|
GLYCERIN (LAXATIVE) 2.8 GRAM/2.7 ML RECTAL SOLUTION [88720]
|
Facility
|
OP
|
$15.76
|
|
|
Service Code
|
NDC 0132019012
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.53 |
| Max. Negotiated Rate |
$15.76 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.44
|
| Rate for Payer: Aetna of WY Medicare |
$10.40
|
| Rate for Payer: Altius Commercial |
$15.13
|
| Rate for Payer: Beech Street Commercial |
$15.44
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.29
|
| Rate for Payer: Cash Price |
$11.03
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.29
|
| Rate for Payer: Cigna of WY Commercial |
$15.44
|
| Rate for Payer: Entrust Commercial |
$14.97
|
| Rate for Payer: First Choice Health Commercial |
$14.97
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.97
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.98
|
| Rate for Payer: HealthUtah PPO |
$15.76
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.29
|
| Rate for Payer: Multiplan Medicare/VA |
$8.53
|
| Rate for Payer: One Health Plan of WY PPO |
$15.44
|
| Rate for Payer: PacificSource Commercial |
$14.18
|
| Rate for Payer: PHCS PPO |
$15.44
|
| Rate for Payer: Three Rivers PPO |
$11.82
|
| Rate for Payer: TriWest Veterans Administration |
$8.98
|
| Rate for Payer: United Healthcare Commercial |
$15.05
|
| Rate for Payer: United Healthcare Medicare |
$8.98
|
| Rate for Payer: WINHealth Partners Commercial |
$15.44
|
| Rate for Payer: Wise Provider Network Commercial |
$14.97
|
|
|
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [2820]
|
Facility
|
IP
|
$24.75
|
|
|
Service Code
|
HCPCS J1596
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.34 |
| Max. Negotiated Rate |
$24.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$24.26
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$24.50
|
| Rate for Payer: Aetna of WY Medicare |
$16.00
|
| Rate for Payer: Aetna of WY Medicare |
$15.84
|
| Rate for Payer: Altius Commercial |
$23.76
|
| Rate for Payer: Altius Commercial |
$24.00
|
| Rate for Payer: Beech Street Commercial |
$24.26
|
| Rate for Payer: Beech Street Commercial |
$24.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$24.01
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$24.25
|
| Rate for Payer: Cash Price |
$17.50
|
| Rate for Payer: Cash Price |
$17.32
|
| Rate for Payer: ChoiceCare Network Commercial |
$24.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$24.01
|
| Rate for Payer: Cigna of WY Commercial |
$24.26
|
| Rate for Payer: Cigna of WY Commercial |
$24.50
|
| Rate for Payer: Entrust Commercial |
$23.51
|
| Rate for Payer: Entrust Commercial |
$23.75
|
| Rate for Payer: First Choice Health Commercial |
$23.51
|
| Rate for Payer: First Choice Health Commercial |
$23.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$23.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$23.51
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$15.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$15.10
|
| Rate for Payer: HealthUtah PPO |
$24.75
|
| Rate for Payer: HealthUtah PPO |
$25.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.25
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.01
|
| Rate for Payer: Multiplan Medicare/VA |
$14.34
|
| Rate for Payer: Multiplan Medicare/VA |
$14.49
|
| Rate for Payer: One Health Plan of WY PPO |
$24.26
|
| Rate for Payer: One Health Plan of WY PPO |
$24.50
|
| Rate for Payer: PacificSource Commercial |
$22.50
|
| Rate for Payer: PacificSource Commercial |
$22.28
|
| Rate for Payer: PHCS PPO |
$24.26
|
| Rate for Payer: PHCS PPO |
$24.50
|
| Rate for Payer: Three Rivers PPO |
$18.75
|
| Rate for Payer: Three Rivers PPO |
$18.56
|
| Rate for Payer: TriWest Veterans Administration |
$15.25
|
| Rate for Payer: TriWest Veterans Administration |
$15.10
|
| Rate for Payer: United Healthcare Commercial |
$23.88
|
| Rate for Payer: United Healthcare Commercial |
$23.64
|
| Rate for Payer: United Healthcare Medicare |
$15.25
|
| Rate for Payer: United Healthcare Medicare |
$15.10
|
| Rate for Payer: WINHealth Partners Commercial |
$23.51
|
| Rate for Payer: WINHealth Partners Commercial |
$23.75
|
| Rate for Payer: Wise Provider Network Commercial |
$23.51
|
| Rate for Payer: Wise Provider Network Commercial |
$23.75
|
|
|
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [2820]
|
Facility
|
OP
|
$25.00
|
|
|
Service Code
|
HCPCS J1596
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.54 |
| Max. Negotiated Rate |
$25.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$24.50
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$24.26
|
| Rate for Payer: Aetna of WY Medicare |
$16.50
|
| Rate for Payer: Aetna of WY Medicare |
$16.34
|
| Rate for Payer: Altius Commercial |
$23.76
|
| Rate for Payer: Altius Commercial |
$24.00
|
| Rate for Payer: Beech Street Commercial |
$24.26
|
| Rate for Payer: Beech Street Commercial |
$24.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$24.25
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$24.01
|
| Rate for Payer: Cash Price |
$17.32
|
| Rate for Payer: Cash Price |
$17.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$24.01
|
| Rate for Payer: ChoiceCare Network Commercial |
$24.25
|
| Rate for Payer: Cigna of WY Commercial |
$24.26
|
| Rate for Payer: Cigna of WY Commercial |
$24.50
|
| Rate for Payer: Entrust Commercial |
$23.75
|
| Rate for Payer: Entrust Commercial |
$23.51
|
| Rate for Payer: First Choice Health Commercial |
$23.75
|
| Rate for Payer: First Choice Health Commercial |
$23.51
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$23.51
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$23.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$14.11
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$14.25
|
| Rate for Payer: HealthUtah PPO |
$24.75
|
| Rate for Payer: HealthUtah PPO |
$25.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.25
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.01
|
| Rate for Payer: Multiplan Medicare/VA |
$13.54
|
| Rate for Payer: Multiplan Medicare/VA |
$13.40
|
| Rate for Payer: One Health Plan of WY PPO |
$24.50
|
| Rate for Payer: One Health Plan of WY PPO |
$24.26
|
| Rate for Payer: PacificSource Commercial |
$22.28
|
| Rate for Payer: PacificSource Commercial |
$22.50
|
| Rate for Payer: PHCS PPO |
$24.50
|
| Rate for Payer: PHCS PPO |
$24.26
|
| Rate for Payer: Three Rivers PPO |
$18.75
|
| Rate for Payer: Three Rivers PPO |
$18.56
|
| Rate for Payer: TriWest Veterans Administration |
$14.11
|
| Rate for Payer: TriWest Veterans Administration |
$14.25
|
| Rate for Payer: United Healthcare Commercial |
$23.64
|
| Rate for Payer: United Healthcare Commercial |
$23.88
|
| Rate for Payer: United Healthcare Medicare |
$14.25
|
| Rate for Payer: United Healthcare Medicare |
$14.11
|
| Rate for Payer: WINHealth Partners Commercial |
$24.26
|
| Rate for Payer: WINHealth Partners Commercial |
$24.50
|
| Rate for Payer: Wise Provider Network Commercial |
$23.75
|
| Rate for Payer: Wise Provider Network Commercial |
$23.51
|
|
|
GOLIMUMAB 12.5 MG/ML INTRAVENOUS SOLUTION [128996]
|
Facility
|
IP
|
$514.80
|
|
|
Service Code
|
HCPCS J1602
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$298.33 |
| Max. Negotiated Rate |
$514.80 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$504.50
|
| Rate for Payer: Aetna of WY Medicare |
$329.47
|
| Rate for Payer: Altius Commercial |
$494.21
|
| Rate for Payer: Beech Street Commercial |
$504.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$499.36
|
| Rate for Payer: Cash Price |
$360.36
|
| Rate for Payer: ChoiceCare Network Commercial |
$499.36
|
| Rate for Payer: Cigna of WY Commercial |
$504.50
|
| Rate for Payer: Entrust Commercial |
$489.06
|
| Rate for Payer: First Choice Health Commercial |
$489.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$489.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$314.03
|
| Rate for Payer: HealthUtah PPO |
$514.80
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$499.36
|
| Rate for Payer: Multiplan Medicare/VA |
$298.33
|
| Rate for Payer: One Health Plan of WY PPO |
$504.50
|
| Rate for Payer: PacificSource Commercial |
$463.32
|
| Rate for Payer: PHCS PPO |
$504.50
|
| Rate for Payer: Three Rivers PPO |
$386.10
|
| Rate for Payer: TriWest Veterans Administration |
$314.03
|
| Rate for Payer: United Healthcare Commercial |
$491.63
|
| Rate for Payer: United Healthcare Medicare |
$314.03
|
| Rate for Payer: WINHealth Partners Commercial |
$489.06
|
| Rate for Payer: Wise Provider Network Commercial |
$489.06
|
|
|
GOLIMUMAB 12.5 MG/ML INTRAVENOUS SOLUTION [128996]
|
Facility
|
OP
|
$514.80
|
|
|
Service Code
|
HCPCS J1602
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$278.76 |
| Max. Negotiated Rate |
$514.80 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$504.50
|
| Rate for Payer: Aetna of WY Medicare |
$339.77
|
| Rate for Payer: Altius Commercial |
$494.21
|
| Rate for Payer: Beech Street Commercial |
$504.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$499.36
|
| Rate for Payer: Cash Price |
$360.36
|
| Rate for Payer: ChoiceCare Network Commercial |
$499.36
|
| Rate for Payer: Cigna of WY Commercial |
$504.50
|
| Rate for Payer: Entrust Commercial |
$489.06
|
| Rate for Payer: First Choice Health Commercial |
$489.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$489.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$293.44
|
| Rate for Payer: HealthUtah PPO |
$514.80
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$499.36
|
| Rate for Payer: Multiplan Medicare/VA |
$278.76
|
| Rate for Payer: One Health Plan of WY PPO |
$504.50
|
| Rate for Payer: PacificSource Commercial |
$463.32
|
| Rate for Payer: PHCS PPO |
$504.50
|
| Rate for Payer: Three Rivers PPO |
$386.10
|
| Rate for Payer: TriWest Veterans Administration |
$293.44
|
| Rate for Payer: United Healthcare Commercial |
$491.63
|
| Rate for Payer: United Healthcare Medicare |
$293.44
|
| Rate for Payer: WINHealth Partners Commercial |
$504.50
|
| Rate for Payer: Wise Provider Network Commercial |
$489.06
|
|
|
GONIOMETER FINGER A4414
|
Facility
|
OP
|
$25.55
|
|
| Hospital Charge Code |
2250164
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$13.84 |
| Max. Negotiated Rate |
$25.55 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$25.04
|
| Rate for Payer: Aetna of WY Medicare |
$16.86
|
| Rate for Payer: Altius Commercial |
$24.53
|
| Rate for Payer: Beech Street Commercial |
$25.04
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$24.78
|
| Rate for Payer: Cash Price |
$17.88
|
| Rate for Payer: ChoiceCare Network Commercial |
$24.78
|
| Rate for Payer: Cigna of WY Commercial |
$25.04
|
| Rate for Payer: Entrust Commercial |
$24.27
|
| Rate for Payer: First Choice Health Commercial |
$24.27
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$24.27
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$14.56
|
| Rate for Payer: HealthUtah PPO |
$25.55
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.78
|
| Rate for Payer: Multiplan Medicare/VA |
$13.84
|
| Rate for Payer: One Health Plan of WY PPO |
$25.04
|
| Rate for Payer: PacificSource Commercial |
$23.00
|
| Rate for Payer: PHCS PPO |
$25.04
|
| Rate for Payer: Three Rivers PPO |
$19.16
|
| Rate for Payer: TriWest Veterans Administration |
$14.56
|
| Rate for Payer: United Healthcare Commercial |
$24.40
|
| Rate for Payer: United Healthcare Medicare |
$14.56
|
| Rate for Payer: WINHealth Partners Commercial |
$25.04
|
| Rate for Payer: Wise Provider Network Commercial |
$24.27
|
|
|
GONIOMETER FINGER A4414
|
Facility
|
IP
|
$25.55
|
|
| Hospital Charge Code |
2250164
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$14.81 |
| Max. Negotiated Rate |
$25.55 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$25.04
|
| Rate for Payer: Aetna of WY Medicare |
$16.35
|
| Rate for Payer: Altius Commercial |
$24.53
|
| Rate for Payer: Beech Street Commercial |
$25.04
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$24.78
|
| Rate for Payer: Cash Price |
$17.88
|
| Rate for Payer: ChoiceCare Network Commercial |
$24.78
|
| Rate for Payer: Cigna of WY Commercial |
$25.04
|
| Rate for Payer: Entrust Commercial |
$24.27
|
| Rate for Payer: First Choice Health Commercial |
$24.27
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$24.27
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$15.59
|
| Rate for Payer: HealthUtah PPO |
$25.55
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.78
|
| Rate for Payer: Multiplan Medicare/VA |
$14.81
|
| Rate for Payer: One Health Plan of WY PPO |
$25.04
|
| Rate for Payer: PacificSource Commercial |
$23.00
|
| Rate for Payer: PHCS PPO |
$25.04
|
| Rate for Payer: Three Rivers PPO |
$19.16
|
| Rate for Payer: TriWest Veterans Administration |
$15.59
|
| Rate for Payer: United Healthcare Commercial |
$24.40
|
| Rate for Payer: United Healthcare Medicare |
$15.59
|
| Rate for Payer: WINHealth Partners Commercial |
$24.27
|
| Rate for Payer: Wise Provider Network Commercial |
$24.27
|
|
|
GRAFIX PRIME 5 X 5 CM
|
Facility
|
IP
|
$8,750.00
|
|
| Hospital Charge Code |
2800133
|
|
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
|
|
|
GRAFIX PRIME 5 X 5 CM
|
Facility
|
OP
|
$8,750.00
|
|
| Hospital Charge Code |
2800133
|
|
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
|
|
|
GRAFT EAR CRTLG AUTOGENOUS NOSE/EAR
|
Professional
|
Both
|
$2,947.00
|
|
|
Service Code
|
HCPCS 21235
|
| Min. Negotiated Rate |
$472.13 |
| Max. Negotiated Rate |
$2,947.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,888.06
|
| Rate for Payer: Aetna of WY Medicare |
$555.45
|
| Rate for Payer: Beech Street Commercial |
$2,799.65
|
| Rate for Payer: Cash Price |
$2,062.90
|
| Rate for Payer: Cash Price |
$2,062.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,858.59
|
| Rate for Payer: Cigna of WY Commercial |
$2,888.06
|
| Rate for Payer: First Choice Health Commercial |
$2,652.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,799.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$555.45
|
| Rate for Payer: HealthUtah PPO |
$2,947.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,858.59
|
| Rate for Payer: Multiplan Medicare/VA |
$472.13
|
| Rate for Payer: One Health Plan of WY PPO |
$2,888.06
|
| Rate for Payer: PacificSource Commercial |
$2,652.30
|
| Rate for Payer: PHCS PPO |
$2,799.65
|
| Rate for Payer: Three Rivers PPO |
$2,210.25
|
| Rate for Payer: TriWest Veterans Administration |
$555.45
|
| Rate for Payer: United Healthcare Commercial |
$2,799.65
|
| Rate for Payer: WINHealth Partners Commercial |
$2,504.95
|
|
|
GRAFT FEMORAL CONDYLE WHOLE RT FRESH
|
Facility
|
IP
|
$66,490.20
|
|
| Hospital Charge Code |
3004777
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$38,531.07 |
| Max. Negotiated Rate |
$66,490.20 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$65,160.40
|
| Rate for Payer: Aetna of WY Medicare |
$42,553.73
|
| Rate for Payer: Altius Commercial |
$63,830.59
|
| Rate for Payer: Beech Street Commercial |
$65,160.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$64,495.49
|
| Rate for Payer: Cash Price |
$46,543.14
|
| Rate for Payer: ChoiceCare Network Commercial |
$64,495.49
|
| Rate for Payer: Cigna of WY Commercial |
$65,160.40
|
| Rate for Payer: Entrust Commercial |
$63,165.69
|
| Rate for Payer: First Choice Health Commercial |
$63,165.69
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$63,165.69
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$40,559.02
|
| Rate for Payer: HealthUtah PPO |
$66,490.20
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$64,495.49
|
| Rate for Payer: Multiplan Medicare/VA |
$38,531.07
|
| Rate for Payer: One Health Plan of WY PPO |
$65,160.40
|
| Rate for Payer: PacificSource Commercial |
$59,841.18
|
| Rate for Payer: PHCS PPO |
$65,160.40
|
| Rate for Payer: Three Rivers PPO |
$49,867.65
|
| Rate for Payer: TriWest Veterans Administration |
$40,559.02
|
| Rate for Payer: United Healthcare Commercial |
$63,498.14
|
| Rate for Payer: United Healthcare Medicare |
$40,559.02
|
| Rate for Payer: WINHealth Partners Commercial |
$63,165.69
|
| Rate for Payer: Wise Provider Network Commercial |
$63,165.69
|
|
|
GRAFT FEMORAL CONDYLE WHOLE RT FRESH
|
Facility
|
OP
|
$66,490.20
|
|
| Hospital Charge Code |
3004777
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$36,004.44 |
| Max. Negotiated Rate |
$66,490.20 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$65,160.40
|
| Rate for Payer: Aetna of WY Medicare |
$43,883.53
|
| Rate for Payer: Altius Commercial |
$63,830.59
|
| Rate for Payer: Beech Street Commercial |
$65,160.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$64,495.49
|
| Rate for Payer: Cash Price |
$46,543.14
|
| Rate for Payer: ChoiceCare Network Commercial |
$64,495.49
|
| Rate for Payer: Cigna of WY Commercial |
$65,160.40
|
| Rate for Payer: Entrust Commercial |
$63,165.69
|
| Rate for Payer: First Choice Health Commercial |
$63,165.69
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$63,165.69
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$37,899.41
|
| Rate for Payer: HealthUtah PPO |
$66,490.20
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$64,495.49
|
| Rate for Payer: Multiplan Medicare/VA |
$36,004.44
|
| Rate for Payer: One Health Plan of WY PPO |
$65,160.40
|
| Rate for Payer: PacificSource Commercial |
$59,841.18
|
| Rate for Payer: PHCS PPO |
$65,160.40
|
| Rate for Payer: Three Rivers PPO |
$49,867.65
|
| Rate for Payer: TriWest Veterans Administration |
$37,899.41
|
| Rate for Payer: United Healthcare Commercial |
$63,498.14
|
| Rate for Payer: United Healthcare Medicare |
$37,899.41
|
| Rate for Payer: WINHealth Partners Commercial |
$65,160.40
|
| Rate for Payer: Wise Provider Network Commercial |
$63,165.69
|
|
|
GRAFTGRISILIS PRESUTURED FPSST
|
Facility
|
IP
|
$4,651.50
|
|
| Hospital Charge Code |
3002384
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,695.54 |
| Max. Negotiated Rate |
$4,651.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4,558.47
|
| Rate for Payer: Aetna of WY Medicare |
$2,976.96
|
| Rate for Payer: Altius Commercial |
$4,465.44
|
| Rate for Payer: Beech Street Commercial |
$4,558.47
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$4,511.96
|
| Rate for Payer: Cash Price |
$3,256.05
|
| Rate for Payer: ChoiceCare Network Commercial |
$4,511.96
|
| Rate for Payer: Cigna of WY Commercial |
$4,558.47
|
| Rate for Payer: Entrust Commercial |
$4,418.92
|
| Rate for Payer: First Choice Health Commercial |
$4,418.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,418.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2,837.42
|
| Rate for Payer: HealthUtah PPO |
$4,651.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4,511.96
|
| Rate for Payer: Multiplan Medicare/VA |
$2,695.54
|
| Rate for Payer: One Health Plan of WY PPO |
$4,558.47
|
| Rate for Payer: PacificSource Commercial |
$4,186.35
|
| Rate for Payer: PHCS PPO |
$4,558.47
|
| Rate for Payer: Three Rivers PPO |
$3,488.62
|
| Rate for Payer: TriWest Veterans Administration |
$2,837.42
|
| Rate for Payer: United Healthcare Commercial |
$4,442.18
|
| Rate for Payer: United Healthcare Medicare |
$2,837.42
|
| Rate for Payer: WINHealth Partners Commercial |
$4,418.92
|
| Rate for Payer: Wise Provider Network Commercial |
$4,418.92
|
|
|
GRAFTGRISILIS PRESUTURED FPSST
|
Facility
|
OP
|
$4,651.50
|
|
| Hospital Charge Code |
3002384
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,518.79 |
| Max. Negotiated Rate |
$4,651.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4,558.47
|
| Rate for Payer: Aetna of WY Medicare |
$3,069.99
|
| Rate for Payer: Altius Commercial |
$4,465.44
|
| Rate for Payer: Beech Street Commercial |
$4,558.47
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$4,511.96
|
| Rate for Payer: Cash Price |
$3,256.05
|
| Rate for Payer: ChoiceCare Network Commercial |
$4,511.96
|
| Rate for Payer: Cigna of WY Commercial |
$4,558.47
|
| Rate for Payer: Entrust Commercial |
$4,418.92
|
| Rate for Payer: First Choice Health Commercial |
$4,418.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,418.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2,651.36
|
| Rate for Payer: HealthUtah PPO |
$4,651.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4,511.96
|
| Rate for Payer: Multiplan Medicare/VA |
$2,518.79
|
| Rate for Payer: One Health Plan of WY PPO |
$4,558.47
|
| Rate for Payer: PacificSource Commercial |
$4,186.35
|
| Rate for Payer: PHCS PPO |
$4,558.47
|
| Rate for Payer: Three Rivers PPO |
$3,488.62
|
| Rate for Payer: TriWest Veterans Administration |
$2,651.36
|
| Rate for Payer: United Healthcare Commercial |
$4,442.18
|
| Rate for Payer: United Healthcare Medicare |
$2,651.36
|
| Rate for Payer: WINHealth Partners Commercial |
$4,558.47
|
| Rate for Payer: Wise Provider Network Commercial |
$4,418.92
|
|
|
GRAFTING OF AUTOLOGOUS SOFT TISS BY DIRECT EXC
|
Professional
|
Both
|
$1,436.00
|
|
|
Service Code
|
HCPCS 15769
|
| Min. Negotiated Rate |
$393.86 |
| Max. Negotiated Rate |
$1,436.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,407.28
|
| Rate for Payer: Aetna of WY Medicare |
$463.37
|
| Rate for Payer: Beech Street Commercial |
$1,364.20
|
| Rate for Payer: Cash Price |
$1,005.20
|
| Rate for Payer: Cash Price |
$1,005.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,392.92
|
| Rate for Payer: Cigna of WY Commercial |
$1,407.28
|
| Rate for Payer: First Choice Health Commercial |
$1,292.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,364.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$463.37
|
| Rate for Payer: HealthUtah PPO |
$1,436.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,392.92
|
| Rate for Payer: Multiplan Medicare/VA |
$393.86
|
| Rate for Payer: One Health Plan of WY PPO |
$1,407.28
|
| Rate for Payer: PacificSource Commercial |
$1,292.40
|
| Rate for Payer: PHCS PPO |
$1,364.20
|
| Rate for Payer: Three Rivers PPO |
$1,077.00
|
| Rate for Payer: TriWest Veterans Administration |
$463.37
|
| Rate for Payer: United Healthcare Commercial |
$1,364.20
|
| Rate for Payer: WINHealth Partners Commercial |
$1,220.60
|
|
|
GRAFT JKT INFORCE 5 X 2
|
Facility
|
OP
|
$6,419.00
|
|
| Hospital Charge Code |
3001354
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,475.89 |
| Max. Negotiated Rate |
$6,419.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$6,290.62
|
| Rate for Payer: Aetna of WY Medicare |
$4,236.54
|
| Rate for Payer: Altius Commercial |
$6,162.24
|
| Rate for Payer: Beech Street Commercial |
$6,290.62
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$6,226.43
|
| Rate for Payer: Cash Price |
$4,493.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$6,226.43
|
| Rate for Payer: Cigna of WY Commercial |
$6,290.62
|
| Rate for Payer: Entrust Commercial |
$6,098.05
|
| Rate for Payer: First Choice Health Commercial |
$6,098.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$6,098.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3,658.83
|
| Rate for Payer: HealthUtah PPO |
$6,419.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$6,226.43
|
| Rate for Payer: Multiplan Medicare/VA |
$3,475.89
|
| Rate for Payer: One Health Plan of WY PPO |
$6,290.62
|
| Rate for Payer: PacificSource Commercial |
$5,777.10
|
| Rate for Payer: PHCS PPO |
$6,290.62
|
| Rate for Payer: Three Rivers PPO |
$4,814.25
|
| Rate for Payer: TriWest Veterans Administration |
$3,658.83
|
| Rate for Payer: United Healthcare Commercial |
$6,130.14
|
| Rate for Payer: United Healthcare Medicare |
$3,658.83
|
| Rate for Payer: WINHealth Partners Commercial |
$6,290.62
|
| Rate for Payer: Wise Provider Network Commercial |
$6,098.05
|
|
|
GRAFT JKT INFORCE 5 X 2
|
Facility
|
IP
|
$6,419.00
|
|
| Hospital Charge Code |
3001354
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,719.81 |
| Max. Negotiated Rate |
$6,419.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$6,290.62
|
| Rate for Payer: Aetna of WY Medicare |
$4,108.16
|
| Rate for Payer: Altius Commercial |
$6,162.24
|
| Rate for Payer: Beech Street Commercial |
$6,290.62
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$6,226.43
|
| Rate for Payer: Cash Price |
$4,493.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$6,226.43
|
| Rate for Payer: Cigna of WY Commercial |
$6,290.62
|
| Rate for Payer: Entrust Commercial |
$6,098.05
|
| Rate for Payer: First Choice Health Commercial |
$6,098.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$6,098.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3,915.59
|
| Rate for Payer: HealthUtah PPO |
$6,419.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$6,226.43
|
| Rate for Payer: Multiplan Medicare/VA |
$3,719.81
|
| Rate for Payer: One Health Plan of WY PPO |
$6,290.62
|
| Rate for Payer: PacificSource Commercial |
$5,777.10
|
| Rate for Payer: PHCS PPO |
$6,290.62
|
| Rate for Payer: Three Rivers PPO |
$4,814.25
|
| Rate for Payer: TriWest Veterans Administration |
$3,915.59
|
| Rate for Payer: United Healthcare Commercial |
$6,130.14
|
| Rate for Payer: United Healthcare Medicare |
$3,915.59
|
| Rate for Payer: WINHealth Partners Commercial |
$6,098.05
|
| Rate for Payer: Wise Provider Network Commercial |
$6,098.05
|
|
|
GRAFT LEFT MEDIAL HEMI CONDYLE
|
Facility
|
IP
|
$38,193.75
|
|
| Hospital Charge Code |
3004288
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$22,133.28 |
| Max. Negotiated Rate |
$38,193.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$37,429.88
|
| Rate for Payer: Aetna of WY Medicare |
$24,444.00
|
| Rate for Payer: Altius Commercial |
$36,666.00
|
| Rate for Payer: Beech Street Commercial |
$37,429.88
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$37,047.94
|
| Rate for Payer: Cash Price |
$26,735.62
|
| Rate for Payer: ChoiceCare Network Commercial |
$37,047.94
|
| Rate for Payer: Cigna of WY Commercial |
$37,429.88
|
| Rate for Payer: Entrust Commercial |
$36,284.06
|
| Rate for Payer: First Choice Health Commercial |
$36,284.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$36,284.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$23,298.19
|
| Rate for Payer: HealthUtah PPO |
$38,193.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$37,047.94
|
| Rate for Payer: Multiplan Medicare/VA |
$22,133.28
|
| Rate for Payer: One Health Plan of WY PPO |
$37,429.88
|
| Rate for Payer: PacificSource Commercial |
$34,374.38
|
| Rate for Payer: PHCS PPO |
$37,429.88
|
| Rate for Payer: Three Rivers PPO |
$28,645.31
|
| Rate for Payer: TriWest Veterans Administration |
$23,298.19
|
| Rate for Payer: United Healthcare Commercial |
$36,475.03
|
| Rate for Payer: United Healthcare Medicare |
$23,298.19
|
| Rate for Payer: WINHealth Partners Commercial |
$36,284.06
|
| Rate for Payer: Wise Provider Network Commercial |
$36,284.06
|
|
|
GRAFT LEFT MEDIAL HEMI CONDYLE
|
Facility
|
OP
|
$38,193.75
|
|
| Hospital Charge Code |
3004288
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$20,681.92 |
| Max. Negotiated Rate |
$38,193.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$37,429.88
|
| Rate for Payer: Aetna of WY Medicare |
$25,207.88
|
| Rate for Payer: Altius Commercial |
$36,666.00
|
| Rate for Payer: Beech Street Commercial |
$37,429.88
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$37,047.94
|
| Rate for Payer: Cash Price |
$26,735.62
|
| Rate for Payer: ChoiceCare Network Commercial |
$37,047.94
|
| Rate for Payer: Cigna of WY Commercial |
$37,429.88
|
| Rate for Payer: Entrust Commercial |
$36,284.06
|
| Rate for Payer: First Choice Health Commercial |
$36,284.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$36,284.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$21,770.44
|
| Rate for Payer: HealthUtah PPO |
$38,193.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$37,047.94
|
| Rate for Payer: Multiplan Medicare/VA |
$20,681.92
|
| Rate for Payer: One Health Plan of WY PPO |
$37,429.88
|
| Rate for Payer: PacificSource Commercial |
$34,374.38
|
| Rate for Payer: PHCS PPO |
$37,429.88
|
| Rate for Payer: Three Rivers PPO |
$28,645.31
|
| Rate for Payer: TriWest Veterans Administration |
$21,770.44
|
| Rate for Payer: United Healthcare Commercial |
$36,475.03
|
| Rate for Payer: United Healthcare Medicare |
$21,770.44
|
| Rate for Payer: WINHealth Partners Commercial |
$37,429.88
|
| Rate for Payer: Wise Provider Network Commercial |
$36,284.06
|
|
|
GRAFT RIGHT MEDIAL HEMI CONDYL
|
Facility
|
OP
|
$38,193.75
|
|
| Hospital Charge Code |
3004386
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$20,681.92 |
| Max. Negotiated Rate |
$38,193.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$37,429.88
|
| Rate for Payer: Aetna of WY Medicare |
$25,207.88
|
| Rate for Payer: Altius Commercial |
$36,666.00
|
| Rate for Payer: Beech Street Commercial |
$37,429.88
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$37,047.94
|
| Rate for Payer: Cash Price |
$26,735.62
|
| Rate for Payer: ChoiceCare Network Commercial |
$37,047.94
|
| Rate for Payer: Cigna of WY Commercial |
$37,429.88
|
| Rate for Payer: Entrust Commercial |
$36,284.06
|
| Rate for Payer: First Choice Health Commercial |
$36,284.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$36,284.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$21,770.44
|
| Rate for Payer: HealthUtah PPO |
$38,193.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$37,047.94
|
| Rate for Payer: Multiplan Medicare/VA |
$20,681.92
|
| Rate for Payer: One Health Plan of WY PPO |
$37,429.88
|
| Rate for Payer: PacificSource Commercial |
$34,374.38
|
| Rate for Payer: PHCS PPO |
$37,429.88
|
| Rate for Payer: Three Rivers PPO |
$28,645.31
|
| Rate for Payer: TriWest Veterans Administration |
$21,770.44
|
| Rate for Payer: United Healthcare Commercial |
$36,475.03
|
| Rate for Payer: United Healthcare Medicare |
$21,770.44
|
| Rate for Payer: WINHealth Partners Commercial |
$37,429.88
|
| Rate for Payer: Wise Provider Network Commercial |
$36,284.06
|
|
|
GRAFT RIGHT MEDIAL HEMI CONDYL
|
Facility
|
IP
|
$38,193.75
|
|
| Hospital Charge Code |
3004386
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$22,133.28 |
| Max. Negotiated Rate |
$38,193.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$37,429.88
|
| Rate for Payer: Aetna of WY Medicare |
$24,444.00
|
| Rate for Payer: Altius Commercial |
$36,666.00
|
| Rate for Payer: Beech Street Commercial |
$37,429.88
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$37,047.94
|
| Rate for Payer: Cash Price |
$26,735.62
|
| Rate for Payer: ChoiceCare Network Commercial |
$37,047.94
|
| Rate for Payer: Cigna of WY Commercial |
$37,429.88
|
| Rate for Payer: Entrust Commercial |
$36,284.06
|
| Rate for Payer: First Choice Health Commercial |
$36,284.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$36,284.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$23,298.19
|
| Rate for Payer: HealthUtah PPO |
$38,193.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$37,047.94
|
| Rate for Payer: Multiplan Medicare/VA |
$22,133.28
|
| Rate for Payer: One Health Plan of WY PPO |
$37,429.88
|
| Rate for Payer: PacificSource Commercial |
$34,374.38
|
| Rate for Payer: PHCS PPO |
$37,429.88
|
| Rate for Payer: Three Rivers PPO |
$28,645.31
|
| Rate for Payer: TriWest Veterans Administration |
$23,298.19
|
| Rate for Payer: United Healthcare Commercial |
$36,475.03
|
| Rate for Payer: United Healthcare Medicare |
$23,298.19
|
| Rate for Payer: WINHealth Partners Commercial |
$36,284.06
|
| Rate for Payer: Wise Provider Network Commercial |
$36,284.06
|
|
|
GRAFT RT LATERAL HEMI CONDYLE
|
Facility
|
IP
|
$37,336.95
|
|
| Hospital Charge Code |
3004589
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$21,636.76 |
| Max. Negotiated Rate |
$37,336.95 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$36,590.21
|
| Rate for Payer: Aetna of WY Medicare |
$23,895.65
|
| Rate for Payer: Altius Commercial |
$35,843.47
|
| Rate for Payer: Beech Street Commercial |
$36,590.21
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$36,216.84
|
| Rate for Payer: Cash Price |
$26,135.87
|
| Rate for Payer: ChoiceCare Network Commercial |
$36,216.84
|
| Rate for Payer: Cigna of WY Commercial |
$36,590.21
|
| Rate for Payer: Entrust Commercial |
$35,470.10
|
| Rate for Payer: First Choice Health Commercial |
$35,470.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$35,470.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$22,775.54
|
| Rate for Payer: HealthUtah PPO |
$37,336.95
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$36,216.84
|
| Rate for Payer: Multiplan Medicare/VA |
$21,636.76
|
| Rate for Payer: One Health Plan of WY PPO |
$36,590.21
|
| Rate for Payer: PacificSource Commercial |
$33,603.26
|
| Rate for Payer: PHCS PPO |
$36,590.21
|
| Rate for Payer: Three Rivers PPO |
$28,002.71
|
| Rate for Payer: TriWest Veterans Administration |
$22,775.54
|
| Rate for Payer: United Healthcare Commercial |
$35,656.79
|
| Rate for Payer: United Healthcare Medicare |
$22,775.54
|
| Rate for Payer: WINHealth Partners Commercial |
$35,470.10
|
| Rate for Payer: Wise Provider Network Commercial |
$35,470.10
|
|
|
GRAFT RT LATERAL HEMI CONDYLE
|
Facility
|
OP
|
$37,336.95
|
|
| Hospital Charge Code |
3004589
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$20,217.96 |
| Max. Negotiated Rate |
$37,336.95 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$36,590.21
|
| Rate for Payer: Aetna of WY Medicare |
$24,642.39
|
| Rate for Payer: Altius Commercial |
$35,843.47
|
| Rate for Payer: Beech Street Commercial |
$36,590.21
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$36,216.84
|
| Rate for Payer: Cash Price |
$26,135.87
|
| Rate for Payer: ChoiceCare Network Commercial |
$36,216.84
|
| Rate for Payer: Cigna of WY Commercial |
$36,590.21
|
| Rate for Payer: Entrust Commercial |
$35,470.10
|
| Rate for Payer: First Choice Health Commercial |
$35,470.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$35,470.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$21,282.06
|
| Rate for Payer: HealthUtah PPO |
$37,336.95
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$36,216.84
|
| Rate for Payer: Multiplan Medicare/VA |
$20,217.96
|
| Rate for Payer: One Health Plan of WY PPO |
$36,590.21
|
| Rate for Payer: PacificSource Commercial |
$33,603.26
|
| Rate for Payer: PHCS PPO |
$36,590.21
|
| Rate for Payer: Three Rivers PPO |
$28,002.71
|
| Rate for Payer: TriWest Veterans Administration |
$21,282.06
|
| Rate for Payer: United Healthcare Commercial |
$35,656.79
|
| Rate for Payer: United Healthcare Medicare |
$21,282.06
|
| Rate for Payer: WINHealth Partners Commercial |
$36,590.21
|
| Rate for Payer: Wise Provider Network Commercial |
$35,470.10
|
|
|
GRAFT SPREADER AR-19007GS
|
Facility
|
IP
|
$1,312.50
|
|
| Hospital Charge Code |
3004118
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$760.59 |
| Max. Negotiated Rate |
$1,312.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,286.25
|
| Rate for Payer: Aetna of WY Medicare |
$840.00
|
| Rate for Payer: Altius Commercial |
$1,260.00
|
| Rate for Payer: Beech Street Commercial |
$1,286.25
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,273.12
|
| Rate for Payer: Cash Price |
$918.75
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,273.12
|
| Rate for Payer: Cigna of WY Commercial |
$1,286.25
|
| Rate for Payer: Entrust Commercial |
$1,246.88
|
| Rate for Payer: First Choice Health Commercial |
$1,246.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,246.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$800.62
|
| Rate for Payer: HealthUtah PPO |
$1,312.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,273.12
|
| Rate for Payer: Multiplan Medicare/VA |
$760.59
|
| Rate for Payer: One Health Plan of WY PPO |
$1,286.25
|
| Rate for Payer: PacificSource Commercial |
$1,181.25
|
| Rate for Payer: PHCS PPO |
$1,286.25
|
| Rate for Payer: Three Rivers PPO |
$984.38
|
| Rate for Payer: TriWest Veterans Administration |
$800.62
|
| Rate for Payer: United Healthcare Commercial |
$1,253.44
|
| Rate for Payer: United Healthcare Medicare |
$800.62
|
| Rate for Payer: WINHealth Partners Commercial |
$1,246.88
|
| Rate for Payer: Wise Provider Network Commercial |
$1,246.88
|
|
|
GRAFT SPREADER AR-19007GS
|
Facility
|
OP
|
$1,312.50
|
|
| Hospital Charge Code |
3004118
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$710.72 |
| Max. Negotiated Rate |
$1,312.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,286.25
|
| Rate for Payer: Aetna of WY Medicare |
$866.25
|
| Rate for Payer: Altius Commercial |
$1,260.00
|
| Rate for Payer: Beech Street Commercial |
$1,286.25
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,273.12
|
| Rate for Payer: Cash Price |
$918.75
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,273.12
|
| Rate for Payer: Cigna of WY Commercial |
$1,286.25
|
| Rate for Payer: Entrust Commercial |
$1,246.88
|
| Rate for Payer: First Choice Health Commercial |
$1,246.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,246.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$748.12
|
| Rate for Payer: HealthUtah PPO |
$1,312.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,273.12
|
| Rate for Payer: Multiplan Medicare/VA |
$710.72
|
| Rate for Payer: One Health Plan of WY PPO |
$1,286.25
|
| Rate for Payer: PacificSource Commercial |
$1,181.25
|
| Rate for Payer: PHCS PPO |
$1,286.25
|
| Rate for Payer: Three Rivers PPO |
$984.38
|
| Rate for Payer: TriWest Veterans Administration |
$748.12
|
| Rate for Payer: United Healthcare Commercial |
$1,253.44
|
| Rate for Payer: United Healthcare Medicare |
$748.12
|
| Rate for Payer: WINHealth Partners Commercial |
$1,286.25
|
| Rate for Payer: Wise Provider Network Commercial |
$1,246.88
|
|
