|
LARYNGOSCOPY INDIRECT W/VOCAL CORD INJECTION
|
Professional
|
Both
|
$607.00
|
|
|
Service Code
|
HCPCS 31513
|
| Hospital Charge Code |
31513
|
| Min. Negotiated Rate |
$107.13 |
| Max. Negotiated Rate |
$607.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$594.86
|
| Rate for Payer: Aetna of WY Medicare |
$126.04
|
| Rate for Payer: Beech Street Commercial |
$576.65
|
| Rate for Payer: Cash Price |
$424.90
|
| Rate for Payer: Cash Price |
$424.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$588.79
|
| Rate for Payer: Cigna of WY Commercial |
$594.86
|
| Rate for Payer: First Choice Health Commercial |
$546.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$576.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$126.04
|
| Rate for Payer: HealthUtah PPO |
$607.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$588.79
|
| Rate for Payer: Multiplan Medicare/VA |
$107.13
|
| Rate for Payer: One Health Plan of WY PPO |
$594.86
|
| Rate for Payer: PacificSource Commercial |
$546.30
|
| Rate for Payer: PHCS PPO |
$576.65
|
| Rate for Payer: Three Rivers PPO |
$455.25
|
| Rate for Payer: TriWest Veterans Administration |
$126.04
|
| Rate for Payer: United Healthcare Commercial |
$528.09
|
| Rate for Payer: United Healthcare Medicare |
$126.04
|
| Rate for Payer: WINHealth Partners Commercial |
$515.95
|
|
|
LARYNGOSCOPY W/BIOPSY MICROSCOPE/TELESCOPE
|
Professional
|
Both
|
$716.00
|
|
|
Service Code
|
HCPCS 31536
|
| Hospital Charge Code |
31536
|
| Min. Negotiated Rate |
$170.53 |
| Max. Negotiated Rate |
$716.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$701.68
|
| Rate for Payer: Aetna of WY Medicare |
$200.62
|
| Rate for Payer: Beech Street Commercial |
$680.20
|
| Rate for Payer: Cash Price |
$501.20
|
| Rate for Payer: Cash Price |
$501.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$694.52
|
| Rate for Payer: Cigna of WY Commercial |
$701.68
|
| Rate for Payer: First Choice Health Commercial |
$644.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$680.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$200.62
|
| Rate for Payer: HealthUtah PPO |
$716.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$694.52
|
| Rate for Payer: Multiplan Medicare/VA |
$170.53
|
| Rate for Payer: One Health Plan of WY PPO |
$701.68
|
| Rate for Payer: PacificSource Commercial |
$644.40
|
| Rate for Payer: PHCS PPO |
$680.20
|
| Rate for Payer: Three Rivers PPO |
$537.00
|
| Rate for Payer: TriWest Veterans Administration |
$200.62
|
| Rate for Payer: United Healthcare Commercial |
$622.92
|
| Rate for Payer: United Healthcare Medicare |
$200.62
|
| Rate for Payer: WINHealth Partners Commercial |
$608.60
|
|
|
LASER FIBER 1000 WIRE
|
Facility
|
IP
|
$1,983.33
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,243.55 |
| Max. Negotiated Rate |
$1,983.33 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,943.66
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,904.00
|
| Rate for Payer: Altius Commercial |
$1,904.00
|
| Rate for Payer: Beech Street Commercial |
$1,943.66
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,628.31
|
| Rate for Payer: Cash Price |
$1,388.33
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,923.83
|
| Rate for Payer: Cigna of WY Commercial |
$1,943.66
|
| Rate for Payer: Entrust Commercial |
$1,884.16
|
| Rate for Payer: First Choice Health Commercial |
$1,884.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,884.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,309.00
|
| Rate for Payer: HealthUtah PPO |
$1,983.33
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,923.83
|
| Rate for Payer: Multiplan Medicare/VA |
$1,243.55
|
| Rate for Payer: One Health Plan of WY PPO |
$1,943.66
|
| Rate for Payer: PacificSource Commercial |
$1,785.00
|
| Rate for Payer: PHCS PPO |
$1,943.66
|
| Rate for Payer: Three Rivers PPO |
$1,487.50
|
| Rate for Payer: TriWest Veterans Administration |
$1,309.00
|
| Rate for Payer: United Healthcare Commercial |
$1,725.50
|
| Rate for Payer: United Healthcare Medicare |
$1,309.00
|
| Rate for Payer: WINHealth Partners Commercial |
$1,884.16
|
| Rate for Payer: Wise Provider Network Commercial |
$1,884.16
|
|
|
LASER FIBER 1000 WIRE
|
Facility
|
OP
|
$1,983.33
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,092.81 |
| Max. Negotiated Rate |
$1,983.33 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,943.66
|
| Rate for Payer: Aetna of WY Medicare |
$1,309.00
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,904.00
|
| Rate for Payer: Altius Commercial |
$1,904.00
|
| Rate for Payer: Beech Street Commercial |
$1,943.66
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,628.31
|
| Rate for Payer: Cash Price |
$1,388.33
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,923.83
|
| Rate for Payer: Cigna of WY Commercial |
$1,943.66
|
| Rate for Payer: Entrust Commercial |
$1,884.16
|
| Rate for Payer: First Choice Health Commercial |
$1,884.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,884.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,150.33
|
| Rate for Payer: HealthUtah PPO |
$1,983.33
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,923.83
|
| Rate for Payer: Multiplan Medicare/VA |
$1,092.81
|
| Rate for Payer: One Health Plan of WY PPO |
$1,943.66
|
| Rate for Payer: PacificSource Commercial |
$1,785.00
|
| Rate for Payer: PHCS PPO |
$1,943.66
|
| Rate for Payer: Three Rivers PPO |
$1,487.50
|
| Rate for Payer: TriWest Veterans Administration |
$1,150.33
|
| Rate for Payer: United Healthcare Commercial |
$1,725.50
|
| Rate for Payer: United Healthcare Medicare |
$1,150.33
|
| Rate for Payer: WINHealth Partners Commercial |
$1,943.66
|
| Rate for Payer: Wise Provider Network Commercial |
$1,884.16
|
|
|
LASER FIBER 270 WIRE
|
Facility
|
IP
|
$773.50
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$484.98 |
| Max. Negotiated Rate |
$773.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$758.03
|
| Rate for Payer: Altius Auto/Workers Compensation |
$742.56
|
| Rate for Payer: Altius Commercial |
$742.56
|
| Rate for Payer: Beech Street Commercial |
$758.03
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$635.04
|
| Rate for Payer: Cash Price |
$541.45
|
| Rate for Payer: ChoiceCare Network Commercial |
$750.30
|
| Rate for Payer: Cigna of WY Commercial |
$758.03
|
| Rate for Payer: Entrust Commercial |
$734.82
|
| Rate for Payer: First Choice Health Commercial |
$734.82
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$734.82
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$510.51
|
| Rate for Payer: HealthUtah PPO |
$773.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$750.30
|
| Rate for Payer: Multiplan Medicare/VA |
$484.98
|
| Rate for Payer: One Health Plan of WY PPO |
$758.03
|
| Rate for Payer: PacificSource Commercial |
$696.15
|
| Rate for Payer: PHCS PPO |
$758.03
|
| Rate for Payer: Three Rivers PPO |
$580.12
|
| Rate for Payer: TriWest Veterans Administration |
$510.51
|
| Rate for Payer: United Healthcare Commercial |
$672.94
|
| Rate for Payer: United Healthcare Medicare |
$510.51
|
| Rate for Payer: WINHealth Partners Commercial |
$734.82
|
| Rate for Payer: Wise Provider Network Commercial |
$734.82
|
|
|
LASER FIBER 270 WIRE
|
Facility
|
OP
|
$773.50
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$426.20 |
| Max. Negotiated Rate |
$773.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$758.03
|
| Rate for Payer: Aetna of WY Medicare |
$510.51
|
| Rate for Payer: Altius Auto/Workers Compensation |
$742.56
|
| Rate for Payer: Altius Commercial |
$742.56
|
| Rate for Payer: Beech Street Commercial |
$758.03
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$635.04
|
| Rate for Payer: Cash Price |
$541.45
|
| Rate for Payer: ChoiceCare Network Commercial |
$750.30
|
| Rate for Payer: Cigna of WY Commercial |
$758.03
|
| Rate for Payer: Entrust Commercial |
$734.82
|
| Rate for Payer: First Choice Health Commercial |
$734.82
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$734.82
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$448.63
|
| Rate for Payer: HealthUtah PPO |
$773.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$750.30
|
| Rate for Payer: Multiplan Medicare/VA |
$426.20
|
| Rate for Payer: One Health Plan of WY PPO |
$758.03
|
| Rate for Payer: PacificSource Commercial |
$696.15
|
| Rate for Payer: PHCS PPO |
$758.03
|
| Rate for Payer: Three Rivers PPO |
$580.12
|
| Rate for Payer: TriWest Veterans Administration |
$448.63
|
| Rate for Payer: United Healthcare Commercial |
$672.94
|
| Rate for Payer: United Healthcare Medicare |
$448.63
|
| Rate for Payer: WINHealth Partners Commercial |
$758.03
|
| Rate for Payer: Wise Provider Network Commercial |
$734.82
|
|
|
LASER FIBER 400 WIRE
|
Facility
|
OP
|
$773.50
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$426.20 |
| Max. Negotiated Rate |
$773.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$758.03
|
| Rate for Payer: Aetna of WY Medicare |
$510.51
|
| Rate for Payer: Altius Auto/Workers Compensation |
$742.56
|
| Rate for Payer: Altius Commercial |
$742.56
|
| Rate for Payer: Beech Street Commercial |
$758.03
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$635.04
|
| Rate for Payer: Cash Price |
$541.45
|
| Rate for Payer: ChoiceCare Network Commercial |
$750.30
|
| Rate for Payer: Cigna of WY Commercial |
$758.03
|
| Rate for Payer: Entrust Commercial |
$734.82
|
| Rate for Payer: First Choice Health Commercial |
$734.82
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$734.82
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$448.63
|
| Rate for Payer: HealthUtah PPO |
$773.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$750.30
|
| Rate for Payer: Multiplan Medicare/VA |
$426.20
|
| Rate for Payer: One Health Plan of WY PPO |
$758.03
|
| Rate for Payer: PacificSource Commercial |
$696.15
|
| Rate for Payer: PHCS PPO |
$758.03
|
| Rate for Payer: Three Rivers PPO |
$580.12
|
| Rate for Payer: TriWest Veterans Administration |
$448.63
|
| Rate for Payer: United Healthcare Commercial |
$672.94
|
| Rate for Payer: United Healthcare Medicare |
$448.63
|
| Rate for Payer: WINHealth Partners Commercial |
$758.03
|
| Rate for Payer: Wise Provider Network Commercial |
$734.82
|
|
|
LASER FIBER 400 WIRE
|
Facility
|
IP
|
$773.50
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$484.98 |
| Max. Negotiated Rate |
$773.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$758.03
|
| Rate for Payer: Altius Auto/Workers Compensation |
$742.56
|
| Rate for Payer: Altius Commercial |
$742.56
|
| Rate for Payer: Beech Street Commercial |
$758.03
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$635.04
|
| Rate for Payer: Cash Price |
$541.45
|
| Rate for Payer: ChoiceCare Network Commercial |
$750.30
|
| Rate for Payer: Cigna of WY Commercial |
$758.03
|
| Rate for Payer: Entrust Commercial |
$734.82
|
| Rate for Payer: First Choice Health Commercial |
$734.82
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$734.82
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$510.51
|
| Rate for Payer: HealthUtah PPO |
$773.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$750.30
|
| Rate for Payer: Multiplan Medicare/VA |
$484.98
|
| Rate for Payer: One Health Plan of WY PPO |
$758.03
|
| Rate for Payer: PacificSource Commercial |
$696.15
|
| Rate for Payer: PHCS PPO |
$758.03
|
| Rate for Payer: Three Rivers PPO |
$580.12
|
| Rate for Payer: TriWest Veterans Administration |
$510.51
|
| Rate for Payer: United Healthcare Commercial |
$672.94
|
| Rate for Payer: United Healthcare Medicare |
$510.51
|
| Rate for Payer: WINHealth Partners Commercial |
$734.82
|
| Rate for Payer: Wise Provider Network Commercial |
$734.82
|
|
|
LASER FIBER 600 WIRE
|
Facility
|
IP
|
$773.50
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$484.98 |
| Max. Negotiated Rate |
$773.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$758.03
|
| Rate for Payer: Altius Auto/Workers Compensation |
$742.56
|
| Rate for Payer: Altius Commercial |
$742.56
|
| Rate for Payer: Beech Street Commercial |
$758.03
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$635.04
|
| Rate for Payer: Cash Price |
$541.45
|
| Rate for Payer: ChoiceCare Network Commercial |
$750.30
|
| Rate for Payer: Cigna of WY Commercial |
$758.03
|
| Rate for Payer: Entrust Commercial |
$734.82
|
| Rate for Payer: First Choice Health Commercial |
$734.82
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$734.82
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$510.51
|
| Rate for Payer: HealthUtah PPO |
$773.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$750.30
|
| Rate for Payer: Multiplan Medicare/VA |
$484.98
|
| Rate for Payer: One Health Plan of WY PPO |
$758.03
|
| Rate for Payer: PacificSource Commercial |
$696.15
|
| Rate for Payer: PHCS PPO |
$758.03
|
| Rate for Payer: Three Rivers PPO |
$580.12
|
| Rate for Payer: TriWest Veterans Administration |
$510.51
|
| Rate for Payer: United Healthcare Commercial |
$672.94
|
| Rate for Payer: United Healthcare Medicare |
$510.51
|
| Rate for Payer: WINHealth Partners Commercial |
$734.82
|
| Rate for Payer: Wise Provider Network Commercial |
$734.82
|
|
|
LASER FIBER 600 WIRE
|
Facility
|
OP
|
$773.50
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$426.20 |
| Max. Negotiated Rate |
$773.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$758.03
|
| Rate for Payer: Aetna of WY Medicare |
$510.51
|
| Rate for Payer: Altius Auto/Workers Compensation |
$742.56
|
| Rate for Payer: Altius Commercial |
$742.56
|
| Rate for Payer: Beech Street Commercial |
$758.03
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$635.04
|
| Rate for Payer: Cash Price |
$541.45
|
| Rate for Payer: ChoiceCare Network Commercial |
$750.30
|
| Rate for Payer: Cigna of WY Commercial |
$758.03
|
| Rate for Payer: Entrust Commercial |
$734.82
|
| Rate for Payer: First Choice Health Commercial |
$734.82
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$734.82
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$448.63
|
| Rate for Payer: HealthUtah PPO |
$773.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$750.30
|
| Rate for Payer: Multiplan Medicare/VA |
$426.20
|
| Rate for Payer: One Health Plan of WY PPO |
$758.03
|
| Rate for Payer: PacificSource Commercial |
$696.15
|
| Rate for Payer: PHCS PPO |
$758.03
|
| Rate for Payer: Three Rivers PPO |
$580.12
|
| Rate for Payer: TriWest Veterans Administration |
$448.63
|
| Rate for Payer: United Healthcare Commercial |
$672.94
|
| Rate for Payer: United Healthcare Medicare |
$448.63
|
| Rate for Payer: WINHealth Partners Commercial |
$758.03
|
| Rate for Payer: Wise Provider Network Commercial |
$734.82
|
|
|
LATANOPROST 0.005 % EYE DROPS [505]
|
Facility
|
OP
|
$16.05
|
|
|
Service Code
|
NDC 6131454701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.84 |
| Max. Negotiated Rate |
$16.05 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.73
|
| Rate for Payer: Aetna of WY Medicare |
$10.59
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.41
|
| Rate for Payer: Altius Commercial |
$15.41
|
| Rate for Payer: Beech Street Commercial |
$15.73
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.18
|
| Rate for Payer: Cash Price |
$11.23
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.57
|
| Rate for Payer: Cigna of WY Commercial |
$15.73
|
| Rate for Payer: Entrust Commercial |
$15.25
|
| Rate for Payer: First Choice Health Commercial |
$15.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.31
|
| Rate for Payer: HealthUtah PPO |
$16.05
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.57
|
| Rate for Payer: Multiplan Medicare/VA |
$8.84
|
| Rate for Payer: One Health Plan of WY PPO |
$15.73
|
| Rate for Payer: PacificSource Commercial |
$14.44
|
| Rate for Payer: PHCS PPO |
$15.73
|
| Rate for Payer: Three Rivers PPO |
$12.04
|
| Rate for Payer: TriWest Veterans Administration |
$9.31
|
| Rate for Payer: United Healthcare Commercial |
$13.96
|
| Rate for Payer: United Healthcare Medicare |
$9.31
|
| Rate for Payer: WINHealth Partners Commercial |
$15.73
|
| Rate for Payer: Wise Provider Network Commercial |
$15.25
|
|
|
LATANOPROST 0.005 % EYE DROPS [505]
|
Facility
|
IP
|
$7.92
|
|
|
Service Code
|
NDC 7006942101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.97 |
| Max. Negotiated Rate |
$7.92 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$7.76
|
| Rate for Payer: Altius Auto/Workers Compensation |
$7.60
|
| Rate for Payer: Altius Commercial |
$7.60
|
| Rate for Payer: Beech Street Commercial |
$7.76
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$6.50
|
| Rate for Payer: Cash Price |
$5.54
|
| Rate for Payer: ChoiceCare Network Commercial |
$7.68
|
| Rate for Payer: Cigna of WY Commercial |
$7.76
|
| Rate for Payer: Entrust Commercial |
$7.52
|
| Rate for Payer: First Choice Health Commercial |
$7.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$7.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$5.23
|
| Rate for Payer: HealthUtah PPO |
$7.92
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$7.68
|
| Rate for Payer: Multiplan Medicare/VA |
$4.97
|
| Rate for Payer: One Health Plan of WY PPO |
$7.76
|
| Rate for Payer: PacificSource Commercial |
$7.13
|
| Rate for Payer: PHCS PPO |
$7.76
|
| Rate for Payer: Three Rivers PPO |
$5.94
|
| Rate for Payer: TriWest Veterans Administration |
$5.23
|
| Rate for Payer: United Healthcare Commercial |
$6.89
|
| Rate for Payer: United Healthcare Medicare |
$5.23
|
| Rate for Payer: WINHealth Partners Commercial |
$7.52
|
| Rate for Payer: Wise Provider Network Commercial |
$7.52
|
|
|
LATANOPROST 0.005 % EYE DROPS [505]
|
Facility
|
OP
|
$7.92
|
|
|
Service Code
|
NDC 7006942101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.36 |
| Max. Negotiated Rate |
$7.92 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$7.76
|
| Rate for Payer: Aetna of WY Medicare |
$5.23
|
| Rate for Payer: Altius Auto/Workers Compensation |
$7.60
|
| Rate for Payer: Altius Commercial |
$7.60
|
| Rate for Payer: Beech Street Commercial |
$7.76
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$6.50
|
| Rate for Payer: Cash Price |
$5.54
|
| Rate for Payer: ChoiceCare Network Commercial |
$7.68
|
| Rate for Payer: Cigna of WY Commercial |
$7.76
|
| Rate for Payer: Entrust Commercial |
$7.52
|
| Rate for Payer: First Choice Health Commercial |
$7.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$7.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$4.59
|
| Rate for Payer: HealthUtah PPO |
$7.92
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$7.68
|
| Rate for Payer: Multiplan Medicare/VA |
$4.36
|
| Rate for Payer: One Health Plan of WY PPO |
$7.76
|
| Rate for Payer: PacificSource Commercial |
$7.13
|
| Rate for Payer: PHCS PPO |
$7.76
|
| Rate for Payer: Three Rivers PPO |
$5.94
|
| Rate for Payer: TriWest Veterans Administration |
$4.59
|
| Rate for Payer: United Healthcare Commercial |
$6.89
|
| Rate for Payer: United Healthcare Medicare |
$4.59
|
| Rate for Payer: WINHealth Partners Commercial |
$7.76
|
| Rate for Payer: Wise Provider Network Commercial |
$7.52
|
|
|
LATANOPROST 0.005 % EYE DROPS [505]
|
Facility
|
IP
|
$16.05
|
|
|
Service Code
|
NDC 6131454701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.06 |
| Max. Negotiated Rate |
$16.05 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.73
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.41
|
| Rate for Payer: Altius Commercial |
$15.41
|
| Rate for Payer: Beech Street Commercial |
$15.73
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.18
|
| Rate for Payer: Cash Price |
$11.23
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.57
|
| Rate for Payer: Cigna of WY Commercial |
$15.73
|
| Rate for Payer: Entrust Commercial |
$15.25
|
| Rate for Payer: First Choice Health Commercial |
$15.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.59
|
| Rate for Payer: HealthUtah PPO |
$16.05
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.57
|
| Rate for Payer: Multiplan Medicare/VA |
$10.06
|
| Rate for Payer: One Health Plan of WY PPO |
$15.73
|
| Rate for Payer: PacificSource Commercial |
$14.44
|
| Rate for Payer: PHCS PPO |
$15.73
|
| Rate for Payer: Three Rivers PPO |
$12.04
|
| Rate for Payer: TriWest Veterans Administration |
$10.59
|
| Rate for Payer: United Healthcare Commercial |
$13.96
|
| Rate for Payer: United Healthcare Medicare |
$10.59
|
| Rate for Payer: WINHealth Partners Commercial |
$15.25
|
| Rate for Payer: Wise Provider Network Commercial |
$15.25
|
|
|
LATERA IMPLANT 20MM
|
Facility
|
IP
|
$6,762.00
|
|
| Hospital Charge Code |
27800000S1
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,239.77 |
| Max. Negotiated Rate |
$6,762.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$6,626.76
|
| Rate for Payer: Altius Auto/Workers Compensation |
$6,491.52
|
| Rate for Payer: Altius Commercial |
$6,491.52
|
| Rate for Payer: Beech Street Commercial |
$6,626.76
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$5,551.60
|
| Rate for Payer: Cash Price |
$4,733.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$6,559.14
|
| Rate for Payer: Cigna of WY Commercial |
$6,626.76
|
| Rate for Payer: Entrust Commercial |
$6,423.90
|
| Rate for Payer: First Choice Health Commercial |
$6,423.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$6,423.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$4,462.92
|
| Rate for Payer: HealthUtah PPO |
$6,762.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$6,559.14
|
| Rate for Payer: Multiplan Medicare/VA |
$4,239.77
|
| Rate for Payer: One Health Plan of WY PPO |
$6,626.76
|
| Rate for Payer: PacificSource Commercial |
$6,085.80
|
| Rate for Payer: PHCS PPO |
$6,626.76
|
| Rate for Payer: Three Rivers PPO |
$5,071.50
|
| Rate for Payer: TriWest Veterans Administration |
$4,462.92
|
| Rate for Payer: United Healthcare Commercial |
$5,882.94
|
| Rate for Payer: United Healthcare Medicare |
$4,462.92
|
| Rate for Payer: WINHealth Partners Commercial |
$6,423.90
|
| Rate for Payer: Wise Provider Network Commercial |
$6,423.90
|
|
|
LATERA IMPLANT 20MM
|
Facility
|
OP
|
$6,762.00
|
|
| Hospital Charge Code |
27800000S1
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,725.86 |
| Max. Negotiated Rate |
$6,762.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$6,626.76
|
| Rate for Payer: Aetna of WY Medicare |
$4,462.92
|
| Rate for Payer: Altius Auto/Workers Compensation |
$6,491.52
|
| Rate for Payer: Altius Commercial |
$6,491.52
|
| Rate for Payer: Beech Street Commercial |
$6,626.76
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$5,551.60
|
| Rate for Payer: Cash Price |
$4,733.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$6,559.14
|
| Rate for Payer: Cigna of WY Commercial |
$6,626.76
|
| Rate for Payer: Entrust Commercial |
$6,423.90
|
| Rate for Payer: First Choice Health Commercial |
$6,423.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$6,423.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3,921.96
|
| Rate for Payer: HealthUtah PPO |
$6,762.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$6,559.14
|
| Rate for Payer: Multiplan Medicare/VA |
$3,725.86
|
| Rate for Payer: One Health Plan of WY PPO |
$6,626.76
|
| Rate for Payer: PacificSource Commercial |
$6,085.80
|
| Rate for Payer: PHCS PPO |
$6,626.76
|
| Rate for Payer: Three Rivers PPO |
$5,071.50
|
| Rate for Payer: TriWest Veterans Administration |
$3,921.96
|
| Rate for Payer: United Healthcare Commercial |
$5,882.94
|
| Rate for Payer: United Healthcare Medicare |
$3,921.96
|
| Rate for Payer: WINHealth Partners Commercial |
$6,626.76
|
| Rate for Payer: Wise Provider Network Commercial |
$6,423.90
|
|
|
LATERA IMPLANT 24MM
|
Facility
|
OP
|
$6,762.00
|
|
| Hospital Charge Code |
27800000S1
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,725.86 |
| Max. Negotiated Rate |
$6,762.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$6,626.76
|
| Rate for Payer: Aetna of WY Medicare |
$4,462.92
|
| Rate for Payer: Altius Auto/Workers Compensation |
$6,491.52
|
| Rate for Payer: Altius Commercial |
$6,491.52
|
| Rate for Payer: Beech Street Commercial |
$6,626.76
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$5,551.60
|
| Rate for Payer: Cash Price |
$4,733.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$6,559.14
|
| Rate for Payer: Cigna of WY Commercial |
$6,626.76
|
| Rate for Payer: Entrust Commercial |
$6,423.90
|
| Rate for Payer: First Choice Health Commercial |
$6,423.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$6,423.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3,921.96
|
| Rate for Payer: HealthUtah PPO |
$6,762.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$6,559.14
|
| Rate for Payer: Multiplan Medicare/VA |
$3,725.86
|
| Rate for Payer: One Health Plan of WY PPO |
$6,626.76
|
| Rate for Payer: PacificSource Commercial |
$6,085.80
|
| Rate for Payer: PHCS PPO |
$6,626.76
|
| Rate for Payer: Three Rivers PPO |
$5,071.50
|
| Rate for Payer: TriWest Veterans Administration |
$3,921.96
|
| Rate for Payer: United Healthcare Commercial |
$5,882.94
|
| Rate for Payer: United Healthcare Medicare |
$3,921.96
|
| Rate for Payer: WINHealth Partners Commercial |
$6,626.76
|
| Rate for Payer: Wise Provider Network Commercial |
$6,423.90
|
|
|
LATERA IMPLANT 24MM
|
Facility
|
IP
|
$6,762.00
|
|
| Hospital Charge Code |
27800000S1
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,239.77 |
| Max. Negotiated Rate |
$6,762.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$6,626.76
|
| Rate for Payer: Altius Auto/Workers Compensation |
$6,491.52
|
| Rate for Payer: Altius Commercial |
$6,491.52
|
| Rate for Payer: Beech Street Commercial |
$6,626.76
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$5,551.60
|
| Rate for Payer: Cash Price |
$4,733.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$6,559.14
|
| Rate for Payer: Cigna of WY Commercial |
$6,626.76
|
| Rate for Payer: Entrust Commercial |
$6,423.90
|
| Rate for Payer: First Choice Health Commercial |
$6,423.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$6,423.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$4,462.92
|
| Rate for Payer: HealthUtah PPO |
$6,762.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$6,559.14
|
| Rate for Payer: Multiplan Medicare/VA |
$4,239.77
|
| Rate for Payer: One Health Plan of WY PPO |
$6,626.76
|
| Rate for Payer: PacificSource Commercial |
$6,085.80
|
| Rate for Payer: PHCS PPO |
$6,626.76
|
| Rate for Payer: Three Rivers PPO |
$5,071.50
|
| Rate for Payer: TriWest Veterans Administration |
$4,462.92
|
| Rate for Payer: United Healthcare Commercial |
$5,882.94
|
| Rate for Payer: United Healthcare Medicare |
$4,462.92
|
| Rate for Payer: WINHealth Partners Commercial |
$6,423.90
|
| Rate for Payer: Wise Provider Network Commercial |
$6,423.90
|
|
|
LATERAL RETINACULAR RELEASE OPEN
|
Professional
|
Both
|
$1,598.00
|
|
|
Service Code
|
HCPCS 27425 80
|
| Hospital Charge Code |
27425
|
| Min. Negotiated Rate |
$380.48 |
| Max. Negotiated Rate |
$1,598.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,566.04
|
| Rate for Payer: Aetna of WY Medicare |
$447.62
|
| Rate for Payer: Beech Street Commercial |
$1,518.10
|
| Rate for Payer: Cash Price |
$1,118.60
|
| Rate for Payer: Cash Price |
$1,118.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,550.06
|
| Rate for Payer: Cigna of WY Commercial |
$1,566.04
|
| Rate for Payer: First Choice Health Commercial |
$1,438.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,518.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$447.62
|
| Rate for Payer: HealthUtah PPO |
$1,598.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,550.06
|
| Rate for Payer: Multiplan Medicare/VA |
$380.48
|
| Rate for Payer: One Health Plan of WY PPO |
$1,566.04
|
| Rate for Payer: PacificSource Commercial |
$1,438.20
|
| Rate for Payer: PHCS PPO |
$1,518.10
|
| Rate for Payer: Three Rivers PPO |
$1,198.50
|
| Rate for Payer: TriWest Veterans Administration |
$447.62
|
| Rate for Payer: United Healthcare Commercial |
$1,390.26
|
| Rate for Payer: United Healthcare Medicare |
$447.62
|
| Rate for Payer: WINHealth Partners Commercial |
$1,358.30
|
|
|
LATERAL RETINACULAR RELEASE OPEN
|
Professional
|
Both
|
$1,598.00
|
|
|
Service Code
|
HCPCS 27425 AS
|
| Hospital Charge Code |
27425
|
| Min. Negotiated Rate |
$380.48 |
| Max. Negotiated Rate |
$1,598.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,566.04
|
| Rate for Payer: Aetna of WY Medicare |
$447.62
|
| Rate for Payer: Beech Street Commercial |
$1,518.10
|
| Rate for Payer: Cash Price |
$1,118.60
|
| Rate for Payer: Cash Price |
$1,118.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,550.06
|
| Rate for Payer: Cigna of WY Commercial |
$1,566.04
|
| Rate for Payer: First Choice Health Commercial |
$1,438.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,518.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$447.62
|
| Rate for Payer: HealthUtah PPO |
$1,598.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,550.06
|
| Rate for Payer: Multiplan Medicare/VA |
$380.48
|
| Rate for Payer: One Health Plan of WY PPO |
$1,566.04
|
| Rate for Payer: PacificSource Commercial |
$1,438.20
|
| Rate for Payer: PHCS PPO |
$1,518.10
|
| Rate for Payer: Three Rivers PPO |
$1,198.50
|
| Rate for Payer: TriWest Veterans Administration |
$447.62
|
| Rate for Payer: United Healthcare Commercial |
$1,390.26
|
| Rate for Payer: United Healthcare Medicare |
$447.62
|
| Rate for Payer: WINHealth Partners Commercial |
$1,358.30
|
|
|
LATERAL RETINACULAR RELEASE OPEN
|
Professional
|
Both
|
$1,598.00
|
|
|
Service Code
|
HCPCS 27425
|
| Hospital Charge Code |
27425
|
| Min. Negotiated Rate |
$380.48 |
| Max. Negotiated Rate |
$1,598.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,566.04
|
| Rate for Payer: Aetna of WY Medicare |
$447.62
|
| Rate for Payer: Beech Street Commercial |
$1,518.10
|
| Rate for Payer: Cash Price |
$1,118.60
|
| Rate for Payer: Cash Price |
$1,118.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,550.06
|
| Rate for Payer: Cigna of WY Commercial |
$1,566.04
|
| Rate for Payer: First Choice Health Commercial |
$1,438.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,518.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$447.62
|
| Rate for Payer: HealthUtah PPO |
$1,598.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,550.06
|
| Rate for Payer: Multiplan Medicare/VA |
$380.48
|
| Rate for Payer: One Health Plan of WY PPO |
$1,566.04
|
| Rate for Payer: PacificSource Commercial |
$1,438.20
|
| Rate for Payer: PHCS PPO |
$1,518.10
|
| Rate for Payer: Three Rivers PPO |
$1,198.50
|
| Rate for Payer: TriWest Veterans Administration |
$447.62
|
| Rate for Payer: United Healthcare Commercial |
$1,390.26
|
| Rate for Payer: United Healthcare Medicare |
$447.62
|
| Rate for Payer: WINHealth Partners Commercial |
$1,358.30
|
|
|
LATERAL RETINACULAR RELEASE OPEN
|
Professional
|
Both
|
$3,196.00
|
|
|
Service Code
|
HCPCS 27425 50
|
| Hospital Charge Code |
27425
|
| Min. Negotiated Rate |
$380.48 |
| Max. Negotiated Rate |
$3,196.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,132.08
|
| Rate for Payer: Aetna of WY Medicare |
$447.62
|
| Rate for Payer: Beech Street Commercial |
$3,036.20
|
| Rate for Payer: Cash Price |
$2,237.20
|
| Rate for Payer: Cash Price |
$2,237.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,100.12
|
| Rate for Payer: Cigna of WY Commercial |
$3,132.08
|
| Rate for Payer: First Choice Health Commercial |
$2,876.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,036.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$447.62
|
| Rate for Payer: HealthUtah PPO |
$3,196.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,100.12
|
| Rate for Payer: Multiplan Medicare/VA |
$380.48
|
| Rate for Payer: One Health Plan of WY PPO |
$3,132.08
|
| Rate for Payer: PacificSource Commercial |
$2,876.40
|
| Rate for Payer: PHCS PPO |
$3,036.20
|
| Rate for Payer: Three Rivers PPO |
$2,397.00
|
| Rate for Payer: TriWest Veterans Administration |
$447.62
|
| Rate for Payer: United Healthcare Commercial |
$2,780.52
|
| Rate for Payer: United Healthcare Medicare |
$447.62
|
| Rate for Payer: WINHealth Partners Commercial |
$2,716.60
|
|
|
LECANEMAB-IRMB 100 MG/ML INTRAVENOUS SOLUTION [180458]
|
Facility
|
IP
|
$206.11
|
|
|
Service Code
|
HCPCS J0174
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$129.23 |
| Max. Negotiated Rate |
$206.11 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$201.99
|
| Rate for Payer: Altius Auto/Workers Compensation |
$197.87
|
| Rate for Payer: Altius Commercial |
$197.87
|
| Rate for Payer: Beech Street Commercial |
$201.99
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$169.22
|
| Rate for Payer: Cash Price |
$144.27
|
| Rate for Payer: Cash Price |
$144.28
|
| Rate for Payer: ChoiceCare Network Commercial |
$199.93
|
| Rate for Payer: Cigna of WY Commercial |
$201.99
|
| Rate for Payer: Entrust Commercial |
$195.80
|
| Rate for Payer: First Choice Health Commercial |
$195.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$195.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$136.03
|
| Rate for Payer: HealthUtah PPO |
$206.11
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$199.93
|
| Rate for Payer: Multiplan Medicare/VA |
$129.23
|
| Rate for Payer: One Health Plan of WY PPO |
$201.99
|
| Rate for Payer: PacificSource Commercial |
$185.50
|
| Rate for Payer: PHCS PPO |
$201.99
|
| Rate for Payer: Three Rivers PPO |
$154.58
|
| Rate for Payer: TriWest Veterans Administration |
$136.03
|
| Rate for Payer: United Healthcare Commercial |
$179.32
|
| Rate for Payer: United Healthcare Medicare |
$136.03
|
| Rate for Payer: WINHealth Partners Commercial |
$195.80
|
| Rate for Payer: Wise Provider Network Commercial |
$195.80
|
|
|
LECANEMAB-IRMB 100 MG/ML INTRAVENOUS SOLUTION [180458]
|
Facility
|
OP
|
$206.11
|
|
|
Service Code
|
HCPCS J0174
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$113.57 |
| Max. Negotiated Rate |
$206.11 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$201.99
|
| Rate for Payer: Aetna of WY Medicare |
$136.03
|
| Rate for Payer: Altius Auto/Workers Compensation |
$197.87
|
| Rate for Payer: Altius Commercial |
$197.87
|
| Rate for Payer: Beech Street Commercial |
$201.99
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$169.22
|
| Rate for Payer: Cash Price |
$144.27
|
| Rate for Payer: Cash Price |
$144.28
|
| Rate for Payer: ChoiceCare Network Commercial |
$199.93
|
| Rate for Payer: Cigna of WY Commercial |
$201.99
|
| Rate for Payer: Entrust Commercial |
$195.80
|
| Rate for Payer: First Choice Health Commercial |
$195.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$195.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$119.54
|
| Rate for Payer: HealthUtah PPO |
$206.11
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$199.93
|
| Rate for Payer: Multiplan Medicare/VA |
$113.57
|
| Rate for Payer: One Health Plan of WY PPO |
$201.99
|
| Rate for Payer: PacificSource Commercial |
$185.50
|
| Rate for Payer: PHCS PPO |
$201.99
|
| Rate for Payer: Three Rivers PPO |
$154.58
|
| Rate for Payer: TriWest Veterans Administration |
$119.54
|
| Rate for Payer: United Healthcare Commercial |
$179.32
|
| Rate for Payer: United Healthcare Medicare |
$119.54
|
| Rate for Payer: WINHealth Partners Commercial |
$201.99
|
| Rate for Payer: Wise Provider Network Commercial |
$195.80
|
|
|
LEG BAG URINE COMB PK LG
|
Facility
|
OP
|
$24.00
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$13.22 |
| Max. Negotiated Rate |
$24.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$23.52
|
| Rate for Payer: Aetna of WY Medicare |
$15.84
|
| Rate for Payer: Altius Auto/Workers Compensation |
$23.04
|
| Rate for Payer: Altius Commercial |
$23.04
|
| Rate for Payer: Beech Street Commercial |
$23.52
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$19.70
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$23.28
|
| Rate for Payer: Cigna of WY Commercial |
$23.52
|
| Rate for Payer: Entrust Commercial |
$22.80
|
| Rate for Payer: First Choice Health Commercial |
$22.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$22.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$13.92
|
| Rate for Payer: HealthUtah PPO |
$24.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$23.28
|
| Rate for Payer: Multiplan Medicare/VA |
$13.22
|
| Rate for Payer: One Health Plan of WY PPO |
$23.52
|
| Rate for Payer: PacificSource Commercial |
$21.60
|
| Rate for Payer: PHCS PPO |
$23.52
|
| Rate for Payer: Three Rivers PPO |
$18.00
|
| Rate for Payer: TriWest Veterans Administration |
$13.92
|
| Rate for Payer: United Healthcare Commercial |
$20.88
|
| Rate for Payer: United Healthcare Medicare |
$13.92
|
| Rate for Payer: WINHealth Partners Commercial |
$23.52
|
| Rate for Payer: Wise Provider Network Commercial |
$22.80
|
|
