|
MNPJ W/ANES SHOULDER JT APPL FIXATION APPARATUS
|
Professional
|
Both
|
$1,007.00
|
|
|
Service Code
|
HCPCS 23700 AS
|
| Hospital Charge Code |
23700
|
| Min. Negotiated Rate |
$162.25 |
| Max. Negotiated Rate |
$1,007.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$986.86
|
| Rate for Payer: Aetna of WY Medicare |
$190.88
|
| Rate for Payer: Beech Street Commercial |
$956.65
|
| Rate for Payer: Cash Price |
$704.90
|
| Rate for Payer: Cash Price |
$704.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$976.79
|
| Rate for Payer: Cigna of WY Commercial |
$986.86
|
| Rate for Payer: First Choice Health Commercial |
$906.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$956.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$190.88
|
| Rate for Payer: HealthUtah PPO |
$1,007.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$976.79
|
| Rate for Payer: Multiplan Medicare/VA |
$162.25
|
| Rate for Payer: One Health Plan of WY PPO |
$986.86
|
| Rate for Payer: PacificSource Commercial |
$906.30
|
| Rate for Payer: PHCS PPO |
$956.65
|
| Rate for Payer: Three Rivers PPO |
$755.25
|
| Rate for Payer: TriWest Veterans Administration |
$190.88
|
| Rate for Payer: United Healthcare Commercial |
$876.09
|
| Rate for Payer: United Healthcare Medicare |
$190.88
|
| Rate for Payer: WINHealth Partners Commercial |
$855.95
|
|
|
MNPJ W/ANES SHOULDER JT APPL FIXATION APPARATUS
|
Professional
|
Both
|
$1,007.00
|
|
|
Service Code
|
HCPCS 23700
|
| Hospital Charge Code |
23700
|
| Min. Negotiated Rate |
$162.25 |
| Max. Negotiated Rate |
$1,007.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$986.86
|
| Rate for Payer: Aetna of WY Medicare |
$190.88
|
| Rate for Payer: Beech Street Commercial |
$956.65
|
| Rate for Payer: Cash Price |
$704.90
|
| Rate for Payer: Cash Price |
$704.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$976.79
|
| Rate for Payer: Cigna of WY Commercial |
$986.86
|
| Rate for Payer: First Choice Health Commercial |
$906.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$956.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$190.88
|
| Rate for Payer: HealthUtah PPO |
$1,007.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$976.79
|
| Rate for Payer: Multiplan Medicare/VA |
$162.25
|
| Rate for Payer: One Health Plan of WY PPO |
$986.86
|
| Rate for Payer: PacificSource Commercial |
$906.30
|
| Rate for Payer: PHCS PPO |
$956.65
|
| Rate for Payer: Three Rivers PPO |
$755.25
|
| Rate for Payer: TriWest Veterans Administration |
$190.88
|
| Rate for Payer: United Healthcare Commercial |
$876.09
|
| Rate for Payer: United Healthcare Medicare |
$190.88
|
| Rate for Payer: WINHealth Partners Commercial |
$855.95
|
|
|
MNTR INTERSTITIAL FLUID PRESSURE CMPRT SYNDROME
|
Professional
|
Both
|
$457.00
|
|
|
Service Code
|
HCPCS 20950 AS
|
| Hospital Charge Code |
20950
|
| Min. Negotiated Rate |
$72.44 |
| Max. Negotiated Rate |
$457.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$447.86
|
| Rate for Payer: Aetna of WY Medicare |
$85.22
|
| Rate for Payer: Beech Street Commercial |
$434.15
|
| Rate for Payer: Cash Price |
$319.90
|
| Rate for Payer: Cash Price |
$319.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$443.29
|
| Rate for Payer: Cigna of WY Commercial |
$447.86
|
| Rate for Payer: First Choice Health Commercial |
$411.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$434.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$85.22
|
| Rate for Payer: HealthUtah PPO |
$457.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$443.29
|
| Rate for Payer: Multiplan Medicare/VA |
$72.44
|
| Rate for Payer: One Health Plan of WY PPO |
$447.86
|
| Rate for Payer: PacificSource Commercial |
$411.30
|
| Rate for Payer: PHCS PPO |
$434.15
|
| Rate for Payer: Three Rivers PPO |
$342.75
|
| Rate for Payer: TriWest Veterans Administration |
$85.22
|
| Rate for Payer: United Healthcare Commercial |
$397.59
|
| Rate for Payer: United Healthcare Medicare |
$85.22
|
| Rate for Payer: WINHealth Partners Commercial |
$388.45
|
|
|
MNTR INTERSTITIAL FLUID PRESSURE CMPRT SYNDROME
|
Professional
|
Both
|
$457.00
|
|
|
Service Code
|
HCPCS 20950
|
| Hospital Charge Code |
20950
|
| Min. Negotiated Rate |
$72.44 |
| Max. Negotiated Rate |
$457.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$447.86
|
| Rate for Payer: Aetna of WY Medicare |
$85.22
|
| Rate for Payer: Beech Street Commercial |
$434.15
|
| Rate for Payer: Cash Price |
$319.90
|
| Rate for Payer: Cash Price |
$319.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$443.29
|
| Rate for Payer: Cigna of WY Commercial |
$447.86
|
| Rate for Payer: First Choice Health Commercial |
$411.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$434.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$85.22
|
| Rate for Payer: HealthUtah PPO |
$457.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$443.29
|
| Rate for Payer: Multiplan Medicare/VA |
$72.44
|
| Rate for Payer: One Health Plan of WY PPO |
$447.86
|
| Rate for Payer: PacificSource Commercial |
$411.30
|
| Rate for Payer: PHCS PPO |
$434.15
|
| Rate for Payer: Three Rivers PPO |
$342.75
|
| Rate for Payer: TriWest Veterans Administration |
$85.22
|
| Rate for Payer: United Healthcare Commercial |
$397.59
|
| Rate for Payer: United Healthcare Medicare |
$85.22
|
| Rate for Payer: WINHealth Partners Commercial |
$388.45
|
|
|
MOBLJ SPLENIC FLXR PFRMD CONJUNCT W/PRTL COLCT
|
Professional
|
Both
|
$626.00
|
|
|
Service Code
|
HCPCS 44139
|
| Hospital Charge Code |
44139
|
| Min. Negotiated Rate |
$95.46 |
| Max. Negotiated Rate |
$626.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$613.48
|
| Rate for Payer: Aetna of WY Medicare |
$112.30
|
| Rate for Payer: Beech Street Commercial |
$594.70
|
| Rate for Payer: Cash Price |
$438.20
|
| Rate for Payer: Cash Price |
$438.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$607.22
|
| Rate for Payer: Cigna of WY Commercial |
$613.48
|
| Rate for Payer: First Choice Health Commercial |
$563.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$594.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$112.30
|
| Rate for Payer: HealthUtah PPO |
$626.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$607.22
|
| Rate for Payer: Multiplan Medicare/VA |
$95.46
|
| Rate for Payer: One Health Plan of WY PPO |
$613.48
|
| Rate for Payer: PacificSource Commercial |
$563.40
|
| Rate for Payer: PHCS PPO |
$594.70
|
| Rate for Payer: Three Rivers PPO |
$469.50
|
| Rate for Payer: TriWest Veterans Administration |
$112.30
|
| Rate for Payer: United Healthcare Commercial |
$544.62
|
| Rate for Payer: United Healthcare Medicare |
$112.30
|
| Rate for Payer: WINHealth Partners Commercial |
$532.10
|
|
|
MOBLJ SPLENIC FLXR PFRMD CONJUNCT W/PRTL COLCT
|
Professional
|
Both
|
$626.00
|
|
|
Service Code
|
HCPCS 44139 80
|
| Hospital Charge Code |
44139
|
| Min. Negotiated Rate |
$95.46 |
| Max. Negotiated Rate |
$626.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$613.48
|
| Rate for Payer: Aetna of WY Medicare |
$112.30
|
| Rate for Payer: Beech Street Commercial |
$594.70
|
| Rate for Payer: Cash Price |
$438.20
|
| Rate for Payer: Cash Price |
$438.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$607.22
|
| Rate for Payer: Cigna of WY Commercial |
$613.48
|
| Rate for Payer: First Choice Health Commercial |
$563.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$594.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$112.30
|
| Rate for Payer: HealthUtah PPO |
$626.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$607.22
|
| Rate for Payer: Multiplan Medicare/VA |
$95.46
|
| Rate for Payer: One Health Plan of WY PPO |
$613.48
|
| Rate for Payer: PacificSource Commercial |
$563.40
|
| Rate for Payer: PHCS PPO |
$594.70
|
| Rate for Payer: Three Rivers PPO |
$469.50
|
| Rate for Payer: TriWest Veterans Administration |
$112.30
|
| Rate for Payer: United Healthcare Commercial |
$544.62
|
| Rate for Payer: United Healthcare Medicare |
$112.30
|
| Rate for Payer: WINHealth Partners Commercial |
$532.10
|
|
|
MODIFIED LANOLIN 100 % TOPICAL CREAM [156346]
|
Facility
|
OP
|
$0.68
|
|
|
Service Code
|
NDC 4467710020
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$0.68 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.67
|
| Rate for Payer: Aetna of WY Medicare |
$0.45
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.65
|
| Rate for Payer: Altius Commercial |
$0.65
|
| Rate for Payer: Beech Street Commercial |
$0.67
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.56
|
| Rate for Payer: Cash Price |
$0.48
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.66
|
| Rate for Payer: Cigna of WY Commercial |
$0.67
|
| Rate for Payer: Entrust Commercial |
$0.65
|
| Rate for Payer: First Choice Health Commercial |
$0.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.39
|
| Rate for Payer: HealthUtah PPO |
$0.68
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.66
|
| Rate for Payer: Multiplan Medicare/VA |
$0.37
|
| Rate for Payer: One Health Plan of WY PPO |
$0.67
|
| Rate for Payer: PacificSource Commercial |
$0.61
|
| Rate for Payer: PHCS PPO |
$0.67
|
| Rate for Payer: Three Rivers PPO |
$0.51
|
| Rate for Payer: TriWest Veterans Administration |
$0.39
|
| Rate for Payer: United Healthcare Commercial |
$0.59
|
| Rate for Payer: United Healthcare Medicare |
$0.39
|
| Rate for Payer: WINHealth Partners Commercial |
$0.67
|
| Rate for Payer: Wise Provider Network Commercial |
$0.65
|
|
|
MODIFIED LANOLIN 100 % TOPICAL CREAM [156346]
|
Facility
|
IP
|
$0.68
|
|
|
Service Code
|
NDC 4467710020
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$0.68 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.67
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.65
|
| Rate for Payer: Altius Commercial |
$0.65
|
| Rate for Payer: Beech Street Commercial |
$0.67
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.56
|
| Rate for Payer: Cash Price |
$0.48
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.66
|
| Rate for Payer: Cigna of WY Commercial |
$0.67
|
| Rate for Payer: Entrust Commercial |
$0.65
|
| Rate for Payer: First Choice Health Commercial |
$0.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.45
|
| Rate for Payer: HealthUtah PPO |
$0.68
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.66
|
| Rate for Payer: Multiplan Medicare/VA |
$0.43
|
| Rate for Payer: One Health Plan of WY PPO |
$0.67
|
| Rate for Payer: PacificSource Commercial |
$0.61
|
| Rate for Payer: PHCS PPO |
$0.67
|
| Rate for Payer: Three Rivers PPO |
$0.51
|
| Rate for Payer: TriWest Veterans Administration |
$0.45
|
| Rate for Payer: United Healthcare Commercial |
$0.59
|
| Rate for Payer: United Healthcare Medicare |
$0.45
|
| Rate for Payer: WINHealth Partners Commercial |
$0.65
|
| Rate for Payer: Wise Provider Network Commercial |
$0.65
|
|
|
MOD SED OTHER PHYS/QHP INITIAL 15 MINS <5 YRS
|
Professional
|
Both
|
$275.00
|
|
|
Service Code
|
HCPCS 99155
|
| Hospital Charge Code |
99155
|
| Min. Negotiated Rate |
$66.67 |
| Max. Negotiated Rate |
$275.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$269.50
|
| Rate for Payer: Aetna of WY Medicare |
$78.43
|
| Rate for Payer: Beech Street Commercial |
$261.25
|
| Rate for Payer: Cash Price |
$192.50
|
| Rate for Payer: Cash Price |
$192.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$266.75
|
| Rate for Payer: Cigna of WY Commercial |
$269.50
|
| Rate for Payer: First Choice Health Commercial |
$247.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$261.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$78.43
|
| Rate for Payer: HealthUtah PPO |
$275.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$266.75
|
| Rate for Payer: Multiplan Medicare/VA |
$66.67
|
| Rate for Payer: One Health Plan of WY PPO |
$269.50
|
| Rate for Payer: PacificSource Commercial |
$247.50
|
| Rate for Payer: PHCS PPO |
$261.25
|
| Rate for Payer: Three Rivers PPO |
$206.25
|
| Rate for Payer: TriWest Veterans Administration |
$78.43
|
| Rate for Payer: United Healthcare Commercial |
$239.25
|
| Rate for Payer: United Healthcare Medicare |
$78.43
|
| Rate for Payer: WINHealth Partners Commercial |
$261.25
|
|
|
MOD SED OTHER PHYS/QHP INITIAL 15 MINS 5/> YRS
|
Professional
|
Both
|
$387.00
|
|
|
Service Code
|
HCPCS 99156
|
| Hospital Charge Code |
99156
|
| Min. Negotiated Rate |
$60.55 |
| Max. Negotiated Rate |
$387.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$379.26
|
| Rate for Payer: Aetna of WY Medicare |
$71.24
|
| Rate for Payer: Beech Street Commercial |
$367.65
|
| Rate for Payer: Cash Price |
$270.90
|
| Rate for Payer: Cash Price |
$270.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$375.39
|
| Rate for Payer: Cigna of WY Commercial |
$379.26
|
| Rate for Payer: First Choice Health Commercial |
$348.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$367.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$71.24
|
| Rate for Payer: HealthUtah PPO |
$387.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$375.39
|
| Rate for Payer: Multiplan Medicare/VA |
$60.55
|
| Rate for Payer: One Health Plan of WY PPO |
$379.26
|
| Rate for Payer: PacificSource Commercial |
$348.30
|
| Rate for Payer: PHCS PPO |
$367.65
|
| Rate for Payer: Three Rivers PPO |
$290.25
|
| Rate for Payer: TriWest Veterans Administration |
$71.24
|
| Rate for Payer: United Healthcare Commercial |
$336.69
|
| Rate for Payer: United Healthcare Medicare |
$71.24
|
| Rate for Payer: WINHealth Partners Commercial |
$367.65
|
|
|
MOD SED SAME PHYS/QHP EACH ADDL 15 MINS
|
Professional
|
Both
|
$44.00
|
|
|
Service Code
|
HCPCS 99153
|
| Hospital Charge Code |
99153
|
| Min. Negotiated Rate |
$9.60 |
| Max. Negotiated Rate |
$44.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$43.12
|
| Rate for Payer: Aetna of WY Medicare |
$11.29
|
| Rate for Payer: Beech Street Commercial |
$41.80
|
| Rate for Payer: Cash Price |
$30.80
|
| Rate for Payer: Cash Price |
$30.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$42.68
|
| Rate for Payer: Cigna of WY Commercial |
$43.12
|
| Rate for Payer: First Choice Health Commercial |
$39.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$41.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.29
|
| Rate for Payer: HealthUtah PPO |
$44.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$42.68
|
| Rate for Payer: Multiplan Medicare/VA |
$9.60
|
| Rate for Payer: One Health Plan of WY PPO |
$43.12
|
| Rate for Payer: PacificSource Commercial |
$39.60
|
| Rate for Payer: PHCS PPO |
$41.80
|
| Rate for Payer: Three Rivers PPO |
$33.00
|
| Rate for Payer: TriWest Veterans Administration |
$11.29
|
| Rate for Payer: United Healthcare Commercial |
$38.28
|
| Rate for Payer: United Healthcare Medicare |
$11.29
|
| Rate for Payer: WINHealth Partners Commercial |
$41.80
|
|
|
MOD SED SAME PHYS/QHP INITIAL 15 MINS 5/> YRS
|
Professional
|
Both
|
$51.00
|
|
|
Service Code
|
HCPCS 99152
|
| Hospital Charge Code |
99152
|
| Min. Negotiated Rate |
$9.80 |
| Max. Negotiated Rate |
$51.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$49.98
|
| Rate for Payer: Aetna of WY Medicare |
$11.53
|
| Rate for Payer: Beech Street Commercial |
$48.45
|
| Rate for Payer: Cash Price |
$35.70
|
| Rate for Payer: Cash Price |
$35.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$49.47
|
| Rate for Payer: Cigna of WY Commercial |
$49.98
|
| Rate for Payer: First Choice Health Commercial |
$45.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$48.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.53
|
| Rate for Payer: HealthUtah PPO |
$51.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$49.47
|
| Rate for Payer: Multiplan Medicare/VA |
$9.80
|
| Rate for Payer: One Health Plan of WY PPO |
$49.98
|
| Rate for Payer: PacificSource Commercial |
$45.90
|
| Rate for Payer: PHCS PPO |
$48.45
|
| Rate for Payer: Three Rivers PPO |
$38.25
|
| Rate for Payer: TriWest Veterans Administration |
$11.53
|
| Rate for Payer: United Healthcare Commercial |
$44.37
|
| Rate for Payer: United Healthcare Medicare |
$11.53
|
| Rate for Payer: WINHealth Partners Commercial |
$48.45
|
|
|
MONICA NOVII WIRELESS PATCH
|
Facility
|
IP
|
$124.69
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$78.18 |
| Max. Negotiated Rate |
$124.69 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$122.20
|
| Rate for Payer: Altius Auto/Workers Compensation |
$119.70
|
| Rate for Payer: Altius Commercial |
$119.70
|
| Rate for Payer: Beech Street Commercial |
$122.20
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$102.37
|
| Rate for Payer: Cash Price |
$87.28
|
| Rate for Payer: ChoiceCare Network Commercial |
$120.95
|
| Rate for Payer: Cigna of WY Commercial |
$122.20
|
| Rate for Payer: Entrust Commercial |
$118.46
|
| Rate for Payer: First Choice Health Commercial |
$118.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$118.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$82.30
|
| Rate for Payer: HealthUtah PPO |
$124.69
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$120.95
|
| Rate for Payer: Multiplan Medicare/VA |
$78.18
|
| Rate for Payer: One Health Plan of WY PPO |
$122.20
|
| Rate for Payer: PacificSource Commercial |
$112.22
|
| Rate for Payer: PHCS PPO |
$122.20
|
| Rate for Payer: Three Rivers PPO |
$93.52
|
| Rate for Payer: TriWest Veterans Administration |
$82.30
|
| Rate for Payer: United Healthcare Commercial |
$108.48
|
| Rate for Payer: United Healthcare Medicare |
$82.30
|
| Rate for Payer: WINHealth Partners Commercial |
$118.46
|
| Rate for Payer: Wise Provider Network Commercial |
$118.46
|
|
|
MONICA NOVII WIRELESS PATCH
|
Facility
|
OP
|
$124.69
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$68.70 |
| Max. Negotiated Rate |
$124.69 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$122.20
|
| Rate for Payer: Aetna of WY Medicare |
$82.30
|
| Rate for Payer: Altius Auto/Workers Compensation |
$119.70
|
| Rate for Payer: Altius Commercial |
$119.70
|
| Rate for Payer: Beech Street Commercial |
$122.20
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$102.37
|
| Rate for Payer: Cash Price |
$87.28
|
| Rate for Payer: ChoiceCare Network Commercial |
$120.95
|
| Rate for Payer: Cigna of WY Commercial |
$122.20
|
| Rate for Payer: Entrust Commercial |
$118.46
|
| Rate for Payer: First Choice Health Commercial |
$118.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$118.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$72.32
|
| Rate for Payer: HealthUtah PPO |
$124.69
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$120.95
|
| Rate for Payer: Multiplan Medicare/VA |
$68.70
|
| Rate for Payer: One Health Plan of WY PPO |
$122.20
|
| Rate for Payer: PacificSource Commercial |
$112.22
|
| Rate for Payer: PHCS PPO |
$122.20
|
| Rate for Payer: Three Rivers PPO |
$93.52
|
| Rate for Payer: TriWest Veterans Administration |
$72.32
|
| Rate for Payer: United Healthcare Commercial |
$108.48
|
| Rate for Payer: United Healthcare Medicare |
$72.32
|
| Rate for Payer: WINHealth Partners Commercial |
$122.20
|
| Rate for Payer: Wise Provider Network Commercial |
$118.46
|
|
|
MONOSUSPENSION ARM/HAND SUPP
|
Professional
|
Both
|
$19.00
|
|
|
Service Code
|
HCPCS L3969
|
| Hospital Charge Code |
L3969
|
| Min. Negotiated Rate |
$14.25 |
| Max. Negotiated Rate |
$19.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18.62
|
| Rate for Payer: Beech Street Commercial |
$18.05
|
| Rate for Payer: Cash Price |
$13.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$18.43
|
| Rate for Payer: Cigna of WY Commercial |
$18.62
|
| Rate for Payer: First Choice Health Commercial |
$17.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$18.05
|
| Rate for Payer: HealthUtah PPO |
$19.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$18.43
|
| Rate for Payer: One Health Plan of WY PPO |
$18.62
|
| Rate for Payer: PacificSource Commercial |
$17.10
|
| Rate for Payer: PHCS PPO |
$18.05
|
| Rate for Payer: Three Rivers PPO |
$14.25
|
| Rate for Payer: United Healthcare Commercial |
$16.53
|
| Rate for Payer: WINHealth Partners Commercial |
$18.05
|
|
|
MONOVISC INJ PER DOSE
|
Professional
|
Both
|
$3,308.00
|
|
|
Service Code
|
HCPCS J7327
|
| Hospital Charge Code |
J7327
|
| Min. Negotiated Rate |
$604.81 |
| Max. Negotiated Rate |
$3,308.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,241.84
|
| Rate for Payer: Aetna of WY Medicare |
$711.54
|
| Rate for Payer: Beech Street Commercial |
$3,142.60
|
| Rate for Payer: Cash Price |
$2,315.60
|
| Rate for Payer: Cash Price |
$2,315.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,208.76
|
| Rate for Payer: Cigna of WY Commercial |
$3,241.84
|
| Rate for Payer: First Choice Health Commercial |
$2,977.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,142.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$711.54
|
| Rate for Payer: HealthUtah PPO |
$3,308.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,208.76
|
| Rate for Payer: Multiplan Medicare/VA |
$604.81
|
| Rate for Payer: One Health Plan of WY PPO |
$3,241.84
|
| Rate for Payer: PacificSource Commercial |
$2,977.20
|
| Rate for Payer: PHCS PPO |
$3,142.60
|
| Rate for Payer: Three Rivers PPO |
$2,481.00
|
| Rate for Payer: TriWest Veterans Administration |
$711.54
|
| Rate for Payer: United Healthcare Commercial |
$2,877.96
|
| Rate for Payer: United Healthcare Medicare |
$711.54
|
| Rate for Payer: WINHealth Partners Commercial |
$3,142.60
|
|
|
MONTELUKAST 10 MG TABLET [15974]
|
Facility
|
OP
|
$0.51
|
|
|
Service Code
|
NDC 3172272690
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$0.51 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.50
|
| Rate for Payer: Aetna of WY Medicare |
$0.34
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.49
|
| Rate for Payer: Altius Commercial |
$0.49
|
| Rate for Payer: Beech Street Commercial |
$0.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.42
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.49
|
| Rate for Payer: Cigna of WY Commercial |
$0.50
|
| Rate for Payer: Entrust Commercial |
$0.48
|
| Rate for Payer: First Choice Health Commercial |
$0.48
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.48
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.30
|
| Rate for Payer: HealthUtah PPO |
$0.51
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.49
|
| Rate for Payer: Multiplan Medicare/VA |
$0.28
|
| Rate for Payer: One Health Plan of WY PPO |
$0.50
|
| Rate for Payer: PacificSource Commercial |
$0.46
|
| Rate for Payer: PHCS PPO |
$0.50
|
| Rate for Payer: Three Rivers PPO |
$0.38
|
| Rate for Payer: TriWest Veterans Administration |
$0.30
|
| Rate for Payer: United Healthcare Commercial |
$0.44
|
| Rate for Payer: United Healthcare Medicare |
$0.30
|
| Rate for Payer: WINHealth Partners Commercial |
$0.50
|
| Rate for Payer: Wise Provider Network Commercial |
$0.48
|
|
|
MONTELUKAST 10 MG TABLET [15974]
|
Facility
|
OP
|
$0.32
|
|
|
Service Code
|
NDC 1672911910
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.31
|
| Rate for Payer: Aetna of WY Medicare |
$0.21
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.31
|
| Rate for Payer: Altius Commercial |
$0.31
|
| Rate for Payer: Beech Street Commercial |
$0.31
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.26
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.31
|
| Rate for Payer: Cigna of WY Commercial |
$0.31
|
| Rate for Payer: Entrust Commercial |
$0.30
|
| Rate for Payer: First Choice Health Commercial |
$0.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.19
|
| Rate for Payer: HealthUtah PPO |
$0.32
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.31
|
| Rate for Payer: Multiplan Medicare/VA |
$0.18
|
| Rate for Payer: One Health Plan of WY PPO |
$0.31
|
| Rate for Payer: PacificSource Commercial |
$0.29
|
| Rate for Payer: PHCS PPO |
$0.31
|
| Rate for Payer: Three Rivers PPO |
$0.24
|
| Rate for Payer: TriWest Veterans Administration |
$0.19
|
| Rate for Payer: United Healthcare Commercial |
$0.28
|
| Rate for Payer: United Healthcare Medicare |
$0.19
|
| Rate for Payer: WINHealth Partners Commercial |
$0.31
|
| Rate for Payer: Wise Provider Network Commercial |
$0.30
|
|
|
MONTELUKAST 10 MG TABLET [15974]
|
Facility
|
IP
|
$0.32
|
|
|
Service Code
|
NDC 1672911910
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.31
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.31
|
| Rate for Payer: Altius Commercial |
$0.31
|
| Rate for Payer: Beech Street Commercial |
$0.31
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.26
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.31
|
| Rate for Payer: Cigna of WY Commercial |
$0.31
|
| Rate for Payer: Entrust Commercial |
$0.30
|
| Rate for Payer: First Choice Health Commercial |
$0.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.21
|
| Rate for Payer: HealthUtah PPO |
$0.32
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.31
|
| Rate for Payer: Multiplan Medicare/VA |
$0.20
|
| Rate for Payer: One Health Plan of WY PPO |
$0.31
|
| Rate for Payer: PacificSource Commercial |
$0.29
|
| Rate for Payer: PHCS PPO |
$0.31
|
| Rate for Payer: Three Rivers PPO |
$0.24
|
| Rate for Payer: TriWest Veterans Administration |
$0.21
|
| Rate for Payer: United Healthcare Commercial |
$0.28
|
| Rate for Payer: United Healthcare Medicare |
$0.21
|
| Rate for Payer: WINHealth Partners Commercial |
$0.30
|
| Rate for Payer: Wise Provider Network Commercial |
$0.30
|
|
|
MONTELUKAST 10 MG TABLET [15974]
|
Facility
|
IP
|
$0.51
|
|
|
Service Code
|
NDC 3172272690
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.51 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.50
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.49
|
| Rate for Payer: Altius Commercial |
$0.49
|
| Rate for Payer: Beech Street Commercial |
$0.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.42
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.49
|
| Rate for Payer: Cigna of WY Commercial |
$0.50
|
| Rate for Payer: Entrust Commercial |
$0.48
|
| Rate for Payer: First Choice Health Commercial |
$0.48
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.48
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.34
|
| Rate for Payer: HealthUtah PPO |
$0.51
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.49
|
| Rate for Payer: Multiplan Medicare/VA |
$0.32
|
| Rate for Payer: One Health Plan of WY PPO |
$0.50
|
| Rate for Payer: PacificSource Commercial |
$0.46
|
| Rate for Payer: PHCS PPO |
$0.50
|
| Rate for Payer: Three Rivers PPO |
$0.38
|
| Rate for Payer: TriWest Veterans Administration |
$0.34
|
| Rate for Payer: United Healthcare Commercial |
$0.44
|
| Rate for Payer: United Healthcare Medicare |
$0.34
|
| Rate for Payer: WINHealth Partners Commercial |
$0.48
|
| Rate for Payer: Wise Provider Network Commercial |
$0.48
|
|
|
MONTELUKAST 10 MG TABLET [15974]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 6808487511
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.10 |
| Max. Negotiated Rate |
$2.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.96
|
| Rate for Payer: Aetna of WY Medicare |
$1.32
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.92
|
| Rate for Payer: Altius Commercial |
$1.92
|
| Rate for Payer: Beech Street Commercial |
$1.96
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.64
|
| Rate for Payer: Cash Price |
$1.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.94
|
| Rate for Payer: Cigna of WY Commercial |
$1.96
|
| Rate for Payer: Entrust Commercial |
$1.90
|
| Rate for Payer: First Choice Health Commercial |
$1.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.16
|
| Rate for Payer: HealthUtah PPO |
$2.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.94
|
| Rate for Payer: Multiplan Medicare/VA |
$1.10
|
| Rate for Payer: One Health Plan of WY PPO |
$1.96
|
| Rate for Payer: PacificSource Commercial |
$1.80
|
| Rate for Payer: PHCS PPO |
$1.96
|
| Rate for Payer: Three Rivers PPO |
$1.50
|
| Rate for Payer: TriWest Veterans Administration |
$1.16
|
| Rate for Payer: United Healthcare Commercial |
$1.74
|
| Rate for Payer: United Healthcare Medicare |
$1.16
|
| Rate for Payer: WINHealth Partners Commercial |
$1.96
|
| Rate for Payer: Wise Provider Network Commercial |
$1.90
|
|
|
MONTELUKAST 10 MG TABLET [15974]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 6808487511
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.25 |
| Max. Negotiated Rate |
$2.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.96
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.92
|
| Rate for Payer: Altius Commercial |
$1.92
|
| Rate for Payer: Beech Street Commercial |
$1.96
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.64
|
| Rate for Payer: Cash Price |
$1.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.94
|
| Rate for Payer: Cigna of WY Commercial |
$1.96
|
| Rate for Payer: Entrust Commercial |
$1.90
|
| Rate for Payer: First Choice Health Commercial |
$1.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.32
|
| Rate for Payer: HealthUtah PPO |
$2.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.94
|
| Rate for Payer: Multiplan Medicare/VA |
$1.25
|
| Rate for Payer: One Health Plan of WY PPO |
$1.96
|
| Rate for Payer: PacificSource Commercial |
$1.80
|
| Rate for Payer: PHCS PPO |
$1.96
|
| Rate for Payer: Three Rivers PPO |
$1.50
|
| Rate for Payer: TriWest Veterans Administration |
$1.32
|
| Rate for Payer: United Healthcare Commercial |
$1.74
|
| Rate for Payer: United Healthcare Medicare |
$1.32
|
| Rate for Payer: WINHealth Partners Commercial |
$1.90
|
| Rate for Payer: Wise Provider Network Commercial |
$1.90
|
|
|
MONTELUKAST 4 MG CHEWABLE TABLET [6061]
|
Facility
|
OP
|
$1.42
|
|
|
Service Code
|
NDC 3172272730
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.78 |
| Max. Negotiated Rate |
$1.42 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.39
|
| Rate for Payer: Aetna of WY Medicare |
$0.94
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.36
|
| Rate for Payer: Altius Commercial |
$1.36
|
| Rate for Payer: Beech Street Commercial |
$1.39
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.17
|
| Rate for Payer: Cash Price |
$0.99
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.38
|
| Rate for Payer: Cigna of WY Commercial |
$1.39
|
| Rate for Payer: Entrust Commercial |
$1.35
|
| Rate for Payer: First Choice Health Commercial |
$1.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.82
|
| Rate for Payer: HealthUtah PPO |
$1.42
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.38
|
| Rate for Payer: Multiplan Medicare/VA |
$0.78
|
| Rate for Payer: One Health Plan of WY PPO |
$1.39
|
| Rate for Payer: PacificSource Commercial |
$1.28
|
| Rate for Payer: PHCS PPO |
$1.39
|
| Rate for Payer: Three Rivers PPO |
$1.06
|
| Rate for Payer: TriWest Veterans Administration |
$0.82
|
| Rate for Payer: United Healthcare Commercial |
$1.24
|
| Rate for Payer: United Healthcare Medicare |
$0.82
|
| Rate for Payer: WINHealth Partners Commercial |
$1.39
|
| Rate for Payer: Wise Provider Network Commercial |
$1.35
|
|
|
MONTELUKAST 4 MG CHEWABLE TABLET [6061]
|
Facility
|
IP
|
$1.42
|
|
|
Service Code
|
NDC 3172272730
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.89 |
| Max. Negotiated Rate |
$1.42 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.39
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.36
|
| Rate for Payer: Altius Commercial |
$1.36
|
| Rate for Payer: Beech Street Commercial |
$1.39
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.17
|
| Rate for Payer: Cash Price |
$0.99
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.38
|
| Rate for Payer: Cigna of WY Commercial |
$1.39
|
| Rate for Payer: Entrust Commercial |
$1.35
|
| Rate for Payer: First Choice Health Commercial |
$1.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.94
|
| Rate for Payer: HealthUtah PPO |
$1.42
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.38
|
| Rate for Payer: Multiplan Medicare/VA |
$0.89
|
| Rate for Payer: One Health Plan of WY PPO |
$1.39
|
| Rate for Payer: PacificSource Commercial |
$1.28
|
| Rate for Payer: PHCS PPO |
$1.39
|
| Rate for Payer: Three Rivers PPO |
$1.06
|
| Rate for Payer: TriWest Veterans Administration |
$0.94
|
| Rate for Payer: United Healthcare Commercial |
$1.24
|
| Rate for Payer: United Healthcare Medicare |
$0.94
|
| Rate for Payer: WINHealth Partners Commercial |
$1.35
|
| Rate for Payer: Wise Provider Network Commercial |
$1.35
|
|
|
MORGAN MEDI FLOW LENS MT2000
|
Facility
|
OP
|
$126.25
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$69.56 |
| Max. Negotiated Rate |
$126.25 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$123.72
|
| Rate for Payer: Aetna of WY Medicare |
$83.32
|
| Rate for Payer: Altius Auto/Workers Compensation |
$121.20
|
| Rate for Payer: Altius Commercial |
$121.20
|
| Rate for Payer: Beech Street Commercial |
$123.72
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$103.65
|
| Rate for Payer: Cash Price |
$88.37
|
| Rate for Payer: ChoiceCare Network Commercial |
$122.46
|
| Rate for Payer: Cigna of WY Commercial |
$123.72
|
| Rate for Payer: Entrust Commercial |
$119.94
|
| Rate for Payer: First Choice Health Commercial |
$119.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$119.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$73.22
|
| Rate for Payer: HealthUtah PPO |
$126.25
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$122.46
|
| Rate for Payer: Multiplan Medicare/VA |
$69.56
|
| Rate for Payer: One Health Plan of WY PPO |
$123.72
|
| Rate for Payer: PacificSource Commercial |
$113.62
|
| Rate for Payer: PHCS PPO |
$123.72
|
| Rate for Payer: Three Rivers PPO |
$94.69
|
| Rate for Payer: TriWest Veterans Administration |
$73.22
|
| Rate for Payer: United Healthcare Commercial |
$109.84
|
| Rate for Payer: United Healthcare Medicare |
$73.22
|
| Rate for Payer: WINHealth Partners Commercial |
$123.72
|
| Rate for Payer: Wise Provider Network Commercial |
$119.94
|
|
