|
INCISION EXTENSOR TENDON SHEATH WRIST
|
Professional
|
Both
|
$2,455.00
|
|
|
Service Code
|
HCPCS 25000 50
|
| Hospital Charge Code |
25000
|
| Min. Negotiated Rate |
$292.32 |
| Max. Negotiated Rate |
$2,455.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,405.90
|
| Rate for Payer: Aetna of WY Medicare |
$343.90
|
| Rate for Payer: Beech Street Commercial |
$2,332.25
|
| Rate for Payer: Cash Price |
$1,718.50
|
| Rate for Payer: Cash Price |
$1,718.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,381.35
|
| Rate for Payer: Cigna of WY Commercial |
$2,405.90
|
| Rate for Payer: First Choice Health Commercial |
$2,209.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,332.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$343.90
|
| Rate for Payer: HealthUtah PPO |
$2,455.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,381.35
|
| Rate for Payer: Multiplan Medicare/VA |
$292.32
|
| Rate for Payer: One Health Plan of WY PPO |
$2,405.90
|
| Rate for Payer: PacificSource Commercial |
$2,209.50
|
| Rate for Payer: PHCS PPO |
$2,332.25
|
| Rate for Payer: Three Rivers PPO |
$1,841.25
|
| Rate for Payer: TriWest Veterans Administration |
$343.90
|
| Rate for Payer: United Healthcare Commercial |
$2,135.85
|
| Rate for Payer: United Healthcare Medicare |
$343.90
|
| Rate for Payer: WINHealth Partners Commercial |
$2,086.75
|
|
|
INCISION LABIAL FRENUM FRENOTOMY
|
Professional
|
Both
|
$156.00
|
|
|
Service Code
|
HCPCS 40806
|
| Hospital Charge Code |
40806
|
| Min. Negotiated Rate |
$117.00 |
| Max. Negotiated Rate |
$156.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$152.88
|
| Rate for Payer: Beech Street Commercial |
$148.20
|
| Rate for Payer: Cash Price |
$109.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$151.32
|
| Rate for Payer: Cigna of WY Commercial |
$152.88
|
| Rate for Payer: First Choice Health Commercial |
$140.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$148.20
|
| Rate for Payer: HealthUtah PPO |
$156.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$151.32
|
| Rate for Payer: One Health Plan of WY PPO |
$152.88
|
| Rate for Payer: PacificSource Commercial |
$140.40
|
| Rate for Payer: PHCS PPO |
$148.20
|
| Rate for Payer: Three Rivers PPO |
$117.00
|
| Rate for Payer: United Healthcare Commercial |
$135.72
|
| Rate for Payer: WINHealth Partners Commercial |
$132.60
|
|
|
INCISION LINGUAL FRENUM FRENOTOMY
|
Professional
|
Both
|
$757.00
|
|
|
Service Code
|
HCPCS 41010
|
| Hospital Charge Code |
41010
|
| Min. Negotiated Rate |
$91.52 |
| Max. Negotiated Rate |
$757.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$741.86
|
| Rate for Payer: Aetna of WY Medicare |
$107.67
|
| Rate for Payer: Beech Street Commercial |
$719.15
|
| Rate for Payer: Cash Price |
$529.90
|
| Rate for Payer: Cash Price |
$529.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$734.29
|
| Rate for Payer: Cigna of WY Commercial |
$741.86
|
| Rate for Payer: First Choice Health Commercial |
$681.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$719.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$107.67
|
| Rate for Payer: HealthUtah PPO |
$757.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$734.29
|
| Rate for Payer: Multiplan Medicare/VA |
$91.52
|
| Rate for Payer: One Health Plan of WY PPO |
$741.86
|
| Rate for Payer: PacificSource Commercial |
$681.30
|
| Rate for Payer: PHCS PPO |
$719.15
|
| Rate for Payer: Three Rivers PPO |
$567.75
|
| Rate for Payer: TriWest Veterans Administration |
$107.67
|
| Rate for Payer: United Healthcare Commercial |
$658.59
|
| Rate for Payer: United Healthcare Medicare |
$107.67
|
| Rate for Payer: WINHealth Partners Commercial |
$643.45
|
|
|
INCISION & REMOVAL FOREIGN BODY SUBQ TISS COMP
|
Professional
|
Both
|
$927.00
|
|
|
Service Code
|
HCPCS 10121
|
| Hospital Charge Code |
10121
|
| Min. Negotiated Rate |
$150.73 |
| Max. Negotiated Rate |
$927.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$908.46
|
| Rate for Payer: Aetna of WY Medicare |
$177.33
|
| Rate for Payer: Beech Street Commercial |
$880.65
|
| Rate for Payer: Cash Price |
$648.90
|
| Rate for Payer: Cash Price |
$648.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$899.19
|
| Rate for Payer: Cigna of WY Commercial |
$908.46
|
| Rate for Payer: First Choice Health Commercial |
$834.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$880.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$177.33
|
| Rate for Payer: HealthUtah PPO |
$927.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$899.19
|
| Rate for Payer: Multiplan Medicare/VA |
$150.73
|
| Rate for Payer: One Health Plan of WY PPO |
$908.46
|
| Rate for Payer: PacificSource Commercial |
$834.30
|
| Rate for Payer: PHCS PPO |
$880.65
|
| Rate for Payer: Three Rivers PPO |
$695.25
|
| Rate for Payer: TriWest Veterans Administration |
$177.33
|
| Rate for Payer: United Healthcare Commercial |
$806.49
|
| Rate for Payer: United Healthcare Medicare |
$177.33
|
| Rate for Payer: WINHealth Partners Commercial |
$787.95
|
|
|
INCISION & REMOVAL FOREIGN BODY SUBQ TISS SIMPLE
|
Professional
|
Both
|
$514.00
|
|
|
Service Code
|
HCPCS 10120
|
| Hospital Charge Code |
10120
|
| Min. Negotiated Rate |
$87.69 |
| Max. Negotiated Rate |
$514.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$503.72
|
| Rate for Payer: Aetna of WY Medicare |
$103.17
|
| Rate for Payer: Beech Street Commercial |
$488.30
|
| Rate for Payer: Cash Price |
$359.80
|
| Rate for Payer: Cash Price |
$359.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$498.58
|
| Rate for Payer: Cigna of WY Commercial |
$503.72
|
| Rate for Payer: First Choice Health Commercial |
$462.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$488.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$103.17
|
| Rate for Payer: HealthUtah PPO |
$514.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$498.58
|
| Rate for Payer: Multiplan Medicare/VA |
$87.69
|
| Rate for Payer: One Health Plan of WY PPO |
$503.72
|
| Rate for Payer: PacificSource Commercial |
$462.60
|
| Rate for Payer: PHCS PPO |
$488.30
|
| Rate for Payer: Three Rivers PPO |
$385.50
|
| Rate for Payer: TriWest Veterans Administration |
$103.17
|
| Rate for Payer: United Healthcare Commercial |
$447.18
|
| Rate for Payer: United Healthcare Medicare |
$103.17
|
| Rate for Payer: WINHealth Partners Commercial |
$436.90
|
|
|
INCISION THROMBOSED HEMORRHOID EXTERNAL
|
Professional
|
Both
|
$562.00
|
|
|
Service Code
|
HCPCS 46083
|
| Hospital Charge Code |
46083
|
| Min. Negotiated Rate |
$90.72 |
| Max. Negotiated Rate |
$562.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$550.76
|
| Rate for Payer: Aetna of WY Medicare |
$106.73
|
| Rate for Payer: Beech Street Commercial |
$533.90
|
| Rate for Payer: Cash Price |
$393.40
|
| Rate for Payer: Cash Price |
$393.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$545.14
|
| Rate for Payer: Cigna of WY Commercial |
$550.76
|
| Rate for Payer: First Choice Health Commercial |
$505.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$533.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$106.73
|
| Rate for Payer: HealthUtah PPO |
$562.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$545.14
|
| Rate for Payer: Multiplan Medicare/VA |
$90.72
|
| Rate for Payer: One Health Plan of WY PPO |
$550.76
|
| Rate for Payer: PacificSource Commercial |
$505.80
|
| Rate for Payer: PHCS PPO |
$533.90
|
| Rate for Payer: Three Rivers PPO |
$421.50
|
| Rate for Payer: TriWest Veterans Administration |
$106.73
|
| Rate for Payer: United Healthcare Commercial |
$488.94
|
| Rate for Payer: United Healthcare Medicare |
$106.73
|
| Rate for Payer: WINHealth Partners Commercial |
$477.70
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION [19092]
|
Facility
|
OP
|
$269.69
|
|
|
Service Code
|
NDC 7010042402
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$148.60 |
| Max. Negotiated Rate |
$269.69 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$264.30
|
| Rate for Payer: Aetna of WY Medicare |
$178.00
|
| Rate for Payer: Altius Auto/Workers Compensation |
$258.90
|
| Rate for Payer: Altius Commercial |
$258.90
|
| Rate for Payer: Beech Street Commercial |
$264.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$221.42
|
| Rate for Payer: Cash Price |
$188.78
|
| Rate for Payer: ChoiceCare Network Commercial |
$261.60
|
| Rate for Payer: Cigna of WY Commercial |
$264.30
|
| Rate for Payer: Entrust Commercial |
$256.21
|
| Rate for Payer: First Choice Health Commercial |
$256.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$256.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$156.42
|
| Rate for Payer: HealthUtah PPO |
$269.69
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$261.60
|
| Rate for Payer: Multiplan Medicare/VA |
$148.60
|
| Rate for Payer: One Health Plan of WY PPO |
$264.30
|
| Rate for Payer: PacificSource Commercial |
$242.72
|
| Rate for Payer: PHCS PPO |
$264.30
|
| Rate for Payer: Three Rivers PPO |
$202.27
|
| Rate for Payer: TriWest Veterans Administration |
$156.42
|
| Rate for Payer: United Healthcare Commercial |
$234.63
|
| Rate for Payer: United Healthcare Medicare |
$156.42
|
| Rate for Payer: WINHealth Partners Commercial |
$264.30
|
| Rate for Payer: Wise Provider Network Commercial |
$256.21
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION [19092]
|
Facility
|
OP
|
$269.69
|
|
|
Service Code
|
NDC 7010042401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$148.60 |
| Max. Negotiated Rate |
$269.69 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$264.30
|
| Rate for Payer: Aetna of WY Medicare |
$178.00
|
| Rate for Payer: Altius Auto/Workers Compensation |
$258.90
|
| Rate for Payer: Altius Commercial |
$258.90
|
| Rate for Payer: Beech Street Commercial |
$264.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$221.42
|
| Rate for Payer: Cash Price |
$188.78
|
| Rate for Payer: ChoiceCare Network Commercial |
$261.60
|
| Rate for Payer: Cigna of WY Commercial |
$264.30
|
| Rate for Payer: Entrust Commercial |
$256.21
|
| Rate for Payer: First Choice Health Commercial |
$256.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$256.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$156.42
|
| Rate for Payer: HealthUtah PPO |
$269.69
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$261.60
|
| Rate for Payer: Multiplan Medicare/VA |
$148.60
|
| Rate for Payer: One Health Plan of WY PPO |
$264.30
|
| Rate for Payer: PacificSource Commercial |
$242.72
|
| Rate for Payer: PHCS PPO |
$264.30
|
| Rate for Payer: Three Rivers PPO |
$202.27
|
| Rate for Payer: TriWest Veterans Administration |
$156.42
|
| Rate for Payer: United Healthcare Commercial |
$234.63
|
| Rate for Payer: United Healthcare Medicare |
$156.42
|
| Rate for Payer: WINHealth Partners Commercial |
$264.30
|
| Rate for Payer: Wise Provider Network Commercial |
$256.21
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION [19092]
|
Facility
|
IP
|
$269.69
|
|
|
Service Code
|
NDC 7010042402
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$169.10 |
| Max. Negotiated Rate |
$269.69 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$264.30
|
| Rate for Payer: Altius Auto/Workers Compensation |
$258.90
|
| Rate for Payer: Altius Commercial |
$258.90
|
| Rate for Payer: Beech Street Commercial |
$264.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$221.42
|
| Rate for Payer: Cash Price |
$188.78
|
| Rate for Payer: ChoiceCare Network Commercial |
$261.60
|
| Rate for Payer: Cigna of WY Commercial |
$264.30
|
| Rate for Payer: Entrust Commercial |
$256.21
|
| Rate for Payer: First Choice Health Commercial |
$256.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$256.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$178.00
|
| Rate for Payer: HealthUtah PPO |
$269.69
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$261.60
|
| Rate for Payer: Multiplan Medicare/VA |
$169.10
|
| Rate for Payer: One Health Plan of WY PPO |
$264.30
|
| Rate for Payer: PacificSource Commercial |
$242.72
|
| Rate for Payer: PHCS PPO |
$264.30
|
| Rate for Payer: Three Rivers PPO |
$202.27
|
| Rate for Payer: TriWest Veterans Administration |
$178.00
|
| Rate for Payer: United Healthcare Commercial |
$234.63
|
| Rate for Payer: United Healthcare Medicare |
$178.00
|
| Rate for Payer: WINHealth Partners Commercial |
$256.21
|
| Rate for Payer: Wise Provider Network Commercial |
$256.21
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION [19092]
|
Facility
|
IP
|
$269.69
|
|
|
Service Code
|
NDC 7010042401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$169.10 |
| Max. Negotiated Rate |
$269.69 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$264.30
|
| Rate for Payer: Altius Auto/Workers Compensation |
$258.90
|
| Rate for Payer: Altius Commercial |
$258.90
|
| Rate for Payer: Beech Street Commercial |
$264.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$221.42
|
| Rate for Payer: Cash Price |
$188.78
|
| Rate for Payer: ChoiceCare Network Commercial |
$261.60
|
| Rate for Payer: Cigna of WY Commercial |
$264.30
|
| Rate for Payer: Entrust Commercial |
$256.21
|
| Rate for Payer: First Choice Health Commercial |
$256.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$256.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$178.00
|
| Rate for Payer: HealthUtah PPO |
$269.69
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$261.60
|
| Rate for Payer: Multiplan Medicare/VA |
$169.10
|
| Rate for Payer: One Health Plan of WY PPO |
$264.30
|
| Rate for Payer: PacificSource Commercial |
$242.72
|
| Rate for Payer: PHCS PPO |
$264.30
|
| Rate for Payer: Three Rivers PPO |
$202.27
|
| Rate for Payer: TriWest Veterans Administration |
$178.00
|
| Rate for Payer: United Healthcare Commercial |
$234.63
|
| Rate for Payer: United Healthcare Medicare |
$178.00
|
| Rate for Payer: WINHealth Partners Commercial |
$256.21
|
| Rate for Payer: Wise Provider Network Commercial |
$256.21
|
|
|
INDOMETHACIN 25 MG CAPSULE [13749]
|
Facility
|
IP
|
$1.43
|
|
|
Service Code
|
NDC 5026843011
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.90 |
| Max. Negotiated Rate |
$1.43 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.40
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.37
|
| Rate for Payer: Altius Commercial |
$1.37
|
| Rate for Payer: Beech Street Commercial |
$1.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.17
|
| Rate for Payer: Cash Price |
$1.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.39
|
| Rate for Payer: Cigna of WY Commercial |
$1.40
|
| Rate for Payer: Entrust Commercial |
$1.36
|
| Rate for Payer: First Choice Health Commercial |
$1.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.94
|
| Rate for Payer: HealthUtah PPO |
$1.43
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.39
|
| Rate for Payer: Multiplan Medicare/VA |
$0.90
|
| Rate for Payer: One Health Plan of WY PPO |
$1.40
|
| Rate for Payer: PacificSource Commercial |
$1.29
|
| Rate for Payer: PHCS PPO |
$1.40
|
| Rate for Payer: Three Rivers PPO |
$1.07
|
| Rate for Payer: TriWest Veterans Administration |
$0.94
|
| Rate for Payer: United Healthcare Commercial |
$1.24
|
| Rate for Payer: United Healthcare Medicare |
$0.94
|
| Rate for Payer: WINHealth Partners Commercial |
$1.36
|
| Rate for Payer: Wise Provider Network Commercial |
$1.36
|
|
|
INDOMETHACIN 25 MG CAPSULE [13749]
|
Facility
|
OP
|
$1.43
|
|
|
Service Code
|
NDC 5026843015
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$1.43 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.40
|
| Rate for Payer: Aetna of WY Medicare |
$0.94
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.37
|
| Rate for Payer: Altius Commercial |
$1.37
|
| Rate for Payer: Beech Street Commercial |
$1.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.17
|
| Rate for Payer: Cash Price |
$1.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.39
|
| Rate for Payer: Cigna of WY Commercial |
$1.40
|
| Rate for Payer: Entrust Commercial |
$1.36
|
| Rate for Payer: First Choice Health Commercial |
$1.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.83
|
| Rate for Payer: HealthUtah PPO |
$1.43
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.39
|
| Rate for Payer: Multiplan Medicare/VA |
$0.79
|
| Rate for Payer: One Health Plan of WY PPO |
$1.40
|
| Rate for Payer: PacificSource Commercial |
$1.29
|
| Rate for Payer: PHCS PPO |
$1.40
|
| Rate for Payer: Three Rivers PPO |
$1.07
|
| Rate for Payer: TriWest Veterans Administration |
$0.83
|
| Rate for Payer: United Healthcare Commercial |
$1.24
|
| Rate for Payer: United Healthcare Medicare |
$0.83
|
| Rate for Payer: WINHealth Partners Commercial |
$1.40
|
| Rate for Payer: Wise Provider Network Commercial |
$1.36
|
|
|
INDOMETHACIN 25 MG CAPSULE [13749]
|
Facility
|
IP
|
$1.43
|
|
|
Service Code
|
NDC 5026843015
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.90 |
| Max. Negotiated Rate |
$1.43 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.40
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.37
|
| Rate for Payer: Altius Commercial |
$1.37
|
| Rate for Payer: Beech Street Commercial |
$1.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.17
|
| Rate for Payer: Cash Price |
$1.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.39
|
| Rate for Payer: Cigna of WY Commercial |
$1.40
|
| Rate for Payer: Entrust Commercial |
$1.36
|
| Rate for Payer: First Choice Health Commercial |
$1.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.94
|
| Rate for Payer: HealthUtah PPO |
$1.43
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.39
|
| Rate for Payer: Multiplan Medicare/VA |
$0.90
|
| Rate for Payer: One Health Plan of WY PPO |
$1.40
|
| Rate for Payer: PacificSource Commercial |
$1.29
|
| Rate for Payer: PHCS PPO |
$1.40
|
| Rate for Payer: Three Rivers PPO |
$1.07
|
| Rate for Payer: TriWest Veterans Administration |
$0.94
|
| Rate for Payer: United Healthcare Commercial |
$1.24
|
| Rate for Payer: United Healthcare Medicare |
$0.94
|
| Rate for Payer: WINHealth Partners Commercial |
$1.36
|
| Rate for Payer: Wise Provider Network Commercial |
$1.36
|
|
|
INDOMETHACIN 25 MG CAPSULE [13749]
|
Facility
|
OP
|
$1.43
|
|
|
Service Code
|
NDC 5026843011
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$1.43 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.40
|
| Rate for Payer: Aetna of WY Medicare |
$0.94
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.37
|
| Rate for Payer: Altius Commercial |
$1.37
|
| Rate for Payer: Beech Street Commercial |
$1.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.17
|
| Rate for Payer: Cash Price |
$1.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.39
|
| Rate for Payer: Cigna of WY Commercial |
$1.40
|
| Rate for Payer: Entrust Commercial |
$1.36
|
| Rate for Payer: First Choice Health Commercial |
$1.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.83
|
| Rate for Payer: HealthUtah PPO |
$1.43
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.39
|
| Rate for Payer: Multiplan Medicare/VA |
$0.79
|
| Rate for Payer: One Health Plan of WY PPO |
$1.40
|
| Rate for Payer: PacificSource Commercial |
$1.29
|
| Rate for Payer: PHCS PPO |
$1.40
|
| Rate for Payer: Three Rivers PPO |
$1.07
|
| Rate for Payer: TriWest Veterans Administration |
$0.83
|
| Rate for Payer: United Healthcare Commercial |
$1.24
|
| Rate for Payer: United Healthcare Medicare |
$0.83
|
| Rate for Payer: WINHealth Partners Commercial |
$1.40
|
| Rate for Payer: Wise Provider Network Commercial |
$1.36
|
|
|
INDUCED ABORT 1/> VAG SUPPOSITORIES DLVR FETUS
|
Professional
|
Both
|
$1,239.00
|
|
|
Service Code
|
HCPCS 59855
|
| Hospital Charge Code |
59855
|
| Min. Negotiated Rate |
$345.21 |
| Max. Negotiated Rate |
$1,239.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,214.22
|
| Rate for Payer: Aetna of WY Medicare |
$406.13
|
| Rate for Payer: Beech Street Commercial |
$1,177.05
|
| Rate for Payer: Cash Price |
$867.30
|
| Rate for Payer: Cash Price |
$867.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,201.83
|
| Rate for Payer: Cigna of WY Commercial |
$1,214.22
|
| Rate for Payer: First Choice Health Commercial |
$1,115.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,177.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$406.13
|
| Rate for Payer: HealthUtah PPO |
$1,239.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,201.83
|
| Rate for Payer: Multiplan Medicare/VA |
$345.21
|
| Rate for Payer: One Health Plan of WY PPO |
$1,214.22
|
| Rate for Payer: PacificSource Commercial |
$1,115.10
|
| Rate for Payer: PHCS PPO |
$1,177.05
|
| Rate for Payer: Three Rivers PPO |
$929.25
|
| Rate for Payer: TriWest Veterans Administration |
$406.13
|
| Rate for Payer: United Healthcare Commercial |
$1,077.93
|
| Rate for Payer: United Healthcare Medicare |
$406.13
|
| Rate for Payer: WINHealth Partners Commercial |
$1,053.15
|
|
|
INDWELLING PRESS MONITORS
|
Facility
|
IP
|
$523.54
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$328.26 |
| Max. Negotiated Rate |
$523.54 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$513.07
|
| Rate for Payer: Altius Auto/Workers Compensation |
$502.60
|
| Rate for Payer: Altius Commercial |
$502.60
|
| Rate for Payer: Beech Street Commercial |
$513.07
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$429.83
|
| Rate for Payer: Cash Price |
$366.48
|
| Rate for Payer: ChoiceCare Network Commercial |
$507.83
|
| Rate for Payer: Cigna of WY Commercial |
$513.07
|
| Rate for Payer: Entrust Commercial |
$497.36
|
| Rate for Payer: First Choice Health Commercial |
$497.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$497.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$345.54
|
| Rate for Payer: HealthUtah PPO |
$523.54
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$507.83
|
| Rate for Payer: Multiplan Medicare/VA |
$328.26
|
| Rate for Payer: One Health Plan of WY PPO |
$513.07
|
| Rate for Payer: PacificSource Commercial |
$471.19
|
| Rate for Payer: PHCS PPO |
$513.07
|
| Rate for Payer: Three Rivers PPO |
$392.66
|
| Rate for Payer: TriWest Veterans Administration |
$345.54
|
| Rate for Payer: United Healthcare Commercial |
$455.48
|
| Rate for Payer: United Healthcare Medicare |
$345.54
|
| Rate for Payer: WINHealth Partners Commercial |
$497.36
|
| Rate for Payer: Wise Provider Network Commercial |
$497.36
|
|
|
INDWELLING PRESS MONITORS
|
Facility
|
OP
|
$523.54
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$288.47 |
| Max. Negotiated Rate |
$523.54 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$513.07
|
| Rate for Payer: Aetna of WY Medicare |
$345.54
|
| Rate for Payer: Altius Auto/Workers Compensation |
$502.60
|
| Rate for Payer: Altius Commercial |
$502.60
|
| Rate for Payer: Beech Street Commercial |
$513.07
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$429.83
|
| Rate for Payer: Cash Price |
$366.48
|
| Rate for Payer: ChoiceCare Network Commercial |
$507.83
|
| Rate for Payer: Cigna of WY Commercial |
$513.07
|
| Rate for Payer: Entrust Commercial |
$497.36
|
| Rate for Payer: First Choice Health Commercial |
$497.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$497.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$303.65
|
| Rate for Payer: HealthUtah PPO |
$523.54
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$507.83
|
| Rate for Payer: Multiplan Medicare/VA |
$288.47
|
| Rate for Payer: One Health Plan of WY PPO |
$513.07
|
| Rate for Payer: PacificSource Commercial |
$471.19
|
| Rate for Payer: PHCS PPO |
$513.07
|
| Rate for Payer: Three Rivers PPO |
$392.66
|
| Rate for Payer: TriWest Veterans Administration |
$303.65
|
| Rate for Payer: United Healthcare Commercial |
$455.48
|
| Rate for Payer: United Healthcare Medicare |
$303.65
|
| Rate for Payer: WINHealth Partners Commercial |
$513.07
|
| Rate for Payer: Wise Provider Network Commercial |
$497.36
|
|
|
INFANT SKIN TEMP PROBE PANDA
|
Facility
|
IP
|
$32.15
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$20.16 |
| Max. Negotiated Rate |
$32.15 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$31.51
|
| Rate for Payer: Altius Auto/Workers Compensation |
$30.86
|
| Rate for Payer: Altius Commercial |
$30.86
|
| Rate for Payer: Beech Street Commercial |
$31.51
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$26.40
|
| Rate for Payer: Cash Price |
$22.51
|
| Rate for Payer: ChoiceCare Network Commercial |
$31.19
|
| Rate for Payer: Cigna of WY Commercial |
$31.51
|
| Rate for Payer: Entrust Commercial |
$30.54
|
| Rate for Payer: First Choice Health Commercial |
$30.54
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$30.54
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$21.22
|
| Rate for Payer: HealthUtah PPO |
$32.15
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$31.19
|
| Rate for Payer: Multiplan Medicare/VA |
$20.16
|
| Rate for Payer: One Health Plan of WY PPO |
$31.51
|
| Rate for Payer: PacificSource Commercial |
$28.94
|
| Rate for Payer: PHCS PPO |
$31.51
|
| Rate for Payer: Three Rivers PPO |
$24.11
|
| Rate for Payer: TriWest Veterans Administration |
$21.22
|
| Rate for Payer: United Healthcare Commercial |
$27.97
|
| Rate for Payer: United Healthcare Medicare |
$21.22
|
| Rate for Payer: WINHealth Partners Commercial |
$30.54
|
| Rate for Payer: Wise Provider Network Commercial |
$30.54
|
|
|
INFANT SKIN TEMP PROBE PANDA
|
Facility
|
OP
|
$32.15
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$17.71 |
| Max. Negotiated Rate |
$32.15 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$31.51
|
| Rate for Payer: Aetna of WY Medicare |
$21.22
|
| Rate for Payer: Altius Auto/Workers Compensation |
$30.86
|
| Rate for Payer: Altius Commercial |
$30.86
|
| Rate for Payer: Beech Street Commercial |
$31.51
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$26.40
|
| Rate for Payer: Cash Price |
$22.51
|
| Rate for Payer: ChoiceCare Network Commercial |
$31.19
|
| Rate for Payer: Cigna of WY Commercial |
$31.51
|
| Rate for Payer: Entrust Commercial |
$30.54
|
| Rate for Payer: First Choice Health Commercial |
$30.54
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$30.54
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$18.65
|
| Rate for Payer: HealthUtah PPO |
$32.15
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$31.19
|
| Rate for Payer: Multiplan Medicare/VA |
$17.71
|
| Rate for Payer: One Health Plan of WY PPO |
$31.51
|
| Rate for Payer: PacificSource Commercial |
$28.94
|
| Rate for Payer: PHCS PPO |
$31.51
|
| Rate for Payer: Three Rivers PPO |
$24.11
|
| Rate for Payer: TriWest Veterans Administration |
$18.65
|
| Rate for Payer: United Healthcare Commercial |
$27.97
|
| Rate for Payer: United Healthcare Medicare |
$18.65
|
| Rate for Payer: WINHealth Partners Commercial |
$31.51
|
| Rate for Payer: Wise Provider Network Commercial |
$30.54
|
|
|
INFECTIOUS AGENT DNA/RNA INFLUENZA 1ST 2 TYPES
|
Professional
|
Both
|
$153.00
|
|
|
Service Code
|
HCPCS 87502
|
| Hospital Charge Code |
87502
|
| Min. Negotiated Rate |
$81.43 |
| Max. Negotiated Rate |
$153.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$149.94
|
| Rate for Payer: Aetna of WY Medicare |
$95.80
|
| Rate for Payer: Beech Street Commercial |
$145.35
|
| Rate for Payer: Cash Price |
$107.10
|
| Rate for Payer: Cash Price |
$107.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$148.41
|
| Rate for Payer: Cigna of WY Commercial |
$149.94
|
| Rate for Payer: First Choice Health Commercial |
$137.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$145.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$95.80
|
| Rate for Payer: HealthUtah PPO |
$153.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$148.41
|
| Rate for Payer: Multiplan Medicare/VA |
$81.43
|
| Rate for Payer: One Health Plan of WY PPO |
$149.94
|
| Rate for Payer: PacificSource Commercial |
$137.70
|
| Rate for Payer: PHCS PPO |
$145.35
|
| Rate for Payer: Three Rivers PPO |
$114.75
|
| Rate for Payer: TriWest Veterans Administration |
$95.80
|
| Rate for Payer: United Healthcare Commercial |
$133.11
|
| Rate for Payer: United Healthcare Medicare |
$95.80
|
| Rate for Payer: WINHealth Partners Commercial |
$145.35
|
|
|
INFECTIOUS AGENT ENZYMATIC ACTV OTH/THN VIRUS
|
Professional
|
Both
|
$66.00
|
|
|
Service Code
|
HCPCS 87905
|
| Hospital Charge Code |
87905
|
| Min. Negotiated Rate |
$10.39 |
| Max. Negotiated Rate |
$66.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$64.68
|
| Rate for Payer: Aetna of WY Medicare |
$12.22
|
| Rate for Payer: Beech Street Commercial |
$62.70
|
| Rate for Payer: Cash Price |
$46.20
|
| Rate for Payer: Cash Price |
$46.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$64.02
|
| Rate for Payer: Cigna of WY Commercial |
$64.68
|
| Rate for Payer: First Choice Health Commercial |
$59.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$62.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$12.22
|
| Rate for Payer: HealthUtah PPO |
$66.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$64.02
|
| Rate for Payer: Multiplan Medicare/VA |
$10.39
|
| Rate for Payer: One Health Plan of WY PPO |
$64.68
|
| Rate for Payer: PacificSource Commercial |
$59.40
|
| Rate for Payer: PHCS PPO |
$62.70
|
| Rate for Payer: Three Rivers PPO |
$49.50
|
| Rate for Payer: TriWest Veterans Administration |
$12.22
|
| Rate for Payer: United Healthcare Commercial |
$57.42
|
| Rate for Payer: United Healthcare Medicare |
$12.22
|
| Rate for Payer: WINHealth Partners Commercial |
$62.70
|
|
|
INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION [141161]
|
Facility
|
IP
|
$961.28
|
|
|
Service Code
|
HCPCS Q5103
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$602.72 |
| Max. Negotiated Rate |
$961.28 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$942.05
|
| Rate for Payer: Altius Auto/Workers Compensation |
$922.83
|
| Rate for Payer: Altius Commercial |
$922.83
|
| Rate for Payer: Beech Street Commercial |
$942.05
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$789.21
|
| Rate for Payer: Cash Price |
$672.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$932.44
|
| Rate for Payer: Cigna of WY Commercial |
$942.05
|
| Rate for Payer: Entrust Commercial |
$913.22
|
| Rate for Payer: First Choice Health Commercial |
$913.22
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$913.22
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$634.44
|
| Rate for Payer: HealthUtah PPO |
$961.28
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$932.44
|
| Rate for Payer: Multiplan Medicare/VA |
$602.72
|
| Rate for Payer: One Health Plan of WY PPO |
$942.05
|
| Rate for Payer: PacificSource Commercial |
$865.15
|
| Rate for Payer: PHCS PPO |
$942.05
|
| Rate for Payer: Three Rivers PPO |
$720.96
|
| Rate for Payer: TriWest Veterans Administration |
$634.44
|
| Rate for Payer: United Healthcare Commercial |
$836.31
|
| Rate for Payer: United Healthcare Medicare |
$634.44
|
| Rate for Payer: WINHealth Partners Commercial |
$913.22
|
| Rate for Payer: Wise Provider Network Commercial |
$913.22
|
|
|
INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION [141161]
|
Facility
|
OP
|
$961.28
|
|
|
Service Code
|
HCPCS Q5103
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$529.67 |
| Max. Negotiated Rate |
$961.28 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$942.05
|
| Rate for Payer: Aetna of WY Medicare |
$634.44
|
| Rate for Payer: Altius Auto/Workers Compensation |
$922.83
|
| Rate for Payer: Altius Commercial |
$922.83
|
| Rate for Payer: Beech Street Commercial |
$942.05
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$789.21
|
| Rate for Payer: Cash Price |
$672.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$932.44
|
| Rate for Payer: Cigna of WY Commercial |
$942.05
|
| Rate for Payer: Entrust Commercial |
$913.22
|
| Rate for Payer: First Choice Health Commercial |
$913.22
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$913.22
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$557.54
|
| Rate for Payer: HealthUtah PPO |
$961.28
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$932.44
|
| Rate for Payer: Multiplan Medicare/VA |
$529.67
|
| Rate for Payer: One Health Plan of WY PPO |
$942.05
|
| Rate for Payer: PacificSource Commercial |
$865.15
|
| Rate for Payer: PHCS PPO |
$942.05
|
| Rate for Payer: Three Rivers PPO |
$720.96
|
| Rate for Payer: TriWest Veterans Administration |
$557.54
|
| Rate for Payer: United Healthcare Commercial |
$836.31
|
| Rate for Payer: United Healthcare Medicare |
$557.54
|
| Rate for Payer: WINHealth Partners Commercial |
$942.05
|
| Rate for Payer: Wise Provider Network Commercial |
$913.22
|
|
|
INFLUENZA VIRUS VACCINE, NOS
|
Professional
|
Both
|
$37.00
|
|
|
Service Code
|
HCPCS Q2039
|
| Hospital Charge Code |
Q2039
|
| Min. Negotiated Rate |
$20.00 |
| 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: 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: TriWest Veterans Administration |
$20.00
|
| Rate for Payer: United Healthcare Commercial |
$32.19
|
| Rate for Payer: WINHealth Partners Commercial |
$35.15
|
|
|
INFUSOR BAG 1L
|
Facility
|
OP
|
$20.56
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$11.33 |
| Max. Negotiated Rate |
$20.56 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$20.15
|
| Rate for Payer: Aetna of WY Medicare |
$13.57
|
| Rate for Payer: Altius Auto/Workers Compensation |
$19.74
|
| Rate for Payer: Altius Commercial |
$19.74
|
| Rate for Payer: Beech Street Commercial |
$20.15
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.88
|
| Rate for Payer: Cash Price |
$14.39
|
| Rate for Payer: ChoiceCare Network Commercial |
$19.94
|
| Rate for Payer: Cigna of WY Commercial |
$20.15
|
| Rate for Payer: Entrust Commercial |
$19.53
|
| Rate for Payer: First Choice Health Commercial |
$19.53
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$19.53
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.92
|
| Rate for Payer: HealthUtah PPO |
$20.56
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$19.94
|
| Rate for Payer: Multiplan Medicare/VA |
$11.33
|
| Rate for Payer: One Health Plan of WY PPO |
$20.15
|
| Rate for Payer: PacificSource Commercial |
$18.50
|
| Rate for Payer: PHCS PPO |
$20.15
|
| Rate for Payer: Three Rivers PPO |
$15.42
|
| Rate for Payer: TriWest Veterans Administration |
$11.92
|
| Rate for Payer: United Healthcare Commercial |
$17.89
|
| Rate for Payer: United Healthcare Medicare |
$11.92
|
| Rate for Payer: WINHealth Partners Commercial |
$20.15
|
| Rate for Payer: Wise Provider Network Commercial |
$19.53
|
|
