|
RCNSTJ PST TIBL TDN W/EXC ACCESSORY TARSL NAVCLR
|
Professional
|
Both
|
$2,510.00
|
|
|
Service Code
|
HCPCS 28238
|
| Hospital Charge Code |
28238
|
| Min. Negotiated Rate |
$405.03 |
| Max. Negotiated Rate |
$2,510.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,459.80
|
| Rate for Payer: Aetna of WY Medicare |
$476.51
|
| Rate for Payer: Beech Street Commercial |
$2,384.50
|
| Rate for Payer: Cash Price |
$1,757.00
|
| Rate for Payer: Cash Price |
$1,757.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,434.70
|
| Rate for Payer: Cigna of WY Commercial |
$2,459.80
|
| Rate for Payer: First Choice Health Commercial |
$2,259.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,384.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$476.51
|
| Rate for Payer: HealthUtah PPO |
$2,510.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,434.70
|
| Rate for Payer: Multiplan Medicare/VA |
$405.03
|
| Rate for Payer: One Health Plan of WY PPO |
$2,459.80
|
| Rate for Payer: PacificSource Commercial |
$2,259.00
|
| Rate for Payer: PHCS PPO |
$2,384.50
|
| Rate for Payer: Three Rivers PPO |
$1,882.50
|
| Rate for Payer: TriWest Veterans Administration |
$476.51
|
| Rate for Payer: United Healthcare Commercial |
$2,183.70
|
| Rate for Payer: United Healthcare Medicare |
$476.51
|
| Rate for Payer: WINHealth Partners Commercial |
$2,133.50
|
|
|
RCNSTJ PST TIBL TDN W/EXC ACCESSORY TARSL NAVCLR
|
Professional
|
Both
|
$2,510.00
|
|
|
Service Code
|
HCPCS 28238 80
|
| Hospital Charge Code |
28238
|
| Min. Negotiated Rate |
$405.03 |
| Max. Negotiated Rate |
$2,510.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,459.80
|
| Rate for Payer: Aetna of WY Medicare |
$476.51
|
| Rate for Payer: Beech Street Commercial |
$2,384.50
|
| Rate for Payer: Cash Price |
$1,757.00
|
| Rate for Payer: Cash Price |
$1,757.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,434.70
|
| Rate for Payer: Cigna of WY Commercial |
$2,459.80
|
| Rate for Payer: First Choice Health Commercial |
$2,259.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,384.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$476.51
|
| Rate for Payer: HealthUtah PPO |
$2,510.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,434.70
|
| Rate for Payer: Multiplan Medicare/VA |
$405.03
|
| Rate for Payer: One Health Plan of WY PPO |
$2,459.80
|
| Rate for Payer: PacificSource Commercial |
$2,259.00
|
| Rate for Payer: PHCS PPO |
$2,384.50
|
| Rate for Payer: Three Rivers PPO |
$1,882.50
|
| Rate for Payer: TriWest Veterans Administration |
$476.51
|
| Rate for Payer: United Healthcare Commercial |
$2,183.70
|
| Rate for Payer: United Healthcare Medicare |
$476.51
|
| Rate for Payer: WINHealth Partners Commercial |
$2,133.50
|
|
|
RCNSTJ STABLJ DSTL U/DSTL JT 2 SOFT TISS STABLJ
|
Professional
|
Both
|
$3,090.00
|
|
|
Service Code
|
HCPCS 25337
|
| Hospital Charge Code |
25337
|
| Min. Negotiated Rate |
$736.06 |
| Max. Negotiated Rate |
$3,090.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,028.20
|
| Rate for Payer: Aetna of WY Medicare |
$865.95
|
| Rate for Payer: Beech Street Commercial |
$2,935.50
|
| Rate for Payer: Cash Price |
$2,163.00
|
| Rate for Payer: Cash Price |
$2,163.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,997.30
|
| Rate for Payer: Cigna of WY Commercial |
$3,028.20
|
| Rate for Payer: First Choice Health Commercial |
$2,781.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,935.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$865.95
|
| Rate for Payer: HealthUtah PPO |
$3,090.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,997.30
|
| Rate for Payer: Multiplan Medicare/VA |
$736.06
|
| Rate for Payer: One Health Plan of WY PPO |
$3,028.20
|
| Rate for Payer: PacificSource Commercial |
$2,781.00
|
| Rate for Payer: PHCS PPO |
$2,935.50
|
| Rate for Payer: Three Rivers PPO |
$2,317.50
|
| Rate for Payer: TriWest Veterans Administration |
$865.95
|
| Rate for Payer: United Healthcare Commercial |
$2,688.30
|
| Rate for Payer: United Healthcare Medicare |
$865.95
|
| Rate for Payer: WINHealth Partners Commercial |
$2,626.50
|
|
|
RCNSTJ TDN PULLEY EA TDN W/TDN/FSCAL GRF SPX
|
Professional
|
Both
|
$9,284.00
|
|
|
Service Code
|
HCPCS 26502
|
| Hospital Charge Code |
26502
|
| Min. Negotiated Rate |
$629.11 |
| Max. Negotiated Rate |
$9,284.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$9,098.32
|
| Rate for Payer: Aetna of WY Medicare |
$740.13
|
| Rate for Payer: Beech Street Commercial |
$8,819.80
|
| Rate for Payer: Cash Price |
$6,498.80
|
| Rate for Payer: Cash Price |
$6,498.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$9,005.48
|
| Rate for Payer: Cigna of WY Commercial |
$9,098.32
|
| Rate for Payer: First Choice Health Commercial |
$8,355.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$8,819.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$740.13
|
| Rate for Payer: HealthUtah PPO |
$9,284.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$9,005.48
|
| Rate for Payer: Multiplan Medicare/VA |
$629.11
|
| Rate for Payer: One Health Plan of WY PPO |
$9,098.32
|
| Rate for Payer: PacificSource Commercial |
$8,355.60
|
| Rate for Payer: PHCS PPO |
$8,819.80
|
| Rate for Payer: Three Rivers PPO |
$6,963.00
|
| Rate for Payer: TriWest Veterans Administration |
$740.13
|
| Rate for Payer: United Healthcare Commercial |
$8,077.08
|
| Rate for Payer: United Healthcare Medicare |
$740.13
|
| Rate for Payer: WINHealth Partners Commercial |
$7,891.40
|
|
|
RCNSTJ TENDON PULLEY EACH W/LOCAL TISSUES SPX
|
Professional
|
Both
|
$5,242.00
|
|
|
Service Code
|
HCPCS 26500
|
| Hospital Charge Code |
26500
|
| Min. Negotiated Rate |
$573.94 |
| Max. Negotiated Rate |
$5,242.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5,137.16
|
| Rate for Payer: Aetna of WY Medicare |
$675.22
|
| Rate for Payer: Beech Street Commercial |
$4,979.90
|
| Rate for Payer: Cash Price |
$3,669.40
|
| Rate for Payer: Cash Price |
$3,669.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$5,084.74
|
| Rate for Payer: Cigna of WY Commercial |
$5,137.16
|
| Rate for Payer: First Choice Health Commercial |
$4,717.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,979.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$675.22
|
| Rate for Payer: HealthUtah PPO |
$5,242.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5,084.74
|
| Rate for Payer: Multiplan Medicare/VA |
$573.94
|
| Rate for Payer: One Health Plan of WY PPO |
$5,137.16
|
| Rate for Payer: PacificSource Commercial |
$4,717.80
|
| Rate for Payer: PHCS PPO |
$4,979.90
|
| Rate for Payer: Three Rivers PPO |
$3,931.50
|
| Rate for Payer: TriWest Veterans Administration |
$675.22
|
| Rate for Payer: United Healthcare Commercial |
$4,560.54
|
| Rate for Payer: United Healthcare Medicare |
$675.22
|
| Rate for Payer: WINHealth Partners Commercial |
$4,455.70
|
|
|
RDCTJ TORSION TSTIS W/WO FIXJ CLAT TESTIS
|
Professional
|
Both
|
$1,506.00
|
|
|
Service Code
|
HCPCS 54600
|
| Hospital Charge Code |
54600
|
| Min. Negotiated Rate |
$372.25 |
| Max. Negotiated Rate |
$1,506.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,475.88
|
| Rate for Payer: Aetna of WY Medicare |
$437.94
|
| Rate for Payer: Beech Street Commercial |
$1,430.70
|
| Rate for Payer: Cash Price |
$1,054.20
|
| Rate for Payer: Cash Price |
$1,054.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,460.82
|
| Rate for Payer: Cigna of WY Commercial |
$1,475.88
|
| Rate for Payer: First Choice Health Commercial |
$1,355.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,430.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$437.94
|
| Rate for Payer: HealthUtah PPO |
$1,506.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,460.82
|
| Rate for Payer: Multiplan Medicare/VA |
$372.25
|
| Rate for Payer: One Health Plan of WY PPO |
$1,475.88
|
| Rate for Payer: PacificSource Commercial |
$1,355.40
|
| Rate for Payer: PHCS PPO |
$1,430.70
|
| Rate for Payer: Three Rivers PPO |
$1,129.50
|
| Rate for Payer: TriWest Veterans Administration |
$437.94
|
| Rate for Payer: United Healthcare Commercial |
$1,310.22
|
| Rate for Payer: United Healthcare Medicare |
$437.94
|
| Rate for Payer: WINHealth Partners Commercial |
$1,280.10
|
|
|
RDCTJ VOLVULUS INTUSSUSCEPTION INT HRNA LAPT
|
Professional
|
Both
|
$1,928.00
|
|
|
Service Code
|
HCPCS 44050
|
| Hospital Charge Code |
44050
|
| Min. Negotiated Rate |
$754.90 |
| Max. Negotiated Rate |
$1,928.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,889.44
|
| Rate for Payer: Aetna of WY Medicare |
$888.12
|
| Rate for Payer: Beech Street Commercial |
$1,831.60
|
| Rate for Payer: Cash Price |
$1,349.60
|
| Rate for Payer: Cash Price |
$1,349.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,870.16
|
| Rate for Payer: Cigna of WY Commercial |
$1,889.44
|
| Rate for Payer: First Choice Health Commercial |
$1,735.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,831.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$888.12
|
| Rate for Payer: HealthUtah PPO |
$1,928.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,870.16
|
| Rate for Payer: Multiplan Medicare/VA |
$754.90
|
| Rate for Payer: One Health Plan of WY PPO |
$1,889.44
|
| Rate for Payer: PacificSource Commercial |
$1,735.20
|
| Rate for Payer: PHCS PPO |
$1,831.60
|
| Rate for Payer: Three Rivers PPO |
$1,446.00
|
| Rate for Payer: TriWest Veterans Administration |
$888.12
|
| Rate for Payer: United Healthcare Commercial |
$1,677.36
|
| Rate for Payer: United Healthcare Medicare |
$888.12
|
| Rate for Payer: WINHealth Partners Commercial |
$1,638.80
|
|
|
RDCTJ VOLVULUS INTUSSUSCEPTION INT HRNA LAPT
|
Professional
|
Both
|
$1,928.00
|
|
|
Service Code
|
HCPCS 44050 80
|
| Hospital Charge Code |
44050
|
| Min. Negotiated Rate |
$754.90 |
| Max. Negotiated Rate |
$1,928.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,889.44
|
| Rate for Payer: Aetna of WY Medicare |
$888.12
|
| Rate for Payer: Beech Street Commercial |
$1,831.60
|
| Rate for Payer: Cash Price |
$1,349.60
|
| Rate for Payer: Cash Price |
$1,349.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,870.16
|
| Rate for Payer: Cigna of WY Commercial |
$1,889.44
|
| Rate for Payer: First Choice Health Commercial |
$1,735.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,831.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$888.12
|
| Rate for Payer: HealthUtah PPO |
$1,928.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,870.16
|
| Rate for Payer: Multiplan Medicare/VA |
$754.90
|
| Rate for Payer: One Health Plan of WY PPO |
$1,889.44
|
| Rate for Payer: PacificSource Commercial |
$1,735.20
|
| Rate for Payer: PHCS PPO |
$1,831.60
|
| Rate for Payer: Three Rivers PPO |
$1,446.00
|
| Rate for Payer: TriWest Veterans Administration |
$888.12
|
| Rate for Payer: United Healthcare Commercial |
$1,677.36
|
| Rate for Payer: United Healthcare Medicare |
$888.12
|
| Rate for Payer: WINHealth Partners Commercial |
$1,638.80
|
|
|
RDCTJ VOLVULUS INTUSSUSCEPTION INT HRNA LAPT
|
Professional
|
Both
|
$1,928.00
|
|
|
Service Code
|
HCPCS 44050 AS
|
| Hospital Charge Code |
44050
|
| Min. Negotiated Rate |
$754.90 |
| Max. Negotiated Rate |
$1,928.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,889.44
|
| Rate for Payer: Aetna of WY Medicare |
$888.12
|
| Rate for Payer: Beech Street Commercial |
$1,831.60
|
| Rate for Payer: Cash Price |
$1,349.60
|
| Rate for Payer: Cash Price |
$1,349.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,870.16
|
| Rate for Payer: Cigna of WY Commercial |
$1,889.44
|
| Rate for Payer: First Choice Health Commercial |
$1,735.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,831.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$888.12
|
| Rate for Payer: HealthUtah PPO |
$1,928.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,870.16
|
| Rate for Payer: Multiplan Medicare/VA |
$754.90
|
| Rate for Payer: One Health Plan of WY PPO |
$1,889.44
|
| Rate for Payer: PacificSource Commercial |
$1,735.20
|
| Rate for Payer: PHCS PPO |
$1,831.60
|
| Rate for Payer: Three Rivers PPO |
$1,446.00
|
| Rate for Payer: TriWest Veterans Administration |
$888.12
|
| Rate for Payer: United Healthcare Commercial |
$1,677.36
|
| Rate for Payer: United Healthcare Medicare |
$888.12
|
| Rate for Payer: WINHealth Partners Commercial |
$1,638.80
|
|
|
RD FAST CUT BUR 7.1 1608-6-145
|
Facility
|
OP
|
$116.03
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$63.93 |
| Max. Negotiated Rate |
$116.03 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$113.71
|
| Rate for Payer: Aetna of WY Medicare |
$76.58
|
| Rate for Payer: Altius Auto/Workers Compensation |
$111.39
|
| Rate for Payer: Altius Commercial |
$111.39
|
| Rate for Payer: Beech Street Commercial |
$113.71
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$95.26
|
| Rate for Payer: Cash Price |
$81.22
|
| Rate for Payer: ChoiceCare Network Commercial |
$112.55
|
| Rate for Payer: Cigna of WY Commercial |
$113.71
|
| Rate for Payer: Entrust Commercial |
$110.23
|
| Rate for Payer: First Choice Health Commercial |
$110.23
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$110.23
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$67.30
|
| Rate for Payer: HealthUtah PPO |
$116.03
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$112.55
|
| Rate for Payer: Multiplan Medicare/VA |
$63.93
|
| Rate for Payer: One Health Plan of WY PPO |
$113.71
|
| Rate for Payer: PacificSource Commercial |
$104.43
|
| Rate for Payer: PHCS PPO |
$113.71
|
| Rate for Payer: Three Rivers PPO |
$87.02
|
| Rate for Payer: TriWest Veterans Administration |
$67.30
|
| Rate for Payer: United Healthcare Commercial |
$100.95
|
| Rate for Payer: United Healthcare Medicare |
$67.30
|
| Rate for Payer: WINHealth Partners Commercial |
$113.71
|
| Rate for Payer: Wise Provider Network Commercial |
$110.23
|
|
|
RD FAST CUT BUR 7.1 1608-6-145
|
Facility
|
IP
|
$116.03
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$72.75 |
| Max. Negotiated Rate |
$116.03 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$113.71
|
| Rate for Payer: Altius Auto/Workers Compensation |
$111.39
|
| Rate for Payer: Altius Commercial |
$111.39
|
| Rate for Payer: Beech Street Commercial |
$113.71
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$95.26
|
| Rate for Payer: Cash Price |
$81.22
|
| Rate for Payer: ChoiceCare Network Commercial |
$112.55
|
| Rate for Payer: Cigna of WY Commercial |
$113.71
|
| Rate for Payer: Entrust Commercial |
$110.23
|
| Rate for Payer: First Choice Health Commercial |
$110.23
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$110.23
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$76.58
|
| Rate for Payer: HealthUtah PPO |
$116.03
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$112.55
|
| Rate for Payer: Multiplan Medicare/VA |
$72.75
|
| Rate for Payer: One Health Plan of WY PPO |
$113.71
|
| Rate for Payer: PacificSource Commercial |
$104.43
|
| Rate for Payer: PHCS PPO |
$113.71
|
| Rate for Payer: Three Rivers PPO |
$87.02
|
| Rate for Payer: TriWest Veterans Administration |
$76.58
|
| Rate for Payer: United Healthcare Commercial |
$100.95
|
| Rate for Payer: United Healthcare Medicare |
$76.58
|
| Rate for Payer: WINHealth Partners Commercial |
$110.23
|
| Rate for Payer: Wise Provider Network Commercial |
$110.23
|
|
|
REALIGNMENT EXTENSOR TENDON HAND EACH TENDON
|
Professional
|
Both
|
$4,047.00
|
|
|
Service Code
|
HCPCS 26437
|
| Hospital Charge Code |
26437
|
| Min. Negotiated Rate |
$556.72 |
| Max. Negotiated Rate |
$4,047.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,966.06
|
| Rate for Payer: Aetna of WY Medicare |
$654.96
|
| Rate for Payer: Beech Street Commercial |
$3,844.65
|
| Rate for Payer: Cash Price |
$2,832.90
|
| Rate for Payer: Cash Price |
$2,832.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,925.59
|
| Rate for Payer: Cigna of WY Commercial |
$3,966.06
|
| Rate for Payer: First Choice Health Commercial |
$3,642.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,844.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$654.96
|
| Rate for Payer: HealthUtah PPO |
$4,047.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,925.59
|
| Rate for Payer: Multiplan Medicare/VA |
$556.72
|
| Rate for Payer: One Health Plan of WY PPO |
$3,966.06
|
| Rate for Payer: PacificSource Commercial |
$3,642.30
|
| Rate for Payer: PHCS PPO |
$3,844.65
|
| Rate for Payer: Three Rivers PPO |
$3,035.25
|
| Rate for Payer: TriWest Veterans Administration |
$654.96
|
| Rate for Payer: United Healthcare Commercial |
$3,520.89
|
| Rate for Payer: United Healthcare Medicare |
$654.96
|
| Rate for Payer: WINHealth Partners Commercial |
$3,439.95
|
|
|
RECMPL WND LID, NOS, EAR <1 CM
|
Professional
|
Both
|
$501.00
|
|
|
Service Code
|
HCPCS 13150
|
| Hospital Charge Code |
13150
|
| Min. Negotiated Rate |
$375.75 |
| Max. Negotiated Rate |
$501.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$490.98
|
| Rate for Payer: Beech Street Commercial |
$475.95
|
| Rate for Payer: Cash Price |
$350.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$485.97
|
| Rate for Payer: Cigna of WY Commercial |
$490.98
|
| Rate for Payer: First Choice Health Commercial |
$450.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$475.95
|
| Rate for Payer: HealthUtah PPO |
$501.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$485.97
|
| Rate for Payer: One Health Plan of WY PPO |
$490.98
|
| Rate for Payer: PacificSource Commercial |
$450.90
|
| Rate for Payer: PHCS PPO |
$475.95
|
| Rate for Payer: Three Rivers PPO |
$375.75
|
| Rate for Payer: United Healthcare Commercial |
$435.87
|
| Rate for Payer: WINHealth Partners Commercial |
$425.85
|
|
|
RECONSTRUCTION NAIL BED W/GRAFT
|
Professional
|
Both
|
$957.00
|
|
|
Service Code
|
HCPCS 11762
|
| Hospital Charge Code |
11762
|
| Min. Negotiated Rate |
$153.74 |
| Max. Negotiated Rate |
$957.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$937.86
|
| Rate for Payer: Aetna of WY Medicare |
$180.87
|
| Rate for Payer: Beech Street Commercial |
$909.15
|
| Rate for Payer: Cash Price |
$669.90
|
| Rate for Payer: Cash Price |
$669.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$928.29
|
| Rate for Payer: Cigna of WY Commercial |
$937.86
|
| Rate for Payer: First Choice Health Commercial |
$861.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$909.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$180.87
|
| Rate for Payer: HealthUtah PPO |
$957.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$928.29
|
| Rate for Payer: Multiplan Medicare/VA |
$153.74
|
| Rate for Payer: One Health Plan of WY PPO |
$937.86
|
| Rate for Payer: PacificSource Commercial |
$861.30
|
| Rate for Payer: PHCS PPO |
$909.15
|
| Rate for Payer: Three Rivers PPO |
$717.75
|
| Rate for Payer: TriWest Veterans Administration |
$180.87
|
| Rate for Payer: United Healthcare Commercial |
$832.59
|
| Rate for Payer: United Healthcare Medicare |
$180.87
|
| Rate for Payer: WINHealth Partners Commercial |
$813.45
|
|
|
RECONSTRUCTION ROTATOR CUFF AVULSION CHRONIC
|
Professional
|
Both
|
$4,981.00
|
|
|
Service Code
|
HCPCS 23420
|
| Hospital Charge Code |
23420
|
| Min. Negotiated Rate |
$801.85 |
| Max. Negotiated Rate |
$4,981.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4,881.38
|
| Rate for Payer: Aetna of WY Medicare |
$943.35
|
| Rate for Payer: Beech Street Commercial |
$4,731.95
|
| Rate for Payer: Cash Price |
$3,486.70
|
| Rate for Payer: Cash Price |
$3,486.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$4,831.57
|
| Rate for Payer: Cigna of WY Commercial |
$4,881.38
|
| Rate for Payer: First Choice Health Commercial |
$4,482.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,731.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$943.35
|
| Rate for Payer: HealthUtah PPO |
$4,981.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4,831.57
|
| Rate for Payer: Multiplan Medicare/VA |
$801.85
|
| Rate for Payer: One Health Plan of WY PPO |
$4,881.38
|
| Rate for Payer: PacificSource Commercial |
$4,482.90
|
| Rate for Payer: PHCS PPO |
$4,731.95
|
| Rate for Payer: Three Rivers PPO |
$3,735.75
|
| Rate for Payer: TriWest Veterans Administration |
$943.35
|
| Rate for Payer: United Healthcare Commercial |
$4,333.47
|
| Rate for Payer: United Healthcare Medicare |
$943.35
|
| Rate for Payer: WINHealth Partners Commercial |
$4,233.85
|
|
|
RECONSTRUCTION ROTATOR CUFF AVULSION CHRONIC
|
Professional
|
Both
|
$4,981.00
|
|
|
Service Code
|
HCPCS 23420 AS
|
| Hospital Charge Code |
23420
|
| Min. Negotiated Rate |
$801.85 |
| Max. Negotiated Rate |
$4,981.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4,881.38
|
| Rate for Payer: Aetna of WY Medicare |
$943.35
|
| Rate for Payer: Beech Street Commercial |
$4,731.95
|
| Rate for Payer: Cash Price |
$3,486.70
|
| Rate for Payer: Cash Price |
$3,486.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$4,831.57
|
| Rate for Payer: Cigna of WY Commercial |
$4,881.38
|
| Rate for Payer: First Choice Health Commercial |
$4,482.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,731.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$943.35
|
| Rate for Payer: HealthUtah PPO |
$4,981.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4,831.57
|
| Rate for Payer: Multiplan Medicare/VA |
$801.85
|
| Rate for Payer: One Health Plan of WY PPO |
$4,881.38
|
| Rate for Payer: PacificSource Commercial |
$4,482.90
|
| Rate for Payer: PHCS PPO |
$4,731.95
|
| Rate for Payer: Three Rivers PPO |
$3,735.75
|
| Rate for Payer: TriWest Veterans Administration |
$943.35
|
| Rate for Payer: United Healthcare Commercial |
$4,333.47
|
| Rate for Payer: United Healthcare Medicare |
$943.35
|
| Rate for Payer: WINHealth Partners Commercial |
$4,233.85
|
|
|
REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE [53294]
|
Facility
|
OP
|
$33.75
|
|
|
Service Code
|
HCPCS J2785
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.60 |
| Max. Negotiated Rate |
$33.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$33.08
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$29.40
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$35.28
|
| Rate for Payer: Aetna of WY Medicare |
$22.28
|
| Rate for Payer: Aetna of WY Medicare |
$23.76
|
| Rate for Payer: Aetna of WY Medicare |
$19.80
|
| Rate for Payer: Altius Auto/Workers Compensation |
$32.40
|
| Rate for Payer: Altius Auto/Workers Compensation |
$28.80
|
| Rate for Payer: Altius Auto/Workers Compensation |
$34.56
|
| Rate for Payer: Altius Commercial |
$32.40
|
| Rate for Payer: Altius Commercial |
$34.56
|
| Rate for Payer: Altius Commercial |
$28.80
|
| Rate for Payer: Beech Street Commercial |
$33.08
|
| Rate for Payer: Beech Street Commercial |
$35.28
|
| Rate for Payer: Beech Street Commercial |
$29.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$27.71
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$24.63
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$29.56
|
| Rate for Payer: Cash Price |
$23.62
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$32.74
|
| Rate for Payer: ChoiceCare Network Commercial |
$34.92
|
| Rate for Payer: ChoiceCare Network Commercial |
$29.10
|
| Rate for Payer: Cigna of WY Commercial |
$35.28
|
| Rate for Payer: Cigna of WY Commercial |
$29.40
|
| Rate for Payer: Cigna of WY Commercial |
$33.08
|
| Rate for Payer: Entrust Commercial |
$34.20
|
| Rate for Payer: Entrust Commercial |
$32.06
|
| Rate for Payer: Entrust Commercial |
$28.50
|
| Rate for Payer: First Choice Health Commercial |
$32.06
|
| Rate for Payer: First Choice Health Commercial |
$28.50
|
| Rate for Payer: First Choice Health Commercial |
$34.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$28.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$34.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$32.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$19.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$17.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$20.88
|
| Rate for Payer: HealthUtah PPO |
$30.00
|
| Rate for Payer: HealthUtah PPO |
$36.00
|
| Rate for Payer: HealthUtah PPO |
$33.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$34.92
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$29.10
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$32.74
|
| Rate for Payer: Multiplan Medicare/VA |
$16.53
|
| Rate for Payer: Multiplan Medicare/VA |
$18.60
|
| Rate for Payer: Multiplan Medicare/VA |
$19.84
|
| Rate for Payer: One Health Plan of WY PPO |
$29.40
|
| Rate for Payer: One Health Plan of WY PPO |
$35.28
|
| Rate for Payer: One Health Plan of WY PPO |
$33.08
|
| Rate for Payer: PacificSource Commercial |
$32.40
|
| Rate for Payer: PacificSource Commercial |
$30.38
|
| Rate for Payer: PacificSource Commercial |
$27.00
|
| Rate for Payer: PHCS PPO |
$33.08
|
| Rate for Payer: PHCS PPO |
$29.40
|
| Rate for Payer: PHCS PPO |
$35.28
|
| Rate for Payer: Three Rivers PPO |
$25.31
|
| Rate for Payer: Three Rivers PPO |
$22.50
|
| Rate for Payer: Three Rivers PPO |
$27.00
|
| Rate for Payer: TriWest Veterans Administration |
$20.88
|
| Rate for Payer: TriWest Veterans Administration |
$19.58
|
| Rate for Payer: TriWest Veterans Administration |
$17.40
|
| Rate for Payer: United Healthcare Commercial |
$26.10
|
| Rate for Payer: United Healthcare Commercial |
$29.36
|
| Rate for Payer: United Healthcare Commercial |
$31.32
|
| Rate for Payer: United Healthcare Medicare |
$20.88
|
| Rate for Payer: United Healthcare Medicare |
$17.40
|
| Rate for Payer: United Healthcare Medicare |
$19.58
|
| Rate for Payer: WINHealth Partners Commercial |
$35.28
|
| Rate for Payer: WINHealth Partners Commercial |
$29.40
|
| Rate for Payer: WINHealth Partners Commercial |
$33.08
|
| Rate for Payer: Wise Provider Network Commercial |
$28.50
|
| Rate for Payer: Wise Provider Network Commercial |
$34.20
|
| Rate for Payer: Wise Provider Network Commercial |
$32.06
|
|
|
REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE [53294]
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
HCPCS J2785
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.81 |
| Max. Negotiated Rate |
$30.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$29.40
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$33.08
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$35.28
|
| Rate for Payer: Altius Auto/Workers Compensation |
$28.80
|
| Rate for Payer: Altius Auto/Workers Compensation |
$32.40
|
| Rate for Payer: Altius Auto/Workers Compensation |
$34.56
|
| Rate for Payer: Altius Commercial |
$32.40
|
| Rate for Payer: Altius Commercial |
$28.80
|
| Rate for Payer: Altius Commercial |
$34.56
|
| Rate for Payer: Beech Street Commercial |
$35.28
|
| Rate for Payer: Beech Street Commercial |
$33.08
|
| Rate for Payer: Beech Street Commercial |
$29.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$24.63
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$29.56
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$27.71
|
| Rate for Payer: Cash Price |
$23.62
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$29.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$34.92
|
| Rate for Payer: ChoiceCare Network Commercial |
$32.74
|
| Rate for Payer: Cigna of WY Commercial |
$33.08
|
| Rate for Payer: Cigna of WY Commercial |
$35.28
|
| Rate for Payer: Cigna of WY Commercial |
$29.40
|
| Rate for Payer: Entrust Commercial |
$34.20
|
| Rate for Payer: Entrust Commercial |
$28.50
|
| Rate for Payer: Entrust Commercial |
$32.06
|
| Rate for Payer: First Choice Health Commercial |
$32.06
|
| Rate for Payer: First Choice Health Commercial |
$34.20
|
| Rate for Payer: First Choice Health Commercial |
$28.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$28.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$34.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$32.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$19.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$22.28
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$23.76
|
| Rate for Payer: HealthUtah PPO |
$30.00
|
| Rate for Payer: HealthUtah PPO |
$33.75
|
| Rate for Payer: HealthUtah PPO |
$36.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$34.92
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$32.74
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$29.10
|
| Rate for Payer: Multiplan Medicare/VA |
$22.57
|
| Rate for Payer: Multiplan Medicare/VA |
$18.81
|
| Rate for Payer: Multiplan Medicare/VA |
$21.16
|
| Rate for Payer: One Health Plan of WY PPO |
$29.40
|
| Rate for Payer: One Health Plan of WY PPO |
$33.08
|
| Rate for Payer: One Health Plan of WY PPO |
$35.28
|
| Rate for Payer: PacificSource Commercial |
$32.40
|
| Rate for Payer: PacificSource Commercial |
$27.00
|
| Rate for Payer: PacificSource Commercial |
$30.38
|
| Rate for Payer: PHCS PPO |
$33.08
|
| Rate for Payer: PHCS PPO |
$29.40
|
| Rate for Payer: PHCS PPO |
$35.28
|
| Rate for Payer: Three Rivers PPO |
$25.31
|
| Rate for Payer: Three Rivers PPO |
$22.50
|
| Rate for Payer: Three Rivers PPO |
$27.00
|
| Rate for Payer: TriWest Veterans Administration |
$22.28
|
| Rate for Payer: TriWest Veterans Administration |
$19.80
|
| Rate for Payer: TriWest Veterans Administration |
$23.76
|
| Rate for Payer: United Healthcare Commercial |
$26.10
|
| Rate for Payer: United Healthcare Commercial |
$31.32
|
| Rate for Payer: United Healthcare Commercial |
$29.36
|
| Rate for Payer: United Healthcare Medicare |
$19.80
|
| Rate for Payer: United Healthcare Medicare |
$23.76
|
| Rate for Payer: United Healthcare Medicare |
$22.28
|
| Rate for Payer: WINHealth Partners Commercial |
$32.06
|
| Rate for Payer: WINHealth Partners Commercial |
$28.50
|
| Rate for Payer: WINHealth Partners Commercial |
$34.20
|
| Rate for Payer: Wise Provider Network Commercial |
$34.20
|
| Rate for Payer: Wise Provider Network Commercial |
$28.50
|
| Rate for Payer: Wise Provider Network Commercial |
$32.06
|
|
|
REINSERTION SPINAL FIXATION DEVICE
|
Professional
|
Both
|
$3,797.00
|
|
|
Service Code
|
HCPCS 22849
|
| Hospital Charge Code |
22849
|
| Min. Negotiated Rate |
$1,058.23 |
| Max. Negotiated Rate |
$3,797.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,721.06
|
| Rate for Payer: Aetna of WY Medicare |
$1,244.98
|
| Rate for Payer: Beech Street Commercial |
$3,607.15
|
| Rate for Payer: Cash Price |
$2,657.90
|
| Rate for Payer: Cash Price |
$2,657.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,683.09
|
| Rate for Payer: Cigna of WY Commercial |
$3,721.06
|
| Rate for Payer: First Choice Health Commercial |
$3,417.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,607.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,244.98
|
| Rate for Payer: HealthUtah PPO |
$3,797.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,683.09
|
| Rate for Payer: Multiplan Medicare/VA |
$1,058.23
|
| Rate for Payer: One Health Plan of WY PPO |
$3,721.06
|
| Rate for Payer: PacificSource Commercial |
$3,417.30
|
| Rate for Payer: PHCS PPO |
$3,607.15
|
| Rate for Payer: Three Rivers PPO |
$2,847.75
|
| Rate for Payer: TriWest Veterans Administration |
$1,244.98
|
| Rate for Payer: United Healthcare Commercial |
$3,303.39
|
| Rate for Payer: United Healthcare Medicare |
$1,244.98
|
| Rate for Payer: WINHealth Partners Commercial |
$3,227.45
|
|
|
RELEASE TARSAL TUNNEL
|
Professional
|
Both
|
$1,836.00
|
|
|
Service Code
|
HCPCS 28035 80
|
| Hospital Charge Code |
28035
|
| Min. Negotiated Rate |
$297.89 |
| Max. Negotiated Rate |
$1,836.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,799.28
|
| Rate for Payer: Aetna of WY Medicare |
$350.46
|
| Rate for Payer: Beech Street Commercial |
$1,744.20
|
| Rate for Payer: Cash Price |
$1,285.20
|
| Rate for Payer: Cash Price |
$1,285.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,780.92
|
| Rate for Payer: Cigna of WY Commercial |
$1,799.28
|
| Rate for Payer: First Choice Health Commercial |
$1,652.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,744.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$350.46
|
| Rate for Payer: HealthUtah PPO |
$1,836.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,780.92
|
| Rate for Payer: Multiplan Medicare/VA |
$297.89
|
| Rate for Payer: One Health Plan of WY PPO |
$1,799.28
|
| Rate for Payer: PacificSource Commercial |
$1,652.40
|
| Rate for Payer: PHCS PPO |
$1,744.20
|
| Rate for Payer: Three Rivers PPO |
$1,377.00
|
| Rate for Payer: TriWest Veterans Administration |
$350.46
|
| Rate for Payer: United Healthcare Commercial |
$1,597.32
|
| Rate for Payer: United Healthcare Medicare |
$350.46
|
| Rate for Payer: WINHealth Partners Commercial |
$1,560.60
|
|
|
RELEASE TARSAL TUNNEL
|
Professional
|
Both
|
$1,836.00
|
|
|
Service Code
|
HCPCS 28035
|
| Hospital Charge Code |
28035
|
| Min. Negotiated Rate |
$297.89 |
| Max. Negotiated Rate |
$1,836.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,799.28
|
| Rate for Payer: Aetna of WY Medicare |
$350.46
|
| Rate for Payer: Beech Street Commercial |
$1,744.20
|
| Rate for Payer: Cash Price |
$1,285.20
|
| Rate for Payer: Cash Price |
$1,285.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,780.92
|
| Rate for Payer: Cigna of WY Commercial |
$1,799.28
|
| Rate for Payer: First Choice Health Commercial |
$1,652.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,744.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$350.46
|
| Rate for Payer: HealthUtah PPO |
$1,836.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,780.92
|
| Rate for Payer: Multiplan Medicare/VA |
$297.89
|
| Rate for Payer: One Health Plan of WY PPO |
$1,799.28
|
| Rate for Payer: PacificSource Commercial |
$1,652.40
|
| Rate for Payer: PHCS PPO |
$1,744.20
|
| Rate for Payer: Three Rivers PPO |
$1,377.00
|
| Rate for Payer: TriWest Veterans Administration |
$350.46
|
| Rate for Payer: United Healthcare Commercial |
$1,597.32
|
| Rate for Payer: United Healthcare Medicare |
$350.46
|
| Rate for Payer: WINHealth Partners Commercial |
$1,560.60
|
|
|
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION [158482]
|
Facility
|
OP
|
$586.48
|
|
|
Service Code
|
HCPCS J0248
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$323.15 |
| Max. Negotiated Rate |
$586.48 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$574.75
|
| Rate for Payer: Aetna of WY Medicare |
$387.08
|
| Rate for Payer: Altius Auto/Workers Compensation |
$563.02
|
| Rate for Payer: Altius Commercial |
$563.02
|
| Rate for Payer: Beech Street Commercial |
$574.75
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$481.50
|
| Rate for Payer: Cash Price |
$410.54
|
| Rate for Payer: ChoiceCare Network Commercial |
$568.89
|
| Rate for Payer: Cigna of WY Commercial |
$574.75
|
| Rate for Payer: Entrust Commercial |
$557.16
|
| Rate for Payer: First Choice Health Commercial |
$557.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$557.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$340.16
|
| Rate for Payer: HealthUtah PPO |
$586.48
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$568.89
|
| Rate for Payer: Multiplan Medicare/VA |
$323.15
|
| Rate for Payer: One Health Plan of WY PPO |
$574.75
|
| Rate for Payer: PacificSource Commercial |
$527.83
|
| Rate for Payer: PHCS PPO |
$574.75
|
| Rate for Payer: Three Rivers PPO |
$439.86
|
| Rate for Payer: TriWest Veterans Administration |
$340.16
|
| Rate for Payer: United Healthcare Commercial |
$510.24
|
| Rate for Payer: United Healthcare Medicare |
$340.16
|
| Rate for Payer: WINHealth Partners Commercial |
$574.75
|
| Rate for Payer: Wise Provider Network Commercial |
$557.16
|
|
|
REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION [158482]
|
Facility
|
IP
|
$586.48
|
|
|
Service Code
|
HCPCS J0248
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$367.72 |
| Max. Negotiated Rate |
$586.48 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$574.75
|
| Rate for Payer: Altius Auto/Workers Compensation |
$563.02
|
| Rate for Payer: Altius Commercial |
$563.02
|
| Rate for Payer: Beech Street Commercial |
$574.75
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$481.50
|
| Rate for Payer: Cash Price |
$410.54
|
| Rate for Payer: ChoiceCare Network Commercial |
$568.89
|
| Rate for Payer: Cigna of WY Commercial |
$574.75
|
| Rate for Payer: Entrust Commercial |
$557.16
|
| Rate for Payer: First Choice Health Commercial |
$557.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$557.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$387.08
|
| Rate for Payer: HealthUtah PPO |
$586.48
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$568.89
|
| Rate for Payer: Multiplan Medicare/VA |
$367.72
|
| Rate for Payer: One Health Plan of WY PPO |
$574.75
|
| Rate for Payer: PacificSource Commercial |
$527.83
|
| Rate for Payer: PHCS PPO |
$574.75
|
| Rate for Payer: Three Rivers PPO |
$439.86
|
| Rate for Payer: TriWest Veterans Administration |
$387.08
|
| Rate for Payer: United Healthcare Commercial |
$510.24
|
| Rate for Payer: United Healthcare Medicare |
$387.08
|
| Rate for Payer: WINHealth Partners Commercial |
$557.16
|
| Rate for Payer: Wise Provider Network Commercial |
$557.16
|
|
|
REMIFENTANIL 1 MG INTRAVENOUS SOLUTION [1214]
|
Facility
|
IP
|
$122.26
|
|
|
Service Code
|
NDC 6745719800
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$76.66 |
| Max. Negotiated Rate |
$122.26 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$119.81
|
| Rate for Payer: Altius Auto/Workers Compensation |
$117.37
|
| Rate for Payer: Altius Commercial |
$117.37
|
| Rate for Payer: Beech Street Commercial |
$119.81
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$100.38
|
| Rate for Payer: Cash Price |
$85.58
|
| Rate for Payer: ChoiceCare Network Commercial |
$118.59
|
| Rate for Payer: Cigna of WY Commercial |
$119.81
|
| Rate for Payer: Entrust Commercial |
$116.15
|
| Rate for Payer: First Choice Health Commercial |
$116.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$116.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$80.69
|
| Rate for Payer: HealthUtah PPO |
$122.26
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$118.59
|
| Rate for Payer: Multiplan Medicare/VA |
$76.66
|
| Rate for Payer: One Health Plan of WY PPO |
$119.81
|
| Rate for Payer: PacificSource Commercial |
$110.03
|
| Rate for Payer: PHCS PPO |
$119.81
|
| Rate for Payer: Three Rivers PPO |
$91.70
|
| Rate for Payer: TriWest Veterans Administration |
$80.69
|
| Rate for Payer: United Healthcare Commercial |
$106.37
|
| Rate for Payer: United Healthcare Medicare |
$80.69
|
| Rate for Payer: WINHealth Partners Commercial |
$116.15
|
| Rate for Payer: Wise Provider Network Commercial |
$116.15
|
|
|
REMIFENTANIL 1 MG INTRAVENOUS SOLUTION [1214]
|
Facility
|
IP
|
$122.26
|
|
|
Service Code
|
NDC 7207803400
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$76.66 |
| Max. Negotiated Rate |
$122.26 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$119.81
|
| Rate for Payer: Altius Auto/Workers Compensation |
$117.37
|
| Rate for Payer: Altius Commercial |
$117.37
|
| Rate for Payer: Beech Street Commercial |
$119.81
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$100.38
|
| Rate for Payer: Cash Price |
$85.58
|
| Rate for Payer: ChoiceCare Network Commercial |
$118.59
|
| Rate for Payer: Cigna of WY Commercial |
$119.81
|
| Rate for Payer: Entrust Commercial |
$116.15
|
| Rate for Payer: First Choice Health Commercial |
$116.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$116.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$80.69
|
| Rate for Payer: HealthUtah PPO |
$122.26
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$118.59
|
| Rate for Payer: Multiplan Medicare/VA |
$76.66
|
| Rate for Payer: One Health Plan of WY PPO |
$119.81
|
| Rate for Payer: PacificSource Commercial |
$110.03
|
| Rate for Payer: PHCS PPO |
$119.81
|
| Rate for Payer: Three Rivers PPO |
$91.70
|
| Rate for Payer: TriWest Veterans Administration |
$80.69
|
| Rate for Payer: United Healthcare Commercial |
$106.37
|
| Rate for Payer: United Healthcare Medicare |
$80.69
|
| Rate for Payer: WINHealth Partners Commercial |
$116.15
|
| Rate for Payer: Wise Provider Network Commercial |
$116.15
|
|
