|
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION [143382]
|
Facility
|
OP
|
$134.12
|
|
|
Service Code
|
NDC 0006542312
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$73.90 |
| Max. Negotiated Rate |
$134.12 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$131.44
|
| Rate for Payer: Aetna of WY Medicare |
$88.52
|
| Rate for Payer: Altius Auto/Workers Compensation |
$128.76
|
| Rate for Payer: Altius Commercial |
$128.76
|
| Rate for Payer: Beech Street Commercial |
$131.44
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$110.11
|
| Rate for Payer: Cash Price |
$93.89
|
| Rate for Payer: ChoiceCare Network Commercial |
$130.10
|
| Rate for Payer: Cigna of WY Commercial |
$131.44
|
| Rate for Payer: Entrust Commercial |
$127.41
|
| Rate for Payer: First Choice Health Commercial |
$127.41
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$127.41
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$77.79
|
| Rate for Payer: HealthUtah PPO |
$134.12
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$130.10
|
| Rate for Payer: Multiplan Medicare/VA |
$73.90
|
| Rate for Payer: One Health Plan of WY PPO |
$131.44
|
| Rate for Payer: PacificSource Commercial |
$120.71
|
| Rate for Payer: PHCS PPO |
$131.44
|
| Rate for Payer: Three Rivers PPO |
$100.59
|
| Rate for Payer: TriWest Veterans Administration |
$77.79
|
| Rate for Payer: United Healthcare Commercial |
$116.68
|
| Rate for Payer: United Healthcare Medicare |
$77.79
|
| Rate for Payer: WINHealth Partners Commercial |
$131.44
|
| Rate for Payer: Wise Provider Network Commercial |
$127.41
|
|
|
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION [143382]
|
Facility
|
OP
|
$134.12
|
|
|
Service Code
|
NDC 0006542302
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$73.90 |
| Max. Negotiated Rate |
$134.12 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$131.44
|
| Rate for Payer: Aetna of WY Medicare |
$88.52
|
| Rate for Payer: Altius Auto/Workers Compensation |
$128.76
|
| Rate for Payer: Altius Commercial |
$128.76
|
| Rate for Payer: Beech Street Commercial |
$131.44
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$110.11
|
| Rate for Payer: Cash Price |
$93.89
|
| Rate for Payer: ChoiceCare Network Commercial |
$130.10
|
| Rate for Payer: Cigna of WY Commercial |
$131.44
|
| Rate for Payer: Entrust Commercial |
$127.41
|
| Rate for Payer: First Choice Health Commercial |
$127.41
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$127.41
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$77.79
|
| Rate for Payer: HealthUtah PPO |
$134.12
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$130.10
|
| Rate for Payer: Multiplan Medicare/VA |
$73.90
|
| Rate for Payer: One Health Plan of WY PPO |
$131.44
|
| Rate for Payer: PacificSource Commercial |
$120.71
|
| Rate for Payer: PHCS PPO |
$131.44
|
| Rate for Payer: Three Rivers PPO |
$100.59
|
| Rate for Payer: TriWest Veterans Administration |
$77.79
|
| Rate for Payer: United Healthcare Commercial |
$116.68
|
| Rate for Payer: United Healthcare Medicare |
$77.79
|
| Rate for Payer: WINHealth Partners Commercial |
$131.44
|
| Rate for Payer: Wise Provider Network Commercial |
$127.41
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION [14810]
|
Facility
|
OP
|
$0.37
|
|
|
Service Code
|
NDC 9999148101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.36
|
| Rate for Payer: Aetna of WY Medicare |
$0.24
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.36
|
| Rate for Payer: Altius Commercial |
$0.36
|
| Rate for Payer: Beech Street Commercial |
$0.36
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.30
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.36
|
| Rate for Payer: Cigna of WY Commercial |
$0.36
|
| Rate for Payer: Entrust Commercial |
$0.35
|
| Rate for Payer: First Choice Health Commercial |
$0.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.21
|
| Rate for Payer: HealthUtah PPO |
$0.37
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.36
|
| Rate for Payer: Multiplan Medicare/VA |
$0.20
|
| Rate for Payer: One Health Plan of WY PPO |
$0.36
|
| Rate for Payer: PacificSource Commercial |
$0.33
|
| Rate for Payer: PHCS PPO |
$0.36
|
| Rate for Payer: Three Rivers PPO |
$0.28
|
| Rate for Payer: TriWest Veterans Administration |
$0.21
|
| Rate for Payer: United Healthcare Commercial |
$0.32
|
| Rate for Payer: United Healthcare Medicare |
$0.21
|
| Rate for Payer: WINHealth Partners Commercial |
$0.36
|
| Rate for Payer: Wise Provider Network Commercial |
$0.35
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION [14810]
|
Facility
|
IP
|
$0.36
|
|
|
Service Code
|
NDC 7095425810
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.35
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.35
|
| Rate for Payer: Altius Commercial |
$0.35
|
| Rate for Payer: Beech Street Commercial |
$0.35
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.30
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.35
|
| Rate for Payer: Cigna of WY Commercial |
$0.35
|
| Rate for Payer: Entrust Commercial |
$0.34
|
| Rate for Payer: First Choice Health Commercial |
$0.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.24
|
| Rate for Payer: HealthUtah PPO |
$0.36
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.35
|
| Rate for Payer: Multiplan Medicare/VA |
$0.23
|
| Rate for Payer: One Health Plan of WY PPO |
$0.35
|
| Rate for Payer: PacificSource Commercial |
$0.32
|
| Rate for Payer: PHCS PPO |
$0.35
|
| Rate for Payer: Three Rivers PPO |
$0.27
|
| Rate for Payer: TriWest Veterans Administration |
$0.24
|
| Rate for Payer: United Healthcare Commercial |
$0.31
|
| Rate for Payer: United Healthcare Medicare |
$0.24
|
| Rate for Payer: WINHealth Partners Commercial |
$0.34
|
| Rate for Payer: Wise Provider Network Commercial |
$0.34
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION [14810]
|
Facility
|
OP
|
$0.36
|
|
|
Service Code
|
NDC 7095425810
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.35
|
| Rate for Payer: Aetna of WY Medicare |
$0.24
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.35
|
| Rate for Payer: Altius Commercial |
$0.35
|
| Rate for Payer: Beech Street Commercial |
$0.35
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.30
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.35
|
| Rate for Payer: Cigna of WY Commercial |
$0.35
|
| Rate for Payer: Entrust Commercial |
$0.34
|
| Rate for Payer: First Choice Health Commercial |
$0.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.21
|
| Rate for Payer: HealthUtah PPO |
$0.36
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.35
|
| Rate for Payer: Multiplan Medicare/VA |
$0.20
|
| Rate for Payer: One Health Plan of WY PPO |
$0.35
|
| Rate for Payer: PacificSource Commercial |
$0.32
|
| Rate for Payer: PHCS PPO |
$0.35
|
| Rate for Payer: Three Rivers PPO |
$0.27
|
| Rate for Payer: TriWest Veterans Administration |
$0.21
|
| Rate for Payer: United Healthcare Commercial |
$0.31
|
| Rate for Payer: United Healthcare Medicare |
$0.21
|
| Rate for Payer: WINHealth Partners Commercial |
$0.35
|
| Rate for Payer: Wise Provider Network Commercial |
$0.34
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION [14810]
|
Facility
|
IP
|
$0.37
|
|
|
Service Code
|
NDC 9999148101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.36
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.36
|
| Rate for Payer: Altius Commercial |
$0.36
|
| Rate for Payer: Beech Street Commercial |
$0.36
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.30
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.36
|
| Rate for Payer: Cigna of WY Commercial |
$0.36
|
| Rate for Payer: Entrust Commercial |
$0.35
|
| Rate for Payer: First Choice Health Commercial |
$0.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.24
|
| Rate for Payer: HealthUtah PPO |
$0.37
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.36
|
| Rate for Payer: Multiplan Medicare/VA |
$0.23
|
| Rate for Payer: One Health Plan of WY PPO |
$0.36
|
| Rate for Payer: PacificSource Commercial |
$0.33
|
| Rate for Payer: PHCS PPO |
$0.36
|
| Rate for Payer: Three Rivers PPO |
$0.28
|
| Rate for Payer: TriWest Veterans Administration |
$0.24
|
| Rate for Payer: United Healthcare Commercial |
$0.32
|
| Rate for Payer: United Healthcare Medicare |
$0.24
|
| Rate for Payer: WINHealth Partners Commercial |
$0.35
|
| Rate for Payer: Wise Provider Network Commercial |
$0.35
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION [14810]
|
Facility
|
IP
|
$0.32
|
|
|
Service Code
|
NDC 0121085416
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.31
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.31
|
| Rate for Payer: Altius Commercial |
$0.31
|
| Rate for Payer: Beech Street Commercial |
$0.31
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.26
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.31
|
| Rate for Payer: Cigna of WY Commercial |
$0.31
|
| Rate for Payer: Entrust Commercial |
$0.30
|
| Rate for Payer: First Choice Health Commercial |
$0.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.21
|
| Rate for Payer: HealthUtah PPO |
$0.32
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.31
|
| Rate for Payer: Multiplan Medicare/VA |
$0.20
|
| Rate for Payer: One Health Plan of WY PPO |
$0.31
|
| Rate for Payer: PacificSource Commercial |
$0.29
|
| Rate for Payer: PHCS PPO |
$0.31
|
| Rate for Payer: Three Rivers PPO |
$0.24
|
| Rate for Payer: TriWest Veterans Administration |
$0.21
|
| Rate for Payer: United Healthcare Commercial |
$0.28
|
| Rate for Payer: United Healthcare Medicare |
$0.21
|
| Rate for Payer: WINHealth Partners Commercial |
$0.30
|
| Rate for Payer: Wise Provider Network Commercial |
$0.30
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION [14810]
|
Facility
|
OP
|
$0.32
|
|
|
Service Code
|
NDC 0121085416
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.31
|
| Rate for Payer: Aetna of WY Medicare |
$0.21
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.31
|
| Rate for Payer: Altius Commercial |
$0.31
|
| Rate for Payer: Beech Street Commercial |
$0.31
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.26
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.31
|
| Rate for Payer: Cigna of WY Commercial |
$0.31
|
| Rate for Payer: Entrust Commercial |
$0.30
|
| Rate for Payer: First Choice Health Commercial |
$0.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.19
|
| Rate for Payer: HealthUtah PPO |
$0.32
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.31
|
| Rate for Payer: Multiplan Medicare/VA |
$0.18
|
| Rate for Payer: One Health Plan of WY PPO |
$0.31
|
| Rate for Payer: PacificSource Commercial |
$0.29
|
| Rate for Payer: PHCS PPO |
$0.31
|
| Rate for Payer: Three Rivers PPO |
$0.24
|
| Rate for Payer: TriWest Veterans Administration |
$0.19
|
| Rate for Payer: United Healthcare Commercial |
$0.28
|
| Rate for Payer: United Healthcare Medicare |
$0.19
|
| Rate for Payer: WINHealth Partners Commercial |
$0.31
|
| Rate for Payer: Wise Provider Network Commercial |
$0.30
|
|
|
SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET [7596]
|
Facility
|
IP
|
$1.05
|
|
|
Service Code
|
NDC 6068761411
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$1.05 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.03
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.01
|
| Rate for Payer: Altius Commercial |
$1.01
|
| Rate for Payer: Beech Street Commercial |
$1.03
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.86
|
| Rate for Payer: Cash Price |
$0.74
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.02
|
| Rate for Payer: Cigna of WY Commercial |
$1.03
|
| Rate for Payer: Entrust Commercial |
$1.00
|
| Rate for Payer: First Choice Health Commercial |
$1.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.69
|
| Rate for Payer: HealthUtah PPO |
$1.05
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.02
|
| Rate for Payer: Multiplan Medicare/VA |
$0.66
|
| Rate for Payer: One Health Plan of WY PPO |
$1.03
|
| Rate for Payer: PacificSource Commercial |
$0.95
|
| Rate for Payer: PHCS PPO |
$1.03
|
| Rate for Payer: Three Rivers PPO |
$0.79
|
| Rate for Payer: TriWest Veterans Administration |
$0.69
|
| Rate for Payer: United Healthcare Commercial |
$0.91
|
| Rate for Payer: United Healthcare Medicare |
$0.69
|
| Rate for Payer: WINHealth Partners Commercial |
$1.00
|
| Rate for Payer: Wise Provider Network Commercial |
$1.00
|
|
|
SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET [7596]
|
Facility
|
OP
|
$1.05
|
|
|
Service Code
|
NDC 6068761411
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$1.05 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.03
|
| Rate for Payer: Aetna of WY Medicare |
$0.69
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.01
|
| Rate for Payer: Altius Commercial |
$1.01
|
| Rate for Payer: Beech Street Commercial |
$1.03
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.86
|
| Rate for Payer: Cash Price |
$0.74
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.02
|
| Rate for Payer: Cigna of WY Commercial |
$1.03
|
| Rate for Payer: Entrust Commercial |
$1.00
|
| Rate for Payer: First Choice Health Commercial |
$1.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.61
|
| Rate for Payer: HealthUtah PPO |
$1.05
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.02
|
| Rate for Payer: Multiplan Medicare/VA |
$0.58
|
| Rate for Payer: One Health Plan of WY PPO |
$1.03
|
| Rate for Payer: PacificSource Commercial |
$0.95
|
| Rate for Payer: PHCS PPO |
$1.03
|
| Rate for Payer: Three Rivers PPO |
$0.79
|
| Rate for Payer: TriWest Veterans Administration |
$0.61
|
| Rate for Payer: United Healthcare Commercial |
$0.91
|
| Rate for Payer: United Healthcare Medicare |
$0.61
|
| Rate for Payer: WINHealth Partners Commercial |
$1.03
|
| Rate for Payer: Wise Provider Network Commercial |
$1.00
|
|
|
SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET [7596]
|
Facility
|
OP
|
$1.05
|
|
|
Service Code
|
NDC 6068761401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$1.05 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.03
|
| Rate for Payer: Aetna of WY Medicare |
$0.69
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.01
|
| Rate for Payer: Altius Commercial |
$1.01
|
| Rate for Payer: Beech Street Commercial |
$1.03
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.86
|
| Rate for Payer: Cash Price |
$0.74
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.02
|
| Rate for Payer: Cigna of WY Commercial |
$1.03
|
| Rate for Payer: Entrust Commercial |
$1.00
|
| Rate for Payer: First Choice Health Commercial |
$1.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.61
|
| Rate for Payer: HealthUtah PPO |
$1.05
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.02
|
| Rate for Payer: Multiplan Medicare/VA |
$0.58
|
| Rate for Payer: One Health Plan of WY PPO |
$1.03
|
| Rate for Payer: PacificSource Commercial |
$0.95
|
| Rate for Payer: PHCS PPO |
$1.03
|
| Rate for Payer: Three Rivers PPO |
$0.79
|
| Rate for Payer: TriWest Veterans Administration |
$0.61
|
| Rate for Payer: United Healthcare Commercial |
$0.91
|
| Rate for Payer: United Healthcare Medicare |
$0.61
|
| Rate for Payer: WINHealth Partners Commercial |
$1.03
|
| Rate for Payer: Wise Provider Network Commercial |
$1.00
|
|
|
SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET [7596]
|
Facility
|
IP
|
$1.05
|
|
|
Service Code
|
NDC 6068761401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$1.05 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.03
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.01
|
| Rate for Payer: Altius Commercial |
$1.01
|
| Rate for Payer: Beech Street Commercial |
$1.03
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.86
|
| Rate for Payer: Cash Price |
$0.74
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.02
|
| Rate for Payer: Cigna of WY Commercial |
$1.03
|
| Rate for Payer: Entrust Commercial |
$1.00
|
| Rate for Payer: First Choice Health Commercial |
$1.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.69
|
| Rate for Payer: HealthUtah PPO |
$1.05
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.02
|
| Rate for Payer: Multiplan Medicare/VA |
$0.66
|
| Rate for Payer: One Health Plan of WY PPO |
$1.03
|
| Rate for Payer: PacificSource Commercial |
$0.95
|
| Rate for Payer: PHCS PPO |
$1.03
|
| Rate for Payer: Three Rivers PPO |
$0.79
|
| Rate for Payer: TriWest Veterans Administration |
$0.69
|
| Rate for Payer: United Healthcare Commercial |
$0.91
|
| Rate for Payer: United Healthcare Medicare |
$0.69
|
| Rate for Payer: WINHealth Partners Commercial |
$1.00
|
| Rate for Payer: Wise Provider Network Commercial |
$1.00
|
|
|
SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION [9943]
|
Facility
|
OP
|
$59.00
|
|
|
Service Code
|
HCPCS J3030
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.51 |
| Max. Negotiated Rate |
$59.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$57.82
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$182.77
|
| Rate for Payer: Aetna of WY Medicare |
$38.94
|
| Rate for Payer: Aetna of WY Medicare |
$123.09
|
| Rate for Payer: Altius Auto/Workers Compensation |
$179.04
|
| Rate for Payer: Altius Auto/Workers Compensation |
$56.64
|
| Rate for Payer: Altius Commercial |
$56.64
|
| Rate for Payer: Altius Commercial |
$179.04
|
| Rate for Payer: Beech Street Commercial |
$182.77
|
| Rate for Payer: Beech Street Commercial |
$57.82
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$48.44
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$153.12
|
| Rate for Payer: Cash Price |
$130.55
|
| Rate for Payer: Cash Price |
$41.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$57.23
|
| Rate for Payer: ChoiceCare Network Commercial |
$180.90
|
| Rate for Payer: Cigna of WY Commercial |
$182.77
|
| Rate for Payer: Cigna of WY Commercial |
$57.82
|
| Rate for Payer: Entrust Commercial |
$56.05
|
| Rate for Payer: Entrust Commercial |
$177.18
|
| Rate for Payer: First Choice Health Commercial |
$177.18
|
| Rate for Payer: First Choice Health Commercial |
$56.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$177.18
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$56.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$34.22
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$108.17
|
| Rate for Payer: HealthUtah PPO |
$186.50
|
| Rate for Payer: HealthUtah PPO |
$59.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$180.90
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$57.23
|
| Rate for Payer: Multiplan Medicare/VA |
$32.51
|
| Rate for Payer: Multiplan Medicare/VA |
$102.76
|
| Rate for Payer: One Health Plan of WY PPO |
$182.77
|
| Rate for Payer: One Health Plan of WY PPO |
$57.82
|
| Rate for Payer: PacificSource Commercial |
$53.10
|
| Rate for Payer: PacificSource Commercial |
$167.85
|
| Rate for Payer: PHCS PPO |
$182.77
|
| Rate for Payer: PHCS PPO |
$57.82
|
| Rate for Payer: Three Rivers PPO |
$139.88
|
| Rate for Payer: Three Rivers PPO |
$44.25
|
| Rate for Payer: TriWest Veterans Administration |
$34.22
|
| Rate for Payer: TriWest Veterans Administration |
$108.17
|
| Rate for Payer: United Healthcare Commercial |
$162.26
|
| Rate for Payer: United Healthcare Commercial |
$51.33
|
| Rate for Payer: United Healthcare Medicare |
$34.22
|
| Rate for Payer: United Healthcare Medicare |
$108.17
|
| Rate for Payer: WINHealth Partners Commercial |
$182.77
|
| Rate for Payer: WINHealth Partners Commercial |
$57.82
|
| Rate for Payer: Wise Provider Network Commercial |
$177.18
|
| Rate for Payer: Wise Provider Network Commercial |
$56.05
|
|
|
SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION [9943]
|
Facility
|
IP
|
$59.00
|
|
|
Service Code
|
HCPCS J3030
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.99 |
| Max. Negotiated Rate |
$59.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$57.82
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$182.77
|
| Rate for Payer: Altius Auto/Workers Compensation |
$56.64
|
| Rate for Payer: Altius Auto/Workers Compensation |
$179.04
|
| Rate for Payer: Altius Commercial |
$179.04
|
| Rate for Payer: Altius Commercial |
$56.64
|
| Rate for Payer: Beech Street Commercial |
$57.82
|
| Rate for Payer: Beech Street Commercial |
$182.77
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$153.12
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$48.44
|
| Rate for Payer: Cash Price |
$41.30
|
| Rate for Payer: Cash Price |
$130.55
|
| Rate for Payer: ChoiceCare Network Commercial |
$180.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$57.23
|
| Rate for Payer: Cigna of WY Commercial |
$57.82
|
| Rate for Payer: Cigna of WY Commercial |
$182.77
|
| Rate for Payer: Entrust Commercial |
$177.18
|
| Rate for Payer: Entrust Commercial |
$56.05
|
| Rate for Payer: First Choice Health Commercial |
$177.18
|
| Rate for Payer: First Choice Health Commercial |
$56.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$177.18
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$56.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$38.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$123.09
|
| Rate for Payer: HealthUtah PPO |
$59.00
|
| Rate for Payer: HealthUtah PPO |
$186.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$180.90
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$57.23
|
| Rate for Payer: Multiplan Medicare/VA |
$36.99
|
| Rate for Payer: Multiplan Medicare/VA |
$116.94
|
| Rate for Payer: One Health Plan of WY PPO |
$57.82
|
| Rate for Payer: One Health Plan of WY PPO |
$182.77
|
| Rate for Payer: PacificSource Commercial |
$53.10
|
| Rate for Payer: PacificSource Commercial |
$167.85
|
| Rate for Payer: PHCS PPO |
$182.77
|
| Rate for Payer: PHCS PPO |
$57.82
|
| Rate for Payer: Three Rivers PPO |
$139.88
|
| Rate for Payer: Three Rivers PPO |
$44.25
|
| Rate for Payer: TriWest Veterans Administration |
$38.94
|
| Rate for Payer: TriWest Veterans Administration |
$123.09
|
| Rate for Payer: United Healthcare Commercial |
$162.26
|
| Rate for Payer: United Healthcare Commercial |
$51.33
|
| Rate for Payer: United Healthcare Medicare |
$38.94
|
| Rate for Payer: United Healthcare Medicare |
$123.09
|
| Rate for Payer: WINHealth Partners Commercial |
$177.18
|
| Rate for Payer: WINHealth Partners Commercial |
$56.05
|
| Rate for Payer: Wise Provider Network Commercial |
$177.18
|
| Rate for Payer: Wise Provider Network Commercial |
$56.05
|
|
|
SUMATRIPTAN SUCCINATE / 6 MG
|
Professional
|
Both
|
$143.00
|
|
|
Service Code
|
HCPCS J3030
|
| Hospital Charge Code |
J3030
|
| Min. Negotiated Rate |
$107.25 |
| Max. Negotiated Rate |
$143.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$140.14
|
| Rate for Payer: Beech Street Commercial |
$135.85
|
| Rate for Payer: Cash Price |
$100.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$138.71
|
| Rate for Payer: Cigna of WY Commercial |
$140.14
|
| Rate for Payer: First Choice Health Commercial |
$128.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$135.85
|
| Rate for Payer: HealthUtah PPO |
$143.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$138.71
|
| Rate for Payer: One Health Plan of WY PPO |
$140.14
|
| Rate for Payer: PacificSource Commercial |
$128.70
|
| Rate for Payer: PHCS PPO |
$135.85
|
| Rate for Payer: Three Rivers PPO |
$107.25
|
| Rate for Payer: United Healthcare Commercial |
$124.41
|
| Rate for Payer: WINHealth Partners Commercial |
$135.85
|
|
|
SUPERVISION NURS FACILITY PATIENT MO 15-29 MIN
|
Professional
|
Both
|
$246.00
|
|
|
Service Code
|
HCPCS 99379
|
| Hospital Charge Code |
99379
|
| Min. Negotiated Rate |
$184.50 |
| Max. Negotiated Rate |
$246.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$241.08
|
| Rate for Payer: Beech Street Commercial |
$233.70
|
| Rate for Payer: Cash Price |
$172.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$238.62
|
| Rate for Payer: Cigna of WY Commercial |
$241.08
|
| Rate for Payer: First Choice Health Commercial |
$221.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$233.70
|
| Rate for Payer: HealthUtah PPO |
$246.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$238.62
|
| Rate for Payer: One Health Plan of WY PPO |
$241.08
|
| Rate for Payer: PacificSource Commercial |
$221.40
|
| Rate for Payer: PHCS PPO |
$233.70
|
| Rate for Payer: Three Rivers PPO |
$184.50
|
| Rate for Payer: United Healthcare Commercial |
$214.02
|
| Rate for Payer: WINHealth Partners Commercial |
$233.70
|
|
|
SUPERVISION NURS FACILITY PATIENT MONTH 30 MIN/>
|
Professional
|
Both
|
$190.00
|
|
|
Service Code
|
HCPCS 99380
|
| Hospital Charge Code |
99380
|
| Min. Negotiated Rate |
$142.50 |
| Max. Negotiated Rate |
$190.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$186.20
|
| Rate for Payer: Beech Street Commercial |
$180.50
|
| 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: HealthUtah PPO |
$190.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$184.30
|
| 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: United Healthcare Commercial |
$165.30
|
| Rate for Payer: WINHealth Partners Commercial |
$180.50
|
|
|
SUPPLEMENTAL NURSING SYSTEM
|
Facility
|
IP
|
$70.06
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$43.93 |
| Max. Negotiated Rate |
$70.06 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$68.66
|
| Rate for Payer: Altius Auto/Workers Compensation |
$67.26
|
| Rate for Payer: Altius Commercial |
$67.26
|
| Rate for Payer: Beech Street Commercial |
$68.66
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$57.52
|
| Rate for Payer: Cash Price |
$49.04
|
| Rate for Payer: ChoiceCare Network Commercial |
$67.96
|
| Rate for Payer: Cigna of WY Commercial |
$68.66
|
| Rate for Payer: Entrust Commercial |
$66.56
|
| Rate for Payer: First Choice Health Commercial |
$66.56
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$66.56
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$46.24
|
| Rate for Payer: HealthUtah PPO |
$70.06
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$67.96
|
| Rate for Payer: Multiplan Medicare/VA |
$43.93
|
| Rate for Payer: One Health Plan of WY PPO |
$68.66
|
| Rate for Payer: PacificSource Commercial |
$63.05
|
| Rate for Payer: PHCS PPO |
$68.66
|
| Rate for Payer: Three Rivers PPO |
$52.54
|
| Rate for Payer: TriWest Veterans Administration |
$46.24
|
| Rate for Payer: United Healthcare Commercial |
$60.95
|
| Rate for Payer: United Healthcare Medicare |
$46.24
|
| Rate for Payer: WINHealth Partners Commercial |
$66.56
|
| Rate for Payer: Wise Provider Network Commercial |
$66.56
|
|
|
SUPPLEMENTAL NURSING SYSTEM
|
Facility
|
OP
|
$70.06
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$38.60 |
| Max. Negotiated Rate |
$70.06 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$68.66
|
| Rate for Payer: Aetna of WY Medicare |
$46.24
|
| Rate for Payer: Altius Auto/Workers Compensation |
$67.26
|
| Rate for Payer: Altius Commercial |
$67.26
|
| Rate for Payer: Beech Street Commercial |
$68.66
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$57.52
|
| Rate for Payer: Cash Price |
$49.04
|
| Rate for Payer: ChoiceCare Network Commercial |
$67.96
|
| Rate for Payer: Cigna of WY Commercial |
$68.66
|
| Rate for Payer: Entrust Commercial |
$66.56
|
| Rate for Payer: First Choice Health Commercial |
$66.56
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$66.56
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$40.63
|
| Rate for Payer: HealthUtah PPO |
$70.06
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$67.96
|
| Rate for Payer: Multiplan Medicare/VA |
$38.60
|
| Rate for Payer: One Health Plan of WY PPO |
$68.66
|
| Rate for Payer: PacificSource Commercial |
$63.05
|
| Rate for Payer: PHCS PPO |
$68.66
|
| Rate for Payer: Three Rivers PPO |
$52.54
|
| Rate for Payer: TriWest Veterans Administration |
$40.63
|
| Rate for Payer: United Healthcare Commercial |
$60.95
|
| Rate for Payer: United Healthcare Medicare |
$40.63
|
| Rate for Payer: WINHealth Partners Commercial |
$68.66
|
| Rate for Payer: Wise Provider Network Commercial |
$66.56
|
|
|
SUPPLIES&MATERIALS ABOVE/BEYOND PROV BY PHYS/QHP
|
Professional
|
Both
|
$43.00
|
|
|
Service Code
|
HCPCS 99070
|
| Hospital Charge Code |
99070
|
| Min. Negotiated Rate |
$32.25 |
| Max. Negotiated Rate |
$43.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$42.14
|
| Rate for Payer: Beech Street Commercial |
$40.85
|
| Rate for Payer: Cash Price |
$30.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$41.71
|
| Rate for Payer: Cigna of WY Commercial |
$42.14
|
| Rate for Payer: First Choice Health Commercial |
$38.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$40.85
|
| Rate for Payer: HealthUtah PPO |
$43.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$41.71
|
| Rate for Payer: One Health Plan of WY PPO |
$42.14
|
| Rate for Payer: PacificSource Commercial |
$38.70
|
| Rate for Payer: PHCS PPO |
$40.85
|
| Rate for Payer: Three Rivers PPO |
$32.25
|
| Rate for Payer: United Healthcare Commercial |
$37.41
|
| Rate for Payer: WINHealth Partners Commercial |
$40.85
|
|
|
SUPRACERVICAL ABDL HYSTER W/WO RMVL TUBE OVARY
|
Professional
|
Both
|
$4,978.00
|
|
|
Service Code
|
HCPCS 58180
|
| Hospital Charge Code |
58180
|
| Min. Negotiated Rate |
$785.54 |
| Max. Negotiated Rate |
$4,978.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4,878.44
|
| Rate for Payer: Aetna of WY Medicare |
$924.17
|
| Rate for Payer: Beech Street Commercial |
$4,729.10
|
| Rate for Payer: Cash Price |
$3,484.60
|
| Rate for Payer: Cash Price |
$3,484.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$4,828.66
|
| Rate for Payer: Cigna of WY Commercial |
$4,878.44
|
| Rate for Payer: First Choice Health Commercial |
$4,480.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,729.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$924.17
|
| Rate for Payer: HealthUtah PPO |
$4,978.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4,828.66
|
| Rate for Payer: Multiplan Medicare/VA |
$785.54
|
| Rate for Payer: One Health Plan of WY PPO |
$4,878.44
|
| Rate for Payer: PacificSource Commercial |
$4,480.20
|
| Rate for Payer: PHCS PPO |
$4,729.10
|
| Rate for Payer: Three Rivers PPO |
$3,733.50
|
| Rate for Payer: TriWest Veterans Administration |
$924.17
|
| Rate for Payer: United Healthcare Commercial |
$4,330.86
|
| Rate for Payer: United Healthcare Medicare |
$924.17
|
| Rate for Payer: WINHealth Partners Commercial |
$4,231.30
|
|
|
SUPRACERVICAL ABDL HYSTER W/WO RMVL TUBE OVARY
|
Professional
|
Both
|
$4,978.00
|
|
|
Service Code
|
HCPCS 58180 AS
|
| Hospital Charge Code |
58180
|
| Min. Negotiated Rate |
$785.54 |
| Max. Negotiated Rate |
$4,978.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4,878.44
|
| Rate for Payer: Aetna of WY Medicare |
$924.17
|
| Rate for Payer: Beech Street Commercial |
$4,729.10
|
| Rate for Payer: Cash Price |
$3,484.60
|
| Rate for Payer: Cash Price |
$3,484.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$4,828.66
|
| Rate for Payer: Cigna of WY Commercial |
$4,878.44
|
| Rate for Payer: First Choice Health Commercial |
$4,480.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,729.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$924.17
|
| Rate for Payer: HealthUtah PPO |
$4,978.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4,828.66
|
| Rate for Payer: Multiplan Medicare/VA |
$785.54
|
| Rate for Payer: One Health Plan of WY PPO |
$4,878.44
|
| Rate for Payer: PacificSource Commercial |
$4,480.20
|
| Rate for Payer: PHCS PPO |
$4,729.10
|
| Rate for Payer: Three Rivers PPO |
$3,733.50
|
| Rate for Payer: TriWest Veterans Administration |
$924.17
|
| Rate for Payer: United Healthcare Commercial |
$4,330.86
|
| Rate for Payer: United Healthcare Medicare |
$924.17
|
| Rate for Payer: WINHealth Partners Commercial |
$4,231.30
|
|
|
SUPRACERVICAL ABDL HYSTER W/WO RMVL TUBE OVARY
|
Professional
|
Both
|
$4,978.00
|
|
|
Service Code
|
HCPCS 58180 80
|
| Hospital Charge Code |
58180
|
| Min. Negotiated Rate |
$785.54 |
| Max. Negotiated Rate |
$4,978.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4,878.44
|
| Rate for Payer: Aetna of WY Medicare |
$924.17
|
| Rate for Payer: Beech Street Commercial |
$4,729.10
|
| Rate for Payer: Cash Price |
$3,484.60
|
| Rate for Payer: Cash Price |
$3,484.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$4,828.66
|
| Rate for Payer: Cigna of WY Commercial |
$4,878.44
|
| Rate for Payer: First Choice Health Commercial |
$4,480.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,729.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$924.17
|
| Rate for Payer: HealthUtah PPO |
$4,978.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4,828.66
|
| Rate for Payer: Multiplan Medicare/VA |
$785.54
|
| Rate for Payer: One Health Plan of WY PPO |
$4,878.44
|
| Rate for Payer: PacificSource Commercial |
$4,480.20
|
| Rate for Payer: PHCS PPO |
$4,729.10
|
| Rate for Payer: Three Rivers PPO |
$3,733.50
|
| Rate for Payer: TriWest Veterans Administration |
$924.17
|
| Rate for Payer: United Healthcare Commercial |
$4,330.86
|
| Rate for Payer: United Healthcare Medicare |
$924.17
|
| Rate for Payer: WINHealth Partners Commercial |
$4,231.30
|
|
|
SUPRAHYOID LYMPHADENECTOMY
|
Professional
|
Both
|
$3,744.00
|
|
|
Service Code
|
HCPCS 38700
|
| Hospital Charge Code |
38700
|
| Min. Negotiated Rate |
$661.62 |
| Max. Negotiated Rate |
$3,744.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,669.12
|
| Rate for Payer: Aetna of WY Medicare |
$778.38
|
| Rate for Payer: Beech Street Commercial |
$3,556.80
|
| Rate for Payer: Cash Price |
$2,620.80
|
| Rate for Payer: Cash Price |
$2,620.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,631.68
|
| Rate for Payer: Cigna of WY Commercial |
$3,669.12
|
| Rate for Payer: First Choice Health Commercial |
$3,369.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,556.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$778.38
|
| Rate for Payer: HealthUtah PPO |
$3,744.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,631.68
|
| Rate for Payer: Multiplan Medicare/VA |
$661.62
|
| Rate for Payer: One Health Plan of WY PPO |
$3,669.12
|
| Rate for Payer: PacificSource Commercial |
$3,369.60
|
| Rate for Payer: PHCS PPO |
$3,556.80
|
| Rate for Payer: Three Rivers PPO |
$2,808.00
|
| Rate for Payer: TriWest Veterans Administration |
$778.38
|
| Rate for Payer: United Healthcare Commercial |
$3,257.28
|
| Rate for Payer: United Healthcare Medicare |
$778.38
|
| Rate for Payer: WINHealth Partners Commercial |
$3,182.40
|
|
|
SURGICAL ARTHROSCOPY SHOULDER BICEPS TENODESIS
|
Professional
|
Both
|
$4,739.00
|
|
|
Service Code
|
HCPCS 29828
|
| Hospital Charge Code |
29828
|
| Min. Negotiated Rate |
$752.43 |
| Max. Negotiated Rate |
$4,739.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4,644.22
|
| Rate for Payer: Aetna of WY Medicare |
$885.21
|
| Rate for Payer: Beech Street Commercial |
$4,502.05
|
| Rate for Payer: Cash Price |
$3,317.30
|
| Rate for Payer: Cash Price |
$3,317.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$4,596.83
|
| Rate for Payer: Cigna of WY Commercial |
$4,644.22
|
| Rate for Payer: First Choice Health Commercial |
$4,265.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,502.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$885.21
|
| Rate for Payer: HealthUtah PPO |
$4,739.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4,596.83
|
| Rate for Payer: Multiplan Medicare/VA |
$752.43
|
| Rate for Payer: One Health Plan of WY PPO |
$4,644.22
|
| Rate for Payer: PacificSource Commercial |
$4,265.10
|
| Rate for Payer: PHCS PPO |
$4,502.05
|
| Rate for Payer: Three Rivers PPO |
$3,554.25
|
| Rate for Payer: TriWest Veterans Administration |
$885.21
|
| Rate for Payer: United Healthcare Commercial |
$4,122.93
|
| Rate for Payer: United Healthcare Medicare |
$885.21
|
| Rate for Payer: WINHealth Partners Commercial |
$4,028.15
|
|
