|
SYRINGE KIT MULTIUSE (A2000) CONTRAST
|
Facility
|
IP
|
$105.00
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$65.84 |
| Max. Negotiated Rate |
$105.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$102.90
|
| Rate for Payer: Altius Auto/Workers Compensation |
$100.80
|
| Rate for Payer: Altius Commercial |
$100.80
|
| Rate for Payer: Beech Street Commercial |
$102.90
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$86.20
|
| Rate for Payer: Cash Price |
$73.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$101.85
|
| Rate for Payer: Cigna of WY Commercial |
$102.90
|
| Rate for Payer: Entrust Commercial |
$99.75
|
| Rate for Payer: First Choice Health Commercial |
$99.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$99.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$69.30
|
| Rate for Payer: HealthUtah PPO |
$105.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$101.85
|
| Rate for Payer: Multiplan Medicare/VA |
$65.84
|
| Rate for Payer: One Health Plan of WY PPO |
$102.90
|
| Rate for Payer: PacificSource Commercial |
$94.50
|
| Rate for Payer: PHCS PPO |
$102.90
|
| Rate for Payer: Three Rivers PPO |
$78.75
|
| Rate for Payer: TriWest Veterans Administration |
$69.30
|
| Rate for Payer: United Healthcare Commercial |
$91.35
|
| Rate for Payer: United Healthcare Medicare |
$69.30
|
| Rate for Payer: WINHealth Partners Commercial |
$99.75
|
| Rate for Payer: Wise Provider Network Commercial |
$99.75
|
|
|
SYRINGE KIT MULTIUSE (A2000) CONTRAST
|
Facility
|
OP
|
$105.00
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$57.86 |
| Max. Negotiated Rate |
$105.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$102.90
|
| Rate for Payer: Aetna of WY Medicare |
$69.30
|
| Rate for Payer: Altius Auto/Workers Compensation |
$100.80
|
| Rate for Payer: Altius Commercial |
$100.80
|
| Rate for Payer: Beech Street Commercial |
$102.90
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$86.20
|
| Rate for Payer: Cash Price |
$73.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$101.85
|
| Rate for Payer: Cigna of WY Commercial |
$102.90
|
| Rate for Payer: Entrust Commercial |
$99.75
|
| Rate for Payer: First Choice Health Commercial |
$99.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$99.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$60.90
|
| Rate for Payer: HealthUtah PPO |
$105.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$101.85
|
| Rate for Payer: Multiplan Medicare/VA |
$57.86
|
| Rate for Payer: One Health Plan of WY PPO |
$102.90
|
| Rate for Payer: PacificSource Commercial |
$94.50
|
| Rate for Payer: PHCS PPO |
$102.90
|
| Rate for Payer: Three Rivers PPO |
$78.75
|
| Rate for Payer: TriWest Veterans Administration |
$60.90
|
| Rate for Payer: United Healthcare Commercial |
$91.35
|
| Rate for Payer: United Healthcare Medicare |
$60.90
|
| Rate for Payer: WINHealth Partners Commercial |
$102.90
|
| Rate for Payer: Wise Provider Network Commercial |
$99.75
|
|
|
TAC TOPICAL GEL [400789]
|
Facility
|
IP
|
$88.00
|
|
|
Service Code
|
NDC 9994007891
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$55.18 |
| Max. Negotiated Rate |
$88.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$86.24
|
| Rate for Payer: Altius Auto/Workers Compensation |
$84.48
|
| Rate for Payer: Altius Commercial |
$84.48
|
| Rate for Payer: Beech Street Commercial |
$86.24
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$72.25
|
| Rate for Payer: Cash Price |
$61.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$85.36
|
| Rate for Payer: Cigna of WY Commercial |
$86.24
|
| Rate for Payer: Entrust Commercial |
$83.60
|
| Rate for Payer: First Choice Health Commercial |
$83.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$83.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$58.08
|
| Rate for Payer: HealthUtah PPO |
$88.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$85.36
|
| Rate for Payer: Multiplan Medicare/VA |
$55.18
|
| Rate for Payer: One Health Plan of WY PPO |
$86.24
|
| Rate for Payer: PacificSource Commercial |
$79.20
|
| Rate for Payer: PHCS PPO |
$86.24
|
| Rate for Payer: Three Rivers PPO |
$66.00
|
| Rate for Payer: TriWest Veterans Administration |
$58.08
|
| Rate for Payer: United Healthcare Commercial |
$76.56
|
| Rate for Payer: United Healthcare Medicare |
$58.08
|
| Rate for Payer: WINHealth Partners Commercial |
$83.60
|
| Rate for Payer: Wise Provider Network Commercial |
$83.60
|
|
|
TAC TOPICAL GEL [400789]
|
Facility
|
OP
|
$88.00
|
|
|
Service Code
|
NDC 9994007891
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$48.49 |
| Max. Negotiated Rate |
$88.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$86.24
|
| Rate for Payer: Aetna of WY Medicare |
$58.08
|
| Rate for Payer: Altius Auto/Workers Compensation |
$84.48
|
| Rate for Payer: Altius Commercial |
$84.48
|
| Rate for Payer: Beech Street Commercial |
$86.24
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$72.25
|
| Rate for Payer: Cash Price |
$61.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$85.36
|
| Rate for Payer: Cigna of WY Commercial |
$86.24
|
| Rate for Payer: Entrust Commercial |
$83.60
|
| Rate for Payer: First Choice Health Commercial |
$83.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$83.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$51.04
|
| Rate for Payer: HealthUtah PPO |
$88.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$85.36
|
| Rate for Payer: Multiplan Medicare/VA |
$48.49
|
| Rate for Payer: One Health Plan of WY PPO |
$86.24
|
| Rate for Payer: PacificSource Commercial |
$79.20
|
| Rate for Payer: PHCS PPO |
$86.24
|
| Rate for Payer: Three Rivers PPO |
$66.00
|
| Rate for Payer: TriWest Veterans Administration |
$51.04
|
| Rate for Payer: United Healthcare Commercial |
$76.56
|
| Rate for Payer: United Healthcare Medicare |
$51.04
|
| Rate for Payer: WINHealth Partners Commercial |
$86.24
|
| Rate for Payer: Wise Provider Network Commercial |
$83.60
|
|
|
TAC TOPICAL GEL [400789]
|
Facility
|
IP
|
$159.56
|
|
|
Service Code
|
NDC 9999400789
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$100.04 |
| Max. Negotiated Rate |
$159.56 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$156.37
|
| Rate for Payer: Altius Auto/Workers Compensation |
$153.18
|
| Rate for Payer: Altius Commercial |
$153.18
|
| Rate for Payer: Beech Street Commercial |
$156.37
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$131.00
|
| Rate for Payer: Cash Price |
$111.69
|
| Rate for Payer: ChoiceCare Network Commercial |
$154.77
|
| Rate for Payer: Cigna of WY Commercial |
$156.37
|
| Rate for Payer: Entrust Commercial |
$151.58
|
| Rate for Payer: First Choice Health Commercial |
$151.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$151.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$105.31
|
| Rate for Payer: HealthUtah PPO |
$159.56
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$154.77
|
| Rate for Payer: Multiplan Medicare/VA |
$100.04
|
| Rate for Payer: One Health Plan of WY PPO |
$156.37
|
| Rate for Payer: PacificSource Commercial |
$143.60
|
| Rate for Payer: PHCS PPO |
$156.37
|
| Rate for Payer: Three Rivers PPO |
$119.67
|
| Rate for Payer: TriWest Veterans Administration |
$105.31
|
| Rate for Payer: United Healthcare Commercial |
$138.82
|
| Rate for Payer: United Healthcare Medicare |
$105.31
|
| Rate for Payer: WINHealth Partners Commercial |
$151.58
|
| Rate for Payer: Wise Provider Network Commercial |
$151.58
|
|
|
TAC TOPICAL GEL [400789]
|
Facility
|
OP
|
$159.56
|
|
|
Service Code
|
NDC 9999400789
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$87.92 |
| Max. Negotiated Rate |
$159.56 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$156.37
|
| Rate for Payer: Aetna of WY Medicare |
$105.31
|
| Rate for Payer: Altius Auto/Workers Compensation |
$153.18
|
| Rate for Payer: Altius Commercial |
$153.18
|
| Rate for Payer: Beech Street Commercial |
$156.37
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$131.00
|
| Rate for Payer: Cash Price |
$111.69
|
| Rate for Payer: ChoiceCare Network Commercial |
$154.77
|
| Rate for Payer: Cigna of WY Commercial |
$156.37
|
| Rate for Payer: Entrust Commercial |
$151.58
|
| Rate for Payer: First Choice Health Commercial |
$151.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$151.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$92.54
|
| Rate for Payer: HealthUtah PPO |
$159.56
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$154.77
|
| Rate for Payer: Multiplan Medicare/VA |
$87.92
|
| Rate for Payer: One Health Plan of WY PPO |
$156.37
|
| Rate for Payer: PacificSource Commercial |
$143.60
|
| Rate for Payer: PHCS PPO |
$156.37
|
| Rate for Payer: Three Rivers PPO |
$119.67
|
| Rate for Payer: TriWest Veterans Administration |
$92.54
|
| Rate for Payer: United Healthcare Commercial |
$138.82
|
| Rate for Payer: United Healthcare Medicare |
$92.54
|
| Rate for Payer: WINHealth Partners Commercial |
$156.37
|
| Rate for Payer: Wise Provider Network Commercial |
$151.58
|
|
|
TAMSULOSIN 0.4 MG CAPSULE [10975]
|
Facility
|
IP
|
$2.36
|
|
|
Service Code
|
NDC 6808429901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.48 |
| Max. Negotiated Rate |
$2.36 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.31
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.27
|
| Rate for Payer: Altius Commercial |
$2.27
|
| Rate for Payer: Beech Street Commercial |
$2.31
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.94
|
| Rate for Payer: Cash Price |
$1.66
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.29
|
| Rate for Payer: Cigna of WY Commercial |
$2.31
|
| Rate for Payer: Entrust Commercial |
$2.24
|
| Rate for Payer: First Choice Health Commercial |
$2.24
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.24
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.56
|
| Rate for Payer: HealthUtah PPO |
$2.36
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.29
|
| Rate for Payer: Multiplan Medicare/VA |
$1.48
|
| Rate for Payer: One Health Plan of WY PPO |
$2.31
|
| Rate for Payer: PacificSource Commercial |
$2.12
|
| Rate for Payer: PHCS PPO |
$2.31
|
| Rate for Payer: Three Rivers PPO |
$1.77
|
| Rate for Payer: TriWest Veterans Administration |
$1.56
|
| Rate for Payer: United Healthcare Commercial |
$2.05
|
| Rate for Payer: United Healthcare Medicare |
$1.56
|
| Rate for Payer: WINHealth Partners Commercial |
$2.24
|
| Rate for Payer: Wise Provider Network Commercial |
$2.24
|
|
|
TAMSULOSIN 0.4 MG CAPSULE [10975]
|
Facility
|
OP
|
$2.36
|
|
|
Service Code
|
NDC 6808429901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$2.36 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.31
|
| Rate for Payer: Aetna of WY Medicare |
$1.56
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.27
|
| Rate for Payer: Altius Commercial |
$2.27
|
| Rate for Payer: Beech Street Commercial |
$2.31
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.94
|
| Rate for Payer: Cash Price |
$1.66
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.29
|
| Rate for Payer: Cigna of WY Commercial |
$2.31
|
| Rate for Payer: Entrust Commercial |
$2.24
|
| Rate for Payer: First Choice Health Commercial |
$2.24
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.24
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.37
|
| Rate for Payer: HealthUtah PPO |
$2.36
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.29
|
| Rate for Payer: Multiplan Medicare/VA |
$1.30
|
| Rate for Payer: One Health Plan of WY PPO |
$2.31
|
| Rate for Payer: PacificSource Commercial |
$2.12
|
| Rate for Payer: PHCS PPO |
$2.31
|
| Rate for Payer: Three Rivers PPO |
$1.77
|
| Rate for Payer: TriWest Veterans Administration |
$1.37
|
| Rate for Payer: United Healthcare Commercial |
$2.05
|
| Rate for Payer: United Healthcare Medicare |
$1.37
|
| Rate for Payer: WINHealth Partners Commercial |
$2.31
|
| Rate for Payer: Wise Provider Network Commercial |
$2.24
|
|
|
TAMSULOSIN 0.4 MG CAPSULE [10975]
|
Facility
|
IP
|
$2.36
|
|
|
Service Code
|
NDC 6808429911
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.48 |
| Max. Negotiated Rate |
$2.36 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.31
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.27
|
| Rate for Payer: Altius Commercial |
$2.27
|
| Rate for Payer: Beech Street Commercial |
$2.31
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.94
|
| Rate for Payer: Cash Price |
$1.66
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.29
|
| Rate for Payer: Cigna of WY Commercial |
$2.31
|
| Rate for Payer: Entrust Commercial |
$2.24
|
| Rate for Payer: First Choice Health Commercial |
$2.24
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.24
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.56
|
| Rate for Payer: HealthUtah PPO |
$2.36
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.29
|
| Rate for Payer: Multiplan Medicare/VA |
$1.48
|
| Rate for Payer: One Health Plan of WY PPO |
$2.31
|
| Rate for Payer: PacificSource Commercial |
$2.12
|
| Rate for Payer: PHCS PPO |
$2.31
|
| Rate for Payer: Three Rivers PPO |
$1.77
|
| Rate for Payer: TriWest Veterans Administration |
$1.56
|
| Rate for Payer: United Healthcare Commercial |
$2.05
|
| Rate for Payer: United Healthcare Medicare |
$1.56
|
| Rate for Payer: WINHealth Partners Commercial |
$2.24
|
| Rate for Payer: Wise Provider Network Commercial |
$2.24
|
|
|
TAMSULOSIN 0.4 MG CAPSULE [10975]
|
Facility
|
OP
|
$2.36
|
|
|
Service Code
|
NDC 6808429911
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$2.36 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.31
|
| Rate for Payer: Aetna of WY Medicare |
$1.56
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.27
|
| Rate for Payer: Altius Commercial |
$2.27
|
| Rate for Payer: Beech Street Commercial |
$2.31
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.94
|
| Rate for Payer: Cash Price |
$1.66
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.29
|
| Rate for Payer: Cigna of WY Commercial |
$2.31
|
| Rate for Payer: Entrust Commercial |
$2.24
|
| Rate for Payer: First Choice Health Commercial |
$2.24
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.24
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.37
|
| Rate for Payer: HealthUtah PPO |
$2.36
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.29
|
| Rate for Payer: Multiplan Medicare/VA |
$1.30
|
| Rate for Payer: One Health Plan of WY PPO |
$2.31
|
| Rate for Payer: PacificSource Commercial |
$2.12
|
| Rate for Payer: PHCS PPO |
$2.31
|
| Rate for Payer: Three Rivers PPO |
$1.77
|
| Rate for Payer: TriWest Veterans Administration |
$1.37
|
| Rate for Payer: United Healthcare Commercial |
$2.05
|
| Rate for Payer: United Healthcare Medicare |
$1.37
|
| Rate for Payer: WINHealth Partners Commercial |
$2.31
|
| Rate for Payer: Wise Provider Network Commercial |
$2.24
|
|
|
TANGENTIAL BIOPSY SKIN EA SEP/ADDITIONAL LESION
|
Professional
|
Both
|
$113.00
|
|
|
Service Code
|
HCPCS 11103
|
| Hospital Charge Code |
11103
|
| Min. Negotiated Rate |
$17.80 |
| Max. Negotiated Rate |
$113.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$110.74
|
| Rate for Payer: Aetna of WY Medicare |
$20.94
|
| Rate for Payer: Beech Street Commercial |
$107.35
|
| Rate for Payer: Cash Price |
$79.10
|
| Rate for Payer: Cash Price |
$79.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$109.61
|
| Rate for Payer: Cigna of WY Commercial |
$110.74
|
| Rate for Payer: First Choice Health Commercial |
$101.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$107.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$20.94
|
| Rate for Payer: HealthUtah PPO |
$113.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$109.61
|
| Rate for Payer: Multiplan Medicare/VA |
$17.80
|
| Rate for Payer: One Health Plan of WY PPO |
$110.74
|
| Rate for Payer: PacificSource Commercial |
$101.70
|
| Rate for Payer: PHCS PPO |
$107.35
|
| Rate for Payer: Three Rivers PPO |
$84.75
|
| Rate for Payer: TriWest Veterans Administration |
$20.94
|
| Rate for Payer: United Healthcare Commercial |
$98.31
|
| Rate for Payer: United Healthcare Medicare |
$20.94
|
| Rate for Payer: WINHealth Partners Commercial |
$96.05
|
|
|
TANGENTIAL BIOPSY SKIN SINGLE LESION
|
Professional
|
Both
|
$195.00
|
|
|
Service Code
|
HCPCS 11102
|
| Hospital Charge Code |
11102
|
| Min. Negotiated Rate |
$30.67 |
| Max. Negotiated Rate |
$195.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$191.10
|
| Rate for Payer: Aetna of WY Medicare |
$36.08
|
| Rate for Payer: Beech Street Commercial |
$185.25
|
| Rate for Payer: Cash Price |
$136.50
|
| Rate for Payer: Cash Price |
$136.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$189.15
|
| Rate for Payer: Cigna of WY Commercial |
$191.10
|
| Rate for Payer: First Choice Health Commercial |
$175.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$185.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$36.08
|
| Rate for Payer: HealthUtah PPO |
$195.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$189.15
|
| Rate for Payer: Multiplan Medicare/VA |
$30.67
|
| Rate for Payer: One Health Plan of WY PPO |
$191.10
|
| Rate for Payer: PacificSource Commercial |
$175.50
|
| Rate for Payer: PHCS PPO |
$185.25
|
| Rate for Payer: Three Rivers PPO |
$146.25
|
| Rate for Payer: TriWest Veterans Administration |
$36.08
|
| Rate for Payer: United Healthcare Commercial |
$169.65
|
| Rate for Payer: United Healthcare Medicare |
$36.08
|
| Rate for Payer: WINHealth Partners Commercial |
$165.75
|
|
|
TAP BLOCK BILATERAL BY INJECTION(S)
|
Professional
|
Both
|
$490.00
|
|
|
Service Code
|
HCPCS 64488
|
| Hospital Charge Code |
64488
|
| Min. Negotiated Rate |
$55.56 |
| Max. Negotiated Rate |
$490.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$480.20
|
| Rate for Payer: Aetna of WY Medicare |
$65.36
|
| Rate for Payer: Beech Street Commercial |
$465.50
|
| Rate for Payer: Cash Price |
$343.00
|
| Rate for Payer: Cash Price |
$343.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$475.30
|
| Rate for Payer: Cigna of WY Commercial |
$480.20
|
| Rate for Payer: First Choice Health Commercial |
$441.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$465.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$65.36
|
| Rate for Payer: HealthUtah PPO |
$490.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$475.30
|
| Rate for Payer: Multiplan Medicare/VA |
$55.56
|
| Rate for Payer: One Health Plan of WY PPO |
$480.20
|
| Rate for Payer: PacificSource Commercial |
$441.00
|
| Rate for Payer: PHCS PPO |
$465.50
|
| Rate for Payer: Three Rivers PPO |
$367.50
|
| Rate for Payer: TriWest Veterans Administration |
$65.36
|
| Rate for Payer: United Healthcare Commercial |
$426.30
|
| Rate for Payer: United Healthcare Medicare |
$65.36
|
| Rate for Payer: WINHealth Partners Commercial |
$416.50
|
|
|
TAP BLOCK BILATERAL BY INJECTION(S)
|
Professional
|
Both
|
$980.00
|
|
|
Service Code
|
HCPCS 64488 50
|
| Hospital Charge Code |
64488
|
| Min. Negotiated Rate |
$55.56 |
| Max. Negotiated Rate |
$980.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$960.40
|
| Rate for Payer: Aetna of WY Medicare |
$65.36
|
| Rate for Payer: Beech Street Commercial |
$931.00
|
| Rate for Payer: Cash Price |
$686.00
|
| Rate for Payer: Cash Price |
$686.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$950.60
|
| Rate for Payer: Cigna of WY Commercial |
$960.40
|
| Rate for Payer: First Choice Health Commercial |
$882.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$931.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$65.36
|
| Rate for Payer: HealthUtah PPO |
$980.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$950.60
|
| Rate for Payer: Multiplan Medicare/VA |
$55.56
|
| Rate for Payer: One Health Plan of WY PPO |
$960.40
|
| Rate for Payer: PacificSource Commercial |
$882.00
|
| Rate for Payer: PHCS PPO |
$931.00
|
| Rate for Payer: Three Rivers PPO |
$735.00
|
| Rate for Payer: TriWest Veterans Administration |
$65.36
|
| Rate for Payer: United Healthcare Commercial |
$852.60
|
| Rate for Payer: United Healthcare Medicare |
$65.36
|
| Rate for Payer: WINHealth Partners Commercial |
$833.00
|
|
|
TAP BLOCK UNILATERAL BY INJECTION(S)
|
Professional
|
Both
|
$562.00
|
|
|
Service Code
|
HCPCS 64486
|
| Hospital Charge Code |
64486
|
| Min. Negotiated Rate |
$44.57 |
| Max. Negotiated Rate |
$562.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$550.76
|
| Rate for Payer: Aetna of WY Medicare |
$52.43
|
| Rate for Payer: Beech Street Commercial |
$533.90
|
| Rate for Payer: Cash Price |
$393.40
|
| Rate for Payer: Cash Price |
$393.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$545.14
|
| Rate for Payer: Cigna of WY Commercial |
$550.76
|
| Rate for Payer: First Choice Health Commercial |
$505.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$533.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$52.43
|
| Rate for Payer: HealthUtah PPO |
$562.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$545.14
|
| Rate for Payer: Multiplan Medicare/VA |
$44.57
|
| Rate for Payer: One Health Plan of WY PPO |
$550.76
|
| Rate for Payer: PacificSource Commercial |
$505.80
|
| Rate for Payer: PHCS PPO |
$533.90
|
| Rate for Payer: Three Rivers PPO |
$421.50
|
| Rate for Payer: TriWest Veterans Administration |
$52.43
|
| Rate for Payer: United Healthcare Commercial |
$488.94
|
| Rate for Payer: United Healthcare Medicare |
$52.43
|
| Rate for Payer: WINHealth Partners Commercial |
$477.70
|
|
|
TAP BLOCK UNILATERAL BY INJECTION(S)
|
Professional
|
Both
|
$1,124.00
|
|
|
Service Code
|
HCPCS 64486 50
|
| Hospital Charge Code |
64486
|
| Min. Negotiated Rate |
$44.57 |
| Max. Negotiated Rate |
$1,124.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,101.52
|
| Rate for Payer: Aetna of WY Medicare |
$52.43
|
| Rate for Payer: Beech Street Commercial |
$1,067.80
|
| Rate for Payer: Cash Price |
$786.80
|
| Rate for Payer: Cash Price |
$786.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,090.28
|
| Rate for Payer: Cigna of WY Commercial |
$1,101.52
|
| Rate for Payer: First Choice Health Commercial |
$1,011.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,067.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$52.43
|
| Rate for Payer: HealthUtah PPO |
$1,124.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,090.28
|
| Rate for Payer: Multiplan Medicare/VA |
$44.57
|
| Rate for Payer: One Health Plan of WY PPO |
$1,101.52
|
| Rate for Payer: PacificSource Commercial |
$1,011.60
|
| Rate for Payer: PHCS PPO |
$1,067.80
|
| Rate for Payer: Three Rivers PPO |
$843.00
|
| Rate for Payer: TriWest Veterans Administration |
$52.43
|
| Rate for Payer: United Healthcare Commercial |
$977.88
|
| Rate for Payer: United Healthcare Medicare |
$52.43
|
| Rate for Payer: WINHealth Partners Commercial |
$955.40
|
|
|
TB CELL MEDIATED ANTIGN RESPNSE GAMMA INTERFERON
|
Professional
|
Both
|
$69.00
|
|
|
Service Code
|
HCPCS 86480
|
| Hospital Charge Code |
86480
|
| Min. Negotiated Rate |
$51.75 |
| Max. Negotiated Rate |
$69.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$67.62
|
| Rate for Payer: Aetna of WY Medicare |
$61.98
|
| Rate for Payer: Beech Street Commercial |
$65.55
|
| Rate for Payer: Cash Price |
$48.30
|
| Rate for Payer: Cash Price |
$48.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$66.93
|
| Rate for Payer: Cigna of WY Commercial |
$67.62
|
| Rate for Payer: First Choice Health Commercial |
$62.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$65.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$61.98
|
| Rate for Payer: HealthUtah PPO |
$69.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$66.93
|
| Rate for Payer: Multiplan Medicare/VA |
$52.68
|
| Rate for Payer: One Health Plan of WY PPO |
$67.62
|
| Rate for Payer: PacificSource Commercial |
$62.10
|
| Rate for Payer: PHCS PPO |
$65.55
|
| Rate for Payer: Three Rivers PPO |
$51.75
|
| Rate for Payer: TriWest Veterans Administration |
$61.98
|
| Rate for Payer: United Healthcare Commercial |
$60.03
|
| Rate for Payer: United Healthcare Medicare |
$61.98
|
| Rate for Payer: WINHealth Partners Commercial |
$65.55
|
|
|
TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE [131264]
|
Facility
|
IP
|
$514.86
|
|
|
Service Code
|
HCPCS J1447
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$322.82 |
| Max. Negotiated Rate |
$514.86 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$504.56
|
| Rate for Payer: Altius Auto/Workers Compensation |
$494.27
|
| Rate for Payer: Altius Commercial |
$494.27
|
| Rate for Payer: Beech Street Commercial |
$504.56
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$422.70
|
| Rate for Payer: Cash Price |
$360.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$499.41
|
| Rate for Payer: Cigna of WY Commercial |
$504.56
|
| Rate for Payer: Entrust Commercial |
$489.12
|
| Rate for Payer: First Choice Health Commercial |
$489.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$489.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$339.81
|
| Rate for Payer: HealthUtah PPO |
$514.86
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$499.41
|
| Rate for Payer: Multiplan Medicare/VA |
$322.82
|
| Rate for Payer: One Health Plan of WY PPO |
$504.56
|
| Rate for Payer: PacificSource Commercial |
$463.37
|
| Rate for Payer: PHCS PPO |
$504.56
|
| Rate for Payer: Three Rivers PPO |
$386.14
|
| Rate for Payer: TriWest Veterans Administration |
$339.81
|
| Rate for Payer: United Healthcare Commercial |
$447.93
|
| Rate for Payer: United Healthcare Medicare |
$339.81
|
| Rate for Payer: WINHealth Partners Commercial |
$489.12
|
| Rate for Payer: Wise Provider Network Commercial |
$489.12
|
|
|
TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE [131264]
|
Facility
|
OP
|
$514.86
|
|
|
Service Code
|
HCPCS J1447
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$283.69 |
| Max. Negotiated Rate |
$514.86 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$504.56
|
| Rate for Payer: Aetna of WY Medicare |
$339.81
|
| Rate for Payer: Altius Auto/Workers Compensation |
$494.27
|
| Rate for Payer: Altius Commercial |
$494.27
|
| Rate for Payer: Beech Street Commercial |
$504.56
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$422.70
|
| Rate for Payer: Cash Price |
$360.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$499.41
|
| Rate for Payer: Cigna of WY Commercial |
$504.56
|
| Rate for Payer: Entrust Commercial |
$489.12
|
| Rate for Payer: First Choice Health Commercial |
$489.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$489.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$298.62
|
| Rate for Payer: HealthUtah PPO |
$514.86
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$499.41
|
| Rate for Payer: Multiplan Medicare/VA |
$283.69
|
| Rate for Payer: One Health Plan of WY PPO |
$504.56
|
| Rate for Payer: PacificSource Commercial |
$463.37
|
| Rate for Payer: PHCS PPO |
$504.56
|
| Rate for Payer: Three Rivers PPO |
$386.14
|
| Rate for Payer: TriWest Veterans Administration |
$298.62
|
| Rate for Payer: United Healthcare Commercial |
$447.93
|
| Rate for Payer: United Healthcare Medicare |
$298.62
|
| Rate for Payer: WINHealth Partners Commercial |
$504.56
|
| Rate for Payer: Wise Provider Network Commercial |
$489.12
|
|
|
TC99M SESTAMIBI
|
Professional
|
Both
|
$736.00
|
|
|
Service Code
|
HCPCS A9500
|
| Hospital Charge Code |
A9500
|
| Min. Negotiated Rate |
$552.00 |
| Max. Negotiated Rate |
$736.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$721.28
|
| Rate for Payer: Beech Street Commercial |
$699.20
|
| Rate for Payer: Cash Price |
$515.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$713.92
|
| Rate for Payer: Cigna of WY Commercial |
$721.28
|
| Rate for Payer: First Choice Health Commercial |
$662.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$699.20
|
| Rate for Payer: HealthUtah PPO |
$736.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$713.92
|
| Rate for Payer: One Health Plan of WY PPO |
$721.28
|
| Rate for Payer: PacificSource Commercial |
$662.40
|
| Rate for Payer: PHCS PPO |
$699.20
|
| Rate for Payer: Three Rivers PPO |
$552.00
|
| Rate for Payer: United Healthcare Commercial |
$640.32
|
| Rate for Payer: WINHealth Partners Commercial |
$699.20
|
|
|
TDAP VACCINE 7 YRS/> IM
|
Professional
|
Both
|
$164.00
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
90715
|
| Min. Negotiated Rate |
$33.22 |
| Max. Negotiated Rate |
$164.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$160.72
|
| Rate for Payer: Aetna of WY Medicare |
$39.09
|
| Rate for Payer: Beech Street Commercial |
$155.80
|
| Rate for Payer: Cash Price |
$114.80
|
| Rate for Payer: Cash Price |
$114.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$159.08
|
| Rate for Payer: Cigna of WY Commercial |
$160.72
|
| Rate for Payer: First Choice Health Commercial |
$147.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$155.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$39.09
|
| Rate for Payer: HealthUtah PPO |
$164.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$159.08
|
| Rate for Payer: Multiplan Medicare/VA |
$33.22
|
| Rate for Payer: One Health Plan of WY PPO |
$160.72
|
| Rate for Payer: PacificSource Commercial |
$147.60
|
| Rate for Payer: PHCS PPO |
$155.80
|
| Rate for Payer: Three Rivers PPO |
$123.00
|
| Rate for Payer: TriWest Veterans Administration |
$39.09
|
| Rate for Payer: United Healthcare Commercial |
$142.68
|
| Rate for Payer: United Healthcare Medicare |
$39.09
|
| Rate for Payer: WINHealth Partners Commercial |
$164.00
|
|
|
TDN TRNSPLJ/TR FLXR/XTNSR F/ARM&/WRST 1 EA TDN
|
Professional
|
Both
|
$2,173.00
|
|
|
Service Code
|
HCPCS 25310 80
|
| Hospital Charge Code |
25310
|
| Min. Negotiated Rate |
$517.50 |
| Max. Negotiated Rate |
$2,173.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,129.54
|
| Rate for Payer: Aetna of WY Medicare |
$608.82
|
| Rate for Payer: Beech Street Commercial |
$2,064.35
|
| Rate for Payer: Cash Price |
$1,521.10
|
| Rate for Payer: Cash Price |
$1,521.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,107.81
|
| Rate for Payer: Cigna of WY Commercial |
$2,129.54
|
| Rate for Payer: First Choice Health Commercial |
$1,955.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,064.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$608.82
|
| Rate for Payer: HealthUtah PPO |
$2,173.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,107.81
|
| Rate for Payer: Multiplan Medicare/VA |
$517.50
|
| Rate for Payer: One Health Plan of WY PPO |
$2,129.54
|
| Rate for Payer: PacificSource Commercial |
$1,955.70
|
| Rate for Payer: PHCS PPO |
$2,064.35
|
| Rate for Payer: Three Rivers PPO |
$1,629.75
|
| Rate for Payer: TriWest Veterans Administration |
$608.82
|
| Rate for Payer: United Healthcare Commercial |
$1,890.51
|
| Rate for Payer: United Healthcare Medicare |
$608.82
|
| Rate for Payer: WINHealth Partners Commercial |
$1,847.05
|
|
|
TDN TRNSPLJ/TR FLXR/XTNSR F/ARM&/WRST 1 EA TDN
|
Professional
|
Both
|
$2,173.00
|
|
|
Service Code
|
HCPCS 25310 AS
|
| Hospital Charge Code |
25310
|
| Min. Negotiated Rate |
$517.50 |
| Max. Negotiated Rate |
$2,173.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,129.54
|
| Rate for Payer: Aetna of WY Medicare |
$608.82
|
| Rate for Payer: Beech Street Commercial |
$2,064.35
|
| Rate for Payer: Cash Price |
$1,521.10
|
| Rate for Payer: Cash Price |
$1,521.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,107.81
|
| Rate for Payer: Cigna of WY Commercial |
$2,129.54
|
| Rate for Payer: First Choice Health Commercial |
$1,955.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,064.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$608.82
|
| Rate for Payer: HealthUtah PPO |
$2,173.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,107.81
|
| Rate for Payer: Multiplan Medicare/VA |
$517.50
|
| Rate for Payer: One Health Plan of WY PPO |
$2,129.54
|
| Rate for Payer: PacificSource Commercial |
$1,955.70
|
| Rate for Payer: PHCS PPO |
$2,064.35
|
| Rate for Payer: Three Rivers PPO |
$1,629.75
|
| Rate for Payer: TriWest Veterans Administration |
$608.82
|
| Rate for Payer: United Healthcare Commercial |
$1,890.51
|
| Rate for Payer: United Healthcare Medicare |
$608.82
|
| Rate for Payer: WINHealth Partners Commercial |
$1,847.05
|
|
|
TDN TRNSPLJ/TR FLXR/XTNSR F/ARM&/WRST 1 EA TDN
|
Professional
|
Both
|
$2,173.00
|
|
|
Service Code
|
HCPCS 25310
|
| Hospital Charge Code |
25310
|
| Min. Negotiated Rate |
$517.50 |
| Max. Negotiated Rate |
$2,173.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,129.54
|
| Rate for Payer: Aetna of WY Medicare |
$608.82
|
| Rate for Payer: Beech Street Commercial |
$2,064.35
|
| Rate for Payer: Cash Price |
$1,521.10
|
| Rate for Payer: Cash Price |
$1,521.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,107.81
|
| Rate for Payer: Cigna of WY Commercial |
$2,129.54
|
| Rate for Payer: First Choice Health Commercial |
$1,955.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,064.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$608.82
|
| Rate for Payer: HealthUtah PPO |
$2,173.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,107.81
|
| Rate for Payer: Multiplan Medicare/VA |
$517.50
|
| Rate for Payer: One Health Plan of WY PPO |
$2,129.54
|
| Rate for Payer: PacificSource Commercial |
$1,955.70
|
| Rate for Payer: PHCS PPO |
$2,064.35
|
| Rate for Payer: Three Rivers PPO |
$1,629.75
|
| Rate for Payer: TriWest Veterans Administration |
$608.82
|
| Rate for Payer: United Healthcare Commercial |
$1,890.51
|
| Rate for Payer: United Healthcare Medicare |
$608.82
|
| Rate for Payer: WINHealth Partners Commercial |
$1,847.05
|
|
|
TDN TRNSPLJ/TR FLXR/XTNSR F/ARM&/WRST 1/TDN GR
|
Professional
|
Both
|
$2,496.00
|
|
|
Service Code
|
HCPCS 25312
|
| Hospital Charge Code |
25312
|
| Min. Negotiated Rate |
$594.28 |
| Max. Negotiated Rate |
$2,496.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,446.08
|
| Rate for Payer: Aetna of WY Medicare |
$699.15
|
| Rate for Payer: Beech Street Commercial |
$2,371.20
|
| Rate for Payer: Cash Price |
$1,747.20
|
| Rate for Payer: Cash Price |
$1,747.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,421.12
|
| Rate for Payer: Cigna of WY Commercial |
$2,446.08
|
| Rate for Payer: First Choice Health Commercial |
$2,246.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,371.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$699.15
|
| Rate for Payer: HealthUtah PPO |
$2,496.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,421.12
|
| Rate for Payer: Multiplan Medicare/VA |
$594.28
|
| Rate for Payer: One Health Plan of WY PPO |
$2,446.08
|
| Rate for Payer: PacificSource Commercial |
$2,246.40
|
| Rate for Payer: PHCS PPO |
$2,371.20
|
| Rate for Payer: Three Rivers PPO |
$1,872.00
|
| Rate for Payer: TriWest Veterans Administration |
$699.15
|
| Rate for Payer: United Healthcare Commercial |
$2,171.52
|
| Rate for Payer: United Healthcare Medicare |
$699.15
|
| Rate for Payer: WINHealth Partners Commercial |
$2,121.60
|
|
