|
ADMIN HEPATITIS B VACCINE
|
Professional
|
Both
|
$18.00
|
|
|
Service Code
|
HCPCS G0010
|
| Hospital Charge Code |
G0010
|
| Min. Negotiated Rate |
$13.50 |
| Max. Negotiated Rate |
$18.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$17.64
|
| Rate for Payer: Beech Street Commercial |
$17.10
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$17.46
|
| Rate for Payer: Cigna of WY Commercial |
$17.64
|
| Rate for Payer: First Choice Health Commercial |
$16.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.10
|
| Rate for Payer: HealthUtah PPO |
$18.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.46
|
| Rate for Payer: One Health Plan of WY PPO |
$17.64
|
| Rate for Payer: PacificSource Commercial |
$16.20
|
| Rate for Payer: PHCS PPO |
$17.10
|
| Rate for Payer: Three Rivers PPO |
$13.50
|
| Rate for Payer: United Healthcare Commercial |
$15.66
|
| Rate for Payer: WINHealth Partners Commercial |
$17.10
|
|
|
ADMIN INFLUENZA VIRUS VAC
|
Professional
|
Both
|
$18.00
|
|
|
Service Code
|
HCPCS G0008
|
| Hospital Charge Code |
G0008
|
| Min. Negotiated Rate |
$13.50 |
| Max. Negotiated Rate |
$20.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$17.64
|
| Rate for Payer: Beech Street Commercial |
$17.10
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$17.46
|
| Rate for Payer: Cigna of WY Commercial |
$17.64
|
| Rate for Payer: First Choice Health Commercial |
$16.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.10
|
| Rate for Payer: HealthUtah PPO |
$18.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.46
|
| Rate for Payer: One Health Plan of WY PPO |
$17.64
|
| Rate for Payer: PacificSource Commercial |
$16.20
|
| Rate for Payer: PHCS PPO |
$17.10
|
| Rate for Payer: Three Rivers PPO |
$13.50
|
| Rate for Payer: TriWest Veterans Administration |
$20.00
|
| Rate for Payer: United Healthcare Commercial |
$15.66
|
| Rate for Payer: WINHealth Partners Commercial |
$17.10
|
|
|
ADMIN PNEUMOCOCCAL VACCINE
|
Professional
|
Both
|
$18.00
|
|
|
Service Code
|
HCPCS G0009
|
| Hospital Charge Code |
G0009
|
| Min. Negotiated Rate |
$13.50 |
| Max. Negotiated Rate |
$18.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$17.64
|
| Rate for Payer: Beech Street Commercial |
$17.10
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$17.46
|
| Rate for Payer: Cigna of WY Commercial |
$17.64
|
| Rate for Payer: First Choice Health Commercial |
$16.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.10
|
| Rate for Payer: HealthUtah PPO |
$18.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.46
|
| Rate for Payer: One Health Plan of WY PPO |
$17.64
|
| Rate for Payer: PacificSource Commercial |
$16.20
|
| Rate for Payer: PHCS PPO |
$17.10
|
| Rate for Payer: Three Rivers PPO |
$13.50
|
| Rate for Payer: United Healthcare Commercial |
$15.66
|
| Rate for Payer: WINHealth Partners Commercial |
$17.10
|
|
|
ADMN RSV MONOC ANTB SEASONAL DOS IM CNSL PHY/QHP
|
Professional
|
Both
|
$67.00
|
|
|
Service Code
|
HCPCS 96380
|
| Hospital Charge Code |
96380
|
| Min. Negotiated Rate |
$18.85 |
| Max. Negotiated Rate |
$67.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$65.66
|
| Rate for Payer: Aetna of WY Medicare |
$22.18
|
| Rate for Payer: Beech Street Commercial |
$63.65
|
| Rate for Payer: Cash Price |
$46.90
|
| Rate for Payer: Cash Price |
$46.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$64.99
|
| Rate for Payer: Cigna of WY Commercial |
$65.66
|
| Rate for Payer: First Choice Health Commercial |
$60.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$63.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$22.18
|
| Rate for Payer: HealthUtah PPO |
$67.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$64.99
|
| Rate for Payer: Multiplan Medicare/VA |
$18.85
|
| Rate for Payer: One Health Plan of WY PPO |
$65.66
|
| Rate for Payer: PacificSource Commercial |
$60.30
|
| Rate for Payer: PHCS PPO |
$63.65
|
| Rate for Payer: Three Rivers PPO |
$50.25
|
| Rate for Payer: TriWest Veterans Administration |
$22.18
|
| Rate for Payer: United Healthcare Commercial |
$58.29
|
| Rate for Payer: United Healthcare Medicare |
$22.18
|
| Rate for Payer: WINHealth Partners Commercial |
$63.65
|
|
|
ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION [126813]
|
Facility
|
IP
|
$5,999.44
|
|
|
Service Code
|
HCPCS J9354
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,761.65 |
| Max. Negotiated Rate |
$5,999.44 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5,879.45
|
| Rate for Payer: Altius Auto/Workers Compensation |
$5,759.46
|
| Rate for Payer: Altius Commercial |
$5,759.46
|
| Rate for Payer: Beech Street Commercial |
$5,879.45
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$4,925.54
|
| Rate for Payer: Cash Price |
$4,199.61
|
| Rate for Payer: ChoiceCare Network Commercial |
$5,819.46
|
| Rate for Payer: Cigna of WY Commercial |
$5,879.45
|
| Rate for Payer: Entrust Commercial |
$5,699.47
|
| Rate for Payer: First Choice Health Commercial |
$5,699.47
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5,699.47
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3,959.63
|
| Rate for Payer: HealthUtah PPO |
$5,999.44
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5,819.46
|
| Rate for Payer: Multiplan Medicare/VA |
$3,761.65
|
| Rate for Payer: One Health Plan of WY PPO |
$5,879.45
|
| Rate for Payer: PacificSource Commercial |
$5,399.50
|
| Rate for Payer: PHCS PPO |
$5,879.45
|
| Rate for Payer: Three Rivers PPO |
$4,499.58
|
| Rate for Payer: TriWest Veterans Administration |
$3,959.63
|
| Rate for Payer: United Healthcare Commercial |
$5,219.51
|
| Rate for Payer: United Healthcare Medicare |
$3,959.63
|
| Rate for Payer: WINHealth Partners Commercial |
$5,699.47
|
| Rate for Payer: Wise Provider Network Commercial |
$5,699.47
|
|
|
ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION [126813]
|
Facility
|
OP
|
$5,999.44
|
|
|
Service Code
|
HCPCS J9354
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,305.69 |
| Max. Negotiated Rate |
$5,999.44 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5,879.45
|
| Rate for Payer: Aetna of WY Medicare |
$3,959.63
|
| Rate for Payer: Altius Auto/Workers Compensation |
$5,759.46
|
| Rate for Payer: Altius Commercial |
$5,759.46
|
| Rate for Payer: Beech Street Commercial |
$5,879.45
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$4,925.54
|
| Rate for Payer: Cash Price |
$4,199.61
|
| Rate for Payer: ChoiceCare Network Commercial |
$5,819.46
|
| Rate for Payer: Cigna of WY Commercial |
$5,879.45
|
| Rate for Payer: Entrust Commercial |
$5,699.47
|
| Rate for Payer: First Choice Health Commercial |
$5,699.47
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5,699.47
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3,479.68
|
| Rate for Payer: HealthUtah PPO |
$5,999.44
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5,819.46
|
| Rate for Payer: Multiplan Medicare/VA |
$3,305.69
|
| Rate for Payer: One Health Plan of WY PPO |
$5,879.45
|
| Rate for Payer: PacificSource Commercial |
$5,399.50
|
| Rate for Payer: PHCS PPO |
$5,879.45
|
| Rate for Payer: Three Rivers PPO |
$4,499.58
|
| Rate for Payer: TriWest Veterans Administration |
$3,479.68
|
| Rate for Payer: United Healthcare Commercial |
$5,219.51
|
| Rate for Payer: United Healthcare Medicare |
$3,479.68
|
| Rate for Payer: WINHealth Partners Commercial |
$5,879.45
|
| Rate for Payer: Wise Provider Network Commercial |
$5,699.47
|
|
|
ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION [126814]
|
Facility
|
OP
|
$9,590.10
|
|
|
Service Code
|
HCPCS J9354
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,284.15 |
| Max. Negotiated Rate |
$9,590.10 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$9,398.30
|
| Rate for Payer: Aetna of WY Medicare |
$6,329.47
|
| Rate for Payer: Altius Auto/Workers Compensation |
$9,206.50
|
| Rate for Payer: Altius Commercial |
$9,206.50
|
| Rate for Payer: Beech Street Commercial |
$9,398.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$7,873.47
|
| Rate for Payer: Cash Price |
$6,713.07
|
| Rate for Payer: ChoiceCare Network Commercial |
$9,302.40
|
| Rate for Payer: Cigna of WY Commercial |
$9,398.30
|
| Rate for Payer: Entrust Commercial |
$9,110.60
|
| Rate for Payer: First Choice Health Commercial |
$9,110.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$9,110.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$5,562.26
|
| Rate for Payer: HealthUtah PPO |
$9,590.10
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$9,302.40
|
| Rate for Payer: Multiplan Medicare/VA |
$5,284.15
|
| Rate for Payer: One Health Plan of WY PPO |
$9,398.30
|
| Rate for Payer: PacificSource Commercial |
$8,631.09
|
| Rate for Payer: PHCS PPO |
$9,398.30
|
| Rate for Payer: Three Rivers PPO |
$7,192.58
|
| Rate for Payer: TriWest Veterans Administration |
$5,562.26
|
| Rate for Payer: United Healthcare Commercial |
$8,343.39
|
| Rate for Payer: United Healthcare Medicare |
$5,562.26
|
| Rate for Payer: WINHealth Partners Commercial |
$9,398.30
|
| Rate for Payer: Wise Provider Network Commercial |
$9,110.60
|
|
|
ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION [126814]
|
Facility
|
IP
|
$9,590.10
|
|
|
Service Code
|
HCPCS J9354
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6,012.99 |
| Max. Negotiated Rate |
$9,590.10 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$9,398.30
|
| Rate for Payer: Altius Auto/Workers Compensation |
$9,206.50
|
| Rate for Payer: Altius Commercial |
$9,206.50
|
| Rate for Payer: Beech Street Commercial |
$9,398.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$7,873.47
|
| Rate for Payer: Cash Price |
$6,713.07
|
| Rate for Payer: ChoiceCare Network Commercial |
$9,302.40
|
| Rate for Payer: Cigna of WY Commercial |
$9,398.30
|
| Rate for Payer: Entrust Commercial |
$9,110.60
|
| Rate for Payer: First Choice Health Commercial |
$9,110.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$9,110.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$6,329.47
|
| Rate for Payer: HealthUtah PPO |
$9,590.10
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$9,302.40
|
| Rate for Payer: Multiplan Medicare/VA |
$6,012.99
|
| Rate for Payer: One Health Plan of WY PPO |
$9,398.30
|
| Rate for Payer: PacificSource Commercial |
$8,631.09
|
| Rate for Payer: PHCS PPO |
$9,398.30
|
| Rate for Payer: Three Rivers PPO |
$7,192.58
|
| Rate for Payer: TriWest Veterans Administration |
$6,329.47
|
| Rate for Payer: United Healthcare Commercial |
$8,343.39
|
| Rate for Payer: United Healthcare Medicare |
$6,329.47
|
| Rate for Payer: WINHealth Partners Commercial |
$9,110.60
|
| Rate for Payer: Wise Provider Network Commercial |
$9,110.60
|
|
|
ADRENALIN EPINEPHRINE INJECT
|
Professional
|
Both
|
$63.00
|
|
|
Service Code
|
HCPCS J0171
|
| Hospital Charge Code |
J0171
|
| Min. Negotiated Rate |
$0.69 |
| Max. Negotiated Rate |
$63.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$61.74
|
| Rate for Payer: Aetna of WY Medicare |
$0.81
|
| Rate for Payer: Beech Street Commercial |
$59.85
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$61.11
|
| Rate for Payer: Cigna of WY Commercial |
$61.74
|
| Rate for Payer: First Choice Health Commercial |
$56.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$59.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.81
|
| Rate for Payer: HealthUtah PPO |
$63.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$61.11
|
| Rate for Payer: Multiplan Medicare/VA |
$0.69
|
| Rate for Payer: One Health Plan of WY PPO |
$61.74
|
| Rate for Payer: PacificSource Commercial |
$56.70
|
| Rate for Payer: PHCS PPO |
$59.85
|
| Rate for Payer: Three Rivers PPO |
$47.25
|
| Rate for Payer: TriWest Veterans Administration |
$0.81
|
| Rate for Payer: United Healthcare Commercial |
$54.81
|
| Rate for Payer: United Healthcare Medicare |
$0.81
|
| Rate for Payer: WINHealth Partners Commercial |
$59.85
|
|
|
ADVANCE CARE PLANNING EA ADDL 30 MINS
|
Professional
|
Both
|
$83.00
|
|
|
Service Code
|
HCPCS 99498
|
| Hospital Charge Code |
99498
|
| Min. Negotiated Rate |
$62.25 |
| Max. Negotiated Rate |
$83.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$81.34
|
| Rate for Payer: Beech Street Commercial |
$78.85
|
| Rate for Payer: Cash Price |
$58.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$80.51
|
| Rate for Payer: Cigna of WY Commercial |
$81.34
|
| Rate for Payer: First Choice Health Commercial |
$74.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$78.85
|
| Rate for Payer: HealthUtah PPO |
$83.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$80.51
|
| Rate for Payer: One Health Plan of WY PPO |
$81.34
|
| Rate for Payer: PacificSource Commercial |
$74.70
|
| Rate for Payer: PHCS PPO |
$78.85
|
| Rate for Payer: Three Rivers PPO |
$62.25
|
| Rate for Payer: United Healthcare Commercial |
$72.21
|
| Rate for Payer: WINHealth Partners Commercial |
$78.85
|
|
|
ADVANCE CARE PLANNING FIRST 30 MINS
|
Professional
|
Both
|
$136.00
|
|
|
Service Code
|
HCPCS 99497
|
| Hospital Charge Code |
99497
|
| Min. Negotiated Rate |
$61.62 |
| Max. Negotiated Rate |
$136.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$133.28
|
| Rate for Payer: Aetna of WY Medicare |
$72.49
|
| Rate for Payer: Beech Street Commercial |
$129.20
|
| Rate for Payer: Cash Price |
$95.20
|
| Rate for Payer: Cash Price |
$95.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$131.92
|
| Rate for Payer: Cigna of WY Commercial |
$133.28
|
| Rate for Payer: First Choice Health Commercial |
$122.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$129.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$72.49
|
| Rate for Payer: HealthUtah PPO |
$136.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$131.92
|
| Rate for Payer: Multiplan Medicare/VA |
$61.62
|
| Rate for Payer: One Health Plan of WY PPO |
$133.28
|
| Rate for Payer: PacificSource Commercial |
$122.40
|
| Rate for Payer: PHCS PPO |
$129.20
|
| Rate for Payer: Three Rivers PPO |
$102.00
|
| Rate for Payer: TriWest Veterans Administration |
$72.49
|
| Rate for Payer: United Healthcare Commercial |
$118.32
|
| Rate for Payer: United Healthcare Medicare |
$72.49
|
| Rate for Payer: WINHealth Partners Commercial |
$129.20
|
|
|
AEROBIKA POSITIVE EXPIRATORY
|
Facility
|
IP
|
$159.50
|
|
| Hospital Charge Code |
27000000S1
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$100.01 |
| Max. Negotiated Rate |
$159.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$156.31
|
| Rate for Payer: Altius Auto/Workers Compensation |
$153.12
|
| Rate for Payer: Altius Commercial |
$153.12
|
| Rate for Payer: Beech Street Commercial |
$156.31
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$130.95
|
| Rate for Payer: Cash Price |
$111.65
|
| Rate for Payer: ChoiceCare Network Commercial |
$154.72
|
| Rate for Payer: Cigna of WY Commercial |
$156.31
|
| Rate for Payer: Entrust Commercial |
$151.52
|
| Rate for Payer: First Choice Health Commercial |
$151.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$151.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$105.27
|
| Rate for Payer: HealthUtah PPO |
$159.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$154.72
|
| Rate for Payer: Multiplan Medicare/VA |
$100.01
|
| Rate for Payer: One Health Plan of WY PPO |
$156.31
|
| Rate for Payer: PacificSource Commercial |
$143.55
|
| Rate for Payer: PHCS PPO |
$156.31
|
| Rate for Payer: Three Rivers PPO |
$119.62
|
| Rate for Payer: TriWest Veterans Administration |
$105.27
|
| Rate for Payer: United Healthcare Commercial |
$138.76
|
| Rate for Payer: United Healthcare Medicare |
$105.27
|
| Rate for Payer: WINHealth Partners Commercial |
$151.52
|
| Rate for Payer: Wise Provider Network Commercial |
$151.52
|
|
|
AEROBIKA POSITIVE EXPIRATORY
|
Facility
|
OP
|
$159.50
|
|
| Hospital Charge Code |
27000000S1
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$87.88 |
| Max. Negotiated Rate |
$159.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$156.31
|
| Rate for Payer: Aetna of WY Medicare |
$105.27
|
| Rate for Payer: Altius Auto/Workers Compensation |
$153.12
|
| Rate for Payer: Altius Commercial |
$153.12
|
| Rate for Payer: Beech Street Commercial |
$156.31
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$130.95
|
| Rate for Payer: Cash Price |
$111.65
|
| Rate for Payer: ChoiceCare Network Commercial |
$154.72
|
| Rate for Payer: Cigna of WY Commercial |
$156.31
|
| Rate for Payer: Entrust Commercial |
$151.52
|
| Rate for Payer: First Choice Health Commercial |
$151.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$151.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$92.51
|
| Rate for Payer: HealthUtah PPO |
$159.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$154.72
|
| Rate for Payer: Multiplan Medicare/VA |
$87.88
|
| Rate for Payer: One Health Plan of WY PPO |
$156.31
|
| Rate for Payer: PacificSource Commercial |
$143.55
|
| Rate for Payer: PHCS PPO |
$156.31
|
| Rate for Payer: Three Rivers PPO |
$119.62
|
| Rate for Payer: TriWest Veterans Administration |
$92.51
|
| Rate for Payer: United Healthcare Commercial |
$138.76
|
| Rate for Payer: United Healthcare Medicare |
$92.51
|
| Rate for Payer: WINHealth Partners Commercial |
$156.31
|
| Rate for Payer: Wise Provider Network Commercial |
$151.52
|
|
|
AFO ANKLE GAUNTLET PRE OTS
|
Professional
|
Both
|
$113.00
|
|
|
Service Code
|
HCPCS L1902
|
| Hospital Charge Code |
L1902
|
| Min. Negotiated Rate |
$74.66 |
| Max. Negotiated Rate |
$113.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$110.74
|
| Rate for Payer: Aetna of WY Medicare |
$87.83
|
| Rate for Payer: Beech Street Commercial |
$107.35
|
| Rate for Payer: Cash Price |
$79.10
|
| Rate for Payer: Cash Price |
$79.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$109.61
|
| Rate for Payer: Cigna of WY Commercial |
$110.74
|
| Rate for Payer: First Choice Health Commercial |
$101.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$107.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$87.83
|
| Rate for Payer: HealthUtah PPO |
$113.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$109.61
|
| Rate for Payer: Multiplan Medicare/VA |
$74.66
|
| Rate for Payer: One Health Plan of WY PPO |
$110.74
|
| Rate for Payer: PacificSource Commercial |
$101.70
|
| Rate for Payer: PHCS PPO |
$107.35
|
| Rate for Payer: Three Rivers PPO |
$84.75
|
| Rate for Payer: TriWest Veterans Administration |
$87.83
|
| Rate for Payer: United Healthcare Commercial |
$98.31
|
| Rate for Payer: United Healthcare Medicare |
$87.83
|
| Rate for Payer: WINHealth Partners Commercial |
$107.35
|
|
|
AFO MULTILIG ANK SUP PRE OTS
|
Professional
|
Both
|
$109.00
|
|
|
Service Code
|
HCPCS L1906
|
| Hospital Charge Code |
L1906
|
| Min. Negotiated Rate |
$81.75 |
| Max. Negotiated Rate |
$109.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$106.82
|
| Rate for Payer: Beech Street Commercial |
$103.55
|
| Rate for Payer: Cash Price |
$76.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$105.73
|
| Rate for Payer: Cigna of WY Commercial |
$106.82
|
| Rate for Payer: First Choice Health Commercial |
$98.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$103.55
|
| Rate for Payer: HealthUtah PPO |
$109.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$105.73
|
| Rate for Payer: One Health Plan of WY PPO |
$106.82
|
| Rate for Payer: PacificSource Commercial |
$98.10
|
| Rate for Payer: PHCS PPO |
$103.55
|
| Rate for Payer: Three Rivers PPO |
$81.75
|
| Rate for Payer: United Healthcare Commercial |
$94.83
|
| Rate for Payer: WINHealth Partners Commercial |
$103.55
|
|
|
AFO PLASTIC
|
Professional
|
Both
|
$308.00
|
|
|
Service Code
|
HCPCS L1930
|
| Hospital Charge Code |
L1930
|
| Min. Negotiated Rate |
$231.00 |
| Max. Negotiated Rate |
$308.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$301.84
|
| Rate for Payer: Beech Street Commercial |
$292.60
|
| Rate for Payer: Cash Price |
$215.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$298.76
|
| Rate for Payer: Cigna of WY Commercial |
$301.84
|
| Rate for Payer: First Choice Health Commercial |
$277.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$292.60
|
| Rate for Payer: HealthUtah PPO |
$308.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$298.76
|
| Rate for Payer: One Health Plan of WY PPO |
$301.84
|
| Rate for Payer: PacificSource Commercial |
$277.20
|
| Rate for Payer: PHCS PPO |
$292.60
|
| Rate for Payer: Three Rivers PPO |
$231.00
|
| Rate for Payer: United Healthcare Commercial |
$267.96
|
| Rate for Payer: WINHealth Partners Commercial |
$292.60
|
|
|
AFO TIBIAL FRACTURE SOFT
|
Professional
|
Both
|
$144.00
|
|
|
Service Code
|
HCPCS L2112
|
| Hospital Charge Code |
L2112
|
| Min. Negotiated Rate |
$108.00 |
| Max. Negotiated Rate |
$144.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$141.12
|
| Rate for Payer: Beech Street Commercial |
$136.80
|
| Rate for Payer: Cash Price |
$100.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$139.68
|
| Rate for Payer: Cigna of WY Commercial |
$141.12
|
| Rate for Payer: First Choice Health Commercial |
$129.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$136.80
|
| Rate for Payer: HealthUtah PPO |
$144.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$139.68
|
| Rate for Payer: One Health Plan of WY PPO |
$141.12
|
| Rate for Payer: PacificSource Commercial |
$129.60
|
| Rate for Payer: PHCS PPO |
$136.80
|
| Rate for Payer: Three Rivers PPO |
$108.00
|
| Rate for Payer: United Healthcare Commercial |
$125.28
|
| Rate for Payer: WINHealth Partners Commercial |
$136.80
|
|
|
AIIV4 VACC INACTIVATED PRSRV FR 0.5ML DOS IM USE
|
Professional
|
Both
|
$104.00
|
|
|
Service Code
|
HCPCS 90694
|
| Hospital Charge Code |
90694
|
| Min. Negotiated Rate |
$20.00 |
| Max. Negotiated Rate |
$104.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$101.92
|
| Rate for Payer: Aetna of WY Medicare |
$77.36
|
| Rate for Payer: Beech Street Commercial |
$98.80
|
| Rate for Payer: Cash Price |
$72.80
|
| Rate for Payer: Cash Price |
$72.80
|
| Rate for Payer: Cash Price |
$72.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$100.88
|
| Rate for Payer: Cigna of WY Commercial |
$101.92
|
| Rate for Payer: First Choice Health Commercial |
$93.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$98.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$77.36
|
| Rate for Payer: HealthUtah PPO |
$104.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$100.88
|
| Rate for Payer: Multiplan Medicare/VA |
$65.76
|
| Rate for Payer: One Health Plan of WY PPO |
$101.92
|
| Rate for Payer: PacificSource Commercial |
$93.60
|
| Rate for Payer: PHCS PPO |
$98.80
|
| Rate for Payer: Three Rivers PPO |
$78.00
|
| Rate for Payer: TriWest Veterans Administration |
$20.00
|
| Rate for Payer: United Healthcare Commercial |
$90.48
|
| Rate for Payer: United Healthcare Medicare |
$77.36
|
| Rate for Payer: WINHealth Partners Commercial |
$104.00
|
|
|
AIR CHARGE DUAL SENSOR CATHETER
|
Facility
|
IP
|
$197.75
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$123.99 |
| Max. Negotiated Rate |
$197.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$193.80
|
| Rate for Payer: Altius Auto/Workers Compensation |
$189.84
|
| Rate for Payer: Altius Commercial |
$189.84
|
| Rate for Payer: Beech Street Commercial |
$193.80
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$162.35
|
| Rate for Payer: Cash Price |
$138.42
|
| Rate for Payer: ChoiceCare Network Commercial |
$191.82
|
| Rate for Payer: Cigna of WY Commercial |
$193.80
|
| Rate for Payer: Entrust Commercial |
$187.86
|
| Rate for Payer: First Choice Health Commercial |
$187.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$187.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$130.52
|
| Rate for Payer: HealthUtah PPO |
$197.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$191.82
|
| Rate for Payer: Multiplan Medicare/VA |
$123.99
|
| Rate for Payer: One Health Plan of WY PPO |
$193.80
|
| Rate for Payer: PacificSource Commercial |
$177.98
|
| Rate for Payer: PHCS PPO |
$193.80
|
| Rate for Payer: Three Rivers PPO |
$148.31
|
| Rate for Payer: TriWest Veterans Administration |
$130.52
|
| Rate for Payer: United Healthcare Commercial |
$172.04
|
| Rate for Payer: United Healthcare Medicare |
$130.52
|
| Rate for Payer: WINHealth Partners Commercial |
$187.86
|
| Rate for Payer: Wise Provider Network Commercial |
$187.86
|
|
|
AIR CHARGE DUAL SENSOR CATHETER
|
Facility
|
OP
|
$197.75
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$108.96 |
| Max. Negotiated Rate |
$197.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$193.80
|
| Rate for Payer: Aetna of WY Medicare |
$130.52
|
| Rate for Payer: Altius Auto/Workers Compensation |
$189.84
|
| Rate for Payer: Altius Commercial |
$189.84
|
| Rate for Payer: Beech Street Commercial |
$193.80
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$162.35
|
| Rate for Payer: Cash Price |
$138.42
|
| Rate for Payer: ChoiceCare Network Commercial |
$191.82
|
| Rate for Payer: Cigna of WY Commercial |
$193.80
|
| Rate for Payer: Entrust Commercial |
$187.86
|
| Rate for Payer: First Choice Health Commercial |
$187.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$187.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$114.70
|
| Rate for Payer: HealthUtah PPO |
$197.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$191.82
|
| Rate for Payer: Multiplan Medicare/VA |
$108.96
|
| Rate for Payer: One Health Plan of WY PPO |
$193.80
|
| Rate for Payer: PacificSource Commercial |
$177.98
|
| Rate for Payer: PHCS PPO |
$193.80
|
| Rate for Payer: Three Rivers PPO |
$148.31
|
| Rate for Payer: TriWest Veterans Administration |
$114.70
|
| Rate for Payer: United Healthcare Commercial |
$172.04
|
| Rate for Payer: United Healthcare Medicare |
$114.70
|
| Rate for Payer: WINHealth Partners Commercial |
$193.80
|
| Rate for Payer: Wise Provider Network Commercial |
$187.86
|
|
|
AIR CHARGE SINGLE SENSOR CATHETER
|
Facility
|
OP
|
$133.00
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$73.28 |
| Max. Negotiated Rate |
$133.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$130.34
|
| Rate for Payer: Aetna of WY Medicare |
$87.78
|
| Rate for Payer: Altius Auto/Workers Compensation |
$127.68
|
| Rate for Payer: Altius Commercial |
$127.68
|
| Rate for Payer: Beech Street Commercial |
$130.34
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$109.19
|
| Rate for Payer: Cash Price |
$93.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$129.01
|
| Rate for Payer: Cigna of WY Commercial |
$130.34
|
| Rate for Payer: Entrust Commercial |
$126.35
|
| Rate for Payer: First Choice Health Commercial |
$126.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$126.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$77.14
|
| Rate for Payer: HealthUtah PPO |
$133.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$129.01
|
| Rate for Payer: Multiplan Medicare/VA |
$73.28
|
| Rate for Payer: One Health Plan of WY PPO |
$130.34
|
| Rate for Payer: PacificSource Commercial |
$119.70
|
| Rate for Payer: PHCS PPO |
$130.34
|
| Rate for Payer: Three Rivers PPO |
$99.75
|
| Rate for Payer: TriWest Veterans Administration |
$77.14
|
| Rate for Payer: United Healthcare Commercial |
$115.71
|
| Rate for Payer: United Healthcare Medicare |
$77.14
|
| Rate for Payer: WINHealth Partners Commercial |
$130.34
|
| Rate for Payer: Wise Provider Network Commercial |
$126.35
|
|
|
AIR CHARGE SINGLE SENSOR CATHETER
|
Facility
|
IP
|
$133.00
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$83.39 |
| Max. Negotiated Rate |
$133.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$130.34
|
| Rate for Payer: Altius Auto/Workers Compensation |
$127.68
|
| Rate for Payer: Altius Commercial |
$127.68
|
| Rate for Payer: Beech Street Commercial |
$130.34
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$109.19
|
| Rate for Payer: Cash Price |
$93.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$129.01
|
| Rate for Payer: Cigna of WY Commercial |
$130.34
|
| Rate for Payer: Entrust Commercial |
$126.35
|
| Rate for Payer: First Choice Health Commercial |
$126.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$126.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$87.78
|
| Rate for Payer: HealthUtah PPO |
$133.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$129.01
|
| Rate for Payer: Multiplan Medicare/VA |
$83.39
|
| Rate for Payer: One Health Plan of WY PPO |
$130.34
|
| Rate for Payer: PacificSource Commercial |
$119.70
|
| Rate for Payer: PHCS PPO |
$130.34
|
| Rate for Payer: Three Rivers PPO |
$99.75
|
| Rate for Payer: TriWest Veterans Administration |
$87.78
|
| Rate for Payer: United Healthcare Commercial |
$115.71
|
| Rate for Payer: United Healthcare Medicare |
$87.78
|
| Rate for Payer: WINHealth Partners Commercial |
$126.35
|
| Rate for Payer: Wise Provider Network Commercial |
$126.35
|
|
|
AIRWAY EXCHANGE CATH 14FR
|
Facility
|
IP
|
$200.20
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$125.53 |
| Max. Negotiated Rate |
$200.20 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$196.20
|
| Rate for Payer: Altius Auto/Workers Compensation |
$192.19
|
| Rate for Payer: Altius Commercial |
$192.19
|
| Rate for Payer: Beech Street Commercial |
$196.20
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$164.36
|
| Rate for Payer: Cash Price |
$140.14
|
| Rate for Payer: ChoiceCare Network Commercial |
$194.19
|
| Rate for Payer: Cigna of WY Commercial |
$196.20
|
| Rate for Payer: Entrust Commercial |
$190.19
|
| Rate for Payer: First Choice Health Commercial |
$190.19
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$190.19
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$132.13
|
| Rate for Payer: HealthUtah PPO |
$200.20
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$194.19
|
| Rate for Payer: Multiplan Medicare/VA |
$125.53
|
| Rate for Payer: One Health Plan of WY PPO |
$196.20
|
| Rate for Payer: PacificSource Commercial |
$180.18
|
| Rate for Payer: PHCS PPO |
$196.20
|
| Rate for Payer: Three Rivers PPO |
$150.15
|
| Rate for Payer: TriWest Veterans Administration |
$132.13
|
| Rate for Payer: United Healthcare Commercial |
$174.17
|
| Rate for Payer: United Healthcare Medicare |
$132.13
|
| Rate for Payer: WINHealth Partners Commercial |
$190.19
|
| Rate for Payer: Wise Provider Network Commercial |
$190.19
|
|
|
AIRWAY EXCHANGE CATH 14FR
|
Facility
|
OP
|
$200.20
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$110.31 |
| Max. Negotiated Rate |
$200.20 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$196.20
|
| Rate for Payer: Aetna of WY Medicare |
$132.13
|
| Rate for Payer: Altius Auto/Workers Compensation |
$192.19
|
| Rate for Payer: Altius Commercial |
$192.19
|
| Rate for Payer: Beech Street Commercial |
$196.20
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$164.36
|
| Rate for Payer: Cash Price |
$140.14
|
| Rate for Payer: ChoiceCare Network Commercial |
$194.19
|
| Rate for Payer: Cigna of WY Commercial |
$196.20
|
| Rate for Payer: Entrust Commercial |
$190.19
|
| Rate for Payer: First Choice Health Commercial |
$190.19
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$190.19
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$116.12
|
| Rate for Payer: HealthUtah PPO |
$200.20
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$194.19
|
| Rate for Payer: Multiplan Medicare/VA |
$110.31
|
| Rate for Payer: One Health Plan of WY PPO |
$196.20
|
| Rate for Payer: PacificSource Commercial |
$180.18
|
| Rate for Payer: PHCS PPO |
$196.20
|
| Rate for Payer: Three Rivers PPO |
$150.15
|
| Rate for Payer: TriWest Veterans Administration |
$116.12
|
| Rate for Payer: United Healthcare Commercial |
$174.17
|
| Rate for Payer: United Healthcare Medicare |
$116.12
|
| Rate for Payer: WINHealth Partners Commercial |
$196.20
|
| Rate for Payer: Wise Provider Network Commercial |
$190.19
|
|
|
AIRWAY EXCHANGE CATH 19FR
|
Facility
|
OP
|
$276.15
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$152.16 |
| Max. Negotiated Rate |
$276.15 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$270.63
|
| Rate for Payer: Aetna of WY Medicare |
$182.26
|
| Rate for Payer: Altius Auto/Workers Compensation |
$265.10
|
| Rate for Payer: Altius Commercial |
$265.10
|
| Rate for Payer: Beech Street Commercial |
$270.63
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$226.72
|
| Rate for Payer: Cash Price |
$193.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$267.87
|
| Rate for Payer: Cigna of WY Commercial |
$270.63
|
| Rate for Payer: Entrust Commercial |
$262.34
|
| Rate for Payer: First Choice Health Commercial |
$262.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$262.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$160.17
|
| Rate for Payer: HealthUtah PPO |
$276.15
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$267.87
|
| Rate for Payer: Multiplan Medicare/VA |
$152.16
|
| Rate for Payer: One Health Plan of WY PPO |
$270.63
|
| Rate for Payer: PacificSource Commercial |
$248.54
|
| Rate for Payer: PHCS PPO |
$270.63
|
| Rate for Payer: Three Rivers PPO |
$207.11
|
| Rate for Payer: TriWest Veterans Administration |
$160.17
|
| Rate for Payer: United Healthcare Commercial |
$240.25
|
| Rate for Payer: United Healthcare Medicare |
$160.17
|
| Rate for Payer: WINHealth Partners Commercial |
$270.63
|
| Rate for Payer: Wise Provider Network Commercial |
$262.34
|
|
