|
IM ADM INTRANSL/ORAL EA VACCINE
|
Professional
|
Both
|
$18.00
|
|
|
Service Code
|
HCPCS 90474
|
| Hospital Charge Code |
90474
|
| Min. Negotiated Rate |
$9.94 |
| Max. Negotiated Rate |
$18.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$17.64
|
| Rate for Payer: Aetna of WY Medicare |
$11.70
|
| Rate for Payer: Beech Street Commercial |
$17.10
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$17.46
|
| Rate for Payer: Cigna of WY Commercial |
$17.64
|
| Rate for Payer: First Choice Health Commercial |
$16.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.70
|
| Rate for Payer: HealthUtah PPO |
$18.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.46
|
| Rate for Payer: Multiplan Medicare/VA |
$9.94
|
| Rate for Payer: One Health Plan of WY PPO |
$17.64
|
| Rate for Payer: PacificSource Commercial |
$16.20
|
| Rate for Payer: PHCS PPO |
$17.10
|
| Rate for Payer: Three Rivers PPO |
$13.50
|
| Rate for Payer: TriWest Veterans Administration |
$11.70
|
| Rate for Payer: United Healthcare Commercial |
$15.66
|
| Rate for Payer: United Healthcare Medicare |
$11.70
|
| Rate for Payer: WINHealth Partners Commercial |
$17.10
|
|
|
IM ADM PRQ ID SUBQ/IM NJXS 1 VACCINE
|
Professional
|
Both
|
$37.00
|
|
|
Service Code
|
HCPCS 90471
|
| Hospital Charge Code |
90471
|
| Min. Negotiated Rate |
$17.19 |
| Max. Negotiated Rate |
$37.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$36.26
|
| Rate for Payer: Aetna of WY Medicare |
$20.22
|
| Rate for Payer: Beech Street Commercial |
$35.15
|
| Rate for Payer: Cash Price |
$25.90
|
| Rate for Payer: Cash Price |
$25.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$35.89
|
| Rate for Payer: Cigna of WY Commercial |
$36.26
|
| Rate for Payer: First Choice Health Commercial |
$33.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$35.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$20.22
|
| Rate for Payer: HealthUtah PPO |
$37.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$35.89
|
| Rate for Payer: Multiplan Medicare/VA |
$17.19
|
| Rate for Payer: One Health Plan of WY PPO |
$36.26
|
| Rate for Payer: PacificSource Commercial |
$33.30
|
| Rate for Payer: PHCS PPO |
$35.15
|
| Rate for Payer: Three Rivers PPO |
$27.75
|
| Rate for Payer: TriWest Veterans Administration |
$20.22
|
| Rate for Payer: United Healthcare Commercial |
$32.19
|
| Rate for Payer: United Healthcare Medicare |
$20.22
|
| Rate for Payer: WINHealth Partners Commercial |
$35.15
|
|
|
IM ADM PRQ ID SUBQ/IM NJXS EA VACCINE
|
Professional
|
Both
|
$37.00
|
|
|
Service Code
|
HCPCS 90472
|
| Hospital Charge Code |
90472
|
| Min. Negotiated Rate |
$12.17 |
| Max. Negotiated Rate |
$37.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$36.26
|
| Rate for Payer: Aetna of WY Medicare |
$14.32
|
| Rate for Payer: Beech Street Commercial |
$35.15
|
| Rate for Payer: Cash Price |
$25.90
|
| Rate for Payer: Cash Price |
$25.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$35.89
|
| Rate for Payer: Cigna of WY Commercial |
$36.26
|
| Rate for Payer: First Choice Health Commercial |
$33.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$35.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$14.32
|
| Rate for Payer: HealthUtah PPO |
$37.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$35.89
|
| Rate for Payer: Multiplan Medicare/VA |
$12.17
|
| Rate for Payer: One Health Plan of WY PPO |
$36.26
|
| Rate for Payer: PacificSource Commercial |
$33.30
|
| Rate for Payer: PHCS PPO |
$35.15
|
| Rate for Payer: Three Rivers PPO |
$27.75
|
| Rate for Payer: TriWest Veterans Administration |
$14.32
|
| Rate for Payer: United Healthcare Commercial |
$32.19
|
| Rate for Payer: United Healthcare Medicare |
$14.32
|
| Rate for Payer: WINHealth Partners Commercial |
$35.15
|
|
|
IM ADM THRU 18YR ANY RTE 1ST/ONLY COMPT VAC/TOX
|
Professional
|
Both
|
$21.72
|
|
|
Service Code
|
HCPCS 90460
|
| Hospital Charge Code |
90460
|
| Min. Negotiated Rate |
$16.29 |
| Max. Negotiated Rate |
$22.42 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$21.29
|
| Rate for Payer: Aetna of WY Medicare |
$22.42
|
| Rate for Payer: Beech Street Commercial |
$20.63
|
| Rate for Payer: Cash Price |
$15.20
|
| Rate for Payer: Cash Price |
$15.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$21.07
|
| Rate for Payer: Cigna of WY Commercial |
$21.29
|
| Rate for Payer: First Choice Health Commercial |
$19.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$20.63
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$22.42
|
| Rate for Payer: HealthUtah PPO |
$21.72
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$21.07
|
| Rate for Payer: Multiplan Medicare/VA |
$19.06
|
| Rate for Payer: One Health Plan of WY PPO |
$21.29
|
| Rate for Payer: PacificSource Commercial |
$19.55
|
| Rate for Payer: PHCS PPO |
$20.63
|
| Rate for Payer: Three Rivers PPO |
$16.29
|
| Rate for Payer: TriWest Veterans Administration |
$22.42
|
| Rate for Payer: United Healthcare Commercial |
$18.90
|
| Rate for Payer: United Healthcare Medicare |
$22.42
|
| Rate for Payer: WINHealth Partners Commercial |
$20.63
|
|
|
IMIPENEM-CILASTATIN 500 MG INTRAVENOUS SOLUTION [4024]
|
Facility
|
OP
|
$69.70
|
|
|
Service Code
|
HCPCS J0743
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$38.40 |
| Max. Negotiated Rate |
$69.70 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$68.31
|
| Rate for Payer: Aetna of WY Medicare |
$46.00
|
| Rate for Payer: Altius Auto/Workers Compensation |
$66.91
|
| Rate for Payer: Altius Commercial |
$66.91
|
| Rate for Payer: Beech Street Commercial |
$68.31
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$57.22
|
| Rate for Payer: Cash Price |
$48.79
|
| Rate for Payer: ChoiceCare Network Commercial |
$67.61
|
| Rate for Payer: Cigna of WY Commercial |
$68.31
|
| Rate for Payer: Entrust Commercial |
$66.22
|
| Rate for Payer: First Choice Health Commercial |
$66.22
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$66.22
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$40.43
|
| Rate for Payer: HealthUtah PPO |
$69.70
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$67.61
|
| Rate for Payer: Multiplan Medicare/VA |
$38.40
|
| Rate for Payer: One Health Plan of WY PPO |
$68.31
|
| Rate for Payer: PacificSource Commercial |
$62.73
|
| Rate for Payer: PHCS PPO |
$68.31
|
| Rate for Payer: Three Rivers PPO |
$52.28
|
| Rate for Payer: TriWest Veterans Administration |
$40.43
|
| Rate for Payer: United Healthcare Commercial |
$60.64
|
| Rate for Payer: United Healthcare Medicare |
$40.43
|
| Rate for Payer: WINHealth Partners Commercial |
$68.31
|
| Rate for Payer: Wise Provider Network Commercial |
$66.22
|
|
|
IMIPENEM-CILASTATIN 500 MG INTRAVENOUS SOLUTION [4024]
|
Facility
|
IP
|
$69.70
|
|
|
Service Code
|
HCPCS J0743
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$43.70 |
| Max. Negotiated Rate |
$69.70 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$68.31
|
| Rate for Payer: Altius Auto/Workers Compensation |
$66.91
|
| Rate for Payer: Altius Commercial |
$66.91
|
| Rate for Payer: Beech Street Commercial |
$68.31
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$57.22
|
| Rate for Payer: Cash Price |
$48.79
|
| Rate for Payer: ChoiceCare Network Commercial |
$67.61
|
| Rate for Payer: Cigna of WY Commercial |
$68.31
|
| Rate for Payer: Entrust Commercial |
$66.22
|
| Rate for Payer: First Choice Health Commercial |
$66.22
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$66.22
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$46.00
|
| Rate for Payer: HealthUtah PPO |
$69.70
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$67.61
|
| Rate for Payer: Multiplan Medicare/VA |
$43.70
|
| Rate for Payer: One Health Plan of WY PPO |
$68.31
|
| Rate for Payer: PacificSource Commercial |
$62.73
|
| Rate for Payer: PHCS PPO |
$68.31
|
| Rate for Payer: Three Rivers PPO |
$52.28
|
| Rate for Payer: TriWest Veterans Administration |
$46.00
|
| Rate for Payer: United Healthcare Commercial |
$60.64
|
| Rate for Payer: United Healthcare Medicare |
$46.00
|
| Rate for Payer: WINHealth Partners Commercial |
$66.22
|
| Rate for Payer: Wise Provider Network Commercial |
$66.22
|
|
|
IMM ADMIN MODERNA BIVALENT 50MCG/.5ML AGE 12+
|
Professional
|
Both
|
$62.00
|
|
|
Service Code
|
HCPCS 0134A
|
| Hospital Charge Code |
0134A
|
| Min. Negotiated Rate |
$46.50 |
| Max. Negotiated Rate |
$62.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$60.76
|
| Rate for Payer: Beech Street Commercial |
$58.90
|
| Rate for Payer: Cash Price |
$43.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$60.14
|
| Rate for Payer: Cigna of WY Commercial |
$60.76
|
| Rate for Payer: First Choice Health Commercial |
$55.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$58.90
|
| Rate for Payer: HealthUtah PPO |
$62.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$60.14
|
| Rate for Payer: One Health Plan of WY PPO |
$60.76
|
| Rate for Payer: PacificSource Commercial |
$55.80
|
| Rate for Payer: PHCS PPO |
$58.90
|
| Rate for Payer: Three Rivers PPO |
$46.50
|
| Rate for Payer: United Healthcare Commercial |
$53.94
|
| Rate for Payer: WINHealth Partners Commercial |
$58.90
|
|
|
IMM ADMN SARSCOV2 30MCG/0.3ML DIL RECON 1ST DOSE
|
Professional
|
Both
|
$62.00
|
|
|
Service Code
|
HCPCS 0001A
|
| Hospital Charge Code |
0001A
|
| Min. Negotiated Rate |
$46.50 |
| Max. Negotiated Rate |
$62.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$60.76
|
| Rate for Payer: Beech Street Commercial |
$58.90
|
| Rate for Payer: Cash Price |
$43.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$60.14
|
| Rate for Payer: Cigna of WY Commercial |
$60.76
|
| Rate for Payer: First Choice Health Commercial |
$55.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$58.90
|
| Rate for Payer: HealthUtah PPO |
$62.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$60.14
|
| Rate for Payer: One Health Plan of WY PPO |
$60.76
|
| Rate for Payer: PacificSource Commercial |
$55.80
|
| Rate for Payer: PHCS PPO |
$58.90
|
| Rate for Payer: Three Rivers PPO |
$46.50
|
| Rate for Payer: United Healthcare Commercial |
$53.94
|
| Rate for Payer: WINHealth Partners Commercial |
$58.90
|
|
|
IMM ADMN SARSCOV2 VACCINE SINGLE DOSE
|
Facility
|
IP
|
$55.00
|
|
|
Service Code
|
HCPCS 90480
|
| Hospital Charge Code |
7719048001
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$34.48 |
| Max. Negotiated Rate |
$55.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$53.90
|
| Rate for Payer: Altius Auto/Workers Compensation |
$52.80
|
| Rate for Payer: Altius Commercial |
$52.80
|
| Rate for Payer: Beech Street Commercial |
$53.90
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$45.16
|
| Rate for Payer: Cash Price |
$38.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$53.35
|
| Rate for Payer: Cigna of WY Commercial |
$53.90
|
| Rate for Payer: Entrust Commercial |
$52.25
|
| Rate for Payer: First Choice Health Commercial |
$52.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$52.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$36.30
|
| Rate for Payer: HealthUtah PPO |
$55.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$53.35
|
| Rate for Payer: Multiplan Medicare/VA |
$34.48
|
| Rate for Payer: One Health Plan of WY PPO |
$53.90
|
| Rate for Payer: PacificSource Commercial |
$49.50
|
| Rate for Payer: PHCS PPO |
$53.90
|
| Rate for Payer: Three Rivers PPO |
$41.25
|
| Rate for Payer: TriWest Veterans Administration |
$36.30
|
| Rate for Payer: United Healthcare Commercial |
$47.85
|
| Rate for Payer: United Healthcare Medicare |
$36.30
|
| Rate for Payer: WINHealth Partners Commercial |
$52.25
|
| Rate for Payer: Wise Provider Network Commercial |
$52.25
|
|
|
IMM ADMN SARSCOV2 VACCINE SINGLE DOSE
|
Professional
|
Both
|
$62.00
|
|
|
Service Code
|
HCPCS 90480
|
| Hospital Charge Code |
90480
|
| Min. Negotiated Rate |
$46.50 |
| Max. Negotiated Rate |
$62.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$60.76
|
| Rate for Payer: Beech Street Commercial |
$58.90
|
| Rate for Payer: Cash Price |
$43.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$60.14
|
| Rate for Payer: Cigna of WY Commercial |
$60.76
|
| Rate for Payer: First Choice Health Commercial |
$55.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$58.90
|
| Rate for Payer: HealthUtah PPO |
$62.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$60.14
|
| Rate for Payer: One Health Plan of WY PPO |
$60.76
|
| Rate for Payer: PacificSource Commercial |
$55.80
|
| Rate for Payer: PHCS PPO |
$58.90
|
| Rate for Payer: Three Rivers PPO |
$46.50
|
| Rate for Payer: United Healthcare Commercial |
$53.94
|
| Rate for Payer: WINHealth Partners Commercial |
$62.00
|
|
|
IMM ADMN SARSCOV2 VACCINE SINGLE DOSE
|
Facility
|
OP
|
$55.00
|
|
|
Service Code
|
HCPCS 90480
|
| Hospital Charge Code |
7719048001
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$30.30 |
| Max. Negotiated Rate |
$55.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$53.90
|
| Rate for Payer: Aetna of WY Medicare |
$36.30
|
| Rate for Payer: Altius Auto/Workers Compensation |
$52.80
|
| Rate for Payer: Altius Commercial |
$52.80
|
| Rate for Payer: Beech Street Commercial |
$53.90
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$45.16
|
| Rate for Payer: Cash Price |
$38.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$53.35
|
| Rate for Payer: Cigna of WY Commercial |
$53.90
|
| Rate for Payer: Entrust Commercial |
$52.25
|
| Rate for Payer: First Choice Health Commercial |
$52.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$52.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$31.90
|
| Rate for Payer: HealthUtah PPO |
$55.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$53.35
|
| Rate for Payer: Multiplan Medicare/VA |
$30.30
|
| Rate for Payer: One Health Plan of WY PPO |
$53.90
|
| Rate for Payer: PacificSource Commercial |
$49.50
|
| Rate for Payer: PHCS PPO |
$53.90
|
| Rate for Payer: Three Rivers PPO |
$41.25
|
| Rate for Payer: TriWest Veterans Administration |
$31.90
|
| Rate for Payer: United Healthcare Commercial |
$47.85
|
| Rate for Payer: United Healthcare Medicare |
$31.90
|
| Rate for Payer: WINHealth Partners Commercial |
$53.90
|
| Rate for Payer: Wise Provider Network Commercial |
$52.25
|
|
|
IMMIGRATION PHYSICAL, INITIAL
|
Professional
|
Both
|
$100.00
|
|
|
Service Code
|
HCPCS TY016
|
| Hospital Charge Code |
TY016
|
| Min. Negotiated Rate |
$75.00 |
| Max. Negotiated Rate |
$100.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$98.00
|
| Rate for Payer: Beech Street Commercial |
$95.00
|
| Rate for Payer: Cash Price |
$70.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$97.00
|
| Rate for Payer: Cigna of WY Commercial |
$98.00
|
| Rate for Payer: First Choice Health Commercial |
$90.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$95.00
|
| Rate for Payer: HealthUtah PPO |
$100.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$97.00
|
| Rate for Payer: One Health Plan of WY PPO |
$98.00
|
| Rate for Payer: PacificSource Commercial |
$90.00
|
| Rate for Payer: PHCS PPO |
$95.00
|
| Rate for Payer: Three Rivers PPO |
$75.00
|
| Rate for Payer: United Healthcare Commercial |
$87.00
|
| Rate for Payer: WINHealth Partners Commercial |
$95.00
|
|
|
IMMOB SHOULDER LRG VP20102-040
|
Facility
|
IP
|
$12.74
|
|
| Hospital Charge Code |
27000000S1
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$7.99 |
| Max. Negotiated Rate |
$12.74 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$12.49
|
| Rate for Payer: Altius Auto/Workers Compensation |
$12.23
|
| Rate for Payer: Altius Commercial |
$12.23
|
| Rate for Payer: Beech Street Commercial |
$12.49
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$10.46
|
| Rate for Payer: Cash Price |
$8.92
|
| Rate for Payer: ChoiceCare Network Commercial |
$12.36
|
| Rate for Payer: Cigna of WY Commercial |
$12.49
|
| Rate for Payer: Entrust Commercial |
$12.10
|
| Rate for Payer: First Choice Health Commercial |
$12.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$12.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.41
|
| Rate for Payer: HealthUtah PPO |
$12.74
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$12.36
|
| Rate for Payer: Multiplan Medicare/VA |
$7.99
|
| Rate for Payer: One Health Plan of WY PPO |
$12.49
|
| Rate for Payer: PacificSource Commercial |
$11.47
|
| Rate for Payer: PHCS PPO |
$12.49
|
| Rate for Payer: Three Rivers PPO |
$9.56
|
| Rate for Payer: TriWest Veterans Administration |
$8.41
|
| Rate for Payer: United Healthcare Commercial |
$11.08
|
| Rate for Payer: United Healthcare Medicare |
$8.41
|
| Rate for Payer: WINHealth Partners Commercial |
$12.10
|
| Rate for Payer: Wise Provider Network Commercial |
$12.10
|
|
|
IMMOB SHOULDER LRG VP20102-040
|
Facility
|
OP
|
$12.74
|
|
| Hospital Charge Code |
27000000S1
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$7.02 |
| Max. Negotiated Rate |
$12.74 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$12.49
|
| Rate for Payer: Aetna of WY Medicare |
$8.41
|
| Rate for Payer: Altius Auto/Workers Compensation |
$12.23
|
| Rate for Payer: Altius Commercial |
$12.23
|
| Rate for Payer: Beech Street Commercial |
$12.49
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$10.46
|
| Rate for Payer: Cash Price |
$8.92
|
| Rate for Payer: ChoiceCare Network Commercial |
$12.36
|
| Rate for Payer: Cigna of WY Commercial |
$12.49
|
| Rate for Payer: Entrust Commercial |
$12.10
|
| Rate for Payer: First Choice Health Commercial |
$12.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$12.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$7.39
|
| Rate for Payer: HealthUtah PPO |
$12.74
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$12.36
|
| Rate for Payer: Multiplan Medicare/VA |
$7.02
|
| Rate for Payer: One Health Plan of WY PPO |
$12.49
|
| Rate for Payer: PacificSource Commercial |
$11.47
|
| Rate for Payer: PHCS PPO |
$12.49
|
| Rate for Payer: Three Rivers PPO |
$9.56
|
| Rate for Payer: TriWest Veterans Administration |
$7.39
|
| Rate for Payer: United Healthcare Commercial |
$11.08
|
| Rate for Payer: United Healthcare Medicare |
$7.39
|
| Rate for Payer: WINHealth Partners Commercial |
$12.49
|
| Rate for Payer: Wise Provider Network Commercial |
$12.10
|
|
|
IMMOB SHOULDER MED VP20102-030
|
Facility
|
OP
|
$23.80
|
|
| Hospital Charge Code |
27000000S1
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$13.11 |
| Max. Negotiated Rate |
$23.80 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$23.32
|
| Rate for Payer: Aetna of WY Medicare |
$15.71
|
| Rate for Payer: Altius Auto/Workers Compensation |
$22.85
|
| Rate for Payer: Altius Commercial |
$22.85
|
| Rate for Payer: Beech Street Commercial |
$23.32
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$19.54
|
| Rate for Payer: Cash Price |
$16.66
|
| Rate for Payer: ChoiceCare Network Commercial |
$23.09
|
| Rate for Payer: Cigna of WY Commercial |
$23.32
|
| Rate for Payer: Entrust Commercial |
$22.61
|
| Rate for Payer: First Choice Health Commercial |
$22.61
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$22.61
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$13.80
|
| Rate for Payer: HealthUtah PPO |
$23.80
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$23.09
|
| Rate for Payer: Multiplan Medicare/VA |
$13.11
|
| Rate for Payer: One Health Plan of WY PPO |
$23.32
|
| Rate for Payer: PacificSource Commercial |
$21.42
|
| Rate for Payer: PHCS PPO |
$23.32
|
| Rate for Payer: Three Rivers PPO |
$17.85
|
| Rate for Payer: TriWest Veterans Administration |
$13.80
|
| Rate for Payer: United Healthcare Commercial |
$20.71
|
| Rate for Payer: United Healthcare Medicare |
$13.80
|
| Rate for Payer: WINHealth Partners Commercial |
$23.32
|
| Rate for Payer: Wise Provider Network Commercial |
$22.61
|
|
|
IMMOB SHOULDER MED VP20102-030
|
Facility
|
IP
|
$23.80
|
|
| Hospital Charge Code |
27000000S1
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$14.92 |
| Max. Negotiated Rate |
$23.80 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$23.32
|
| Rate for Payer: Altius Auto/Workers Compensation |
$22.85
|
| Rate for Payer: Altius Commercial |
$22.85
|
| Rate for Payer: Beech Street Commercial |
$23.32
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$19.54
|
| Rate for Payer: Cash Price |
$16.66
|
| Rate for Payer: ChoiceCare Network Commercial |
$23.09
|
| Rate for Payer: Cigna of WY Commercial |
$23.32
|
| Rate for Payer: Entrust Commercial |
$22.61
|
| Rate for Payer: First Choice Health Commercial |
$22.61
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$22.61
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$15.71
|
| Rate for Payer: HealthUtah PPO |
$23.80
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$23.09
|
| Rate for Payer: Multiplan Medicare/VA |
$14.92
|
| Rate for Payer: One Health Plan of WY PPO |
$23.32
|
| Rate for Payer: PacificSource Commercial |
$21.42
|
| Rate for Payer: PHCS PPO |
$23.32
|
| Rate for Payer: Three Rivers PPO |
$17.85
|
| Rate for Payer: TriWest Veterans Administration |
$15.71
|
| Rate for Payer: United Healthcare Commercial |
$20.71
|
| Rate for Payer: United Healthcare Medicare |
$15.71
|
| Rate for Payer: WINHealth Partners Commercial |
$22.61
|
| Rate for Payer: Wise Provider Network Commercial |
$22.61
|
|
|
IMMOB SHOULDER SM VP20102-020
|
Facility
|
OP
|
$8.51
|
|
| Hospital Charge Code |
27000000S1
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$4.69 |
| Max. Negotiated Rate |
$8.51 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$8.34
|
| Rate for Payer: Aetna of WY Medicare |
$5.62
|
| Rate for Payer: Altius Auto/Workers Compensation |
$8.17
|
| Rate for Payer: Altius Commercial |
$8.17
|
| Rate for Payer: Beech Street Commercial |
$8.34
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$6.99
|
| Rate for Payer: Cash Price |
$5.95
|
| Rate for Payer: ChoiceCare Network Commercial |
$8.25
|
| Rate for Payer: Cigna of WY Commercial |
$8.34
|
| Rate for Payer: Entrust Commercial |
$8.08
|
| Rate for Payer: First Choice Health Commercial |
$8.08
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$8.08
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$4.94
|
| Rate for Payer: HealthUtah PPO |
$8.51
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$8.25
|
| Rate for Payer: Multiplan Medicare/VA |
$4.69
|
| Rate for Payer: One Health Plan of WY PPO |
$8.34
|
| Rate for Payer: PacificSource Commercial |
$7.66
|
| Rate for Payer: PHCS PPO |
$8.34
|
| Rate for Payer: Three Rivers PPO |
$6.38
|
| Rate for Payer: TriWest Veterans Administration |
$4.94
|
| Rate for Payer: United Healthcare Commercial |
$7.40
|
| Rate for Payer: United Healthcare Medicare |
$4.94
|
| Rate for Payer: WINHealth Partners Commercial |
$8.34
|
| Rate for Payer: Wise Provider Network Commercial |
$8.08
|
|
|
IMMOB SHOULDER SM VP20102-020
|
Facility
|
IP
|
$8.51
|
|
| Hospital Charge Code |
27000000S1
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$5.34 |
| Max. Negotiated Rate |
$8.51 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$8.34
|
| Rate for Payer: Altius Auto/Workers Compensation |
$8.17
|
| Rate for Payer: Altius Commercial |
$8.17
|
| Rate for Payer: Beech Street Commercial |
$8.34
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$6.99
|
| Rate for Payer: Cash Price |
$5.95
|
| Rate for Payer: ChoiceCare Network Commercial |
$8.25
|
| Rate for Payer: Cigna of WY Commercial |
$8.34
|
| Rate for Payer: Entrust Commercial |
$8.08
|
| Rate for Payer: First Choice Health Commercial |
$8.08
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$8.08
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$5.62
|
| Rate for Payer: HealthUtah PPO |
$8.51
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$8.25
|
| Rate for Payer: Multiplan Medicare/VA |
$5.34
|
| Rate for Payer: One Health Plan of WY PPO |
$8.34
|
| Rate for Payer: PacificSource Commercial |
$7.66
|
| Rate for Payer: PHCS PPO |
$8.34
|
| Rate for Payer: Three Rivers PPO |
$6.38
|
| Rate for Payer: TriWest Veterans Administration |
$5.62
|
| Rate for Payer: United Healthcare Commercial |
$7.40
|
| Rate for Payer: United Healthcare Medicare |
$5.62
|
| Rate for Payer: WINHealth Partners Commercial |
$8.08
|
| Rate for Payer: Wise Provider Network Commercial |
$8.08
|
|
|
IMMOB SHOULDER XLG 79-84168
|
Facility
|
OP
|
$12.74
|
|
| Hospital Charge Code |
27000000S1
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$7.02 |
| Max. Negotiated Rate |
$12.74 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$12.49
|
| Rate for Payer: Aetna of WY Medicare |
$8.41
|
| Rate for Payer: Altius Auto/Workers Compensation |
$12.23
|
| Rate for Payer: Altius Commercial |
$12.23
|
| Rate for Payer: Beech Street Commercial |
$12.49
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$10.46
|
| Rate for Payer: Cash Price |
$8.92
|
| Rate for Payer: ChoiceCare Network Commercial |
$12.36
|
| Rate for Payer: Cigna of WY Commercial |
$12.49
|
| Rate for Payer: Entrust Commercial |
$12.10
|
| Rate for Payer: First Choice Health Commercial |
$12.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$12.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$7.39
|
| Rate for Payer: HealthUtah PPO |
$12.74
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$12.36
|
| Rate for Payer: Multiplan Medicare/VA |
$7.02
|
| Rate for Payer: One Health Plan of WY PPO |
$12.49
|
| Rate for Payer: PacificSource Commercial |
$11.47
|
| Rate for Payer: PHCS PPO |
$12.49
|
| Rate for Payer: Three Rivers PPO |
$9.56
|
| Rate for Payer: TriWest Veterans Administration |
$7.39
|
| Rate for Payer: United Healthcare Commercial |
$11.08
|
| Rate for Payer: United Healthcare Medicare |
$7.39
|
| Rate for Payer: WINHealth Partners Commercial |
$12.49
|
| Rate for Payer: Wise Provider Network Commercial |
$12.10
|
|
|
IMMOB SHOULDER XLG 79-84168
|
Facility
|
IP
|
$12.74
|
|
| Hospital Charge Code |
27000000S1
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$7.99 |
| Max. Negotiated Rate |
$12.74 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$12.49
|
| Rate for Payer: Altius Auto/Workers Compensation |
$12.23
|
| Rate for Payer: Altius Commercial |
$12.23
|
| Rate for Payer: Beech Street Commercial |
$12.49
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$10.46
|
| Rate for Payer: Cash Price |
$8.92
|
| Rate for Payer: ChoiceCare Network Commercial |
$12.36
|
| Rate for Payer: Cigna of WY Commercial |
$12.49
|
| Rate for Payer: Entrust Commercial |
$12.10
|
| Rate for Payer: First Choice Health Commercial |
$12.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$12.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.41
|
| Rate for Payer: HealthUtah PPO |
$12.74
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$12.36
|
| Rate for Payer: Multiplan Medicare/VA |
$7.99
|
| Rate for Payer: One Health Plan of WY PPO |
$12.49
|
| Rate for Payer: PacificSource Commercial |
$11.47
|
| Rate for Payer: PHCS PPO |
$12.49
|
| Rate for Payer: Three Rivers PPO |
$9.56
|
| Rate for Payer: TriWest Veterans Administration |
$8.41
|
| Rate for Payer: United Healthcare Commercial |
$11.08
|
| Rate for Payer: United Healthcare Medicare |
$8.41
|
| Rate for Payer: WINHealth Partners Commercial |
$12.10
|
| Rate for Payer: Wise Provider Network Commercial |
$12.10
|
|
|
IMMUNE GLOB,GAMM(IGG)10 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION [137480]
|
Facility
|
OP
|
$57.03
|
|
|
Service Code
|
HCPCS J1568
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.42 |
| Max. Negotiated Rate |
$57.03 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$55.89
|
| Rate for Payer: Aetna of WY Medicare |
$37.64
|
| Rate for Payer: Altius Auto/Workers Compensation |
$54.75
|
| Rate for Payer: Altius Commercial |
$54.75
|
| Rate for Payer: Beech Street Commercial |
$55.89
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$46.82
|
| Rate for Payer: Cash Price |
$39.92
|
| Rate for Payer: ChoiceCare Network Commercial |
$55.32
|
| Rate for Payer: Cigna of WY Commercial |
$55.89
|
| Rate for Payer: Entrust Commercial |
$54.18
|
| Rate for Payer: First Choice Health Commercial |
$54.18
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$54.18
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$33.08
|
| Rate for Payer: HealthUtah PPO |
$57.03
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$55.32
|
| Rate for Payer: Multiplan Medicare/VA |
$31.42
|
| Rate for Payer: One Health Plan of WY PPO |
$55.89
|
| Rate for Payer: PacificSource Commercial |
$51.33
|
| Rate for Payer: PHCS PPO |
$55.89
|
| Rate for Payer: Three Rivers PPO |
$42.77
|
| Rate for Payer: TriWest Veterans Administration |
$33.08
|
| Rate for Payer: United Healthcare Commercial |
$49.62
|
| Rate for Payer: United Healthcare Medicare |
$33.08
|
| Rate for Payer: WINHealth Partners Commercial |
$55.89
|
| Rate for Payer: Wise Provider Network Commercial |
$54.18
|
|
|
IMMUNE GLOB,GAMM(IGG)10 %-MALT-IGA OVER 50 MCG/ML INTRAVENOUS SOLUTION [137480]
|
Facility
|
IP
|
$57.03
|
|
|
Service Code
|
HCPCS J1568
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.76 |
| Max. Negotiated Rate |
$57.03 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$55.89
|
| Rate for Payer: Altius Auto/Workers Compensation |
$54.75
|
| Rate for Payer: Altius Commercial |
$54.75
|
| Rate for Payer: Beech Street Commercial |
$55.89
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$46.82
|
| Rate for Payer: Cash Price |
$39.92
|
| Rate for Payer: ChoiceCare Network Commercial |
$55.32
|
| Rate for Payer: Cigna of WY Commercial |
$55.89
|
| Rate for Payer: Entrust Commercial |
$54.18
|
| Rate for Payer: First Choice Health Commercial |
$54.18
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$54.18
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$37.64
|
| Rate for Payer: HealthUtah PPO |
$57.03
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$55.32
|
| Rate for Payer: Multiplan Medicare/VA |
$35.76
|
| Rate for Payer: One Health Plan of WY PPO |
$55.89
|
| Rate for Payer: PacificSource Commercial |
$51.33
|
| Rate for Payer: PHCS PPO |
$55.89
|
| Rate for Payer: Three Rivers PPO |
$42.77
|
| Rate for Payer: TriWest Veterans Administration |
$37.64
|
| Rate for Payer: United Healthcare Commercial |
$49.62
|
| Rate for Payer: United Healthcare Medicare |
$37.64
|
| Rate for Payer: WINHealth Partners Commercial |
$54.18
|
| Rate for Payer: Wise Provider Network Commercial |
$54.18
|
|
|
IMMUNIZ ADMIN, IM/INTRANASAL, W COUNSEL, H1N1
|
Professional
|
Both
|
$37.00
|
|
|
Service Code
|
HCPCS 90470
|
| Hospital Charge Code |
90470
|
| Min. Negotiated Rate |
$27.75 |
| Max. Negotiated Rate |
$37.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$36.26
|
| Rate for Payer: Beech Street Commercial |
$35.15
|
| Rate for Payer: Cash Price |
$25.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$35.89
|
| Rate for Payer: Cigna of WY Commercial |
$36.26
|
| Rate for Payer: First Choice Health Commercial |
$33.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$35.15
|
| Rate for Payer: HealthUtah PPO |
$37.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$35.89
|
| Rate for Payer: One Health Plan of WY PPO |
$36.26
|
| Rate for Payer: PacificSource Commercial |
$33.30
|
| Rate for Payer: PHCS PPO |
$35.15
|
| Rate for Payer: Three Rivers PPO |
$27.75
|
| Rate for Payer: United Healthcare Commercial |
$32.19
|
| Rate for Payer: WINHealth Partners Commercial |
$35.15
|
|
|
IMMUNOASSAY ANALYTE QUAL/SEMIQUAN MULTIPLE STEP
|
Professional
|
Both
|
$200.00
|
|
|
Service Code
|
HCPCS 83516
|
| Hospital Charge Code |
83516
|
| Min. Negotiated Rate |
$9.80 |
| Max. Negotiated Rate |
$200.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$196.00
|
| Rate for Payer: Aetna of WY Medicare |
$11.53
|
| Rate for Payer: Beech Street Commercial |
$190.00
|
| Rate for Payer: Cash Price |
$140.00
|
| Rate for Payer: Cash Price |
$140.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$194.00
|
| Rate for Payer: Cigna of WY Commercial |
$196.00
|
| Rate for Payer: First Choice Health Commercial |
$180.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$190.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.53
|
| Rate for Payer: HealthUtah PPO |
$200.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$194.00
|
| Rate for Payer: Multiplan Medicare/VA |
$9.80
|
| Rate for Payer: One Health Plan of WY PPO |
$196.00
|
| Rate for Payer: PacificSource Commercial |
$180.00
|
| Rate for Payer: PHCS PPO |
$190.00
|
| Rate for Payer: Three Rivers PPO |
$150.00
|
| Rate for Payer: TriWest Veterans Administration |
$11.53
|
| Rate for Payer: United Healthcare Commercial |
$174.00
|
| Rate for Payer: United Healthcare Medicare |
$11.53
|
| Rate for Payer: WINHealth Partners Commercial |
$190.00
|
|
|
IMMUNOASSAY ANALYTE QUANTITATIVE NOS
|
Professional
|
Both
|
$283.00
|
|
|
Service Code
|
HCPCS 83520
|
| Hospital Charge Code |
83520
|
| Min. Negotiated Rate |
$14.68 |
| Max. Negotiated Rate |
$283.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$277.34
|
| Rate for Payer: Aetna of WY Medicare |
$17.27
|
| Rate for Payer: Beech Street Commercial |
$268.85
|
| Rate for Payer: Cash Price |
$198.10
|
| Rate for Payer: Cash Price |
$198.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$274.51
|
| Rate for Payer: Cigna of WY Commercial |
$277.34
|
| Rate for Payer: First Choice Health Commercial |
$254.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$268.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$17.27
|
| Rate for Payer: HealthUtah PPO |
$283.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$274.51
|
| Rate for Payer: Multiplan Medicare/VA |
$14.68
|
| Rate for Payer: One Health Plan of WY PPO |
$277.34
|
| Rate for Payer: PacificSource Commercial |
$254.70
|
| Rate for Payer: PHCS PPO |
$268.85
|
| Rate for Payer: Three Rivers PPO |
$212.25
|
| Rate for Payer: TriWest Veterans Administration |
$17.27
|
| Rate for Payer: United Healthcare Commercial |
$246.21
|
| Rate for Payer: United Healthcare Medicare |
$17.27
|
| Rate for Payer: WINHealth Partners Commercial |
$268.85
|
|
