|
SLING SHOULDER SLINGSHOT 3 XLG
|
Facility
|
OP
|
$122.50
|
|
| Hospital Charge Code |
27000000S1
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$67.50 |
| Max. Negotiated Rate |
$122.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$120.05
|
| Rate for Payer: Aetna of WY Medicare |
$80.85
|
| Rate for Payer: Altius Auto/Workers Compensation |
$117.60
|
| Rate for Payer: Altius Commercial |
$117.60
|
| Rate for Payer: Beech Street Commercial |
$120.05
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$100.57
|
| Rate for Payer: Cash Price |
$85.75
|
| Rate for Payer: ChoiceCare Network Commercial |
$118.82
|
| Rate for Payer: Cigna of WY Commercial |
$120.05
|
| Rate for Payer: Entrust Commercial |
$116.38
|
| Rate for Payer: First Choice Health Commercial |
$116.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$116.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$71.05
|
| Rate for Payer: HealthUtah PPO |
$122.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$118.82
|
| Rate for Payer: Multiplan Medicare/VA |
$67.50
|
| Rate for Payer: One Health Plan of WY PPO |
$120.05
|
| Rate for Payer: PacificSource Commercial |
$110.25
|
| Rate for Payer: PHCS PPO |
$120.05
|
| Rate for Payer: Three Rivers PPO |
$91.88
|
| Rate for Payer: TriWest Veterans Administration |
$71.05
|
| Rate for Payer: United Healthcare Commercial |
$106.58
|
| Rate for Payer: United Healthcare Medicare |
$71.05
|
| Rate for Payer: WINHealth Partners Commercial |
$120.05
|
| Rate for Payer: Wise Provider Network Commercial |
$116.38
|
|
|
SLING SHOULDER SLINGSHOT 3 XLG
|
Facility
|
IP
|
$122.50
|
|
| Hospital Charge Code |
27000000S1
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$76.81 |
| Max. Negotiated Rate |
$122.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$120.05
|
| Rate for Payer: Altius Auto/Workers Compensation |
$117.60
|
| Rate for Payer: Altius Commercial |
$117.60
|
| Rate for Payer: Beech Street Commercial |
$120.05
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$100.57
|
| Rate for Payer: Cash Price |
$85.75
|
| Rate for Payer: ChoiceCare Network Commercial |
$118.82
|
| Rate for Payer: Cigna of WY Commercial |
$120.05
|
| Rate for Payer: Entrust Commercial |
$116.38
|
| Rate for Payer: First Choice Health Commercial |
$116.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$116.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$80.85
|
| Rate for Payer: HealthUtah PPO |
$122.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$118.82
|
| Rate for Payer: Multiplan Medicare/VA |
$76.81
|
| Rate for Payer: One Health Plan of WY PPO |
$120.05
|
| Rate for Payer: PacificSource Commercial |
$110.25
|
| Rate for Payer: PHCS PPO |
$120.05
|
| Rate for Payer: Three Rivers PPO |
$91.88
|
| Rate for Payer: TriWest Veterans Administration |
$80.85
|
| Rate for Payer: United Healthcare Commercial |
$106.58
|
| Rate for Payer: United Healthcare Medicare |
$80.85
|
| Rate for Payer: WINHealth Partners Commercial |
$116.38
|
| Rate for Payer: Wise Provider Network Commercial |
$116.38
|
|
|
SLING&SWATH UNIV BREG VP10899
|
Facility
|
OP
|
$25.55
|
|
| Hospital Charge Code |
27000000S1
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$14.08 |
| Max. Negotiated Rate |
$25.55 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$25.04
|
| Rate for Payer: Aetna of WY Medicare |
$16.86
|
| Rate for Payer: Altius Auto/Workers Compensation |
$24.53
|
| Rate for Payer: Altius Commercial |
$24.53
|
| Rate for Payer: Beech Street Commercial |
$25.04
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$20.98
|
| Rate for Payer: Cash Price |
$17.88
|
| Rate for Payer: ChoiceCare Network Commercial |
$24.78
|
| Rate for Payer: Cigna of WY Commercial |
$25.04
|
| Rate for Payer: Entrust Commercial |
$24.27
|
| Rate for Payer: First Choice Health Commercial |
$24.27
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$24.27
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$14.82
|
| Rate for Payer: HealthUtah PPO |
$25.55
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.78
|
| Rate for Payer: Multiplan Medicare/VA |
$14.08
|
| Rate for Payer: One Health Plan of WY PPO |
$25.04
|
| Rate for Payer: PacificSource Commercial |
$23.00
|
| Rate for Payer: PHCS PPO |
$25.04
|
| Rate for Payer: Three Rivers PPO |
$19.16
|
| Rate for Payer: TriWest Veterans Administration |
$14.82
|
| Rate for Payer: United Healthcare Commercial |
$22.23
|
| Rate for Payer: United Healthcare Medicare |
$14.82
|
| Rate for Payer: WINHealth Partners Commercial |
$25.04
|
| Rate for Payer: Wise Provider Network Commercial |
$24.27
|
|
|
SLING&SWATH UNIV BREG VP10899
|
Facility
|
IP
|
$25.55
|
|
| Hospital Charge Code |
27000000S1
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$16.02 |
| Max. Negotiated Rate |
$25.55 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$25.04
|
| Rate for Payer: Altius Auto/Workers Compensation |
$24.53
|
| Rate for Payer: Altius Commercial |
$24.53
|
| Rate for Payer: Beech Street Commercial |
$25.04
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$20.98
|
| Rate for Payer: Cash Price |
$17.88
|
| Rate for Payer: ChoiceCare Network Commercial |
$24.78
|
| Rate for Payer: Cigna of WY Commercial |
$25.04
|
| Rate for Payer: Entrust Commercial |
$24.27
|
| Rate for Payer: First Choice Health Commercial |
$24.27
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$24.27
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$16.86
|
| Rate for Payer: HealthUtah PPO |
$25.55
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.78
|
| Rate for Payer: Multiplan Medicare/VA |
$16.02
|
| Rate for Payer: One Health Plan of WY PPO |
$25.04
|
| Rate for Payer: PacificSource Commercial |
$23.00
|
| Rate for Payer: PHCS PPO |
$25.04
|
| Rate for Payer: Three Rivers PPO |
$19.16
|
| Rate for Payer: TriWest Veterans Administration |
$16.86
|
| Rate for Payer: United Healthcare Commercial |
$22.23
|
| Rate for Payer: United Healthcare Medicare |
$16.86
|
| Rate for Payer: WINHealth Partners Commercial |
$24.27
|
| Rate for Payer: Wise Provider Network Commercial |
$24.27
|
|
|
SMART RELEASE CARPAL BLADE
|
Facility
|
OP
|
$886.67
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$488.56 |
| Max. Negotiated Rate |
$886.67 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$868.94
|
| Rate for Payer: Aetna of WY Medicare |
$585.20
|
| Rate for Payer: Altius Auto/Workers Compensation |
$851.20
|
| Rate for Payer: Altius Commercial |
$851.20
|
| Rate for Payer: Beech Street Commercial |
$868.94
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$727.96
|
| Rate for Payer: Cash Price |
$620.67
|
| Rate for Payer: ChoiceCare Network Commercial |
$860.07
|
| Rate for Payer: Cigna of WY Commercial |
$868.94
|
| Rate for Payer: Entrust Commercial |
$842.34
|
| Rate for Payer: First Choice Health Commercial |
$842.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$842.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$514.27
|
| Rate for Payer: HealthUtah PPO |
$886.67
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$860.07
|
| Rate for Payer: Multiplan Medicare/VA |
$488.56
|
| Rate for Payer: One Health Plan of WY PPO |
$868.94
|
| Rate for Payer: PacificSource Commercial |
$798.00
|
| Rate for Payer: PHCS PPO |
$868.94
|
| Rate for Payer: Three Rivers PPO |
$665.00
|
| Rate for Payer: TriWest Veterans Administration |
$514.27
|
| Rate for Payer: United Healthcare Commercial |
$771.40
|
| Rate for Payer: United Healthcare Medicare |
$514.27
|
| Rate for Payer: WINHealth Partners Commercial |
$868.94
|
| Rate for Payer: Wise Provider Network Commercial |
$842.34
|
|
|
SMART RELEASE CARPAL BLADE
|
Facility
|
IP
|
$886.67
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$555.94 |
| Max. Negotiated Rate |
$886.67 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$868.94
|
| Rate for Payer: Altius Auto/Workers Compensation |
$851.20
|
| Rate for Payer: Altius Commercial |
$851.20
|
| Rate for Payer: Beech Street Commercial |
$868.94
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$727.96
|
| Rate for Payer: Cash Price |
$620.67
|
| Rate for Payer: ChoiceCare Network Commercial |
$860.07
|
| Rate for Payer: Cigna of WY Commercial |
$868.94
|
| Rate for Payer: Entrust Commercial |
$842.34
|
| Rate for Payer: First Choice Health Commercial |
$842.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$842.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$585.20
|
| Rate for Payer: HealthUtah PPO |
$886.67
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$860.07
|
| Rate for Payer: Multiplan Medicare/VA |
$555.94
|
| Rate for Payer: One Health Plan of WY PPO |
$868.94
|
| Rate for Payer: PacificSource Commercial |
$798.00
|
| Rate for Payer: PHCS PPO |
$868.94
|
| Rate for Payer: Three Rivers PPO |
$665.00
|
| Rate for Payer: TriWest Veterans Administration |
$585.20
|
| Rate for Payer: United Healthcare Commercial |
$771.40
|
| Rate for Payer: United Healthcare Medicare |
$585.20
|
| Rate for Payer: WINHealth Partners Commercial |
$842.34
|
| Rate for Payer: Wise Provider Network Commercial |
$842.34
|
|
|
SMOG ENEMA [400790]
|
Facility
|
OP
|
$0.27
|
|
|
Service Code
|
NDC 9999400790
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.26
|
| Rate for Payer: Aetna of WY Medicare |
$0.18
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.26
|
| Rate for Payer: Altius Commercial |
$0.26
|
| Rate for Payer: Beech Street Commercial |
$0.26
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.22
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.26
|
| Rate for Payer: Cigna of WY Commercial |
$0.26
|
| Rate for Payer: Entrust Commercial |
$0.26
|
| Rate for Payer: First Choice Health Commercial |
$0.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.16
|
| Rate for Payer: HealthUtah PPO |
$0.27
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.26
|
| Rate for Payer: Multiplan Medicare/VA |
$0.15
|
| Rate for Payer: One Health Plan of WY PPO |
$0.26
|
| Rate for Payer: PacificSource Commercial |
$0.24
|
| Rate for Payer: PHCS PPO |
$0.26
|
| Rate for Payer: Three Rivers PPO |
$0.20
|
| Rate for Payer: TriWest Veterans Administration |
$0.16
|
| Rate for Payer: United Healthcare Commercial |
$0.23
|
| Rate for Payer: United Healthcare Medicare |
$0.16
|
| Rate for Payer: WINHealth Partners Commercial |
$0.26
|
| Rate for Payer: Wise Provider Network Commercial |
$0.26
|
|
|
SMOG ENEMA [400790]
|
Facility
|
IP
|
$0.27
|
|
|
Service Code
|
NDC 9999400790
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.26
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.26
|
| Rate for Payer: Altius Commercial |
$0.26
|
| Rate for Payer: Beech Street Commercial |
$0.26
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.22
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.26
|
| Rate for Payer: Cigna of WY Commercial |
$0.26
|
| Rate for Payer: Entrust Commercial |
$0.26
|
| Rate for Payer: First Choice Health Commercial |
$0.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.18
|
| Rate for Payer: HealthUtah PPO |
$0.27
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.26
|
| Rate for Payer: Multiplan Medicare/VA |
$0.17
|
| Rate for Payer: One Health Plan of WY PPO |
$0.26
|
| Rate for Payer: PacificSource Commercial |
$0.24
|
| Rate for Payer: PHCS PPO |
$0.26
|
| Rate for Payer: Three Rivers PPO |
$0.20
|
| Rate for Payer: TriWest Veterans Administration |
$0.18
|
| Rate for Payer: United Healthcare Commercial |
$0.23
|
| Rate for Payer: United Healthcare Medicare |
$0.18
|
| Rate for Payer: WINHealth Partners Commercial |
$0.26
|
| Rate for Payer: Wise Provider Network Commercial |
$0.26
|
|
|
SMPL REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.6-7.5CM
|
Professional
|
Both
|
$395.00
|
|
|
Service Code
|
HCPCS 12002
|
| Hospital Charge Code |
12002
|
| Min. Negotiated Rate |
$47.39 |
| Max. Negotiated Rate |
$395.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$387.10
|
| Rate for Payer: Aetna of WY Medicare |
$55.75
|
| Rate for Payer: Beech Street Commercial |
$375.25
|
| Rate for Payer: Cash Price |
$276.50
|
| Rate for Payer: Cash Price |
$276.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$383.15
|
| Rate for Payer: Cigna of WY Commercial |
$387.10
|
| Rate for Payer: First Choice Health Commercial |
$355.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$375.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$55.75
|
| Rate for Payer: HealthUtah PPO |
$395.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$383.15
|
| Rate for Payer: Multiplan Medicare/VA |
$47.39
|
| Rate for Payer: One Health Plan of WY PPO |
$387.10
|
| Rate for Payer: PacificSource Commercial |
$355.50
|
| Rate for Payer: PHCS PPO |
$375.25
|
| Rate for Payer: Three Rivers PPO |
$296.25
|
| Rate for Payer: TriWest Veterans Administration |
$55.75
|
| Rate for Payer: United Healthcare Commercial |
$343.65
|
| Rate for Payer: United Healthcare Medicare |
$55.75
|
| Rate for Payer: WINHealth Partners Commercial |
$335.75
|
|
|
SMPL RPR SCALP/NECK/AX/GENIT/TRUNK 12.6-20.0CM
|
Professional
|
Both
|
$483.00
|
|
|
Service Code
|
HCPCS 12005
|
| Hospital Charge Code |
12005
|
| Min. Negotiated Rate |
$75.86 |
| Max. Negotiated Rate |
$483.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$473.34
|
| Rate for Payer: Aetna of WY Medicare |
$89.25
|
| 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 |
$89.25
|
| Rate for Payer: HealthUtah PPO |
$483.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$468.51
|
| Rate for Payer: Multiplan Medicare/VA |
$75.86
|
| 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 |
$89.25
|
| Rate for Payer: United Healthcare Commercial |
$420.21
|
| Rate for Payer: United Healthcare Medicare |
$89.25
|
| Rate for Payer: WINHealth Partners Commercial |
$410.55
|
|
|
SMPL RPR SCALP/NECK/AX/GENIT/TRUNK 20.1-30.0CM
|
Professional
|
Both
|
$706.00
|
|
|
Service Code
|
HCPCS 12006
|
| Hospital Charge Code |
12006
|
| Min. Negotiated Rate |
$92.89 |
| Max. Negotiated Rate |
$706.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$691.88
|
| Rate for Payer: Aetna of WY Medicare |
$109.28
|
| Rate for Payer: Beech Street Commercial |
$670.70
|
| Rate for Payer: Cash Price |
$494.20
|
| Rate for Payer: Cash Price |
$494.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$684.82
|
| Rate for Payer: Cigna of WY Commercial |
$691.88
|
| Rate for Payer: First Choice Health Commercial |
$635.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$670.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$109.28
|
| Rate for Payer: HealthUtah PPO |
$706.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$684.82
|
| Rate for Payer: Multiplan Medicare/VA |
$92.89
|
| Rate for Payer: One Health Plan of WY PPO |
$691.88
|
| Rate for Payer: PacificSource Commercial |
$635.40
|
| Rate for Payer: PHCS PPO |
$670.70
|
| Rate for Payer: Three Rivers PPO |
$529.50
|
| Rate for Payer: TriWest Veterans Administration |
$109.28
|
| Rate for Payer: United Healthcare Commercial |
$614.22
|
| Rate for Payer: United Healthcare Medicare |
$109.28
|
| Rate for Payer: WINHealth Partners Commercial |
$600.10
|
|
|
SMR PRIM SRC GRAM/GIEMSA STAIN BCT FUNGI/CELL
|
Professional
|
Both
|
$82.00
|
|
|
Service Code
|
HCPCS 87205
|
| Hospital Charge Code |
87205
|
| Min. Negotiated Rate |
$3.63 |
| Max. Negotiated Rate |
$82.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$80.36
|
| Rate for Payer: Aetna of WY Medicare |
$4.27
|
| 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 |
$4.27
|
| Rate for Payer: HealthUtah PPO |
$82.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$79.54
|
| Rate for Payer: Multiplan Medicare/VA |
$3.63
|
| 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 |
$4.27
|
| Rate for Payer: United Healthcare Commercial |
$71.34
|
| Rate for Payer: United Healthcare Medicare |
$4.27
|
| Rate for Payer: WINHealth Partners Commercial |
$77.90
|
|
|
SMR PRIM SRC WET MOUNT NFCT AGT
|
Professional
|
Both
|
$48.00
|
|
|
Service Code
|
HCPCS 87210
|
| Hospital Charge Code |
87210
|
| Min. Negotiated Rate |
$4.95 |
| Max. Negotiated Rate |
$48.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$47.04
|
| Rate for Payer: Aetna of WY Medicare |
$5.82
|
| Rate for Payer: Beech Street Commercial |
$45.60
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$46.56
|
| Rate for Payer: Cigna of WY Commercial |
$47.04
|
| Rate for Payer: First Choice Health Commercial |
$43.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$45.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$5.82
|
| Rate for Payer: HealthUtah PPO |
$48.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$46.56
|
| Rate for Payer: Multiplan Medicare/VA |
$4.95
|
| Rate for Payer: One Health Plan of WY PPO |
$47.04
|
| Rate for Payer: PacificSource Commercial |
$43.20
|
| Rate for Payer: PHCS PPO |
$45.60
|
| Rate for Payer: Three Rivers PPO |
$36.00
|
| Rate for Payer: TriWest Veterans Administration |
$5.82
|
| Rate for Payer: United Healthcare Commercial |
$41.76
|
| Rate for Payer: United Healthcare Medicare |
$5.82
|
| Rate for Payer: WINHealth Partners Commercial |
$45.60
|
|
|
SNARE 10MM HOT/COLD OLYMPUS
|
Facility
|
IP
|
$56.77
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$35.59 |
| Max. Negotiated Rate |
$56.77 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$55.63
|
| Rate for Payer: Altius Auto/Workers Compensation |
$54.50
|
| Rate for Payer: Altius Commercial |
$54.50
|
| Rate for Payer: Beech Street Commercial |
$55.63
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$46.61
|
| Rate for Payer: Cash Price |
$39.74
|
| Rate for Payer: ChoiceCare Network Commercial |
$55.07
|
| Rate for Payer: Cigna of WY Commercial |
$55.63
|
| Rate for Payer: Entrust Commercial |
$53.93
|
| Rate for Payer: First Choice Health Commercial |
$53.93
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$53.93
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$37.47
|
| Rate for Payer: HealthUtah PPO |
$56.77
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$55.07
|
| Rate for Payer: Multiplan Medicare/VA |
$35.59
|
| Rate for Payer: One Health Plan of WY PPO |
$55.63
|
| Rate for Payer: PacificSource Commercial |
$51.09
|
| Rate for Payer: PHCS PPO |
$55.63
|
| Rate for Payer: Three Rivers PPO |
$42.58
|
| Rate for Payer: TriWest Veterans Administration |
$37.47
|
| Rate for Payer: United Healthcare Commercial |
$49.39
|
| Rate for Payer: United Healthcare Medicare |
$37.47
|
| Rate for Payer: WINHealth Partners Commercial |
$53.93
|
| Rate for Payer: Wise Provider Network Commercial |
$53.93
|
|
|
SNARE 10MM HOT/COLD OLYMPUS
|
Facility
|
OP
|
$56.77
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$31.28 |
| Max. Negotiated Rate |
$56.77 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$55.63
|
| Rate for Payer: Aetna of WY Medicare |
$37.47
|
| Rate for Payer: Altius Auto/Workers Compensation |
$54.50
|
| Rate for Payer: Altius Commercial |
$54.50
|
| Rate for Payer: Beech Street Commercial |
$55.63
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$46.61
|
| Rate for Payer: Cash Price |
$39.74
|
| Rate for Payer: ChoiceCare Network Commercial |
$55.07
|
| Rate for Payer: Cigna of WY Commercial |
$55.63
|
| Rate for Payer: Entrust Commercial |
$53.93
|
| Rate for Payer: First Choice Health Commercial |
$53.93
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$53.93
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$32.93
|
| Rate for Payer: HealthUtah PPO |
$56.77
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$55.07
|
| Rate for Payer: Multiplan Medicare/VA |
$31.28
|
| Rate for Payer: One Health Plan of WY PPO |
$55.63
|
| Rate for Payer: PacificSource Commercial |
$51.09
|
| Rate for Payer: PHCS PPO |
$55.63
|
| Rate for Payer: Three Rivers PPO |
$42.58
|
| Rate for Payer: TriWest Veterans Administration |
$32.93
|
| Rate for Payer: United Healthcare Commercial |
$49.39
|
| Rate for Payer: United Healthcare Medicare |
$32.93
|
| Rate for Payer: WINHealth Partners Commercial |
$55.63
|
| Rate for Payer: Wise Provider Network Commercial |
$53.93
|
|
|
SNARE ROTATABLE 20MM 01-25-230
|
Facility
|
IP
|
$77.00
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$48.28 |
| Max. Negotiated Rate |
$77.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$75.46
|
| Rate for Payer: Altius Auto/Workers Compensation |
$73.92
|
| Rate for Payer: Altius Commercial |
$73.92
|
| Rate for Payer: Beech Street Commercial |
$75.46
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$63.22
|
| Rate for Payer: Cash Price |
$53.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$74.69
|
| Rate for Payer: Cigna of WY Commercial |
$75.46
|
| Rate for Payer: Entrust Commercial |
$73.15
|
| Rate for Payer: First Choice Health Commercial |
$73.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$73.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$50.82
|
| Rate for Payer: HealthUtah PPO |
$77.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$74.69
|
| Rate for Payer: Multiplan Medicare/VA |
$48.28
|
| Rate for Payer: One Health Plan of WY PPO |
$75.46
|
| Rate for Payer: PacificSource Commercial |
$69.30
|
| Rate for Payer: PHCS PPO |
$75.46
|
| Rate for Payer: Three Rivers PPO |
$57.75
|
| Rate for Payer: TriWest Veterans Administration |
$50.82
|
| Rate for Payer: United Healthcare Commercial |
$66.99
|
| Rate for Payer: United Healthcare Medicare |
$50.82
|
| Rate for Payer: WINHealth Partners Commercial |
$73.15
|
| Rate for Payer: Wise Provider Network Commercial |
$73.15
|
|
|
SNARE ROTATABLE 20MM 01-25-230
|
Facility
|
OP
|
$77.00
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$42.43 |
| Max. Negotiated Rate |
$77.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$75.46
|
| Rate for Payer: Aetna of WY Medicare |
$50.82
|
| Rate for Payer: Altius Auto/Workers Compensation |
$73.92
|
| Rate for Payer: Altius Commercial |
$73.92
|
| Rate for Payer: Beech Street Commercial |
$75.46
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$63.22
|
| Rate for Payer: Cash Price |
$53.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$74.69
|
| Rate for Payer: Cigna of WY Commercial |
$75.46
|
| Rate for Payer: Entrust Commercial |
$73.15
|
| Rate for Payer: First Choice Health Commercial |
$73.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$73.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$44.66
|
| Rate for Payer: HealthUtah PPO |
$77.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$74.69
|
| Rate for Payer: Multiplan Medicare/VA |
$42.43
|
| Rate for Payer: One Health Plan of WY PPO |
$75.46
|
| Rate for Payer: PacificSource Commercial |
$69.30
|
| Rate for Payer: PHCS PPO |
$75.46
|
| Rate for Payer: Three Rivers PPO |
$57.75
|
| Rate for Payer: TriWest Veterans Administration |
$44.66
|
| Rate for Payer: United Healthcare Commercial |
$66.99
|
| Rate for Payer: United Healthcare Medicare |
$44.66
|
| Rate for Payer: WINHealth Partners Commercial |
$75.46
|
| Rate for Payer: Wise Provider Network Commercial |
$73.15
|
|
|
SNARE W/BARB OLYMPUS
|
Facility
|
IP
|
$72.45
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$45.43 |
| Max. Negotiated Rate |
$72.45 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$71.00
|
| Rate for Payer: Altius Auto/Workers Compensation |
$69.55
|
| Rate for Payer: Altius Commercial |
$69.55
|
| Rate for Payer: Beech Street Commercial |
$71.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$59.48
|
| Rate for Payer: Cash Price |
$50.71
|
| Rate for Payer: ChoiceCare Network Commercial |
$70.28
|
| Rate for Payer: Cigna of WY Commercial |
$71.00
|
| Rate for Payer: Entrust Commercial |
$68.83
|
| Rate for Payer: First Choice Health Commercial |
$68.83
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$68.83
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$47.82
|
| Rate for Payer: HealthUtah PPO |
$72.45
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$70.28
|
| Rate for Payer: Multiplan Medicare/VA |
$45.43
|
| Rate for Payer: One Health Plan of WY PPO |
$71.00
|
| Rate for Payer: PacificSource Commercial |
$65.20
|
| Rate for Payer: PHCS PPO |
$71.00
|
| Rate for Payer: Three Rivers PPO |
$54.34
|
| Rate for Payer: TriWest Veterans Administration |
$47.82
|
| Rate for Payer: United Healthcare Commercial |
$63.03
|
| Rate for Payer: United Healthcare Medicare |
$47.82
|
| Rate for Payer: WINHealth Partners Commercial |
$68.83
|
| Rate for Payer: Wise Provider Network Commercial |
$68.83
|
|
|
SNARE W/BARB OLYMPUS
|
Facility
|
OP
|
$72.45
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$39.92 |
| Max. Negotiated Rate |
$72.45 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$71.00
|
| Rate for Payer: Aetna of WY Medicare |
$47.82
|
| Rate for Payer: Altius Auto/Workers Compensation |
$69.55
|
| Rate for Payer: Altius Commercial |
$69.55
|
| Rate for Payer: Beech Street Commercial |
$71.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$59.48
|
| Rate for Payer: Cash Price |
$50.71
|
| Rate for Payer: ChoiceCare Network Commercial |
$70.28
|
| Rate for Payer: Cigna of WY Commercial |
$71.00
|
| Rate for Payer: Entrust Commercial |
$68.83
|
| Rate for Payer: First Choice Health Commercial |
$68.83
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$68.83
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$42.02
|
| Rate for Payer: HealthUtah PPO |
$72.45
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$70.28
|
| Rate for Payer: Multiplan Medicare/VA |
$39.92
|
| Rate for Payer: One Health Plan of WY PPO |
$71.00
|
| Rate for Payer: PacificSource Commercial |
$65.20
|
| Rate for Payer: PHCS PPO |
$71.00
|
| Rate for Payer: Three Rivers PPO |
$54.34
|
| Rate for Payer: TriWest Veterans Administration |
$42.02
|
| Rate for Payer: United Healthcare Commercial |
$63.03
|
| Rate for Payer: United Healthcare Medicare |
$42.02
|
| Rate for Payer: WINHealth Partners Commercial |
$71.00
|
| Rate for Payer: Wise Provider Network Commercial |
$68.83
|
|
|
SO 8 ABD RESTRAINT PRE OTS
|
Professional
|
Both
|
$37.00
|
|
|
Service Code
|
HCPCS L3650
|
| Hospital Charge Code |
L3650
|
| Min. Negotiated Rate |
$27.75 |
| Max. Negotiated Rate |
$37.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$36.26
|
| Rate for Payer: Beech Street Commercial |
$35.15
|
| Rate for Payer: Cash Price |
$25.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$35.89
|
| Rate for Payer: Cigna of WY Commercial |
$36.26
|
| Rate for Payer: First Choice Health Commercial |
$33.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$35.15
|
| Rate for Payer: HealthUtah PPO |
$37.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$35.89
|
| Rate for Payer: One Health Plan of WY PPO |
$36.26
|
| Rate for Payer: PacificSource Commercial |
$33.30
|
| Rate for Payer: PHCS PPO |
$35.15
|
| Rate for Payer: Three Rivers PPO |
$27.75
|
| Rate for Payer: United Healthcare Commercial |
$32.19
|
| Rate for Payer: WINHealth Partners Commercial |
$35.15
|
|
|
SO ACRO/CLAV CAN WEB PRE OTS
|
Professional
|
Both
|
$60.00
|
|
|
Service Code
|
HCPCS L3670
|
| Hospital Charge Code |
L3670
|
| Min. Negotiated Rate |
$45.00 |
| Max. Negotiated Rate |
$121.74 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$58.80
|
| Rate for Payer: Aetna of WY Medicare |
$121.74
|
| Rate for Payer: Beech Street Commercial |
$57.00
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$58.20
|
| Rate for Payer: Cigna of WY Commercial |
$58.80
|
| Rate for Payer: First Choice Health Commercial |
$54.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$57.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$121.74
|
| Rate for Payer: HealthUtah PPO |
$60.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$58.20
|
| Rate for Payer: Multiplan Medicare/VA |
$103.48
|
| Rate for Payer: One Health Plan of WY PPO |
$58.80
|
| Rate for Payer: PacificSource Commercial |
$54.00
|
| Rate for Payer: PHCS PPO |
$57.00
|
| Rate for Payer: Three Rivers PPO |
$45.00
|
| Rate for Payer: TriWest Veterans Administration |
$121.74
|
| Rate for Payer: United Healthcare Commercial |
$52.20
|
| Rate for Payer: United Healthcare Medicare |
$121.74
|
| Rate for Payer: WINHealth Partners Commercial |
$57.00
|
|
|
SOCK FRACTURE OR EQUAL EACH
|
Professional
|
Both
|
$62.00
|
|
|
Service Code
|
HCPCS L3995
|
| Hospital Charge Code |
L3995
|
| Min. Negotiated Rate |
$46.50 |
| Max. Negotiated Rate |
$62.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$60.76
|
| Rate for Payer: Beech Street Commercial |
$58.90
|
| Rate for Payer: Cash Price |
$43.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$60.14
|
| Rate for Payer: Cigna of WY Commercial |
$60.76
|
| Rate for Payer: First Choice Health Commercial |
$55.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$58.90
|
| Rate for Payer: HealthUtah PPO |
$62.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$60.14
|
| Rate for Payer: One Health Plan of WY PPO |
$60.76
|
| Rate for Payer: PacificSource Commercial |
$55.80
|
| Rate for Payer: PHCS PPO |
$58.90
|
| Rate for Payer: Three Rivers PPO |
$46.50
|
| Rate for Payer: United Healthcare Commercial |
$53.94
|
| Rate for Payer: WINHealth Partners Commercial |
$58.90
|
|
|
SOD BICARB-CITRIC AC-SIMETH 2.21 GRAM-1.53 GRAM/4 GRAM GRANULES EFFERV [101197]
|
Facility
|
OP
|
$9.45
|
|
|
Service Code
|
NDC 1036179301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.21 |
| Max. Negotiated Rate |
$9.45 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$9.26
|
| Rate for Payer: Aetna of WY Medicare |
$6.24
|
| Rate for Payer: Altius Auto/Workers Compensation |
$9.07
|
| Rate for Payer: Altius Commercial |
$9.07
|
| Rate for Payer: Beech Street Commercial |
$9.26
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$7.76
|
| Rate for Payer: Cash Price |
$6.62
|
| Rate for Payer: ChoiceCare Network Commercial |
$9.17
|
| Rate for Payer: Cigna of WY Commercial |
$9.26
|
| Rate for Payer: Entrust Commercial |
$8.98
|
| Rate for Payer: First Choice Health Commercial |
$8.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$8.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$5.48
|
| Rate for Payer: HealthUtah PPO |
$9.45
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$9.17
|
| Rate for Payer: Multiplan Medicare/VA |
$5.21
|
| Rate for Payer: One Health Plan of WY PPO |
$9.26
|
| Rate for Payer: PacificSource Commercial |
$8.50
|
| Rate for Payer: PHCS PPO |
$9.26
|
| Rate for Payer: Three Rivers PPO |
$7.09
|
| Rate for Payer: TriWest Veterans Administration |
$5.48
|
| Rate for Payer: United Healthcare Commercial |
$8.22
|
| Rate for Payer: United Healthcare Medicare |
$5.48
|
| Rate for Payer: WINHealth Partners Commercial |
$9.26
|
| Rate for Payer: Wise Provider Network Commercial |
$8.98
|
|
|
SOD BICARB-CITRIC AC-SIMETH 2.21 GRAM-1.53 GRAM/4 GRAM GRANULES EFFERV [101197]
|
Facility
|
IP
|
$9.45
|
|
|
Service Code
|
NDC 1036179301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.93 |
| Max. Negotiated Rate |
$9.45 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$9.26
|
| Rate for Payer: Altius Auto/Workers Compensation |
$9.07
|
| Rate for Payer: Altius Commercial |
$9.07
|
| Rate for Payer: Beech Street Commercial |
$9.26
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$7.76
|
| Rate for Payer: Cash Price |
$6.62
|
| Rate for Payer: ChoiceCare Network Commercial |
$9.17
|
| Rate for Payer: Cigna of WY Commercial |
$9.26
|
| Rate for Payer: Entrust Commercial |
$8.98
|
| Rate for Payer: First Choice Health Commercial |
$8.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$8.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$6.24
|
| Rate for Payer: HealthUtah PPO |
$9.45
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$9.17
|
| Rate for Payer: Multiplan Medicare/VA |
$5.93
|
| Rate for Payer: One Health Plan of WY PPO |
$9.26
|
| Rate for Payer: PacificSource Commercial |
$8.50
|
| Rate for Payer: PHCS PPO |
$9.26
|
| Rate for Payer: Three Rivers PPO |
$7.09
|
| Rate for Payer: TriWest Veterans Administration |
$6.24
|
| Rate for Payer: United Healthcare Commercial |
$8.22
|
| Rate for Payer: United Healthcare Medicare |
$6.24
|
| Rate for Payer: WINHealth Partners Commercial |
$8.98
|
| Rate for Payer: Wise Provider Network Commercial |
$8.98
|
|
|
SOD CHLORIDE-SOD BICARB-HYALURONATE SOD-ALOE 0.9 % NASAL GEL [94598]
|
Facility
|
IP
|
$0.78
|
|
|
Service Code
|
NDC 0592800099
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$0.78 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.76
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.75
|
| Rate for Payer: Altius Commercial |
$0.75
|
| Rate for Payer: Beech Street Commercial |
$0.76
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.64
|
| Rate for Payer: Cash Price |
$0.55
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.76
|
| Rate for Payer: Cigna of WY Commercial |
$0.76
|
| Rate for Payer: Entrust Commercial |
$0.74
|
| Rate for Payer: First Choice Health Commercial |
$0.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.51
|
| Rate for Payer: HealthUtah PPO |
$0.78
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.76
|
| Rate for Payer: Multiplan Medicare/VA |
$0.49
|
| Rate for Payer: One Health Plan of WY PPO |
$0.76
|
| Rate for Payer: PacificSource Commercial |
$0.70
|
| Rate for Payer: PHCS PPO |
$0.76
|
| Rate for Payer: Three Rivers PPO |
$0.59
|
| Rate for Payer: TriWest Veterans Administration |
$0.51
|
| Rate for Payer: United Healthcare Commercial |
$0.68
|
| Rate for Payer: United Healthcare Medicare |
$0.51
|
| Rate for Payer: WINHealth Partners Commercial |
$0.74
|
| Rate for Payer: Wise Provider Network Commercial |
$0.74
|
|
