|
RIVASTIGMINE 3 MG CAPSULE [19692]
|
Facility
|
OP
|
$2.33
|
|
|
Service Code
|
NDC 6233206460
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.28 |
| Max. Negotiated Rate |
$2.33 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.28
|
| Rate for Payer: Aetna of WY Medicare |
$1.54
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.24
|
| Rate for Payer: Altius Commercial |
$2.24
|
| Rate for Payer: Beech Street Commercial |
$2.28
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.91
|
| Rate for Payer: Cash Price |
$1.63
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.26
|
| Rate for Payer: Cigna of WY Commercial |
$2.28
|
| Rate for Payer: Entrust Commercial |
$2.21
|
| Rate for Payer: First Choice Health Commercial |
$2.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.35
|
| Rate for Payer: HealthUtah PPO |
$2.33
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.26
|
| Rate for Payer: Multiplan Medicare/VA |
$1.28
|
| Rate for Payer: One Health Plan of WY PPO |
$2.28
|
| Rate for Payer: PacificSource Commercial |
$2.10
|
| Rate for Payer: PHCS PPO |
$2.28
|
| Rate for Payer: Three Rivers PPO |
$1.75
|
| Rate for Payer: TriWest Veterans Administration |
$1.35
|
| Rate for Payer: United Healthcare Commercial |
$2.03
|
| Rate for Payer: United Healthcare Medicare |
$1.35
|
| Rate for Payer: WINHealth Partners Commercial |
$2.28
|
| Rate for Payer: Wise Provider Network Commercial |
$2.21
|
|
|
RIVASTIGMINE 3 MG CAPSULE [19692]
|
Facility
|
IP
|
$4.17
|
|
|
Service Code
|
NDC 5199179406
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.61 |
| Max. Negotiated Rate |
$4.17 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4.09
|
| Rate for Payer: Altius Auto/Workers Compensation |
$4.00
|
| Rate for Payer: Altius Commercial |
$4.00
|
| Rate for Payer: Beech Street Commercial |
$4.09
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3.42
|
| Rate for Payer: Cash Price |
$2.92
|
| Rate for Payer: ChoiceCare Network Commercial |
$4.04
|
| Rate for Payer: Cigna of WY Commercial |
$4.09
|
| Rate for Payer: Entrust Commercial |
$3.96
|
| Rate for Payer: First Choice Health Commercial |
$3.96
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3.96
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2.75
|
| Rate for Payer: HealthUtah PPO |
$4.17
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4.04
|
| Rate for Payer: Multiplan Medicare/VA |
$2.61
|
| Rate for Payer: One Health Plan of WY PPO |
$4.09
|
| Rate for Payer: PacificSource Commercial |
$3.75
|
| Rate for Payer: PHCS PPO |
$4.09
|
| Rate for Payer: Three Rivers PPO |
$3.13
|
| Rate for Payer: TriWest Veterans Administration |
$2.75
|
| Rate for Payer: United Healthcare Commercial |
$3.63
|
| Rate for Payer: United Healthcare Medicare |
$2.75
|
| Rate for Payer: WINHealth Partners Commercial |
$3.96
|
| Rate for Payer: Wise Provider Network Commercial |
$3.96
|
|
|
RIVASTIGMINE 3 MG CAPSULE [19692]
|
Facility
|
OP
|
$4.17
|
|
|
Service Code
|
NDC 5199179406
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.30 |
| Max. Negotiated Rate |
$4.17 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4.09
|
| Rate for Payer: Aetna of WY Medicare |
$2.75
|
| Rate for Payer: Altius Auto/Workers Compensation |
$4.00
|
| Rate for Payer: Altius Commercial |
$4.00
|
| Rate for Payer: Beech Street Commercial |
$4.09
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3.42
|
| Rate for Payer: Cash Price |
$2.92
|
| Rate for Payer: ChoiceCare Network Commercial |
$4.04
|
| Rate for Payer: Cigna of WY Commercial |
$4.09
|
| Rate for Payer: Entrust Commercial |
$3.96
|
| Rate for Payer: First Choice Health Commercial |
$3.96
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3.96
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2.42
|
| Rate for Payer: HealthUtah PPO |
$4.17
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4.04
|
| Rate for Payer: Multiplan Medicare/VA |
$2.30
|
| Rate for Payer: One Health Plan of WY PPO |
$4.09
|
| Rate for Payer: PacificSource Commercial |
$3.75
|
| Rate for Payer: PHCS PPO |
$4.09
|
| Rate for Payer: Three Rivers PPO |
$3.13
|
| Rate for Payer: TriWest Veterans Administration |
$2.42
|
| Rate for Payer: United Healthcare Commercial |
$3.63
|
| Rate for Payer: United Healthcare Medicare |
$2.42
|
| Rate for Payer: WINHealth Partners Commercial |
$4.09
|
| Rate for Payer: Wise Provider Network Commercial |
$3.96
|
|
|
RIVASTIGMINE 3 MG CAPSULE [19692]
|
Facility
|
IP
|
$2.33
|
|
|
Service Code
|
NDC 6233206460
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.46 |
| Max. Negotiated Rate |
$2.33 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.28
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.24
|
| Rate for Payer: Altius Commercial |
$2.24
|
| Rate for Payer: Beech Street Commercial |
$2.28
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.91
|
| Rate for Payer: Cash Price |
$1.63
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.26
|
| Rate for Payer: Cigna of WY Commercial |
$2.28
|
| Rate for Payer: Entrust Commercial |
$2.21
|
| Rate for Payer: First Choice Health Commercial |
$2.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.54
|
| Rate for Payer: HealthUtah PPO |
$2.33
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.26
|
| Rate for Payer: Multiplan Medicare/VA |
$1.46
|
| Rate for Payer: One Health Plan of WY PPO |
$2.28
|
| Rate for Payer: PacificSource Commercial |
$2.10
|
| Rate for Payer: PHCS PPO |
$2.28
|
| Rate for Payer: Three Rivers PPO |
$1.75
|
| Rate for Payer: TriWest Veterans Administration |
$1.54
|
| Rate for Payer: United Healthcare Commercial |
$2.03
|
| Rate for Payer: United Healthcare Medicare |
$1.54
|
| Rate for Payer: WINHealth Partners Commercial |
$2.21
|
| Rate for Payer: Wise Provider Network Commercial |
$2.21
|
|
|
R & L HRT CATH WINJX HRT ART& L VENTR IMG
|
Professional
|
Both
|
$5,329.00
|
|
|
Service Code
|
HCPCS 93460
|
| Hospital Charge Code |
93460
|
| Min. Negotiated Rate |
$1,011.56 |
| Max. Negotiated Rate |
$5,329.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5,222.42
|
| Rate for Payer: Aetna of WY Medicare |
$1,190.07
|
| Rate for Payer: Beech Street Commercial |
$5,062.55
|
| Rate for Payer: Cash Price |
$3,730.30
|
| Rate for Payer: Cash Price |
$3,730.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$5,169.13
|
| Rate for Payer: Cigna of WY Commercial |
$5,222.42
|
| Rate for Payer: First Choice Health Commercial |
$4,796.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5,062.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,190.07
|
| Rate for Payer: HealthUtah PPO |
$5,329.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5,169.13
|
| Rate for Payer: Multiplan Medicare/VA |
$1,011.56
|
| Rate for Payer: One Health Plan of WY PPO |
$5,222.42
|
| Rate for Payer: PacificSource Commercial |
$4,796.10
|
| Rate for Payer: PHCS PPO |
$5,062.55
|
| Rate for Payer: Three Rivers PPO |
$3,996.75
|
| Rate for Payer: TriWest Veterans Administration |
$1,190.07
|
| Rate for Payer: United Healthcare Commercial |
$4,636.23
|
| Rate for Payer: United Healthcare Medicare |
$1,190.07
|
| Rate for Payer: WINHealth Partners Commercial |
$5,062.55
|
|
|
RMVL DEVITAL TISS N-SLCTV DBRDMT W/O ANES 1 SESS
|
Professional
|
Both
|
$483.00
|
|
|
Service Code
|
HCPCS 97602
|
| Hospital Charge Code |
97602
|
| Min. Negotiated Rate |
$362.25 |
| Max. Negotiated Rate |
$483.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$473.34
|
| Rate for Payer: Beech Street Commercial |
$458.85
|
| Rate for Payer: Cash Price |
$338.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$468.51
|
| Rate for Payer: Cigna of WY Commercial |
$473.34
|
| Rate for Payer: First Choice Health Commercial |
$434.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$458.85
|
| Rate for Payer: HealthUtah PPO |
$483.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$468.51
|
| Rate for Payer: One Health Plan of WY PPO |
$473.34
|
| Rate for Payer: PacificSource Commercial |
$434.70
|
| Rate for Payer: PHCS PPO |
$458.85
|
| Rate for Payer: Three Rivers PPO |
$362.25
|
| Rate for Payer: United Healthcare Commercial |
$420.21
|
| Rate for Payer: WINHealth Partners Commercial |
$458.85
|
|
|
RMVL EMBEDDED FB VESTIBULE MOUTH COMP
|
Professional
|
Both
|
$1,082.00
|
|
|
Service Code
|
HCPCS 40805
|
| Hospital Charge Code |
40805
|
| Min. Negotiated Rate |
$163.44 |
| Max. Negotiated Rate |
$1,082.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,060.36
|
| Rate for Payer: Aetna of WY Medicare |
$192.28
|
| Rate for Payer: Beech Street Commercial |
$1,027.90
|
| Rate for Payer: Cash Price |
$757.40
|
| Rate for Payer: Cash Price |
$757.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,049.54
|
| Rate for Payer: Cigna of WY Commercial |
$1,060.36
|
| Rate for Payer: First Choice Health Commercial |
$973.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,027.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$192.28
|
| Rate for Payer: HealthUtah PPO |
$1,082.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,049.54
|
| Rate for Payer: Multiplan Medicare/VA |
$163.44
|
| Rate for Payer: One Health Plan of WY PPO |
$1,060.36
|
| Rate for Payer: PacificSource Commercial |
$973.80
|
| Rate for Payer: PHCS PPO |
$1,027.90
|
| Rate for Payer: Three Rivers PPO |
$811.50
|
| Rate for Payer: TriWest Veterans Administration |
$192.28
|
| Rate for Payer: United Healthcare Commercial |
$941.34
|
| Rate for Payer: United Healthcare Medicare |
$192.28
|
| Rate for Payer: WINHealth Partners Commercial |
$919.70
|
|
|
RMVL FB XTRNL AUDITORY CANAL ANES
|
Professional
|
Both
|
$483.00
|
|
|
Service Code
|
HCPCS 69205
|
| Hospital Charge Code |
69205
|
| Min. Negotiated Rate |
$78.92 |
| Max. Negotiated Rate |
$483.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$473.34
|
| Rate for Payer: Aetna of WY Medicare |
$92.85
|
| Rate for Payer: Beech Street Commercial |
$458.85
|
| Rate for Payer: Cash Price |
$338.10
|
| Rate for Payer: Cash Price |
$338.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$468.51
|
| Rate for Payer: Cigna of WY Commercial |
$473.34
|
| Rate for Payer: First Choice Health Commercial |
$434.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$458.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$92.85
|
| Rate for Payer: HealthUtah PPO |
$483.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$468.51
|
| Rate for Payer: Multiplan Medicare/VA |
$78.92
|
| Rate for Payer: One Health Plan of WY PPO |
$473.34
|
| Rate for Payer: PacificSource Commercial |
$434.70
|
| Rate for Payer: PHCS PPO |
$458.85
|
| Rate for Payer: Three Rivers PPO |
$362.25
|
| Rate for Payer: TriWest Veterans Administration |
$92.85
|
| Rate for Payer: United Healthcare Commercial |
$420.21
|
| Rate for Payer: United Healthcare Medicare |
$92.85
|
| Rate for Payer: WINHealth Partners Commercial |
$410.55
|
|
|
RMVL FB XTRNL AUDITORY CANAL ANES
|
Professional
|
Both
|
$966.00
|
|
|
Service Code
|
HCPCS 69205 50
|
| Hospital Charge Code |
69205
|
| Min. Negotiated Rate |
$78.92 |
| Max. Negotiated Rate |
$966.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$946.68
|
| Rate for Payer: Aetna of WY Medicare |
$92.85
|
| Rate for Payer: Beech Street Commercial |
$917.70
|
| Rate for Payer: Cash Price |
$676.20
|
| Rate for Payer: Cash Price |
$676.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$937.02
|
| Rate for Payer: Cigna of WY Commercial |
$946.68
|
| Rate for Payer: First Choice Health Commercial |
$869.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$917.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$92.85
|
| Rate for Payer: HealthUtah PPO |
$966.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$937.02
|
| Rate for Payer: Multiplan Medicare/VA |
$78.92
|
| Rate for Payer: One Health Plan of WY PPO |
$946.68
|
| Rate for Payer: PacificSource Commercial |
$869.40
|
| Rate for Payer: PHCS PPO |
$917.70
|
| Rate for Payer: Three Rivers PPO |
$724.50
|
| Rate for Payer: TriWest Veterans Administration |
$92.85
|
| Rate for Payer: United Healthcare Commercial |
$840.42
|
| Rate for Payer: United Healthcare Medicare |
$92.85
|
| Rate for Payer: WINHealth Partners Commercial |
$821.10
|
|
|
RMVL FB XTRNL AUDITORY CANAL W/O ANES
|
Professional
|
Both
|
$559.00
|
|
|
Service Code
|
HCPCS 69200 50
|
| Hospital Charge Code |
69200
|
| Min. Negotiated Rate |
$38.73 |
| Max. Negotiated Rate |
$559.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$547.82
|
| Rate for Payer: Aetna of WY Medicare |
$45.56
|
| Rate for Payer: Beech Street Commercial |
$531.05
|
| Rate for Payer: Cash Price |
$391.30
|
| Rate for Payer: Cash Price |
$391.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$542.23
|
| Rate for Payer: Cigna of WY Commercial |
$547.82
|
| Rate for Payer: First Choice Health Commercial |
$503.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$531.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$45.56
|
| Rate for Payer: HealthUtah PPO |
$559.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$542.23
|
| Rate for Payer: Multiplan Medicare/VA |
$38.73
|
| Rate for Payer: One Health Plan of WY PPO |
$547.82
|
| Rate for Payer: PacificSource Commercial |
$503.10
|
| Rate for Payer: PHCS PPO |
$531.05
|
| Rate for Payer: Three Rivers PPO |
$419.25
|
| Rate for Payer: TriWest Veterans Administration |
$45.56
|
| Rate for Payer: United Healthcare Commercial |
$486.33
|
| Rate for Payer: United Healthcare Medicare |
$45.56
|
| Rate for Payer: WINHealth Partners Commercial |
$475.15
|
|
|
RMVL FB XTRNL AUDITORY CANAL W/O ANES
|
Professional
|
Both
|
$280.00
|
|
|
Service Code
|
HCPCS 69200
|
| Hospital Charge Code |
69200
|
| Min. Negotiated Rate |
$38.73 |
| Max. Negotiated Rate |
$280.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$274.40
|
| Rate for Payer: Aetna of WY Medicare |
$45.56
|
| Rate for Payer: Beech Street Commercial |
$266.00
|
| Rate for Payer: Cash Price |
$196.00
|
| Rate for Payer: Cash Price |
$196.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$271.60
|
| Rate for Payer: Cigna of WY Commercial |
$274.40
|
| Rate for Payer: First Choice Health Commercial |
$252.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$266.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$45.56
|
| Rate for Payer: HealthUtah PPO |
$280.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$271.60
|
| Rate for Payer: Multiplan Medicare/VA |
$38.73
|
| Rate for Payer: One Health Plan of WY PPO |
$274.40
|
| Rate for Payer: PacificSource Commercial |
$252.00
|
| Rate for Payer: PHCS PPO |
$266.00
|
| Rate for Payer: Three Rivers PPO |
$210.00
|
| Rate for Payer: TriWest Veterans Administration |
$45.56
|
| Rate for Payer: United Healthcare Commercial |
$243.60
|
| Rate for Payer: United Healthcare Medicare |
$45.56
|
| Rate for Payer: WINHealth Partners Commercial |
$238.00
|
|
|
RMVL FB XTRNL EYE CORNEAL W/O SLIT LAMP
|
Professional
|
Both
|
$214.00
|
|
|
Service Code
|
HCPCS 65220
|
| Hospital Charge Code |
65220
|
| Min. Negotiated Rate |
$33.58 |
| Max. Negotiated Rate |
$214.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$209.72
|
| Rate for Payer: Aetna of WY Medicare |
$39.51
|
| Rate for Payer: Beech Street Commercial |
$203.30
|
| Rate for Payer: Cash Price |
$149.80
|
| Rate for Payer: Cash Price |
$149.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$207.58
|
| Rate for Payer: Cigna of WY Commercial |
$209.72
|
| Rate for Payer: First Choice Health Commercial |
$192.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$203.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$39.51
|
| Rate for Payer: HealthUtah PPO |
$214.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$207.58
|
| Rate for Payer: Multiplan Medicare/VA |
$33.58
|
| Rate for Payer: One Health Plan of WY PPO |
$209.72
|
| Rate for Payer: PacificSource Commercial |
$192.60
|
| Rate for Payer: PHCS PPO |
$203.30
|
| Rate for Payer: Three Rivers PPO |
$160.50
|
| Rate for Payer: TriWest Veterans Administration |
$39.51
|
| Rate for Payer: United Healthcare Commercial |
$186.18
|
| Rate for Payer: United Healthcare Medicare |
$39.51
|
| Rate for Payer: WINHealth Partners Commercial |
$181.90
|
|
|
RMVL FOREIGN BODY MUSCLE/TENDON SHEATH DEEP/COMP
|
Professional
|
Both
|
$1,272.00
|
|
|
Service Code
|
HCPCS 20525
|
| Hospital Charge Code |
20525
|
| Min. Negotiated Rate |
$202.56 |
| Max. Negotiated Rate |
$1,272.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,246.56
|
| Rate for Payer: Aetna of WY Medicare |
$238.30
|
| Rate for Payer: Beech Street Commercial |
$1,208.40
|
| Rate for Payer: Cash Price |
$890.40
|
| Rate for Payer: Cash Price |
$890.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,233.84
|
| Rate for Payer: Cigna of WY Commercial |
$1,246.56
|
| Rate for Payer: First Choice Health Commercial |
$1,144.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,208.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$238.30
|
| Rate for Payer: HealthUtah PPO |
$1,272.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,233.84
|
| Rate for Payer: Multiplan Medicare/VA |
$202.56
|
| Rate for Payer: One Health Plan of WY PPO |
$1,246.56
|
| Rate for Payer: PacificSource Commercial |
$1,144.80
|
| Rate for Payer: PHCS PPO |
$1,208.40
|
| Rate for Payer: Three Rivers PPO |
$954.00
|
| Rate for Payer: TriWest Veterans Administration |
$238.30
|
| Rate for Payer: United Healthcare Commercial |
$1,106.64
|
| Rate for Payer: United Healthcare Medicare |
$238.30
|
| Rate for Payer: WINHealth Partners Commercial |
$1,081.20
|
|
|
RMVL FOREIGN BODY UPPER ARM/ELBOW SUBCUTANEOUS
|
Professional
|
Both
|
$766.00
|
|
|
Service Code
|
HCPCS 24200
|
| Hospital Charge Code |
24200
|
| Min. Negotiated Rate |
$117.28 |
| Max. Negotiated Rate |
$766.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$750.68
|
| Rate for Payer: Aetna of WY Medicare |
$137.98
|
| Rate for Payer: Beech Street Commercial |
$727.70
|
| Rate for Payer: Cash Price |
$536.20
|
| Rate for Payer: Cash Price |
$536.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$743.02
|
| Rate for Payer: Cigna of WY Commercial |
$750.68
|
| Rate for Payer: First Choice Health Commercial |
$689.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$727.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$137.98
|
| Rate for Payer: HealthUtah PPO |
$766.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$743.02
|
| Rate for Payer: Multiplan Medicare/VA |
$117.28
|
| Rate for Payer: One Health Plan of WY PPO |
$750.68
|
| Rate for Payer: PacificSource Commercial |
$689.40
|
| Rate for Payer: PHCS PPO |
$727.70
|
| Rate for Payer: Three Rivers PPO |
$574.50
|
| Rate for Payer: TriWest Veterans Administration |
$137.98
|
| Rate for Payer: United Healthcare Commercial |
$666.42
|
| Rate for Payer: United Healthcare Medicare |
$137.98
|
| Rate for Payer: WINHealth Partners Commercial |
$651.10
|
|
|
RMVL NDWELLG TUNNELED PLEURAL CATHETER W/CUFF
|
Professional
|
Both
|
$815.00
|
|
|
Service Code
|
HCPCS 32552
|
| Hospital Charge Code |
32552
|
| Min. Negotiated Rate |
$127.02 |
| Max. Negotiated Rate |
$815.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$798.70
|
| Rate for Payer: Aetna of WY Medicare |
$149.43
|
| Rate for Payer: Beech Street Commercial |
$774.25
|
| Rate for Payer: Cash Price |
$570.50
|
| Rate for Payer: Cash Price |
$570.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$790.55
|
| Rate for Payer: Cigna of WY Commercial |
$798.70
|
| Rate for Payer: First Choice Health Commercial |
$733.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$774.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$149.43
|
| Rate for Payer: HealthUtah PPO |
$815.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$790.55
|
| Rate for Payer: Multiplan Medicare/VA |
$127.02
|
| Rate for Payer: One Health Plan of WY PPO |
$798.70
|
| Rate for Payer: PacificSource Commercial |
$733.50
|
| Rate for Payer: PHCS PPO |
$774.25
|
| Rate for Payer: Three Rivers PPO |
$611.25
|
| Rate for Payer: TriWest Veterans Administration |
$149.43
|
| Rate for Payer: United Healthcare Commercial |
$709.05
|
| Rate for Payer: United Healthcare Medicare |
$149.43
|
| Rate for Payer: WINHealth Partners Commercial |
$692.75
|
|
|
RMVL NONINFCT MESH/PROSTH AA/PARASTOMAL HRNA RPR
|
Professional
|
Both
|
$652.00
|
|
|
Service Code
|
HCPCS 49623
|
| Hospital Charge Code |
49623
|
| Min. Negotiated Rate |
$157.91 |
| Max. Negotiated Rate |
$652.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$638.96
|
| Rate for Payer: Aetna of WY Medicare |
$185.78
|
| Rate for Payer: Beech Street Commercial |
$619.40
|
| Rate for Payer: Cash Price |
$456.40
|
| Rate for Payer: Cash Price |
$456.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$632.44
|
| Rate for Payer: Cigna of WY Commercial |
$638.96
|
| Rate for Payer: First Choice Health Commercial |
$586.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$619.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$185.78
|
| Rate for Payer: HealthUtah PPO |
$652.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$632.44
|
| Rate for Payer: Multiplan Medicare/VA |
$157.91
|
| Rate for Payer: One Health Plan of WY PPO |
$638.96
|
| Rate for Payer: PacificSource Commercial |
$586.80
|
| Rate for Payer: PHCS PPO |
$619.40
|
| Rate for Payer: Three Rivers PPO |
$489.00
|
| Rate for Payer: TriWest Veterans Administration |
$185.78
|
| Rate for Payer: United Healthcare Commercial |
$567.24
|
| Rate for Payer: United Healthcare Medicare |
$185.78
|
| Rate for Payer: WINHealth Partners Commercial |
$554.20
|
|
|
RMVL PROSTC MATRL/MESH ABDL WALL FOR INFECTION
|
Professional
|
Both
|
$1,378.00
|
|
|
Service Code
|
HCPCS 11008
|
| Hospital Charge Code |
11008
|
| Min. Negotiated Rate |
$215.95 |
| Max. Negotiated Rate |
$1,378.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,350.44
|
| Rate for Payer: Aetna of WY Medicare |
$254.06
|
| Rate for Payer: Beech Street Commercial |
$1,309.10
|
| Rate for Payer: Cash Price |
$964.60
|
| Rate for Payer: Cash Price |
$964.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,336.66
|
| Rate for Payer: Cigna of WY Commercial |
$1,350.44
|
| Rate for Payer: First Choice Health Commercial |
$1,240.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,309.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$254.06
|
| Rate for Payer: HealthUtah PPO |
$1,378.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,336.66
|
| Rate for Payer: Multiplan Medicare/VA |
$215.95
|
| Rate for Payer: One Health Plan of WY PPO |
$1,350.44
|
| Rate for Payer: PacificSource Commercial |
$1,240.20
|
| Rate for Payer: PHCS PPO |
$1,309.10
|
| Rate for Payer: Three Rivers PPO |
$1,033.50
|
| Rate for Payer: TriWest Veterans Administration |
$254.06
|
| Rate for Payer: United Healthcare Commercial |
$1,198.86
|
| Rate for Payer: United Healthcare Medicare |
$254.06
|
| Rate for Payer: WINHealth Partners Commercial |
$1,171.30
|
|
|
RMVL PROSTH TOT KNEE PROSTH MMA W/WO INSJ SPACER
|
Professional
|
Both
|
$6,197.00
|
|
|
Service Code
|
HCPCS 27488 AS
|
| Hospital Charge Code |
27488
|
| Min. Negotiated Rate |
$981.60 |
| Max. Negotiated Rate |
$6,197.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$6,073.06
|
| Rate for Payer: Aetna of WY Medicare |
$1,154.82
|
| Rate for Payer: Beech Street Commercial |
$5,887.15
|
| Rate for Payer: Cash Price |
$4,337.90
|
| Rate for Payer: Cash Price |
$4,337.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$6,011.09
|
| Rate for Payer: Cigna of WY Commercial |
$6,073.06
|
| Rate for Payer: First Choice Health Commercial |
$5,577.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5,887.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,154.82
|
| Rate for Payer: HealthUtah PPO |
$6,197.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$6,011.09
|
| Rate for Payer: Multiplan Medicare/VA |
$981.60
|
| Rate for Payer: One Health Plan of WY PPO |
$6,073.06
|
| Rate for Payer: PacificSource Commercial |
$5,577.30
|
| Rate for Payer: PHCS PPO |
$5,887.15
|
| Rate for Payer: Three Rivers PPO |
$4,647.75
|
| Rate for Payer: TriWest Veterans Administration |
$1,154.82
|
| Rate for Payer: United Healthcare Commercial |
$5,391.39
|
| Rate for Payer: United Healthcare Medicare |
$1,154.82
|
| Rate for Payer: WINHealth Partners Commercial |
$5,267.45
|
|
|
RMVL PROSTH TOT KNEE PROSTH MMA W/WO INSJ SPACER
|
Professional
|
Both
|
$6,197.00
|
|
|
Service Code
|
HCPCS 27488 80
|
| Hospital Charge Code |
27488
|
| Min. Negotiated Rate |
$981.60 |
| Max. Negotiated Rate |
$6,197.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$6,073.06
|
| Rate for Payer: Aetna of WY Medicare |
$1,154.82
|
| Rate for Payer: Beech Street Commercial |
$5,887.15
|
| Rate for Payer: Cash Price |
$4,337.90
|
| Rate for Payer: Cash Price |
$4,337.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$6,011.09
|
| Rate for Payer: Cigna of WY Commercial |
$6,073.06
|
| Rate for Payer: First Choice Health Commercial |
$5,577.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5,887.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,154.82
|
| Rate for Payer: HealthUtah PPO |
$6,197.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$6,011.09
|
| Rate for Payer: Multiplan Medicare/VA |
$981.60
|
| Rate for Payer: One Health Plan of WY PPO |
$6,073.06
|
| Rate for Payer: PacificSource Commercial |
$5,577.30
|
| Rate for Payer: PHCS PPO |
$5,887.15
|
| Rate for Payer: Three Rivers PPO |
$4,647.75
|
| Rate for Payer: TriWest Veterans Administration |
$1,154.82
|
| Rate for Payer: United Healthcare Commercial |
$5,391.39
|
| Rate for Payer: United Healthcare Medicare |
$1,154.82
|
| Rate for Payer: WINHealth Partners Commercial |
$5,267.45
|
|
|
RMVL PROSTH TOT KNEE PROSTH MMA W/WO INSJ SPACER
|
Professional
|
Both
|
$6,197.00
|
|
|
Service Code
|
HCPCS 27488
|
| Hospital Charge Code |
27488
|
| Min. Negotiated Rate |
$981.60 |
| Max. Negotiated Rate |
$6,197.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$6,073.06
|
| Rate for Payer: Aetna of WY Medicare |
$1,154.82
|
| Rate for Payer: Beech Street Commercial |
$5,887.15
|
| Rate for Payer: Cash Price |
$4,337.90
|
| Rate for Payer: Cash Price |
$4,337.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$6,011.09
|
| Rate for Payer: Cigna of WY Commercial |
$6,073.06
|
| Rate for Payer: First Choice Health Commercial |
$5,577.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5,887.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,154.82
|
| Rate for Payer: HealthUtah PPO |
$6,197.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$6,011.09
|
| Rate for Payer: Multiplan Medicare/VA |
$981.60
|
| Rate for Payer: One Health Plan of WY PPO |
$6,073.06
|
| Rate for Payer: PacificSource Commercial |
$5,577.30
|
| Rate for Payer: PHCS PPO |
$5,887.15
|
| Rate for Payer: Three Rivers PPO |
$4,647.75
|
| Rate for Payer: TriWest Veterans Administration |
$1,154.82
|
| Rate for Payer: United Healthcare Commercial |
$5,391.39
|
| Rate for Payer: United Healthcare Medicare |
$1,154.82
|
| Rate for Payer: WINHealth Partners Commercial |
$5,267.45
|
|
|
RMVL/REVJ SLING STRESS INCONTINENCE
|
Professional
|
Both
|
$4,320.00
|
|
|
Service Code
|
HCPCS 57287
|
| Hospital Charge Code |
57287
|
| Min. Negotiated Rate |
$611.52 |
| Max. Negotiated Rate |
$4,320.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4,233.60
|
| Rate for Payer: Aetna of WY Medicare |
$719.44
|
| Rate for Payer: Beech Street Commercial |
$4,104.00
|
| Rate for Payer: Cash Price |
$3,024.00
|
| Rate for Payer: Cash Price |
$3,024.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$4,190.40
|
| Rate for Payer: Cigna of WY Commercial |
$4,233.60
|
| Rate for Payer: First Choice Health Commercial |
$3,888.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,104.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$719.44
|
| Rate for Payer: HealthUtah PPO |
$4,320.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4,190.40
|
| Rate for Payer: Multiplan Medicare/VA |
$611.52
|
| Rate for Payer: One Health Plan of WY PPO |
$4,233.60
|
| Rate for Payer: PacificSource Commercial |
$3,888.00
|
| Rate for Payer: PHCS PPO |
$4,104.00
|
| Rate for Payer: Three Rivers PPO |
$3,240.00
|
| Rate for Payer: TriWest Veterans Administration |
$719.44
|
| Rate for Payer: United Healthcare Commercial |
$3,758.40
|
| Rate for Payer: United Healthcare Medicare |
$719.44
|
| Rate for Payer: WINHealth Partners Commercial |
$3,672.00
|
|
|
RMVL SKIN TAGS MLT FIBRQ TAGS ANY EA ADDL 10
|
Professional
|
Both
|
$82.00
|
|
|
Service Code
|
HCPCS 11201
|
| Hospital Charge Code |
11201
|
| Min. Negotiated Rate |
$13.14 |
| Max. Negotiated Rate |
$82.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$80.36
|
| Rate for Payer: Aetna of WY Medicare |
$15.46
|
| Rate for Payer: Beech Street Commercial |
$77.90
|
| Rate for Payer: Cash Price |
$57.40
|
| Rate for Payer: Cash Price |
$57.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$79.54
|
| Rate for Payer: Cigna of WY Commercial |
$80.36
|
| Rate for Payer: First Choice Health Commercial |
$73.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$77.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$15.46
|
| Rate for Payer: HealthUtah PPO |
$82.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$79.54
|
| Rate for Payer: Multiplan Medicare/VA |
$13.14
|
| Rate for Payer: One Health Plan of WY PPO |
$80.36
|
| Rate for Payer: PacificSource Commercial |
$73.80
|
| Rate for Payer: PHCS PPO |
$77.90
|
| Rate for Payer: Three Rivers PPO |
$61.50
|
| Rate for Payer: TriWest Veterans Administration |
$15.46
|
| Rate for Payer: United Healthcare Commercial |
$71.34
|
| Rate for Payer: United Healthcare Medicare |
$15.46
|
| Rate for Payer: WINHealth Partners Commercial |
$69.70
|
|
|
RMVL SKIN TAGS MLT FIBRQ TAGS ANY UP TO&INC 15
|
Professional
|
Both
|
$369.00
|
|
|
Service Code
|
HCPCS 11200
|
| Hospital Charge Code |
11200
|
| Min. Negotiated Rate |
$63.64 |
| Max. Negotiated Rate |
$369.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$361.62
|
| Rate for Payer: Aetna of WY Medicare |
$74.87
|
| Rate for Payer: Beech Street Commercial |
$350.55
|
| Rate for Payer: Cash Price |
$258.30
|
| Rate for Payer: Cash Price |
$258.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$357.93
|
| Rate for Payer: Cigna of WY Commercial |
$361.62
|
| Rate for Payer: First Choice Health Commercial |
$332.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$350.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$74.87
|
| Rate for Payer: HealthUtah PPO |
$369.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$357.93
|
| Rate for Payer: Multiplan Medicare/VA |
$63.64
|
| Rate for Payer: One Health Plan of WY PPO |
$361.62
|
| Rate for Payer: PacificSource Commercial |
$332.10
|
| Rate for Payer: PHCS PPO |
$350.55
|
| Rate for Payer: Three Rivers PPO |
$276.75
|
| Rate for Payer: TriWest Veterans Administration |
$74.87
|
| Rate for Payer: United Healthcare Commercial |
$321.03
|
| Rate for Payer: United Healthcare Medicare |
$74.87
|
| Rate for Payer: WINHealth Partners Commercial |
$313.65
|
|
|
RMVL SPINAL NSTIM ELTRD PRQ ARRAY INCL FLUOR
|
Professional
|
Both
|
$1,668.00
|
|
|
Service Code
|
HCPCS 63661
|
| Hospital Charge Code |
63661
|
| Min. Negotiated Rate |
$269.53 |
| Max. Negotiated Rate |
$1,668.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,634.64
|
| Rate for Payer: Aetna of WY Medicare |
$317.09
|
| Rate for Payer: Beech Street Commercial |
$1,584.60
|
| Rate for Payer: Cash Price |
$1,167.60
|
| Rate for Payer: Cash Price |
$1,167.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,617.96
|
| Rate for Payer: Cigna of WY Commercial |
$1,634.64
|
| Rate for Payer: First Choice Health Commercial |
$1,501.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,584.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$317.09
|
| Rate for Payer: HealthUtah PPO |
$1,668.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,617.96
|
| Rate for Payer: Multiplan Medicare/VA |
$269.53
|
| Rate for Payer: One Health Plan of WY PPO |
$1,634.64
|
| Rate for Payer: PacificSource Commercial |
$1,501.20
|
| Rate for Payer: PHCS PPO |
$1,584.60
|
| Rate for Payer: Three Rivers PPO |
$1,251.00
|
| Rate for Payer: TriWest Veterans Administration |
$317.09
|
| Rate for Payer: United Healthcare Commercial |
$1,451.16
|
| Rate for Payer: United Healthcare Medicare |
$317.09
|
| Rate for Payer: WINHealth Partners Commercial |
$1,417.80
|
|
|
RMVL SYNTH ROD & INSJ FLXR TDN GRF H/F EA ROD
|
Professional
|
Both
|
$3,481.00
|
|
|
Service Code
|
HCPCS 26392
|
| Hospital Charge Code |
26392
|
| Min. Negotiated Rate |
$829.23 |
| Max. Negotiated Rate |
$3,481.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,411.38
|
| Rate for Payer: Aetna of WY Medicare |
$975.57
|
| Rate for Payer: Beech Street Commercial |
$3,306.95
|
| Rate for Payer: Cash Price |
$2,436.70
|
| Rate for Payer: Cash Price |
$2,436.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,376.57
|
| Rate for Payer: Cigna of WY Commercial |
$3,411.38
|
| Rate for Payer: First Choice Health Commercial |
$3,132.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,306.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$975.57
|
| Rate for Payer: HealthUtah PPO |
$3,481.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,376.57
|
| Rate for Payer: Multiplan Medicare/VA |
$829.23
|
| Rate for Payer: One Health Plan of WY PPO |
$3,411.38
|
| Rate for Payer: PacificSource Commercial |
$3,132.90
|
| Rate for Payer: PHCS PPO |
$3,306.95
|
| Rate for Payer: Three Rivers PPO |
$2,610.75
|
| Rate for Payer: TriWest Veterans Administration |
$975.57
|
| Rate for Payer: United Healthcare Commercial |
$3,028.47
|
| Rate for Payer: United Healthcare Medicare |
$975.57
|
| Rate for Payer: WINHealth Partners Commercial |
$2,958.85
|
|
