|
SAW BLD OSC ZIMMER 105X25X1.37
|
Facility
|
IP
|
$157.50
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$98.75 |
| Max. Negotiated Rate |
$157.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$154.35
|
| Rate for Payer: Altius Auto/Workers Compensation |
$151.20
|
| Rate for Payer: Altius Commercial |
$151.20
|
| Rate for Payer: Beech Street Commercial |
$154.35
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$129.31
|
| Rate for Payer: Cash Price |
$110.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$152.78
|
| Rate for Payer: Cigna of WY Commercial |
$154.35
|
| Rate for Payer: Entrust Commercial |
$149.62
|
| Rate for Payer: First Choice Health Commercial |
$149.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$149.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$103.95
|
| Rate for Payer: HealthUtah PPO |
$157.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$152.78
|
| Rate for Payer: Multiplan Medicare/VA |
$98.75
|
| Rate for Payer: One Health Plan of WY PPO |
$154.35
|
| Rate for Payer: PacificSource Commercial |
$141.75
|
| Rate for Payer: PHCS PPO |
$154.35
|
| Rate for Payer: Three Rivers PPO |
$118.12
|
| Rate for Payer: TriWest Veterans Administration |
$103.95
|
| Rate for Payer: United Healthcare Commercial |
$137.02
|
| Rate for Payer: United Healthcare Medicare |
$103.95
|
| Rate for Payer: WINHealth Partners Commercial |
$149.62
|
| Rate for Payer: Wise Provider Network Commercial |
$149.62
|
|
|
SAW BLD OSC ZIMMER 105X25X1.37
|
Facility
|
OP
|
$157.50
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$86.78 |
| Max. Negotiated Rate |
$157.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$154.35
|
| Rate for Payer: Aetna of WY Medicare |
$103.95
|
| Rate for Payer: Altius Auto/Workers Compensation |
$151.20
|
| Rate for Payer: Altius Commercial |
$151.20
|
| Rate for Payer: Beech Street Commercial |
$154.35
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$129.31
|
| Rate for Payer: Cash Price |
$110.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$152.78
|
| Rate for Payer: Cigna of WY Commercial |
$154.35
|
| Rate for Payer: Entrust Commercial |
$149.62
|
| Rate for Payer: First Choice Health Commercial |
$149.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$149.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$91.35
|
| Rate for Payer: HealthUtah PPO |
$157.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$152.78
|
| Rate for Payer: Multiplan Medicare/VA |
$86.78
|
| Rate for Payer: One Health Plan of WY PPO |
$154.35
|
| Rate for Payer: PacificSource Commercial |
$141.75
|
| Rate for Payer: PHCS PPO |
$154.35
|
| Rate for Payer: Three Rivers PPO |
$118.12
|
| Rate for Payer: TriWest Veterans Administration |
$91.35
|
| Rate for Payer: United Healthcare Commercial |
$137.02
|
| Rate for Payer: United Healthcare Medicare |
$91.35
|
| Rate for Payer: WINHealth Partners Commercial |
$154.35
|
| Rate for Payer: Wise Provider Network Commercial |
$149.62
|
|
|
SAW BL LG WIDE AGGR 2296-3-504
|
Facility
|
IP
|
$87.36
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$54.77 |
| Max. Negotiated Rate |
$87.36 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$85.61
|
| Rate for Payer: Altius Auto/Workers Compensation |
$83.87
|
| Rate for Payer: Altius Commercial |
$83.87
|
| Rate for Payer: Beech Street Commercial |
$85.61
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$71.72
|
| Rate for Payer: Cash Price |
$61.15
|
| Rate for Payer: ChoiceCare Network Commercial |
$84.74
|
| Rate for Payer: Cigna of WY Commercial |
$85.61
|
| Rate for Payer: Entrust Commercial |
$82.99
|
| Rate for Payer: First Choice Health Commercial |
$82.99
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$82.99
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$57.66
|
| Rate for Payer: HealthUtah PPO |
$87.36
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$84.74
|
| Rate for Payer: Multiplan Medicare/VA |
$54.77
|
| Rate for Payer: One Health Plan of WY PPO |
$85.61
|
| Rate for Payer: PacificSource Commercial |
$78.62
|
| Rate for Payer: PHCS PPO |
$85.61
|
| Rate for Payer: Three Rivers PPO |
$65.52
|
| Rate for Payer: TriWest Veterans Administration |
$57.66
|
| Rate for Payer: United Healthcare Commercial |
$76.00
|
| Rate for Payer: United Healthcare Medicare |
$57.66
|
| Rate for Payer: WINHealth Partners Commercial |
$82.99
|
| Rate for Payer: Wise Provider Network Commercial |
$82.99
|
|
|
SAW BL LG WIDE AGGR 2296-3-504
|
Facility
|
OP
|
$87.36
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$48.14 |
| Max. Negotiated Rate |
$87.36 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$85.61
|
| Rate for Payer: Aetna of WY Medicare |
$57.66
|
| Rate for Payer: Altius Auto/Workers Compensation |
$83.87
|
| Rate for Payer: Altius Commercial |
$83.87
|
| Rate for Payer: Beech Street Commercial |
$85.61
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$71.72
|
| Rate for Payer: Cash Price |
$61.15
|
| Rate for Payer: ChoiceCare Network Commercial |
$84.74
|
| Rate for Payer: Cigna of WY Commercial |
$85.61
|
| Rate for Payer: Entrust Commercial |
$82.99
|
| Rate for Payer: First Choice Health Commercial |
$82.99
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$82.99
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$50.67
|
| Rate for Payer: HealthUtah PPO |
$87.36
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$84.74
|
| Rate for Payer: Multiplan Medicare/VA |
$48.14
|
| Rate for Payer: One Health Plan of WY PPO |
$85.61
|
| Rate for Payer: PacificSource Commercial |
$78.62
|
| Rate for Payer: PHCS PPO |
$85.61
|
| Rate for Payer: Three Rivers PPO |
$65.52
|
| Rate for Payer: TriWest Veterans Administration |
$50.67
|
| Rate for Payer: United Healthcare Commercial |
$76.00
|
| Rate for Payer: United Healthcare Medicare |
$50.67
|
| Rate for Payer: WINHealth Partners Commercial |
$85.61
|
| Rate for Payer: Wise Provider Network Commercial |
$82.99
|
|
|
SAW BL MED. NARROW 2296-3-412
|
Facility
|
OP
|
$87.36
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$48.14 |
| Max. Negotiated Rate |
$87.36 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$85.61
|
| Rate for Payer: Aetna of WY Medicare |
$57.66
|
| Rate for Payer: Altius Auto/Workers Compensation |
$83.87
|
| Rate for Payer: Altius Commercial |
$83.87
|
| Rate for Payer: Beech Street Commercial |
$85.61
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$71.72
|
| Rate for Payer: Cash Price |
$61.15
|
| Rate for Payer: ChoiceCare Network Commercial |
$84.74
|
| Rate for Payer: Cigna of WY Commercial |
$85.61
|
| Rate for Payer: Entrust Commercial |
$82.99
|
| Rate for Payer: First Choice Health Commercial |
$82.99
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$82.99
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$50.67
|
| Rate for Payer: HealthUtah PPO |
$87.36
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$84.74
|
| Rate for Payer: Multiplan Medicare/VA |
$48.14
|
| Rate for Payer: One Health Plan of WY PPO |
$85.61
|
| Rate for Payer: PacificSource Commercial |
$78.62
|
| Rate for Payer: PHCS PPO |
$85.61
|
| Rate for Payer: Three Rivers PPO |
$65.52
|
| Rate for Payer: TriWest Veterans Administration |
$50.67
|
| Rate for Payer: United Healthcare Commercial |
$76.00
|
| Rate for Payer: United Healthcare Medicare |
$50.67
|
| Rate for Payer: WINHealth Partners Commercial |
$85.61
|
| Rate for Payer: Wise Provider Network Commercial |
$82.99
|
|
|
SAW BL MED. NARROW 2296-3-412
|
Facility
|
IP
|
$87.36
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$54.77 |
| Max. Negotiated Rate |
$87.36 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$85.61
|
| Rate for Payer: Altius Auto/Workers Compensation |
$83.87
|
| Rate for Payer: Altius Commercial |
$83.87
|
| Rate for Payer: Beech Street Commercial |
$85.61
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$71.72
|
| Rate for Payer: Cash Price |
$61.15
|
| Rate for Payer: ChoiceCare Network Commercial |
$84.74
|
| Rate for Payer: Cigna of WY Commercial |
$85.61
|
| Rate for Payer: Entrust Commercial |
$82.99
|
| Rate for Payer: First Choice Health Commercial |
$82.99
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$82.99
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$57.66
|
| Rate for Payer: HealthUtah PPO |
$87.36
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$84.74
|
| Rate for Payer: Multiplan Medicare/VA |
$54.77
|
| Rate for Payer: One Health Plan of WY PPO |
$85.61
|
| Rate for Payer: PacificSource Commercial |
$78.62
|
| Rate for Payer: PHCS PPO |
$85.61
|
| Rate for Payer: Three Rivers PPO |
$65.52
|
| Rate for Payer: TriWest Veterans Administration |
$57.66
|
| Rate for Payer: United Healthcare Commercial |
$76.00
|
| Rate for Payer: United Healthcare Medicare |
$57.66
|
| Rate for Payer: WINHealth Partners Commercial |
$82.99
|
| Rate for Payer: Wise Provider Network Commercial |
$82.99
|
|
|
SAW OSC SAGITTAL 9.0 2296-3-105
|
Facility
|
IP
|
$87.36
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$54.77 |
| Max. Negotiated Rate |
$87.36 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$85.61
|
| Rate for Payer: Altius Auto/Workers Compensation |
$83.87
|
| Rate for Payer: Altius Commercial |
$83.87
|
| Rate for Payer: Beech Street Commercial |
$85.61
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$71.72
|
| Rate for Payer: Cash Price |
$61.15
|
| Rate for Payer: ChoiceCare Network Commercial |
$84.74
|
| Rate for Payer: Cigna of WY Commercial |
$85.61
|
| Rate for Payer: Entrust Commercial |
$82.99
|
| Rate for Payer: First Choice Health Commercial |
$82.99
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$82.99
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$57.66
|
| Rate for Payer: HealthUtah PPO |
$87.36
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$84.74
|
| Rate for Payer: Multiplan Medicare/VA |
$54.77
|
| Rate for Payer: One Health Plan of WY PPO |
$85.61
|
| Rate for Payer: PacificSource Commercial |
$78.62
|
| Rate for Payer: PHCS PPO |
$85.61
|
| Rate for Payer: Three Rivers PPO |
$65.52
|
| Rate for Payer: TriWest Veterans Administration |
$57.66
|
| Rate for Payer: United Healthcare Commercial |
$76.00
|
| Rate for Payer: United Healthcare Medicare |
$57.66
|
| Rate for Payer: WINHealth Partners Commercial |
$82.99
|
| Rate for Payer: Wise Provider Network Commercial |
$82.99
|
|
|
SAW OSC SAGITTAL 9.0 2296-3-105
|
Facility
|
OP
|
$87.36
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$48.14 |
| Max. Negotiated Rate |
$87.36 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$85.61
|
| Rate for Payer: Aetna of WY Medicare |
$57.66
|
| Rate for Payer: Altius Auto/Workers Compensation |
$83.87
|
| Rate for Payer: Altius Commercial |
$83.87
|
| Rate for Payer: Beech Street Commercial |
$85.61
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$71.72
|
| Rate for Payer: Cash Price |
$61.15
|
| Rate for Payer: ChoiceCare Network Commercial |
$84.74
|
| Rate for Payer: Cigna of WY Commercial |
$85.61
|
| Rate for Payer: Entrust Commercial |
$82.99
|
| Rate for Payer: First Choice Health Commercial |
$82.99
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$82.99
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$50.67
|
| Rate for Payer: HealthUtah PPO |
$87.36
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$84.74
|
| Rate for Payer: Multiplan Medicare/VA |
$48.14
|
| Rate for Payer: One Health Plan of WY PPO |
$85.61
|
| Rate for Payer: PacificSource Commercial |
$78.62
|
| Rate for Payer: PHCS PPO |
$85.61
|
| Rate for Payer: Three Rivers PPO |
$65.52
|
| Rate for Payer: TriWest Veterans Administration |
$50.67
|
| Rate for Payer: United Healthcare Commercial |
$76.00
|
| Rate for Payer: United Healthcare Medicare |
$50.67
|
| Rate for Payer: WINHealth Partners Commercial |
$85.61
|
| Rate for Payer: Wise Provider Network Commercial |
$82.99
|
|
|
SAW PATELLA FAN 2108-197-000
|
Facility
|
IP
|
$157.50
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$98.75 |
| Max. Negotiated Rate |
$157.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$154.35
|
| Rate for Payer: Altius Auto/Workers Compensation |
$151.20
|
| Rate for Payer: Altius Commercial |
$151.20
|
| Rate for Payer: Beech Street Commercial |
$154.35
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$129.31
|
| Rate for Payer: Cash Price |
$110.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$152.78
|
| Rate for Payer: Cigna of WY Commercial |
$154.35
|
| Rate for Payer: Entrust Commercial |
$149.62
|
| Rate for Payer: First Choice Health Commercial |
$149.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$149.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$103.95
|
| Rate for Payer: HealthUtah PPO |
$157.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$152.78
|
| Rate for Payer: Multiplan Medicare/VA |
$98.75
|
| Rate for Payer: One Health Plan of WY PPO |
$154.35
|
| Rate for Payer: PacificSource Commercial |
$141.75
|
| Rate for Payer: PHCS PPO |
$154.35
|
| Rate for Payer: Three Rivers PPO |
$118.12
|
| Rate for Payer: TriWest Veterans Administration |
$103.95
|
| Rate for Payer: United Healthcare Commercial |
$137.02
|
| Rate for Payer: United Healthcare Medicare |
$103.95
|
| Rate for Payer: WINHealth Partners Commercial |
$149.62
|
| Rate for Payer: Wise Provider Network Commercial |
$149.62
|
|
|
SAW PATELLA FAN 2108-197-000
|
Facility
|
OP
|
$157.50
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$86.78 |
| Max. Negotiated Rate |
$157.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$154.35
|
| Rate for Payer: Aetna of WY Medicare |
$103.95
|
| Rate for Payer: Altius Auto/Workers Compensation |
$151.20
|
| Rate for Payer: Altius Commercial |
$151.20
|
| Rate for Payer: Beech Street Commercial |
$154.35
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$129.31
|
| Rate for Payer: Cash Price |
$110.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$152.78
|
| Rate for Payer: Cigna of WY Commercial |
$154.35
|
| Rate for Payer: Entrust Commercial |
$149.62
|
| Rate for Payer: First Choice Health Commercial |
$149.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$149.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$91.35
|
| Rate for Payer: HealthUtah PPO |
$157.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$152.78
|
| Rate for Payer: Multiplan Medicare/VA |
$86.78
|
| Rate for Payer: One Health Plan of WY PPO |
$154.35
|
| Rate for Payer: PacificSource Commercial |
$141.75
|
| Rate for Payer: PHCS PPO |
$154.35
|
| Rate for Payer: Three Rivers PPO |
$118.12
|
| Rate for Payer: TriWest Veterans Administration |
$91.35
|
| Rate for Payer: United Healthcare Commercial |
$137.02
|
| Rate for Payer: United Healthcare Medicare |
$91.35
|
| Rate for Payer: WINHealth Partners Commercial |
$154.35
|
| Rate for Payer: Wise Provider Network Commercial |
$149.62
|
|
|
SAW PRECISION THIN 9X.38X25MM
|
Facility
|
IP
|
$74.58
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$46.76 |
| Max. Negotiated Rate |
$74.58 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$73.09
|
| Rate for Payer: Altius Auto/Workers Compensation |
$71.60
|
| Rate for Payer: Altius Commercial |
$71.60
|
| Rate for Payer: Beech Street Commercial |
$73.09
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$61.23
|
| Rate for Payer: Cash Price |
$52.21
|
| Rate for Payer: ChoiceCare Network Commercial |
$72.34
|
| Rate for Payer: Cigna of WY Commercial |
$73.09
|
| Rate for Payer: Entrust Commercial |
$70.85
|
| Rate for Payer: First Choice Health Commercial |
$70.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$70.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$49.22
|
| Rate for Payer: HealthUtah PPO |
$74.58
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$72.34
|
| Rate for Payer: Multiplan Medicare/VA |
$46.76
|
| Rate for Payer: One Health Plan of WY PPO |
$73.09
|
| Rate for Payer: PacificSource Commercial |
$67.12
|
| Rate for Payer: PHCS PPO |
$73.09
|
| Rate for Payer: Three Rivers PPO |
$55.94
|
| Rate for Payer: TriWest Veterans Administration |
$49.22
|
| Rate for Payer: United Healthcare Commercial |
$64.88
|
| Rate for Payer: United Healthcare Medicare |
$49.22
|
| Rate for Payer: WINHealth Partners Commercial |
$70.85
|
| Rate for Payer: Wise Provider Network Commercial |
$70.85
|
|
|
SAW PRECISION THIN 9X.38X25MM
|
Facility
|
OP
|
$74.58
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$41.09 |
| Max. Negotiated Rate |
$74.58 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$73.09
|
| Rate for Payer: Aetna of WY Medicare |
$49.22
|
| Rate for Payer: Altius Auto/Workers Compensation |
$71.60
|
| Rate for Payer: Altius Commercial |
$71.60
|
| Rate for Payer: Beech Street Commercial |
$73.09
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$61.23
|
| Rate for Payer: Cash Price |
$52.21
|
| Rate for Payer: ChoiceCare Network Commercial |
$72.34
|
| Rate for Payer: Cigna of WY Commercial |
$73.09
|
| Rate for Payer: Entrust Commercial |
$70.85
|
| Rate for Payer: First Choice Health Commercial |
$70.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$70.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$43.26
|
| Rate for Payer: HealthUtah PPO |
$74.58
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$72.34
|
| Rate for Payer: Multiplan Medicare/VA |
$41.09
|
| Rate for Payer: One Health Plan of WY PPO |
$73.09
|
| Rate for Payer: PacificSource Commercial |
$67.12
|
| Rate for Payer: PHCS PPO |
$73.09
|
| Rate for Payer: Three Rivers PPO |
$55.94
|
| Rate for Payer: TriWest Veterans Administration |
$43.26
|
| Rate for Payer: United Healthcare Commercial |
$64.88
|
| Rate for Payer: United Healthcare Medicare |
$43.26
|
| Rate for Payer: WINHealth Partners Commercial |
$73.09
|
| Rate for Payer: Wise Provider Network Commercial |
$70.85
|
|
|
SBSQ HOSPITAL IP/OBS CARE HIGH MDM 50 MINUTES
|
Professional
|
Both
|
$329.00
|
|
|
Service Code
|
HCPCS 99233
|
| Hospital Charge Code |
99233
|
| Min. Negotiated Rate |
$96.66 |
| Max. Negotiated Rate |
$322.42 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$322.42
|
| Rate for Payer: Aetna of WY Medicare |
$113.72
|
| Rate for Payer: Beech Street Commercial |
$312.55
|
| Rate for Payer: Cash Price |
$230.30
|
| Rate for Payer: Cash Price |
$230.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$319.13
|
| Rate for Payer: Cigna of WY Commercial |
$322.42
|
| Rate for Payer: First Choice Health Commercial |
$296.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$312.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$113.72
|
| Rate for Payer: HealthUtah PPO |
$97.13
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$319.13
|
| Rate for Payer: Multiplan Medicare/VA |
$96.66
|
| Rate for Payer: One Health Plan of WY PPO |
$322.42
|
| Rate for Payer: PacificSource Commercial |
$296.10
|
| Rate for Payer: PHCS PPO |
$312.55
|
| Rate for Payer: Three Rivers PPO |
$246.75
|
| Rate for Payer: TriWest Veterans Administration |
$113.72
|
| Rate for Payer: United Healthcare Commercial |
$286.23
|
| Rate for Payer: United Healthcare Medicare |
$113.72
|
| Rate for Payer: WINHealth Partners Commercial |
$312.55
|
|
|
SBSQ HOSPITAL IP/OBS CARE MOD MDM 35 MINUTES
|
Professional
|
Both
|
$234.00
|
|
|
Service Code
|
HCPCS 99232
|
| Hospital Charge Code |
99232
|
| Min. Negotiated Rate |
$64.26 |
| Max. Negotiated Rate |
$229.32 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$229.32
|
| Rate for Payer: Aetna of WY Medicare |
$75.60
|
| Rate for Payer: Beech Street Commercial |
$222.30
|
| Rate for Payer: Cash Price |
$163.80
|
| Rate for Payer: Cash Price |
$163.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$226.98
|
| Rate for Payer: Cigna of WY Commercial |
$229.32
|
| Rate for Payer: First Choice Health Commercial |
$210.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$222.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$75.60
|
| Rate for Payer: HealthUtah PPO |
$68.20
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$226.98
|
| Rate for Payer: Multiplan Medicare/VA |
$64.26
|
| Rate for Payer: One Health Plan of WY PPO |
$229.32
|
| Rate for Payer: PacificSource Commercial |
$210.60
|
| Rate for Payer: PHCS PPO |
$222.30
|
| Rate for Payer: Three Rivers PPO |
$175.50
|
| Rate for Payer: TriWest Veterans Administration |
$75.60
|
| Rate for Payer: United Healthcare Commercial |
$203.58
|
| Rate for Payer: United Healthcare Medicare |
$75.60
|
| Rate for Payer: WINHealth Partners Commercial |
$222.30
|
|
|
SBSQ HOSPITAL IP/OBS CARE SF/LOW MDM 25 MINUTES
|
Professional
|
Both
|
$165.00
|
|
|
Service Code
|
HCPCS 99231
|
| Hospital Charge Code |
99231
|
| Min. Negotiated Rate |
$40.26 |
| Max. Negotiated Rate |
$161.70 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$161.70
|
| Rate for Payer: Aetna of WY Medicare |
$47.36
|
| Rate for Payer: Beech Street Commercial |
$156.75
|
| Rate for Payer: Cash Price |
$115.50
|
| Rate for Payer: Cash Price |
$115.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$160.05
|
| Rate for Payer: Cigna of WY Commercial |
$161.70
|
| Rate for Payer: First Choice Health Commercial |
$148.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$156.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$47.36
|
| Rate for Payer: HealthUtah PPO |
$41.44
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$160.05
|
| Rate for Payer: Multiplan Medicare/VA |
$40.26
|
| Rate for Payer: One Health Plan of WY PPO |
$161.70
|
| Rate for Payer: PacificSource Commercial |
$148.50
|
| Rate for Payer: PHCS PPO |
$156.75
|
| Rate for Payer: Three Rivers PPO |
$123.75
|
| Rate for Payer: TriWest Veterans Administration |
$47.36
|
| Rate for Payer: United Healthcare Commercial |
$143.55
|
| Rate for Payer: United Healthcare Medicare |
$47.36
|
| Rate for Payer: WINHealth Partners Commercial |
$156.75
|
|
|
SBSQ NURSING FACILITY CARE HIGH MDM 45 MINUTES
|
Professional
|
Both
|
$321.00
|
|
|
Service Code
|
HCPCS 99310
|
| Hospital Charge Code |
99310
|
| Min. Negotiated Rate |
$126.02 |
| Max. Negotiated Rate |
$321.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$314.58
|
| Rate for Payer: Aetna of WY Medicare |
$148.26
|
| Rate for Payer: Beech Street Commercial |
$304.95
|
| Rate for Payer: Cash Price |
$224.70
|
| Rate for Payer: Cash Price |
$224.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$311.37
|
| Rate for Payer: Cigna of WY Commercial |
$314.58
|
| Rate for Payer: First Choice Health Commercial |
$288.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$304.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$148.26
|
| Rate for Payer: HealthUtah PPO |
$321.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$311.37
|
| Rate for Payer: Multiplan Medicare/VA |
$126.02
|
| Rate for Payer: One Health Plan of WY PPO |
$314.58
|
| Rate for Payer: PacificSource Commercial |
$288.90
|
| Rate for Payer: PHCS PPO |
$304.95
|
| Rate for Payer: Three Rivers PPO |
$240.75
|
| Rate for Payer: TriWest Veterans Administration |
$148.26
|
| Rate for Payer: United Healthcare Commercial |
$279.27
|
| Rate for Payer: United Healthcare Medicare |
$148.26
|
| Rate for Payer: WINHealth Partners Commercial |
$304.95
|
|
|
SBSQ NURSING FACILITY CARE LOW MDM 20 MINUTES
|
Professional
|
Both
|
$152.00
|
|
|
Service Code
|
HCPCS 99308
|
| Hospital Charge Code |
99308
|
| Min. Negotiated Rate |
$61.13 |
| Max. Negotiated Rate |
$152.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$148.96
|
| Rate for Payer: Aetna of WY Medicare |
$71.92
|
| Rate for Payer: Beech Street Commercial |
$144.40
|
| Rate for Payer: Cash Price |
$106.40
|
| Rate for Payer: Cash Price |
$106.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$147.44
|
| Rate for Payer: Cigna of WY Commercial |
$148.96
|
| Rate for Payer: First Choice Health Commercial |
$136.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$144.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$71.92
|
| Rate for Payer: HealthUtah PPO |
$152.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$147.44
|
| Rate for Payer: Multiplan Medicare/VA |
$61.13
|
| Rate for Payer: One Health Plan of WY PPO |
$148.96
|
| Rate for Payer: PacificSource Commercial |
$136.80
|
| Rate for Payer: PHCS PPO |
$144.40
|
| Rate for Payer: Three Rivers PPO |
$114.00
|
| Rate for Payer: TriWest Veterans Administration |
$71.92
|
| Rate for Payer: United Healthcare Commercial |
$132.24
|
| Rate for Payer: United Healthcare Medicare |
$71.92
|
| Rate for Payer: WINHealth Partners Commercial |
$144.40
|
|
|
SBSQ NURSING FACILITY CARE MOD MDM 30 MINUTES
|
Professional
|
Both
|
$190.00
|
|
|
Service Code
|
HCPCS 99309
|
| Hospital Charge Code |
99309
|
| Min. Negotiated Rate |
$88.40 |
| Max. Negotiated Rate |
$190.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$186.20
|
| Rate for Payer: Aetna of WY Medicare |
$104.00
|
| Rate for Payer: Beech Street Commercial |
$180.50
|
| Rate for Payer: Cash Price |
$133.00
|
| Rate for Payer: Cash Price |
$133.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$184.30
|
| Rate for Payer: Cigna of WY Commercial |
$186.20
|
| Rate for Payer: First Choice Health Commercial |
$171.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$180.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$104.00
|
| Rate for Payer: HealthUtah PPO |
$190.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$184.30
|
| Rate for Payer: Multiplan Medicare/VA |
$88.40
|
| Rate for Payer: One Health Plan of WY PPO |
$186.20
|
| Rate for Payer: PacificSource Commercial |
$171.00
|
| Rate for Payer: PHCS PPO |
$180.50
|
| Rate for Payer: Three Rivers PPO |
$142.50
|
| Rate for Payer: TriWest Veterans Administration |
$104.00
|
| Rate for Payer: United Healthcare Commercial |
$165.30
|
| Rate for Payer: United Healthcare Medicare |
$104.00
|
| Rate for Payer: WINHealth Partners Commercial |
$180.50
|
|
|
SBSQ NURSING FACILITY CARE SF MDM 10 MINUTES
|
Professional
|
Both
|
$125.00
|
|
|
Service Code
|
HCPCS 99307
|
| Hospital Charge Code |
99307
|
| Min. Negotiated Rate |
$33.04 |
| Max. Negotiated Rate |
$125.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$122.50
|
| Rate for Payer: Aetna of WY Medicare |
$38.87
|
| Rate for Payer: Beech Street Commercial |
$118.75
|
| Rate for Payer: Cash Price |
$87.50
|
| Rate for Payer: Cash Price |
$87.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$121.25
|
| Rate for Payer: Cigna of WY Commercial |
$122.50
|
| Rate for Payer: First Choice Health Commercial |
$112.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$118.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$38.87
|
| Rate for Payer: HealthUtah PPO |
$125.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$121.25
|
| Rate for Payer: Multiplan Medicare/VA |
$33.04
|
| Rate for Payer: One Health Plan of WY PPO |
$122.50
|
| Rate for Payer: PacificSource Commercial |
$112.50
|
| Rate for Payer: PHCS PPO |
$118.75
|
| Rate for Payer: Three Rivers PPO |
$93.75
|
| Rate for Payer: TriWest Veterans Administration |
$38.87
|
| Rate for Payer: United Healthcare Commercial |
$108.75
|
| Rate for Payer: United Healthcare Medicare |
$38.87
|
| Rate for Payer: WINHealth Partners Commercial |
$118.75
|
|
|
SBSQ OBSERVATION CARE/DAY 15 MINUTES
|
Professional
|
Both
|
$177.00
|
|
|
Service Code
|
HCPCS 99224
|
| Hospital Charge Code |
99224
|
| Min. Negotiated Rate |
$132.75 |
| Max. Negotiated Rate |
$177.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$173.46
|
| Rate for Payer: Beech Street Commercial |
$168.15
|
| Rate for Payer: Cash Price |
$123.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$171.69
|
| Rate for Payer: Cigna of WY Commercial |
$173.46
|
| Rate for Payer: First Choice Health Commercial |
$159.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$168.15
|
| Rate for Payer: HealthUtah PPO |
$177.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$171.69
|
| Rate for Payer: One Health Plan of WY PPO |
$173.46
|
| Rate for Payer: PacificSource Commercial |
$159.30
|
| Rate for Payer: PHCS PPO |
$168.15
|
| Rate for Payer: Three Rivers PPO |
$132.75
|
| Rate for Payer: United Healthcare Commercial |
$153.99
|
| Rate for Payer: WINHealth Partners Commercial |
$168.15
|
|
|
SBSQ OBSERVATION CARE/DAY 25 MINUTES
|
Professional
|
Both
|
$241.00
|
|
|
Service Code
|
HCPCS 99225
|
| Hospital Charge Code |
99225
|
| Min. Negotiated Rate |
$180.75 |
| Max. Negotiated Rate |
$241.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$236.18
|
| Rate for Payer: Beech Street Commercial |
$228.95
|
| Rate for Payer: Cash Price |
$168.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$233.77
|
| Rate for Payer: Cigna of WY Commercial |
$236.18
|
| Rate for Payer: First Choice Health Commercial |
$216.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$228.95
|
| Rate for Payer: HealthUtah PPO |
$241.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$233.77
|
| Rate for Payer: One Health Plan of WY PPO |
$236.18
|
| Rate for Payer: PacificSource Commercial |
$216.90
|
| Rate for Payer: PHCS PPO |
$228.95
|
| Rate for Payer: Three Rivers PPO |
$180.75
|
| Rate for Payer: United Healthcare Commercial |
$209.67
|
| Rate for Payer: WINHealth Partners Commercial |
$228.95
|
|
|
SBSQ OBSERVATION CARE/DAY 35 MINUTES
|
Professional
|
Both
|
$288.00
|
|
|
Service Code
|
HCPCS 99226
|
| Hospital Charge Code |
99226
|
| Min. Negotiated Rate |
$216.00 |
| Max. Negotiated Rate |
$288.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$282.24
|
| Rate for Payer: Beech Street Commercial |
$273.60
|
| Rate for Payer: Cash Price |
$201.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$279.36
|
| Rate for Payer: Cigna of WY Commercial |
$282.24
|
| Rate for Payer: First Choice Health Commercial |
$259.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$273.60
|
| Rate for Payer: HealthUtah PPO |
$288.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$279.36
|
| Rate for Payer: One Health Plan of WY PPO |
$282.24
|
| Rate for Payer: PacificSource Commercial |
$259.20
|
| Rate for Payer: PHCS PPO |
$273.60
|
| Rate for Payer: Three Rivers PPO |
$216.00
|
| Rate for Payer: United Healthcare Commercial |
$250.56
|
| Rate for Payer: WINHealth Partners Commercial |
$273.60
|
|
|
SBSQ PSYCHIATRIC COLLAB CARE MGMT 1ST 60 MINS
|
Professional
|
Both
|
$479.00
|
|
|
Service Code
|
HCPCS 99493
|
| Hospital Charge Code |
99493
|
| Min. Negotiated Rate |
$83.87 |
| Max. Negotiated Rate |
$479.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$469.42
|
| Rate for Payer: Aetna of WY Medicare |
$98.67
|
| Rate for Payer: Beech Street Commercial |
$455.05
|
| Rate for Payer: Cash Price |
$335.30
|
| Rate for Payer: Cash Price |
$335.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$464.63
|
| Rate for Payer: Cigna of WY Commercial |
$469.42
|
| Rate for Payer: First Choice Health Commercial |
$431.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$455.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$98.67
|
| Rate for Payer: HealthUtah PPO |
$479.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$464.63
|
| Rate for Payer: Multiplan Medicare/VA |
$83.87
|
| Rate for Payer: One Health Plan of WY PPO |
$469.42
|
| Rate for Payer: PacificSource Commercial |
$431.10
|
| Rate for Payer: PHCS PPO |
$455.05
|
| Rate for Payer: Three Rivers PPO |
$359.25
|
| Rate for Payer: TriWest Veterans Administration |
$98.67
|
| Rate for Payer: United Healthcare Commercial |
$416.73
|
| Rate for Payer: United Healthcare Medicare |
$98.67
|
| Rate for Payer: WINHealth Partners Commercial |
$455.05
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [17765]
|
Facility
|
IP
|
$30.88
|
|
|
Service Code
|
NDC 4580258046
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.36 |
| Max. Negotiated Rate |
$30.88 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$30.26
|
| Rate for Payer: Altius Auto/Workers Compensation |
$29.64
|
| Rate for Payer: Altius Commercial |
$29.64
|
| Rate for Payer: Beech Street Commercial |
$30.26
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$25.35
|
| Rate for Payer: Cash Price |
$21.61
|
| Rate for Payer: ChoiceCare Network Commercial |
$29.95
|
| Rate for Payer: Cigna of WY Commercial |
$30.26
|
| Rate for Payer: Entrust Commercial |
$29.34
|
| Rate for Payer: First Choice Health Commercial |
$29.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$29.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$20.38
|
| Rate for Payer: HealthUtah PPO |
$30.88
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$29.95
|
| Rate for Payer: Multiplan Medicare/VA |
$19.36
|
| Rate for Payer: One Health Plan of WY PPO |
$30.26
|
| Rate for Payer: PacificSource Commercial |
$27.79
|
| Rate for Payer: PHCS PPO |
$30.26
|
| Rate for Payer: Three Rivers PPO |
$23.16
|
| Rate for Payer: TriWest Veterans Administration |
$20.38
|
| Rate for Payer: United Healthcare Commercial |
$26.87
|
| Rate for Payer: United Healthcare Medicare |
$20.38
|
| Rate for Payer: WINHealth Partners Commercial |
$29.34
|
| Rate for Payer: Wise Provider Network Commercial |
$29.34
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [17765]
|
Facility
|
OP
|
$30.88
|
|
|
Service Code
|
NDC 4580258001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.01 |
| Max. Negotiated Rate |
$30.88 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$30.26
|
| Rate for Payer: Aetna of WY Medicare |
$20.38
|
| Rate for Payer: Altius Auto/Workers Compensation |
$29.64
|
| Rate for Payer: Altius Commercial |
$29.64
|
| Rate for Payer: Beech Street Commercial |
$30.26
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$25.35
|
| Rate for Payer: Cash Price |
$21.61
|
| Rate for Payer: ChoiceCare Network Commercial |
$29.95
|
| Rate for Payer: Cigna of WY Commercial |
$30.26
|
| Rate for Payer: Entrust Commercial |
$29.34
|
| Rate for Payer: First Choice Health Commercial |
$29.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$29.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$17.91
|
| Rate for Payer: HealthUtah PPO |
$30.88
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$29.95
|
| Rate for Payer: Multiplan Medicare/VA |
$17.01
|
| Rate for Payer: One Health Plan of WY PPO |
$30.26
|
| Rate for Payer: PacificSource Commercial |
$27.79
|
| Rate for Payer: PHCS PPO |
$30.26
|
| Rate for Payer: Three Rivers PPO |
$23.16
|
| Rate for Payer: TriWest Veterans Administration |
$17.91
|
| Rate for Payer: United Healthcare Commercial |
$26.87
|
| Rate for Payer: United Healthcare Medicare |
$17.91
|
| Rate for Payer: WINHealth Partners Commercial |
$30.26
|
| Rate for Payer: Wise Provider Network Commercial |
$29.34
|
|
