|
HC PUNCTURE ASPIRATION CYST BREAST
|
Facility
|
IP
|
$45.00
|
|
|
Service Code
|
HCPCS 19000
|
| Hospital Charge Code |
5101900001
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$28.22 |
| Max. Negotiated Rate |
$45.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$44.10
|
| Rate for Payer: Altius Auto/Workers Compensation |
$43.20
|
| Rate for Payer: Altius Commercial |
$43.20
|
| Rate for Payer: Beech Street Commercial |
$44.10
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$36.94
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$43.65
|
| Rate for Payer: Cigna of WY Commercial |
$44.10
|
| Rate for Payer: Entrust Commercial |
$42.75
|
| Rate for Payer: First Choice Health Commercial |
$42.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$42.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$29.70
|
| Rate for Payer: HealthUtah PPO |
$45.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$43.65
|
| Rate for Payer: Multiplan Medicare/VA |
$28.22
|
| Rate for Payer: One Health Plan of WY PPO |
$44.10
|
| Rate for Payer: PacificSource Commercial |
$40.50
|
| Rate for Payer: PHCS PPO |
$44.10
|
| Rate for Payer: Three Rivers PPO |
$33.75
|
| Rate for Payer: TriWest Veterans Administration |
$29.70
|
| Rate for Payer: United Healthcare Commercial |
$39.15
|
| Rate for Payer: United Healthcare Medicare |
$29.70
|
| Rate for Payer: WINHealth Partners Commercial |
$42.75
|
| Rate for Payer: Wise Provider Network Commercial |
$42.75
|
|
|
HC PUNCTURE ASPIRATION CYST BREAST W/IMAGING
|
Facility
|
OP
|
$585.00
|
|
|
Service Code
|
HCPCS 19000
|
| Hospital Charge Code |
4021900001
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$322.34 |
| Max. Negotiated Rate |
$585.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$573.30
|
| Rate for Payer: Aetna of WY Medicare |
$386.10
|
| Rate for Payer: Altius Auto/Workers Compensation |
$561.60
|
| Rate for Payer: Altius Commercial |
$561.60
|
| Rate for Payer: Beech Street Commercial |
$573.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$480.28
|
| Rate for Payer: Cash Price |
$409.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$567.45
|
| Rate for Payer: Cigna of WY Commercial |
$573.30
|
| Rate for Payer: Entrust Commercial |
$555.75
|
| Rate for Payer: First Choice Health Commercial |
$555.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$555.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$339.30
|
| Rate for Payer: HealthUtah PPO |
$585.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$567.45
|
| Rate for Payer: Multiplan Medicare/VA |
$322.34
|
| Rate for Payer: One Health Plan of WY PPO |
$573.30
|
| Rate for Payer: PacificSource Commercial |
$526.50
|
| Rate for Payer: PHCS PPO |
$573.30
|
| Rate for Payer: Three Rivers PPO |
$438.75
|
| Rate for Payer: TriWest Veterans Administration |
$339.30
|
| Rate for Payer: United Healthcare Commercial |
$508.95
|
| Rate for Payer: United Healthcare Medicare |
$339.30
|
| Rate for Payer: WINHealth Partners Commercial |
$573.30
|
| Rate for Payer: Wise Provider Network Commercial |
$555.75
|
|
|
HC PUNCTURE ASPIRATION CYST BREAST W/IMAGING
|
Facility
|
IP
|
$585.00
|
|
|
Service Code
|
HCPCS 19000
|
| Hospital Charge Code |
4021900001
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$366.80 |
| Max. Negotiated Rate |
$585.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$573.30
|
| Rate for Payer: Altius Auto/Workers Compensation |
$561.60
|
| Rate for Payer: Altius Commercial |
$561.60
|
| Rate for Payer: Beech Street Commercial |
$573.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$480.28
|
| Rate for Payer: Cash Price |
$409.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$567.45
|
| Rate for Payer: Cigna of WY Commercial |
$573.30
|
| Rate for Payer: Entrust Commercial |
$555.75
|
| Rate for Payer: First Choice Health Commercial |
$555.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$555.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$386.10
|
| Rate for Payer: HealthUtah PPO |
$585.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$567.45
|
| Rate for Payer: Multiplan Medicare/VA |
$366.80
|
| Rate for Payer: One Health Plan of WY PPO |
$573.30
|
| Rate for Payer: PacificSource Commercial |
$526.50
|
| Rate for Payer: PHCS PPO |
$573.30
|
| Rate for Payer: Three Rivers PPO |
$438.75
|
| Rate for Payer: TriWest Veterans Administration |
$386.10
|
| Rate for Payer: United Healthcare Commercial |
$508.95
|
| Rate for Payer: United Healthcare Medicare |
$386.10
|
| Rate for Payer: WINHealth Partners Commercial |
$555.75
|
| Rate for Payer: Wise Provider Network Commercial |
$555.75
|
|
|
HC PUNCTURE ASPIRATION CYST BREAST W/IMAGING
|
Facility
|
IP
|
$3,375.00
|
|
|
Service Code
|
HCPCS 73723
|
| Hospital Charge Code |
4027372301
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$2,116.12 |
| Max. Negotiated Rate |
$3,375.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,307.50
|
| Rate for Payer: Altius Auto/Workers Compensation |
$3,240.00
|
| Rate for Payer: Altius Commercial |
$3,240.00
|
| Rate for Payer: Beech Street Commercial |
$3,307.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,770.88
|
| Rate for Payer: Cash Price |
$2,362.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,273.75
|
| Rate for Payer: Cigna of WY Commercial |
$3,307.50
|
| Rate for Payer: Entrust Commercial |
$3,206.25
|
| Rate for Payer: First Choice Health Commercial |
$3,206.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,206.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2,227.50
|
| Rate for Payer: HealthUtah PPO |
$3,375.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,273.75
|
| Rate for Payer: Multiplan Medicare/VA |
$2,116.12
|
| Rate for Payer: One Health Plan of WY PPO |
$3,307.50
|
| Rate for Payer: PacificSource Commercial |
$3,037.50
|
| Rate for Payer: PHCS PPO |
$3,307.50
|
| Rate for Payer: Three Rivers PPO |
$2,531.25
|
| Rate for Payer: TriWest Veterans Administration |
$2,227.50
|
| Rate for Payer: United Healthcare Commercial |
$2,936.25
|
| Rate for Payer: United Healthcare Medicare |
$2,227.50
|
| Rate for Payer: WINHealth Partners Commercial |
$3,206.25
|
| Rate for Payer: Wise Provider Network Commercial |
$3,206.25
|
|
|
HC PUNCTURE ASPIRATION CYST BREAST W/IMAGING
|
Facility
|
OP
|
$3,375.00
|
|
|
Service Code
|
HCPCS 73723
|
| Hospital Charge Code |
4027372301
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$1,859.62 |
| Max. Negotiated Rate |
$3,375.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,307.50
|
| Rate for Payer: Aetna of WY Medicare |
$2,227.50
|
| Rate for Payer: Altius Auto/Workers Compensation |
$3,240.00
|
| Rate for Payer: Altius Commercial |
$3,240.00
|
| Rate for Payer: Beech Street Commercial |
$3,307.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,770.88
|
| Rate for Payer: Cash Price |
$2,362.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,273.75
|
| Rate for Payer: Cigna of WY Commercial |
$3,307.50
|
| Rate for Payer: Entrust Commercial |
$3,206.25
|
| Rate for Payer: First Choice Health Commercial |
$3,206.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,206.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,957.50
|
| Rate for Payer: HealthUtah PPO |
$3,375.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,273.75
|
| Rate for Payer: Multiplan Medicare/VA |
$1,859.62
|
| Rate for Payer: One Health Plan of WY PPO |
$3,307.50
|
| Rate for Payer: PacificSource Commercial |
$3,037.50
|
| Rate for Payer: PHCS PPO |
$3,307.50
|
| Rate for Payer: Three Rivers PPO |
$2,531.25
|
| Rate for Payer: TriWest Veterans Administration |
$1,957.50
|
| Rate for Payer: United Healthcare Commercial |
$2,936.25
|
| Rate for Payer: United Healthcare Medicare |
$1,957.50
|
| Rate for Payer: WINHealth Partners Commercial |
$3,307.50
|
| Rate for Payer: Wise Provider Network Commercial |
$3,206.25
|
|
|
HC Q FEVER ANTIBODY - COXIELLA BRUNETII Q FEVER ANTIBODY
|
Facility
|
OP
|
$80.00
|
|
|
Service Code
|
HCPCS 86638
|
| Hospital Charge Code |
3028663801
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$44.08 |
| Max. Negotiated Rate |
$80.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$78.40
|
| Rate for Payer: Aetna of WY Medicare |
$52.80
|
| Rate for Payer: Altius Auto/Workers Compensation |
$76.80
|
| Rate for Payer: Altius Commercial |
$76.80
|
| Rate for Payer: Beech Street Commercial |
$78.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$65.68
|
| Rate for Payer: Cash Price |
$56.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$77.60
|
| Rate for Payer: Cigna of WY Commercial |
$78.40
|
| Rate for Payer: Entrust Commercial |
$76.00
|
| Rate for Payer: First Choice Health Commercial |
$76.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$76.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$46.40
|
| Rate for Payer: HealthUtah PPO |
$80.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$77.60
|
| Rate for Payer: Multiplan Medicare/VA |
$44.08
|
| Rate for Payer: One Health Plan of WY PPO |
$78.40
|
| Rate for Payer: PacificSource Commercial |
$72.00
|
| Rate for Payer: PHCS PPO |
$78.40
|
| Rate for Payer: Three Rivers PPO |
$60.00
|
| Rate for Payer: TriWest Veterans Administration |
$46.40
|
| Rate for Payer: United Healthcare Commercial |
$69.60
|
| Rate for Payer: United Healthcare Medicare |
$46.40
|
| Rate for Payer: WINHealth Partners Commercial |
$78.40
|
| Rate for Payer: Wise Provider Network Commercial |
$76.00
|
|
|
HC Q FEVER ANTIBODY - COXIELLA BRUNETII Q FEVER ANTIBODY
|
Facility
|
IP
|
$80.00
|
|
|
Service Code
|
HCPCS 86638
|
| Hospital Charge Code |
3028663801
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$50.16 |
| Max. Negotiated Rate |
$80.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$78.40
|
| Rate for Payer: Altius Auto/Workers Compensation |
$76.80
|
| Rate for Payer: Altius Commercial |
$76.80
|
| Rate for Payer: Beech Street Commercial |
$78.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$65.68
|
| Rate for Payer: Cash Price |
$56.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$77.60
|
| Rate for Payer: Cigna of WY Commercial |
$78.40
|
| Rate for Payer: Entrust Commercial |
$76.00
|
| Rate for Payer: First Choice Health Commercial |
$76.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$76.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$52.80
|
| Rate for Payer: HealthUtah PPO |
$80.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$77.60
|
| Rate for Payer: Multiplan Medicare/VA |
$50.16
|
| Rate for Payer: One Health Plan of WY PPO |
$78.40
|
| Rate for Payer: PacificSource Commercial |
$72.00
|
| Rate for Payer: PHCS PPO |
$78.40
|
| Rate for Payer: Three Rivers PPO |
$60.00
|
| Rate for Payer: TriWest Veterans Administration |
$52.80
|
| Rate for Payer: United Healthcare Commercial |
$69.60
|
| Rate for Payer: United Healthcare Medicare |
$52.80
|
| Rate for Payer: WINHealth Partners Commercial |
$76.00
|
| Rate for Payer: Wise Provider Network Commercial |
$76.00
|
|
|
HC QUANTITATION DRUG NOT ELSEWHERE SPECIFIED - CERTOLIZUMAB LEVEL
|
Facility
|
OP
|
$285.00
|
|
|
Service Code
|
HCPCS 80299
|
| Hospital Charge Code |
3018029922
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$157.04 |
| Max. Negotiated Rate |
$285.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$279.30
|
| Rate for Payer: Aetna of WY Medicare |
$188.10
|
| Rate for Payer: Altius Auto/Workers Compensation |
$273.60
|
| Rate for Payer: Altius Commercial |
$273.60
|
| Rate for Payer: Beech Street Commercial |
$279.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$233.98
|
| Rate for Payer: Cash Price |
$199.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$276.45
|
| Rate for Payer: Cigna of WY Commercial |
$279.30
|
| Rate for Payer: Entrust Commercial |
$270.75
|
| Rate for Payer: First Choice Health Commercial |
$270.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$270.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$165.30
|
| Rate for Payer: HealthUtah PPO |
$285.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$276.45
|
| Rate for Payer: Multiplan Medicare/VA |
$157.04
|
| Rate for Payer: One Health Plan of WY PPO |
$279.30
|
| Rate for Payer: PacificSource Commercial |
$256.50
|
| Rate for Payer: PHCS PPO |
$279.30
|
| Rate for Payer: Three Rivers PPO |
$213.75
|
| Rate for Payer: TriWest Veterans Administration |
$165.30
|
| Rate for Payer: United Healthcare Commercial |
$247.95
|
| Rate for Payer: United Healthcare Medicare |
$165.30
|
| Rate for Payer: WINHealth Partners Commercial |
$279.30
|
| Rate for Payer: Wise Provider Network Commercial |
$270.75
|
|
|
HC QUANTITATION DRUG NOT ELSEWHERE SPECIFIED - CERTOLIZUMAB LEVEL
|
Facility
|
IP
|
$285.00
|
|
|
Service Code
|
HCPCS 80299
|
| Hospital Charge Code |
3018029922
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$178.70 |
| Max. Negotiated Rate |
$285.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$279.30
|
| Rate for Payer: Altius Auto/Workers Compensation |
$273.60
|
| Rate for Payer: Altius Commercial |
$273.60
|
| Rate for Payer: Beech Street Commercial |
$279.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$233.98
|
| Rate for Payer: Cash Price |
$199.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$276.45
|
| Rate for Payer: Cigna of WY Commercial |
$279.30
|
| Rate for Payer: Entrust Commercial |
$270.75
|
| Rate for Payer: First Choice Health Commercial |
$270.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$270.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$188.10
|
| Rate for Payer: HealthUtah PPO |
$285.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$276.45
|
| Rate for Payer: Multiplan Medicare/VA |
$178.70
|
| Rate for Payer: One Health Plan of WY PPO |
$279.30
|
| Rate for Payer: PacificSource Commercial |
$256.50
|
| Rate for Payer: PHCS PPO |
$279.30
|
| Rate for Payer: Three Rivers PPO |
$213.75
|
| Rate for Payer: TriWest Veterans Administration |
$188.10
|
| Rate for Payer: United Healthcare Commercial |
$247.95
|
| Rate for Payer: United Healthcare Medicare |
$188.10
|
| Rate for Payer: WINHealth Partners Commercial |
$270.75
|
| Rate for Payer: Wise Provider Network Commercial |
$270.75
|
|
|
HC QUANTITATION DRUG NOT ELSEWHERE SPECIFIED - DEXAMETHASONE LEVEL
|
Facility
|
OP
|
$285.00
|
|
|
Service Code
|
HCPCS 80299
|
| Hospital Charge Code |
3018029926
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$157.04 |
| Max. Negotiated Rate |
$285.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$279.30
|
| Rate for Payer: Aetna of WY Medicare |
$188.10
|
| Rate for Payer: Altius Auto/Workers Compensation |
$273.60
|
| Rate for Payer: Altius Commercial |
$273.60
|
| Rate for Payer: Beech Street Commercial |
$279.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$233.98
|
| Rate for Payer: Cash Price |
$199.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$276.45
|
| Rate for Payer: Cigna of WY Commercial |
$279.30
|
| Rate for Payer: Entrust Commercial |
$270.75
|
| Rate for Payer: First Choice Health Commercial |
$270.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$270.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$165.30
|
| Rate for Payer: HealthUtah PPO |
$285.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$276.45
|
| Rate for Payer: Multiplan Medicare/VA |
$157.04
|
| Rate for Payer: One Health Plan of WY PPO |
$279.30
|
| Rate for Payer: PacificSource Commercial |
$256.50
|
| Rate for Payer: PHCS PPO |
$279.30
|
| Rate for Payer: Three Rivers PPO |
$213.75
|
| Rate for Payer: TriWest Veterans Administration |
$165.30
|
| Rate for Payer: United Healthcare Commercial |
$247.95
|
| Rate for Payer: United Healthcare Medicare |
$165.30
|
| Rate for Payer: WINHealth Partners Commercial |
$279.30
|
| Rate for Payer: Wise Provider Network Commercial |
$270.75
|
|
|
HC QUANTITATION DRUG NOT ELSEWHERE SPECIFIED - DEXAMETHASONE LEVEL
|
Facility
|
IP
|
$285.00
|
|
|
Service Code
|
HCPCS 80299
|
| Hospital Charge Code |
3018029926
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$178.70 |
| Max. Negotiated Rate |
$285.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$279.30
|
| Rate for Payer: Altius Auto/Workers Compensation |
$273.60
|
| Rate for Payer: Altius Commercial |
$273.60
|
| Rate for Payer: Beech Street Commercial |
$279.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$233.98
|
| Rate for Payer: Cash Price |
$199.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$276.45
|
| Rate for Payer: Cigna of WY Commercial |
$279.30
|
| Rate for Payer: Entrust Commercial |
$270.75
|
| Rate for Payer: First Choice Health Commercial |
$270.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$270.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$188.10
|
| Rate for Payer: HealthUtah PPO |
$285.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$276.45
|
| Rate for Payer: Multiplan Medicare/VA |
$178.70
|
| Rate for Payer: One Health Plan of WY PPO |
$279.30
|
| Rate for Payer: PacificSource Commercial |
$256.50
|
| Rate for Payer: PHCS PPO |
$279.30
|
| Rate for Payer: Three Rivers PPO |
$213.75
|
| Rate for Payer: TriWest Veterans Administration |
$188.10
|
| Rate for Payer: United Healthcare Commercial |
$247.95
|
| Rate for Payer: United Healthcare Medicare |
$188.10
|
| Rate for Payer: WINHealth Partners Commercial |
$270.75
|
| Rate for Payer: Wise Provider Network Commercial |
$270.75
|
|
|
HC QUANTITATION DRUG NOT ELSEWHERE SPECIFIED - FLECAINIDE LEVEL
|
Facility
|
OP
|
$285.00
|
|
|
Service Code
|
HCPCS 80299
|
| Hospital Charge Code |
3018029915
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$157.04 |
| Max. Negotiated Rate |
$285.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$279.30
|
| Rate for Payer: Aetna of WY Medicare |
$188.10
|
| Rate for Payer: Altius Auto/Workers Compensation |
$273.60
|
| Rate for Payer: Altius Commercial |
$273.60
|
| Rate for Payer: Beech Street Commercial |
$279.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$233.98
|
| Rate for Payer: Cash Price |
$199.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$276.45
|
| Rate for Payer: Cigna of WY Commercial |
$279.30
|
| Rate for Payer: Entrust Commercial |
$270.75
|
| Rate for Payer: First Choice Health Commercial |
$270.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$270.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$165.30
|
| Rate for Payer: HealthUtah PPO |
$285.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$276.45
|
| Rate for Payer: Multiplan Medicare/VA |
$157.04
|
| Rate for Payer: One Health Plan of WY PPO |
$279.30
|
| Rate for Payer: PacificSource Commercial |
$256.50
|
| Rate for Payer: PHCS PPO |
$279.30
|
| Rate for Payer: Three Rivers PPO |
$213.75
|
| Rate for Payer: TriWest Veterans Administration |
$165.30
|
| Rate for Payer: United Healthcare Commercial |
$247.95
|
| Rate for Payer: United Healthcare Medicare |
$165.30
|
| Rate for Payer: WINHealth Partners Commercial |
$279.30
|
| Rate for Payer: Wise Provider Network Commercial |
$270.75
|
|
|
HC QUANTITATION DRUG NOT ELSEWHERE SPECIFIED - FLECAINIDE LEVEL
|
Facility
|
IP
|
$285.00
|
|
|
Service Code
|
HCPCS 80299
|
| Hospital Charge Code |
3018029915
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$178.70 |
| Max. Negotiated Rate |
$285.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$279.30
|
| Rate for Payer: Altius Auto/Workers Compensation |
$273.60
|
| Rate for Payer: Altius Commercial |
$273.60
|
| Rate for Payer: Beech Street Commercial |
$279.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$233.98
|
| Rate for Payer: Cash Price |
$199.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$276.45
|
| Rate for Payer: Cigna of WY Commercial |
$279.30
|
| Rate for Payer: Entrust Commercial |
$270.75
|
| Rate for Payer: First Choice Health Commercial |
$270.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$270.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$188.10
|
| Rate for Payer: HealthUtah PPO |
$285.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$276.45
|
| Rate for Payer: Multiplan Medicare/VA |
$178.70
|
| Rate for Payer: One Health Plan of WY PPO |
$279.30
|
| Rate for Payer: PacificSource Commercial |
$256.50
|
| Rate for Payer: PHCS PPO |
$279.30
|
| Rate for Payer: Three Rivers PPO |
$213.75
|
| Rate for Payer: TriWest Veterans Administration |
$188.10
|
| Rate for Payer: United Healthcare Commercial |
$247.95
|
| Rate for Payer: United Healthcare Medicare |
$188.10
|
| Rate for Payer: WINHealth Partners Commercial |
$270.75
|
| Rate for Payer: Wise Provider Network Commercial |
$270.75
|
|
|
HC QUANTITATION DRUG NOT ELSEWHERE SPECIFIED - FLUOXETINE
|
Facility
|
OP
|
$285.00
|
|
|
Service Code
|
HCPCS 80299
|
| Hospital Charge Code |
3018029928
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$157.04 |
| Max. Negotiated Rate |
$285.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$279.30
|
| Rate for Payer: Aetna of WY Medicare |
$188.10
|
| Rate for Payer: Altius Auto/Workers Compensation |
$273.60
|
| Rate for Payer: Altius Commercial |
$273.60
|
| Rate for Payer: Beech Street Commercial |
$279.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$233.98
|
| Rate for Payer: Cash Price |
$199.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$276.45
|
| Rate for Payer: Cigna of WY Commercial |
$279.30
|
| Rate for Payer: Entrust Commercial |
$270.75
|
| Rate for Payer: First Choice Health Commercial |
$270.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$270.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$165.30
|
| Rate for Payer: HealthUtah PPO |
$285.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$276.45
|
| Rate for Payer: Multiplan Medicare/VA |
$157.04
|
| Rate for Payer: One Health Plan of WY PPO |
$279.30
|
| Rate for Payer: PacificSource Commercial |
$256.50
|
| Rate for Payer: PHCS PPO |
$279.30
|
| Rate for Payer: Three Rivers PPO |
$213.75
|
| Rate for Payer: TriWest Veterans Administration |
$165.30
|
| Rate for Payer: United Healthcare Commercial |
$247.95
|
| Rate for Payer: United Healthcare Medicare |
$165.30
|
| Rate for Payer: WINHealth Partners Commercial |
$279.30
|
| Rate for Payer: Wise Provider Network Commercial |
$270.75
|
|
|
HC QUANTITATION DRUG NOT ELSEWHERE SPECIFIED - FLUOXETINE
|
Facility
|
IP
|
$285.00
|
|
|
Service Code
|
HCPCS 80299
|
| Hospital Charge Code |
3018029928
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$178.70 |
| Max. Negotiated Rate |
$285.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$279.30
|
| Rate for Payer: Altius Auto/Workers Compensation |
$273.60
|
| Rate for Payer: Altius Commercial |
$273.60
|
| Rate for Payer: Beech Street Commercial |
$279.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$233.98
|
| Rate for Payer: Cash Price |
$199.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$276.45
|
| Rate for Payer: Cigna of WY Commercial |
$279.30
|
| Rate for Payer: Entrust Commercial |
$270.75
|
| Rate for Payer: First Choice Health Commercial |
$270.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$270.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$188.10
|
| Rate for Payer: HealthUtah PPO |
$285.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$276.45
|
| Rate for Payer: Multiplan Medicare/VA |
$178.70
|
| Rate for Payer: One Health Plan of WY PPO |
$279.30
|
| Rate for Payer: PacificSource Commercial |
$256.50
|
| Rate for Payer: PHCS PPO |
$279.30
|
| Rate for Payer: Three Rivers PPO |
$213.75
|
| Rate for Payer: TriWest Veterans Administration |
$188.10
|
| Rate for Payer: United Healthcare Commercial |
$247.95
|
| Rate for Payer: United Healthcare Medicare |
$188.10
|
| Rate for Payer: WINHealth Partners Commercial |
$270.75
|
| Rate for Payer: Wise Provider Network Commercial |
$270.75
|
|
|
HC QUANTITATION DRUG NOT ELSEWHERE SPECIFIED - FLUVOXAMINE
|
Facility
|
OP
|
$285.00
|
|
|
Service Code
|
HCPCS 80299
|
| Hospital Charge Code |
3018029930
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$157.04 |
| Max. Negotiated Rate |
$285.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$279.30
|
| Rate for Payer: Aetna of WY Medicare |
$188.10
|
| Rate for Payer: Altius Auto/Workers Compensation |
$273.60
|
| Rate for Payer: Altius Commercial |
$273.60
|
| Rate for Payer: Beech Street Commercial |
$279.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$233.98
|
| Rate for Payer: Cash Price |
$199.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$276.45
|
| Rate for Payer: Cigna of WY Commercial |
$279.30
|
| Rate for Payer: Entrust Commercial |
$270.75
|
| Rate for Payer: First Choice Health Commercial |
$270.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$270.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$165.30
|
| Rate for Payer: HealthUtah PPO |
$285.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$276.45
|
| Rate for Payer: Multiplan Medicare/VA |
$157.04
|
| Rate for Payer: One Health Plan of WY PPO |
$279.30
|
| Rate for Payer: PacificSource Commercial |
$256.50
|
| Rate for Payer: PHCS PPO |
$279.30
|
| Rate for Payer: Three Rivers PPO |
$213.75
|
| Rate for Payer: TriWest Veterans Administration |
$165.30
|
| Rate for Payer: United Healthcare Commercial |
$247.95
|
| Rate for Payer: United Healthcare Medicare |
$165.30
|
| Rate for Payer: WINHealth Partners Commercial |
$279.30
|
| Rate for Payer: Wise Provider Network Commercial |
$270.75
|
|
|
HC QUANTITATION DRUG NOT ELSEWHERE SPECIFIED - FLUVOXAMINE
|
Facility
|
IP
|
$285.00
|
|
|
Service Code
|
HCPCS 80299
|
| Hospital Charge Code |
3018029930
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$178.70 |
| Max. Negotiated Rate |
$285.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$279.30
|
| Rate for Payer: Altius Auto/Workers Compensation |
$273.60
|
| Rate for Payer: Altius Commercial |
$273.60
|
| Rate for Payer: Beech Street Commercial |
$279.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$233.98
|
| Rate for Payer: Cash Price |
$199.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$276.45
|
| Rate for Payer: Cigna of WY Commercial |
$279.30
|
| Rate for Payer: Entrust Commercial |
$270.75
|
| Rate for Payer: First Choice Health Commercial |
$270.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$270.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$188.10
|
| Rate for Payer: HealthUtah PPO |
$285.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$276.45
|
| Rate for Payer: Multiplan Medicare/VA |
$178.70
|
| Rate for Payer: One Health Plan of WY PPO |
$279.30
|
| Rate for Payer: PacificSource Commercial |
$256.50
|
| Rate for Payer: PHCS PPO |
$279.30
|
| Rate for Payer: Three Rivers PPO |
$213.75
|
| Rate for Payer: TriWest Veterans Administration |
$188.10
|
| Rate for Payer: United Healthcare Commercial |
$247.95
|
| Rate for Payer: United Healthcare Medicare |
$188.10
|
| Rate for Payer: WINHealth Partners Commercial |
$270.75
|
| Rate for Payer: Wise Provider Network Commercial |
$270.75
|
|
|
HC QUANTITATION DRUG NOT ELSEWHERE SPECIFIED - ITRACONAZOLE LEVEL
|
Facility
|
OP
|
$285.00
|
|
|
Service Code
|
HCPCS 80299
|
| Hospital Charge Code |
3018029923
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$157.04 |
| Max. Negotiated Rate |
$285.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$279.30
|
| Rate for Payer: Aetna of WY Medicare |
$188.10
|
| Rate for Payer: Altius Auto/Workers Compensation |
$273.60
|
| Rate for Payer: Altius Commercial |
$273.60
|
| Rate for Payer: Beech Street Commercial |
$279.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$233.98
|
| Rate for Payer: Cash Price |
$199.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$276.45
|
| Rate for Payer: Cigna of WY Commercial |
$279.30
|
| Rate for Payer: Entrust Commercial |
$270.75
|
| Rate for Payer: First Choice Health Commercial |
$270.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$270.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$165.30
|
| Rate for Payer: HealthUtah PPO |
$285.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$276.45
|
| Rate for Payer: Multiplan Medicare/VA |
$157.04
|
| Rate for Payer: One Health Plan of WY PPO |
$279.30
|
| Rate for Payer: PacificSource Commercial |
$256.50
|
| Rate for Payer: PHCS PPO |
$279.30
|
| Rate for Payer: Three Rivers PPO |
$213.75
|
| Rate for Payer: TriWest Veterans Administration |
$165.30
|
| Rate for Payer: United Healthcare Commercial |
$247.95
|
| Rate for Payer: United Healthcare Medicare |
$165.30
|
| Rate for Payer: WINHealth Partners Commercial |
$279.30
|
| Rate for Payer: Wise Provider Network Commercial |
$270.75
|
|
|
HC QUANTITATION DRUG NOT ELSEWHERE SPECIFIED - ITRACONAZOLE LEVEL
|
Facility
|
IP
|
$285.00
|
|
|
Service Code
|
HCPCS 80299
|
| Hospital Charge Code |
3018029923
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$178.70 |
| Max. Negotiated Rate |
$285.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$279.30
|
| Rate for Payer: Altius Auto/Workers Compensation |
$273.60
|
| Rate for Payer: Altius Commercial |
$273.60
|
| Rate for Payer: Beech Street Commercial |
$279.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$233.98
|
| Rate for Payer: Cash Price |
$199.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$276.45
|
| Rate for Payer: Cigna of WY Commercial |
$279.30
|
| Rate for Payer: Entrust Commercial |
$270.75
|
| Rate for Payer: First Choice Health Commercial |
$270.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$270.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$188.10
|
| Rate for Payer: HealthUtah PPO |
$285.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$276.45
|
| Rate for Payer: Multiplan Medicare/VA |
$178.70
|
| Rate for Payer: One Health Plan of WY PPO |
$279.30
|
| Rate for Payer: PacificSource Commercial |
$256.50
|
| Rate for Payer: PHCS PPO |
$279.30
|
| Rate for Payer: Three Rivers PPO |
$213.75
|
| Rate for Payer: TriWest Veterans Administration |
$188.10
|
| Rate for Payer: United Healthcare Commercial |
$247.95
|
| Rate for Payer: United Healthcare Medicare |
$188.10
|
| Rate for Payer: WINHealth Partners Commercial |
$270.75
|
| Rate for Payer: Wise Provider Network Commercial |
$270.75
|
|
|
HC QUANTITATION DRUG NOT ELSEWHERE SPECIFIED - MERCAPTOPURINE LEVEL
|
Facility
|
OP
|
$285.00
|
|
|
Service Code
|
HCPCS 80299
|
| Hospital Charge Code |
3018029924
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$157.04 |
| Max. Negotiated Rate |
$285.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$279.30
|
| Rate for Payer: Aetna of WY Medicare |
$188.10
|
| Rate for Payer: Altius Auto/Workers Compensation |
$273.60
|
| Rate for Payer: Altius Commercial |
$273.60
|
| Rate for Payer: Beech Street Commercial |
$279.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$233.98
|
| Rate for Payer: Cash Price |
$199.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$276.45
|
| Rate for Payer: Cigna of WY Commercial |
$279.30
|
| Rate for Payer: Entrust Commercial |
$270.75
|
| Rate for Payer: First Choice Health Commercial |
$270.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$270.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$165.30
|
| Rate for Payer: HealthUtah PPO |
$285.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$276.45
|
| Rate for Payer: Multiplan Medicare/VA |
$157.04
|
| Rate for Payer: One Health Plan of WY PPO |
$279.30
|
| Rate for Payer: PacificSource Commercial |
$256.50
|
| Rate for Payer: PHCS PPO |
$279.30
|
| Rate for Payer: Three Rivers PPO |
$213.75
|
| Rate for Payer: TriWest Veterans Administration |
$165.30
|
| Rate for Payer: United Healthcare Commercial |
$247.95
|
| Rate for Payer: United Healthcare Medicare |
$165.30
|
| Rate for Payer: WINHealth Partners Commercial |
$279.30
|
| Rate for Payer: Wise Provider Network Commercial |
$270.75
|
|
|
HC QUANTITATION DRUG NOT ELSEWHERE SPECIFIED - MERCAPTOPURINE LEVEL
|
Facility
|
IP
|
$285.00
|
|
|
Service Code
|
HCPCS 80299
|
| Hospital Charge Code |
3018029924
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$178.70 |
| Max. Negotiated Rate |
$285.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$279.30
|
| Rate for Payer: Altius Auto/Workers Compensation |
$273.60
|
| Rate for Payer: Altius Commercial |
$273.60
|
| Rate for Payer: Beech Street Commercial |
$279.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$233.98
|
| Rate for Payer: Cash Price |
$199.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$276.45
|
| Rate for Payer: Cigna of WY Commercial |
$279.30
|
| Rate for Payer: Entrust Commercial |
$270.75
|
| Rate for Payer: First Choice Health Commercial |
$270.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$270.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$188.10
|
| Rate for Payer: HealthUtah PPO |
$285.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$276.45
|
| Rate for Payer: Multiplan Medicare/VA |
$178.70
|
| Rate for Payer: One Health Plan of WY PPO |
$279.30
|
| Rate for Payer: PacificSource Commercial |
$256.50
|
| Rate for Payer: PHCS PPO |
$279.30
|
| Rate for Payer: Three Rivers PPO |
$213.75
|
| Rate for Payer: TriWest Veterans Administration |
$188.10
|
| Rate for Payer: United Healthcare Commercial |
$247.95
|
| Rate for Payer: United Healthcare Medicare |
$188.10
|
| Rate for Payer: WINHealth Partners Commercial |
$270.75
|
| Rate for Payer: Wise Provider Network Commercial |
$270.75
|
|
|
HC QUANTITATION DRUG NOT ELSEWHERE SPECIFIED - METHOTREXATE LEVEL
|
Facility
|
IP
|
$285.00
|
|
|
Service Code
|
HCPCS 80299
|
| Hospital Charge Code |
3018029903
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$178.70 |
| Max. Negotiated Rate |
$285.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$279.30
|
| Rate for Payer: Altius Auto/Workers Compensation |
$273.60
|
| Rate for Payer: Altius Commercial |
$273.60
|
| Rate for Payer: Beech Street Commercial |
$279.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$233.98
|
| Rate for Payer: Cash Price |
$199.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$276.45
|
| Rate for Payer: Cigna of WY Commercial |
$279.30
|
| Rate for Payer: Entrust Commercial |
$270.75
|
| Rate for Payer: First Choice Health Commercial |
$270.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$270.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$188.10
|
| Rate for Payer: HealthUtah PPO |
$285.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$276.45
|
| Rate for Payer: Multiplan Medicare/VA |
$178.70
|
| Rate for Payer: One Health Plan of WY PPO |
$279.30
|
| Rate for Payer: PacificSource Commercial |
$256.50
|
| Rate for Payer: PHCS PPO |
$279.30
|
| Rate for Payer: Three Rivers PPO |
$213.75
|
| Rate for Payer: TriWest Veterans Administration |
$188.10
|
| Rate for Payer: United Healthcare Commercial |
$247.95
|
| Rate for Payer: United Healthcare Medicare |
$188.10
|
| Rate for Payer: WINHealth Partners Commercial |
$270.75
|
| Rate for Payer: Wise Provider Network Commercial |
$270.75
|
|
|
HC QUANTITATION DRUG NOT ELSEWHERE SPECIFIED - METHOTREXATE LEVEL
|
Facility
|
OP
|
$285.00
|
|
|
Service Code
|
HCPCS 80299
|
| Hospital Charge Code |
3018029903
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$157.04 |
| Max. Negotiated Rate |
$285.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$279.30
|
| Rate for Payer: Aetna of WY Medicare |
$188.10
|
| Rate for Payer: Altius Auto/Workers Compensation |
$273.60
|
| Rate for Payer: Altius Commercial |
$273.60
|
| Rate for Payer: Beech Street Commercial |
$279.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$233.98
|
| Rate for Payer: Cash Price |
$199.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$276.45
|
| Rate for Payer: Cigna of WY Commercial |
$279.30
|
| Rate for Payer: Entrust Commercial |
$270.75
|
| Rate for Payer: First Choice Health Commercial |
$270.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$270.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$165.30
|
| Rate for Payer: HealthUtah PPO |
$285.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$276.45
|
| Rate for Payer: Multiplan Medicare/VA |
$157.04
|
| Rate for Payer: One Health Plan of WY PPO |
$279.30
|
| Rate for Payer: PacificSource Commercial |
$256.50
|
| Rate for Payer: PHCS PPO |
$279.30
|
| Rate for Payer: Three Rivers PPO |
$213.75
|
| Rate for Payer: TriWest Veterans Administration |
$165.30
|
| Rate for Payer: United Healthcare Commercial |
$247.95
|
| Rate for Payer: United Healthcare Medicare |
$165.30
|
| Rate for Payer: WINHealth Partners Commercial |
$279.30
|
| Rate for Payer: Wise Provider Network Commercial |
$270.75
|
|
|
HC QUANTITATION DRUG NOT ELSEWHERE SPECIFIED - MEXILETINE LEVEL
|
Facility
|
IP
|
$285.00
|
|
|
Service Code
|
HCPCS 80299
|
| Hospital Charge Code |
3018029921
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$178.70 |
| Max. Negotiated Rate |
$285.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$279.30
|
| Rate for Payer: Altius Auto/Workers Compensation |
$273.60
|
| Rate for Payer: Altius Commercial |
$273.60
|
| Rate for Payer: Beech Street Commercial |
$279.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$233.98
|
| Rate for Payer: Cash Price |
$199.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$276.45
|
| Rate for Payer: Cigna of WY Commercial |
$279.30
|
| Rate for Payer: Entrust Commercial |
$270.75
|
| Rate for Payer: First Choice Health Commercial |
$270.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$270.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$188.10
|
| Rate for Payer: HealthUtah PPO |
$285.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$276.45
|
| Rate for Payer: Multiplan Medicare/VA |
$178.70
|
| Rate for Payer: One Health Plan of WY PPO |
$279.30
|
| Rate for Payer: PacificSource Commercial |
$256.50
|
| Rate for Payer: PHCS PPO |
$279.30
|
| Rate for Payer: Three Rivers PPO |
$213.75
|
| Rate for Payer: TriWest Veterans Administration |
$188.10
|
| Rate for Payer: United Healthcare Commercial |
$247.95
|
| Rate for Payer: United Healthcare Medicare |
$188.10
|
| Rate for Payer: WINHealth Partners Commercial |
$270.75
|
| Rate for Payer: Wise Provider Network Commercial |
$270.75
|
|
|
HC QUANTITATION DRUG NOT ELSEWHERE SPECIFIED - MEXILETINE LEVEL
|
Facility
|
OP
|
$285.00
|
|
|
Service Code
|
HCPCS 80299
|
| Hospital Charge Code |
3018029921
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$157.04 |
| Max. Negotiated Rate |
$285.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$279.30
|
| Rate for Payer: Aetna of WY Medicare |
$188.10
|
| Rate for Payer: Altius Auto/Workers Compensation |
$273.60
|
| Rate for Payer: Altius Commercial |
$273.60
|
| Rate for Payer: Beech Street Commercial |
$279.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$233.98
|
| Rate for Payer: Cash Price |
$199.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$276.45
|
| Rate for Payer: Cigna of WY Commercial |
$279.30
|
| Rate for Payer: Entrust Commercial |
$270.75
|
| Rate for Payer: First Choice Health Commercial |
$270.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$270.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$165.30
|
| Rate for Payer: HealthUtah PPO |
$285.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$276.45
|
| Rate for Payer: Multiplan Medicare/VA |
$157.04
|
| Rate for Payer: One Health Plan of WY PPO |
$279.30
|
| Rate for Payer: PacificSource Commercial |
$256.50
|
| Rate for Payer: PHCS PPO |
$279.30
|
| Rate for Payer: Three Rivers PPO |
$213.75
|
| Rate for Payer: TriWest Veterans Administration |
$165.30
|
| Rate for Payer: United Healthcare Commercial |
$247.95
|
| Rate for Payer: United Healthcare Medicare |
$165.30
|
| Rate for Payer: WINHealth Partners Commercial |
$279.30
|
| Rate for Payer: Wise Provider Network Commercial |
$270.75
|
|
