payer: PacificSource Commercial |
$1,020.10
|
| Rate for Payer: PHCS PPO |
$1,110.77
|
| Rate for Payer: Three Rivers PPO |
$850.08
|
| Rate for Payer: TriWest Veterans Administration |
$646.06
|
| Rate for Payer: United Healthcare Commercial |
$1,082.44
|
| Rate for Payer: United Healthcare Medicare |
$646.06
|
| Rate for Payer: WINHealth Partners Commercial |
$1,110.77
|
| Rate for Payer: Wise Provider Network Commercial |
$1,076.77
|
|
|
FORCEPS BOEDECKER MAGILL 25CM
|
Facility
|
IP
|
$1,133.44
|
|
| Hospital Charge Code |
2400273
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$656.83 |
| Max. Negotiated Rate |
$1,133.44 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,110.77
|
| Rate for Payer: Aetna of WY Medicare |
$725.40
|
| Rate for Payer: Altius Commercial |
$1,088.10
|
| Rate for Payer: Beech Street Commercial |
$1,110.77
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,099.44
|
| Rate for Payer: Cash Price |
$793.41
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,099.44
|
| Rate for Payer: Cigna of WY Commercial |
$1,110.77
|
| Rate for Payer: Entrust Commercial |
$1,076.77
|
| Rate for Payer: First Choice Health Commercial |
$1,076.77
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,076.77
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$691.40
|
| Rate for Payer: HealthUtah PPO |
$1,133.44
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,099.44
|
| Rate for Payer: Multiplan Medicare/VA |
$656.83
|
| Rate for Payer: One Health Plan of WY PPO |
$1,110.77
|
| Rate for Payer: PacificSource Commercial |
$1,020.10
|
| Rate for Payer: PHCS PPO |
$1,110.77
|
| Rate for Payer: Three Rivers PPO |
$850.08
|
| Rate for Payer: TriWest Veterans Administration |
$691.40
|
| Rate for Payer: United Healthcare Commercial |
$1,082.44
|
| Rate for Payer: United Healthcare Medicare |
$691.40
|
| Rate for Payer: WINHealth Partners Commercial |
$1,076.77
|
| Rate for Payer: Wise Provider Network Commercial |
$1,076.77
|
|
|
FORCEPS GRASPING ROTATABLE
|
Facility
|
IP
|
$562.52
|
|
| Hospital Charge Code |
2650011
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$325.98 |
| Max. Negotiated Rate |
$562.52 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$551.27
|
| Rate for Payer: Aetna of WY Medicare |
$360.01
|
| Rate for Payer: Altius Commercial |
$540.02
|
| Rate for Payer: Beech Street Commercial |
$551.27
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$545.64
|
| Rate for Payer: Cash Price |
$393.76
|
| Rate for Payer: ChoiceCare Network Commercial |
$545.64
|
| Rate for Payer: Cigna of WY Commercial |
$551.27
|
| Rate for Payer: Entrust Commercial |
$534.39
|
| Rate for Payer: First Choice Health Commercial |
$534.39
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$534.39
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$343.14
|
| Rate for Payer: HealthUtah PPO |
$562.52
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$545.64
|
| Rate for Payer: Multiplan Medicare/VA |
$325.98
|
| Rate for Payer: One Health Plan of WY PPO |
$551.27
|
| Rate for Payer: PacificSource Commercial |
$506.27
|
| Rate for Payer: PHCS PPO |
$551.27
|
| Rate for Payer: Three Rivers PPO |
$421.89
|
| Rate for Payer: TriWest Veterans Administration |
$343.14
|
| Rate for Payer: United Healthcare Commercial |
$537.21
|
| Rate for Payer: United Healthcare Medicare |
$343.14
|
| Rate for Payer: WINHealth Partners Commercial |
$534.39
|
| Rate for Payer: Wise Provider Network Commercial |
$534.39
|
|
|
FORCEPS GRASPING ROTATABLE
|
Facility
|
OP
|
$562.52
|
|
| Hospital Charge Code |
2650011
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$304.60 |
| Max. Negotiated Rate |
$562.52 |
| Rate for Payer: United Healthcare Commercial |
$537.21
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$551.27
|
| Rate for Payer: Aetna of WY Medicare |
$371.26
|
| Rate for Payer: Altius Commercial |
$540.02
|
| Rate for Payer: Beech Street Commercial |
$551.27
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$545.64
|
| Rate for Payer: Cash Price |
$393.76
|
| Rate for Payer: ChoiceCare Network Commercial |
$545.64
|
| Rate for Payer: Cigna of WY Commercial |
$551.27
|
| Rate for Payer: Entrust Commercial |
$534.39
|
| Rate for Payer: First Choice Health Commercial |
$534.39
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$534.39
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$320.64
|
| Rate for Payer: HealthUtah PPO |
$562.52
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$545.64
|
| Rate for Payer: Multiplan Medicare/VA |
$304.60
|
| Rate for Payer: One Health Plan of WY PPO |
$551.27
|
| Rate for Payer: PacificSource Commercial |
$506.27
|
| Rate for Payer: PHCS PPO |
$551.27
|
| Rate for Payer: Three Rivers PPO |
$421.89
|
| Rate for Payer: TriWest Veterans Administration |
$320.64
|
| Rate for Payer: United Healthcare Medicare |
$320.64
|
| Rate for Payer: WINHealth Partners Commercial |
$551.27
|
| Rate for Payer: Wise Provider Network Commercial |
$534.39
|
|
|
FORCEPS POINTED W/RACHET, NARROR LONG
|
Facility
|
IP
|
$5,915.00
|
|
| Hospital Charge Code |
3004645
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,427.74 |
| Max. Negotiated Rate |
$5,915.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5,796.70
|
| Rate for Payer: Aetna of WY Medicare |
$3,785.60
|
| Rate for Payer: Altius Commercial |
$5,678.40
|
| Rate for Payer: Beech Street Commercial |
$5,796.70
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$5,737.55
|
| Rate for Payer: Cash Price |
$4,140.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$5,737.55
|
| Rate for Payer: Cigna of WY Commercial |
$5,796.70
|
| Rate for Payer: Entrust Commercial |
$5,619.25
|
| Rate for Payer: First Choice Health Commercial |
$5,619.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5,619.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3,608.15
|
| Rate for Payer: HealthUtah PPO |
$5,915.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5,737.55
|
| Rate for Payer: Multiplan Medicare/VA |
$3,427.74
|
| Rate for Payer: One Health Plan of WY PPO |
$5,796.70
|
| Rate for Payer: PacificSource Commercial |
$5,323.50
|
| Rate for Payer: PHCS PPO |
$5,796.70
|
| Rate for Payer: Three Rivers PPO |
$4,436.25
|
| Rate for Payer: TriWest Veterans Administration |
$3,608.15
|
| Rate for Payer: United Healthcare Commercial |
$5,648.82
|
| Rate for Payer: United Healthcare Medicare |
$3,608.15
|
| Rate for Payer: WINHealth Partners Commercial |
$5,619.25
|
| Rate for Payer: Wise Provider Network Commercial |
$5,619.25
|
|
|
FORCEPS POINTED W/RACHET, NARROR LONG
|
Facility
|
OP
|
$5,915.00
|
|
| Hospital Charge Code |
3004645
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,202.97 |
| Max. Negotiated Rate |
$5,915.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5,796.70
|
| Rate for Payer: Aetna of WY Medicare |
$3,903.90
|
| Rate for Payer: Altius Commercial |
$5,678.40
|
| Rate for Payer: Beech Street Commercial |
$5,796.70
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$5,737.55
|
| Rate for Payer: Cash Price |
$4,140.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$5,737.55
|
| Rate for Payer: Cigna of WY Commercial |
$5,796.70
|
| Rate for Payer: Entrust Commercial |
$5,619.25
|
| Rate for Payer: First Choice Health Commercial |
$5,619.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5,619.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3,371.55
|
| Rate for Payer: HealthUtah PPO |
$5,915.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5,737.55
|
| Rate for Payer: Multiplan Medicare/VA |
$3,202.97
|
| Rate for Payer: One Health Plan of WY PPO |
$5,796.70
|
| Rate for Payer: PacificSource Commercial |
$5,323.50
|
| Rate for Payer: PHCS PPO |
$5,796.70
|
| Rate for Payer: Three Rivers PPO |
$4,436.25
|
| Rate for Payer: TriWest Veterans Administration |
$3,371.55
|
| Rate for Payer: United Healthcare Commercial |
$5,648.82
|
| Rate for Payer: United Healthcare Medicare |
$3,371.55
|
| Rate for Payer: WINHealth Partners Commercial |
$5,796.70
|
| Rate for Payer: Wise Provider Network Commercial |
$5,619.25
|
|
|
FORESKN MANJ W/LSS PREPUTIAL ADS&STRETCHING
|
Professional
|
Both
|
$247.00
|
|
|
Service Code
|
HCPCS 54450
|
| Min. Negotiated Rate |
$46.02 |
| Max. Negotiated Rate |
$247.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$242.06
|
| Rate for Payer: Aetna of WY Medicare |
$54.14
|
| Rate for Payer: Beech Street Commercial |
$234.65
|
| Rate for Payer: Cash Price |
$172.90
|
| Rate for Payer: Cash Price |
$172.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$239.59
|
| Rate for Payer: Cigna of WY Commercial |
$242.06
|
| Rate for Payer: First Choice Health Commercial |
$222.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$234.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$54.14
|
| Rate for Payer: HealthUtah PPO |
$247.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$239.59
|
| Rate for Payer: Multiplan Medicare/VA |
$46.02
|
| Rate for Payer: One Health Plan of WY PPO |
$242.06
|
| Rate for Payer: PacificSource Commercial |
$222.30
|
| Rate for Payer: PHCS PPO |
$234.65
|
| Rate for Payer: Three Rivers PPO |
$185.25
|
| Rate for Payer: TriWest Veterans Administration |
$54.14
|
| Rate for Payer: United Healthcare Commercial |
$234.65
|
| Rate for Payer: WINHealth Partners Commercial |
$209.95
|
|
|
FOSAPREPITANT 150 MG INTRAVENOUS POWDER FOR SOLUTION [91002]
|
Facility
|
IP
|
$65.00
|
|
|
Service Code
|
HCPCS J1453
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.67 |
| Max. Negotiated Rate |
$65.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$63.70
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$126.18
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$155.64
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$69.58
|
| Rate for Payer: Aetna of WY Medicare |
$45.44
|
| Rate for Payer: Aetna of WY Medicare |
$82.40
|
| Rate for Payer: Aetna of WY Medicare |
$41.60
|
| Rate for Payer: Aetna of WY Medicare |
$101.64
|
| Rate for Payer: Altius Commercial |
$62.40
|
| Rate for Payer: Altius Commercial |
$68.16
|
| Rate for Payer: Altius Commercial |
$123.60
|
| Rate for Payer: Altius Commercial |
$152.47
|
| Rate for Payer: Beech Street Commercial |
$69.58
|
| Rate for Payer: Beech Street Commercial |
$63.70
|
| Rate for Payer: Beech Street Commercial |
$126.18
|
| Rate for Payer: Beech Street Commercial |
$155.64
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$63.05
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$154.06
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$124.89
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$68.87
|
| Rate for Payer: Cash Price |
$111.17
|
| Rate for Payer: Cash Price |
$49.70
|
| Rate for Payer: Cash Price |
$90.12
|
| Rate for Payer: Cash Price |
$45.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$68.87
|
| Rate for Payer: ChoiceCare Network Commercial |
$124.89
|
| Rate for Payer: ChoiceCare Network Commercial |
$63.05
|
| Rate for Payer: ChoiceCare Network Commercial |
$154.06
|
| Rate for Payer: Cigna of WY Commercial |
$155.64
|
| Rate for Payer: Cigna of WY Commercial |
$126.18
|
| Rate for Payer: Cigna of WY Commercial |
$63.70
|
| Rate for Payer: Cigna of WY Commercial |
$69.58
|
| Rate for Payer: Entrust Commercial |
$122.31
|
| Rate for Payer: Entrust Commercial |
$150.88
|
| Rate for Payer: Entrust Commercial |
$61.75
|
| Rate for Payer: Entrust Commercial |
$67.45
|
| Rate for Payer: First Choice Health Commercial |
$61.75
|
| Rate for Payer: First Choice Health Commercial |
$122.31
|
| Rate for Payer: First Choice Health Commercial |
$67.45
|
| Rate for Payer: First Choice Health Commercial |
$150.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$122.31
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$150.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$61.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$67.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$43.31
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$39.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$78.54
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$96.88
|
| Rate for Payer: HealthUtah PPO |
$71.00
|
| Rate for Payer: HealthUtah PPO |
$128.75
|
| Rate for Payer: HealthUtah PPO |
$158.82
|
| Rate for Payer: HealthUtah PPO |
$65.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$154.06
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$68.87
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$124.89
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$63.05
|
| Rate for Payer: Multiplan Medicare/VA |
$37.67
|
| Rate for Payer: Multiplan Medicare/VA |
$74.61
|
| Rate for Payer: Multiplan Medicare/VA |
$92.04
|
| Rate for Payer: Multiplan Medicare/VA |
$41.14
|
| Rate for Payer: One Health Plan of WY PPO |
$126.18
|
| Rate for Payer: One Health Plan of WY PPO |
$63.70
|
| Rate for Payer: One Health Plan of WY PPO |
$69.58
|
| Rate for Payer: One Health Plan of WY PPO |
$155.64
|
| Rate for Payer: PacificSource Commercial |
$63.90
|
| Rate for Payer: PacificSource Commercial |
$142.94
|
| Rate for Payer: PacificSource Commercial |
$58.50
|
| Rate for Payer: PacificSource Commercial |
$115.88
|
| Rate for Payer: PHCS PPO |
$126.18
|
| Rate for Payer: PHCS PPO |
$63.70
|
| Rate for Payer: PHCS PPO |
$155.64
|
| Rate for Payer: PHCS PPO |
$69.58
|
| Rate for Payer: Three Rivers PPO |
$96.56
|
| Rate for Payer: Three Rivers PPO |
$48.75
|
| Rate for Payer: Three Rivers PPO |
$53.25
|
| Rate for Payer: Three Rivers PPO |
$119.12
|
| Rate for Payer: TriWest Veterans Administration |
$96.88
|
| Rate for Payer: TriWest Veterans Administration |
$78.54
|
| Rate for Payer: TriWest Veterans Administration |
$39.65
|
| Rate for Payer: TriWest Veterans Administration |
$43.31
|
| Rate for Payer: United Healthcare Commercial |
$67.80
|
| Rate for Payer: United Healthcare Commercial |
$122.96
|
| Rate for Payer: United Healthcare Commercial |
$151.67
|
| Rate for Payer: United Healthcare Commercial |
$62.08
|
| Rate for Payer: United Healthcare Medicare |
$39.65
|
| Rate for Payer: United Healthcare Medicare |
$43.31
|
| Rate for Payer: United Healthcare Medicare |
$78.54
|
| Rate for Payer: United Healthcare Medicare |
$96.88
|
| Rate for Payer: WINHealth Partners Commercial |
$122.31
|
| Rate for Payer: WINHealth Partners Commercial |
$61.75
|
| Rate for Payer: WINHealth Partners Commercial |
$67.45
|
| Rate for Payer: WINHealth Partners Commercial |
$150.88
|
| Rate for Payer: Wise Provider Network Commercial |
$67.45
|
| Rate for Payer: Wise Provider Network Commercial |
$150.88
|
| Rate for Payer: Wise Provider Network Commercial |
$61.75
|
| Rate for Payer: Wise Provider Network Commercial |
$122.31
|
|
|
FOSAPREPITANT 150 MG INTRAVENOUS POWDER FOR SOLUTION [91002]
|
Facility
|
OP
|
$158.82
|
|
|
Service Code
|
HCPCS J1453
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$86.00 |
| Max. Negotiated Rate |
$158.82 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$155.64
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$126.18
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$69.58
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$63.70
|
| Rate for Payer: Aetna of WY Medicare |
$84.98
|
| Rate for Payer: Aetna of WY Medicare |
$42.90
|
| Rate for Payer: Aetna of WY Medicare |
$104.82
|
| Rate for Payer: Aetna of WY Medicare |
$46.86
|
| Rate for Payer: Altius Commercial |
$123.60
|
| Rate for Payer: Altius Commercial |
$152.47
|
| Rate for Payer: Altius Commercial |
$68.16
|
| Rate for Payer: Altius Commercial |
$62.40
|
| Rate for Payer: Beech Street Commercial |
$63.70
|
| Rate for Payer: Beech Street Commercial |
$126.18
|
| Rate for Payer: Beech Street Commercial |
$155.64
|
| Rate for Payer: Beech Street Commercial |
$69.58
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$124.89
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$68.87
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$154.06
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$63.05
|
| Rate for Payer: Cash Price |
$49.70
|
| Rate for Payer: Cash Price |
$111.17
|
| Rate for Payer: Cash Price |
$45.50
|
| Rate for Payer: Cash Price |
$90.12
|
| Rate for Payer: ChoiceCare Network Commercial |
$124.89
|
| Rate for Payer: ChoiceCare Network Commercial |
$154.06
|
| Rate for Payer: ChoiceCare Network Commercial |
$63.05
|
| Rate for Payer: ChoiceCare Network Commercial |
$68.87
|
| Rate for Payer: Cigna of WY Commercial |
$126.18
|
| Rate for Payer: Cigna of WY Commercial |
$69.58
|
| Rate for Payer: Cigna of WY Commercial |
$155.64
|
| Rate for Payer: Cigna of WY Commercial |
$63.70
|
| Rate for Payer: Entrust Commercial |
$150.88
|
| Rate for Payer: Entrust Commercial |
$61.75
|
| Rate for Payer: Entrust Commercial |
$122.31
|
| Rate for Payer: Entrust Commercial |
$67.45
|
| Rate for Payer: First Choice Health Commercial |
$61.75
|
| Rate for Payer: First Choice Health Commercial |
$67.45
|
| Rate for Payer: First Choice Health Commercial |
$122.31
|
| Rate for Payer: First Choice Health Commercial |
$150.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$150.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$67.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$61.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$122.31
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$73.39
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$90.53
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$37.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$40.47
|
| Rate for Payer: HealthUtah PPO |
$71.00
|
| Rate for Payer: HealthUtah PPO |
$128.75
|
| Rate for Payer: HealthUtah PPO |
$65.00
|
| Rate for Payer: HealthUtah PPO |
$158.82
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$124.89
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$68.87
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$154.06
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$63.05
|
| Rate for Payer: Multiplan Medicare/VA |
$35.20
|
| Rate for Payer: Multiplan Medicare/VA |
$38.45
|
| Rate for Payer: Multiplan Medicare/VA |
$69.72
|
| Rate for Payer: Multiplan Medicare/VA |
$86.00
|
| Rate for Payer: One Health Plan of WY PPO |
$126.18
|
| Rate for Payer: One Health Plan of WY PPO |
$63.70
|
| Rate for Payer: One Health Plan of WY PPO |
$69.58
|
| Rate for Payer: One Health Plan of WY PPO |
$155.64
|
| Rate for Payer: PacificSource Commercial |
$115.88
|
| Rate for Payer: PacificSource Commercial |
$142.94
|
| Rate for Payer: PacificSource Commercial |
$58.50
|
| Rate for Payer: PacificSource Commercial |
$63.90
|
| Rate for Payer: PHCS PPO |
$63.70
|
| Rate for Payer: PHCS PPO |
$155.64
|
| Rate for Payer: PHCS PPO |
$69.58
|
| Rate for Payer: PHCS PPO |
$126.18
|
| Rate for Payer: Three Rivers PPO |
$53.25
|
| Rate for Payer: Three Rivers PPO |
$119.12
|
| Rate for Payer: Three Rivers PPO |
$48.75
|
| Rate for Payer: Three Rivers PPO |
$96.56
|
| Rate for Payer: TriWest Veterans Administration |
$73.39
|
| Rate for Payer: TriWest Veterans Administration |
$37.05
|
| Rate for Payer: TriWest Veterans Administration |
$90.53
|
| Rate for Payer: TriWest Veterans Administration |
$40.47
|
| Rate for Payer: United Healthcare Commercial |
$67.80
|
| Rate for Payer: United Healthcare Commercial |
$122.96
|
| Rate for Payer: United Healthcare Commercial |
$62.08
|
| Rate for Payer: United Healthcare Commercial |
$151.67
|
| Rate for Payer: United Healthcare Medicare |
$37.05
|
| Rate for Payer: United Healthcare Medicare |
$90.53
|
| Rate for Payer: United Healthcare Medicare |
$73.39
|
| Rate for Payer: United Healthcare Medicare |
$40.47
|
| Rate for Payer: WINHealth Partners Commercial |
$63.70
|
| Rate for Payer: WINHealth Partners Commercial |
$155.64
|
| Rate for Payer: WINHealth Partners Commercial |
$69.58
|
| Rate for Payer: WINHealth Partners Commercial |
$126.18
|
| Rate for Payer: Wise Provider Network Commercial |
$122.31
|
| Rate for Payer: Wise Provider Network Commercial |
$150.88
|
| Rate for Payer: Wise Provider Network Commercial |
$61.75
|
| Rate for Payer: Wise Provider Network Commercial |
$67.45
|
|
|
FO W/O JOINTS CF
|
Professional
|
Both
|
$271.00
|
|
|
Service Code
|
HCPCS L3933
|
| Min. Negotiated Rate |
$203.25 |
| Max. Negotiated Rate |
$271.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$265.58
|
| Rate for Payer: Beech Street Commercial |
$257.45
|
| Rate for Payer: Cash Price |
$189.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$262.87
|
| Rate for Payer: Cigna of WY Commercial |
$265.58
|
| Rate for Payer: First Choice Health Commercial |
$243.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$257.45
|
| Rate for Payer: HealthUtah PPO |
$271.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$262.87
|
| Rate for Payer: One Health Plan of WY PPO |
$265.58
|
| Rate for Payer: PacificSource Commercial |
$243.90
|
| Rate for Payer: PHCS PPO |
$257.45
|
| Rate for Payer: Three Rivers PPO |
$203.25
|
| Rate for Payer: United Healthcare Commercial |
$257.45
|
| Rate for Payer: WINHealth Partners Commercial |
$257.45
|
|
|
FRACTURE NASAL INFERIOR TURBINATE THERAPEUTIC
|
Professional
|
Both
|
$518.00
|
|
|
Service Code
|
HCPCS 30930
|
| Min. Negotiated Rate |
$98.54 |
| Max. Negotiated Rate |
$518.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$507.64
|
| Rate for Payer: Aetna of WY Medicare |
$115.93
|
| Rate for Payer: Beech Street Commercial |
$492.10
|
| Rate for Payer: Cash Price |
$362.60
|
| Rate for Payer: Cash Price |
$362.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$502.46
|
| Rate for Payer: Cigna of WY Commercial |
$507.64
|
| Rate for Payer: First Choice Health Commercial |
$466.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$492.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$115.93
|
| Rate for Payer: HealthUtah PPO |
$518.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$502.46
|
| Rate for Payer: Multiplan Medicare/VA |
$98.54
|
| Rate for Payer: One Health Plan of WY PPO |
$507.64
|
| Rate for Payer: PacificSource Commercial |
$466.20
|
| Rate for Payer: PHCS PPO |
$492.10
|
| Rate for Payer: Three Rivers PPO |
$388.50
|
| Rate for Payer: TriWest Veterans Administration |
$115.93
|
| Rate for Payer: United Healthcare Commercial |
$492.10
|
| Rate for Payer: WINHealth Partners Commercial |
$440.30
|
|
