|
UROLOGY DRAIN BAG 5300
|
Facility
|
OP
|
$19.25
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$10.61 |
| Max. Negotiated Rate |
$19.25 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18.86
|
| Rate for Payer: Aetna of WY Medicare |
$12.70
|
| Rate for Payer: Altius Auto/Workers Compensation |
$18.48
|
| Rate for Payer: Altius Commercial |
$18.48
|
| Rate for Payer: Beech Street Commercial |
$18.86
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.80
|
| Rate for Payer: Cash Price |
$13.47
|
| Rate for Payer: ChoiceCare Network Commercial |
$18.67
|
| Rate for Payer: Cigna of WY Commercial |
$18.86
|
| Rate for Payer: Entrust Commercial |
$18.29
|
| Rate for Payer: First Choice Health Commercial |
$18.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$18.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.16
|
| Rate for Payer: HealthUtah PPO |
$19.25
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$18.67
|
| Rate for Payer: Multiplan Medicare/VA |
$10.61
|
| Rate for Payer: One Health Plan of WY PPO |
$18.86
|
| Rate for Payer: PacificSource Commercial |
$17.32
|
| Rate for Payer: PHCS PPO |
$18.86
|
| Rate for Payer: Three Rivers PPO |
$14.44
|
| Rate for Payer: TriWest Veterans Administration |
$11.16
|
| Rate for Payer: United Healthcare Commercial |
$16.75
|
| Rate for Payer: United Healthcare Medicare |
$11.16
|
| Rate for Payer: WINHealth Partners Commercial |
$18.86
|
| Rate for Payer: Wise Provider Network Commercial |
$18.29
|
|
|
UROLOGY DRAIN BAG 5300
|
Facility
|
IP
|
$19.25
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$12.07 |
| Max. Negotiated Rate |
$19.25 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18.86
|
| Rate for Payer: Altius Auto/Workers Compensation |
$18.48
|
| Rate for Payer: Altius Commercial |
$18.48
|
| Rate for Payer: Beech Street Commercial |
$18.86
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.80
|
| Rate for Payer: Cash Price |
$13.47
|
| Rate for Payer: ChoiceCare Network Commercial |
$18.67
|
| Rate for Payer: Cigna of WY Commercial |
$18.86
|
| Rate for Payer: Entrust Commercial |
$18.29
|
| Rate for Payer: First Choice Health Commercial |
$18.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$18.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$12.70
|
| Rate for Payer: HealthUtah PPO |
$19.25
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$18.67
|
| Rate for Payer: Multiplan Medicare/VA |
$12.07
|
| Rate for Payer: One Health Plan of WY PPO |
$18.86
|
| Rate for Payer: PacificSource Commercial |
$17.32
|
| Rate for Payer: PHCS PPO |
$18.86
|
| Rate for Payer: Three Rivers PPO |
$14.44
|
| Rate for Payer: TriWest Veterans Administration |
$12.70
|
| Rate for Payer: United Healthcare Commercial |
$16.75
|
| Rate for Payer: United Healthcare Medicare |
$12.70
|
| Rate for Payer: WINHealth Partners Commercial |
$18.29
|
| Rate for Payer: Wise Provider Network Commercial |
$18.29
|
|
|
UROLOGY DRAPE PACK
|
Facility
|
OP
|
$118.28
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$65.17 |
| Max. Negotiated Rate |
$118.28 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$115.91
|
| Rate for Payer: Aetna of WY Medicare |
$78.06
|
| Rate for Payer: Altius Auto/Workers Compensation |
$113.55
|
| Rate for Payer: Altius Commercial |
$113.55
|
| Rate for Payer: Beech Street Commercial |
$115.91
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$97.11
|
| Rate for Payer: Cash Price |
$82.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$114.73
|
| Rate for Payer: Cigna of WY Commercial |
$115.91
|
| Rate for Payer: Entrust Commercial |
$112.37
|
| Rate for Payer: First Choice Health Commercial |
$112.37
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$112.37
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$68.60
|
| Rate for Payer: HealthUtah PPO |
$118.28
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$114.73
|
| Rate for Payer: Multiplan Medicare/VA |
$65.17
|
| Rate for Payer: One Health Plan of WY PPO |
$115.91
|
| Rate for Payer: PacificSource Commercial |
$106.45
|
| Rate for Payer: PHCS PPO |
$115.91
|
| Rate for Payer: Three Rivers PPO |
$88.71
|
| Rate for Payer: TriWest Veterans Administration |
$68.60
|
| Rate for Payer: United Healthcare Commercial |
$102.90
|
| Rate for Payer: United Healthcare Medicare |
$68.60
|
| Rate for Payer: WINHealth Partners Commercial |
$115.91
|
| Rate for Payer: Wise Provider Network Commercial |
$112.37
|
|
|
UROLOGY DRAPE PACK
|
Facility
|
IP
|
$118.28
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$74.16 |
| Max. Negotiated Rate |
$118.28 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$115.91
|
| Rate for Payer: Altius Auto/Workers Compensation |
$113.55
|
| Rate for Payer: Altius Commercial |
$113.55
|
| Rate for Payer: Beech Street Commercial |
$115.91
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$97.11
|
| Rate for Payer: Cash Price |
$82.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$114.73
|
| Rate for Payer: Cigna of WY Commercial |
$115.91
|
| Rate for Payer: Entrust Commercial |
$112.37
|
| Rate for Payer: First Choice Health Commercial |
$112.37
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$112.37
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$78.06
|
| Rate for Payer: HealthUtah PPO |
$118.28
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$114.73
|
| Rate for Payer: Multiplan Medicare/VA |
$74.16
|
| Rate for Payer: One Health Plan of WY PPO |
$115.91
|
| Rate for Payer: PacificSource Commercial |
$106.45
|
| Rate for Payer: PHCS PPO |
$115.91
|
| Rate for Payer: Three Rivers PPO |
$88.71
|
| Rate for Payer: TriWest Veterans Administration |
$78.06
|
| Rate for Payer: United Healthcare Commercial |
$102.90
|
| Rate for Payer: United Healthcare Medicare |
$78.06
|
| Rate for Payer: WINHealth Partners Commercial |
$112.37
|
| Rate for Payer: Wise Provider Network Commercial |
$112.37
|
|
|
UROLOK II SCOPE ADAPTOR
|
Facility
|
IP
|
$69.78
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$43.75 |
| Max. Negotiated Rate |
$69.78 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$68.38
|
| Rate for Payer: Altius Auto/Workers Compensation |
$66.99
|
| Rate for Payer: Altius Commercial |
$66.99
|
| Rate for Payer: Beech Street Commercial |
$68.38
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$57.29
|
| Rate for Payer: Cash Price |
$48.85
|
| Rate for Payer: ChoiceCare Network Commercial |
$67.69
|
| Rate for Payer: Cigna of WY Commercial |
$68.38
|
| Rate for Payer: Entrust Commercial |
$66.29
|
| Rate for Payer: First Choice Health Commercial |
$66.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$66.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$46.05
|
| Rate for Payer: HealthUtah PPO |
$69.78
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$67.69
|
| Rate for Payer: Multiplan Medicare/VA |
$43.75
|
| Rate for Payer: One Health Plan of WY PPO |
$68.38
|
| Rate for Payer: PacificSource Commercial |
$62.80
|
| Rate for Payer: PHCS PPO |
$68.38
|
| Rate for Payer: Three Rivers PPO |
$52.34
|
| Rate for Payer: TriWest Veterans Administration |
$46.05
|
| Rate for Payer: United Healthcare Commercial |
$60.71
|
| Rate for Payer: United Healthcare Medicare |
$46.05
|
| Rate for Payer: WINHealth Partners Commercial |
$66.29
|
| Rate for Payer: Wise Provider Network Commercial |
$66.29
|
|
|
UROLOK II SCOPE ADAPTOR
|
Facility
|
OP
|
$69.78
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$38.45 |
| Max. Negotiated Rate |
$69.78 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$68.38
|
| Rate for Payer: Aetna of WY Medicare |
$46.05
|
| Rate for Payer: Altius Auto/Workers Compensation |
$66.99
|
| Rate for Payer: Altius Commercial |
$66.99
|
| Rate for Payer: Beech Street Commercial |
$68.38
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$57.29
|
| Rate for Payer: Cash Price |
$48.85
|
| Rate for Payer: ChoiceCare Network Commercial |
$67.69
|
| Rate for Payer: Cigna of WY Commercial |
$68.38
|
| Rate for Payer: Entrust Commercial |
$66.29
|
| Rate for Payer: First Choice Health Commercial |
$66.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$66.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$40.47
|
| Rate for Payer: HealthUtah PPO |
$69.78
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$67.69
|
| Rate for Payer: Multiplan Medicare/VA |
$38.45
|
| Rate for Payer: One Health Plan of WY PPO |
$68.38
|
| Rate for Payer: PacificSource Commercial |
$62.80
|
| Rate for Payer: PHCS PPO |
$68.38
|
| Rate for Payer: Three Rivers PPO |
$52.34
|
| Rate for Payer: TriWest Veterans Administration |
$40.47
|
| Rate for Payer: United Healthcare Commercial |
$60.71
|
| Rate for Payer: United Healthcare Medicare |
$40.47
|
| Rate for Payer: WINHealth Partners Commercial |
$68.38
|
| Rate for Payer: Wise Provider Network Commercial |
$66.29
|
|
|
UROVAC BLADDER EVACUATOR
|
Facility
|
IP
|
$85.95
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$53.89 |
| Max. Negotiated Rate |
$85.95 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$84.23
|
| Rate for Payer: Altius Auto/Workers Compensation |
$82.51
|
| Rate for Payer: Altius Commercial |
$82.51
|
| Rate for Payer: Beech Street Commercial |
$84.23
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$70.56
|
| Rate for Payer: Cash Price |
$60.17
|
| Rate for Payer: ChoiceCare Network Commercial |
$83.37
|
| Rate for Payer: Cigna of WY Commercial |
$84.23
|
| Rate for Payer: Entrust Commercial |
$81.65
|
| Rate for Payer: First Choice Health Commercial |
$81.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$81.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$56.73
|
| Rate for Payer: HealthUtah PPO |
$85.95
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$83.37
|
| Rate for Payer: Multiplan Medicare/VA |
$53.89
|
| Rate for Payer: One Health Plan of WY PPO |
$84.23
|
| Rate for Payer: PacificSource Commercial |
$77.36
|
| Rate for Payer: PHCS PPO |
$84.23
|
| Rate for Payer: Three Rivers PPO |
$64.46
|
| Rate for Payer: TriWest Veterans Administration |
$56.73
|
| Rate for Payer: United Healthcare Commercial |
$74.78
|
| Rate for Payer: United Healthcare Medicare |
$56.73
|
| Rate for Payer: WINHealth Partners Commercial |
$81.65
|
| Rate for Payer: Wise Provider Network Commercial |
$81.65
|
|
|
UROVAC BLADDER EVACUATOR
|
Facility
|
OP
|
$85.95
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$47.36 |
| Max. Negotiated Rate |
$85.95 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$84.23
|
| Rate for Payer: Aetna of WY Medicare |
$56.73
|
| Rate for Payer: Altius Auto/Workers Compensation |
$82.51
|
| Rate for Payer: Altius Commercial |
$82.51
|
| Rate for Payer: Beech Street Commercial |
$84.23
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$70.56
|
| Rate for Payer: Cash Price |
$60.17
|
| Rate for Payer: ChoiceCare Network Commercial |
$83.37
|
| Rate for Payer: Cigna of WY Commercial |
$84.23
|
| Rate for Payer: Entrust Commercial |
$81.65
|
| Rate for Payer: First Choice Health Commercial |
$81.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$81.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$49.85
|
| Rate for Payer: HealthUtah PPO |
$85.95
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$83.37
|
| Rate for Payer: Multiplan Medicare/VA |
$47.36
|
| Rate for Payer: One Health Plan of WY PPO |
$84.23
|
| Rate for Payer: PacificSource Commercial |
$77.36
|
| Rate for Payer: PHCS PPO |
$84.23
|
| Rate for Payer: Three Rivers PPO |
$64.46
|
| Rate for Payer: TriWest Veterans Administration |
$49.85
|
| Rate for Payer: United Healthcare Commercial |
$74.78
|
| Rate for Payer: United Healthcare Medicare |
$49.85
|
| Rate for Payer: WINHealth Partners Commercial |
$84.23
|
| Rate for Payer: Wise Provider Network Commercial |
$81.65
|
|
|
URSODIOL 300 MG CAPSULE [13374]
|
Facility
|
IP
|
$4.09
|
|
|
Service Code
|
NDC 0591315901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.56 |
| Max. Negotiated Rate |
$4.09 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4.01
|
| Rate for Payer: Altius Auto/Workers Compensation |
$3.93
|
| Rate for Payer: Altius Commercial |
$3.93
|
| Rate for Payer: Beech Street Commercial |
$4.01
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3.36
|
| Rate for Payer: Cash Price |
$2.86
|
| Rate for Payer: ChoiceCare Network Commercial |
$3.97
|
| Rate for Payer: Cigna of WY Commercial |
$4.01
|
| Rate for Payer: Entrust Commercial |
$3.89
|
| Rate for Payer: First Choice Health Commercial |
$3.89
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3.89
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2.70
|
| Rate for Payer: HealthUtah PPO |
$4.09
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3.97
|
| Rate for Payer: Multiplan Medicare/VA |
$2.56
|
| Rate for Payer: One Health Plan of WY PPO |
$4.01
|
| Rate for Payer: PacificSource Commercial |
$3.68
|
| Rate for Payer: PHCS PPO |
$4.01
|
| Rate for Payer: Three Rivers PPO |
$3.07
|
| Rate for Payer: TriWest Veterans Administration |
$2.70
|
| Rate for Payer: United Healthcare Commercial |
$3.56
|
| Rate for Payer: United Healthcare Medicare |
$2.70
|
| Rate for Payer: WINHealth Partners Commercial |
$3.89
|
| Rate for Payer: Wise Provider Network Commercial |
$3.89
|
|
|
URSODIOL 300 MG CAPSULE [13374]
|
Facility
|
OP
|
$4.09
|
|
|
Service Code
|
NDC 0591315901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.25 |
| Max. Negotiated Rate |
$4.09 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4.01
|
| Rate for Payer: Aetna of WY Medicare |
$2.70
|
| Rate for Payer: Altius Auto/Workers Compensation |
$3.93
|
| Rate for Payer: Altius Commercial |
$3.93
|
| Rate for Payer: Beech Street Commercial |
$4.01
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3.36
|
| Rate for Payer: Cash Price |
$2.86
|
| Rate for Payer: ChoiceCare Network Commercial |
$3.97
|
| Rate for Payer: Cigna of WY Commercial |
$4.01
|
| Rate for Payer: Entrust Commercial |
$3.89
|
| Rate for Payer: First Choice Health Commercial |
$3.89
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3.89
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2.37
|
| Rate for Payer: HealthUtah PPO |
$4.09
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3.97
|
| Rate for Payer: Multiplan Medicare/VA |
$2.25
|
| Rate for Payer: One Health Plan of WY PPO |
$4.01
|
| Rate for Payer: PacificSource Commercial |
$3.68
|
| Rate for Payer: PHCS PPO |
$4.01
|
| Rate for Payer: Three Rivers PPO |
$3.07
|
| Rate for Payer: TriWest Veterans Administration |
$2.37
|
| Rate for Payer: United Healthcare Commercial |
$3.56
|
| Rate for Payer: United Healthcare Medicare |
$2.37
|
| Rate for Payer: WINHealth Partners Commercial |
$4.01
|
| Rate for Payer: Wise Provider Network Commercial |
$3.89
|
|
|
US ABDOMINAL REAL TIME W/IMAGE LIMITED
|
Professional
|
Both
|
$387.00
|
|
|
Service Code
|
HCPCS 76705 26
|
| Hospital Charge Code |
76705
|
| Min. Negotiated Rate |
$22.60 |
| Max. Negotiated Rate |
$387.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$379.26
|
| Rate for Payer: Aetna of WY Medicare |
$26.59
|
| Rate for Payer: Beech Street Commercial |
$367.65
|
| Rate for Payer: Cash Price |
$270.90
|
| Rate for Payer: Cash Price |
$270.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$375.39
|
| Rate for Payer: Cigna of WY Commercial |
$379.26
|
| Rate for Payer: First Choice Health Commercial |
$348.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$367.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$26.59
|
| Rate for Payer: HealthUtah PPO |
$387.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$375.39
|
| Rate for Payer: Multiplan Medicare/VA |
$22.60
|
| Rate for Payer: One Health Plan of WY PPO |
$379.26
|
| Rate for Payer: PacificSource Commercial |
$348.30
|
| Rate for Payer: PHCS PPO |
$367.65
|
| Rate for Payer: Three Rivers PPO |
$290.25
|
| Rate for Payer: TriWest Veterans Administration |
$26.59
|
| Rate for Payer: United Healthcare Commercial |
$336.69
|
| Rate for Payer: United Healthcare Medicare |
$26.59
|
| Rate for Payer: WINHealth Partners Commercial |
$367.65
|
|
|
US, BREAST(S), REAL TIME
|
Professional
|
Both
|
$620.00
|
|
|
Service Code
|
HCPCS 76645
|
| Hospital Charge Code |
76645
|
| Min. Negotiated Rate |
$465.00 |
| Max. Negotiated Rate |
$620.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$607.60
|
| Rate for Payer: Beech Street Commercial |
$589.00
|
| Rate for Payer: Cash Price |
$434.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$601.40
|
| Rate for Payer: Cigna of WY Commercial |
$607.60
|
| Rate for Payer: First Choice Health Commercial |
$558.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$589.00
|
| Rate for Payer: HealthUtah PPO |
$620.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$601.40
|
| Rate for Payer: One Health Plan of WY PPO |
$607.60
|
| Rate for Payer: PacificSource Commercial |
$558.00
|
| Rate for Payer: PHCS PPO |
$589.00
|
| Rate for Payer: Three Rivers PPO |
$465.00
|
| Rate for Payer: United Healthcare Commercial |
$539.40
|
| Rate for Payer: WINHealth Partners Commercial |
$589.00
|
|
|
US FETAL NUCHAL TRANSLUCENCY 1ST GESTATION
|
Professional
|
Both
|
$495.00
|
|
|
Service Code
|
HCPCS 76813
|
| Hospital Charge Code |
76813
|
| Min. Negotiated Rate |
$96.29 |
| Max. Negotiated Rate |
$495.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$485.10
|
| Rate for Payer: Aetna of WY Medicare |
$113.28
|
| Rate for Payer: Beech Street Commercial |
$470.25
|
| Rate for Payer: Cash Price |
$346.50
|
| Rate for Payer: Cash Price |
$346.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$480.15
|
| Rate for Payer: Cigna of WY Commercial |
$485.10
|
| Rate for Payer: First Choice Health Commercial |
$445.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$470.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$113.28
|
| Rate for Payer: HealthUtah PPO |
$495.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$480.15
|
| Rate for Payer: Multiplan Medicare/VA |
$96.29
|
| Rate for Payer: One Health Plan of WY PPO |
$485.10
|
| Rate for Payer: PacificSource Commercial |
$445.50
|
| Rate for Payer: PHCS PPO |
$470.25
|
| Rate for Payer: Three Rivers PPO |
$371.25
|
| Rate for Payer: TriWest Veterans Administration |
$113.28
|
| Rate for Payer: United Healthcare Commercial |
$430.65
|
| Rate for Payer: United Healthcare Medicare |
$113.28
|
| Rate for Payer: WINHealth Partners Commercial |
$470.25
|
|
|
US GUIDANCE NEEDLE PLACEMENT IMG S&I
|
Professional
|
Both
|
$199.00
|
|
|
Service Code
|
HCPCS 76942
|
| Hospital Charge Code |
76942
|
| Min. Negotiated Rate |
$24.56 |
| Max. Negotiated Rate |
$199.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$195.02
|
| Rate for Payer: Aetna of WY Medicare |
$56.63
|
| Rate for Payer: Beech Street Commercial |
$189.05
|
| Rate for Payer: Cash Price |
$139.30
|
| Rate for Payer: Cash Price |
$139.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$193.03
|
| Rate for Payer: Cigna of WY Commercial |
$195.02
|
| Rate for Payer: First Choice Health Commercial |
$179.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$189.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$56.63
|
| Rate for Payer: HealthUtah PPO |
$199.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$193.03
|
| Rate for Payer: Multiplan Medicare/VA |
$48.14
|
| Rate for Payer: One Health Plan of WY PPO |
$195.02
|
| Rate for Payer: PacificSource Commercial |
$179.10
|
| Rate for Payer: PHCS PPO |
$189.05
|
| Rate for Payer: Three Rivers PPO |
$149.25
|
| Rate for Payer: TriWest Veterans Administration |
$56.63
|
| Rate for Payer: United Healthcare Commercial |
$173.13
|
| Rate for Payer: United Healthcare Medicare |
$56.63
|
| Rate for Payer: WINHealth Partners Commercial |
$189.05
|
|
|
US GUIDANCE NEEDLE PLACEMENT IMG S&I
|
Professional
|
Both
|
$199.00
|
|
|
Service Code
|
HCPCS 76942 26
|
| Hospital Charge Code |
76942
|
| Min. Negotiated Rate |
$24.56 |
| Max. Negotiated Rate |
$199.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$195.02
|
| Rate for Payer: Aetna of WY Medicare |
$28.89
|
| Rate for Payer: Beech Street Commercial |
$189.05
|
| Rate for Payer: Cash Price |
$139.30
|
| Rate for Payer: Cash Price |
$139.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$193.03
|
| Rate for Payer: Cigna of WY Commercial |
$195.02
|
| Rate for Payer: First Choice Health Commercial |
$179.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$189.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$28.89
|
| Rate for Payer: HealthUtah PPO |
$199.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$193.03
|
| Rate for Payer: Multiplan Medicare/VA |
$24.56
|
| Rate for Payer: One Health Plan of WY PPO |
$195.02
|
| Rate for Payer: PacificSource Commercial |
$179.10
|
| Rate for Payer: PHCS PPO |
$189.05
|
| Rate for Payer: Three Rivers PPO |
$149.25
|
| Rate for Payer: TriWest Veterans Administration |
$28.89
|
| Rate for Payer: United Healthcare Commercial |
$173.13
|
| Rate for Payer: United Healthcare Medicare |
$28.89
|
| Rate for Payer: WINHealth Partners Commercial |
$189.05
|
|
|
US PELVIC NONOBSTETRIC IMAGE DCMTN LIMITED/F/U
|
Professional
|
Both
|
$168.00
|
|
|
Service Code
|
HCPCS 76857
|
| Hospital Charge Code |
76857
|
| Min. Negotiated Rate |
$40.98 |
| Max. Negotiated Rate |
$168.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$164.64
|
| Rate for Payer: Aetna of WY Medicare |
$48.21
|
| Rate for Payer: Beech Street Commercial |
$159.60
|
| Rate for Payer: Cash Price |
$117.60
|
| Rate for Payer: Cash Price |
$117.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$162.96
|
| Rate for Payer: Cigna of WY Commercial |
$164.64
|
| Rate for Payer: First Choice Health Commercial |
$151.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$159.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$48.21
|
| Rate for Payer: HealthUtah PPO |
$168.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$162.96
|
| Rate for Payer: Multiplan Medicare/VA |
$40.98
|
| Rate for Payer: One Health Plan of WY PPO |
$164.64
|
| Rate for Payer: PacificSource Commercial |
$151.20
|
| Rate for Payer: PHCS PPO |
$159.60
|
| Rate for Payer: Three Rivers PPO |
$126.00
|
| Rate for Payer: TriWest Veterans Administration |
$48.21
|
| Rate for Payer: United Healthcare Commercial |
$146.16
|
| Rate for Payer: United Healthcare Medicare |
$48.21
|
| Rate for Payer: WINHealth Partners Commercial |
$159.60
|
|
|
US PREGNANT UTERUS 14 WK TRANSABDL 1/1ST GESTAT
|
Professional
|
Both
|
$571.00
|
|
|
Service Code
|
HCPCS 76801
|
| Hospital Charge Code |
76801
|
| Min. Negotiated Rate |
$97.61 |
| Max. Negotiated Rate |
$571.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$559.58
|
| Rate for Payer: Aetna of WY Medicare |
$114.83
|
| Rate for Payer: Beech Street Commercial |
$542.45
|
| Rate for Payer: Cash Price |
$399.70
|
| Rate for Payer: Cash Price |
$399.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$553.87
|
| Rate for Payer: Cigna of WY Commercial |
$559.58
|
| Rate for Payer: First Choice Health Commercial |
$513.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$542.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$114.83
|
| Rate for Payer: HealthUtah PPO |
$571.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$553.87
|
| Rate for Payer: Multiplan Medicare/VA |
$97.61
|
| Rate for Payer: One Health Plan of WY PPO |
$559.58
|
| Rate for Payer: PacificSource Commercial |
$513.90
|
| Rate for Payer: PHCS PPO |
$542.45
|
| Rate for Payer: Three Rivers PPO |
$428.25
|
| Rate for Payer: TriWest Veterans Administration |
$114.83
|
| Rate for Payer: United Healthcare Commercial |
$496.77
|
| Rate for Payer: United Healthcare Medicare |
$114.83
|
| Rate for Payer: WINHealth Partners Commercial |
$542.45
|
|
|
US PREGNANT UTERUS LIMITED 1/> FETUSES
|
Professional
|
Both
|
$352.00
|
|
|
Service Code
|
HCPCS 76815
|
| Hospital Charge Code |
76815
|
| Min. Negotiated Rate |
$67.35 |
| Max. Negotiated Rate |
$352.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$344.96
|
| Rate for Payer: Aetna of WY Medicare |
$79.23
|
| Rate for Payer: Beech Street Commercial |
$334.40
|
| Rate for Payer: Cash Price |
$246.40
|
| Rate for Payer: Cash Price |
$246.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$341.44
|
| Rate for Payer: Cigna of WY Commercial |
$344.96
|
| Rate for Payer: First Choice Health Commercial |
$316.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$334.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$79.23
|
| Rate for Payer: HealthUtah PPO |
$352.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$341.44
|
| Rate for Payer: Multiplan Medicare/VA |
$67.35
|
| Rate for Payer: One Health Plan of WY PPO |
$344.96
|
| Rate for Payer: PacificSource Commercial |
$316.80
|
| Rate for Payer: PHCS PPO |
$334.40
|
| Rate for Payer: Three Rivers PPO |
$264.00
|
| Rate for Payer: TriWest Veterans Administration |
$79.23
|
| Rate for Payer: United Healthcare Commercial |
$306.24
|
| Rate for Payer: United Healthcare Medicare |
$79.23
|
| Rate for Payer: WINHealth Partners Commercial |
$334.40
|
|
|
US PREG UTERUS > 1ST TRIMESTER ABDL EA GESTATIO
|
Professional
|
Both
|
$970.00
|
|
|
Service Code
|
HCPCS 76810
|
| Hospital Charge Code |
76810
|
| Min. Negotiated Rate |
$72.70 |
| Max. Negotiated Rate |
$970.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$950.60
|
| Rate for Payer: Aetna of WY Medicare |
$85.53
|
| Rate for Payer: Beech Street Commercial |
$921.50
|
| Rate for Payer: Cash Price |
$679.00
|
| Rate for Payer: Cash Price |
$679.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$940.90
|
| Rate for Payer: Cigna of WY Commercial |
$950.60
|
| Rate for Payer: First Choice Health Commercial |
$873.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$921.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$85.53
|
| Rate for Payer: HealthUtah PPO |
$970.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$940.90
|
| Rate for Payer: Multiplan Medicare/VA |
$72.70
|
| Rate for Payer: One Health Plan of WY PPO |
$950.60
|
| Rate for Payer: PacificSource Commercial |
$873.00
|
| Rate for Payer: PHCS PPO |
$921.50
|
| Rate for Payer: Three Rivers PPO |
$727.50
|
| Rate for Payer: TriWest Veterans Administration |
$85.53
|
| Rate for Payer: United Healthcare Commercial |
$843.90
|
| Rate for Payer: United Healthcare Medicare |
$85.53
|
| Rate for Payer: WINHealth Partners Commercial |
$921.50
|
|
|
US PREG UTERUS AFTER 1ST TRIMEST 1/1ST GESTATION
|
Professional
|
Both
|
$571.00
|
|
|
Service Code
|
HCPCS 76805
|
| Hospital Charge Code |
76805
|
| Min. Negotiated Rate |
$112.85 |
| Max. Negotiated Rate |
$571.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$559.58
|
| Rate for Payer: Aetna of WY Medicare |
$132.76
|
| Rate for Payer: Beech Street Commercial |
$542.45
|
| Rate for Payer: Cash Price |
$399.70
|
| Rate for Payer: Cash Price |
$399.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$553.87
|
| Rate for Payer: Cigna of WY Commercial |
$559.58
|
| Rate for Payer: First Choice Health Commercial |
$513.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$542.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$132.76
|
| Rate for Payer: HealthUtah PPO |
$571.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$553.87
|
| Rate for Payer: Multiplan Medicare/VA |
$112.85
|
| Rate for Payer: One Health Plan of WY PPO |
$559.58
|
| Rate for Payer: PacificSource Commercial |
$513.90
|
| Rate for Payer: PHCS PPO |
$542.45
|
| Rate for Payer: Three Rivers PPO |
$428.25
|
| Rate for Payer: TriWest Veterans Administration |
$132.76
|
| Rate for Payer: United Healthcare Commercial |
$496.77
|
| Rate for Payer: United Healthcare Medicare |
$132.76
|
| Rate for Payer: WINHealth Partners Commercial |
$542.45
|
|
|
US PREG UTERUS REAL TIME F/U TRNSABDL PER FETUS
|
Professional
|
Both
|
$535.00
|
|
|
Service Code
|
HCPCS 76816
|
| Hospital Charge Code |
76816
|
| Min. Negotiated Rate |
$91.63 |
| Max. Negotiated Rate |
$535.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$524.30
|
| Rate for Payer: Aetna of WY Medicare |
$107.80
|
| Rate for Payer: Beech Street Commercial |
$508.25
|
| Rate for Payer: Cash Price |
$374.50
|
| Rate for Payer: Cash Price |
$374.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$518.95
|
| Rate for Payer: Cigna of WY Commercial |
$524.30
|
| Rate for Payer: First Choice Health Commercial |
$481.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$508.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$107.80
|
| Rate for Payer: HealthUtah PPO |
$535.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$518.95
|
| Rate for Payer: Multiplan Medicare/VA |
$91.63
|
| Rate for Payer: One Health Plan of WY PPO |
$524.30
|
| Rate for Payer: PacificSource Commercial |
$481.50
|
| Rate for Payer: PHCS PPO |
$508.25
|
| Rate for Payer: Three Rivers PPO |
$401.25
|
| Rate for Payer: TriWest Veterans Administration |
$107.80
|
| Rate for Payer: United Healthcare Commercial |
$465.45
|
| Rate for Payer: United Healthcare Medicare |
$107.80
|
| Rate for Payer: WINHealth Partners Commercial |
$508.25
|
|
|
US PREG UTERUS REAL TIME W/IMAGE DCMTN TRANSVAG
|
Professional
|
Both
|
$635.00
|
|
|
Service Code
|
HCPCS 76817
|
| Hospital Charge Code |
76817
|
| Min. Negotiated Rate |
$77.09 |
| Max. Negotiated Rate |
$635.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$622.30
|
| Rate for Payer: Aetna of WY Medicare |
$90.69
|
| Rate for Payer: Beech Street Commercial |
$603.25
|
| Rate for Payer: Cash Price |
$444.50
|
| Rate for Payer: Cash Price |
$444.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$615.95
|
| Rate for Payer: Cigna of WY Commercial |
$622.30
|
| Rate for Payer: First Choice Health Commercial |
$571.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$603.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$90.69
|
| Rate for Payer: HealthUtah PPO |
$635.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$615.95
|
| Rate for Payer: Multiplan Medicare/VA |
$77.09
|
| Rate for Payer: One Health Plan of WY PPO |
$622.30
|
| Rate for Payer: PacificSource Commercial |
$571.50
|
| Rate for Payer: PHCS PPO |
$603.25
|
| Rate for Payer: Three Rivers PPO |
$476.25
|
| Rate for Payer: TriWest Veterans Administration |
$90.69
|
| Rate for Payer: United Healthcare Commercial |
$552.45
|
| Rate for Payer: United Healthcare Medicare |
$90.69
|
| Rate for Payer: WINHealth Partners Commercial |
$603.25
|
|
|
USTEKINUMAB 130 MG/26 ML INTRAVENOUS SOLUTION [146738]
|
Facility
|
OP
|
$144.78
|
|
|
Service Code
|
HCPCS J3358
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$79.77 |
| Max. Negotiated Rate |
$144.78 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$141.88
|
| Rate for Payer: Aetna of WY Medicare |
$95.55
|
| Rate for Payer: Altius Auto/Workers Compensation |
$138.99
|
| Rate for Payer: Altius Commercial |
$138.99
|
| Rate for Payer: Beech Street Commercial |
$141.88
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$118.86
|
| Rate for Payer: Cash Price |
$101.34
|
| Rate for Payer: ChoiceCare Network Commercial |
$140.44
|
| Rate for Payer: Cigna of WY Commercial |
$141.88
|
| Rate for Payer: Entrust Commercial |
$137.54
|
| Rate for Payer: First Choice Health Commercial |
$137.54
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$137.54
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$83.97
|
| Rate for Payer: HealthUtah PPO |
$144.78
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$140.44
|
| Rate for Payer: Multiplan Medicare/VA |
$79.77
|
| Rate for Payer: One Health Plan of WY PPO |
$141.88
|
| Rate for Payer: PacificSource Commercial |
$130.30
|
| Rate for Payer: PHCS PPO |
$141.88
|
| Rate for Payer: Three Rivers PPO |
$108.58
|
| Rate for Payer: TriWest Veterans Administration |
$83.97
|
| Rate for Payer: United Healthcare Commercial |
$125.96
|
| Rate for Payer: United Healthcare Medicare |
$83.97
|
| Rate for Payer: WINHealth Partners Commercial |
$141.88
|
| Rate for Payer: Wise Provider Network Commercial |
$137.54
|
|
|
USTEKINUMAB 130 MG/26 ML INTRAVENOUS SOLUTION [146738]
|
Facility
|
IP
|
$144.78
|
|
|
Service Code
|
HCPCS J3358
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$90.78 |
| Max. Negotiated Rate |
$144.78 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$141.88
|
| Rate for Payer: Altius Auto/Workers Compensation |
$138.99
|
| Rate for Payer: Altius Commercial |
$138.99
|
| Rate for Payer: Beech Street Commercial |
$141.88
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$118.86
|
| Rate for Payer: Cash Price |
$101.34
|
| Rate for Payer: ChoiceCare Network Commercial |
$140.44
|
| Rate for Payer: Cigna of WY Commercial |
$141.88
|
| Rate for Payer: Entrust Commercial |
$137.54
|
| Rate for Payer: First Choice Health Commercial |
$137.54
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$137.54
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$95.55
|
| Rate for Payer: HealthUtah PPO |
$144.78
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$140.44
|
| Rate for Payer: Multiplan Medicare/VA |
$90.78
|
| Rate for Payer: One Health Plan of WY PPO |
$141.88
|
| Rate for Payer: PacificSource Commercial |
$130.30
|
| Rate for Payer: PHCS PPO |
$141.88
|
| Rate for Payer: Three Rivers PPO |
$108.58
|
| Rate for Payer: TriWest Veterans Administration |
$95.55
|
| Rate for Payer: United Healthcare Commercial |
$125.96
|
| Rate for Payer: United Healthcare Medicare |
$95.55
|
| Rate for Payer: WINHealth Partners Commercial |
$137.54
|
| Rate for Payer: Wise Provider Network Commercial |
$137.54
|
|
|
US TRANSVAGINAL
|
Professional
|
Both
|
$610.00
|
|
|
Service Code
|
HCPCS 76830
|
| Hospital Charge Code |
76830
|
| Min. Negotiated Rate |
$99.28 |
| Max. Negotiated Rate |
$610.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$597.80
|
| Rate for Payer: Aetna of WY Medicare |
$116.80
|
| Rate for Payer: Beech Street Commercial |
$579.50
|
| Rate for Payer: Cash Price |
$427.00
|
| Rate for Payer: Cash Price |
$427.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$591.70
|
| Rate for Payer: Cigna of WY Commercial |
$597.80
|
| Rate for Payer: First Choice Health Commercial |
$549.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$579.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$116.80
|
| Rate for Payer: HealthUtah PPO |
$610.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$591.70
|
| Rate for Payer: Multiplan Medicare/VA |
$99.28
|
| Rate for Payer: One Health Plan of WY PPO |
$597.80
|
| Rate for Payer: PacificSource Commercial |
$549.00
|
| Rate for Payer: PHCS PPO |
$579.50
|
| Rate for Payer: Three Rivers PPO |
$457.50
|
| Rate for Payer: TriWest Veterans Administration |
$116.80
|
| Rate for Payer: United Healthcare Commercial |
$530.70
|
| Rate for Payer: United Healthcare Medicare |
$116.80
|
| Rate for Payer: WINHealth Partners Commercial |
$579.50
|
|
