|
NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET [14687]
|
Facility
|
IP
|
$0.42
|
|
|
Service Code
|
NDC 6846263925
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.41
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.40
|
| Rate for Payer: Altius Commercial |
$0.40
|
| Rate for Payer: Beech Street Commercial |
$0.41
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.34
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.41
|
| Rate for Payer: Cigna of WY Commercial |
$0.41
|
| Rate for Payer: Entrust Commercial |
$0.40
|
| Rate for Payer: First Choice Health Commercial |
$0.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.28
|
| Rate for Payer: HealthUtah PPO |
$0.42
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.41
|
| Rate for Payer: Multiplan Medicare/VA |
$0.26
|
| Rate for Payer: One Health Plan of WY PPO |
$0.41
|
| Rate for Payer: PacificSource Commercial |
$0.38
|
| Rate for Payer: PHCS PPO |
$0.41
|
| Rate for Payer: Three Rivers PPO |
$0.32
|
| Rate for Payer: TriWest Veterans Administration |
$0.28
|
| Rate for Payer: United Healthcare Commercial |
$0.37
|
| Rate for Payer: United Healthcare Medicare |
$0.28
|
| Rate for Payer: WINHealth Partners Commercial |
$0.40
|
| Rate for Payer: Wise Provider Network Commercial |
$0.40
|
|
|
NITROGLYCERIN 2 % TRANSDERMAL OINTMENT [15792]
|
Facility
|
OP
|
$9.69
|
|
|
Service Code
|
NDC 0281032608
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.34 |
| Max. Negotiated Rate |
$9.69 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$9.50
|
| Rate for Payer: Aetna of WY Medicare |
$6.40
|
| Rate for Payer: Altius Auto/Workers Compensation |
$9.30
|
| Rate for Payer: Altius Commercial |
$9.30
|
| Rate for Payer: Beech Street Commercial |
$9.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$7.96
|
| Rate for Payer: Cash Price |
$6.78
|
| Rate for Payer: ChoiceCare Network Commercial |
$9.40
|
| Rate for Payer: Cigna of WY Commercial |
$9.50
|
| Rate for Payer: Entrust Commercial |
$9.21
|
| Rate for Payer: First Choice Health Commercial |
$9.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$9.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$5.62
|
| Rate for Payer: HealthUtah PPO |
$9.69
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$9.40
|
| Rate for Payer: Multiplan Medicare/VA |
$5.34
|
| Rate for Payer: One Health Plan of WY PPO |
$9.50
|
| Rate for Payer: PacificSource Commercial |
$8.72
|
| Rate for Payer: PHCS PPO |
$9.50
|
| Rate for Payer: Three Rivers PPO |
$7.27
|
| Rate for Payer: TriWest Veterans Administration |
$5.62
|
| Rate for Payer: United Healthcare Commercial |
$8.43
|
| Rate for Payer: United Healthcare Medicare |
$5.62
|
| Rate for Payer: WINHealth Partners Commercial |
$9.50
|
| Rate for Payer: Wise Provider Network Commercial |
$9.21
|
|
|
NITROGLYCERIN 2 % TRANSDERMAL OINTMENT [15792]
|
Facility
|
IP
|
$9.69
|
|
|
Service Code
|
NDC 0281032608
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.08 |
| Max. Negotiated Rate |
$9.69 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$9.50
|
| Rate for Payer: Altius Auto/Workers Compensation |
$9.30
|
| Rate for Payer: Altius Commercial |
$9.30
|
| Rate for Payer: Beech Street Commercial |
$9.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$7.96
|
| Rate for Payer: Cash Price |
$6.78
|
| Rate for Payer: ChoiceCare Network Commercial |
$9.40
|
| Rate for Payer: Cigna of WY Commercial |
$9.50
|
| Rate for Payer: Entrust Commercial |
$9.21
|
| Rate for Payer: First Choice Health Commercial |
$9.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$9.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$6.40
|
| Rate for Payer: HealthUtah PPO |
$9.69
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$9.40
|
| Rate for Payer: Multiplan Medicare/VA |
$6.08
|
| Rate for Payer: One Health Plan of WY PPO |
$9.50
|
| Rate for Payer: PacificSource Commercial |
$8.72
|
| Rate for Payer: PHCS PPO |
$9.50
|
| Rate for Payer: Three Rivers PPO |
$7.27
|
| Rate for Payer: TriWest Veterans Administration |
$6.40
|
| Rate for Payer: United Healthcare Commercial |
$8.43
|
| Rate for Payer: United Healthcare Medicare |
$6.40
|
| Rate for Payer: WINHealth Partners Commercial |
$9.21
|
| Rate for Payer: Wise Provider Network Commercial |
$9.21
|
|
|
NITROGLYCERIN 50 MG/250 ML (200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS [9246]
|
Facility
|
IP
|
$15.36
|
|
|
Service Code
|
HCPCS J2305
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.63 |
| Max. Negotiated Rate |
$15.36 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.05
|
| Rate for Payer: Altius Auto/Workers Compensation |
$14.75
|
| Rate for Payer: Altius Commercial |
$14.75
|
| Rate for Payer: Beech Street Commercial |
$15.05
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.61
|
| Rate for Payer: Cash Price |
$10.75
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.90
|
| Rate for Payer: Cigna of WY Commercial |
$15.05
|
| Rate for Payer: Entrust Commercial |
$14.59
|
| Rate for Payer: First Choice Health Commercial |
$14.59
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.59
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.14
|
| Rate for Payer: HealthUtah PPO |
$15.36
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.90
|
| Rate for Payer: Multiplan Medicare/VA |
$9.63
|
| Rate for Payer: One Health Plan of WY PPO |
$15.05
|
| Rate for Payer: PacificSource Commercial |
$13.82
|
| Rate for Payer: PHCS PPO |
$15.05
|
| Rate for Payer: Three Rivers PPO |
$11.52
|
| Rate for Payer: TriWest Veterans Administration |
$10.14
|
| Rate for Payer: United Healthcare Commercial |
$13.36
|
| Rate for Payer: United Healthcare Medicare |
$10.14
|
| Rate for Payer: WINHealth Partners Commercial |
$14.59
|
| Rate for Payer: Wise Provider Network Commercial |
$14.59
|
|
|
NITROGLYCERIN 50 MG/250 ML (200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS [9246]
|
Facility
|
OP
|
$15.36
|
|
|
Service Code
|
HCPCS J2305
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.46 |
| Max. Negotiated Rate |
$15.36 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.05
|
| Rate for Payer: Aetna of WY Medicare |
$10.14
|
| Rate for Payer: Altius Auto/Workers Compensation |
$14.75
|
| Rate for Payer: Altius Commercial |
$14.75
|
| Rate for Payer: Beech Street Commercial |
$15.05
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.61
|
| Rate for Payer: Cash Price |
$10.75
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.90
|
| Rate for Payer: Cigna of WY Commercial |
$15.05
|
| Rate for Payer: Entrust Commercial |
$14.59
|
| Rate for Payer: First Choice Health Commercial |
$14.59
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.59
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.91
|
| Rate for Payer: HealthUtah PPO |
$15.36
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.90
|
| Rate for Payer: Multiplan Medicare/VA |
$8.46
|
| Rate for Payer: One Health Plan of WY PPO |
$15.05
|
| Rate for Payer: PacificSource Commercial |
$13.82
|
| Rate for Payer: PHCS PPO |
$15.05
|
| Rate for Payer: Three Rivers PPO |
$11.52
|
| Rate for Payer: TriWest Veterans Administration |
$8.91
|
| Rate for Payer: United Healthcare Commercial |
$13.36
|
| Rate for Payer: United Healthcare Medicare |
$8.91
|
| Rate for Payer: WINHealth Partners Commercial |
$15.05
|
| Rate for Payer: Wise Provider Network Commercial |
$14.59
|
|
|
NIVOLUMAB 10 MG/ML INTRAVENOUS SOLUTION (WRAPPED) [4000704]
|
Facility
|
OP
|
$339.47
|
|
|
Service Code
|
HCPCS J9299
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$187.05 |
| Max. Negotiated Rate |
$339.47 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$332.68
|
| Rate for Payer: Aetna of WY Medicare |
$224.05
|
| Rate for Payer: Altius Auto/Workers Compensation |
$325.89
|
| Rate for Payer: Altius Commercial |
$325.89
|
| Rate for Payer: Beech Street Commercial |
$332.68
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$278.70
|
| Rate for Payer: Cash Price |
$237.63
|
| Rate for Payer: ChoiceCare Network Commercial |
$329.29
|
| Rate for Payer: Cigna of WY Commercial |
$332.68
|
| Rate for Payer: Entrust Commercial |
$322.50
|
| Rate for Payer: First Choice Health Commercial |
$322.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$322.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$196.89
|
| Rate for Payer: HealthUtah PPO |
$339.47
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$329.29
|
| Rate for Payer: Multiplan Medicare/VA |
$187.05
|
| Rate for Payer: One Health Plan of WY PPO |
$332.68
|
| Rate for Payer: PacificSource Commercial |
$305.52
|
| Rate for Payer: PHCS PPO |
$332.68
|
| Rate for Payer: Three Rivers PPO |
$254.60
|
| Rate for Payer: TriWest Veterans Administration |
$196.89
|
| Rate for Payer: United Healthcare Commercial |
$295.34
|
| Rate for Payer: United Healthcare Medicare |
$196.89
|
| Rate for Payer: WINHealth Partners Commercial |
$332.68
|
| Rate for Payer: Wise Provider Network Commercial |
$322.50
|
|
|
NIVOLUMAB 10 MG/ML INTRAVENOUS SOLUTION (WRAPPED) [4000704]
|
Facility
|
IP
|
$339.47
|
|
|
Service Code
|
HCPCS J9299
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$212.85 |
| Max. Negotiated Rate |
$339.47 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$332.68
|
| Rate for Payer: Altius Auto/Workers Compensation |
$325.89
|
| Rate for Payer: Altius Commercial |
$325.89
|
| Rate for Payer: Beech Street Commercial |
$332.68
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$278.70
|
| Rate for Payer: Cash Price |
$237.63
|
| Rate for Payer: ChoiceCare Network Commercial |
$329.29
|
| Rate for Payer: Cigna of WY Commercial |
$332.68
|
| Rate for Payer: Entrust Commercial |
$322.50
|
| Rate for Payer: First Choice Health Commercial |
$322.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$322.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$224.05
|
| Rate for Payer: HealthUtah PPO |
$339.47
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$329.29
|
| Rate for Payer: Multiplan Medicare/VA |
$212.85
|
| Rate for Payer: One Health Plan of WY PPO |
$332.68
|
| Rate for Payer: PacificSource Commercial |
$305.52
|
| Rate for Payer: PHCS PPO |
$332.68
|
| Rate for Payer: Three Rivers PPO |
$254.60
|
| Rate for Payer: TriWest Veterans Administration |
$224.05
|
| Rate for Payer: United Healthcare Commercial |
$295.34
|
| Rate for Payer: United Healthcare Medicare |
$224.05
|
| Rate for Payer: WINHealth Partners Commercial |
$322.50
|
| Rate for Payer: Wise Provider Network Commercial |
$322.50
|
|
|
NJX AA&/STRD PLANTAR COMMON DIGITAL NERVES
|
Professional
|
Both
|
$179.00
|
|
|
Service Code
|
HCPCS 64455
|
| Hospital Charge Code |
64455
|
| Min. Negotiated Rate |
$27.12 |
| Max. Negotiated Rate |
$179.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$175.42
|
| Rate for Payer: Aetna of WY Medicare |
$31.90
|
| Rate for Payer: Beech Street Commercial |
$170.05
|
| Rate for Payer: Cash Price |
$125.30
|
| Rate for Payer: Cash Price |
$125.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$173.63
|
| Rate for Payer: Cigna of WY Commercial |
$175.42
|
| Rate for Payer: First Choice Health Commercial |
$161.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$170.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$31.90
|
| Rate for Payer: HealthUtah PPO |
$179.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$173.63
|
| Rate for Payer: Multiplan Medicare/VA |
$27.12
|
| Rate for Payer: One Health Plan of WY PPO |
$175.42
|
| Rate for Payer: PacificSource Commercial |
$161.10
|
| Rate for Payer: PHCS PPO |
$170.05
|
| Rate for Payer: Three Rivers PPO |
$134.25
|
| Rate for Payer: TriWest Veterans Administration |
$31.90
|
| Rate for Payer: United Healthcare Commercial |
$155.73
|
| Rate for Payer: United Healthcare Medicare |
$31.90
|
| Rate for Payer: WINHealth Partners Commercial |
$152.15
|
|
|
NJX AA&/STRD PLANTAR COMMON DIGITAL NERVES
|
Professional
|
Both
|
$358.00
|
|
|
Service Code
|
HCPCS 64455 50
|
| Hospital Charge Code |
64455
|
| Min. Negotiated Rate |
$27.12 |
| Max. Negotiated Rate |
$358.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$350.84
|
| Rate for Payer: Aetna of WY Medicare |
$31.90
|
| Rate for Payer: Beech Street Commercial |
$340.10
|
| Rate for Payer: Cash Price |
$250.60
|
| Rate for Payer: Cash Price |
$250.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$347.26
|
| Rate for Payer: Cigna of WY Commercial |
$350.84
|
| Rate for Payer: First Choice Health Commercial |
$322.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$340.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$31.90
|
| Rate for Payer: HealthUtah PPO |
$358.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$347.26
|
| Rate for Payer: Multiplan Medicare/VA |
$27.12
|
| Rate for Payer: One Health Plan of WY PPO |
$350.84
|
| Rate for Payer: PacificSource Commercial |
$322.20
|
| Rate for Payer: PHCS PPO |
$340.10
|
| Rate for Payer: Three Rivers PPO |
$268.50
|
| Rate for Payer: TriWest Veterans Administration |
$31.90
|
| Rate for Payer: United Healthcare Commercial |
$311.46
|
| Rate for Payer: United Healthcare Medicare |
$31.90
|
| Rate for Payer: WINHealth Partners Commercial |
$304.30
|
|
|
NJX AA&/STRD TFRML EPI CERVICAL/THORACIC 1 LEVEL
|
Professional
|
Both
|
$1,850.00
|
|
|
Service Code
|
HCPCS 64479 50
|
| Hospital Charge Code |
64479
|
| Min. Negotiated Rate |
$106.74 |
| Max. Negotiated Rate |
$1,850.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,813.00
|
| Rate for Payer: Aetna of WY Medicare |
$125.58
|
| Rate for Payer: Beech Street Commercial |
$1,757.50
|
| Rate for Payer: Cash Price |
$1,295.00
|
| Rate for Payer: Cash Price |
$1,295.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,794.50
|
| Rate for Payer: Cigna of WY Commercial |
$1,813.00
|
| Rate for Payer: First Choice Health Commercial |
$1,665.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,757.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$125.58
|
| Rate for Payer: HealthUtah PPO |
$1,850.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,794.50
|
| Rate for Payer: Multiplan Medicare/VA |
$106.74
|
| Rate for Payer: One Health Plan of WY PPO |
$1,813.00
|
| Rate for Payer: PacificSource Commercial |
$1,665.00
|
| Rate for Payer: PHCS PPO |
$1,757.50
|
| Rate for Payer: Three Rivers PPO |
$1,387.50
|
| Rate for Payer: TriWest Veterans Administration |
$125.58
|
| Rate for Payer: United Healthcare Commercial |
$1,609.50
|
| Rate for Payer: United Healthcare Medicare |
$125.58
|
| Rate for Payer: WINHealth Partners Commercial |
$1,572.50
|
|
|
NJX AA&/STRD TFRML EPI CERVICAL/THORACIC 1 LEVEL
|
Professional
|
Both
|
$925.00
|
|
|
Service Code
|
HCPCS 64479
|
| Hospital Charge Code |
64479
|
| Min. Negotiated Rate |
$106.74 |
| Max. Negotiated Rate |
$925.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$906.50
|
| Rate for Payer: Aetna of WY Medicare |
$125.58
|
| Rate for Payer: Beech Street Commercial |
$878.75
|
| Rate for Payer: Cash Price |
$647.50
|
| Rate for Payer: Cash Price |
$647.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$897.25
|
| Rate for Payer: Cigna of WY Commercial |
$906.50
|
| Rate for Payer: First Choice Health Commercial |
$832.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$878.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$125.58
|
| Rate for Payer: HealthUtah PPO |
$925.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$897.25
|
| Rate for Payer: Multiplan Medicare/VA |
$106.74
|
| Rate for Payer: One Health Plan of WY PPO |
$906.50
|
| Rate for Payer: PacificSource Commercial |
$832.50
|
| Rate for Payer: PHCS PPO |
$878.75
|
| Rate for Payer: Three Rivers PPO |
$693.75
|
| Rate for Payer: TriWest Veterans Administration |
$125.58
|
| Rate for Payer: United Healthcare Commercial |
$804.75
|
| Rate for Payer: United Healthcare Medicare |
$125.58
|
| Rate for Payer: WINHealth Partners Commercial |
$786.25
|
|
|
NJX AA&/STRD TFRML EPI CERVICAL/THORACIC EA ADDL
|
Professional
|
Both
|
$469.00
|
|
|
Service Code
|
HCPCS 64480
|
| Hospital Charge Code |
64480
|
| Min. Negotiated Rate |
$49.58 |
| Max. Negotiated Rate |
$469.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$459.62
|
| Rate for Payer: Aetna of WY Medicare |
$58.33
|
| Rate for Payer: Beech Street Commercial |
$445.55
|
| Rate for Payer: Cash Price |
$328.30
|
| Rate for Payer: Cash Price |
$328.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$454.93
|
| Rate for Payer: Cigna of WY Commercial |
$459.62
|
| Rate for Payer: First Choice Health Commercial |
$422.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$445.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$58.33
|
| Rate for Payer: HealthUtah PPO |
$469.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$454.93
|
| Rate for Payer: Multiplan Medicare/VA |
$49.58
|
| Rate for Payer: One Health Plan of WY PPO |
$459.62
|
| Rate for Payer: PacificSource Commercial |
$422.10
|
| Rate for Payer: PHCS PPO |
$445.55
|
| Rate for Payer: Three Rivers PPO |
$351.75
|
| Rate for Payer: TriWest Veterans Administration |
$58.33
|
| Rate for Payer: United Healthcare Commercial |
$408.03
|
| Rate for Payer: United Healthcare Medicare |
$58.33
|
| Rate for Payer: WINHealth Partners Commercial |
$398.65
|
|
|
NJX AA&/STRD TFRML EPI CERVICAL/THORACIC EA ADDL
|
Professional
|
Both
|
$938.00
|
|
|
Service Code
|
HCPCS 64480 50
|
| Hospital Charge Code |
64480
|
| Min. Negotiated Rate |
$49.58 |
| Max. Negotiated Rate |
$938.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$919.24
|
| Rate for Payer: Aetna of WY Medicare |
$58.33
|
| Rate for Payer: Beech Street Commercial |
$891.10
|
| Rate for Payer: Cash Price |
$656.60
|
| Rate for Payer: Cash Price |
$656.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$909.86
|
| Rate for Payer: Cigna of WY Commercial |
$919.24
|
| Rate for Payer: First Choice Health Commercial |
$844.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$891.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$58.33
|
| Rate for Payer: HealthUtah PPO |
$938.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$909.86
|
| Rate for Payer: Multiplan Medicare/VA |
$49.58
|
| Rate for Payer: One Health Plan of WY PPO |
$919.24
|
| Rate for Payer: PacificSource Commercial |
$844.20
|
| Rate for Payer: PHCS PPO |
$891.10
|
| Rate for Payer: Three Rivers PPO |
$703.50
|
| Rate for Payer: TriWest Veterans Administration |
$58.33
|
| Rate for Payer: United Healthcare Commercial |
$816.06
|
| Rate for Payer: United Healthcare Medicare |
$58.33
|
| Rate for Payer: WINHealth Partners Commercial |
$797.30
|
|
|
NJX AA&/STRD TFRML EPI LUMBAR/SACRAL 1 LEVEL
|
Professional
|
Both
|
$859.00
|
|
|
Service Code
|
HCPCS 64483
|
| Hospital Charge Code |
64483
|
| Min. Negotiated Rate |
$91.09 |
| Max. Negotiated Rate |
$859.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$841.82
|
| Rate for Payer: Aetna of WY Medicare |
$107.17
|
| Rate for Payer: Beech Street Commercial |
$816.05
|
| Rate for Payer: Cash Price |
$601.30
|
| Rate for Payer: Cash Price |
$601.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$833.23
|
| Rate for Payer: Cigna of WY Commercial |
$841.82
|
| Rate for Payer: First Choice Health Commercial |
$773.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$816.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$107.17
|
| Rate for Payer: HealthUtah PPO |
$859.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$833.23
|
| Rate for Payer: Multiplan Medicare/VA |
$91.09
|
| Rate for Payer: One Health Plan of WY PPO |
$841.82
|
| Rate for Payer: PacificSource Commercial |
$773.10
|
| Rate for Payer: PHCS PPO |
$816.05
|
| Rate for Payer: Three Rivers PPO |
$644.25
|
| Rate for Payer: TriWest Veterans Administration |
$107.17
|
| Rate for Payer: United Healthcare Commercial |
$747.33
|
| Rate for Payer: United Healthcare Medicare |
$107.17
|
| Rate for Payer: WINHealth Partners Commercial |
$730.15
|
|
|
NJX AA&/STRD TFRML EPI LUMBAR/SACRAL 1 LEVEL
|
Professional
|
Both
|
$1,718.00
|
|
|
Service Code
|
HCPCS 64483 50
|
| Hospital Charge Code |
64483
|
| Min. Negotiated Rate |
$91.09 |
| Max. Negotiated Rate |
$1,718.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,683.64
|
| Rate for Payer: Aetna of WY Medicare |
$107.17
|
| Rate for Payer: Beech Street Commercial |
$1,632.10
|
| Rate for Payer: Cash Price |
$1,202.60
|
| Rate for Payer: Cash Price |
$1,202.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,666.46
|
| Rate for Payer: Cigna of WY Commercial |
$1,683.64
|
| Rate for Payer: First Choice Health Commercial |
$1,546.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,632.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$107.17
|
| Rate for Payer: HealthUtah PPO |
$1,718.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,666.46
|
| Rate for Payer: Multiplan Medicare/VA |
$91.09
|
| Rate for Payer: One Health Plan of WY PPO |
$1,683.64
|
| Rate for Payer: PacificSource Commercial |
$1,546.20
|
| Rate for Payer: PHCS PPO |
$1,632.10
|
| Rate for Payer: Three Rivers PPO |
$1,288.50
|
| Rate for Payer: TriWest Veterans Administration |
$107.17
|
| Rate for Payer: United Healthcare Commercial |
$1,494.66
|
| Rate for Payer: United Healthcare Medicare |
$107.17
|
| Rate for Payer: WINHealth Partners Commercial |
$1,460.30
|
|
|
NJX AA&/STRD TFRML EPI LUMBAR/SACRAL EA ADDL
|
Professional
|
Both
|
$387.00
|
|
|
Service Code
|
HCPCS 64484
|
| Hospital Charge Code |
64484
|
| Min. Negotiated Rate |
$41.85 |
| Max. Negotiated Rate |
$387.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$379.26
|
| Rate for Payer: Aetna of WY Medicare |
$49.24
|
| 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 |
$49.24
|
| Rate for Payer: HealthUtah PPO |
$387.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$375.39
|
| Rate for Payer: Multiplan Medicare/VA |
$41.85
|
| 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 |
$49.24
|
| Rate for Payer: United Healthcare Commercial |
$336.69
|
| Rate for Payer: United Healthcare Medicare |
$49.24
|
| Rate for Payer: WINHealth Partners Commercial |
$328.95
|
|
|
NJX AA&/STRD TFRML EPI LUMBAR/SACRAL EA ADDL
|
Professional
|
Both
|
$774.00
|
|
|
Service Code
|
HCPCS 64484 50
|
| Hospital Charge Code |
64484
|
| Min. Negotiated Rate |
$41.85 |
| Max. Negotiated Rate |
$774.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$758.52
|
| Rate for Payer: Aetna of WY Medicare |
$49.24
|
| Rate for Payer: Beech Street Commercial |
$735.30
|
| Rate for Payer: Cash Price |
$541.80
|
| Rate for Payer: Cash Price |
$541.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$750.78
|
| Rate for Payer: Cigna of WY Commercial |
$758.52
|
| Rate for Payer: First Choice Health Commercial |
$696.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$735.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$49.24
|
| Rate for Payer: HealthUtah PPO |
$774.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$750.78
|
| Rate for Payer: Multiplan Medicare/VA |
$41.85
|
| Rate for Payer: One Health Plan of WY PPO |
$758.52
|
| Rate for Payer: PacificSource Commercial |
$696.60
|
| Rate for Payer: PHCS PPO |
$735.30
|
| Rate for Payer: Three Rivers PPO |
$580.50
|
| Rate for Payer: TriWest Veterans Administration |
$49.24
|
| Rate for Payer: United Healthcare Commercial |
$673.38
|
| Rate for Payer: United Healthcare Medicare |
$49.24
|
| Rate for Payer: WINHealth Partners Commercial |
$657.90
|
|
|
NJX ANES STELLATE GANGLION CRV SYMPATHETIC
|
Professional
|
Both
|
$510.00
|
|
|
Service Code
|
HCPCS 64510
|
| Hospital Charge Code |
64510
|
| Min. Negotiated Rate |
$63.15 |
| Max. Negotiated Rate |
$510.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$499.80
|
| Rate for Payer: Aetna of WY Medicare |
$74.29
|
| Rate for Payer: Beech Street Commercial |
$484.50
|
| Rate for Payer: Cash Price |
$357.00
|
| Rate for Payer: Cash Price |
$357.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$494.70
|
| Rate for Payer: Cigna of WY Commercial |
$499.80
|
| Rate for Payer: First Choice Health Commercial |
$459.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$484.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$74.29
|
| Rate for Payer: HealthUtah PPO |
$510.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$494.70
|
| Rate for Payer: Multiplan Medicare/VA |
$63.15
|
| Rate for Payer: One Health Plan of WY PPO |
$499.80
|
| Rate for Payer: PacificSource Commercial |
$459.00
|
| Rate for Payer: PHCS PPO |
$484.50
|
| Rate for Payer: Three Rivers PPO |
$382.50
|
| Rate for Payer: TriWest Veterans Administration |
$74.29
|
| Rate for Payer: United Healthcare Commercial |
$443.70
|
| Rate for Payer: United Healthcare Medicare |
$74.29
|
| Rate for Payer: WINHealth Partners Commercial |
$433.50
|
|
|
NJX ANES STELLATE GANGLION CRV SYMPATHETIC
|
Professional
|
Both
|
$1,020.00
|
|
|
Service Code
|
HCPCS 64510 50
|
| Hospital Charge Code |
64510
|
| Min. Negotiated Rate |
$63.15 |
| Max. Negotiated Rate |
$1,020.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$999.60
|
| Rate for Payer: Aetna of WY Medicare |
$74.29
|
| Rate for Payer: Beech Street Commercial |
$969.00
|
| Rate for Payer: Cash Price |
$714.00
|
| Rate for Payer: Cash Price |
$714.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$989.40
|
| Rate for Payer: Cigna of WY Commercial |
$999.60
|
| Rate for Payer: First Choice Health Commercial |
$918.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$969.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$74.29
|
| Rate for Payer: HealthUtah PPO |
$1,020.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$989.40
|
| Rate for Payer: Multiplan Medicare/VA |
$63.15
|
| Rate for Payer: One Health Plan of WY PPO |
$999.60
|
| Rate for Payer: PacificSource Commercial |
$918.00
|
| Rate for Payer: PHCS PPO |
$969.00
|
| Rate for Payer: Three Rivers PPO |
$765.00
|
| Rate for Payer: TriWest Veterans Administration |
$74.29
|
| Rate for Payer: United Healthcare Commercial |
$887.40
|
| Rate for Payer: United Healthcare Medicare |
$74.29
|
| Rate for Payer: WINHealth Partners Commercial |
$867.00
|
|
|
NJX DRG C-CATHJ SUPRAVALVULAR AORTOGRAPHY S&I
|
Professional
|
Both
|
$122.00
|
|
|
Service Code
|
HCPCS 93567
|
| Hospital Charge Code |
93567
|
| Min. Negotiated Rate |
$29.45 |
| Max. Negotiated Rate |
$122.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$119.56
|
| Rate for Payer: Aetna of WY Medicare |
$34.65
|
| Rate for Payer: Beech Street Commercial |
$115.90
|
| Rate for Payer: Cash Price |
$85.40
|
| Rate for Payer: Cash Price |
$85.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$118.34
|
| Rate for Payer: Cigna of WY Commercial |
$119.56
|
| Rate for Payer: First Choice Health Commercial |
$109.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$115.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$34.65
|
| Rate for Payer: HealthUtah PPO |
$122.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$118.34
|
| Rate for Payer: Multiplan Medicare/VA |
$29.45
|
| Rate for Payer: One Health Plan of WY PPO |
$119.56
|
| Rate for Payer: PacificSource Commercial |
$109.80
|
| Rate for Payer: PHCS PPO |
$115.90
|
| Rate for Payer: Three Rivers PPO |
$91.50
|
| Rate for Payer: TriWest Veterans Administration |
$34.65
|
| Rate for Payer: United Healthcare Commercial |
$106.14
|
| Rate for Payer: United Healthcare Medicare |
$34.65
|
| Rate for Payer: WINHealth Partners Commercial |
$115.90
|
|
|
NJX DX/THER AGT PVRT FACET JT CRV/THRC 1 LEVEL
|
Professional
|
Both
|
$672.00
|
|
|
Service Code
|
HCPCS 64490
|
| Hospital Charge Code |
64490
|
| Min. Negotiated Rate |
$86.09 |
| Max. Negotiated Rate |
$672.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$658.56
|
| Rate for Payer: Aetna of WY Medicare |
$101.28
|
| Rate for Payer: Beech Street Commercial |
$638.40
|
| Rate for Payer: Cash Price |
$470.40
|
| Rate for Payer: Cash Price |
$470.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$651.84
|
| Rate for Payer: Cigna of WY Commercial |
$658.56
|
| Rate for Payer: First Choice Health Commercial |
$604.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$638.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$101.28
|
| Rate for Payer: HealthUtah PPO |
$672.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$651.84
|
| Rate for Payer: Multiplan Medicare/VA |
$86.09
|
| Rate for Payer: One Health Plan of WY PPO |
$658.56
|
| Rate for Payer: PacificSource Commercial |
$604.80
|
| Rate for Payer: PHCS PPO |
$638.40
|
| Rate for Payer: Three Rivers PPO |
$504.00
|
| Rate for Payer: TriWest Veterans Administration |
$101.28
|
| Rate for Payer: United Healthcare Commercial |
$584.64
|
| Rate for Payer: United Healthcare Medicare |
$101.28
|
| Rate for Payer: WINHealth Partners Commercial |
$571.20
|
|
|
NJX DX/THER AGT PVRT FACET JT CRV/THRC 1 LEVEL
|
Professional
|
Both
|
$1,344.00
|
|
|
Service Code
|
HCPCS 64490 50
|
| Hospital Charge Code |
64490
|
| Min. Negotiated Rate |
$86.09 |
| Max. Negotiated Rate |
$1,344.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,317.12
|
| Rate for Payer: Aetna of WY Medicare |
$101.28
|
| Rate for Payer: Beech Street Commercial |
$1,276.80
|
| Rate for Payer: Cash Price |
$940.80
|
| Rate for Payer: Cash Price |
$940.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,303.68
|
| Rate for Payer: Cigna of WY Commercial |
$1,317.12
|
| Rate for Payer: First Choice Health Commercial |
$1,209.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,276.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$101.28
|
| Rate for Payer: HealthUtah PPO |
$1,344.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,303.68
|
| Rate for Payer: Multiplan Medicare/VA |
$86.09
|
| Rate for Payer: One Health Plan of WY PPO |
$1,317.12
|
| Rate for Payer: PacificSource Commercial |
$1,209.60
|
| Rate for Payer: PHCS PPO |
$1,276.80
|
| Rate for Payer: Three Rivers PPO |
$1,008.00
|
| Rate for Payer: TriWest Veterans Administration |
$101.28
|
| Rate for Payer: United Healthcare Commercial |
$1,169.28
|
| Rate for Payer: United Healthcare Medicare |
$101.28
|
| Rate for Payer: WINHealth Partners Commercial |
$1,142.40
|
|
|
NJX DX/THER AGT PVRT FACET JT CRV/THRC 2ND LEVEL
|
Professional
|
Both
|
$337.00
|
|
|
Service Code
|
HCPCS 64491
|
| Hospital Charge Code |
64491
|
| Min. Negotiated Rate |
$48.11 |
| Max. Negotiated Rate |
$337.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$330.26
|
| Rate for Payer: Aetna of WY Medicare |
$56.60
|
| Rate for Payer: Beech Street Commercial |
$320.15
|
| Rate for Payer: Cash Price |
$235.90
|
| Rate for Payer: Cash Price |
$235.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$326.89
|
| Rate for Payer: Cigna of WY Commercial |
$330.26
|
| Rate for Payer: First Choice Health Commercial |
$303.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$320.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$56.60
|
| Rate for Payer: HealthUtah PPO |
$337.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$326.89
|
| Rate for Payer: Multiplan Medicare/VA |
$48.11
|
| Rate for Payer: One Health Plan of WY PPO |
$330.26
|
| Rate for Payer: PacificSource Commercial |
$303.30
|
| Rate for Payer: PHCS PPO |
$320.15
|
| Rate for Payer: Three Rivers PPO |
$252.75
|
| Rate for Payer: TriWest Veterans Administration |
$56.60
|
| Rate for Payer: United Healthcare Commercial |
$293.19
|
| Rate for Payer: United Healthcare Medicare |
$56.60
|
| Rate for Payer: WINHealth Partners Commercial |
$286.45
|
|
|
NJX DX/THER AGT PVRT FACET JT CRV/THRC 2ND LEVEL
|
Professional
|
Both
|
$674.00
|
|
|
Service Code
|
HCPCS 64491 50
|
| Hospital Charge Code |
64491
|
| Min. Negotiated Rate |
$48.11 |
| Max. Negotiated Rate |
$674.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$660.52
|
| Rate for Payer: Aetna of WY Medicare |
$56.60
|
| Rate for Payer: Beech Street Commercial |
$640.30
|
| Rate for Payer: Cash Price |
$471.80
|
| Rate for Payer: Cash Price |
$471.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$653.78
|
| Rate for Payer: Cigna of WY Commercial |
$660.52
|
| Rate for Payer: First Choice Health Commercial |
$606.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$640.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$56.60
|
| Rate for Payer: HealthUtah PPO |
$674.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$653.78
|
| Rate for Payer: Multiplan Medicare/VA |
$48.11
|
| Rate for Payer: One Health Plan of WY PPO |
$660.52
|
| Rate for Payer: PacificSource Commercial |
$606.60
|
| Rate for Payer: PHCS PPO |
$640.30
|
| Rate for Payer: Three Rivers PPO |
$505.50
|
| Rate for Payer: TriWest Veterans Administration |
$56.60
|
| Rate for Payer: United Healthcare Commercial |
$586.38
|
| Rate for Payer: United Healthcare Medicare |
$56.60
|
| Rate for Payer: WINHealth Partners Commercial |
$572.90
|
|
|
NJX DX/THER AGT PVRT FACET JT CRV/THRC 3+ LEVEL
|
Professional
|
Both
|
$676.00
|
|
|
Service Code
|
HCPCS 64492 50
|
| Hospital Charge Code |
64492
|
| Min. Negotiated Rate |
$48.95 |
| Max. Negotiated Rate |
$676.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$662.48
|
| Rate for Payer: Aetna of WY Medicare |
$57.59
|
| Rate for Payer: Beech Street Commercial |
$642.20
|
| Rate for Payer: Cash Price |
$473.20
|
| Rate for Payer: Cash Price |
$473.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$655.72
|
| Rate for Payer: Cigna of WY Commercial |
$662.48
|
| Rate for Payer: First Choice Health Commercial |
$608.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$642.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$57.59
|
| Rate for Payer: HealthUtah PPO |
$676.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$655.72
|
| Rate for Payer: Multiplan Medicare/VA |
$48.95
|
| Rate for Payer: One Health Plan of WY PPO |
$662.48
|
| Rate for Payer: PacificSource Commercial |
$608.40
|
| Rate for Payer: PHCS PPO |
$642.20
|
| Rate for Payer: Three Rivers PPO |
$507.00
|
| Rate for Payer: TriWest Veterans Administration |
$57.59
|
| Rate for Payer: United Healthcare Commercial |
$588.12
|
| Rate for Payer: United Healthcare Medicare |
$57.59
|
| Rate for Payer: WINHealth Partners Commercial |
$574.60
|
|
