|
LACTOSE-REDUCED FOOD WITH FIBER 0.04 GRAM-1.06 KCAL/ML ORAL LIQUID [146583]
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 7007464758
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.02
|
| Rate for Payer: Aetna of WY Medicare |
$0.01
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.02
|
| Rate for Payer: Altius Commercial |
$0.02
|
| Rate for Payer: Beech Street Commercial |
$0.02
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.02
|
| Rate for Payer: Cigna of WY Commercial |
$0.02
|
| Rate for Payer: Entrust Commercial |
$0.02
|
| Rate for Payer: First Choice Health Commercial |
$0.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.01
|
| Rate for Payer: HealthUtah PPO |
$0.02
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.02
|
| Rate for Payer: Multiplan Medicare/VA |
$0.01
|
| Rate for Payer: One Health Plan of WY PPO |
$0.02
|
| Rate for Payer: PacificSource Commercial |
$0.02
|
| Rate for Payer: PHCS PPO |
$0.02
|
| Rate for Payer: Three Rivers PPO |
$0.02
|
| Rate for Payer: TriWest Veterans Administration |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.02
|
| Rate for Payer: United Healthcare Medicare |
$0.01
|
| Rate for Payer: WINHealth Partners Commercial |
$0.02
|
| Rate for Payer: Wise Provider Network Commercial |
$0.02
|
|
|
LACTOSE-REDUCED FOOD WITH FIBER 0.04 GRAM-1.06 KCAL/ML ORAL LIQUID [146583]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 7007464758
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.02
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.02
|
| Rate for Payer: Altius Commercial |
$0.02
|
| Rate for Payer: Beech Street Commercial |
$0.02
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.02
|
| Rate for Payer: Cigna of WY Commercial |
$0.02
|
| Rate for Payer: Entrust Commercial |
$0.02
|
| Rate for Payer: First Choice Health Commercial |
$0.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.01
|
| Rate for Payer: HealthUtah PPO |
$0.02
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.02
|
| Rate for Payer: Multiplan Medicare/VA |
$0.01
|
| Rate for Payer: One Health Plan of WY PPO |
$0.02
|
| Rate for Payer: PacificSource Commercial |
$0.02
|
| Rate for Payer: PHCS PPO |
$0.02
|
| Rate for Payer: Three Rivers PPO |
$0.02
|
| Rate for Payer: TriWest Veterans Administration |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.02
|
| Rate for Payer: United Healthcare Medicare |
$0.01
|
| Rate for Payer: WINHealth Partners Commercial |
$0.02
|
| Rate for Payer: Wise Provider Network Commercial |
$0.02
|
|
|
LACTOSE-REDUCED FOOD WITH FIBER 0.06 GRAM-1.5 KCAL/ML ORAL LIQUID [89510]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 7007464626
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.03
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.03
|
| Rate for Payer: Altius Commercial |
$0.03
|
| Rate for Payer: Beech Street Commercial |
$0.03
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.03
|
| Rate for Payer: Cigna of WY Commercial |
$0.03
|
| Rate for Payer: Entrust Commercial |
$0.03
|
| Rate for Payer: First Choice Health Commercial |
$0.03
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.03
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.02
|
| Rate for Payer: HealthUtah PPO |
$0.03
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.03
|
| Rate for Payer: Multiplan Medicare/VA |
$0.02
|
| Rate for Payer: One Health Plan of WY PPO |
$0.03
|
| Rate for Payer: PacificSource Commercial |
$0.03
|
| Rate for Payer: PHCS PPO |
$0.03
|
| Rate for Payer: Three Rivers PPO |
$0.02
|
| Rate for Payer: TriWest Veterans Administration |
$0.02
|
| Rate for Payer: United Healthcare Commercial |
$0.03
|
| Rate for Payer: United Healthcare Medicare |
$0.02
|
| Rate for Payer: WINHealth Partners Commercial |
$0.03
|
| Rate for Payer: Wise Provider Network Commercial |
$0.03
|
|
|
LACTOSE-REDUCED FOOD WITH FIBER 0.06 GRAM-1.5 KCAL/ML ORAL LIQUID [89510]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 7007464626
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.03
|
| Rate for Payer: Aetna of WY Medicare |
$0.02
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.03
|
| Rate for Payer: Altius Commercial |
$0.03
|
| Rate for Payer: Beech Street Commercial |
$0.03
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.03
|
| Rate for Payer: Cigna of WY Commercial |
$0.03
|
| Rate for Payer: Entrust Commercial |
$0.03
|
| Rate for Payer: First Choice Health Commercial |
$0.03
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.03
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.02
|
| Rate for Payer: HealthUtah PPO |
$0.03
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.03
|
| Rate for Payer: Multiplan Medicare/VA |
$0.02
|
| Rate for Payer: One Health Plan of WY PPO |
$0.03
|
| Rate for Payer: PacificSource Commercial |
$0.03
|
| Rate for Payer: PHCS PPO |
$0.03
|
| Rate for Payer: Three Rivers PPO |
$0.02
|
| Rate for Payer: TriWest Veterans Administration |
$0.02
|
| Rate for Payer: United Healthcare Commercial |
$0.03
|
| Rate for Payer: United Healthcare Medicare |
$0.02
|
| Rate for Payer: WINHealth Partners Commercial |
$0.03
|
| Rate for Payer: Wise Provider Network Commercial |
$0.03
|
|
|
LACTULOSE 10 GRAM/15 ML ORAL SOLUTION (WRAPPED) [4000702]
|
Facility
|
OP
|
$0.16
|
|
|
Service Code
|
NDC 0121457715
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.16
|
| Rate for Payer: Aetna of WY Medicare |
$0.11
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.15
|
| Rate for Payer: Altius Commercial |
$0.15
|
| Rate for Payer: Beech Street Commercial |
$0.16
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.13
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.16
|
| Rate for Payer: Cigna of WY Commercial |
$0.16
|
| Rate for Payer: Entrust Commercial |
$0.15
|
| Rate for Payer: First Choice Health Commercial |
$0.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.09
|
| Rate for Payer: HealthUtah PPO |
$0.16
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.16
|
| Rate for Payer: Multiplan Medicare/VA |
$0.09
|
| Rate for Payer: One Health Plan of WY PPO |
$0.16
|
| Rate for Payer: PacificSource Commercial |
$0.14
|
| Rate for Payer: PHCS PPO |
$0.16
|
| Rate for Payer: Three Rivers PPO |
$0.12
|
| Rate for Payer: TriWest Veterans Administration |
$0.09
|
| Rate for Payer: United Healthcare Commercial |
$0.14
|
| Rate for Payer: United Healthcare Medicare |
$0.09
|
| Rate for Payer: WINHealth Partners Commercial |
$0.16
|
| Rate for Payer: Wise Provider Network Commercial |
$0.15
|
|
|
LACTULOSE 10 GRAM/15 ML ORAL SOLUTION (WRAPPED) [4000702]
|
Facility
|
IP
|
$0.16
|
|
|
Service Code
|
NDC 0121457715
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.16
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.15
|
| Rate for Payer: Altius Commercial |
$0.15
|
| Rate for Payer: Beech Street Commercial |
$0.16
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.13
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.16
|
| Rate for Payer: Cigna of WY Commercial |
$0.16
|
| Rate for Payer: Entrust Commercial |
$0.15
|
| Rate for Payer: First Choice Health Commercial |
$0.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.11
|
| Rate for Payer: HealthUtah PPO |
$0.16
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.16
|
| Rate for Payer: Multiplan Medicare/VA |
$0.10
|
| Rate for Payer: One Health Plan of WY PPO |
$0.16
|
| Rate for Payer: PacificSource Commercial |
$0.14
|
| Rate for Payer: PHCS PPO |
$0.16
|
| Rate for Payer: Three Rivers PPO |
$0.12
|
| Rate for Payer: TriWest Veterans Administration |
$0.11
|
| Rate for Payer: United Healthcare Commercial |
$0.14
|
| Rate for Payer: United Healthcare Medicare |
$0.11
|
| Rate for Payer: WINHealth Partners Commercial |
$0.15
|
| Rate for Payer: Wise Provider Network Commercial |
$0.15
|
|
|
LAIV3 VACCINE LIVE FOR INTRANASAL USE
|
Professional
|
Both
|
$78.00
|
|
|
Service Code
|
HCPCS 90660
|
| Hospital Charge Code |
90660
|
| Min. Negotiated Rate |
$20.00 |
| Max. Negotiated Rate |
$78.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$76.44
|
| Rate for Payer: Beech Street Commercial |
$74.10
|
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$75.66
|
| Rate for Payer: Cigna of WY Commercial |
$76.44
|
| Rate for Payer: First Choice Health Commercial |
$70.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$74.10
|
| Rate for Payer: HealthUtah PPO |
$78.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$75.66
|
| Rate for Payer: One Health Plan of WY PPO |
$76.44
|
| Rate for Payer: PacificSource Commercial |
$70.20
|
| Rate for Payer: PHCS PPO |
$74.10
|
| Rate for Payer: Three Rivers PPO |
$58.50
|
| Rate for Payer: TriWest Veterans Administration |
$20.00
|
| Rate for Payer: United Healthcare Commercial |
$67.86
|
| Rate for Payer: WINHealth Partners Commercial |
$78.00
|
|
|
LAIV4 VACCINE FOR INTRANASAL USE
|
Professional
|
Both
|
$78.00
|
|
|
Service Code
|
HCPCS 90672
|
| Hospital Charge Code |
90672
|
| Min. Negotiated Rate |
$20.00 |
| Max. Negotiated Rate |
$78.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$76.44
|
| Rate for Payer: Aetna of WY Medicare |
$27.79
|
| Rate for Payer: Beech Street Commercial |
$74.10
|
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$75.66
|
| Rate for Payer: Cigna of WY Commercial |
$76.44
|
| Rate for Payer: First Choice Health Commercial |
$70.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$74.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$27.79
|
| Rate for Payer: HealthUtah PPO |
$78.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$75.66
|
| Rate for Payer: Multiplan Medicare/VA |
$23.62
|
| Rate for Payer: One Health Plan of WY PPO |
$76.44
|
| Rate for Payer: PacificSource Commercial |
$70.20
|
| Rate for Payer: PHCS PPO |
$74.10
|
| Rate for Payer: Three Rivers PPO |
$58.50
|
| Rate for Payer: TriWest Veterans Administration |
$20.00
|
| Rate for Payer: United Healthcare Commercial |
$67.86
|
| Rate for Payer: United Healthcare Medicare |
$27.79
|
| Rate for Payer: WINHealth Partners Commercial |
$78.00
|
|
|
LAM EXC/EVAC ISPI LESION OTH/THN NEO XDRL LUMBAR
|
Professional
|
Both
|
$6,395.00
|
|
|
Service Code
|
HCPCS 63267
|
| Hospital Charge Code |
63267
|
| Min. Negotiated Rate |
$4,796.25 |
| Max. Negotiated Rate |
$6,395.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$6,267.10
|
| Rate for Payer: Beech Street Commercial |
$6,075.25
|
| Rate for Payer: Cash Price |
$4,476.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$6,203.15
|
| Rate for Payer: Cigna of WY Commercial |
$6,267.10
|
| Rate for Payer: First Choice Health Commercial |
$5,755.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$6,075.25
|
| Rate for Payer: HealthUtah PPO |
$6,395.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$6,203.15
|
| Rate for Payer: One Health Plan of WY PPO |
$6,267.10
|
| Rate for Payer: PacificSource Commercial |
$5,755.50
|
| Rate for Payer: PHCS PPO |
$6,075.25
|
| Rate for Payer: Three Rivers PPO |
$4,796.25
|
| Rate for Payer: United Healthcare Commercial |
$5,563.65
|
| Rate for Payer: WINHealth Partners Commercial |
$5,435.75
|
|
|
LAM FACETEC/FORAMOT DRG ARTHRD LMBR EA ADDL SGM
|
Professional
|
Both
|
$752.00
|
|
|
Service Code
|
HCPCS 63053
|
| Hospital Charge Code |
63053
|
| Min. Negotiated Rate |
$182.14 |
| Max. Negotiated Rate |
$752.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$736.96
|
| Rate for Payer: Aetna of WY Medicare |
$214.28
|
| Rate for Payer: Beech Street Commercial |
$714.40
|
| Rate for Payer: Cash Price |
$526.40
|
| Rate for Payer: Cash Price |
$526.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$729.44
|
| Rate for Payer: Cigna of WY Commercial |
$736.96
|
| Rate for Payer: First Choice Health Commercial |
$676.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$714.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$214.28
|
| Rate for Payer: HealthUtah PPO |
$752.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$729.44
|
| Rate for Payer: Multiplan Medicare/VA |
$182.14
|
| Rate for Payer: One Health Plan of WY PPO |
$736.96
|
| Rate for Payer: PacificSource Commercial |
$676.80
|
| Rate for Payer: PHCS PPO |
$714.40
|
| Rate for Payer: Three Rivers PPO |
$564.00
|
| Rate for Payer: TriWest Veterans Administration |
$214.28
|
| Rate for Payer: United Healthcare Commercial |
$654.24
|
| Rate for Payer: United Healthcare Medicare |
$214.28
|
| Rate for Payer: WINHealth Partners Commercial |
$639.20
|
|
|
LAM FACETEC/FORAMOT DRG ARTHRD LMBR EA ADDL SGM
|
Professional
|
Both
|
$752.00
|
|
|
Service Code
|
HCPCS 63053 AS
|
| Hospital Charge Code |
63053
|
| Min. Negotiated Rate |
$182.14 |
| Max. Negotiated Rate |
$752.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$736.96
|
| Rate for Payer: Aetna of WY Medicare |
$214.28
|
| Rate for Payer: Beech Street Commercial |
$714.40
|
| Rate for Payer: Cash Price |
$526.40
|
| Rate for Payer: Cash Price |
$526.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$729.44
|
| Rate for Payer: Cigna of WY Commercial |
$736.96
|
| Rate for Payer: First Choice Health Commercial |
$676.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$714.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$214.28
|
| Rate for Payer: HealthUtah PPO |
$752.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$729.44
|
| Rate for Payer: Multiplan Medicare/VA |
$182.14
|
| Rate for Payer: One Health Plan of WY PPO |
$736.96
|
| Rate for Payer: PacificSource Commercial |
$676.80
|
| Rate for Payer: PHCS PPO |
$714.40
|
| Rate for Payer: Three Rivers PPO |
$564.00
|
| Rate for Payer: TriWest Veterans Administration |
$214.28
|
| Rate for Payer: United Healthcare Commercial |
$654.24
|
| Rate for Payer: United Healthcare Medicare |
$214.28
|
| Rate for Payer: WINHealth Partners Commercial |
$639.20
|
|
|
LAM FACETEC/FORAMOT DRG ARTHRD LUMBAR 1 VRT SGM
|
Professional
|
Both
|
$1,014.00
|
|
|
Service Code
|
HCPCS 63052 AS
|
| Hospital Charge Code |
63052
|
| Min. Negotiated Rate |
$204.99 |
| Max. Negotiated Rate |
$1,014.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$993.72
|
| Rate for Payer: Aetna of WY Medicare |
$241.16
|
| Rate for Payer: Beech Street Commercial |
$963.30
|
| Rate for Payer: Cash Price |
$709.80
|
| Rate for Payer: Cash Price |
$709.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$983.58
|
| Rate for Payer: Cigna of WY Commercial |
$993.72
|
| Rate for Payer: First Choice Health Commercial |
$912.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$963.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$241.16
|
| Rate for Payer: HealthUtah PPO |
$1,014.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$983.58
|
| Rate for Payer: Multiplan Medicare/VA |
$204.99
|
| Rate for Payer: One Health Plan of WY PPO |
$993.72
|
| Rate for Payer: PacificSource Commercial |
$912.60
|
| Rate for Payer: PHCS PPO |
$963.30
|
| Rate for Payer: Three Rivers PPO |
$760.50
|
| Rate for Payer: TriWest Veterans Administration |
$241.16
|
| Rate for Payer: United Healthcare Commercial |
$882.18
|
| Rate for Payer: United Healthcare Medicare |
$241.16
|
| Rate for Payer: WINHealth Partners Commercial |
$861.90
|
|
|
LAM FACETEC/FORAMOT DRG ARTHRD LUMBAR 1 VRT SGM
|
Professional
|
Both
|
$1,014.00
|
|
|
Service Code
|
HCPCS 63052
|
| Hospital Charge Code |
63052
|
| Min. Negotiated Rate |
$204.99 |
| Max. Negotiated Rate |
$1,014.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$993.72
|
| Rate for Payer: Aetna of WY Medicare |
$241.16
|
| Rate for Payer: Beech Street Commercial |
$963.30
|
| Rate for Payer: Cash Price |
$709.80
|
| Rate for Payer: Cash Price |
$709.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$983.58
|
| Rate for Payer: Cigna of WY Commercial |
$993.72
|
| Rate for Payer: First Choice Health Commercial |
$912.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$963.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$241.16
|
| Rate for Payer: HealthUtah PPO |
$1,014.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$983.58
|
| Rate for Payer: Multiplan Medicare/VA |
$204.99
|
| Rate for Payer: One Health Plan of WY PPO |
$993.72
|
| Rate for Payer: PacificSource Commercial |
$912.60
|
| Rate for Payer: PHCS PPO |
$963.30
|
| Rate for Payer: Three Rivers PPO |
$760.50
|
| Rate for Payer: TriWest Veterans Administration |
$241.16
|
| Rate for Payer: United Healthcare Commercial |
$882.18
|
| Rate for Payer: United Healthcare Medicare |
$241.16
|
| Rate for Payer: WINHealth Partners Commercial |
$861.90
|
|
|
LAM FACETECTOMY&FORAMOT 1 VRT SGM EA ADDL SGM
|
Professional
|
Both
|
$1,086.00
|
|
|
Service Code
|
HCPCS 63048
|
| Hospital Charge Code |
63048
|
| Min. Negotiated Rate |
$167.28 |
| Max. Negotiated Rate |
$1,086.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,064.28
|
| Rate for Payer: Aetna of WY Medicare |
$196.80
|
| Rate for Payer: Beech Street Commercial |
$1,031.70
|
| Rate for Payer: Cash Price |
$760.20
|
| Rate for Payer: Cash Price |
$760.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,053.42
|
| Rate for Payer: Cigna of WY Commercial |
$1,064.28
|
| Rate for Payer: First Choice Health Commercial |
$977.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,031.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$196.80
|
| Rate for Payer: HealthUtah PPO |
$1,086.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,053.42
|
| Rate for Payer: Multiplan Medicare/VA |
$167.28
|
| Rate for Payer: One Health Plan of WY PPO |
$1,064.28
|
| Rate for Payer: PacificSource Commercial |
$977.40
|
| Rate for Payer: PHCS PPO |
$1,031.70
|
| Rate for Payer: Three Rivers PPO |
$814.50
|
| Rate for Payer: TriWest Veterans Administration |
$196.80
|
| Rate for Payer: United Healthcare Commercial |
$944.82
|
| Rate for Payer: United Healthcare Medicare |
$196.80
|
| Rate for Payer: WINHealth Partners Commercial |
$923.10
|
|
|
LAM FACETECTOMY & FORAMOTOMY 1 VRT SGM LUMBAR
|
Professional
|
Both
|
$5,663.00
|
|
|
Service Code
|
HCPCS 63047
|
| Hospital Charge Code |
63047
|
| Min. Negotiated Rate |
$899.72 |
| Max. Negotiated Rate |
$5,663.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5,549.74
|
| Rate for Payer: Aetna of WY Medicare |
$1,058.49
|
| Rate for Payer: Beech Street Commercial |
$5,379.85
|
| Rate for Payer: Cash Price |
$3,964.10
|
| Rate for Payer: Cash Price |
$3,964.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$5,493.11
|
| Rate for Payer: Cigna of WY Commercial |
$5,549.74
|
| Rate for Payer: First Choice Health Commercial |
$5,096.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5,379.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,058.49
|
| Rate for Payer: HealthUtah PPO |
$5,663.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5,493.11
|
| Rate for Payer: Multiplan Medicare/VA |
$899.72
|
| Rate for Payer: One Health Plan of WY PPO |
$5,549.74
|
| Rate for Payer: PacificSource Commercial |
$5,096.70
|
| Rate for Payer: PHCS PPO |
$5,379.85
|
| Rate for Payer: Three Rivers PPO |
$4,247.25
|
| Rate for Payer: TriWest Veterans Administration |
$1,058.49
|
| Rate for Payer: United Healthcare Commercial |
$4,926.81
|
| Rate for Payer: United Healthcare Medicare |
$1,058.49
|
| Rate for Payer: WINHealth Partners Commercial |
$4,813.55
|
|
|
LAM IMPLTJ NSTIM ELTRDS PLATE/PADDLE EDRL
|
Professional
|
Both
|
$4,261.00
|
|
|
Service Code
|
HCPCS 63655
|
| Hospital Charge Code |
63655
|
| Min. Negotiated Rate |
$684.76 |
| Max. Negotiated Rate |
$4,261.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4,175.78
|
| Rate for Payer: Aetna of WY Medicare |
$805.60
|
| Rate for Payer: Beech Street Commercial |
$4,047.95
|
| Rate for Payer: Cash Price |
$2,982.70
|
| Rate for Payer: Cash Price |
$2,982.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$4,133.17
|
| Rate for Payer: Cigna of WY Commercial |
$4,175.78
|
| Rate for Payer: First Choice Health Commercial |
$3,834.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,047.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$805.60
|
| Rate for Payer: HealthUtah PPO |
$4,261.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4,133.17
|
| Rate for Payer: Multiplan Medicare/VA |
$684.76
|
| Rate for Payer: One Health Plan of WY PPO |
$4,175.78
|
| Rate for Payer: PacificSource Commercial |
$3,834.90
|
| Rate for Payer: PHCS PPO |
$4,047.95
|
| Rate for Payer: Three Rivers PPO |
$3,195.75
|
| Rate for Payer: TriWest Veterans Administration |
$805.60
|
| Rate for Payer: United Healthcare Commercial |
$3,707.07
|
| Rate for Payer: United Healthcare Medicare |
$805.60
|
| Rate for Payer: WINHealth Partners Commercial |
$3,621.85
|
|
|
LAMINECTOMY W/RMVL ABNORMAL FACETS LUMBAR
|
Professional
|
Both
|
$6,124.00
|
|
|
Service Code
|
HCPCS 63012
|
| Hospital Charge Code |
63012
|
| Min. Negotiated Rate |
$969.05 |
| Max. Negotiated Rate |
$6,124.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$6,001.52
|
| Rate for Payer: Aetna of WY Medicare |
$1,140.06
|
| Rate for Payer: Beech Street Commercial |
$5,817.80
|
| Rate for Payer: Cash Price |
$4,286.80
|
| Rate for Payer: Cash Price |
$4,286.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$5,940.28
|
| Rate for Payer: Cigna of WY Commercial |
$6,001.52
|
| Rate for Payer: First Choice Health Commercial |
$5,511.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5,817.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,140.06
|
| Rate for Payer: HealthUtah PPO |
$6,124.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5,940.28
|
| Rate for Payer: Multiplan Medicare/VA |
$969.05
|
| Rate for Payer: One Health Plan of WY PPO |
$6,001.52
|
| Rate for Payer: PacificSource Commercial |
$5,511.60
|
| Rate for Payer: PHCS PPO |
$5,817.80
|
| Rate for Payer: Three Rivers PPO |
$4,593.00
|
| Rate for Payer: TriWest Veterans Administration |
$1,140.06
|
| Rate for Payer: United Healthcare Commercial |
$5,327.88
|
| Rate for Payer: United Healthcare Medicare |
$1,140.06
|
| Rate for Payer: WINHealth Partners Commercial |
$5,205.40
|
|
|
LAMINECTOMY W/RMVL ABNORMAL FACETS LUMBAR
|
Professional
|
Both
|
$12,248.00
|
|
|
Service Code
|
HCPCS 63012 50
|
| Hospital Charge Code |
63012
|
| Min. Negotiated Rate |
$969.05 |
| Max. Negotiated Rate |
$12,248.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$12,003.04
|
| Rate for Payer: Aetna of WY Medicare |
$1,140.06
|
| Rate for Payer: Beech Street Commercial |
$11,635.60
|
| Rate for Payer: Cash Price |
$8,573.60
|
| Rate for Payer: Cash Price |
$8,573.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$11,880.56
|
| Rate for Payer: Cigna of WY Commercial |
$12,003.04
|
| Rate for Payer: First Choice Health Commercial |
$11,023.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$11,635.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,140.06
|
| Rate for Payer: HealthUtah PPO |
$12,248.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$11,880.56
|
| Rate for Payer: Multiplan Medicare/VA |
$969.05
|
| Rate for Payer: One Health Plan of WY PPO |
$12,003.04
|
| Rate for Payer: PacificSource Commercial |
$11,023.20
|
| Rate for Payer: PHCS PPO |
$11,635.60
|
| Rate for Payer: Three Rivers PPO |
$9,186.00
|
| Rate for Payer: TriWest Veterans Administration |
$1,140.06
|
| Rate for Payer: United Healthcare Commercial |
$10,655.76
|
| Rate for Payer: United Healthcare Medicare |
$1,140.06
|
| Rate for Payer: WINHealth Partners Commercial |
$10,410.80
|
|
|
LAMNOTMY INCL W/DCMPRSN NRV ROOT 1 INTRSPC LUMBR
|
Professional
|
Both
|
$4,556.00
|
|
|
Service Code
|
HCPCS 63030 AS
|
| Hospital Charge Code |
63030
|
| Min. Negotiated Rate |
$746.81 |
| Max. Negotiated Rate |
$4,556.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4,464.88
|
| Rate for Payer: Aetna of WY Medicare |
$878.60
|
| Rate for Payer: Beech Street Commercial |
$4,328.20
|
| Rate for Payer: Cash Price |
$3,189.20
|
| Rate for Payer: Cash Price |
$3,189.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$4,419.32
|
| Rate for Payer: Cigna of WY Commercial |
$4,464.88
|
| Rate for Payer: First Choice Health Commercial |
$4,100.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,328.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$878.60
|
| Rate for Payer: HealthUtah PPO |
$4,556.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4,419.32
|
| Rate for Payer: Multiplan Medicare/VA |
$746.81
|
| Rate for Payer: One Health Plan of WY PPO |
$4,464.88
|
| Rate for Payer: PacificSource Commercial |
$4,100.40
|
| Rate for Payer: PHCS PPO |
$4,328.20
|
| Rate for Payer: Three Rivers PPO |
$3,417.00
|
| Rate for Payer: TriWest Veterans Administration |
$878.60
|
| Rate for Payer: United Healthcare Commercial |
$3,963.72
|
| Rate for Payer: United Healthcare Medicare |
$878.60
|
| Rate for Payer: WINHealth Partners Commercial |
$3,872.60
|
|
|
LAMNOTMY INCL W/DCMPRSN NRV ROOT 1 INTRSPC LUMBR
|
Professional
|
Both
|
$4,556.00
|
|
|
Service Code
|
HCPCS 63030 80
|
| Hospital Charge Code |
63030
|
| Min. Negotiated Rate |
$746.81 |
| Max. Negotiated Rate |
$4,556.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4,464.88
|
| Rate for Payer: Aetna of WY Medicare |
$878.60
|
| Rate for Payer: Beech Street Commercial |
$4,328.20
|
| Rate for Payer: Cash Price |
$3,189.20
|
| Rate for Payer: Cash Price |
$3,189.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$4,419.32
|
| Rate for Payer: Cigna of WY Commercial |
$4,464.88
|
| Rate for Payer: First Choice Health Commercial |
$4,100.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,328.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$878.60
|
| Rate for Payer: HealthUtah PPO |
$4,556.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4,419.32
|
| Rate for Payer: Multiplan Medicare/VA |
$746.81
|
| Rate for Payer: One Health Plan of WY PPO |
$4,464.88
|
| Rate for Payer: PacificSource Commercial |
$4,100.40
|
| Rate for Payer: PHCS PPO |
$4,328.20
|
| Rate for Payer: Three Rivers PPO |
$3,417.00
|
| Rate for Payer: TriWest Veterans Administration |
$878.60
|
| Rate for Payer: United Healthcare Commercial |
$3,963.72
|
| Rate for Payer: United Healthcare Medicare |
$878.60
|
| Rate for Payer: WINHealth Partners Commercial |
$3,872.60
|
|
|
LAMNOTMY INCL W/DCMPRSN NRV ROOT 1 INTRSPC LUMBR
|
Professional
|
Both
|
$9,112.00
|
|
|
Service Code
|
HCPCS 63030 50
|
| Hospital Charge Code |
63030
|
| Min. Negotiated Rate |
$746.81 |
| Max. Negotiated Rate |
$9,112.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$8,929.76
|
| Rate for Payer: Aetna of WY Medicare |
$878.60
|
| Rate for Payer: Beech Street Commercial |
$8,656.40
|
| Rate for Payer: Cash Price |
$6,378.40
|
| Rate for Payer: Cash Price |
$6,378.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$8,838.64
|
| Rate for Payer: Cigna of WY Commercial |
$8,929.76
|
| Rate for Payer: First Choice Health Commercial |
$8,200.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$8,656.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$878.60
|
| Rate for Payer: HealthUtah PPO |
$9,112.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$8,838.64
|
| Rate for Payer: Multiplan Medicare/VA |
$746.81
|
| Rate for Payer: One Health Plan of WY PPO |
$8,929.76
|
| Rate for Payer: PacificSource Commercial |
$8,200.80
|
| Rate for Payer: PHCS PPO |
$8,656.40
|
| Rate for Payer: Three Rivers PPO |
$6,834.00
|
| Rate for Payer: TriWest Veterans Administration |
$878.60
|
| Rate for Payer: United Healthcare Commercial |
$7,927.44
|
| Rate for Payer: United Healthcare Medicare |
$878.60
|
| Rate for Payer: WINHealth Partners Commercial |
$7,745.20
|
|
|
LAMNOTMY INCL W/DCMPRSN NRV ROOT 1 INTRSPC LUMBR
|
Professional
|
Both
|
$4,556.00
|
|
|
Service Code
|
HCPCS 63030
|
| Hospital Charge Code |
63030
|
| Min. Negotiated Rate |
$746.81 |
| Max. Negotiated Rate |
$4,556.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4,464.88
|
| Rate for Payer: Aetna of WY Medicare |
$878.60
|
| Rate for Payer: Beech Street Commercial |
$4,328.20
|
| Rate for Payer: Cash Price |
$3,189.20
|
| Rate for Payer: Cash Price |
$3,189.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$4,419.32
|
| Rate for Payer: Cigna of WY Commercial |
$4,464.88
|
| Rate for Payer: First Choice Health Commercial |
$4,100.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,328.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$878.60
|
| Rate for Payer: HealthUtah PPO |
$4,556.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4,419.32
|
| Rate for Payer: Multiplan Medicare/VA |
$746.81
|
| Rate for Payer: One Health Plan of WY PPO |
$4,464.88
|
| Rate for Payer: PacificSource Commercial |
$4,100.40
|
| Rate for Payer: PHCS PPO |
$4,328.20
|
| Rate for Payer: Three Rivers PPO |
$3,417.00
|
| Rate for Payer: TriWest Veterans Administration |
$878.60
|
| Rate for Payer: United Healthcare Commercial |
$3,963.72
|
| Rate for Payer: United Healthcare Medicare |
$878.60
|
| Rate for Payer: WINHealth Partners Commercial |
$3,872.60
|
|
|
LAMNOTMY W/DCMPRSN NRV EACH ADDL CRVCL/LMBR
|
Professional
|
Both
|
$983.00
|
|
|
Service Code
|
HCPCS 63035
|
| Hospital Charge Code |
63035
|
| Min. Negotiated Rate |
$185.48 |
| Max. Negotiated Rate |
$983.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$963.34
|
| Rate for Payer: Aetna of WY Medicare |
$218.21
|
| Rate for Payer: Beech Street Commercial |
$933.85
|
| Rate for Payer: Cash Price |
$688.10
|
| Rate for Payer: Cash Price |
$688.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$953.51
|
| Rate for Payer: Cigna of WY Commercial |
$963.34
|
| Rate for Payer: First Choice Health Commercial |
$884.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$933.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$218.21
|
| Rate for Payer: HealthUtah PPO |
$983.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$953.51
|
| Rate for Payer: Multiplan Medicare/VA |
$185.48
|
| Rate for Payer: One Health Plan of WY PPO |
$963.34
|
| Rate for Payer: PacificSource Commercial |
$884.70
|
| Rate for Payer: PHCS PPO |
$933.85
|
| Rate for Payer: Three Rivers PPO |
$737.25
|
| Rate for Payer: TriWest Veterans Administration |
$218.21
|
| Rate for Payer: United Healthcare Commercial |
$855.21
|
| Rate for Payer: United Healthcare Medicare |
$218.21
|
| Rate for Payer: WINHealth Partners Commercial |
$835.55
|
|
|
LAMNOTMY W/DCMPRSN NRV EACH ADDL CRVCL/LMBR
|
Professional
|
Both
|
$983.00
|
|
|
Service Code
|
HCPCS 63035 AS
|
| Hospital Charge Code |
63035
|
| Min. Negotiated Rate |
$185.48 |
| Max. Negotiated Rate |
$983.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$963.34
|
| Rate for Payer: Aetna of WY Medicare |
$218.21
|
| Rate for Payer: Beech Street Commercial |
$933.85
|
| Rate for Payer: Cash Price |
$688.10
|
| Rate for Payer: Cash Price |
$688.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$953.51
|
| Rate for Payer: Cigna of WY Commercial |
$963.34
|
| Rate for Payer: First Choice Health Commercial |
$884.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$933.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$218.21
|
| Rate for Payer: HealthUtah PPO |
$983.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$953.51
|
| Rate for Payer: Multiplan Medicare/VA |
$185.48
|
| Rate for Payer: One Health Plan of WY PPO |
$963.34
|
| Rate for Payer: PacificSource Commercial |
$884.70
|
| Rate for Payer: PHCS PPO |
$933.85
|
| Rate for Payer: Three Rivers PPO |
$737.25
|
| Rate for Payer: TriWest Veterans Administration |
$218.21
|
| Rate for Payer: United Healthcare Commercial |
$855.21
|
| Rate for Payer: United Healthcare Medicare |
$218.21
|
| Rate for Payer: WINHealth Partners Commercial |
$835.55
|
|
|
LAMNOTMY W/DCMPRSN NRV EACH ADDL CRVCL/LMBR
|
Professional
|
Both
|
$1,966.00
|
|
|
Service Code
|
HCPCS 63035 50
|
| Hospital Charge Code |
63035
|
| Min. Negotiated Rate |
$185.48 |
| Max. Negotiated Rate |
$1,966.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,926.68
|
| Rate for Payer: Aetna of WY Medicare |
$218.21
|
| Rate for Payer: Beech Street Commercial |
$1,867.70
|
| Rate for Payer: Cash Price |
$1,376.20
|
| Rate for Payer: Cash Price |
$1,376.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,907.02
|
| Rate for Payer: Cigna of WY Commercial |
$1,926.68
|
| Rate for Payer: First Choice Health Commercial |
$1,769.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,867.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$218.21
|
| Rate for Payer: HealthUtah PPO |
$1,966.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,907.02
|
| Rate for Payer: Multiplan Medicare/VA |
$185.48
|
| Rate for Payer: One Health Plan of WY PPO |
$1,926.68
|
| Rate for Payer: PacificSource Commercial |
$1,769.40
|
| Rate for Payer: PHCS PPO |
$1,867.70
|
| Rate for Payer: Three Rivers PPO |
$1,474.50
|
| Rate for Payer: TriWest Veterans Administration |
$218.21
|
| Rate for Payer: United Healthcare Commercial |
$1,710.42
|
| Rate for Payer: United Healthcare Medicare |
$218.21
|
| Rate for Payer: WINHealth Partners Commercial |
$1,671.10
|
|
