|
MASK BVM INFANT PEEP & MANOMETER
|
Facility
|
IP
|
$38.62
|
|
| Hospital Charge Code |
27000000S1
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$24.21 |
| Max. Negotiated Rate |
$38.62 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$37.85
|
| Rate for Payer: Altius Auto/Workers Compensation |
$37.08
|
| Rate for Payer: Altius Commercial |
$37.08
|
| Rate for Payer: Beech Street Commercial |
$37.85
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$31.71
|
| Rate for Payer: Cash Price |
$27.04
|
| Rate for Payer: ChoiceCare Network Commercial |
$37.46
|
| Rate for Payer: Cigna of WY Commercial |
$37.85
|
| Rate for Payer: Entrust Commercial |
$36.69
|
| Rate for Payer: First Choice Health Commercial |
$36.69
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$36.69
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$25.49
|
| Rate for Payer: HealthUtah PPO |
$38.62
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$37.46
|
| Rate for Payer: Multiplan Medicare/VA |
$24.21
|
| Rate for Payer: One Health Plan of WY PPO |
$37.85
|
| Rate for Payer: PacificSource Commercial |
$34.76
|
| Rate for Payer: PHCS PPO |
$37.85
|
| Rate for Payer: Three Rivers PPO |
$28.96
|
| Rate for Payer: TriWest Veterans Administration |
$25.49
|
| Rate for Payer: United Healthcare Commercial |
$33.60
|
| Rate for Payer: United Healthcare Medicare |
$25.49
|
| Rate for Payer: WINHealth Partners Commercial |
$36.69
|
| Rate for Payer: Wise Provider Network Commercial |
$36.69
|
|
|
MASK BVM PEDS PEEP & MANOMETER
|
Facility
|
IP
|
$42.02
|
|
| Hospital Charge Code |
27000000S1
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$26.35 |
| Max. Negotiated Rate |
$42.02 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$41.18
|
| Rate for Payer: Altius Auto/Workers Compensation |
$40.34
|
| Rate for Payer: Altius Commercial |
$40.34
|
| Rate for Payer: Beech Street Commercial |
$41.18
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$34.50
|
| Rate for Payer: Cash Price |
$29.42
|
| Rate for Payer: ChoiceCare Network Commercial |
$40.76
|
| Rate for Payer: Cigna of WY Commercial |
$41.18
|
| Rate for Payer: Entrust Commercial |
$39.92
|
| Rate for Payer: First Choice Health Commercial |
$39.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$39.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$27.73
|
| Rate for Payer: HealthUtah PPO |
$42.02
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$40.76
|
| Rate for Payer: Multiplan Medicare/VA |
$26.35
|
| Rate for Payer: One Health Plan of WY PPO |
$41.18
|
| Rate for Payer: PacificSource Commercial |
$37.82
|
| Rate for Payer: PHCS PPO |
$41.18
|
| Rate for Payer: Three Rivers PPO |
$31.52
|
| Rate for Payer: TriWest Veterans Administration |
$27.73
|
| Rate for Payer: United Healthcare Commercial |
$36.56
|
| Rate for Payer: United Healthcare Medicare |
$27.73
|
| Rate for Payer: WINHealth Partners Commercial |
$39.92
|
| Rate for Payer: Wise Provider Network Commercial |
$39.92
|
|
|
MASK BVM PEDS PEEP & MANOMETER
|
Facility
|
OP
|
$42.02
|
|
| Hospital Charge Code |
27000000S1
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$23.15 |
| Max. Negotiated Rate |
$42.02 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$41.18
|
| Rate for Payer: Aetna of WY Medicare |
$27.73
|
| Rate for Payer: Altius Auto/Workers Compensation |
$40.34
|
| Rate for Payer: Altius Commercial |
$40.34
|
| Rate for Payer: Beech Street Commercial |
$41.18
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$34.50
|
| Rate for Payer: Cash Price |
$29.42
|
| Rate for Payer: ChoiceCare Network Commercial |
$40.76
|
| Rate for Payer: Cigna of WY Commercial |
$41.18
|
| Rate for Payer: Entrust Commercial |
$39.92
|
| Rate for Payer: First Choice Health Commercial |
$39.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$39.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$24.37
|
| Rate for Payer: HealthUtah PPO |
$42.02
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$40.76
|
| Rate for Payer: Multiplan Medicare/VA |
$23.15
|
| Rate for Payer: One Health Plan of WY PPO |
$41.18
|
| Rate for Payer: PacificSource Commercial |
$37.82
|
| Rate for Payer: PHCS PPO |
$41.18
|
| Rate for Payer: Three Rivers PPO |
$31.52
|
| Rate for Payer: TriWest Veterans Administration |
$24.37
|
| Rate for Payer: United Healthcare Commercial |
$36.56
|
| Rate for Payer: United Healthcare Medicare |
$24.37
|
| Rate for Payer: WINHealth Partners Commercial |
$41.18
|
| Rate for Payer: Wise Provider Network Commercial |
$39.92
|
|
|
MASK NEO 42MM RD804
|
Facility
|
OP
|
$18.91
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$10.42 |
| Max. Negotiated Rate |
$18.91 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18.53
|
| Rate for Payer: Aetna of WY Medicare |
$12.48
|
| Rate for Payer: Altius Auto/Workers Compensation |
$18.15
|
| Rate for Payer: Altius Commercial |
$18.15
|
| Rate for Payer: Beech Street Commercial |
$18.53
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.53
|
| Rate for Payer: Cash Price |
$13.23
|
| Rate for Payer: ChoiceCare Network Commercial |
$18.34
|
| Rate for Payer: Cigna of WY Commercial |
$18.53
|
| Rate for Payer: Entrust Commercial |
$17.96
|
| Rate for Payer: First Choice Health Commercial |
$17.96
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.96
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.97
|
| Rate for Payer: HealthUtah PPO |
$18.91
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$18.34
|
| Rate for Payer: Multiplan Medicare/VA |
$10.42
|
| Rate for Payer: One Health Plan of WY PPO |
$18.53
|
| Rate for Payer: PacificSource Commercial |
$17.02
|
| Rate for Payer: PHCS PPO |
$18.53
|
| Rate for Payer: Three Rivers PPO |
$14.18
|
| Rate for Payer: TriWest Veterans Administration |
$10.97
|
| Rate for Payer: United Healthcare Commercial |
$16.45
|
| Rate for Payer: United Healthcare Medicare |
$10.97
|
| Rate for Payer: WINHealth Partners Commercial |
$18.53
|
| Rate for Payer: Wise Provider Network Commercial |
$17.96
|
|
|
MASK NEO 42MM RD804
|
Facility
|
IP
|
$18.91
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$11.86 |
| Max. Negotiated Rate |
$18.91 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18.53
|
| Rate for Payer: Altius Auto/Workers Compensation |
$18.15
|
| Rate for Payer: Altius Commercial |
$18.15
|
| Rate for Payer: Beech Street Commercial |
$18.53
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.53
|
| Rate for Payer: Cash Price |
$13.23
|
| Rate for Payer: ChoiceCare Network Commercial |
$18.34
|
| Rate for Payer: Cigna of WY Commercial |
$18.53
|
| Rate for Payer: Entrust Commercial |
$17.96
|
| Rate for Payer: First Choice Health Commercial |
$17.96
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.96
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$12.48
|
| Rate for Payer: HealthUtah PPO |
$18.91
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$18.34
|
| Rate for Payer: Multiplan Medicare/VA |
$11.86
|
| Rate for Payer: One Health Plan of WY PPO |
$18.53
|
| Rate for Payer: PacificSource Commercial |
$17.02
|
| Rate for Payer: PHCS PPO |
$18.53
|
| Rate for Payer: Three Rivers PPO |
$14.18
|
| Rate for Payer: TriWest Veterans Administration |
$12.48
|
| Rate for Payer: United Healthcare Commercial |
$16.45
|
| Rate for Payer: United Healthcare Medicare |
$12.48
|
| Rate for Payer: WINHealth Partners Commercial |
$17.96
|
| Rate for Payer: Wise Provider Network Commercial |
$17.96
|
|
|
MASK NEO-PUFF 60MM RD806
|
Facility
|
OP
|
$19.72
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$10.87 |
| Max. Negotiated Rate |
$19.72 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$19.33
|
| Rate for Payer: Aetna of WY Medicare |
$13.02
|
| Rate for Payer: Altius Auto/Workers Compensation |
$18.93
|
| Rate for Payer: Altius Commercial |
$18.93
|
| Rate for Payer: Beech Street Commercial |
$19.33
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.19
|
| Rate for Payer: Cash Price |
$13.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$19.13
|
| Rate for Payer: Cigna of WY Commercial |
$19.33
|
| Rate for Payer: Entrust Commercial |
$18.73
|
| Rate for Payer: First Choice Health Commercial |
$18.73
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$18.73
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.44
|
| Rate for Payer: HealthUtah PPO |
$19.72
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$19.13
|
| Rate for Payer: Multiplan Medicare/VA |
$10.87
|
| Rate for Payer: One Health Plan of WY PPO |
$19.33
|
| Rate for Payer: PacificSource Commercial |
$17.75
|
| Rate for Payer: PHCS PPO |
$19.33
|
| Rate for Payer: Three Rivers PPO |
$14.79
|
| Rate for Payer: TriWest Veterans Administration |
$11.44
|
| Rate for Payer: United Healthcare Commercial |
$17.16
|
| Rate for Payer: United Healthcare Medicare |
$11.44
|
| Rate for Payer: WINHealth Partners Commercial |
$19.33
|
| Rate for Payer: Wise Provider Network Commercial |
$18.73
|
|
|
MASK NEO-PUFF 60MM RD806
|
Facility
|
IP
|
$19.72
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$12.36 |
| Max. Negotiated Rate |
$19.72 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$19.33
|
| Rate for Payer: Altius Auto/Workers Compensation |
$18.93
|
| Rate for Payer: Altius Commercial |
$18.93
|
| Rate for Payer: Beech Street Commercial |
$19.33
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.19
|
| Rate for Payer: Cash Price |
$13.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$19.13
|
| Rate for Payer: Cigna of WY Commercial |
$19.33
|
| Rate for Payer: Entrust Commercial |
$18.73
|
| Rate for Payer: First Choice Health Commercial |
$18.73
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$18.73
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$13.02
|
| Rate for Payer: HealthUtah PPO |
$19.72
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$19.13
|
| Rate for Payer: Multiplan Medicare/VA |
$12.36
|
| Rate for Payer: One Health Plan of WY PPO |
$19.33
|
| Rate for Payer: PacificSource Commercial |
$17.75
|
| Rate for Payer: PHCS PPO |
$19.33
|
| Rate for Payer: Three Rivers PPO |
$14.79
|
| Rate for Payer: TriWest Veterans Administration |
$13.02
|
| Rate for Payer: United Healthcare Commercial |
$17.16
|
| Rate for Payer: United Healthcare Medicare |
$13.02
|
| Rate for Payer: WINHealth Partners Commercial |
$18.73
|
| Rate for Payer: Wise Provider Network Commercial |
$18.73
|
|
|
MASK OXY ADULT OM-1125-8
|
Facility
|
OP
|
$12.60
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$6.94 |
| Max. Negotiated Rate |
$12.60 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$12.35
|
| Rate for Payer: Aetna of WY Medicare |
$8.32
|
| Rate for Payer: Altius Auto/Workers Compensation |
$12.10
|
| Rate for Payer: Altius Commercial |
$12.10
|
| Rate for Payer: Beech Street Commercial |
$12.35
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$10.34
|
| Rate for Payer: Cash Price |
$8.82
|
| Rate for Payer: ChoiceCare Network Commercial |
$12.22
|
| Rate for Payer: Cigna of WY Commercial |
$12.35
|
| Rate for Payer: Entrust Commercial |
$11.97
|
| Rate for Payer: First Choice Health Commercial |
$11.97
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$11.97
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$7.31
|
| Rate for Payer: HealthUtah PPO |
$12.60
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$12.22
|
| Rate for Payer: Multiplan Medicare/VA |
$6.94
|
| Rate for Payer: One Health Plan of WY PPO |
$12.35
|
| Rate for Payer: PacificSource Commercial |
$11.34
|
| Rate for Payer: PHCS PPO |
$12.35
|
| Rate for Payer: Three Rivers PPO |
$9.45
|
| Rate for Payer: TriWest Veterans Administration |
$7.31
|
| Rate for Payer: United Healthcare Commercial |
$10.96
|
| Rate for Payer: United Healthcare Medicare |
$7.31
|
| Rate for Payer: WINHealth Partners Commercial |
$12.35
|
| Rate for Payer: Wise Provider Network Commercial |
$11.97
|
|
|
MASK OXY ADULT OM-1125-8
|
Facility
|
IP
|
$12.60
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$7.90 |
| Max. Negotiated Rate |
$12.60 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$12.35
|
| Rate for Payer: Altius Auto/Workers Compensation |
$12.10
|
| Rate for Payer: Altius Commercial |
$12.10
|
| Rate for Payer: Beech Street Commercial |
$12.35
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$10.34
|
| Rate for Payer: Cash Price |
$8.82
|
| Rate for Payer: ChoiceCare Network Commercial |
$12.22
|
| Rate for Payer: Cigna of WY Commercial |
$12.35
|
| Rate for Payer: Entrust Commercial |
$11.97
|
| Rate for Payer: First Choice Health Commercial |
$11.97
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$11.97
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.32
|
| Rate for Payer: HealthUtah PPO |
$12.60
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$12.22
|
| Rate for Payer: Multiplan Medicare/VA |
$7.90
|
| Rate for Payer: One Health Plan of WY PPO |
$12.35
|
| Rate for Payer: PacificSource Commercial |
$11.34
|
| Rate for Payer: PHCS PPO |
$12.35
|
| Rate for Payer: Three Rivers PPO |
$9.45
|
| Rate for Payer: TriWest Veterans Administration |
$8.32
|
| Rate for Payer: United Healthcare Commercial |
$10.96
|
| Rate for Payer: United Healthcare Medicare |
$8.32
|
| Rate for Payer: WINHealth Partners Commercial |
$11.97
|
| Rate for Payer: Wise Provider Network Commercial |
$11.97
|
|
|
MASK OXY KIDS OK-1125-8
|
Facility
|
OP
|
$13.69
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$7.54 |
| Max. Negotiated Rate |
$13.69 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$13.42
|
| Rate for Payer: Aetna of WY Medicare |
$9.04
|
| Rate for Payer: Altius Auto/Workers Compensation |
$13.14
|
| Rate for Payer: Altius Commercial |
$13.14
|
| Rate for Payer: Beech Street Commercial |
$13.42
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$11.24
|
| Rate for Payer: Cash Price |
$9.58
|
| Rate for Payer: ChoiceCare Network Commercial |
$13.28
|
| Rate for Payer: Cigna of WY Commercial |
$13.42
|
| Rate for Payer: Entrust Commercial |
$13.01
|
| Rate for Payer: First Choice Health Commercial |
$13.01
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$13.01
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$7.94
|
| Rate for Payer: HealthUtah PPO |
$13.69
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$13.28
|
| Rate for Payer: Multiplan Medicare/VA |
$7.54
|
| Rate for Payer: One Health Plan of WY PPO |
$13.42
|
| Rate for Payer: PacificSource Commercial |
$12.32
|
| Rate for Payer: PHCS PPO |
$13.42
|
| Rate for Payer: Three Rivers PPO |
$10.27
|
| Rate for Payer: TriWest Veterans Administration |
$7.94
|
| Rate for Payer: United Healthcare Commercial |
$11.91
|
| Rate for Payer: United Healthcare Medicare |
$7.94
|
| Rate for Payer: WINHealth Partners Commercial |
$13.42
|
| Rate for Payer: Wise Provider Network Commercial |
$13.01
|
|
|
MASK OXY KIDS OK-1125-8
|
Facility
|
IP
|
$13.69
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$8.58 |
| Max. Negotiated Rate |
$13.69 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$13.42
|
| Rate for Payer: Altius Auto/Workers Compensation |
$13.14
|
| Rate for Payer: Altius Commercial |
$13.14
|
| Rate for Payer: Beech Street Commercial |
$13.42
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$11.24
|
| Rate for Payer: Cash Price |
$9.58
|
| Rate for Payer: ChoiceCare Network Commercial |
$13.28
|
| Rate for Payer: Cigna of WY Commercial |
$13.42
|
| Rate for Payer: Entrust Commercial |
$13.01
|
| Rate for Payer: First Choice Health Commercial |
$13.01
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$13.01
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.04
|
| Rate for Payer: HealthUtah PPO |
$13.69
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$13.28
|
| Rate for Payer: Multiplan Medicare/VA |
$8.58
|
| Rate for Payer: One Health Plan of WY PPO |
$13.42
|
| Rate for Payer: PacificSource Commercial |
$12.32
|
| Rate for Payer: PHCS PPO |
$13.42
|
| Rate for Payer: Three Rivers PPO |
$10.27
|
| Rate for Payer: TriWest Veterans Administration |
$9.04
|
| Rate for Payer: United Healthcare Commercial |
$11.91
|
| Rate for Payer: United Healthcare Medicare |
$9.04
|
| Rate for Payer: WINHealth Partners Commercial |
$13.01
|
| Rate for Payer: Wise Provider Network Commercial |
$13.01
|
|
|
MASK OXY PLUS ADULT OP-1125-8
|
Facility
|
IP
|
$14.15
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$8.87 |
| Max. Negotiated Rate |
$14.15 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$13.87
|
| Rate for Payer: Altius Auto/Workers Compensation |
$13.58
|
| Rate for Payer: Altius Commercial |
$13.58
|
| Rate for Payer: Beech Street Commercial |
$13.87
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$11.62
|
| Rate for Payer: Cash Price |
$9.91
|
| Rate for Payer: ChoiceCare Network Commercial |
$13.73
|
| Rate for Payer: Cigna of WY Commercial |
$13.87
|
| Rate for Payer: Entrust Commercial |
$13.44
|
| Rate for Payer: First Choice Health Commercial |
$13.44
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$13.44
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.34
|
| Rate for Payer: HealthUtah PPO |
$14.15
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$13.73
|
| Rate for Payer: Multiplan Medicare/VA |
$8.87
|
| Rate for Payer: One Health Plan of WY PPO |
$13.87
|
| Rate for Payer: PacificSource Commercial |
$12.74
|
| Rate for Payer: PHCS PPO |
$13.87
|
| Rate for Payer: Three Rivers PPO |
$10.61
|
| Rate for Payer: TriWest Veterans Administration |
$9.34
|
| Rate for Payer: United Healthcare Commercial |
$12.31
|
| Rate for Payer: United Healthcare Medicare |
$9.34
|
| Rate for Payer: WINHealth Partners Commercial |
$13.44
|
| Rate for Payer: Wise Provider Network Commercial |
$13.44
|
|
|
MASK OXY PLUS ADULT OP-1125-8
|
Facility
|
OP
|
$14.15
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$7.80 |
| Max. Negotiated Rate |
$14.15 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$13.87
|
| Rate for Payer: Aetna of WY Medicare |
$9.34
|
| Rate for Payer: Altius Auto/Workers Compensation |
$13.58
|
| Rate for Payer: Altius Commercial |
$13.58
|
| Rate for Payer: Beech Street Commercial |
$13.87
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$11.62
|
| Rate for Payer: Cash Price |
$9.91
|
| Rate for Payer: ChoiceCare Network Commercial |
$13.73
|
| Rate for Payer: Cigna of WY Commercial |
$13.87
|
| Rate for Payer: Entrust Commercial |
$13.44
|
| Rate for Payer: First Choice Health Commercial |
$13.44
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$13.44
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.21
|
| Rate for Payer: HealthUtah PPO |
$14.15
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$13.73
|
| Rate for Payer: Multiplan Medicare/VA |
$7.80
|
| Rate for Payer: One Health Plan of WY PPO |
$13.87
|
| Rate for Payer: PacificSource Commercial |
$12.74
|
| Rate for Payer: PHCS PPO |
$13.87
|
| Rate for Payer: Three Rivers PPO |
$10.61
|
| Rate for Payer: TriWest Veterans Administration |
$8.21
|
| Rate for Payer: United Healthcare Commercial |
$12.31
|
| Rate for Payer: United Healthcare Medicare |
$8.21
|
| Rate for Payer: WINHealth Partners Commercial |
$13.87
|
| Rate for Payer: Wise Provider Network Commercial |
$13.44
|
|
|
MASK POM ADULT 1001-MM
|
Facility
|
IP
|
$25.70
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$16.11 |
| Max. Negotiated Rate |
$25.70 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$25.19
|
| Rate for Payer: Altius Auto/Workers Compensation |
$24.67
|
| Rate for Payer: Altius Commercial |
$24.67
|
| Rate for Payer: Beech Street Commercial |
$25.19
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$21.10
|
| Rate for Payer: Cash Price |
$17.99
|
| Rate for Payer: ChoiceCare Network Commercial |
$24.93
|
| Rate for Payer: Cigna of WY Commercial |
$25.19
|
| Rate for Payer: Entrust Commercial |
$24.42
|
| Rate for Payer: First Choice Health Commercial |
$24.42
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$24.42
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$16.96
|
| Rate for Payer: HealthUtah PPO |
$25.70
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.93
|
| Rate for Payer: Multiplan Medicare/VA |
$16.11
|
| Rate for Payer: One Health Plan of WY PPO |
$25.19
|
| Rate for Payer: PacificSource Commercial |
$23.13
|
| Rate for Payer: PHCS PPO |
$25.19
|
| Rate for Payer: Three Rivers PPO |
$19.28
|
| Rate for Payer: TriWest Veterans Administration |
$16.96
|
| Rate for Payer: United Healthcare Commercial |
$22.36
|
| Rate for Payer: United Healthcare Medicare |
$16.96
|
| Rate for Payer: WINHealth Partners Commercial |
$24.42
|
| Rate for Payer: Wise Provider Network Commercial |
$24.42
|
|
|
MASK POM ADULT 1001-MM
|
Facility
|
OP
|
$25.70
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$14.16 |
| Max. Negotiated Rate |
$25.70 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$25.19
|
| Rate for Payer: Aetna of WY Medicare |
$16.96
|
| Rate for Payer: Altius Auto/Workers Compensation |
$24.67
|
| Rate for Payer: Altius Commercial |
$24.67
|
| Rate for Payer: Beech Street Commercial |
$25.19
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$21.10
|
| Rate for Payer: Cash Price |
$17.99
|
| Rate for Payer: ChoiceCare Network Commercial |
$24.93
|
| Rate for Payer: Cigna of WY Commercial |
$25.19
|
| Rate for Payer: Entrust Commercial |
$24.42
|
| Rate for Payer: First Choice Health Commercial |
$24.42
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$24.42
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$14.91
|
| Rate for Payer: HealthUtah PPO |
$25.70
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.93
|
| Rate for Payer: Multiplan Medicare/VA |
$14.16
|
| Rate for Payer: One Health Plan of WY PPO |
$25.19
|
| Rate for Payer: PacificSource Commercial |
$23.13
|
| Rate for Payer: PHCS PPO |
$25.19
|
| Rate for Payer: Three Rivers PPO |
$19.28
|
| Rate for Payer: TriWest Veterans Administration |
$14.91
|
| Rate for Payer: United Healthcare Commercial |
$22.36
|
| Rate for Payer: United Healthcare Medicare |
$14.91
|
| Rate for Payer: WINHealth Partners Commercial |
$25.19
|
| Rate for Payer: Wise Provider Network Commercial |
$24.42
|
|
|
MASTECTOMY PARTIAL
|
Professional
|
Both
|
$3,363.00
|
|
|
Service Code
|
HCPCS 19301
|
| Hospital Charge Code |
19301
|
| Min. Negotiated Rate |
$536.10 |
| Max. Negotiated Rate |
$3,363.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,295.74
|
| Rate for Payer: Aetna of WY Medicare |
$630.71
|
| Rate for Payer: Beech Street Commercial |
$3,194.85
|
| Rate for Payer: Cash Price |
$2,354.10
|
| Rate for Payer: Cash Price |
$2,354.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,262.11
|
| Rate for Payer: Cigna of WY Commercial |
$3,295.74
|
| Rate for Payer: First Choice Health Commercial |
$3,026.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,194.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$630.71
|
| Rate for Payer: HealthUtah PPO |
$3,363.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,262.11
|
| Rate for Payer: Multiplan Medicare/VA |
$536.10
|
| Rate for Payer: One Health Plan of WY PPO |
$3,295.74
|
| Rate for Payer: PacificSource Commercial |
$3,026.70
|
| Rate for Payer: PHCS PPO |
$3,194.85
|
| Rate for Payer: Three Rivers PPO |
$2,522.25
|
| Rate for Payer: TriWest Veterans Administration |
$630.71
|
| Rate for Payer: United Healthcare Commercial |
$2,925.81
|
| Rate for Payer: United Healthcare Medicare |
$630.71
|
| Rate for Payer: WINHealth Partners Commercial |
$2,858.55
|
|
|
MASTECTOMY PARTIAL
|
Professional
|
Both
|
$3,363.00
|
|
|
Service Code
|
HCPCS 19301 80
|
| Hospital Charge Code |
19301
|
| Min. Negotiated Rate |
$536.10 |
| Max. Negotiated Rate |
$3,363.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,295.74
|
| Rate for Payer: Aetna of WY Medicare |
$630.71
|
| Rate for Payer: Beech Street Commercial |
$3,194.85
|
| Rate for Payer: Cash Price |
$2,354.10
|
| Rate for Payer: Cash Price |
$2,354.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,262.11
|
| Rate for Payer: Cigna of WY Commercial |
$3,295.74
|
| Rate for Payer: First Choice Health Commercial |
$3,026.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,194.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$630.71
|
| Rate for Payer: HealthUtah PPO |
$3,363.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,262.11
|
| Rate for Payer: Multiplan Medicare/VA |
$536.10
|
| Rate for Payer: One Health Plan of WY PPO |
$3,295.74
|
| Rate for Payer: PacificSource Commercial |
$3,026.70
|
| Rate for Payer: PHCS PPO |
$3,194.85
|
| Rate for Payer: Three Rivers PPO |
$2,522.25
|
| Rate for Payer: TriWest Veterans Administration |
$630.71
|
| Rate for Payer: United Healthcare Commercial |
$2,925.81
|
| Rate for Payer: United Healthcare Medicare |
$630.71
|
| Rate for Payer: WINHealth Partners Commercial |
$2,858.55
|
|
|
MASTECTOMY SIMPLE COMPLETE
|
Professional
|
Both
|
$4,913.00
|
|
|
Service Code
|
HCPCS 19303 80
|
| Hospital Charge Code |
19303
|
| Min. Negotiated Rate |
$776.42 |
| Max. Negotiated Rate |
$4,913.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4,814.74
|
| Rate for Payer: Aetna of WY Medicare |
$913.43
|
| Rate for Payer: Beech Street Commercial |
$4,667.35
|
| Rate for Payer: Cash Price |
$3,439.10
|
| Rate for Payer: Cash Price |
$3,439.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$4,765.61
|
| Rate for Payer: Cigna of WY Commercial |
$4,814.74
|
| Rate for Payer: First Choice Health Commercial |
$4,421.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,667.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$913.43
|
| Rate for Payer: HealthUtah PPO |
$4,913.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4,765.61
|
| Rate for Payer: Multiplan Medicare/VA |
$776.42
|
| Rate for Payer: One Health Plan of WY PPO |
$4,814.74
|
| Rate for Payer: PacificSource Commercial |
$4,421.70
|
| Rate for Payer: PHCS PPO |
$4,667.35
|
| Rate for Payer: Three Rivers PPO |
$3,684.75
|
| Rate for Payer: TriWest Veterans Administration |
$913.43
|
| Rate for Payer: United Healthcare Commercial |
$4,274.31
|
| Rate for Payer: United Healthcare Medicare |
$913.43
|
| Rate for Payer: WINHealth Partners Commercial |
$4,176.05
|
|
|
MASTECTOMY SIMPLE COMPLETE
|
Professional
|
Both
|
$4,913.00
|
|
|
Service Code
|
HCPCS 19303 AS
|
| Hospital Charge Code |
19303
|
| Min. Negotiated Rate |
$776.42 |
| Max. Negotiated Rate |
$4,913.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4,814.74
|
| Rate for Payer: Aetna of WY Medicare |
$913.43
|
| Rate for Payer: Beech Street Commercial |
$4,667.35
|
| Rate for Payer: Cash Price |
$3,439.10
|
| Rate for Payer: Cash Price |
$3,439.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$4,765.61
|
| Rate for Payer: Cigna of WY Commercial |
$4,814.74
|
| Rate for Payer: First Choice Health Commercial |
$4,421.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,667.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$913.43
|
| Rate for Payer: HealthUtah PPO |
$4,913.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4,765.61
|
| Rate for Payer: Multiplan Medicare/VA |
$776.42
|
| Rate for Payer: One Health Plan of WY PPO |
$4,814.74
|
| Rate for Payer: PacificSource Commercial |
$4,421.70
|
| Rate for Payer: PHCS PPO |
$4,667.35
|
| Rate for Payer: Three Rivers PPO |
$3,684.75
|
| Rate for Payer: TriWest Veterans Administration |
$913.43
|
| Rate for Payer: United Healthcare Commercial |
$4,274.31
|
| Rate for Payer: United Healthcare Medicare |
$913.43
|
| Rate for Payer: WINHealth Partners Commercial |
$4,176.05
|
|
|
MASTECTOMY SIMPLE COMPLETE
|
Professional
|
Both
|
$9,826.00
|
|
|
Service Code
|
HCPCS 19303 50
|
| Hospital Charge Code |
19303
|
| Min. Negotiated Rate |
$776.42 |
| Max. Negotiated Rate |
$9,826.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$9,629.48
|
| Rate for Payer: Aetna of WY Medicare |
$913.43
|
| Rate for Payer: Beech Street Commercial |
$9,334.70
|
| Rate for Payer: Cash Price |
$6,878.20
|
| Rate for Payer: Cash Price |
$6,878.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$9,531.22
|
| Rate for Payer: Cigna of WY Commercial |
$9,629.48
|
| Rate for Payer: First Choice Health Commercial |
$8,843.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$9,334.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$913.43
|
| Rate for Payer: HealthUtah PPO |
$9,826.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$9,531.22
|
| Rate for Payer: Multiplan Medicare/VA |
$776.42
|
| Rate for Payer: One Health Plan of WY PPO |
$9,629.48
|
| Rate for Payer: PacificSource Commercial |
$8,843.40
|
| Rate for Payer: PHCS PPO |
$9,334.70
|
| Rate for Payer: Three Rivers PPO |
$7,369.50
|
| Rate for Payer: TriWest Veterans Administration |
$913.43
|
| Rate for Payer: United Healthcare Commercial |
$8,548.62
|
| Rate for Payer: United Healthcare Medicare |
$913.43
|
| Rate for Payer: WINHealth Partners Commercial |
$8,352.10
|
|
|
MASTECTOMY SIMPLE COMPLETE
|
Professional
|
Both
|
$4,913.00
|
|
|
Service Code
|
HCPCS 19303
|
| Hospital Charge Code |
19303
|
| Min. Negotiated Rate |
$776.42 |
| Max. Negotiated Rate |
$4,913.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4,814.74
|
| Rate for Payer: Aetna of WY Medicare |
$913.43
|
| Rate for Payer: Beech Street Commercial |
$4,667.35
|
| Rate for Payer: Cash Price |
$3,439.10
|
| Rate for Payer: Cash Price |
$3,439.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$4,765.61
|
| Rate for Payer: Cigna of WY Commercial |
$4,814.74
|
| Rate for Payer: First Choice Health Commercial |
$4,421.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,667.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$913.43
|
| Rate for Payer: HealthUtah PPO |
$4,913.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4,765.61
|
| Rate for Payer: Multiplan Medicare/VA |
$776.42
|
| Rate for Payer: One Health Plan of WY PPO |
$4,814.74
|
| Rate for Payer: PacificSource Commercial |
$4,421.70
|
| Rate for Payer: PHCS PPO |
$4,667.35
|
| Rate for Payer: Three Rivers PPO |
$3,684.75
|
| Rate for Payer: TriWest Veterans Administration |
$913.43
|
| Rate for Payer: United Healthcare Commercial |
$4,274.31
|
| Rate for Payer: United Healthcare Medicare |
$913.43
|
| Rate for Payer: WINHealth Partners Commercial |
$4,176.05
|
|
|
MASTECTOMY, SUBCUTANEOUS
|
Professional
|
Both
|
$13,645.00
|
|
|
Service Code
|
HCPCS 19304 50
|
| Hospital Charge Code |
19304
|
| Min. Negotiated Rate |
$10,233.75 |
| Max. Negotiated Rate |
$13,645.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$13,372.10
|
| Rate for Payer: Beech Street Commercial |
$12,962.75
|
| Rate for Payer: Cash Price |
$9,551.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$13,235.65
|
| Rate for Payer: Cigna of WY Commercial |
$13,372.10
|
| Rate for Payer: First Choice Health Commercial |
$12,280.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$12,962.75
|
| Rate for Payer: HealthUtah PPO |
$13,645.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$13,235.65
|
| Rate for Payer: One Health Plan of WY PPO |
$13,372.10
|
| Rate for Payer: PacificSource Commercial |
$12,280.50
|
| Rate for Payer: PHCS PPO |
$12,962.75
|
| Rate for Payer: Three Rivers PPO |
$10,233.75
|
| Rate for Payer: United Healthcare Commercial |
$11,871.15
|
| Rate for Payer: WINHealth Partners Commercial |
$11,598.25
|
|
|
MASTECTOMY, SUBCUTANEOUS
|
Professional
|
Both
|
$6,822.00
|
|
|
Service Code
|
HCPCS 19304
|
| Hospital Charge Code |
19304
|
| Min. Negotiated Rate |
$5,116.50 |
| Max. Negotiated Rate |
$6,822.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$6,685.56
|
| Rate for Payer: Beech Street Commercial |
$6,480.90
|
| Rate for Payer: Cash Price |
$4,775.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$6,617.34
|
| Rate for Payer: Cigna of WY Commercial |
$6,685.56
|
| Rate for Payer: First Choice Health Commercial |
$6,139.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$6,480.90
|
| Rate for Payer: HealthUtah PPO |
$6,822.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$6,617.34
|
| Rate for Payer: One Health Plan of WY PPO |
$6,685.56
|
| Rate for Payer: PacificSource Commercial |
$6,139.80
|
| Rate for Payer: PHCS PPO |
$6,480.90
|
| Rate for Payer: Three Rivers PPO |
$5,116.50
|
| Rate for Payer: United Healthcare Commercial |
$5,935.14
|
| Rate for Payer: WINHealth Partners Commercial |
$5,798.70
|
|
|
MAST MODF RAD W/AX LYMPH NOD W/WO PECT/ALIS MIN
|
Professional
|
Both
|
$6,176.00
|
|
|
Service Code
|
HCPCS 19307 AS
|
| Hospital Charge Code |
19307
|
| Min. Negotiated Rate |
$956.39 |
| Max. Negotiated Rate |
$6,176.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$6,052.48
|
| Rate for Payer: Aetna of WY Medicare |
$1,125.17
|
| Rate for Payer: Beech Street Commercial |
$5,867.20
|
| Rate for Payer: Cash Price |
$4,323.20
|
| Rate for Payer: Cash Price |
$4,323.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$5,990.72
|
| Rate for Payer: Cigna of WY Commercial |
$6,052.48
|
| Rate for Payer: First Choice Health Commercial |
$5,558.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5,867.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,125.17
|
| Rate for Payer: HealthUtah PPO |
$6,176.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5,990.72
|
| Rate for Payer: Multiplan Medicare/VA |
$956.39
|
| Rate for Payer: One Health Plan of WY PPO |
$6,052.48
|
| Rate for Payer: PacificSource Commercial |
$5,558.40
|
| Rate for Payer: PHCS PPO |
$5,867.20
|
| Rate for Payer: Three Rivers PPO |
$4,632.00
|
| Rate for Payer: TriWest Veterans Administration |
$1,125.17
|
| Rate for Payer: United Healthcare Commercial |
$5,373.12
|
| Rate for Payer: United Healthcare Medicare |
$1,125.17
|
| Rate for Payer: WINHealth Partners Commercial |
$5,249.60
|
|
|
MAST MODF RAD W/AX LYMPH NOD W/WO PECT/ALIS MIN
|
Professional
|
Both
|
$6,176.00
|
|
|
Service Code
|
HCPCS 19307
|
| Hospital Charge Code |
19307
|
| Min. Negotiated Rate |
$956.39 |
| Max. Negotiated Rate |
$6,176.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$6,052.48
|
| Rate for Payer: Aetna of WY Medicare |
$1,125.17
|
| Rate for Payer: Beech Street Commercial |
$5,867.20
|
| Rate for Payer: Cash Price |
$4,323.20
|
| Rate for Payer: Cash Price |
$4,323.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$5,990.72
|
| Rate for Payer: Cigna of WY Commercial |
$6,052.48
|
| Rate for Payer: First Choice Health Commercial |
$5,558.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5,867.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,125.17
|
| Rate for Payer: HealthUtah PPO |
$6,176.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5,990.72
|
| Rate for Payer: Multiplan Medicare/VA |
$956.39
|
| Rate for Payer: One Health Plan of WY PPO |
$6,052.48
|
| Rate for Payer: PacificSource Commercial |
$5,558.40
|
| Rate for Payer: PHCS PPO |
$5,867.20
|
| Rate for Payer: Three Rivers PPO |
$4,632.00
|
| Rate for Payer: TriWest Veterans Administration |
$1,125.17
|
| Rate for Payer: United Healthcare Commercial |
$5,373.12
|
| Rate for Payer: United Healthcare Medicare |
$1,125.17
|
| Rate for Payer: WINHealth Partners Commercial |
$5,249.60
|
|
