|
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION [41211]
|
Facility
|
OP
|
$16.77
|
|
|
Service Code
|
NDC 0143959425
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.24 |
| Max. Negotiated Rate |
$16.77 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.43
|
| Rate for Payer: Aetna of WY Medicare |
$11.07
|
| Rate for Payer: Altius Auto/Workers Compensation |
$16.10
|
| Rate for Payer: Altius Commercial |
$16.10
|
| Rate for Payer: Beech Street Commercial |
$16.43
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.77
|
| Rate for Payer: Cash Price |
$11.74
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.27
|
| Rate for Payer: Cigna of WY Commercial |
$16.43
|
| Rate for Payer: Entrust Commercial |
$15.93
|
| Rate for Payer: First Choice Health Commercial |
$15.93
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.93
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.73
|
| Rate for Payer: HealthUtah PPO |
$16.77
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.27
|
| Rate for Payer: Multiplan Medicare/VA |
$9.24
|
| Rate for Payer: One Health Plan of WY PPO |
$16.43
|
| Rate for Payer: PacificSource Commercial |
$15.09
|
| Rate for Payer: PHCS PPO |
$16.43
|
| Rate for Payer: Three Rivers PPO |
$12.58
|
| Rate for Payer: TriWest Veterans Administration |
$9.73
|
| Rate for Payer: United Healthcare Commercial |
$14.59
|
| Rate for Payer: United Healthcare Medicare |
$9.73
|
| Rate for Payer: WINHealth Partners Commercial |
$16.43
|
| Rate for Payer: Wise Provider Network Commercial |
$15.93
|
|
|
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION [41211]
|
Facility
|
IP
|
$16.77
|
|
|
Service Code
|
NDC 0143959425
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.51 |
| Max. Negotiated Rate |
$16.77 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.43
|
| Rate for Payer: Altius Auto/Workers Compensation |
$16.10
|
| Rate for Payer: Altius Commercial |
$16.10
|
| Rate for Payer: Beech Street Commercial |
$16.43
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.77
|
| Rate for Payer: Cash Price |
$11.74
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.27
|
| Rate for Payer: Cigna of WY Commercial |
$16.43
|
| Rate for Payer: Entrust Commercial |
$15.93
|
| Rate for Payer: First Choice Health Commercial |
$15.93
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.93
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.07
|
| Rate for Payer: HealthUtah PPO |
$16.77
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.27
|
| Rate for Payer: Multiplan Medicare/VA |
$10.51
|
| Rate for Payer: One Health Plan of WY PPO |
$16.43
|
| Rate for Payer: PacificSource Commercial |
$15.09
|
| Rate for Payer: PHCS PPO |
$16.43
|
| Rate for Payer: Three Rivers PPO |
$12.58
|
| Rate for Payer: TriWest Veterans Administration |
$11.07
|
| Rate for Payer: United Healthcare Commercial |
$14.59
|
| Rate for Payer: United Healthcare Medicare |
$11.07
|
| Rate for Payer: WINHealth Partners Commercial |
$15.93
|
| Rate for Payer: Wise Provider Network Commercial |
$15.93
|
|
|
LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION [41213]
|
Facility
|
OP
|
$15.35
|
|
|
Service Code
|
NDC 0409427801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.46 |
| Max. Negotiated Rate |
$15.35 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.04
|
| Rate for Payer: Aetna of WY Medicare |
$10.13
|
| Rate for Payer: Altius Auto/Workers Compensation |
$14.74
|
| Rate for Payer: Altius Commercial |
$14.74
|
| Rate for Payer: Beech Street Commercial |
$15.04
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.60
|
| Rate for Payer: Cash Price |
$10.74
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.89
|
| Rate for Payer: Cigna of WY Commercial |
$15.04
|
| Rate for Payer: Entrust Commercial |
$14.58
|
| Rate for Payer: First Choice Health Commercial |
$14.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.90
|
| Rate for Payer: HealthUtah PPO |
$15.35
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.89
|
| Rate for Payer: Multiplan Medicare/VA |
$8.46
|
| Rate for Payer: One Health Plan of WY PPO |
$15.04
|
| Rate for Payer: PacificSource Commercial |
$13.82
|
| Rate for Payer: PHCS PPO |
$15.04
|
| Rate for Payer: Three Rivers PPO |
$11.51
|
| Rate for Payer: TriWest Veterans Administration |
$8.90
|
| Rate for Payer: United Healthcare Commercial |
$13.35
|
| Rate for Payer: United Healthcare Medicare |
$8.90
|
| Rate for Payer: WINHealth Partners Commercial |
$15.04
|
| Rate for Payer: Wise Provider Network Commercial |
$14.58
|
|
|
LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION [41213]
|
Facility
|
OP
|
$15.35
|
|
|
Service Code
|
NDC 0409427816
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.46 |
| Max. Negotiated Rate |
$15.35 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.04
|
| Rate for Payer: Aetna of WY Medicare |
$10.13
|
| Rate for Payer: Altius Auto/Workers Compensation |
$14.74
|
| Rate for Payer: Altius Commercial |
$14.74
|
| Rate for Payer: Beech Street Commercial |
$15.04
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.60
|
| Rate for Payer: Cash Price |
$10.74
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.89
|
| Rate for Payer: Cigna of WY Commercial |
$15.04
|
| Rate for Payer: Entrust Commercial |
$14.58
|
| Rate for Payer: First Choice Health Commercial |
$14.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.90
|
| Rate for Payer: HealthUtah PPO |
$15.35
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.89
|
| Rate for Payer: Multiplan Medicare/VA |
$8.46
|
| Rate for Payer: One Health Plan of WY PPO |
$15.04
|
| Rate for Payer: PacificSource Commercial |
$13.82
|
| Rate for Payer: PHCS PPO |
$15.04
|
| Rate for Payer: Three Rivers PPO |
$11.51
|
| Rate for Payer: TriWest Veterans Administration |
$8.90
|
| Rate for Payer: United Healthcare Commercial |
$13.35
|
| Rate for Payer: United Healthcare Medicare |
$8.90
|
| Rate for Payer: WINHealth Partners Commercial |
$15.04
|
| Rate for Payer: Wise Provider Network Commercial |
$14.58
|
|
|
LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION [41213]
|
Facility
|
IP
|
$15.35
|
|
|
Service Code
|
NDC 0409427801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.62 |
| Max. Negotiated Rate |
$15.35 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.04
|
| Rate for Payer: Altius Auto/Workers Compensation |
$14.74
|
| Rate for Payer: Altius Commercial |
$14.74
|
| Rate for Payer: Beech Street Commercial |
$15.04
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.60
|
| Rate for Payer: Cash Price |
$10.74
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.89
|
| Rate for Payer: Cigna of WY Commercial |
$15.04
|
| Rate for Payer: Entrust Commercial |
$14.58
|
| Rate for Payer: First Choice Health Commercial |
$14.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.13
|
| Rate for Payer: HealthUtah PPO |
$15.35
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.89
|
| Rate for Payer: Multiplan Medicare/VA |
$9.62
|
| Rate for Payer: One Health Plan of WY PPO |
$15.04
|
| Rate for Payer: PacificSource Commercial |
$13.82
|
| Rate for Payer: PHCS PPO |
$15.04
|
| Rate for Payer: Three Rivers PPO |
$11.51
|
| Rate for Payer: TriWest Veterans Administration |
$10.13
|
| Rate for Payer: United Healthcare Commercial |
$13.35
|
| Rate for Payer: United Healthcare Medicare |
$10.13
|
| Rate for Payer: WINHealth Partners Commercial |
$14.58
|
| Rate for Payer: Wise Provider Network Commercial |
$14.58
|
|
|
LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION [41213]
|
Facility
|
IP
|
$16.16
|
|
|
Service Code
|
NDC 6332349101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.13 |
| Max. Negotiated Rate |
$16.16 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.84
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.51
|
| Rate for Payer: Altius Commercial |
$15.51
|
| Rate for Payer: Beech Street Commercial |
$15.84
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.27
|
| Rate for Payer: Cash Price |
$11.31
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.68
|
| Rate for Payer: Cigna of WY Commercial |
$15.84
|
| Rate for Payer: Entrust Commercial |
$15.35
|
| Rate for Payer: First Choice Health Commercial |
$15.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.67
|
| Rate for Payer: HealthUtah PPO |
$16.16
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.68
|
| Rate for Payer: Multiplan Medicare/VA |
$10.13
|
| Rate for Payer: One Health Plan of WY PPO |
$15.84
|
| Rate for Payer: PacificSource Commercial |
$14.54
|
| Rate for Payer: PHCS PPO |
$15.84
|
| Rate for Payer: Three Rivers PPO |
$12.12
|
| Rate for Payer: TriWest Veterans Administration |
$10.67
|
| Rate for Payer: United Healthcare Commercial |
$14.06
|
| Rate for Payer: United Healthcare Medicare |
$10.67
|
| Rate for Payer: WINHealth Partners Commercial |
$15.35
|
| Rate for Payer: Wise Provider Network Commercial |
$15.35
|
|
|
LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION [41213]
|
Facility
|
OP
|
$16.16
|
|
|
Service Code
|
NDC 6332349101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.90 |
| Max. Negotiated Rate |
$16.16 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.84
|
| Rate for Payer: Aetna of WY Medicare |
$10.67
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.51
|
| Rate for Payer: Altius Commercial |
$15.51
|
| Rate for Payer: Beech Street Commercial |
$15.84
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.27
|
| Rate for Payer: Cash Price |
$11.31
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.68
|
| Rate for Payer: Cigna of WY Commercial |
$15.84
|
| Rate for Payer: Entrust Commercial |
$15.35
|
| Rate for Payer: First Choice Health Commercial |
$15.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.37
|
| Rate for Payer: HealthUtah PPO |
$16.16
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.68
|
| Rate for Payer: Multiplan Medicare/VA |
$8.90
|
| Rate for Payer: One Health Plan of WY PPO |
$15.84
|
| Rate for Payer: PacificSource Commercial |
$14.54
|
| Rate for Payer: PHCS PPO |
$15.84
|
| Rate for Payer: Three Rivers PPO |
$12.12
|
| Rate for Payer: TriWest Veterans Administration |
$9.37
|
| Rate for Payer: United Healthcare Commercial |
$14.06
|
| Rate for Payer: United Healthcare Medicare |
$9.37
|
| Rate for Payer: WINHealth Partners Commercial |
$15.84
|
| Rate for Payer: Wise Provider Network Commercial |
$15.35
|
|
|
LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION [41213]
|
Facility
|
IP
|
$15.35
|
|
|
Service Code
|
NDC 0409427816
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.62 |
| Max. Negotiated Rate |
$15.35 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.04
|
| Rate for Payer: Altius Auto/Workers Compensation |
$14.74
|
| Rate for Payer: Altius Commercial |
$14.74
|
| Rate for Payer: Beech Street Commercial |
$15.04
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.60
|
| Rate for Payer: Cash Price |
$10.74
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.89
|
| Rate for Payer: Cigna of WY Commercial |
$15.04
|
| Rate for Payer: Entrust Commercial |
$14.58
|
| Rate for Payer: First Choice Health Commercial |
$14.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.13
|
| Rate for Payer: HealthUtah PPO |
$15.35
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.89
|
| Rate for Payer: Multiplan Medicare/VA |
$9.62
|
| Rate for Payer: One Health Plan of WY PPO |
$15.04
|
| Rate for Payer: PacificSource Commercial |
$13.82
|
| Rate for Payer: PHCS PPO |
$15.04
|
| Rate for Payer: Three Rivers PPO |
$11.51
|
| Rate for Payer: TriWest Veterans Administration |
$10.13
|
| Rate for Payer: United Healthcare Commercial |
$13.35
|
| Rate for Payer: United Healthcare Medicare |
$10.13
|
| Rate for Payer: WINHealth Partners Commercial |
$14.58
|
| Rate for Payer: Wise Provider Network Commercial |
$14.58
|
|
|
LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM [8326]
|
Facility
|
IP
|
$3.02
|
|
|
Service Code
|
NDC 6233258231
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.89 |
| Max. Negotiated Rate |
$3.02 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.96
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.90
|
| Rate for Payer: Altius Commercial |
$2.90
|
| Rate for Payer: Beech Street Commercial |
$2.96
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.48
|
| Rate for Payer: Cash Price |
$2.11
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.93
|
| Rate for Payer: Cigna of WY Commercial |
$2.96
|
| Rate for Payer: Entrust Commercial |
$2.87
|
| Rate for Payer: First Choice Health Commercial |
$2.87
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.87
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.99
|
| Rate for Payer: HealthUtah PPO |
$3.02
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.93
|
| Rate for Payer: Multiplan Medicare/VA |
$1.89
|
| Rate for Payer: One Health Plan of WY PPO |
$2.96
|
| Rate for Payer: PacificSource Commercial |
$2.72
|
| Rate for Payer: PHCS PPO |
$2.96
|
| Rate for Payer: Three Rivers PPO |
$2.26
|
| Rate for Payer: TriWest Veterans Administration |
$1.99
|
| Rate for Payer: United Healthcare Commercial |
$2.63
|
| Rate for Payer: United Healthcare Medicare |
$1.99
|
| Rate for Payer: WINHealth Partners Commercial |
$2.87
|
| Rate for Payer: Wise Provider Network Commercial |
$2.87
|
|
|
LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM [8326]
|
Facility
|
IP
|
$6.61
|
|
|
Service Code
|
NDC 0168035705
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.14 |
| Max. Negotiated Rate |
$6.61 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$6.48
|
| Rate for Payer: Altius Auto/Workers Compensation |
$6.35
|
| Rate for Payer: Altius Commercial |
$6.35
|
| Rate for Payer: Beech Street Commercial |
$6.48
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$5.43
|
| Rate for Payer: Cash Price |
$4.63
|
| Rate for Payer: ChoiceCare Network Commercial |
$6.41
|
| Rate for Payer: Cigna of WY Commercial |
$6.48
|
| Rate for Payer: Entrust Commercial |
$6.28
|
| Rate for Payer: First Choice Health Commercial |
$6.28
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$6.28
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$4.36
|
| Rate for Payer: HealthUtah PPO |
$6.61
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$6.41
|
| Rate for Payer: Multiplan Medicare/VA |
$4.14
|
| Rate for Payer: One Health Plan of WY PPO |
$6.48
|
| Rate for Payer: PacificSource Commercial |
$5.95
|
| Rate for Payer: PHCS PPO |
$6.48
|
| Rate for Payer: Three Rivers PPO |
$4.96
|
| Rate for Payer: TriWest Veterans Administration |
$4.36
|
| Rate for Payer: United Healthcare Commercial |
$5.75
|
| Rate for Payer: United Healthcare Medicare |
$4.36
|
| Rate for Payer: WINHealth Partners Commercial |
$6.28
|
| Rate for Payer: Wise Provider Network Commercial |
$6.28
|
|
|
LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM [8326]
|
Facility
|
OP
|
$3.02
|
|
|
Service Code
|
NDC 6233258231
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.66 |
| Max. Negotiated Rate |
$3.02 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.96
|
| Rate for Payer: Aetna of WY Medicare |
$1.99
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.90
|
| Rate for Payer: Altius Commercial |
$2.90
|
| Rate for Payer: Beech Street Commercial |
$2.96
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.48
|
| Rate for Payer: Cash Price |
$2.11
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.93
|
| Rate for Payer: Cigna of WY Commercial |
$2.96
|
| Rate for Payer: Entrust Commercial |
$2.87
|
| Rate for Payer: First Choice Health Commercial |
$2.87
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.87
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.75
|
| Rate for Payer: HealthUtah PPO |
$3.02
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.93
|
| Rate for Payer: Multiplan Medicare/VA |
$1.66
|
| Rate for Payer: One Health Plan of WY PPO |
$2.96
|
| Rate for Payer: PacificSource Commercial |
$2.72
|
| Rate for Payer: PHCS PPO |
$2.96
|
| Rate for Payer: Three Rivers PPO |
$2.26
|
| Rate for Payer: TriWest Veterans Administration |
$1.75
|
| Rate for Payer: United Healthcare Commercial |
$2.63
|
| Rate for Payer: United Healthcare Medicare |
$1.75
|
| Rate for Payer: WINHealth Partners Commercial |
$2.96
|
| Rate for Payer: Wise Provider Network Commercial |
$2.87
|
|
|
LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM [8326]
|
Facility
|
OP
|
$6.61
|
|
|
Service Code
|
NDC 0168035705
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.64 |
| Max. Negotiated Rate |
$6.61 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$6.48
|
| Rate for Payer: Aetna of WY Medicare |
$4.36
|
| Rate for Payer: Altius Auto/Workers Compensation |
$6.35
|
| Rate for Payer: Altius Commercial |
$6.35
|
| Rate for Payer: Beech Street Commercial |
$6.48
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$5.43
|
| Rate for Payer: Cash Price |
$4.63
|
| Rate for Payer: ChoiceCare Network Commercial |
$6.41
|
| Rate for Payer: Cigna of WY Commercial |
$6.48
|
| Rate for Payer: Entrust Commercial |
$6.28
|
| Rate for Payer: First Choice Health Commercial |
$6.28
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$6.28
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3.83
|
| Rate for Payer: HealthUtah PPO |
$6.61
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$6.41
|
| Rate for Payer: Multiplan Medicare/VA |
$3.64
|
| Rate for Payer: One Health Plan of WY PPO |
$6.48
|
| Rate for Payer: PacificSource Commercial |
$5.95
|
| Rate for Payer: PHCS PPO |
$6.48
|
| Rate for Payer: Three Rivers PPO |
$4.96
|
| Rate for Payer: TriWest Veterans Administration |
$3.83
|
| Rate for Payer: United Healthcare Commercial |
$5.75
|
| Rate for Payer: United Healthcare Medicare |
$3.83
|
| Rate for Payer: WINHealth Partners Commercial |
$6.48
|
| Rate for Payer: Wise Provider Network Commercial |
$6.28
|
|
|
LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM [8326]
|
Facility
|
IP
|
$4.61
|
|
|
Service Code
|
NDC 5038366730
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.89 |
| Max. Negotiated Rate |
$4.61 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4.52
|
| Rate for Payer: Altius Auto/Workers Compensation |
$4.43
|
| Rate for Payer: Altius Commercial |
$4.43
|
| Rate for Payer: Beech Street Commercial |
$4.52
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3.78
|
| Rate for Payer: Cash Price |
$3.22
|
| Rate for Payer: ChoiceCare Network Commercial |
$4.47
|
| Rate for Payer: Cigna of WY Commercial |
$4.52
|
| Rate for Payer: Entrust Commercial |
$4.38
|
| Rate for Payer: First Choice Health Commercial |
$4.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3.04
|
| Rate for Payer: HealthUtah PPO |
$4.61
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4.47
|
| Rate for Payer: Multiplan Medicare/VA |
$2.89
|
| Rate for Payer: One Health Plan of WY PPO |
$4.52
|
| Rate for Payer: PacificSource Commercial |
$4.15
|
| Rate for Payer: PHCS PPO |
$4.52
|
| Rate for Payer: Three Rivers PPO |
$3.46
|
| Rate for Payer: TriWest Veterans Administration |
$3.04
|
| Rate for Payer: United Healthcare Commercial |
$4.01
|
| Rate for Payer: United Healthcare Medicare |
$3.04
|
| Rate for Payer: WINHealth Partners Commercial |
$4.38
|
| Rate for Payer: Wise Provider Network Commercial |
$4.38
|
|
|
LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM [8326]
|
Facility
|
OP
|
$4.61
|
|
|
Service Code
|
NDC 5038366730
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.54 |
| Max. Negotiated Rate |
$4.61 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4.52
|
| Rate for Payer: Aetna of WY Medicare |
$3.04
|
| Rate for Payer: Altius Auto/Workers Compensation |
$4.43
|
| Rate for Payer: Altius Commercial |
$4.43
|
| Rate for Payer: Beech Street Commercial |
$4.52
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3.78
|
| Rate for Payer: Cash Price |
$3.22
|
| Rate for Payer: ChoiceCare Network Commercial |
$4.47
|
| Rate for Payer: Cigna of WY Commercial |
$4.52
|
| Rate for Payer: Entrust Commercial |
$4.38
|
| Rate for Payer: First Choice Health Commercial |
$4.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2.67
|
| Rate for Payer: HealthUtah PPO |
$4.61
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4.47
|
| Rate for Payer: Multiplan Medicare/VA |
$2.54
|
| Rate for Payer: One Health Plan of WY PPO |
$4.52
|
| Rate for Payer: PacificSource Commercial |
$4.15
|
| Rate for Payer: PHCS PPO |
$4.52
|
| Rate for Payer: Three Rivers PPO |
$3.46
|
| Rate for Payer: TriWest Veterans Administration |
$2.67
|
| Rate for Payer: United Healthcare Commercial |
$4.01
|
| Rate for Payer: United Healthcare Medicare |
$2.67
|
| Rate for Payer: WINHealth Partners Commercial |
$4.52
|
| Rate for Payer: Wise Provider Network Commercial |
$4.38
|
|
|
LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL KIT [6353]
|
Facility
|
IP
|
$82.64
|
|
|
Service Code
|
NDC 0168035756
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$51.82 |
| Max. Negotiated Rate |
$82.64 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$80.99
|
| Rate for Payer: Altius Auto/Workers Compensation |
$79.33
|
| Rate for Payer: Altius Commercial |
$79.33
|
| Rate for Payer: Beech Street Commercial |
$80.99
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$67.85
|
| Rate for Payer: Cash Price |
$57.85
|
| Rate for Payer: ChoiceCare Network Commercial |
$80.16
|
| Rate for Payer: Cigna of WY Commercial |
$80.99
|
| Rate for Payer: Entrust Commercial |
$78.51
|
| Rate for Payer: First Choice Health Commercial |
$78.51
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$78.51
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$54.54
|
| Rate for Payer: HealthUtah PPO |
$82.64
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$80.16
|
| Rate for Payer: Multiplan Medicare/VA |
$51.82
|
| Rate for Payer: One Health Plan of WY PPO |
$80.99
|
| Rate for Payer: PacificSource Commercial |
$74.38
|
| Rate for Payer: PHCS PPO |
$80.99
|
| Rate for Payer: Three Rivers PPO |
$61.98
|
| Rate for Payer: TriWest Veterans Administration |
$54.54
|
| Rate for Payer: United Healthcare Commercial |
$71.90
|
| Rate for Payer: United Healthcare Medicare |
$54.54
|
| Rate for Payer: WINHealth Partners Commercial |
$78.51
|
| Rate for Payer: Wise Provider Network Commercial |
$78.51
|
|
|
LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL KIT [6353]
|
Facility
|
OP
|
$82.64
|
|
|
Service Code
|
NDC 0168035756
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$45.53 |
| Max. Negotiated Rate |
$82.64 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$80.99
|
| Rate for Payer: Aetna of WY Medicare |
$54.54
|
| Rate for Payer: Altius Auto/Workers Compensation |
$79.33
|
| Rate for Payer: Altius Commercial |
$79.33
|
| Rate for Payer: Beech Street Commercial |
$80.99
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$67.85
|
| Rate for Payer: Cash Price |
$57.85
|
| Rate for Payer: ChoiceCare Network Commercial |
$80.16
|
| Rate for Payer: Cigna of WY Commercial |
$80.99
|
| Rate for Payer: Entrust Commercial |
$78.51
|
| Rate for Payer: First Choice Health Commercial |
$78.51
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$78.51
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$47.93
|
| Rate for Payer: HealthUtah PPO |
$82.64
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$80.16
|
| Rate for Payer: Multiplan Medicare/VA |
$45.53
|
| Rate for Payer: One Health Plan of WY PPO |
$80.99
|
| Rate for Payer: PacificSource Commercial |
$74.38
|
| Rate for Payer: PHCS PPO |
$80.99
|
| Rate for Payer: Three Rivers PPO |
$61.98
|
| Rate for Payer: TriWest Veterans Administration |
$47.93
|
| Rate for Payer: United Healthcare Commercial |
$71.90
|
| Rate for Payer: United Healthcare Medicare |
$47.93
|
| Rate for Payer: WINHealth Partners Commercial |
$80.99
|
| Rate for Payer: Wise Provider Network Commercial |
$78.51
|
|
|
LIGACLIP LARGE YELLOW
|
Facility
|
OP
|
$75.09
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$41.37 |
| Max. Negotiated Rate |
$75.09 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$73.59
|
| Rate for Payer: Aetna of WY Medicare |
$49.56
|
| Rate for Payer: Altius Auto/Workers Compensation |
$72.09
|
| Rate for Payer: Altius Commercial |
$72.09
|
| Rate for Payer: Beech Street Commercial |
$73.59
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$61.65
|
| Rate for Payer: Cash Price |
$52.56
|
| Rate for Payer: ChoiceCare Network Commercial |
$72.84
|
| Rate for Payer: Cigna of WY Commercial |
$73.59
|
| Rate for Payer: Entrust Commercial |
$71.34
|
| Rate for Payer: First Choice Health Commercial |
$71.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$71.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$43.55
|
| Rate for Payer: HealthUtah PPO |
$75.09
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$72.84
|
| Rate for Payer: Multiplan Medicare/VA |
$41.37
|
| Rate for Payer: One Health Plan of WY PPO |
$73.59
|
| Rate for Payer: PacificSource Commercial |
$67.58
|
| Rate for Payer: PHCS PPO |
$73.59
|
| Rate for Payer: Three Rivers PPO |
$56.32
|
| Rate for Payer: TriWest Veterans Administration |
$43.55
|
| Rate for Payer: United Healthcare Commercial |
$65.33
|
| Rate for Payer: United Healthcare Medicare |
$43.55
|
| Rate for Payer: WINHealth Partners Commercial |
$73.59
|
| Rate for Payer: Wise Provider Network Commercial |
$71.34
|
|
|
LIGACLIP LARGE YELLOW
|
Facility
|
IP
|
$75.09
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$47.08 |
| Max. Negotiated Rate |
$75.09 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$73.59
|
| Rate for Payer: Altius Auto/Workers Compensation |
$72.09
|
| Rate for Payer: Altius Commercial |
$72.09
|
| Rate for Payer: Beech Street Commercial |
$73.59
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$61.65
|
| Rate for Payer: Cash Price |
$52.56
|
| Rate for Payer: ChoiceCare Network Commercial |
$72.84
|
| Rate for Payer: Cigna of WY Commercial |
$73.59
|
| Rate for Payer: Entrust Commercial |
$71.34
|
| Rate for Payer: First Choice Health Commercial |
$71.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$71.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$49.56
|
| Rate for Payer: HealthUtah PPO |
$75.09
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$72.84
|
| Rate for Payer: Multiplan Medicare/VA |
$47.08
|
| Rate for Payer: One Health Plan of WY PPO |
$73.59
|
| Rate for Payer: PacificSource Commercial |
$67.58
|
| Rate for Payer: PHCS PPO |
$73.59
|
| Rate for Payer: Three Rivers PPO |
$56.32
|
| Rate for Payer: TriWest Veterans Administration |
$49.56
|
| Rate for Payer: United Healthcare Commercial |
$65.33
|
| Rate for Payer: United Healthcare Medicare |
$49.56
|
| Rate for Payer: WINHealth Partners Commercial |
$71.34
|
| Rate for Payer: Wise Provider Network Commercial |
$71.34
|
|
|
LIGAMAX 5 CLIP APPLIER EL5ML
|
Facility
|
OP
|
$225.25
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$124.11 |
| Max. Negotiated Rate |
$225.25 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$220.74
|
| Rate for Payer: Aetna of WY Medicare |
$148.66
|
| Rate for Payer: Altius Auto/Workers Compensation |
$216.24
|
| Rate for Payer: Altius Commercial |
$216.24
|
| Rate for Payer: Beech Street Commercial |
$220.74
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$184.93
|
| Rate for Payer: Cash Price |
$157.67
|
| Rate for Payer: ChoiceCare Network Commercial |
$218.49
|
| Rate for Payer: Cigna of WY Commercial |
$220.74
|
| Rate for Payer: Entrust Commercial |
$213.99
|
| Rate for Payer: First Choice Health Commercial |
$213.99
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$213.99
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$130.64
|
| Rate for Payer: HealthUtah PPO |
$225.25
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$218.49
|
| Rate for Payer: Multiplan Medicare/VA |
$124.11
|
| Rate for Payer: One Health Plan of WY PPO |
$220.74
|
| Rate for Payer: PacificSource Commercial |
$202.72
|
| Rate for Payer: PHCS PPO |
$220.74
|
| Rate for Payer: Three Rivers PPO |
$168.94
|
| Rate for Payer: TriWest Veterans Administration |
$130.64
|
| Rate for Payer: United Healthcare Commercial |
$195.97
|
| Rate for Payer: United Healthcare Medicare |
$130.64
|
| Rate for Payer: WINHealth Partners Commercial |
$220.74
|
| Rate for Payer: Wise Provider Network Commercial |
$213.99
|
|
|
LIGAMAX 5 CLIP APPLIER EL5ML
|
Facility
|
IP
|
$225.25
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$141.23 |
| Max. Negotiated Rate |
$225.25 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$220.74
|
| Rate for Payer: Altius Auto/Workers Compensation |
$216.24
|
| Rate for Payer: Altius Commercial |
$216.24
|
| Rate for Payer: Beech Street Commercial |
$220.74
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$184.93
|
| Rate for Payer: Cash Price |
$157.67
|
| Rate for Payer: ChoiceCare Network Commercial |
$218.49
|
| Rate for Payer: Cigna of WY Commercial |
$220.74
|
| Rate for Payer: Entrust Commercial |
$213.99
|
| Rate for Payer: First Choice Health Commercial |
$213.99
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$213.99
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$148.66
|
| Rate for Payer: HealthUtah PPO |
$225.25
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$218.49
|
| Rate for Payer: Multiplan Medicare/VA |
$141.23
|
| Rate for Payer: One Health Plan of WY PPO |
$220.74
|
| Rate for Payer: PacificSource Commercial |
$202.72
|
| Rate for Payer: PHCS PPO |
$220.74
|
| Rate for Payer: Three Rivers PPO |
$168.94
|
| Rate for Payer: TriWest Veterans Administration |
$148.66
|
| Rate for Payer: United Healthcare Commercial |
$195.97
|
| Rate for Payer: United Healthcare Medicare |
$148.66
|
| Rate for Payer: WINHealth Partners Commercial |
$213.99
|
| Rate for Payer: Wise Provider Network Commercial |
$213.99
|
|
|
LIGAMENTOUS RECONSTRUCTION KNEE EXTRA-ARTICULAR
|
Professional
|
Both
|
$3,671.00
|
|
|
Service Code
|
HCPCS 27427
|
| Hospital Charge Code |
27427
|
| Min. Negotiated Rate |
$585.91 |
| Max. Negotiated Rate |
$3,671.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,597.58
|
| Rate for Payer: Aetna of WY Medicare |
$689.31
|
| Rate for Payer: Beech Street Commercial |
$3,487.45
|
| Rate for Payer: Cash Price |
$2,569.70
|
| Rate for Payer: Cash Price |
$2,569.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,560.87
|
| Rate for Payer: Cigna of WY Commercial |
$3,597.58
|
| Rate for Payer: First Choice Health Commercial |
$3,303.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,487.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$689.31
|
| Rate for Payer: HealthUtah PPO |
$3,671.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,560.87
|
| Rate for Payer: Multiplan Medicare/VA |
$585.91
|
| Rate for Payer: One Health Plan of WY PPO |
$3,597.58
|
| Rate for Payer: PacificSource Commercial |
$3,303.90
|
| Rate for Payer: PHCS PPO |
$3,487.45
|
| Rate for Payer: Three Rivers PPO |
$2,753.25
|
| Rate for Payer: TriWest Veterans Administration |
$689.31
|
| Rate for Payer: United Healthcare Commercial |
$3,193.77
|
| Rate for Payer: United Healthcare Medicare |
$689.31
|
| Rate for Payer: WINHealth Partners Commercial |
$3,120.35
|
|
|
LIGAMENTOUS RECONSTRUCTION KNEE EXTRA-ARTICULAR
|
Professional
|
Both
|
$3,671.00
|
|
|
Service Code
|
HCPCS 27427 AS
|
| Hospital Charge Code |
27427
|
| Min. Negotiated Rate |
$585.91 |
| Max. Negotiated Rate |
$3,671.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,597.58
|
| Rate for Payer: Aetna of WY Medicare |
$689.31
|
| Rate for Payer: Beech Street Commercial |
$3,487.45
|
| Rate for Payer: Cash Price |
$2,569.70
|
| Rate for Payer: Cash Price |
$2,569.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,560.87
|
| Rate for Payer: Cigna of WY Commercial |
$3,597.58
|
| Rate for Payer: First Choice Health Commercial |
$3,303.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,487.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$689.31
|
| Rate for Payer: HealthUtah PPO |
$3,671.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,560.87
|
| Rate for Payer: Multiplan Medicare/VA |
$585.91
|
| Rate for Payer: One Health Plan of WY PPO |
$3,597.58
|
| Rate for Payer: PacificSource Commercial |
$3,303.90
|
| Rate for Payer: PHCS PPO |
$3,487.45
|
| Rate for Payer: Three Rivers PPO |
$2,753.25
|
| Rate for Payer: TriWest Veterans Administration |
$689.31
|
| Rate for Payer: United Healthcare Commercial |
$3,193.77
|
| Rate for Payer: United Healthcare Medicare |
$689.31
|
| Rate for Payer: WINHealth Partners Commercial |
$3,120.35
|
|
|
LIGAMENTOUS RECONSTRUCTION KNEE INTRA-ARTICULAR
|
Professional
|
Both
|
$5,753.00
|
|
|
Service Code
|
HCPCS 27428 AS
|
| Hospital Charge Code |
27428
|
| Min. Negotiated Rate |
$918.54 |
| Max. Negotiated Rate |
$5,753.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5,637.94
|
| Rate for Payer: Aetna of WY Medicare |
$1,080.63
|
| Rate for Payer: Beech Street Commercial |
$5,465.35
|
| Rate for Payer: Cash Price |
$4,027.10
|
| Rate for Payer: Cash Price |
$4,027.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$5,580.41
|
| Rate for Payer: Cigna of WY Commercial |
$5,637.94
|
| Rate for Payer: First Choice Health Commercial |
$5,177.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5,465.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,080.63
|
| Rate for Payer: HealthUtah PPO |
$5,753.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5,580.41
|
| Rate for Payer: Multiplan Medicare/VA |
$918.54
|
| Rate for Payer: One Health Plan of WY PPO |
$5,637.94
|
| Rate for Payer: PacificSource Commercial |
$5,177.70
|
| Rate for Payer: PHCS PPO |
$5,465.35
|
| Rate for Payer: Three Rivers PPO |
$4,314.75
|
| Rate for Payer: TriWest Veterans Administration |
$1,080.63
|
| Rate for Payer: United Healthcare Commercial |
$5,005.11
|
| Rate for Payer: United Healthcare Medicare |
$1,080.63
|
| Rate for Payer: WINHealth Partners Commercial |
$4,890.05
|
|
|
LIGAMENTOUS RECONSTRUCTION KNEE INTRA-ARTICULAR
|
Professional
|
Both
|
$5,753.00
|
|
|
Service Code
|
HCPCS 27428 80
|
| Hospital Charge Code |
27428
|
| Min. Negotiated Rate |
$918.54 |
| Max. Negotiated Rate |
$5,753.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5,637.94
|
| Rate for Payer: Aetna of WY Medicare |
$1,080.63
|
| Rate for Payer: Beech Street Commercial |
$5,465.35
|
| Rate for Payer: Cash Price |
$4,027.10
|
| Rate for Payer: Cash Price |
$4,027.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$5,580.41
|
| Rate for Payer: Cigna of WY Commercial |
$5,637.94
|
| Rate for Payer: First Choice Health Commercial |
$5,177.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5,465.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,080.63
|
| Rate for Payer: HealthUtah PPO |
$5,753.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5,580.41
|
| Rate for Payer: Multiplan Medicare/VA |
$918.54
|
| Rate for Payer: One Health Plan of WY PPO |
$5,637.94
|
| Rate for Payer: PacificSource Commercial |
$5,177.70
|
| Rate for Payer: PHCS PPO |
$5,465.35
|
| Rate for Payer: Three Rivers PPO |
$4,314.75
|
| Rate for Payer: TriWest Veterans Administration |
$1,080.63
|
| Rate for Payer: United Healthcare Commercial |
$5,005.11
|
| Rate for Payer: United Healthcare Medicare |
$1,080.63
|
| Rate for Payer: WINHealth Partners Commercial |
$4,890.05
|
|
|
LIGAMENTOUS RECONSTRUCTION KNEE INTRA-ARTICULAR
|
Professional
|
Both
|
$5,753.00
|
|
|
Service Code
|
HCPCS 27428
|
| Hospital Charge Code |
27428
|
| Min. Negotiated Rate |
$918.54 |
| Max. Negotiated Rate |
$5,753.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5,637.94
|
| Rate for Payer: Aetna of WY Medicare |
$1,080.63
|
| Rate for Payer: Beech Street Commercial |
$5,465.35
|
| Rate for Payer: Cash Price |
$4,027.10
|
| Rate for Payer: Cash Price |
$4,027.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$5,580.41
|
| Rate for Payer: Cigna of WY Commercial |
$5,637.94
|
| Rate for Payer: First Choice Health Commercial |
$5,177.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5,465.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,080.63
|
| Rate for Payer: HealthUtah PPO |
$5,753.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5,580.41
|
| Rate for Payer: Multiplan Medicare/VA |
$918.54
|
| Rate for Payer: One Health Plan of WY PPO |
$5,637.94
|
| Rate for Payer: PacificSource Commercial |
$5,177.70
|
| Rate for Payer: PHCS PPO |
$5,465.35
|
| Rate for Payer: Three Rivers PPO |
$4,314.75
|
| Rate for Payer: TriWest Veterans Administration |
$1,080.63
|
| Rate for Payer: United Healthcare Commercial |
$5,005.11
|
| Rate for Payer: United Healthcare Medicare |
$1,080.63
|
| Rate for Payer: WINHealth Partners Commercial |
$4,890.05
|
|
