|
TMAX FACE MASK DISPOSABLE
|
Facility
|
IP
|
$77.71
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$48.72 |
| Max. Negotiated Rate |
$77.71 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$76.16
|
| Rate for Payer: Altius Auto/Workers Compensation |
$74.60
|
| Rate for Payer: Altius Commercial |
$74.60
|
| Rate for Payer: Beech Street Commercial |
$76.16
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$63.80
|
| Rate for Payer: Cash Price |
$54.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$75.38
|
| Rate for Payer: Cigna of WY Commercial |
$76.16
|
| Rate for Payer: Entrust Commercial |
$73.82
|
| Rate for Payer: First Choice Health Commercial |
$73.82
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$73.82
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$51.29
|
| Rate for Payer: HealthUtah PPO |
$77.71
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$75.38
|
| Rate for Payer: Multiplan Medicare/VA |
$48.72
|
| Rate for Payer: One Health Plan of WY PPO |
$76.16
|
| Rate for Payer: PacificSource Commercial |
$69.94
|
| Rate for Payer: PHCS PPO |
$76.16
|
| Rate for Payer: Three Rivers PPO |
$58.28
|
| Rate for Payer: TriWest Veterans Administration |
$51.29
|
| Rate for Payer: United Healthcare Commercial |
$67.61
|
| Rate for Payer: United Healthcare Medicare |
$51.29
|
| Rate for Payer: WINHealth Partners Commercial |
$73.82
|
| Rate for Payer: Wise Provider Network Commercial |
$73.82
|
|
|
TMAX FACE MASK DISPOSABLE
|
Facility
|
OP
|
$77.71
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$42.82 |
| Max. Negotiated Rate |
$77.71 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$76.16
|
| Rate for Payer: Aetna of WY Medicare |
$51.29
|
| Rate for Payer: Altius Auto/Workers Compensation |
$74.60
|
| Rate for Payer: Altius Commercial |
$74.60
|
| Rate for Payer: Beech Street Commercial |
$76.16
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$63.80
|
| Rate for Payer: Cash Price |
$54.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$75.38
|
| Rate for Payer: Cigna of WY Commercial |
$76.16
|
| Rate for Payer: Entrust Commercial |
$73.82
|
| Rate for Payer: First Choice Health Commercial |
$73.82
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$73.82
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$45.07
|
| Rate for Payer: HealthUtah PPO |
$77.71
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$75.38
|
| Rate for Payer: Multiplan Medicare/VA |
$42.82
|
| Rate for Payer: One Health Plan of WY PPO |
$76.16
|
| Rate for Payer: PacificSource Commercial |
$69.94
|
| Rate for Payer: PHCS PPO |
$76.16
|
| Rate for Payer: Three Rivers PPO |
$58.28
|
| Rate for Payer: TriWest Veterans Administration |
$45.07
|
| Rate for Payer: United Healthcare Commercial |
$67.61
|
| Rate for Payer: United Healthcare Medicare |
$45.07
|
| Rate for Payer: WINHealth Partners Commercial |
$76.16
|
| Rate for Payer: Wise Provider Network Commercial |
$73.82
|
|
|
TNOLS FLXR/XTNSR TENDON FOREARM&/WRIST 1 EA
|
Professional
|
Both
|
$3,194.00
|
|
|
Service Code
|
HCPCS 25295
|
| Hospital Charge Code |
25295
|
| Min. Negotiated Rate |
$439.99 |
| Max. Negotiated Rate |
$3,194.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,130.12
|
| Rate for Payer: Aetna of WY Medicare |
$517.64
|
| Rate for Payer: Beech Street Commercial |
$3,034.30
|
| Rate for Payer: Cash Price |
$2,235.80
|
| Rate for Payer: Cash Price |
$2,235.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,098.18
|
| Rate for Payer: Cigna of WY Commercial |
$3,130.12
|
| Rate for Payer: First Choice Health Commercial |
$2,874.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,034.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$517.64
|
| Rate for Payer: HealthUtah PPO |
$3,194.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,098.18
|
| Rate for Payer: Multiplan Medicare/VA |
$439.99
|
| Rate for Payer: One Health Plan of WY PPO |
$3,130.12
|
| Rate for Payer: PacificSource Commercial |
$2,874.60
|
| Rate for Payer: PHCS PPO |
$3,034.30
|
| Rate for Payer: Three Rivers PPO |
$2,395.50
|
| Rate for Payer: TriWest Veterans Administration |
$517.64
|
| Rate for Payer: United Healthcare Commercial |
$2,778.78
|
| Rate for Payer: United Healthcare Medicare |
$517.64
|
| Rate for Payer: WINHealth Partners Commercial |
$2,714.90
|
|
|
TNOT ELBOW LATERAL/MEDIAL DEBRIDE OPEN
|
Professional
|
Both
|
$2,714.00
|
|
|
Service Code
|
HCPCS 24358
|
| Hospital Charge Code |
24358
|
| Min. Negotiated Rate |
$442.35 |
| Max. Negotiated Rate |
$2,714.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,659.72
|
| Rate for Payer: Aetna of WY Medicare |
$520.41
|
| Rate for Payer: Beech Street Commercial |
$2,578.30
|
| Rate for Payer: Cash Price |
$1,899.80
|
| Rate for Payer: Cash Price |
$1,899.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,632.58
|
| Rate for Payer: Cigna of WY Commercial |
$2,659.72
|
| Rate for Payer: First Choice Health Commercial |
$2,442.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,578.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$520.41
|
| Rate for Payer: HealthUtah PPO |
$2,714.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,632.58
|
| Rate for Payer: Multiplan Medicare/VA |
$442.35
|
| Rate for Payer: One Health Plan of WY PPO |
$2,659.72
|
| Rate for Payer: PacificSource Commercial |
$2,442.60
|
| Rate for Payer: PHCS PPO |
$2,578.30
|
| Rate for Payer: Three Rivers PPO |
$2,035.50
|
| Rate for Payer: TriWest Veterans Administration |
$520.41
|
| Rate for Payer: United Healthcare Commercial |
$2,361.18
|
| Rate for Payer: United Healthcare Medicare |
$520.41
|
| Rate for Payer: WINHealth Partners Commercial |
$2,306.90
|
|
|
TNOT ELBOW LATERAL/MEDIAL DEBRIDE OPEN
|
Professional
|
Both
|
$2,714.00
|
|
|
Service Code
|
HCPCS 24358 AS
|
| Hospital Charge Code |
24358
|
| Min. Negotiated Rate |
$442.35 |
| Max. Negotiated Rate |
$2,714.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,659.72
|
| Rate for Payer: Aetna of WY Medicare |
$520.41
|
| Rate for Payer: Beech Street Commercial |
$2,578.30
|
| Rate for Payer: Cash Price |
$1,899.80
|
| Rate for Payer: Cash Price |
$1,899.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,632.58
|
| Rate for Payer: Cigna of WY Commercial |
$2,659.72
|
| Rate for Payer: First Choice Health Commercial |
$2,442.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,578.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$520.41
|
| Rate for Payer: HealthUtah PPO |
$2,714.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,632.58
|
| Rate for Payer: Multiplan Medicare/VA |
$442.35
|
| Rate for Payer: One Health Plan of WY PPO |
$2,659.72
|
| Rate for Payer: PacificSource Commercial |
$2,442.60
|
| Rate for Payer: PHCS PPO |
$2,578.30
|
| Rate for Payer: Three Rivers PPO |
$2,035.50
|
| Rate for Payer: TriWest Veterans Administration |
$520.41
|
| Rate for Payer: United Healthcare Commercial |
$2,361.18
|
| Rate for Payer: United Healthcare Medicare |
$520.41
|
| Rate for Payer: WINHealth Partners Commercial |
$2,306.90
|
|
|
TNOT ELBOW LATERAL/MEDIAL DEBRIDE OPEN
|
Professional
|
Both
|
$2,714.00
|
|
|
Service Code
|
HCPCS 24358 80
|
| Hospital Charge Code |
24358
|
| Min. Negotiated Rate |
$442.35 |
| Max. Negotiated Rate |
$2,714.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,659.72
|
| Rate for Payer: Aetna of WY Medicare |
$520.41
|
| Rate for Payer: Beech Street Commercial |
$2,578.30
|
| Rate for Payer: Cash Price |
$1,899.80
|
| Rate for Payer: Cash Price |
$1,899.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,632.58
|
| Rate for Payer: Cigna of WY Commercial |
$2,659.72
|
| Rate for Payer: First Choice Health Commercial |
$2,442.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,578.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$520.41
|
| Rate for Payer: HealthUtah PPO |
$2,714.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,632.58
|
| Rate for Payer: Multiplan Medicare/VA |
$442.35
|
| Rate for Payer: One Health Plan of WY PPO |
$2,659.72
|
| Rate for Payer: PacificSource Commercial |
$2,442.60
|
| Rate for Payer: PHCS PPO |
$2,578.30
|
| Rate for Payer: Three Rivers PPO |
$2,035.50
|
| Rate for Payer: TriWest Veterans Administration |
$520.41
|
| Rate for Payer: United Healthcare Commercial |
$2,361.18
|
| Rate for Payer: United Healthcare Medicare |
$520.41
|
| Rate for Payer: WINHealth Partners Commercial |
$2,306.90
|
|
|
TNOT ELBOW LATERAL/MEDIAL DEBRIDE OPEN TDN RPR
|
Professional
|
Both
|
$3,415.00
|
|
|
Service Code
|
HCPCS 24359 AS
|
| Hospital Charge Code |
24359
|
| Min. Negotiated Rate |
$550.62 |
| Max. Negotiated Rate |
$3,415.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,346.70
|
| Rate for Payer: Aetna of WY Medicare |
$647.79
|
| Rate for Payer: Beech Street Commercial |
$3,244.25
|
| Rate for Payer: Cash Price |
$2,390.50
|
| Rate for Payer: Cash Price |
$2,390.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,312.55
|
| Rate for Payer: Cigna of WY Commercial |
$3,346.70
|
| Rate for Payer: First Choice Health Commercial |
$3,073.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,244.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$647.79
|
| Rate for Payer: HealthUtah PPO |
$3,415.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,312.55
|
| Rate for Payer: Multiplan Medicare/VA |
$550.62
|
| Rate for Payer: One Health Plan of WY PPO |
$3,346.70
|
| Rate for Payer: PacificSource Commercial |
$3,073.50
|
| Rate for Payer: PHCS PPO |
$3,244.25
|
| Rate for Payer: Three Rivers PPO |
$2,561.25
|
| Rate for Payer: TriWest Veterans Administration |
$647.79
|
| Rate for Payer: United Healthcare Commercial |
$2,971.05
|
| Rate for Payer: United Healthcare Medicare |
$647.79
|
| Rate for Payer: WINHealth Partners Commercial |
$2,902.75
|
|
|
TNOT ELBOW LATERAL/MEDIAL DEBRIDE OPEN TDN RPR
|
Professional
|
Both
|
$3,415.00
|
|
|
Service Code
|
HCPCS 24359
|
| Hospital Charge Code |
24359
|
| Min. Negotiated Rate |
$550.62 |
| Max. Negotiated Rate |
$3,415.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,346.70
|
| Rate for Payer: Aetna of WY Medicare |
$647.79
|
| Rate for Payer: Beech Street Commercial |
$3,244.25
|
| Rate for Payer: Cash Price |
$2,390.50
|
| Rate for Payer: Cash Price |
$2,390.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,312.55
|
| Rate for Payer: Cigna of WY Commercial |
$3,346.70
|
| Rate for Payer: First Choice Health Commercial |
$3,073.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,244.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$647.79
|
| Rate for Payer: HealthUtah PPO |
$3,415.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,312.55
|
| Rate for Payer: Multiplan Medicare/VA |
$550.62
|
| Rate for Payer: One Health Plan of WY PPO |
$3,346.70
|
| Rate for Payer: PacificSource Commercial |
$3,073.50
|
| Rate for Payer: PHCS PPO |
$3,244.25
|
| Rate for Payer: Three Rivers PPO |
$2,561.25
|
| Rate for Payer: TriWest Veterans Administration |
$647.79
|
| Rate for Payer: United Healthcare Commercial |
$2,971.05
|
| Rate for Payer: United Healthcare Medicare |
$647.79
|
| Rate for Payer: WINHealth Partners Commercial |
$2,902.75
|
|
|
TNOT ELBOW LATERAL/MEDIAL DEBRIDE OPEN TDN RPR
|
Professional
|
Both
|
$3,415.00
|
|
|
Service Code
|
HCPCS 24359 80
|
| Hospital Charge Code |
24359
|
| Min. Negotiated Rate |
$550.62 |
| Max. Negotiated Rate |
$3,415.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,346.70
|
| Rate for Payer: Aetna of WY Medicare |
$647.79
|
| Rate for Payer: Beech Street Commercial |
$3,244.25
|
| Rate for Payer: Cash Price |
$2,390.50
|
| Rate for Payer: Cash Price |
$2,390.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,312.55
|
| Rate for Payer: Cigna of WY Commercial |
$3,346.70
|
| Rate for Payer: First Choice Health Commercial |
$3,073.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,244.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$647.79
|
| Rate for Payer: HealthUtah PPO |
$3,415.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,312.55
|
| Rate for Payer: Multiplan Medicare/VA |
$550.62
|
| Rate for Payer: One Health Plan of WY PPO |
$3,346.70
|
| Rate for Payer: PacificSource Commercial |
$3,073.50
|
| Rate for Payer: PHCS PPO |
$3,244.25
|
| Rate for Payer: Three Rivers PPO |
$2,561.25
|
| Rate for Payer: TriWest Veterans Administration |
$647.79
|
| Rate for Payer: United Healthcare Commercial |
$2,971.05
|
| Rate for Payer: United Healthcare Medicare |
$647.79
|
| Rate for Payer: WINHealth Partners Commercial |
$2,902.75
|
|
|
TOBACCO USE CESSATION INTENSIVE >10 MINUTES
|
Professional
|
Both
|
$113.00
|
|
|
Service Code
|
HCPCS 99407
|
| Hospital Charge Code |
99407
|
| Min. Negotiated Rate |
$20.31 |
| Max. Negotiated Rate |
$113.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$110.74
|
| Rate for Payer: Aetna of WY Medicare |
$23.89
|
| 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 |
$23.89
|
| Rate for Payer: HealthUtah PPO |
$113.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$109.61
|
| Rate for Payer: Multiplan Medicare/VA |
$20.31
|
| 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 |
$23.89
|
| Rate for Payer: United Healthcare Commercial |
$98.31
|
| Rate for Payer: United Healthcare Medicare |
$23.89
|
| Rate for Payer: WINHealth Partners Commercial |
$107.35
|
|
|
TOBACCO USE CESSATION INTERMEDIATE 3-10 MINUTES
|
Professional
|
Both
|
$48.00
|
|
|
Service Code
|
HCPCS 99406
|
| Hospital Charge Code |
99406
|
| Min. Negotiated Rate |
$9.60 |
| Max. Negotiated Rate |
$48.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$47.04
|
| Rate for Payer: Aetna of WY Medicare |
$11.29
|
| 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 |
$11.29
|
| Rate for Payer: HealthUtah PPO |
$48.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$46.56
|
| Rate for Payer: Multiplan Medicare/VA |
$9.60
|
| 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 |
$11.29
|
| Rate for Payer: United Healthcare Commercial |
$41.76
|
| Rate for Payer: United Healthcare Medicare |
$11.29
|
| Rate for Payer: WINHealth Partners Commercial |
$45.60
|
|
|
TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION [20573]
|
Facility
|
IP
|
$38.02
|
|
|
Service Code
|
NDC 0574403105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.84 |
| Max. Negotiated Rate |
$38.02 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$37.26
|
| Rate for Payer: Altius Auto/Workers Compensation |
$36.50
|
| Rate for Payer: Altius Commercial |
$36.50
|
| Rate for Payer: Beech Street Commercial |
$37.26
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$31.21
|
| Rate for Payer: Cash Price |
$26.62
|
| Rate for Payer: ChoiceCare Network Commercial |
$36.88
|
| Rate for Payer: Cigna of WY Commercial |
$37.26
|
| Rate for Payer: Entrust Commercial |
$36.12
|
| Rate for Payer: First Choice Health Commercial |
$36.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$36.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$25.09
|
| Rate for Payer: HealthUtah PPO |
$38.02
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$36.88
|
| Rate for Payer: Multiplan Medicare/VA |
$23.84
|
| Rate for Payer: One Health Plan of WY PPO |
$37.26
|
| Rate for Payer: PacificSource Commercial |
$34.22
|
| Rate for Payer: PHCS PPO |
$37.26
|
| Rate for Payer: Three Rivers PPO |
$28.52
|
| Rate for Payer: TriWest Veterans Administration |
$25.09
|
| Rate for Payer: United Healthcare Commercial |
$33.08
|
| Rate for Payer: United Healthcare Medicare |
$25.09
|
| Rate for Payer: WINHealth Partners Commercial |
$36.12
|
| Rate for Payer: Wise Provider Network Commercial |
$36.12
|
|
|
TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION [20573]
|
Facility
|
OP
|
$38.02
|
|
|
Service Code
|
NDC 0574403105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.95 |
| Max. Negotiated Rate |
$38.02 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$37.26
|
| Rate for Payer: Aetna of WY Medicare |
$25.09
|
| Rate for Payer: Altius Auto/Workers Compensation |
$36.50
|
| Rate for Payer: Altius Commercial |
$36.50
|
| Rate for Payer: Beech Street Commercial |
$37.26
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$31.21
|
| Rate for Payer: Cash Price |
$26.62
|
| Rate for Payer: ChoiceCare Network Commercial |
$36.88
|
| Rate for Payer: Cigna of WY Commercial |
$37.26
|
| Rate for Payer: Entrust Commercial |
$36.12
|
| Rate for Payer: First Choice Health Commercial |
$36.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$36.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$22.05
|
| Rate for Payer: HealthUtah PPO |
$38.02
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$36.88
|
| Rate for Payer: Multiplan Medicare/VA |
$20.95
|
| Rate for Payer: One Health Plan of WY PPO |
$37.26
|
| Rate for Payer: PacificSource Commercial |
$34.22
|
| Rate for Payer: PHCS PPO |
$37.26
|
| Rate for Payer: Three Rivers PPO |
$28.52
|
| Rate for Payer: TriWest Veterans Administration |
$22.05
|
| Rate for Payer: United Healthcare Commercial |
$33.08
|
| Rate for Payer: United Healthcare Medicare |
$22.05
|
| Rate for Payer: WINHealth Partners Commercial |
$37.26
|
| Rate for Payer: Wise Provider Network Commercial |
$36.12
|
|
|
TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION [20573]
|
Facility
|
IP
|
$37.93
|
|
|
Service Code
|
NDC 0574403125
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.78 |
| Max. Negotiated Rate |
$37.93 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$37.17
|
| Rate for Payer: Altius Auto/Workers Compensation |
$36.41
|
| Rate for Payer: Altius Commercial |
$36.41
|
| Rate for Payer: Beech Street Commercial |
$37.17
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$31.14
|
| Rate for Payer: Cash Price |
$26.55
|
| Rate for Payer: ChoiceCare Network Commercial |
$36.79
|
| Rate for Payer: Cigna of WY Commercial |
$37.17
|
| Rate for Payer: Entrust Commercial |
$36.03
|
| Rate for Payer: First Choice Health Commercial |
$36.03
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$36.03
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$25.03
|
| Rate for Payer: HealthUtah PPO |
$37.93
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$36.79
|
| Rate for Payer: Multiplan Medicare/VA |
$23.78
|
| Rate for Payer: One Health Plan of WY PPO |
$37.17
|
| Rate for Payer: PacificSource Commercial |
$34.14
|
| Rate for Payer: PHCS PPO |
$37.17
|
| Rate for Payer: Three Rivers PPO |
$28.45
|
| Rate for Payer: TriWest Veterans Administration |
$25.03
|
| Rate for Payer: United Healthcare Commercial |
$33.00
|
| Rate for Payer: United Healthcare Medicare |
$25.03
|
| Rate for Payer: WINHealth Partners Commercial |
$36.03
|
| Rate for Payer: Wise Provider Network Commercial |
$36.03
|
|
|
TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION [20573]
|
Facility
|
OP
|
$37.93
|
|
|
Service Code
|
NDC 0574403125
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.90 |
| Max. Negotiated Rate |
$37.93 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$37.17
|
| Rate for Payer: Aetna of WY Medicare |
$25.03
|
| Rate for Payer: Altius Auto/Workers Compensation |
$36.41
|
| Rate for Payer: Altius Commercial |
$36.41
|
| Rate for Payer: Beech Street Commercial |
$37.17
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$31.14
|
| Rate for Payer: Cash Price |
$26.55
|
| Rate for Payer: ChoiceCare Network Commercial |
$36.79
|
| Rate for Payer: Cigna of WY Commercial |
$37.17
|
| Rate for Payer: Entrust Commercial |
$36.03
|
| Rate for Payer: First Choice Health Commercial |
$36.03
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$36.03
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$22.00
|
| Rate for Payer: HealthUtah PPO |
$37.93
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$36.79
|
| Rate for Payer: Multiplan Medicare/VA |
$20.90
|
| Rate for Payer: One Health Plan of WY PPO |
$37.17
|
| Rate for Payer: PacificSource Commercial |
$34.14
|
| Rate for Payer: PHCS PPO |
$37.17
|
| Rate for Payer: Three Rivers PPO |
$28.45
|
| Rate for Payer: TriWest Veterans Administration |
$22.00
|
| Rate for Payer: United Healthcare Commercial |
$33.00
|
| Rate for Payer: United Healthcare Medicare |
$22.00
|
| Rate for Payer: WINHealth Partners Commercial |
$37.17
|
| Rate for Payer: Wise Provider Network Commercial |
$36.03
|
|
|
TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION [13959]
|
Facility
|
IP
|
$155.00
|
|
|
Service Code
|
HCPCS J3260
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$97.18 |
| Max. Negotiated Rate |
$155.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$151.90
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$143.32
|
| Rate for Payer: Altius Auto/Workers Compensation |
$148.80
|
| Rate for Payer: Altius Auto/Workers Compensation |
$140.40
|
| Rate for Payer: Altius Commercial |
$140.40
|
| Rate for Payer: Altius Commercial |
$148.80
|
| Rate for Payer: Beech Street Commercial |
$151.90
|
| Rate for Payer: Beech Street Commercial |
$143.32
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$120.07
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$127.26
|
| Rate for Payer: Cash Price |
$108.50
|
| Rate for Payer: Cash Price |
$102.38
|
| Rate for Payer: ChoiceCare Network Commercial |
$141.86
|
| Rate for Payer: ChoiceCare Network Commercial |
$150.35
|
| Rate for Payer: Cigna of WY Commercial |
$151.90
|
| Rate for Payer: Cigna of WY Commercial |
$143.32
|
| Rate for Payer: Entrust Commercial |
$138.94
|
| Rate for Payer: Entrust Commercial |
$147.25
|
| Rate for Payer: First Choice Health Commercial |
$138.94
|
| Rate for Payer: First Choice Health Commercial |
$147.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$138.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$147.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$102.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$96.52
|
| Rate for Payer: HealthUtah PPO |
$155.00
|
| Rate for Payer: HealthUtah PPO |
$146.25
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$141.86
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$150.35
|
| Rate for Payer: Multiplan Medicare/VA |
$97.18
|
| Rate for Payer: Multiplan Medicare/VA |
$91.70
|
| Rate for Payer: One Health Plan of WY PPO |
$151.90
|
| Rate for Payer: One Health Plan of WY PPO |
$143.32
|
| Rate for Payer: PacificSource Commercial |
$139.50
|
| Rate for Payer: PacificSource Commercial |
$131.62
|
| Rate for Payer: PHCS PPO |
$143.32
|
| Rate for Payer: PHCS PPO |
$151.90
|
| Rate for Payer: Three Rivers PPO |
$109.69
|
| Rate for Payer: Three Rivers PPO |
$116.25
|
| Rate for Payer: TriWest Veterans Administration |
$102.30
|
| Rate for Payer: TriWest Veterans Administration |
$96.52
|
| Rate for Payer: United Healthcare Commercial |
$127.24
|
| Rate for Payer: United Healthcare Commercial |
$134.85
|
| Rate for Payer: United Healthcare Medicare |
$102.30
|
| Rate for Payer: United Healthcare Medicare |
$96.52
|
| Rate for Payer: WINHealth Partners Commercial |
$138.94
|
| Rate for Payer: WINHealth Partners Commercial |
$147.25
|
| Rate for Payer: Wise Provider Network Commercial |
$138.94
|
| Rate for Payer: Wise Provider Network Commercial |
$147.25
|
|
|
TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION [13959]
|
Facility
|
OP
|
$155.00
|
|
|
Service Code
|
HCPCS J3260
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$85.40 |
| Max. Negotiated Rate |
$155.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$151.90
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$143.32
|
| Rate for Payer: Aetna of WY Medicare |
$102.30
|
| Rate for Payer: Aetna of WY Medicare |
$96.52
|
| Rate for Payer: Altius Auto/Workers Compensation |
$140.40
|
| Rate for Payer: Altius Auto/Workers Compensation |
$148.80
|
| Rate for Payer: Altius Commercial |
$148.80
|
| Rate for Payer: Altius Commercial |
$140.40
|
| Rate for Payer: Beech Street Commercial |
$143.32
|
| Rate for Payer: Beech Street Commercial |
$151.90
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$127.26
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$120.07
|
| Rate for Payer: Cash Price |
$102.38
|
| Rate for Payer: Cash Price |
$108.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$150.35
|
| Rate for Payer: ChoiceCare Network Commercial |
$141.86
|
| Rate for Payer: Cigna of WY Commercial |
$143.32
|
| Rate for Payer: Cigna of WY Commercial |
$151.90
|
| Rate for Payer: Entrust Commercial |
$147.25
|
| Rate for Payer: Entrust Commercial |
$138.94
|
| Rate for Payer: First Choice Health Commercial |
$138.94
|
| Rate for Payer: First Choice Health Commercial |
$147.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$138.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$147.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$89.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$84.82
|
| Rate for Payer: HealthUtah PPO |
$146.25
|
| Rate for Payer: HealthUtah PPO |
$155.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$141.86
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$150.35
|
| Rate for Payer: Multiplan Medicare/VA |
$85.40
|
| Rate for Payer: Multiplan Medicare/VA |
$80.58
|
| Rate for Payer: One Health Plan of WY PPO |
$143.32
|
| Rate for Payer: One Health Plan of WY PPO |
$151.90
|
| Rate for Payer: PacificSource Commercial |
$139.50
|
| Rate for Payer: PacificSource Commercial |
$131.62
|
| Rate for Payer: PHCS PPO |
$143.32
|
| Rate for Payer: PHCS PPO |
$151.90
|
| Rate for Payer: Three Rivers PPO |
$109.69
|
| Rate for Payer: Three Rivers PPO |
$116.25
|
| Rate for Payer: TriWest Veterans Administration |
$89.90
|
| Rate for Payer: TriWest Veterans Administration |
$84.82
|
| Rate for Payer: United Healthcare Commercial |
$127.24
|
| Rate for Payer: United Healthcare Commercial |
$134.85
|
| Rate for Payer: United Healthcare Medicare |
$89.90
|
| Rate for Payer: United Healthcare Medicare |
$84.82
|
| Rate for Payer: WINHealth Partners Commercial |
$143.32
|
| Rate for Payer: WINHealth Partners Commercial |
$151.90
|
| Rate for Payer: Wise Provider Network Commercial |
$138.94
|
| Rate for Payer: Wise Provider Network Commercial |
$147.25
|
|
|
TOCILIZUMAB 20 MG/ML INTRAVENOUS SOLUTION (WRAPPED) [4000720]
|
Facility
|
IP
|
$214.19
|
|
|
Service Code
|
HCPCS J3262
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$134.30 |
| Max. Negotiated Rate |
$214.19 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$209.91
|
| Rate for Payer: Altius Auto/Workers Compensation |
$205.62
|
| Rate for Payer: Altius Commercial |
$205.62
|
| Rate for Payer: Beech Street Commercial |
$209.91
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$175.85
|
| Rate for Payer: Cash Price |
$149.93
|
| Rate for Payer: ChoiceCare Network Commercial |
$207.76
|
| Rate for Payer: Cigna of WY Commercial |
$209.91
|
| Rate for Payer: Entrust Commercial |
$203.48
|
| Rate for Payer: First Choice Health Commercial |
$203.48
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$203.48
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$141.37
|
| Rate for Payer: HealthUtah PPO |
$214.19
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$207.76
|
| Rate for Payer: Multiplan Medicare/VA |
$134.30
|
| Rate for Payer: One Health Plan of WY PPO |
$209.91
|
| Rate for Payer: PacificSource Commercial |
$192.77
|
| Rate for Payer: PHCS PPO |
$209.91
|
| Rate for Payer: Three Rivers PPO |
$160.64
|
| Rate for Payer: TriWest Veterans Administration |
$141.37
|
| Rate for Payer: United Healthcare Commercial |
$186.35
|
| Rate for Payer: United Healthcare Medicare |
$141.37
|
| Rate for Payer: WINHealth Partners Commercial |
$203.48
|
| Rate for Payer: Wise Provider Network Commercial |
$203.48
|
|
|
TOCILIZUMAB 20 MG/ML INTRAVENOUS SOLUTION (WRAPPED) [4000720]
|
Facility
|
OP
|
$214.19
|
|
|
Service Code
|
HCPCS J3262
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$118.02 |
| Max. Negotiated Rate |
$214.19 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$209.91
|
| Rate for Payer: Aetna of WY Medicare |
$141.37
|
| Rate for Payer: Altius Auto/Workers Compensation |
$205.62
|
| Rate for Payer: Altius Commercial |
$205.62
|
| Rate for Payer: Beech Street Commercial |
$209.91
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$175.85
|
| Rate for Payer: Cash Price |
$149.93
|
| Rate for Payer: ChoiceCare Network Commercial |
$207.76
|
| Rate for Payer: Cigna of WY Commercial |
$209.91
|
| Rate for Payer: Entrust Commercial |
$203.48
|
| Rate for Payer: First Choice Health Commercial |
$203.48
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$203.48
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$124.23
|
| Rate for Payer: HealthUtah PPO |
$214.19
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$207.76
|
| Rate for Payer: Multiplan Medicare/VA |
$118.02
|
| Rate for Payer: One Health Plan of WY PPO |
$209.91
|
| Rate for Payer: PacificSource Commercial |
$192.77
|
| Rate for Payer: PHCS PPO |
$209.91
|
| Rate for Payer: Three Rivers PPO |
$160.64
|
| Rate for Payer: TriWest Veterans Administration |
$124.23
|
| Rate for Payer: United Healthcare Commercial |
$186.35
|
| Rate for Payer: United Healthcare Medicare |
$124.23
|
| Rate for Payer: WINHealth Partners Commercial |
$209.91
|
| Rate for Payer: Wise Provider Network Commercial |
$203.48
|
|
|
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION [88791]
|
Facility
|
IP
|
$214.18
|
|
|
Service Code
|
HCPCS Q0249
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$134.29 |
| Max. Negotiated Rate |
$214.18 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$209.90
|
| Rate for Payer: Altius Auto/Workers Compensation |
$205.61
|
| Rate for Payer: Altius Commercial |
$205.61
|
| Rate for Payer: Beech Street Commercial |
$209.90
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$175.84
|
| Rate for Payer: Cash Price |
$149.93
|
| Rate for Payer: ChoiceCare Network Commercial |
$207.75
|
| Rate for Payer: Cigna of WY Commercial |
$209.90
|
| Rate for Payer: Entrust Commercial |
$203.47
|
| Rate for Payer: First Choice Health Commercial |
$203.47
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$203.47
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$141.36
|
| Rate for Payer: HealthUtah PPO |
$214.18
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$207.75
|
| Rate for Payer: Multiplan Medicare/VA |
$134.29
|
| Rate for Payer: One Health Plan of WY PPO |
$209.90
|
| Rate for Payer: PacificSource Commercial |
$192.76
|
| Rate for Payer: PHCS PPO |
$209.90
|
| Rate for Payer: Three Rivers PPO |
$160.64
|
| Rate for Payer: TriWest Veterans Administration |
$141.36
|
| Rate for Payer: United Healthcare Commercial |
$186.34
|
| Rate for Payer: United Healthcare Medicare |
$141.36
|
| Rate for Payer: WINHealth Partners Commercial |
$203.47
|
| Rate for Payer: Wise Provider Network Commercial |
$203.47
|
|
|
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION [88791]
|
Facility
|
OP
|
$214.18
|
|
|
Service Code
|
HCPCS Q0249
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$118.01 |
| Max. Negotiated Rate |
$214.18 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$209.90
|
| Rate for Payer: Aetna of WY Medicare |
$141.36
|
| Rate for Payer: Altius Auto/Workers Compensation |
$205.61
|
| Rate for Payer: Altius Commercial |
$205.61
|
| Rate for Payer: Beech Street Commercial |
$209.90
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$175.84
|
| Rate for Payer: Cash Price |
$149.93
|
| Rate for Payer: ChoiceCare Network Commercial |
$207.75
|
| Rate for Payer: Cigna of WY Commercial |
$209.90
|
| Rate for Payer: Entrust Commercial |
$203.47
|
| Rate for Payer: First Choice Health Commercial |
$203.47
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$203.47
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$124.22
|
| Rate for Payer: HealthUtah PPO |
$214.18
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$207.75
|
| Rate for Payer: Multiplan Medicare/VA |
$118.01
|
| Rate for Payer: One Health Plan of WY PPO |
$209.90
|
| Rate for Payer: PacificSource Commercial |
$192.76
|
| Rate for Payer: PHCS PPO |
$209.90
|
| Rate for Payer: Three Rivers PPO |
$160.64
|
| Rate for Payer: TriWest Veterans Administration |
$124.22
|
| Rate for Payer: United Healthcare Commercial |
$186.34
|
| Rate for Payer: United Healthcare Medicare |
$124.22
|
| Rate for Payer: WINHealth Partners Commercial |
$209.90
|
| Rate for Payer: Wise Provider Network Commercial |
$203.47
|
|
|
TOLTERODINE ER 4 MG CAPSULE,EXTENDED RELEASE 24 HR [3875]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 2724119230
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.51 |
| Max. Negotiated Rate |
$4.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3.92
|
| Rate for Payer: Altius Auto/Workers Compensation |
$3.84
|
| Rate for Payer: Altius Commercial |
$3.84
|
| Rate for Payer: Beech Street Commercial |
$3.92
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3.28
|
| Rate for Payer: Cash Price |
$2.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$3.88
|
| Rate for Payer: Cigna of WY Commercial |
$3.92
|
| Rate for Payer: Entrust Commercial |
$3.80
|
| Rate for Payer: First Choice Health Commercial |
$3.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2.64
|
| Rate for Payer: HealthUtah PPO |
$4.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3.88
|
| Rate for Payer: Multiplan Medicare/VA |
$2.51
|
| Rate for Payer: One Health Plan of WY PPO |
$3.92
|
| Rate for Payer: PacificSource Commercial |
$3.60
|
| Rate for Payer: PHCS PPO |
$3.92
|
| Rate for Payer: Three Rivers PPO |
$3.00
|
| Rate for Payer: TriWest Veterans Administration |
$2.64
|
| Rate for Payer: United Healthcare Commercial |
$3.48
|
| Rate for Payer: United Healthcare Medicare |
$2.64
|
| Rate for Payer: WINHealth Partners Commercial |
$3.80
|
| Rate for Payer: Wise Provider Network Commercial |
$3.80
|
|
|
TOLTERODINE ER 4 MG CAPSULE,EXTENDED RELEASE 24 HR [3875]
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 2724119230
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.20 |
| Max. Negotiated Rate |
$4.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3.92
|
| Rate for Payer: Aetna of WY Medicare |
$2.64
|
| Rate for Payer: Altius Auto/Workers Compensation |
$3.84
|
| Rate for Payer: Altius Commercial |
$3.84
|
| Rate for Payer: Beech Street Commercial |
$3.92
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3.28
|
| Rate for Payer: Cash Price |
$2.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$3.88
|
| Rate for Payer: Cigna of WY Commercial |
$3.92
|
| Rate for Payer: Entrust Commercial |
$3.80
|
| Rate for Payer: First Choice Health Commercial |
$3.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2.32
|
| Rate for Payer: HealthUtah PPO |
$4.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3.88
|
| Rate for Payer: Multiplan Medicare/VA |
$2.20
|
| Rate for Payer: One Health Plan of WY PPO |
$3.92
|
| Rate for Payer: PacificSource Commercial |
$3.60
|
| Rate for Payer: PHCS PPO |
$3.92
|
| Rate for Payer: Three Rivers PPO |
$3.00
|
| Rate for Payer: TriWest Veterans Administration |
$2.32
|
| Rate for Payer: United Healthcare Commercial |
$3.48
|
| Rate for Payer: United Healthcare Medicare |
$2.32
|
| Rate for Payer: WINHealth Partners Commercial |
$3.92
|
| Rate for Payer: Wise Provider Network Commercial |
$3.80
|
|
|
TONSILLECTOMY & ADENOIDECTOMY <AGE 12
|
Professional
|
Both
|
$1,482.00
|
|
|
Service Code
|
HCPCS 42820
|
| Hospital Charge Code |
42820
|
| Min. Negotiated Rate |
$241.88 |
| Max. Negotiated Rate |
$1,482.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,452.36
|
| Rate for Payer: Aetna of WY Medicare |
$284.57
|
| Rate for Payer: Beech Street Commercial |
$1,407.90
|
| Rate for Payer: Cash Price |
$1,037.40
|
| Rate for Payer: Cash Price |
$1,037.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,437.54
|
| Rate for Payer: Cigna of WY Commercial |
$1,452.36
|
| Rate for Payer: First Choice Health Commercial |
$1,333.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,407.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$284.57
|
| Rate for Payer: HealthUtah PPO |
$1,482.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,437.54
|
| Rate for Payer: Multiplan Medicare/VA |
$241.88
|
| Rate for Payer: One Health Plan of WY PPO |
$1,452.36
|
| Rate for Payer: PacificSource Commercial |
$1,333.80
|
| Rate for Payer: PHCS PPO |
$1,407.90
|
| Rate for Payer: Three Rivers PPO |
$1,111.50
|
| Rate for Payer: TriWest Veterans Administration |
$284.57
|
| Rate for Payer: United Healthcare Commercial |
$1,289.34
|
| Rate for Payer: United Healthcare Medicare |
$284.57
|
| Rate for Payer: WINHealth Partners Commercial |
$1,259.70
|
|
|
TONSILLECTOMY & ADENOIDECTOMY AGE 12/>
|
Professional
|
Both
|
$1,546.00
|
|
|
Service Code
|
HCPCS 42821
|
| Hospital Charge Code |
42821
|
| Min. Negotiated Rate |
$252.59 |
| Max. Negotiated Rate |
$1,546.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,515.08
|
| Rate for Payer: Aetna of WY Medicare |
$297.17
|
| Rate for Payer: Beech Street Commercial |
$1,468.70
|
| Rate for Payer: Cash Price |
$1,082.20
|
| Rate for Payer: Cash Price |
$1,082.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,499.62
|
| Rate for Payer: Cigna of WY Commercial |
$1,515.08
|
| Rate for Payer: First Choice Health Commercial |
$1,391.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,468.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$297.17
|
| Rate for Payer: HealthUtah PPO |
$1,546.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,499.62
|
| Rate for Payer: Multiplan Medicare/VA |
$252.59
|
| Rate for Payer: One Health Plan of WY PPO |
$1,515.08
|
| Rate for Payer: PacificSource Commercial |
$1,391.40
|
| Rate for Payer: PHCS PPO |
$1,468.70
|
| Rate for Payer: Three Rivers PPO |
$1,159.50
|
| Rate for Payer: TriWest Veterans Administration |
$297.17
|
| Rate for Payer: United Healthcare Commercial |
$1,345.02
|
| Rate for Payer: United Healthcare Medicare |
$297.17
|
| Rate for Payer: WINHealth Partners Commercial |
$1,314.10
|
|
