|
PERMANENT SLED BAG
|
Facility
|
OP
|
$52.50
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$28.93 |
| Max. Negotiated Rate |
$52.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$51.45
|
| Rate for Payer: Aetna of WY Medicare |
$34.65
|
| Rate for Payer: Altius Auto/Workers Compensation |
$50.40
|
| Rate for Payer: Altius Commercial |
$50.40
|
| Rate for Payer: Beech Street Commercial |
$51.45
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$43.10
|
| Rate for Payer: Cash Price |
$36.75
|
| Rate for Payer: ChoiceCare Network Commercial |
$50.92
|
| Rate for Payer: Cigna of WY Commercial |
$51.45
|
| Rate for Payer: Entrust Commercial |
$49.88
|
| Rate for Payer: First Choice Health Commercial |
$49.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$49.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$30.45
|
| Rate for Payer: HealthUtah PPO |
$52.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$50.92
|
| Rate for Payer: Multiplan Medicare/VA |
$28.93
|
| Rate for Payer: One Health Plan of WY PPO |
$51.45
|
| Rate for Payer: PacificSource Commercial |
$47.25
|
| Rate for Payer: PHCS PPO |
$51.45
|
| Rate for Payer: Three Rivers PPO |
$39.38
|
| Rate for Payer: TriWest Veterans Administration |
$30.45
|
| Rate for Payer: United Healthcare Commercial |
$45.68
|
| Rate for Payer: United Healthcare Medicare |
$30.45
|
| Rate for Payer: WINHealth Partners Commercial |
$51.45
|
| Rate for Payer: Wise Provider Network Commercial |
$49.88
|
|
|
PERMANENT SLED BAG
|
Facility
|
IP
|
$52.50
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$32.92 |
| Max. Negotiated Rate |
$52.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$51.45
|
| Rate for Payer: Altius Auto/Workers Compensation |
$50.40
|
| Rate for Payer: Altius Commercial |
$50.40
|
| Rate for Payer: Beech Street Commercial |
$51.45
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$43.10
|
| Rate for Payer: Cash Price |
$36.75
|
| Rate for Payer: ChoiceCare Network Commercial |
$50.92
|
| Rate for Payer: Cigna of WY Commercial |
$51.45
|
| Rate for Payer: Entrust Commercial |
$49.88
|
| Rate for Payer: First Choice Health Commercial |
$49.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$49.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$34.65
|
| Rate for Payer: HealthUtah PPO |
$52.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$50.92
|
| Rate for Payer: Multiplan Medicare/VA |
$32.92
|
| Rate for Payer: One Health Plan of WY PPO |
$51.45
|
| Rate for Payer: PacificSource Commercial |
$47.25
|
| Rate for Payer: PHCS PPO |
$51.45
|
| Rate for Payer: Three Rivers PPO |
$39.38
|
| Rate for Payer: TriWest Veterans Administration |
$34.65
|
| Rate for Payer: United Healthcare Commercial |
$45.68
|
| Rate for Payer: United Healthcare Medicare |
$34.65
|
| Rate for Payer: WINHealth Partners Commercial |
$49.88
|
| Rate for Payer: Wise Provider Network Commercial |
$49.88
|
|
|
PERQ DRAINAGE PLEURA INSERT CATH W/O IMAGING
|
Professional
|
Both
|
$1,521.00
|
|
|
Service Code
|
HCPCS 32556
|
| Hospital Charge Code |
32556
|
| Min. Negotiated Rate |
$99.18 |
| Max. Negotiated Rate |
$1,521.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,490.58
|
| Rate for Payer: Aetna of WY Medicare |
$116.68
|
| Rate for Payer: Beech Street Commercial |
$1,444.95
|
| Rate for Payer: Cash Price |
$1,064.70
|
| Rate for Payer: Cash Price |
$1,064.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,475.37
|
| Rate for Payer: Cigna of WY Commercial |
$1,490.58
|
| Rate for Payer: First Choice Health Commercial |
$1,368.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,444.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$116.68
|
| Rate for Payer: HealthUtah PPO |
$1,521.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,475.37
|
| Rate for Payer: Multiplan Medicare/VA |
$99.18
|
| Rate for Payer: One Health Plan of WY PPO |
$1,490.58
|
| Rate for Payer: PacificSource Commercial |
$1,368.90
|
| Rate for Payer: PHCS PPO |
$1,444.95
|
| Rate for Payer: Three Rivers PPO |
$1,140.75
|
| Rate for Payer: TriWest Veterans Administration |
$116.68
|
| Rate for Payer: United Healthcare Commercial |
$1,323.27
|
| Rate for Payer: United Healthcare Medicare |
$116.68
|
| Rate for Payer: WINHealth Partners Commercial |
$1,292.85
|
|
|
PERQ REPLACEMENT GTUBE NOT REQ REVJ GSTRST TRC
|
Professional
|
Both
|
$1,165.00
|
|
|
Service Code
|
HCPCS 43762
|
| Hospital Charge Code |
43762
|
| Min. Negotiated Rate |
$29.88 |
| Max. Negotiated Rate |
$1,165.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,141.70
|
| Rate for Payer: Aetna of WY Medicare |
$35.15
|
| Rate for Payer: Beech Street Commercial |
$1,106.75
|
| Rate for Payer: Cash Price |
$815.50
|
| Rate for Payer: Cash Price |
$815.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,130.05
|
| Rate for Payer: Cigna of WY Commercial |
$1,141.70
|
| Rate for Payer: First Choice Health Commercial |
$1,048.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,106.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$35.15
|
| Rate for Payer: HealthUtah PPO |
$1,165.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,130.05
|
| Rate for Payer: Multiplan Medicare/VA |
$29.88
|
| Rate for Payer: One Health Plan of WY PPO |
$1,141.70
|
| Rate for Payer: PacificSource Commercial |
$1,048.50
|
| Rate for Payer: PHCS PPO |
$1,106.75
|
| Rate for Payer: Three Rivers PPO |
$873.75
|
| Rate for Payer: TriWest Veterans Administration |
$35.15
|
| Rate for Payer: United Healthcare Commercial |
$1,013.55
|
| Rate for Payer: United Healthcare Medicare |
$35.15
|
| Rate for Payer: WINHealth Partners Commercial |
$990.25
|
|
|
PERQ SKELETAL FIXATION ULNAR STYLOID FRACTURE
|
Professional
|
Both
|
$2,518.00
|
|
|
Service Code
|
HCPCS 25651 80
|
| Hospital Charge Code |
25651
|
| Min. Negotiated Rate |
$412.27 |
| Max. Negotiated Rate |
$2,518.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,467.64
|
| Rate for Payer: Aetna of WY Medicare |
$485.02
|
| Rate for Payer: Beech Street Commercial |
$2,392.10
|
| Rate for Payer: Cash Price |
$1,762.60
|
| Rate for Payer: Cash Price |
$1,762.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,442.46
|
| Rate for Payer: Cigna of WY Commercial |
$2,467.64
|
| Rate for Payer: First Choice Health Commercial |
$2,266.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,392.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$485.02
|
| Rate for Payer: HealthUtah PPO |
$2,518.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,442.46
|
| Rate for Payer: Multiplan Medicare/VA |
$412.27
|
| Rate for Payer: One Health Plan of WY PPO |
$2,467.64
|
| Rate for Payer: PacificSource Commercial |
$2,266.20
|
| Rate for Payer: PHCS PPO |
$2,392.10
|
| Rate for Payer: Three Rivers PPO |
$1,888.50
|
| Rate for Payer: TriWest Veterans Administration |
$485.02
|
| Rate for Payer: United Healthcare Commercial |
$2,190.66
|
| Rate for Payer: United Healthcare Medicare |
$485.02
|
| Rate for Payer: WINHealth Partners Commercial |
$2,140.30
|
|
|
PERQ SKELETAL FIXATION ULNAR STYLOID FRACTURE
|
Professional
|
Both
|
$2,518.00
|
|
|
Service Code
|
HCPCS 25651
|
| Hospital Charge Code |
25651
|
| Min. Negotiated Rate |
$412.27 |
| Max. Negotiated Rate |
$2,518.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,467.64
|
| Rate for Payer: Aetna of WY Medicare |
$485.02
|
| Rate for Payer: Beech Street Commercial |
$2,392.10
|
| Rate for Payer: Cash Price |
$1,762.60
|
| Rate for Payer: Cash Price |
$1,762.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,442.46
|
| Rate for Payer: Cigna of WY Commercial |
$2,467.64
|
| Rate for Payer: First Choice Health Commercial |
$2,266.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,392.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$485.02
|
| Rate for Payer: HealthUtah PPO |
$2,518.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,442.46
|
| Rate for Payer: Multiplan Medicare/VA |
$412.27
|
| Rate for Payer: One Health Plan of WY PPO |
$2,467.64
|
| Rate for Payer: PacificSource Commercial |
$2,266.20
|
| Rate for Payer: PHCS PPO |
$2,392.10
|
| Rate for Payer: Three Rivers PPO |
$1,888.50
|
| Rate for Payer: TriWest Veterans Administration |
$485.02
|
| Rate for Payer: United Healthcare Commercial |
$2,190.66
|
| Rate for Payer: United Healthcare Medicare |
$485.02
|
| Rate for Payer: WINHealth Partners Commercial |
$2,140.30
|
|
|
PERQ SKELETAL FIXATION ULNAR STYLOID FRACTURE
|
Professional
|
Both
|
$2,518.00
|
|
|
Service Code
|
HCPCS 25651 AS
|
| Hospital Charge Code |
25651
|
| Min. Negotiated Rate |
$412.27 |
| Max. Negotiated Rate |
$2,518.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,467.64
|
| Rate for Payer: Aetna of WY Medicare |
$485.02
|
| Rate for Payer: Beech Street Commercial |
$2,392.10
|
| Rate for Payer: Cash Price |
$1,762.60
|
| Rate for Payer: Cash Price |
$1,762.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,442.46
|
| Rate for Payer: Cigna of WY Commercial |
$2,467.64
|
| Rate for Payer: First Choice Health Commercial |
$2,266.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,392.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$485.02
|
| Rate for Payer: HealthUtah PPO |
$2,518.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,442.46
|
| Rate for Payer: Multiplan Medicare/VA |
$412.27
|
| Rate for Payer: One Health Plan of WY PPO |
$2,467.64
|
| Rate for Payer: PacificSource Commercial |
$2,266.20
|
| Rate for Payer: PHCS PPO |
$2,392.10
|
| Rate for Payer: Three Rivers PPO |
$1,888.50
|
| Rate for Payer: TriWest Veterans Administration |
$485.02
|
| Rate for Payer: United Healthcare Commercial |
$2,190.66
|
| Rate for Payer: United Healthcare Medicare |
$485.02
|
| Rate for Payer: WINHealth Partners Commercial |
$2,140.30
|
|
|
PERQ SKELETAL FIXJ DISTAL RADIOULNAR DISLOCATION
|
Professional
|
Both
|
$2,675.00
|
|
|
Service Code
|
HCPCS 25671
|
| Hospital Charge Code |
25671
|
| Min. Negotiated Rate |
$448.46 |
| Max. Negotiated Rate |
$2,675.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,621.50
|
| Rate for Payer: Aetna of WY Medicare |
$527.60
|
| Rate for Payer: Beech Street Commercial |
$2,541.25
|
| Rate for Payer: Cash Price |
$1,872.50
|
| Rate for Payer: Cash Price |
$1,872.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,594.75
|
| Rate for Payer: Cigna of WY Commercial |
$2,621.50
|
| Rate for Payer: First Choice Health Commercial |
$2,407.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,541.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$527.60
|
| Rate for Payer: HealthUtah PPO |
$2,675.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,594.75
|
| Rate for Payer: Multiplan Medicare/VA |
$448.46
|
| Rate for Payer: One Health Plan of WY PPO |
$2,621.50
|
| Rate for Payer: PacificSource Commercial |
$2,407.50
|
| Rate for Payer: PHCS PPO |
$2,541.25
|
| Rate for Payer: Three Rivers PPO |
$2,006.25
|
| Rate for Payer: TriWest Veterans Administration |
$527.60
|
| Rate for Payer: United Healthcare Commercial |
$2,327.25
|
| Rate for Payer: United Healthcare Medicare |
$527.60
|
| Rate for Payer: WINHealth Partners Commercial |
$2,273.75
|
|
|
PERQ SKEL FIXJ DISTAL RADIAL FX/EPIPHYSL SEP
|
Professional
|
Both
|
$2,342.00
|
|
|
Service Code
|
HCPCS 25606
|
| Hospital Charge Code |
25606
|
| Min. Negotiated Rate |
$557.80 |
| Max. Negotiated Rate |
$2,342.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,295.16
|
| Rate for Payer: Aetna of WY Medicare |
$656.24
|
| Rate for Payer: Beech Street Commercial |
$2,224.90
|
| Rate for Payer: Cash Price |
$1,639.40
|
| Rate for Payer: Cash Price |
$1,639.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,271.74
|
| Rate for Payer: Cigna of WY Commercial |
$2,295.16
|
| Rate for Payer: First Choice Health Commercial |
$2,107.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,224.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$656.24
|
| Rate for Payer: HealthUtah PPO |
$2,342.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,271.74
|
| Rate for Payer: Multiplan Medicare/VA |
$557.80
|
| Rate for Payer: One Health Plan of WY PPO |
$2,295.16
|
| Rate for Payer: PacificSource Commercial |
$2,107.80
|
| Rate for Payer: PHCS PPO |
$2,224.90
|
| Rate for Payer: Three Rivers PPO |
$1,756.50
|
| Rate for Payer: TriWest Veterans Administration |
$656.24
|
| Rate for Payer: United Healthcare Commercial |
$2,037.54
|
| Rate for Payer: United Healthcare Medicare |
$656.24
|
| Rate for Payer: WINHealth Partners Commercial |
$1,990.70
|
|
|
PERQ SKEL FIXJ DISTAL RADIAL FX/EPIPHYSL SEP
|
Professional
|
Both
|
$2,342.00
|
|
|
Service Code
|
HCPCS 25606 AS
|
| Hospital Charge Code |
25606
|
| Min. Negotiated Rate |
$557.80 |
| Max. Negotiated Rate |
$2,342.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,295.16
|
| Rate for Payer: Aetna of WY Medicare |
$656.24
|
| Rate for Payer: Beech Street Commercial |
$2,224.90
|
| Rate for Payer: Cash Price |
$1,639.40
|
| Rate for Payer: Cash Price |
$1,639.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,271.74
|
| Rate for Payer: Cigna of WY Commercial |
$2,295.16
|
| Rate for Payer: First Choice Health Commercial |
$2,107.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,224.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$656.24
|
| Rate for Payer: HealthUtah PPO |
$2,342.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,271.74
|
| Rate for Payer: Multiplan Medicare/VA |
$557.80
|
| Rate for Payer: One Health Plan of WY PPO |
$2,295.16
|
| Rate for Payer: PacificSource Commercial |
$2,107.80
|
| Rate for Payer: PHCS PPO |
$2,224.90
|
| Rate for Payer: Three Rivers PPO |
$1,756.50
|
| Rate for Payer: TriWest Veterans Administration |
$656.24
|
| Rate for Payer: United Healthcare Commercial |
$2,037.54
|
| Rate for Payer: United Healthcare Medicare |
$656.24
|
| Rate for Payer: WINHealth Partners Commercial |
$1,990.70
|
|
|
PERQ SKEL FIXJ DISTAL RADIAL FX/EPIPHYSL SEP
|
Professional
|
Both
|
$2,342.00
|
|
|
Service Code
|
HCPCS 25606 80
|
| Hospital Charge Code |
25606
|
| Min. Negotiated Rate |
$557.80 |
| Max. Negotiated Rate |
$2,342.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,295.16
|
| Rate for Payer: Aetna of WY Medicare |
$656.24
|
| Rate for Payer: Beech Street Commercial |
$2,224.90
|
| Rate for Payer: Cash Price |
$1,639.40
|
| Rate for Payer: Cash Price |
$1,639.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,271.74
|
| Rate for Payer: Cigna of WY Commercial |
$2,295.16
|
| Rate for Payer: First Choice Health Commercial |
$2,107.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,224.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$656.24
|
| Rate for Payer: HealthUtah PPO |
$2,342.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,271.74
|
| Rate for Payer: Multiplan Medicare/VA |
$557.80
|
| Rate for Payer: One Health Plan of WY PPO |
$2,295.16
|
| Rate for Payer: PacificSource Commercial |
$2,107.80
|
| Rate for Payer: PHCS PPO |
$2,224.90
|
| Rate for Payer: Three Rivers PPO |
$1,756.50
|
| Rate for Payer: TriWest Veterans Administration |
$656.24
|
| Rate for Payer: United Healthcare Commercial |
$2,037.54
|
| Rate for Payer: United Healthcare Medicare |
$656.24
|
| Rate for Payer: WINHealth Partners Commercial |
$1,990.70
|
|
|
PERQ VERT AGMNTJ CAVITY CRTJ UNI/BI CANNULATION
|
Professional
|
Both
|
$19,614.00
|
|
|
Service Code
|
HCPCS 22513
|
| Hospital Charge Code |
22513
|
| Min. Negotiated Rate |
$411.49 |
| Max. Negotiated Rate |
$19,614.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$19,221.72
|
| Rate for Payer: Aetna of WY Medicare |
$484.11
|
| Rate for Payer: Beech Street Commercial |
$18,633.30
|
| Rate for Payer: Cash Price |
$13,729.80
|
| Rate for Payer: Cash Price |
$13,729.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$19,025.58
|
| Rate for Payer: Cigna of WY Commercial |
$19,221.72
|
| Rate for Payer: First Choice Health Commercial |
$17,652.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$18,633.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$484.11
|
| Rate for Payer: HealthUtah PPO |
$19,614.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$19,025.58
|
| Rate for Payer: Multiplan Medicare/VA |
$411.49
|
| Rate for Payer: One Health Plan of WY PPO |
$19,221.72
|
| Rate for Payer: PacificSource Commercial |
$17,652.60
|
| Rate for Payer: PHCS PPO |
$18,633.30
|
| Rate for Payer: Three Rivers PPO |
$14,710.50
|
| Rate for Payer: TriWest Veterans Administration |
$484.11
|
| Rate for Payer: United Healthcare Commercial |
$17,064.18
|
| Rate for Payer: United Healthcare Medicare |
$484.11
|
| Rate for Payer: WINHealth Partners Commercial |
$16,671.90
|
|
|
PERQ VERT AGMNTJ CAVITY CRTJ UNI/BI CANNULATION
|
Professional
|
Both
|
$19,614.00
|
|
|
Service Code
|
HCPCS 22513 80
|
| Hospital Charge Code |
22513
|
| Min. Negotiated Rate |
$411.49 |
| Max. Negotiated Rate |
$19,614.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$19,221.72
|
| Rate for Payer: Aetna of WY Medicare |
$484.11
|
| Rate for Payer: Beech Street Commercial |
$18,633.30
|
| Rate for Payer: Cash Price |
$13,729.80
|
| Rate for Payer: Cash Price |
$13,729.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$19,025.58
|
| Rate for Payer: Cigna of WY Commercial |
$19,221.72
|
| Rate for Payer: First Choice Health Commercial |
$17,652.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$18,633.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$484.11
|
| Rate for Payer: HealthUtah PPO |
$19,614.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$19,025.58
|
| Rate for Payer: Multiplan Medicare/VA |
$411.49
|
| Rate for Payer: One Health Plan of WY PPO |
$19,221.72
|
| Rate for Payer: PacificSource Commercial |
$17,652.60
|
| Rate for Payer: PHCS PPO |
$18,633.30
|
| Rate for Payer: Three Rivers PPO |
$14,710.50
|
| Rate for Payer: TriWest Veterans Administration |
$484.11
|
| Rate for Payer: United Healthcare Commercial |
$17,064.18
|
| Rate for Payer: United Healthcare Medicare |
$484.11
|
| Rate for Payer: WINHealth Partners Commercial |
$16,671.90
|
|
|
PERQ VERT AGMNTJ CAVITY CRTJ UNI/BI CANNULJ LMBR
|
Professional
|
Both
|
$19,532.00
|
|
|
Service Code
|
HCPCS 22514
|
| Hospital Charge Code |
22514
|
| Min. Negotiated Rate |
$383.77 |
| Max. Negotiated Rate |
$19,532.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$19,141.36
|
| Rate for Payer: Aetna of WY Medicare |
$451.49
|
| Rate for Payer: Beech Street Commercial |
$18,555.40
|
| Rate for Payer: Cash Price |
$13,672.40
|
| Rate for Payer: Cash Price |
$13,672.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$18,946.04
|
| Rate for Payer: Cigna of WY Commercial |
$19,141.36
|
| Rate for Payer: First Choice Health Commercial |
$17,578.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$18,555.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$451.49
|
| Rate for Payer: HealthUtah PPO |
$19,532.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$18,946.04
|
| Rate for Payer: Multiplan Medicare/VA |
$383.77
|
| Rate for Payer: One Health Plan of WY PPO |
$19,141.36
|
| Rate for Payer: PacificSource Commercial |
$17,578.80
|
| Rate for Payer: PHCS PPO |
$18,555.40
|
| Rate for Payer: Three Rivers PPO |
$14,649.00
|
| Rate for Payer: TriWest Veterans Administration |
$451.49
|
| Rate for Payer: United Healthcare Commercial |
$16,992.84
|
| Rate for Payer: United Healthcare Medicare |
$451.49
|
| Rate for Payer: WINHealth Partners Commercial |
$16,602.20
|
|
|
PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION [98346]
|
Facility
|
OP
|
$502.18
|
|
|
Service Code
|
HCPCS J9306
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$276.70 |
| Max. Negotiated Rate |
$502.18 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$492.14
|
| Rate for Payer: Aetna of WY Medicare |
$331.44
|
| Rate for Payer: Altius Auto/Workers Compensation |
$482.09
|
| Rate for Payer: Altius Commercial |
$482.09
|
| Rate for Payer: Beech Street Commercial |
$492.14
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$412.29
|
| Rate for Payer: Cash Price |
$351.52
|
| Rate for Payer: ChoiceCare Network Commercial |
$487.11
|
| Rate for Payer: Cigna of WY Commercial |
$492.14
|
| Rate for Payer: Entrust Commercial |
$477.07
|
| Rate for Payer: First Choice Health Commercial |
$477.07
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$477.07
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$291.26
|
| Rate for Payer: HealthUtah PPO |
$502.18
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$487.11
|
| Rate for Payer: Multiplan Medicare/VA |
$276.70
|
| Rate for Payer: One Health Plan of WY PPO |
$492.14
|
| Rate for Payer: PacificSource Commercial |
$451.96
|
| Rate for Payer: PHCS PPO |
$492.14
|
| Rate for Payer: Three Rivers PPO |
$376.64
|
| Rate for Payer: TriWest Veterans Administration |
$291.26
|
| Rate for Payer: United Healthcare Commercial |
$436.90
|
| Rate for Payer: United Healthcare Medicare |
$291.26
|
| Rate for Payer: WINHealth Partners Commercial |
$492.14
|
| Rate for Payer: Wise Provider Network Commercial |
$477.07
|
|
|
PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION [98346]
|
Facility
|
IP
|
$502.18
|
|
|
Service Code
|
HCPCS J9306
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$314.87 |
| Max. Negotiated Rate |
$502.18 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$492.14
|
| Rate for Payer: Altius Auto/Workers Compensation |
$482.09
|
| Rate for Payer: Altius Commercial |
$482.09
|
| Rate for Payer: Beech Street Commercial |
$492.14
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$412.29
|
| Rate for Payer: Cash Price |
$351.52
|
| Rate for Payer: ChoiceCare Network Commercial |
$487.11
|
| Rate for Payer: Cigna of WY Commercial |
$492.14
|
| Rate for Payer: Entrust Commercial |
$477.07
|
| Rate for Payer: First Choice Health Commercial |
$477.07
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$477.07
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$331.44
|
| Rate for Payer: HealthUtah PPO |
$502.18
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$487.11
|
| Rate for Payer: Multiplan Medicare/VA |
$314.87
|
| Rate for Payer: One Health Plan of WY PPO |
$492.14
|
| Rate for Payer: PacificSource Commercial |
$451.96
|
| Rate for Payer: PHCS PPO |
$492.14
|
| Rate for Payer: Three Rivers PPO |
$376.64
|
| Rate for Payer: TriWest Veterans Administration |
$331.44
|
| Rate for Payer: United Healthcare Commercial |
$436.90
|
| Rate for Payer: United Healthcare Medicare |
$331.44
|
| Rate for Payer: WINHealth Partners Commercial |
$477.07
|
| Rate for Payer: Wise Provider Network Commercial |
$477.07
|
|
|
PESSARY REUSABLE NONRUBBER
|
Professional
|
Both
|
$102.00
|
|
|
Service Code
|
HCPCS A4562
|
| Hospital Charge Code |
A4562
|
| Min. Negotiated Rate |
$76.50 |
| Max. Negotiated Rate |
$102.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$99.96
|
| Rate for Payer: Beech Street Commercial |
$96.90
|
| Rate for Payer: Cash Price |
$71.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$98.94
|
| Rate for Payer: Cigna of WY Commercial |
$99.96
|
| Rate for Payer: First Choice Health Commercial |
$91.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$96.90
|
| Rate for Payer: HealthUtah PPO |
$102.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$98.94
|
| Rate for Payer: One Health Plan of WY PPO |
$99.96
|
| Rate for Payer: PacificSource Commercial |
$91.80
|
| Rate for Payer: PHCS PPO |
$96.90
|
| Rate for Payer: Three Rivers PPO |
$76.50
|
| Rate for Payer: United Healthcare Commercial |
$88.74
|
| Rate for Payer: WINHealth Partners Commercial |
$96.90
|
|
|
PESSARY REUSABLE RUB ANYTYPE
|
Professional
|
Both
|
$187.00
|
|
|
Service Code
|
HCPCS A4561
|
| Hospital Charge Code |
A4561
|
| Min. Negotiated Rate |
$23.96 |
| Max. Negotiated Rate |
$187.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$183.26
|
| Rate for Payer: Aetna of WY Medicare |
$28.19
|
| Rate for Payer: Beech Street Commercial |
$177.65
|
| Rate for Payer: Cash Price |
$130.90
|
| Rate for Payer: Cash Price |
$130.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$181.39
|
| Rate for Payer: Cigna of WY Commercial |
$183.26
|
| Rate for Payer: First Choice Health Commercial |
$168.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$177.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$28.19
|
| Rate for Payer: HealthUtah PPO |
$187.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$181.39
|
| Rate for Payer: Multiplan Medicare/VA |
$23.96
|
| Rate for Payer: One Health Plan of WY PPO |
$183.26
|
| Rate for Payer: PacificSource Commercial |
$168.30
|
| Rate for Payer: PHCS PPO |
$177.65
|
| Rate for Payer: Three Rivers PPO |
$140.25
|
| Rate for Payer: TriWest Veterans Administration |
$28.19
|
| Rate for Payer: United Healthcare Commercial |
$162.69
|
| Rate for Payer: United Healthcare Medicare |
$28.19
|
| Rate for Payer: WINHealth Partners Commercial |
$177.65
|
|
|
PHENAZOPYRIDINE 100 MG TABLET [11659]
|
Facility
|
IP
|
$1.28
|
|
|
Service Code
|
NDC 6516268110
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$1.28 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.25
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.23
|
| Rate for Payer: Altius Commercial |
$1.23
|
| Rate for Payer: Beech Street Commercial |
$1.25
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.05
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.24
|
| Rate for Payer: Cigna of WY Commercial |
$1.25
|
| Rate for Payer: Entrust Commercial |
$1.22
|
| Rate for Payer: First Choice Health Commercial |
$1.22
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.22
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.84
|
| Rate for Payer: HealthUtah PPO |
$1.28
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.24
|
| Rate for Payer: Multiplan Medicare/VA |
$0.80
|
| Rate for Payer: One Health Plan of WY PPO |
$1.25
|
| Rate for Payer: PacificSource Commercial |
$1.15
|
| Rate for Payer: PHCS PPO |
$1.25
|
| Rate for Payer: Three Rivers PPO |
$0.96
|
| Rate for Payer: TriWest Veterans Administration |
$0.84
|
| Rate for Payer: United Healthcare Commercial |
$1.11
|
| Rate for Payer: United Healthcare Medicare |
$0.84
|
| Rate for Payer: WINHealth Partners Commercial |
$1.22
|
| Rate for Payer: Wise Provider Network Commercial |
$1.22
|
|
|
PHENAZOPYRIDINE 100 MG TABLET [11659]
|
Facility
|
OP
|
$1.28
|
|
|
Service Code
|
NDC 6516268110
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.71 |
| Max. Negotiated Rate |
$1.28 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.25
|
| Rate for Payer: Aetna of WY Medicare |
$0.84
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.23
|
| Rate for Payer: Altius Commercial |
$1.23
|
| Rate for Payer: Beech Street Commercial |
$1.25
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.05
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.24
|
| Rate for Payer: Cigna of WY Commercial |
$1.25
|
| Rate for Payer: Entrust Commercial |
$1.22
|
| Rate for Payer: First Choice Health Commercial |
$1.22
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.22
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.74
|
| Rate for Payer: HealthUtah PPO |
$1.28
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.24
|
| Rate for Payer: Multiplan Medicare/VA |
$0.71
|
| Rate for Payer: One Health Plan of WY PPO |
$1.25
|
| Rate for Payer: PacificSource Commercial |
$1.15
|
| Rate for Payer: PHCS PPO |
$1.25
|
| Rate for Payer: Three Rivers PPO |
$0.96
|
| Rate for Payer: TriWest Veterans Administration |
$0.74
|
| Rate for Payer: United Healthcare Commercial |
$1.11
|
| Rate for Payer: United Healthcare Medicare |
$0.74
|
| Rate for Payer: WINHealth Partners Commercial |
$1.25
|
| Rate for Payer: Wise Provider Network Commercial |
$1.22
|
|
|
PHENAZOPYRIDINE 95 MG TABLET [11227]
|
Facility
|
OP
|
$0.50
|
|
|
Service Code
|
NDC 4612233765
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.49
|
| Rate for Payer: Aetna of WY Medicare |
$0.33
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.48
|
| Rate for Payer: Altius Commercial |
$0.48
|
| Rate for Payer: Beech Street Commercial |
$0.49
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.41
|
| Rate for Payer: Cash Price |
$0.35
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.49
|
| Rate for Payer: Cigna of WY Commercial |
$0.49
|
| 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 |
$0.29
|
| Rate for Payer: HealthUtah PPO |
$0.50
|
| 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 |
$0.49
|
| Rate for Payer: PacificSource Commercial |
$0.45
|
| Rate for Payer: PHCS PPO |
$0.49
|
| Rate for Payer: Three Rivers PPO |
$0.38
|
| Rate for Payer: TriWest Veterans Administration |
$0.29
|
| Rate for Payer: United Healthcare Commercial |
$0.44
|
| Rate for Payer: United Healthcare Medicare |
$0.29
|
| Rate for Payer: WINHealth Partners Commercial |
$0.49
|
| Rate for Payer: Wise Provider Network Commercial |
$0.48
|
|
|
PHENAZOPYRIDINE 95 MG TABLET [11227]
|
Facility
|
IP
|
$0.50
|
|
|
Service Code
|
NDC 4612233765
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.49
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.48
|
| Rate for Payer: Altius Commercial |
$0.48
|
| Rate for Payer: Beech Street Commercial |
$0.49
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.41
|
| Rate for Payer: Cash Price |
$0.35
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.49
|
| Rate for Payer: Cigna of WY Commercial |
$0.49
|
| 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 |
$0.33
|
| Rate for Payer: HealthUtah PPO |
$0.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.49
|
| Rate for Payer: Multiplan Medicare/VA |
$0.31
|
| Rate for Payer: One Health Plan of WY PPO |
$0.49
|
| Rate for Payer: PacificSource Commercial |
$0.45
|
| Rate for Payer: PHCS PPO |
$0.49
|
| Rate for Payer: Three Rivers PPO |
$0.38
|
| Rate for Payer: TriWest Veterans Administration |
$0.33
|
| Rate for Payer: United Healthcare Commercial |
$0.44
|
| Rate for Payer: United Healthcare Medicare |
$0.33
|
| Rate for Payer: WINHealth Partners Commercial |
$0.48
|
| Rate for Payer: Wise Provider Network Commercial |
$0.48
|
|
|
PHENOBARB-HYOSCYAMN-ATROPINE-SCOP 16.2 MG-0.1037 MG/5 ML (5 ML) ELIXIR [124969]
|
Facility
|
IP
|
$24.57
|
|
|
Service Code
|
NDC 6668906301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.41 |
| Max. Negotiated Rate |
$24.57 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$24.08
|
| Rate for Payer: Altius Auto/Workers Compensation |
$23.59
|
| Rate for Payer: Altius Commercial |
$23.59
|
| Rate for Payer: Beech Street Commercial |
$24.08
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$20.17
|
| Rate for Payer: Cash Price |
$17.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$23.83
|
| Rate for Payer: Cigna of WY Commercial |
$24.08
|
| Rate for Payer: Entrust Commercial |
$23.34
|
| Rate for Payer: First Choice Health Commercial |
$23.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$23.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$16.22
|
| Rate for Payer: HealthUtah PPO |
$24.57
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$23.83
|
| Rate for Payer: Multiplan Medicare/VA |
$15.41
|
| Rate for Payer: One Health Plan of WY PPO |
$24.08
|
| Rate for Payer: PacificSource Commercial |
$22.11
|
| Rate for Payer: PHCS PPO |
$24.08
|
| Rate for Payer: Three Rivers PPO |
$18.43
|
| Rate for Payer: TriWest Veterans Administration |
$16.22
|
| Rate for Payer: United Healthcare Commercial |
$21.38
|
| Rate for Payer: United Healthcare Medicare |
$16.22
|
| Rate for Payer: WINHealth Partners Commercial |
$23.34
|
| Rate for Payer: Wise Provider Network Commercial |
$23.34
|
|
|
PHENOBARB-HYOSCYAMN-ATROPINE-SCOP 16.2 MG-0.1037 MG/5 ML (5 ML) ELIXIR [124969]
|
Facility
|
OP
|
$24.57
|
|
|
Service Code
|
NDC 6668906301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.54 |
| Max. Negotiated Rate |
$24.57 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$24.08
|
| Rate for Payer: Aetna of WY Medicare |
$16.22
|
| Rate for Payer: Altius Auto/Workers Compensation |
$23.59
|
| Rate for Payer: Altius Commercial |
$23.59
|
| Rate for Payer: Beech Street Commercial |
$24.08
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$20.17
|
| Rate for Payer: Cash Price |
$17.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$23.83
|
| Rate for Payer: Cigna of WY Commercial |
$24.08
|
| Rate for Payer: Entrust Commercial |
$23.34
|
| Rate for Payer: First Choice Health Commercial |
$23.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$23.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$14.25
|
| Rate for Payer: HealthUtah PPO |
$24.57
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$23.83
|
| Rate for Payer: Multiplan Medicare/VA |
$13.54
|
| Rate for Payer: One Health Plan of WY PPO |
$24.08
|
| Rate for Payer: PacificSource Commercial |
$22.11
|
| Rate for Payer: PHCS PPO |
$24.08
|
| Rate for Payer: Three Rivers PPO |
$18.43
|
| Rate for Payer: TriWest Veterans Administration |
$14.25
|
| Rate for Payer: United Healthcare Commercial |
$21.38
|
| Rate for Payer: United Healthcare Medicare |
$14.25
|
| Rate for Payer: WINHealth Partners Commercial |
$24.08
|
| Rate for Payer: Wise Provider Network Commercial |
$23.34
|
|
|
PHENOBARBITAL SODIUM 65 MG/ML INJECTION SOLUTION [540]
|
Facility
|
OP
|
$67.71
|
|
|
Service Code
|
HCPCS J2560
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.31 |
| Max. Negotiated Rate |
$67.71 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$66.36
|
| Rate for Payer: Aetna of WY Medicare |
$44.69
|
| Rate for Payer: Altius Auto/Workers Compensation |
$65.00
|
| Rate for Payer: Altius Commercial |
$65.00
|
| Rate for Payer: Beech Street Commercial |
$66.36
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$55.59
|
| Rate for Payer: Cash Price |
$47.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$65.68
|
| Rate for Payer: Cigna of WY Commercial |
$66.36
|
| Rate for Payer: Entrust Commercial |
$64.32
|
| Rate for Payer: First Choice Health Commercial |
$64.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$64.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$39.27
|
| Rate for Payer: HealthUtah PPO |
$67.71
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$65.68
|
| Rate for Payer: Multiplan Medicare/VA |
$37.31
|
| Rate for Payer: One Health Plan of WY PPO |
$66.36
|
| Rate for Payer: PacificSource Commercial |
$60.94
|
| Rate for Payer: PHCS PPO |
$66.36
|
| Rate for Payer: Three Rivers PPO |
$50.78
|
| Rate for Payer: TriWest Veterans Administration |
$39.27
|
| Rate for Payer: United Healthcare Commercial |
$58.91
|
| Rate for Payer: United Healthcare Medicare |
$39.27
|
| Rate for Payer: WINHealth Partners Commercial |
$66.36
|
| Rate for Payer: Wise Provider Network Commercial |
$64.32
|
|
