|
TYMPANOPLASTY W/O MASTOIDEC 1ST/REVJ PROSTH TORP
|
Professional
|
Both
|
$10,645.00
|
|
|
Service Code
|
HCPCS 69633 50
|
| Hospital Charge Code |
69633
|
| Min. Negotiated Rate |
$870.66 |
| Max. Negotiated Rate |
$10,645.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$10,432.10
|
| Rate for Payer: Aetna of WY Medicare |
$1,024.30
|
| Rate for Payer: Beech Street Commercial |
$10,112.75
|
| Rate for Payer: Cash Price |
$7,451.50
|
| Rate for Payer: Cash Price |
$7,451.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$10,325.65
|
| Rate for Payer: Cigna of WY Commercial |
$10,432.10
|
| Rate for Payer: First Choice Health Commercial |
$9,580.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$10,112.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,024.30
|
| Rate for Payer: HealthUtah PPO |
$10,645.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$10,325.65
|
| Rate for Payer: Multiplan Medicare/VA |
$870.66
|
| Rate for Payer: One Health Plan of WY PPO |
$10,432.10
|
| Rate for Payer: PacificSource Commercial |
$9,580.50
|
| Rate for Payer: PHCS PPO |
$10,112.75
|
| Rate for Payer: Three Rivers PPO |
$7,983.75
|
| Rate for Payer: TriWest Veterans Administration |
$1,024.30
|
| Rate for Payer: United Healthcare Commercial |
$9,261.15
|
| Rate for Payer: United Healthcare Medicare |
$1,024.30
|
| Rate for Payer: WINHealth Partners Commercial |
$9,048.25
|
|
|
TYMPANOPLASTY W/O MASTOIDEC 1ST/REVJ PROSTH TORP
|
Professional
|
Both
|
$5,322.00
|
|
|
Service Code
|
HCPCS 69633
|
| Hospital Charge Code |
69633
|
| Min. Negotiated Rate |
$870.66 |
| Max. Negotiated Rate |
$5,322.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5,215.56
|
| Rate for Payer: Aetna of WY Medicare |
$1,024.30
|
| Rate for Payer: Beech Street Commercial |
$5,055.90
|
| Rate for Payer: Cash Price |
$3,725.40
|
| Rate for Payer: Cash Price |
$3,725.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$5,162.34
|
| Rate for Payer: Cigna of WY Commercial |
$5,215.56
|
| Rate for Payer: First Choice Health Commercial |
$4,789.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5,055.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,024.30
|
| Rate for Payer: HealthUtah PPO |
$5,322.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5,162.34
|
| Rate for Payer: Multiplan Medicare/VA |
$870.66
|
| Rate for Payer: One Health Plan of WY PPO |
$5,215.56
|
| Rate for Payer: PacificSource Commercial |
$4,789.80
|
| Rate for Payer: PHCS PPO |
$5,055.90
|
| Rate for Payer: Three Rivers PPO |
$3,991.50
|
| Rate for Payer: TriWest Veterans Administration |
$1,024.30
|
| Rate for Payer: United Healthcare Commercial |
$4,630.14
|
| Rate for Payer: United Healthcare Medicare |
$1,024.30
|
| Rate for Payer: WINHealth Partners Commercial |
$4,523.70
|
|
|
TYMPANOPLASTY W/O MASTOIDECT W/O OSSICLE RECNSTJ
|
Professional
|
Both
|
$9,021.00
|
|
|
Service Code
|
HCPCS 69631 50
|
| Hospital Charge Code |
69631
|
| Min. Negotiated Rate |
$737.60 |
| Max. Negotiated Rate |
$9,021.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$8,840.58
|
| Rate for Payer: Aetna of WY Medicare |
$867.76
|
| Rate for Payer: Beech Street Commercial |
$8,569.95
|
| Rate for Payer: Cash Price |
$6,314.70
|
| Rate for Payer: Cash Price |
$6,314.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$8,750.37
|
| Rate for Payer: Cigna of WY Commercial |
$8,840.58
|
| Rate for Payer: First Choice Health Commercial |
$8,118.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$8,569.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$867.76
|
| Rate for Payer: HealthUtah PPO |
$9,021.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$8,750.37
|
| Rate for Payer: Multiplan Medicare/VA |
$737.60
|
| Rate for Payer: One Health Plan of WY PPO |
$8,840.58
|
| Rate for Payer: PacificSource Commercial |
$8,118.90
|
| Rate for Payer: PHCS PPO |
$8,569.95
|
| Rate for Payer: Three Rivers PPO |
$6,765.75
|
| Rate for Payer: TriWest Veterans Administration |
$867.76
|
| Rate for Payer: United Healthcare Commercial |
$7,848.27
|
| Rate for Payer: United Healthcare Medicare |
$867.76
|
| Rate for Payer: WINHealth Partners Commercial |
$7,667.85
|
|
|
TYMPANOPLASTY W/O MASTOIDECT W/O OSSICLE RECNSTJ
|
Professional
|
Both
|
$4,510.00
|
|
|
Service Code
|
HCPCS 69631
|
| Hospital Charge Code |
69631
|
| Min. Negotiated Rate |
$737.60 |
| Max. Negotiated Rate |
$4,510.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4,419.80
|
| Rate for Payer: Aetna of WY Medicare |
$867.76
|
| Rate for Payer: Beech Street Commercial |
$4,284.50
|
| Rate for Payer: Cash Price |
$3,157.00
|
| Rate for Payer: Cash Price |
$3,157.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$4,374.70
|
| Rate for Payer: Cigna of WY Commercial |
$4,419.80
|
| Rate for Payer: First Choice Health Commercial |
$4,059.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,284.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$867.76
|
| Rate for Payer: HealthUtah PPO |
$4,510.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4,374.70
|
| Rate for Payer: Multiplan Medicare/VA |
$737.60
|
| Rate for Payer: One Health Plan of WY PPO |
$4,419.80
|
| Rate for Payer: PacificSource Commercial |
$4,059.00
|
| Rate for Payer: PHCS PPO |
$4,284.50
|
| Rate for Payer: Three Rivers PPO |
$3,382.50
|
| Rate for Payer: TriWest Veterans Administration |
$867.76
|
| Rate for Payer: United Healthcare Commercial |
$3,923.70
|
| Rate for Payer: United Healthcare Medicare |
$867.76
|
| Rate for Payer: WINHealth Partners Commercial |
$3,833.50
|
|
|
TYMPANOSTOMY GENERAL ANESTHESIA
|
Professional
|
Both
|
$1,610.00
|
|
|
Service Code
|
HCPCS 69436 50
|
| Hospital Charge Code |
69436
|
| Min. Negotiated Rate |
$132.60 |
| Max. Negotiated Rate |
$1,610.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,577.80
|
| Rate for Payer: Aetna of WY Medicare |
$156.00
|
| Rate for Payer: Beech Street Commercial |
$1,529.50
|
| Rate for Payer: Cash Price |
$1,127.00
|
| Rate for Payer: Cash Price |
$1,127.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,561.70
|
| Rate for Payer: Cigna of WY Commercial |
$1,577.80
|
| Rate for Payer: First Choice Health Commercial |
$1,449.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,529.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$156.00
|
| Rate for Payer: HealthUtah PPO |
$1,610.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,561.70
|
| Rate for Payer: Multiplan Medicare/VA |
$132.60
|
| Rate for Payer: One Health Plan of WY PPO |
$1,577.80
|
| Rate for Payer: PacificSource Commercial |
$1,449.00
|
| Rate for Payer: PHCS PPO |
$1,529.50
|
| Rate for Payer: Three Rivers PPO |
$1,207.50
|
| Rate for Payer: TriWest Veterans Administration |
$156.00
|
| Rate for Payer: United Healthcare Commercial |
$1,400.70
|
| Rate for Payer: United Healthcare Medicare |
$156.00
|
| Rate for Payer: WINHealth Partners Commercial |
$1,368.50
|
|
|
TYMPANOSTOMY GENERAL ANESTHESIA
|
Professional
|
Both
|
$805.00
|
|
|
Service Code
|
HCPCS 69436
|
| Hospital Charge Code |
69436
|
| Min. Negotiated Rate |
$132.60 |
| Max. Negotiated Rate |
$805.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$788.90
|
| Rate for Payer: Aetna of WY Medicare |
$156.00
|
| Rate for Payer: Beech Street Commercial |
$764.75
|
| Rate for Payer: Cash Price |
$563.50
|
| Rate for Payer: Cash Price |
$563.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$780.85
|
| Rate for Payer: Cigna of WY Commercial |
$788.90
|
| Rate for Payer: First Choice Health Commercial |
$724.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$764.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$156.00
|
| Rate for Payer: HealthUtah PPO |
$805.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$780.85
|
| Rate for Payer: Multiplan Medicare/VA |
$132.60
|
| Rate for Payer: One Health Plan of WY PPO |
$788.90
|
| Rate for Payer: PacificSource Commercial |
$724.50
|
| Rate for Payer: PHCS PPO |
$764.75
|
| Rate for Payer: Three Rivers PPO |
$603.75
|
| Rate for Payer: TriWest Veterans Administration |
$156.00
|
| Rate for Payer: United Healthcare Commercial |
$700.35
|
| Rate for Payer: United Healthcare Medicare |
$156.00
|
| Rate for Payer: WINHealth Partners Commercial |
$684.25
|
|
|
TYMPANOSTOMY LOCAL/TOPICAL ANESTHESIA
|
Professional
|
Both
|
$2,024.00
|
|
|
Service Code
|
HCPCS 69433 50
|
| Hospital Charge Code |
69433
|
| Min. Negotiated Rate |
$110.22 |
| Max. Negotiated Rate |
$2,024.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,983.52
|
| Rate for Payer: Aetna of WY Medicare |
$129.67
|
| Rate for Payer: Beech Street Commercial |
$1,922.80
|
| Rate for Payer: Cash Price |
$1,416.80
|
| Rate for Payer: Cash Price |
$1,416.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,963.28
|
| Rate for Payer: Cigna of WY Commercial |
$1,983.52
|
| Rate for Payer: First Choice Health Commercial |
$1,821.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,922.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$129.67
|
| Rate for Payer: HealthUtah PPO |
$2,024.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,963.28
|
| Rate for Payer: Multiplan Medicare/VA |
$110.22
|
| Rate for Payer: One Health Plan of WY PPO |
$1,983.52
|
| Rate for Payer: PacificSource Commercial |
$1,821.60
|
| Rate for Payer: PHCS PPO |
$1,922.80
|
| Rate for Payer: Three Rivers PPO |
$1,518.00
|
| Rate for Payer: TriWest Veterans Administration |
$129.67
|
| Rate for Payer: United Healthcare Commercial |
$1,760.88
|
| Rate for Payer: United Healthcare Medicare |
$129.67
|
| Rate for Payer: WINHealth Partners Commercial |
$1,720.40
|
|
|
TYMPANOSTOMY LOCAL/TOPICAL ANESTHESIA
|
Professional
|
Both
|
$1,012.00
|
|
|
Service Code
|
HCPCS 69433
|
| Hospital Charge Code |
69433
|
| Min. Negotiated Rate |
$110.22 |
| Max. Negotiated Rate |
$1,012.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$991.76
|
| Rate for Payer: Aetna of WY Medicare |
$129.67
|
| Rate for Payer: Beech Street Commercial |
$961.40
|
| Rate for Payer: Cash Price |
$708.40
|
| Rate for Payer: Cash Price |
$708.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$981.64
|
| Rate for Payer: Cigna of WY Commercial |
$991.76
|
| Rate for Payer: First Choice Health Commercial |
$910.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$961.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$129.67
|
| Rate for Payer: HealthUtah PPO |
$1,012.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$981.64
|
| Rate for Payer: Multiplan Medicare/VA |
$110.22
|
| Rate for Payer: One Health Plan of WY PPO |
$991.76
|
| Rate for Payer: PacificSource Commercial |
$910.80
|
| Rate for Payer: PHCS PPO |
$961.40
|
| Rate for Payer: Three Rivers PPO |
$759.00
|
| Rate for Payer: TriWest Veterans Administration |
$129.67
|
| Rate for Payer: United Healthcare Commercial |
$880.44
|
| Rate for Payer: United Healthcare Medicare |
$129.67
|
| Rate for Payer: WINHealth Partners Commercial |
$860.20
|
|
|
TYPHOID VACCINE LIVE ORAL
|
Professional
|
Both
|
$165.00
|
|
|
Service Code
|
HCPCS 90690
|
| Hospital Charge Code |
90690
|
| Min. Negotiated Rate |
$123.75 |
| Max. Negotiated Rate |
$165.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$161.70
|
| Rate for Payer: Beech Street Commercial |
$156.75
|
| Rate for Payer: Cash Price |
$115.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$160.05
|
| Rate for Payer: Cigna of WY Commercial |
$161.70
|
| Rate for Payer: First Choice Health Commercial |
$148.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$156.75
|
| Rate for Payer: HealthUtah PPO |
$165.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$160.05
|
| Rate for Payer: One Health Plan of WY PPO |
$161.70
|
| Rate for Payer: PacificSource Commercial |
$148.50
|
| Rate for Payer: PHCS PPO |
$156.75
|
| Rate for Payer: Three Rivers PPO |
$123.75
|
| Rate for Payer: United Healthcare Commercial |
$143.55
|
| Rate for Payer: WINHealth Partners Commercial |
$165.00
|
|
|
TYPHOID VACCINE VI CAPSULAR POLYSACCHARIDE IM
|
Professional
|
Both
|
$126.00
|
|
|
Service Code
|
HCPCS 90691
|
| Hospital Charge Code |
90691
|
| Min. Negotiated Rate |
$94.50 |
| Max. Negotiated Rate |
$126.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$123.48
|
| Rate for Payer: Beech Street Commercial |
$119.70
|
| Rate for Payer: Cash Price |
$88.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$122.22
|
| Rate for Payer: Cigna of WY Commercial |
$123.48
|
| Rate for Payer: First Choice Health Commercial |
$113.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$119.70
|
| Rate for Payer: HealthUtah PPO |
$126.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$122.22
|
| Rate for Payer: One Health Plan of WY PPO |
$123.48
|
| Rate for Payer: PacificSource Commercial |
$113.40
|
| Rate for Payer: PHCS PPO |
$119.70
|
| Rate for Payer: Three Rivers PPO |
$94.50
|
| Rate for Payer: United Healthcare Commercial |
$109.62
|
| Rate for Payer: WINHealth Partners Commercial |
$126.00
|
|
|
TYPHOID VI POLYSACCH VACCINE 25 MCG/0.5 ML INTRAMUSCULAR SYRINGE [25833]
|
Facility
|
IP
|
$381.42
|
|
|
Service Code
|
NDC 4928179051
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$239.15 |
| Max. Negotiated Rate |
$381.42 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$373.79
|
| Rate for Payer: Altius Auto/Workers Compensation |
$366.16
|
| Rate for Payer: Altius Commercial |
$366.16
|
| Rate for Payer: Beech Street Commercial |
$373.79
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$313.15
|
| Rate for Payer: Cash Price |
$267.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$369.98
|
| Rate for Payer: Cigna of WY Commercial |
$373.79
|
| Rate for Payer: Entrust Commercial |
$362.35
|
| Rate for Payer: First Choice Health Commercial |
$362.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$362.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$251.74
|
| Rate for Payer: HealthUtah PPO |
$381.42
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$369.98
|
| Rate for Payer: Multiplan Medicare/VA |
$239.15
|
| Rate for Payer: One Health Plan of WY PPO |
$373.79
|
| Rate for Payer: PacificSource Commercial |
$343.28
|
| Rate for Payer: PHCS PPO |
$373.79
|
| Rate for Payer: Three Rivers PPO |
$286.06
|
| Rate for Payer: TriWest Veterans Administration |
$251.74
|
| Rate for Payer: United Healthcare Commercial |
$331.84
|
| Rate for Payer: United Healthcare Medicare |
$251.74
|
| Rate for Payer: WINHealth Partners Commercial |
$362.35
|
| Rate for Payer: Wise Provider Network Commercial |
$362.35
|
|
|
TYPHOID VI POLYSACCH VACCINE 25 MCG/0.5 ML INTRAMUSCULAR SYRINGE [25833]
|
Facility
|
OP
|
$381.42
|
|
|
Service Code
|
NDC 4928179051
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$210.16 |
| Max. Negotiated Rate |
$381.42 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$373.79
|
| Rate for Payer: Aetna of WY Medicare |
$251.74
|
| Rate for Payer: Altius Auto/Workers Compensation |
$366.16
|
| Rate for Payer: Altius Commercial |
$366.16
|
| Rate for Payer: Beech Street Commercial |
$373.79
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$313.15
|
| Rate for Payer: Cash Price |
$267.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$369.98
|
| Rate for Payer: Cigna of WY Commercial |
$373.79
|
| Rate for Payer: Entrust Commercial |
$362.35
|
| Rate for Payer: First Choice Health Commercial |
$362.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$362.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$221.22
|
| Rate for Payer: HealthUtah PPO |
$381.42
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$369.98
|
| Rate for Payer: Multiplan Medicare/VA |
$210.16
|
| Rate for Payer: One Health Plan of WY PPO |
$373.79
|
| Rate for Payer: PacificSource Commercial |
$343.28
|
| Rate for Payer: PHCS PPO |
$373.79
|
| Rate for Payer: Three Rivers PPO |
$286.06
|
| Rate for Payer: TriWest Veterans Administration |
$221.22
|
| Rate for Payer: United Healthcare Commercial |
$331.84
|
| Rate for Payer: United Healthcare Medicare |
$221.22
|
| Rate for Payer: WINHealth Partners Commercial |
$373.79
|
| Rate for Payer: Wise Provider Network Commercial |
$362.35
|
|
|
UBLITUXIMAB-XIIY 25 MG/ML INTRAVENOUS SOLUTION [180367]
|
Facility
|
IP
|
$1,653.89
|
|
|
Service Code
|
HCPCS J2329
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,036.99 |
| Max. Negotiated Rate |
$1,653.89 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,620.81
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,587.73
|
| Rate for Payer: Altius Commercial |
$1,587.73
|
| Rate for Payer: Beech Street Commercial |
$1,620.81
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,357.84
|
| Rate for Payer: Cash Price |
$1,157.72
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,604.27
|
| Rate for Payer: Cigna of WY Commercial |
$1,620.81
|
| Rate for Payer: Entrust Commercial |
$1,571.20
|
| Rate for Payer: First Choice Health Commercial |
$1,571.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,571.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,091.57
|
| Rate for Payer: HealthUtah PPO |
$1,653.89
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,604.27
|
| Rate for Payer: Multiplan Medicare/VA |
$1,036.99
|
| Rate for Payer: One Health Plan of WY PPO |
$1,620.81
|
| Rate for Payer: PacificSource Commercial |
$1,488.50
|
| Rate for Payer: PHCS PPO |
$1,620.81
|
| Rate for Payer: Three Rivers PPO |
$1,240.42
|
| Rate for Payer: TriWest Veterans Administration |
$1,091.57
|
| Rate for Payer: United Healthcare Commercial |
$1,438.88
|
| Rate for Payer: United Healthcare Medicare |
$1,091.57
|
| Rate for Payer: WINHealth Partners Commercial |
$1,571.20
|
| Rate for Payer: Wise Provider Network Commercial |
$1,571.20
|
|
|
UBLITUXIMAB-XIIY 25 MG/ML INTRAVENOUS SOLUTION [180367]
|
Facility
|
OP
|
$1,653.89
|
|
|
Service Code
|
HCPCS J2329
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$911.29 |
| Max. Negotiated Rate |
$1,653.89 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,620.81
|
| Rate for Payer: Aetna of WY Medicare |
$1,091.57
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,587.73
|
| Rate for Payer: Altius Commercial |
$1,587.73
|
| Rate for Payer: Beech Street Commercial |
$1,620.81
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,357.84
|
| Rate for Payer: Cash Price |
$1,157.72
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,604.27
|
| Rate for Payer: Cigna of WY Commercial |
$1,620.81
|
| Rate for Payer: Entrust Commercial |
$1,571.20
|
| Rate for Payer: First Choice Health Commercial |
$1,571.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,571.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$959.26
|
| Rate for Payer: HealthUtah PPO |
$1,653.89
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,604.27
|
| Rate for Payer: Multiplan Medicare/VA |
$911.29
|
| Rate for Payer: One Health Plan of WY PPO |
$1,620.81
|
| Rate for Payer: PacificSource Commercial |
$1,488.50
|
| Rate for Payer: PHCS PPO |
$1,620.81
|
| Rate for Payer: Three Rivers PPO |
$1,240.42
|
| Rate for Payer: TriWest Veterans Administration |
$959.26
|
| Rate for Payer: United Healthcare Commercial |
$1,438.88
|
| Rate for Payer: United Healthcare Medicare |
$959.26
|
| Rate for Payer: WINHealth Partners Commercial |
$1,620.81
|
| Rate for Payer: Wise Provider Network Commercial |
$1,571.20
|
|
|
UCL INTERNAL BRACE SYSTEM
|
Facility
|
IP
|
$4,819.74
|
|
| Hospital Charge Code |
27800000S1
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,021.98 |
| Max. Negotiated Rate |
$4,819.74 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4,723.35
|
| Rate for Payer: Altius Auto/Workers Compensation |
$4,626.95
|
| Rate for Payer: Altius Commercial |
$4,626.95
|
| Rate for Payer: Beech Street Commercial |
$4,723.35
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3,957.01
|
| Rate for Payer: Cash Price |
$3,373.82
|
| Rate for Payer: ChoiceCare Network Commercial |
$4,675.15
|
| Rate for Payer: Cigna of WY Commercial |
$4,723.35
|
| Rate for Payer: Entrust Commercial |
$4,578.75
|
| Rate for Payer: First Choice Health Commercial |
$4,578.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,578.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3,181.03
|
| Rate for Payer: HealthUtah PPO |
$4,819.74
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4,675.15
|
| Rate for Payer: Multiplan Medicare/VA |
$3,021.98
|
| Rate for Payer: One Health Plan of WY PPO |
$4,723.35
|
| Rate for Payer: PacificSource Commercial |
$4,337.77
|
| Rate for Payer: PHCS PPO |
$4,723.35
|
| Rate for Payer: Three Rivers PPO |
$3,614.80
|
| Rate for Payer: TriWest Veterans Administration |
$3,181.03
|
| Rate for Payer: United Healthcare Commercial |
$4,193.17
|
| Rate for Payer: United Healthcare Medicare |
$3,181.03
|
| Rate for Payer: WINHealth Partners Commercial |
$4,578.75
|
| Rate for Payer: Wise Provider Network Commercial |
$4,578.75
|
|
|
UCL INTERNAL BRACE SYSTEM
|
Facility
|
OP
|
$4,819.74
|
|
| Hospital Charge Code |
27800000S1
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,655.68 |
| Max. Negotiated Rate |
$4,819.74 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4,723.35
|
| Rate for Payer: Aetna of WY Medicare |
$3,181.03
|
| Rate for Payer: Altius Auto/Workers Compensation |
$4,626.95
|
| Rate for Payer: Altius Commercial |
$4,626.95
|
| Rate for Payer: Beech Street Commercial |
$4,723.35
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3,957.01
|
| Rate for Payer: Cash Price |
$3,373.82
|
| Rate for Payer: ChoiceCare Network Commercial |
$4,675.15
|
| Rate for Payer: Cigna of WY Commercial |
$4,723.35
|
| Rate for Payer: Entrust Commercial |
$4,578.75
|
| Rate for Payer: First Choice Health Commercial |
$4,578.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,578.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2,795.45
|
| Rate for Payer: HealthUtah PPO |
$4,819.74
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4,675.15
|
| Rate for Payer: Multiplan Medicare/VA |
$2,655.68
|
| Rate for Payer: One Health Plan of WY PPO |
$4,723.35
|
| Rate for Payer: PacificSource Commercial |
$4,337.77
|
| Rate for Payer: PHCS PPO |
$4,723.35
|
| Rate for Payer: Three Rivers PPO |
$3,614.80
|
| Rate for Payer: TriWest Veterans Administration |
$2,795.45
|
| Rate for Payer: United Healthcare Commercial |
$4,193.17
|
| Rate for Payer: United Healthcare Medicare |
$2,795.45
|
| Rate for Payer: WINHealth Partners Commercial |
$4,723.35
|
| Rate for Payer: Wise Provider Network Commercial |
$4,578.75
|
|
|
ULNAR NERVE PROTECTION
|
Facility
|
OP
|
$6.26
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3.45 |
| Max. Negotiated Rate |
$6.26 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$6.13
|
| Rate for Payer: Aetna of WY Medicare |
$4.13
|
| Rate for Payer: Altius Auto/Workers Compensation |
$6.01
|
| Rate for Payer: Altius Commercial |
$6.01
|
| Rate for Payer: Beech Street Commercial |
$6.13
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$5.14
|
| Rate for Payer: Cash Price |
$4.38
|
| Rate for Payer: ChoiceCare Network Commercial |
$6.07
|
| Rate for Payer: Cigna of WY Commercial |
$6.13
|
| Rate for Payer: Entrust Commercial |
$5.95
|
| Rate for Payer: First Choice Health Commercial |
$5.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3.63
|
| Rate for Payer: HealthUtah PPO |
$6.26
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$6.07
|
| Rate for Payer: Multiplan Medicare/VA |
$3.45
|
| Rate for Payer: One Health Plan of WY PPO |
$6.13
|
| Rate for Payer: PacificSource Commercial |
$5.63
|
| Rate for Payer: PHCS PPO |
$6.13
|
| Rate for Payer: Three Rivers PPO |
$4.70
|
| Rate for Payer: TriWest Veterans Administration |
$3.63
|
| Rate for Payer: United Healthcare Commercial |
$5.45
|
| Rate for Payer: United Healthcare Medicare |
$3.63
|
| Rate for Payer: WINHealth Partners Commercial |
$6.13
|
| Rate for Payer: Wise Provider Network Commercial |
$5.95
|
|
|
ULNAR NERVE PROTECTION
|
Facility
|
IP
|
$6.26
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3.93 |
| Max. Negotiated Rate |
$6.26 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$6.13
|
| Rate for Payer: Altius Auto/Workers Compensation |
$6.01
|
| Rate for Payer: Altius Commercial |
$6.01
|
| Rate for Payer: Beech Street Commercial |
$6.13
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$5.14
|
| Rate for Payer: Cash Price |
$4.38
|
| Rate for Payer: ChoiceCare Network Commercial |
$6.07
|
| Rate for Payer: Cigna of WY Commercial |
$6.13
|
| Rate for Payer: Entrust Commercial |
$5.95
|
| Rate for Payer: First Choice Health Commercial |
$5.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$4.13
|
| Rate for Payer: HealthUtah PPO |
$6.26
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$6.07
|
| Rate for Payer: Multiplan Medicare/VA |
$3.93
|
| Rate for Payer: One Health Plan of WY PPO |
$6.13
|
| Rate for Payer: PacificSource Commercial |
$5.63
|
| Rate for Payer: PHCS PPO |
$6.13
|
| Rate for Payer: Three Rivers PPO |
$4.70
|
| Rate for Payer: TriWest Veterans Administration |
$4.13
|
| Rate for Payer: United Healthcare Commercial |
$5.45
|
| Rate for Payer: United Healthcare Medicare |
$4.13
|
| Rate for Payer: WINHealth Partners Commercial |
$5.95
|
| Rate for Payer: Wise Provider Network Commercial |
$5.95
|
|
|
UMBILICAL INSERTION TRAY
|
Facility
|
IP
|
$174.15
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$109.19 |
| Max. Negotiated Rate |
$174.15 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$170.67
|
| Rate for Payer: Altius Auto/Workers Compensation |
$167.18
|
| Rate for Payer: Altius Commercial |
$167.18
|
| Rate for Payer: Beech Street Commercial |
$170.67
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$142.98
|
| Rate for Payer: Cash Price |
$121.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$168.93
|
| Rate for Payer: Cigna of WY Commercial |
$170.67
|
| Rate for Payer: Entrust Commercial |
$165.44
|
| Rate for Payer: First Choice Health Commercial |
$165.44
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$165.44
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$114.94
|
| Rate for Payer: HealthUtah PPO |
$174.15
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$168.93
|
| Rate for Payer: Multiplan Medicare/VA |
$109.19
|
| Rate for Payer: One Health Plan of WY PPO |
$170.67
|
| Rate for Payer: PacificSource Commercial |
$156.74
|
| Rate for Payer: PHCS PPO |
$170.67
|
| Rate for Payer: Three Rivers PPO |
$130.61
|
| Rate for Payer: TriWest Veterans Administration |
$114.94
|
| Rate for Payer: United Healthcare Commercial |
$151.51
|
| Rate for Payer: United Healthcare Medicare |
$114.94
|
| Rate for Payer: WINHealth Partners Commercial |
$165.44
|
| Rate for Payer: Wise Provider Network Commercial |
$165.44
|
|
|
UMBILICAL INSERTION TRAY
|
Facility
|
OP
|
$174.15
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$95.96 |
| Max. Negotiated Rate |
$174.15 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$170.67
|
| Rate for Payer: Aetna of WY Medicare |
$114.94
|
| Rate for Payer: Altius Auto/Workers Compensation |
$167.18
|
| Rate for Payer: Altius Commercial |
$167.18
|
| Rate for Payer: Beech Street Commercial |
$170.67
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$142.98
|
| Rate for Payer: Cash Price |
$121.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$168.93
|
| Rate for Payer: Cigna of WY Commercial |
$170.67
|
| Rate for Payer: Entrust Commercial |
$165.44
|
| Rate for Payer: First Choice Health Commercial |
$165.44
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$165.44
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$101.01
|
| Rate for Payer: HealthUtah PPO |
$174.15
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$168.93
|
| Rate for Payer: Multiplan Medicare/VA |
$95.96
|
| Rate for Payer: One Health Plan of WY PPO |
$170.67
|
| Rate for Payer: PacificSource Commercial |
$156.74
|
| Rate for Payer: PHCS PPO |
$170.67
|
| Rate for Payer: Three Rivers PPO |
$130.61
|
| Rate for Payer: TriWest Veterans Administration |
$101.01
|
| Rate for Payer: United Healthcare Commercial |
$151.51
|
| Rate for Payer: United Healthcare Medicare |
$101.01
|
| Rate for Payer: WINHealth Partners Commercial |
$170.67
|
| Rate for Payer: Wise Provider Network Commercial |
$165.44
|
|
|
UNCLASSIFIED BIOLOGICS
|
Professional
|
Both
|
$25.00
|
|
|
Service Code
|
HCPCS J3590
|
| Hospital Charge Code |
J3590
|
| Min. Negotiated Rate |
$18.75 |
| Max. Negotiated Rate |
$25.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$24.50
|
| Rate for Payer: Beech Street Commercial |
$23.75
|
| Rate for Payer: Cash Price |
$17.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$24.25
|
| Rate for Payer: Cigna of WY Commercial |
$24.50
|
| Rate for Payer: First Choice Health Commercial |
$22.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$23.75
|
| Rate for Payer: HealthUtah PPO |
$25.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.25
|
| Rate for Payer: One Health Plan of WY PPO |
$24.50
|
| Rate for Payer: PacificSource Commercial |
$22.50
|
| Rate for Payer: PHCS PPO |
$23.75
|
| Rate for Payer: Three Rivers PPO |
$18.75
|
| Rate for Payer: United Healthcare Commercial |
$21.75
|
| Rate for Payer: WINHealth Partners Commercial |
$23.75
|
|
|
UNIV CERVICAL COLLAR 11019
|
Facility
|
IP
|
$15.37
|
|
| Hospital Charge Code |
27000000S1
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$9.64 |
| Max. Negotiated Rate |
$15.37 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.06
|
| Rate for Payer: Altius Auto/Workers Compensation |
$14.76
|
| Rate for Payer: Altius Commercial |
$14.76
|
| Rate for Payer: Beech Street Commercial |
$15.06
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.62
|
| Rate for Payer: Cash Price |
$10.76
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.91
|
| Rate for Payer: Cigna of WY Commercial |
$15.06
|
| Rate for Payer: Entrust Commercial |
$14.60
|
| Rate for Payer: First Choice Health Commercial |
$14.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.14
|
| Rate for Payer: HealthUtah PPO |
$15.37
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.91
|
| Rate for Payer: Multiplan Medicare/VA |
$9.64
|
| Rate for Payer: One Health Plan of WY PPO |
$15.06
|
| Rate for Payer: PacificSource Commercial |
$13.83
|
| Rate for Payer: PHCS PPO |
$15.06
|
| Rate for Payer: Three Rivers PPO |
$11.53
|
| Rate for Payer: TriWest Veterans Administration |
$10.14
|
| Rate for Payer: United Healthcare Commercial |
$13.37
|
| Rate for Payer: United Healthcare Medicare |
$10.14
|
| Rate for Payer: WINHealth Partners Commercial |
$14.60
|
| Rate for Payer: Wise Provider Network Commercial |
$14.60
|
|
|
UNIV CERVICAL COLLAR 11019
|
Facility
|
OP
|
$15.37
|
|
| Hospital Charge Code |
27000000S1
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$8.47 |
| Max. Negotiated Rate |
$15.37 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.06
|
| Rate for Payer: Aetna of WY Medicare |
$10.14
|
| Rate for Payer: Altius Auto/Workers Compensation |
$14.76
|
| Rate for Payer: Altius Commercial |
$14.76
|
| Rate for Payer: Beech Street Commercial |
$15.06
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.62
|
| Rate for Payer: Cash Price |
$10.76
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.91
|
| Rate for Payer: Cigna of WY Commercial |
$15.06
|
| Rate for Payer: Entrust Commercial |
$14.60
|
| Rate for Payer: First Choice Health Commercial |
$14.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.91
|
| Rate for Payer: HealthUtah PPO |
$15.37
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.91
|
| Rate for Payer: Multiplan Medicare/VA |
$8.47
|
| Rate for Payer: One Health Plan of WY PPO |
$15.06
|
| Rate for Payer: PacificSource Commercial |
$13.83
|
| Rate for Payer: PHCS PPO |
$15.06
|
| Rate for Payer: Three Rivers PPO |
$11.53
|
| Rate for Payer: TriWest Veterans Administration |
$8.91
|
| Rate for Payer: United Healthcare Commercial |
$13.37
|
| Rate for Payer: United Healthcare Medicare |
$8.91
|
| Rate for Payer: WINHealth Partners Commercial |
$15.06
|
| Rate for Payer: Wise Provider Network Commercial |
$14.60
|
|
|
UNLISTED LAPS PX HRNAP HERNIORRHAPHY HERNIOTOMY
|
Professional
|
Both
|
$3,694.00
|
|
|
Service Code
|
HCPCS 49659 80
|
| Hospital Charge Code |
49659
|
| Min. Negotiated Rate |
$2,770.50 |
| Max. Negotiated Rate |
$3,694.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,620.12
|
| Rate for Payer: Beech Street Commercial |
$3,509.30
|
| Rate for Payer: Cash Price |
$2,585.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,583.18
|
| Rate for Payer: Cigna of WY Commercial |
$3,620.12
|
| Rate for Payer: First Choice Health Commercial |
$3,324.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,509.30
|
| Rate for Payer: HealthUtah PPO |
$3,694.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,583.18
|
| Rate for Payer: One Health Plan of WY PPO |
$3,620.12
|
| Rate for Payer: PacificSource Commercial |
$3,324.60
|
| Rate for Payer: PHCS PPO |
$3,509.30
|
| Rate for Payer: Three Rivers PPO |
$2,770.50
|
| Rate for Payer: United Healthcare Commercial |
$3,213.78
|
| Rate for Payer: WINHealth Partners Commercial |
$3,139.90
|
|
|
UNLISTED LAPS PX HRNAP HERNIORRHAPHY HERNIOTOMY
|
Professional
|
Both
|
$3,694.00
|
|
|
Service Code
|
HCPCS 49659
|
| Hospital Charge Code |
49659
|
| Min. Negotiated Rate |
$2,770.50 |
| Max. Negotiated Rate |
$3,694.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,620.12
|
| Rate for Payer: Beech Street Commercial |
$3,509.30
|
| Rate for Payer: Cash Price |
$2,585.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,583.18
|
| Rate for Payer: Cigna of WY Commercial |
$3,620.12
|
| Rate for Payer: First Choice Health Commercial |
$3,324.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,509.30
|
| Rate for Payer: HealthUtah PPO |
$3,694.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,583.18
|
| Rate for Payer: One Health Plan of WY PPO |
$3,620.12
|
| Rate for Payer: PacificSource Commercial |
$3,324.60
|
| Rate for Payer: PHCS PPO |
$3,509.30
|
| Rate for Payer: Three Rivers PPO |
$2,770.50
|
| Rate for Payer: United Healthcare Commercial |
$3,213.78
|
| Rate for Payer: WINHealth Partners Commercial |
$3,139.90
|
|
