|
AUTOGRAFT SPINE SURGERY BICORT/TRICORT SEP INC
|
Professional
|
Both
|
$808.00
|
|
|
Service Code
|
HCPCS 20938 AS
|
| Min. Negotiated Rate |
$606.00 |
| Max. Negotiated Rate |
$808.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$791.84
|
| Rate for Payer: Beech Street Commercial |
$767.60
|
| Rate for Payer: Cash Price |
$565.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$783.76
|
| Rate for Payer: Cigna of WY Commercial |
$791.84
|
| Rate for Payer: First Choice Health Commercial |
$727.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$767.60
|
| Rate for Payer: HealthUtah PPO |
$808.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$783.76
|
| Rate for Payer: One Health Plan of WY PPO |
$791.84
|
| Rate for Payer: PacificSource Commercial |
$727.20
|
| Rate for Payer: PHCS PPO |
$767.60
|
| Rate for Payer: Three Rivers PPO |
$606.00
|
| Rate for Payer: United Healthcare Commercial |
$767.60
|
| Rate for Payer: WINHealth Partners Commercial |
$686.80
|
|
|
AUTOGRAFT SPINE SURGERY BICORT/TRICORT SEP INC
|
Professional
|
Both
|
$808.00
|
|
|
Service Code
|
HCPCS 20938 80
|
| Min. Negotiated Rate |
$606.00 |
| Max. Negotiated Rate |
$808.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$791.84
|
| Rate for Payer: Beech Street Commercial |
$767.60
|
| Rate for Payer: Cash Price |
$565.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$783.76
|
| Rate for Payer: Cigna of WY Commercial |
$791.84
|
| Rate for Payer: First Choice Health Commercial |
$727.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$767.60
|
| Rate for Payer: HealthUtah PPO |
$808.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$783.76
|
| Rate for Payer: One Health Plan of WY PPO |
$791.84
|
| Rate for Payer: PacificSource Commercial |
$727.20
|
| Rate for Payer: PHCS PPO |
$767.60
|
| Rate for Payer: Three Rivers PPO |
$606.00
|
| Rate for Payer: United Healthcare Commercial |
$767.60
|
| Rate for Payer: WINHealth Partners Commercial |
$686.80
|
|
|
AUTOGRAFT SPINE SURGERY LOCAL FROM SAME INCISION
|
Professional
|
Both
|
$1,114.00
|
|
|
Service Code
|
HCPCS 20936
|
| Min. Negotiated Rate |
$835.50 |
| Max. Negotiated Rate |
$1,114.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,091.72
|
| Rate for Payer: Beech Street Commercial |
$1,058.30
|
| Rate for Payer: Cash Price |
$779.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,080.58
|
| Rate for Payer: Cigna of WY Commercial |
$1,091.72
|
| Rate for Payer: First Choice Health Commercial |
$1,002.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,058.30
|
| Rate for Payer: HealthUtah PPO |
$1,114.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,080.58
|
| Rate for Payer: One Health Plan of WY PPO |
$1,091.72
|
| Rate for Payer: PacificSource Commercial |
$1,002.60
|
| Rate for Payer: PHCS PPO |
$1,058.30
|
| Rate for Payer: Three Rivers PPO |
$835.50
|
| Rate for Payer: United Healthcare Commercial |
$1,058.30
|
| Rate for Payer: WINHealth Partners Commercial |
$946.90
|
|
|
AUTOGRAFT SPINE SURGERY MORSELIZED SEP INCISION
|
Professional
|
Both
|
$737.00
|
|
|
Service Code
|
HCPCS 20937 AS
|
| Min. Negotiated Rate |
$132.80 |
| Max. Negotiated Rate |
$737.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$722.26
|
| Rate for Payer: Beech Street Commercial |
$700.15
|
| Rate for Payer: Cash Price |
$515.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$714.89
|
| Rate for Payer: Cigna of WY Commercial |
$722.26
|
| Rate for Payer: First Choice Health Commercial |
$663.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$700.15
|
| Rate for Payer: HealthUtah PPO |
$737.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$714.89
|
| Rate for Payer: One Health Plan of WY PPO |
$722.26
|
| Rate for Payer: PacificSource Commercial |
$663.30
|
| Rate for Payer: PHCS PPO |
$700.15
|
| Rate for Payer: Three Rivers PPO |
$552.75
|
| Rate for Payer: United Healthcare Commercial |
$700.15
|
| Rate for Payer: WINHealth Partners Commercial |
$626.45
|
|
|
AUTOGRAFT SPINE SURGERY MORSELIZED SEP INCISION
|
Professional
|
Both
|
$737.00
|
|
|
Service Code
|
HCPCS 20937
|
| Min. Negotiated Rate |
$132.80 |
| Max. Negotiated Rate |
$737.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$722.26
|
| Rate for Payer: Aetna of WY Medicare |
$156.23
|
| Rate for Payer: Beech Street Commercial |
$700.15
|
| Rate for Payer: Cash Price |
$515.90
|
| Rate for Payer: Cash Price |
$515.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$714.89
|
| Rate for Payer: Cigna of WY Commercial |
$722.26
|
| Rate for Payer: First Choice Health Commercial |
$663.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$700.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$156.23
|
| Rate for Payer: HealthUtah PPO |
$737.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$714.89
|
| Rate for Payer: Multiplan Medicare/VA |
$132.80
|
| Rate for Payer: One Health Plan of WY PPO |
$722.26
|
| Rate for Payer: PacificSource Commercial |
$663.30
|
| Rate for Payer: PHCS PPO |
$700.15
|
| Rate for Payer: Three Rivers PPO |
$552.75
|
| Rate for Payer: TriWest Veterans Administration |
$156.23
|
| Rate for Payer: United Healthcare Commercial |
$700.15
|
| Rate for Payer: WINHealth Partners Commercial |
$626.45
|
|
|
AUTOGRAFT SPINE SURGERY MORSELIZED SEP INCISION
|
Professional
|
Both
|
$737.00
|
|
|
Service Code
|
HCPCS 20937 80
|
| Min. Negotiated Rate |
$132.80 |
| Max. Negotiated Rate |
$737.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$722.26
|
| Rate for Payer: Beech Street Commercial |
$700.15
|
| Rate for Payer: Cash Price |
$515.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$714.89
|
| Rate for Payer: Cigna of WY Commercial |
$722.26
|
| Rate for Payer: First Choice Health Commercial |
$663.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$700.15
|
| Rate for Payer: HealthUtah PPO |
$737.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$714.89
|
| Rate for Payer: One Health Plan of WY PPO |
$722.26
|
| Rate for Payer: PacificSource Commercial |
$663.30
|
| Rate for Payer: PHCS PPO |
$700.15
|
| Rate for Payer: Three Rivers PPO |
$552.75
|
| Rate for Payer: United Healthcare Commercial |
$700.15
|
| Rate for Payer: WINHealth Partners Commercial |
$626.45
|
|
|
AUTOLOGOUS PLATELET SYSTEM PRP
|
Facility
|
IP
|
$556.50
|
|
| Hospital Charge Code |
3002180
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$322.49 |
| Max. Negotiated Rate |
$556.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$545.37
|
| Rate for Payer: Aetna of WY Medicare |
$356.16
|
| Rate for Payer: Altius Commercial |
$534.24
|
| Rate for Payer: Beech Street Commercial |
$545.37
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$539.80
|
| Rate for Payer: Cash Price |
$389.55
|
| Rate for Payer: ChoiceCare Network Commercial |
$539.80
|
| Rate for Payer: Cigna of WY Commercial |
$545.37
|
| Rate for Payer: Entrust Commercial |
$528.68
|
| Rate for Payer: First Choice Health Commercial |
$528.68
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$528.68
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$339.46
|
| Rate for Payer: HealthUtah PPO |
$556.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$539.80
|
| Rate for Payer: Multiplan Medicare/VA |
$322.49
|
| Rate for Payer: One Health Plan of WY PPO |
$545.37
|
| Rate for Payer: PacificSource Commercial |
$500.85
|
| Rate for Payer: PHCS PPO |
$545.37
|
| Rate for Payer: Three Rivers PPO |
$417.38
|
| Rate for Payer: TriWest Veterans Administration |
$339.46
|
| Rate for Payer: United Healthcare Commercial |
$531.46
|
| Rate for Payer: United Healthcare Medicare |
$339.46
|
| Rate for Payer: WINHealth Partners Commercial |
$528.68
|
| Rate for Payer: Wise Provider Network Commercial |
$528.68
|
|
|
AUTOLOGOUS PLATELET SYSTEM PRP
|
Facility
|
OP
|
$556.50
|
|
| Hospital Charge Code |
3002180
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$301.34 |
| Max. Negotiated Rate |
$556.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$545.37
|
| Rate for Payer: Aetna of WY Medicare |
$367.29
|
| Rate for Payer: Altius Commercial |
$534.24
|
| Rate for Payer: Beech Street Commercial |
$545.37
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$539.80
|
| Rate for Payer: Cash Price |
$389.55
|
| Rate for Payer: ChoiceCare Network Commercial |
$539.80
|
| Rate for Payer: Cigna of WY Commercial |
$545.37
|
| Rate for Payer: Entrust Commercial |
$528.68
|
| Rate for Payer: First Choice Health Commercial |
$528.68
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$528.68
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$317.20
|
| Rate for Payer: HealthUtah PPO |
$556.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$539.80
|
| Rate for Payer: Multiplan Medicare/VA |
$301.34
|
| Rate for Payer: One Health Plan of WY PPO |
$545.37
|
| Rate for Payer: PacificSource Commercial |
$500.85
|
| Rate for Payer: PHCS PPO |
$545.37
|
| Rate for Payer: Three Rivers PPO |
$417.38
|
| Rate for Payer: TriWest Veterans Administration |
$317.20
|
| Rate for Payer: United Healthcare Commercial |
$531.46
|
| Rate for Payer: United Healthcare Medicare |
$317.20
|
| Rate for Payer: WINHealth Partners Commercial |
$545.37
|
| Rate for Payer: Wise Provider Network Commercial |
$528.68
|
|
|
AUTOLOGOUS TISSUE COLLECTOR
|
Facility
|
IP
|
$1,573.88
|
|
| Hospital Charge Code |
3004231
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$912.06 |
| Max. Negotiated Rate |
$1,573.88 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,542.40
|
| Rate for Payer: Aetna of WY Medicare |
$1,007.28
|
| Rate for Payer: Altius Commercial |
$1,510.92
|
| Rate for Payer: Beech Street Commercial |
$1,542.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,526.66
|
| Rate for Payer: Cash Price |
$1,101.72
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,526.66
|
| Rate for Payer: Cigna of WY Commercial |
$1,542.40
|
| Rate for Payer: Entrust Commercial |
$1,495.19
|
| Rate for Payer: First Choice Health Commercial |
$1,495.19
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,495.19
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$960.07
|
| Rate for Payer: HealthUtah PPO |
$1,573.88
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,526.66
|
| Rate for Payer: Multiplan Medicare/VA |
$912.06
|
| Rate for Payer: One Health Plan of WY PPO |
$1,542.40
|
| Rate for Payer: PacificSource Commercial |
$1,416.49
|
| Rate for Payer: PHCS PPO |
$1,542.40
|
| Rate for Payer: Three Rivers PPO |
$1,180.41
|
| Rate for Payer: TriWest Veterans Administration |
$960.07
|
| Rate for Payer: United Healthcare Commercial |
$1,503.06
|
| Rate for Payer: United Healthcare Medicare |
$960.07
|
| Rate for Payer: WINHealth Partners Commercial |
$1,495.19
|
| Rate for Payer: Wise Provider Network Commercial |
$1,495.19
|
|
|
AUTOLOGOUS TISSUE COLLECTOR
|
Facility
|
OP
|
$1,573.88
|
|
| Hospital Charge Code |
3004231
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$852.26 |
| Max. Negotiated Rate |
$1,573.88 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,542.40
|
| Rate for Payer: Aetna of WY Medicare |
$1,038.76
|
| Rate for Payer: Altius Commercial |
$1,510.92
|
| Rate for Payer: Beech Street Commercial |
$1,542.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,526.66
|
| Rate for Payer: Cash Price |
$1,101.72
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,526.66
|
| Rate for Payer: Cigna of WY Commercial |
$1,542.40
|
| Rate for Payer: Entrust Commercial |
$1,495.19
|
| Rate for Payer: First Choice Health Commercial |
$1,495.19
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,495.19
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$897.11
|
| Rate for Payer: HealthUtah PPO |
$1,573.88
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,526.66
|
| Rate for Payer: Multiplan Medicare/VA |
$852.26
|
| Rate for Payer: One Health Plan of WY PPO |
$1,542.40
|
| Rate for Payer: PacificSource Commercial |
$1,416.49
|
| Rate for Payer: PHCS PPO |
$1,542.40
|
| Rate for Payer: Three Rivers PPO |
$1,180.41
|
| Rate for Payer: TriWest Veterans Administration |
$897.11
|
| Rate for Payer: United Healthcare Commercial |
$1,503.06
|
| Rate for Payer: United Healthcare Medicare |
$897.11
|
| Rate for Payer: WINHealth Partners Commercial |
$1,542.40
|
| Rate for Payer: Wise Provider Network Commercial |
$1,495.19
|
|
|
AUTOPLEX & TRADE W/O NDL
|
Facility
|
IP
|
$2,537.50
|
|
| Hospital Charge Code |
3001320
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,470.48 |
| Max. Negotiated Rate |
$2,537.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,486.75
|
| Rate for Payer: Aetna of WY Medicare |
$1,624.00
|
| Rate for Payer: Altius Commercial |
$2,436.00
|
| Rate for Payer: Beech Street Commercial |
$2,486.75
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,461.38
|
| Rate for Payer: Cash Price |
$1,776.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,461.38
|
| Rate for Payer: Cigna of WY Commercial |
$2,486.75
|
| Rate for Payer: Entrust Commercial |
$2,410.62
|
| Rate for Payer: First Choice Health Commercial |
$2,410.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,410.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,547.88
|
| Rate for Payer: HealthUtah PPO |
$2,537.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,461.38
|
| Rate for Payer: Multiplan Medicare/VA |
$1,470.48
|
| Rate for Payer: One Health Plan of WY PPO |
$2,486.75
|
| Rate for Payer: PacificSource Commercial |
$2,283.75
|
| Rate for Payer: PHCS PPO |
$2,486.75
|
| Rate for Payer: Three Rivers PPO |
$1,903.12
|
| Rate for Payer: TriWest Veterans Administration |
$1,547.88
|
| Rate for Payer: United Healthcare Commercial |
$2,423.31
|
| Rate for Payer: United Healthcare Medicare |
$1,547.88
|
| Rate for Payer: WINHealth Partners Commercial |
$2,410.62
|
| Rate for Payer: Wise Provider Network Commercial |
$2,410.62
|
|
|
AUTOPLEX & TRADE W/O NDL
|
Facility
|
OP
|
$2,537.50
|
|
| Hospital Charge Code |
3001320
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,374.06 |
| Max. Negotiated Rate |
$2,537.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,486.75
|
| Rate for Payer: Aetna of WY Medicare |
$1,674.75
|
| Rate for Payer: Altius Commercial |
$2,436.00
|
| Rate for Payer: Beech Street Commercial |
$2,486.75
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,461.38
|
| Rate for Payer: Cash Price |
$1,776.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,461.38
|
| Rate for Payer: Cigna of WY Commercial |
$2,486.75
|
| Rate for Payer: Entrust Commercial |
$2,410.62
|
| Rate for Payer: First Choice Health Commercial |
$2,410.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,410.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,446.38
|
| Rate for Payer: HealthUtah PPO |
$2,537.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,461.38
|
| Rate for Payer: Multiplan Medicare/VA |
$1,374.06
|
| Rate for Payer: One Health Plan of WY PPO |
$2,486.75
|
| Rate for Payer: PacificSource Commercial |
$2,283.75
|
| Rate for Payer: PHCS PPO |
$2,486.75
|
| Rate for Payer: Three Rivers PPO |
$1,903.12
|
| Rate for Payer: TriWest Veterans Administration |
$1,446.38
|
| Rate for Payer: United Healthcare Commercial |
$2,423.31
|
| Rate for Payer: United Healthcare Medicare |
$1,446.38
|
| Rate for Payer: WINHealth Partners Commercial |
$2,486.75
|
| Rate for Payer: Wise Provider Network Commercial |
$2,410.62
|
|
|
AVULSION NAIL PLATE PARTIAL/COMPLETE SIMPLE 1
|
Professional
|
Both
|
$235.00
|
|
|
Service Code
|
HCPCS 11730
|
| Min. Negotiated Rate |
$43.88 |
| Max. Negotiated Rate |
$235.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$230.30
|
| Rate for Payer: Aetna of WY Medicare |
$51.62
|
| Rate for Payer: Beech Street Commercial |
$223.25
|
| Rate for Payer: Cash Price |
$164.50
|
| Rate for Payer: Cash Price |
$164.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$227.95
|
| Rate for Payer: Cigna of WY Commercial |
$230.30
|
| Rate for Payer: First Choice Health Commercial |
$211.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$223.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$51.62
|
| Rate for Payer: HealthUtah PPO |
$235.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$227.95
|
| Rate for Payer: Multiplan Medicare/VA |
$43.88
|
| Rate for Payer: One Health Plan of WY PPO |
$230.30
|
| Rate for Payer: PacificSource Commercial |
$211.50
|
| Rate for Payer: PHCS PPO |
$223.25
|
| Rate for Payer: Three Rivers PPO |
$176.25
|
| Rate for Payer: TriWest Veterans Administration |
$51.62
|
| Rate for Payer: United Healthcare Commercial |
$223.25
|
| Rate for Payer: WINHealth Partners Commercial |
$199.75
|
|
|
AVULSION NAIL PLATE PARTIAL/COMP SIMPLE EA ADDL
|
Professional
|
Both
|
$76.00
|
|
|
Service Code
|
HCPCS 11732
|
| Min. Negotiated Rate |
$13.70 |
| Max. Negotiated Rate |
$76.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$74.48
|
| Rate for Payer: Aetna of WY Medicare |
$16.12
|
| Rate for Payer: Beech Street Commercial |
$72.20
|
| Rate for Payer: Cash Price |
$53.20
|
| Rate for Payer: Cash Price |
$53.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$73.72
|
| Rate for Payer: Cigna of WY Commercial |
$74.48
|
| Rate for Payer: First Choice Health Commercial |
$68.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$72.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$16.12
|
| Rate for Payer: HealthUtah PPO |
$76.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$73.72
|
| Rate for Payer: Multiplan Medicare/VA |
$13.70
|
| Rate for Payer: One Health Plan of WY PPO |
$74.48
|
| Rate for Payer: PacificSource Commercial |
$68.40
|
| Rate for Payer: PHCS PPO |
$72.20
|
| Rate for Payer: Three Rivers PPO |
$57.00
|
| Rate for Payer: TriWest Veterans Administration |
$16.12
|
| Rate for Payer: United Healthcare Commercial |
$72.20
|
| Rate for Payer: WINHealth Partners Commercial |
$64.60
|
|
|
AWL 3.8 MM TAPERED
|
Facility
|
IP
|
$213.50
|
|
| Hospital Charge Code |
3003263
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$123.72 |
| Max. Negotiated Rate |
$213.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$209.23
|
| Rate for Payer: Aetna of WY Medicare |
$136.64
|
| Rate for Payer: Altius Commercial |
$204.96
|
| Rate for Payer: Beech Street Commercial |
$209.23
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$207.10
|
| Rate for Payer: Cash Price |
$149.45
|
| Rate for Payer: ChoiceCare Network Commercial |
$207.10
|
| Rate for Payer: Cigna of WY Commercial |
$209.23
|
| Rate for Payer: Entrust Commercial |
$202.82
|
| Rate for Payer: First Choice Health Commercial |
$202.82
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$202.82
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$130.24
|
| Rate for Payer: HealthUtah PPO |
$213.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$207.10
|
| Rate for Payer: Multiplan Medicare/VA |
$123.72
|
| Rate for Payer: One Health Plan of WY PPO |
$209.23
|
| Rate for Payer: PacificSource Commercial |
$192.15
|
| Rate for Payer: PHCS PPO |
$209.23
|
| Rate for Payer: Three Rivers PPO |
$160.12
|
| Rate for Payer: TriWest Veterans Administration |
$130.24
|
| Rate for Payer: United Healthcare Commercial |
$203.89
|
| Rate for Payer: United Healthcare Medicare |
$130.24
|
| Rate for Payer: WINHealth Partners Commercial |
$202.82
|
| Rate for Payer: Wise Provider Network Commercial |
$202.82
|
|
|
AWL 3.8 MM TAPERED
|
Facility
|
OP
|
$213.50
|
|
| Hospital Charge Code |
3003263
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$115.61 |
| Max. Negotiated Rate |
$213.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$209.23
|
| Rate for Payer: Aetna of WY Medicare |
$140.91
|
| Rate for Payer: Altius Commercial |
$204.96
|
| Rate for Payer: Beech Street Commercial |
$209.23
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$207.10
|
| Rate for Payer: Cash Price |
$149.45
|
| Rate for Payer: ChoiceCare Network Commercial |
$207.10
|
| Rate for Payer: Cigna of WY Commercial |
$209.23
|
| Rate for Payer: Entrust Commercial |
$202.82
|
| Rate for Payer: First Choice Health Commercial |
$202.82
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$202.82
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$121.70
|
| Rate for Payer: HealthUtah PPO |
$213.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$207.10
|
| Rate for Payer: Multiplan Medicare/VA |
$115.61
|
| Rate for Payer: One Health Plan of WY PPO |
$209.23
|
| Rate for Payer: PacificSource Commercial |
$192.15
|
| Rate for Payer: PHCS PPO |
$209.23
|
| Rate for Payer: Three Rivers PPO |
$160.12
|
| Rate for Payer: TriWest Veterans Administration |
$121.70
|
| Rate for Payer: United Healthcare Commercial |
$203.89
|
| Rate for Payer: United Healthcare Medicare |
$121.70
|
| Rate for Payer: WINHealth Partners Commercial |
$209.23
|
| Rate for Payer: Wise Provider Network Commercial |
$202.82
|
|
|
AXONICS CHARGING SYSTEM
|
Facility
|
IP
|
$3,150.03
|
|
| Hospital Charge Code |
3004677
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1,825.44 |
| Max. Negotiated Rate |
$3,150.03 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,087.03
|
| Rate for Payer: Aetna of WY Medicare |
$2,016.02
|
| Rate for Payer: Altius Commercial |
$3,024.03
|
| Rate for Payer: Beech Street Commercial |
$3,087.03
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3,055.53
|
| Rate for Payer: Cash Price |
$2,205.02
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,055.53
|
| Rate for Payer: Cigna of WY Commercial |
$3,087.03
|
| Rate for Payer: Entrust Commercial |
$2,992.53
|
| Rate for Payer: First Choice Health Commercial |
$2,992.53
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,992.53
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,921.52
|
| Rate for Payer: HealthUtah PPO |
$3,150.03
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,055.53
|
| Rate for Payer: Multiplan Medicare/VA |
$1,825.44
|
| Rate for Payer: One Health Plan of WY PPO |
$3,087.03
|
| Rate for Payer: PacificSource Commercial |
$2,835.03
|
| Rate for Payer: PHCS PPO |
$3,087.03
|
| Rate for Payer: Three Rivers PPO |
$2,362.52
|
| Rate for Payer: TriWest Veterans Administration |
$1,921.52
|
| Rate for Payer: United Healthcare Commercial |
$3,008.28
|
| Rate for Payer: United Healthcare Medicare |
$1,921.52
|
| Rate for Payer: WINHealth Partners Commercial |
$2,992.53
|
| Rate for Payer: Wise Provider Network Commercial |
$2,992.53
|
|
|
AXONICS CHARGING SYSTEM
|
Facility
|
OP
|
$3,150.03
|
|
| Hospital Charge Code |
3004677
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1,705.74 |
| Max. Negotiated Rate |
$3,150.03 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,087.03
|
| Rate for Payer: Aetna of WY Medicare |
$2,079.02
|
| Rate for Payer: Altius Commercial |
$3,024.03
|
| Rate for Payer: Beech Street Commercial |
$3,087.03
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3,055.53
|
| Rate for Payer: Cash Price |
$2,205.02
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,055.53
|
| Rate for Payer: Cigna of WY Commercial |
$3,087.03
|
| Rate for Payer: Entrust Commercial |
$2,992.53
|
| Rate for Payer: First Choice Health Commercial |
$2,992.53
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,992.53
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,795.52
|
| Rate for Payer: HealthUtah PPO |
$3,150.03
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,055.53
|
| Rate for Payer: Multiplan Medicare/VA |
$1,705.74
|
| Rate for Payer: One Health Plan of WY PPO |
$3,087.03
|
| Rate for Payer: PacificSource Commercial |
$2,835.03
|
| Rate for Payer: PHCS PPO |
$3,087.03
|
| Rate for Payer: Three Rivers PPO |
$2,362.52
|
| Rate for Payer: TriWest Veterans Administration |
$1,795.52
|
| Rate for Payer: United Healthcare Commercial |
$3,008.28
|
| Rate for Payer: United Healthcare Medicare |
$1,795.52
|
| Rate for Payer: WINHealth Partners Commercial |
$3,087.03
|
| Rate for Payer: Wise Provider Network Commercial |
$2,992.53
|
|
|
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION [17517]
|
Facility
|
IP
|
$18.49
|
|
|
Service Code
|
NDC 0093202631
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.71 |
| Max. Negotiated Rate |
$18.49 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18.12
|
| Rate for Payer: Aetna of WY Medicare |
$11.83
|
| Rate for Payer: Altius Commercial |
$17.75
|
| Rate for Payer: Beech Street Commercial |
$18.12
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$17.94
|
| Rate for Payer: Cash Price |
$12.94
|
| Rate for Payer: ChoiceCare Network Commercial |
$17.94
|
| Rate for Payer: Cigna of WY Commercial |
$18.12
|
| Rate for Payer: Entrust Commercial |
$17.57
|
| Rate for Payer: First Choice Health Commercial |
$17.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.28
|
| Rate for Payer: HealthUtah PPO |
$18.49
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.94
|
| Rate for Payer: Multiplan Medicare/VA |
$10.71
|
| Rate for Payer: One Health Plan of WY PPO |
$18.12
|
| Rate for Payer: PacificSource Commercial |
$16.64
|
| Rate for Payer: PHCS PPO |
$18.12
|
| Rate for Payer: Three Rivers PPO |
$13.87
|
| Rate for Payer: TriWest Veterans Administration |
$11.28
|
| Rate for Payer: United Healthcare Commercial |
$17.66
|
| Rate for Payer: United Healthcare Medicare |
$11.28
|
| Rate for Payer: WINHealth Partners Commercial |
$17.57
|
| Rate for Payer: Wise Provider Network Commercial |
$17.57
|
|
|
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION [17517]
|
Facility
|
OP
|
$18.49
|
|
|
Service Code
|
NDC 0093202631
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.01 |
| Max. Negotiated Rate |
$18.49 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18.12
|
| Rate for Payer: Aetna of WY Medicare |
$12.20
|
| Rate for Payer: Altius Commercial |
$17.75
|
| Rate for Payer: Beech Street Commercial |
$18.12
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$17.94
|
| Rate for Payer: Cash Price |
$12.94
|
| Rate for Payer: ChoiceCare Network Commercial |
$17.94
|
| Rate for Payer: Cigna of WY Commercial |
$18.12
|
| Rate for Payer: Entrust Commercial |
$17.57
|
| Rate for Payer: First Choice Health Commercial |
$17.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.54
|
| Rate for Payer: HealthUtah PPO |
$18.49
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.94
|
| Rate for Payer: Multiplan Medicare/VA |
$10.01
|
| Rate for Payer: One Health Plan of WY PPO |
$18.12
|
| Rate for Payer: PacificSource Commercial |
$16.64
|
| Rate for Payer: PHCS PPO |
$18.12
|
| Rate for Payer: Three Rivers PPO |
$13.87
|
| Rate for Payer: TriWest Veterans Administration |
$10.54
|
| Rate for Payer: United Healthcare Commercial |
$17.66
|
| Rate for Payer: United Healthcare Medicare |
$10.54
|
| Rate for Payer: WINHealth Partners Commercial |
$18.12
|
| Rate for Payer: Wise Provider Network Commercial |
$17.57
|
|
|
AZITHROMYCIN 250 MG TABLET [3126]
|
Facility
|
IP
|
$25.00
|
|
|
Service Code
|
NDC 6586264169
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.49 |
| Max. Negotiated Rate |
$25.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$24.50
|
| Rate for Payer: Aetna of WY Medicare |
$16.00
|
| Rate for Payer: Altius Commercial |
$24.00
|
| Rate for Payer: Beech Street Commercial |
$24.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$24.25
|
| Rate for Payer: Cash Price |
$17.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$24.25
|
| Rate for Payer: Cigna of WY Commercial |
$24.50
|
| Rate for Payer: Entrust Commercial |
$23.75
|
| 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) Medicare |
$15.25
|
| Rate for Payer: HealthUtah PPO |
$25.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.25
|
| Rate for Payer: Multiplan Medicare/VA |
$14.49
|
| Rate for Payer: One Health Plan of WY PPO |
$24.50
|
| Rate for Payer: PacificSource Commercial |
$22.50
|
| Rate for Payer: PHCS PPO |
$24.50
|
| Rate for Payer: Three Rivers PPO |
$18.75
|
| Rate for Payer: TriWest Veterans Administration |
$15.25
|
| Rate for Payer: United Healthcare Commercial |
$23.88
|
| Rate for Payer: United Healthcare Medicare |
$15.25
|
| Rate for Payer: WINHealth Partners Commercial |
$23.75
|
| Rate for Payer: Wise Provider Network Commercial |
$23.75
|
|
|
AZITHROMYCIN 250 MG TABLET [3126]
|
Facility
|
OP
|
$25.00
|
|
|
Service Code
|
NDC 6586264169
|
|
Hospital Revenue Code
|
250
|
| 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 Medicare |
$16.50
|
| Rate for Payer: Altius Commercial |
$24.00
|
| Rate for Payer: Beech Street Commercial |
$24.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$24.25
|
| Rate for Payer: Cash Price |
$17.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$24.25
|
| Rate for Payer: Cigna of WY Commercial |
$24.50
|
| Rate for Payer: Entrust Commercial |
$23.75
|
| 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) Medicare |
$14.25
|
| Rate for Payer: HealthUtah PPO |
$25.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.25
|
| Rate for Payer: Multiplan Medicare/VA |
$13.54
|
| Rate for Payer: One Health Plan of WY PPO |
$24.50
|
| Rate for Payer: PacificSource Commercial |
$22.50
|
| Rate for Payer: PHCS PPO |
$24.50
|
| Rate for Payer: Three Rivers PPO |
$18.75
|
| Rate for Payer: TriWest Veterans Administration |
$14.25
|
| Rate for Payer: United Healthcare Commercial |
$23.88
|
| Rate for Payer: United Healthcare Medicare |
$14.25
|
| Rate for Payer: WINHealth Partners Commercial |
$24.50
|
| Rate for Payer: Wise Provider Network Commercial |
$23.75
|
|
|
AZITHROMYCIN 250 MG TABLET [3126]
|
Facility
|
OP
|
$17.94
|
|
|
Service Code
|
NDC 5011178751
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.71 |
| Max. Negotiated Rate |
$17.94 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$17.58
|
| Rate for Payer: Aetna of WY Medicare |
$11.84
|
| Rate for Payer: Altius Commercial |
$17.22
|
| Rate for Payer: Beech Street Commercial |
$17.58
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$17.40
|
| Rate for Payer: Cash Price |
$12.56
|
| Rate for Payer: ChoiceCare Network Commercial |
$17.40
|
| Rate for Payer: Cigna of WY Commercial |
$17.58
|
| Rate for Payer: Entrust Commercial |
$17.04
|
| Rate for Payer: First Choice Health Commercial |
$17.04
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.04
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.23
|
| Rate for Payer: HealthUtah PPO |
$17.94
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.40
|
| Rate for Payer: Multiplan Medicare/VA |
$9.71
|
| Rate for Payer: One Health Plan of WY PPO |
$17.58
|
| Rate for Payer: PacificSource Commercial |
$16.15
|
| Rate for Payer: PHCS PPO |
$17.58
|
| Rate for Payer: Three Rivers PPO |
$13.46
|
| Rate for Payer: TriWest Veterans Administration |
$10.23
|
| Rate for Payer: United Healthcare Commercial |
$17.13
|
| Rate for Payer: United Healthcare Medicare |
$10.23
|
| Rate for Payer: WINHealth Partners Commercial |
$17.58
|
| Rate for Payer: Wise Provider Network Commercial |
$17.04
|
|
|
AZITHROMYCIN 250 MG TABLET [3126]
|
Facility
|
IP
|
$17.94
|
|
|
Service Code
|
NDC 5011178751
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.40 |
| Max. Negotiated Rate |
$17.94 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$17.58
|
| Rate for Payer: Aetna of WY Medicare |
$11.48
|
| Rate for Payer: Altius Commercial |
$17.22
|
| Rate for Payer: Beech Street Commercial |
$17.58
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$17.40
|
| Rate for Payer: Cash Price |
$12.56
|
| Rate for Payer: ChoiceCare Network Commercial |
$17.40
|
| Rate for Payer: Cigna of WY Commercial |
$17.58
|
| Rate for Payer: Entrust Commercial |
$17.04
|
| Rate for Payer: First Choice Health Commercial |
$17.04
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.04
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.94
|
| Rate for Payer: HealthUtah PPO |
$17.94
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.40
|
| Rate for Payer: Multiplan Medicare/VA |
$10.40
|
| Rate for Payer: One Health Plan of WY PPO |
$17.58
|
| Rate for Payer: PacificSource Commercial |
$16.15
|
| Rate for Payer: PHCS PPO |
$17.58
|
| Rate for Payer: Three Rivers PPO |
$13.46
|
| Rate for Payer: TriWest Veterans Administration |
$10.94
|
| Rate for Payer: United Healthcare Commercial |
$17.13
|
| Rate for Payer: United Healthcare Medicare |
$10.94
|
| Rate for Payer: WINHealth Partners Commercial |
$17.04
|
| Rate for Payer: Wise Provider Network Commercial |
$17.04
|
|
|
AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION [14310]
|
Facility
|
OP
|
$36.70
|
|
|
Service Code
|
HCPCS J0456
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.87 |
| Max. Negotiated Rate |
$36.70 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$35.97
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$33.08
|
| Rate for Payer: Aetna of WY Medicare |
$22.28
|
| Rate for Payer: Aetna of WY Medicare |
$24.22
|
| Rate for Payer: Altius Commercial |
$32.40
|
| Rate for Payer: Altius Commercial |
$35.23
|
| Rate for Payer: Beech Street Commercial |
$33.08
|
| Rate for Payer: Beech Street Commercial |
$35.97
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$35.60
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$32.74
|
| Rate for Payer: Cash Price |
$25.69
|
| Rate for Payer: Cash Price |
$23.62
|
| Rate for Payer: ChoiceCare Network Commercial |
$35.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$32.74
|
| Rate for Payer: Cigna of WY Commercial |
$33.08
|
| Rate for Payer: Cigna of WY Commercial |
$35.97
|
| Rate for Payer: Entrust Commercial |
$34.86
|
| Rate for Payer: Entrust Commercial |
$32.06
|
| Rate for Payer: First Choice Health Commercial |
$34.86
|
| Rate for Payer: First Choice Health Commercial |
$32.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$34.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$32.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$19.24
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$20.92
|
| Rate for Payer: HealthUtah PPO |
$33.75
|
| Rate for Payer: HealthUtah PPO |
$36.70
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$35.60
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$32.74
|
| Rate for Payer: Multiplan Medicare/VA |
$18.28
|
| Rate for Payer: Multiplan Medicare/VA |
$19.87
|
| Rate for Payer: One Health Plan of WY PPO |
$35.97
|
| Rate for Payer: One Health Plan of WY PPO |
$33.08
|
| Rate for Payer: PacificSource Commercial |
$30.38
|
| Rate for Payer: PacificSource Commercial |
$33.03
|
| Rate for Payer: PHCS PPO |
$33.08
|
| Rate for Payer: PHCS PPO |
$35.97
|
| Rate for Payer: Three Rivers PPO |
$27.52
|
| Rate for Payer: Three Rivers PPO |
$25.31
|
| Rate for Payer: TriWest Veterans Administration |
$20.92
|
| Rate for Payer: TriWest Veterans Administration |
$19.24
|
| Rate for Payer: United Healthcare Commercial |
$35.05
|
| Rate for Payer: United Healthcare Commercial |
$32.23
|
| Rate for Payer: United Healthcare Medicare |
$19.24
|
| Rate for Payer: United Healthcare Medicare |
$20.92
|
| Rate for Payer: WINHealth Partners Commercial |
$35.97
|
| Rate for Payer: WINHealth Partners Commercial |
$33.08
|
| Rate for Payer: Wise Provider Network Commercial |
$32.06
|
| Rate for Payer: Wise Provider Network Commercial |
$34.86
|
|
