|
WOLVERINE CUTTING BALLOON 2.5MM X 10MM
|
Facility
|
IP
|
$2,660.00
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,667.82 |
| Max. Negotiated Rate |
$2,660.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,606.80
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2,553.60
|
| Rate for Payer: Altius Commercial |
$2,553.60
|
| Rate for Payer: Beech Street Commercial |
$2,606.80
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,183.86
|
| Rate for Payer: Cash Price |
$1,862.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,580.20
|
| Rate for Payer: Cigna of WY Commercial |
$2,606.80
|
| Rate for Payer: Entrust Commercial |
$2,527.00
|
| Rate for Payer: First Choice Health Commercial |
$2,527.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,527.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,755.60
|
| Rate for Payer: HealthUtah PPO |
$2,660.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,580.20
|
| Rate for Payer: Multiplan Medicare/VA |
$1,667.82
|
| Rate for Payer: One Health Plan of WY PPO |
$2,606.80
|
| Rate for Payer: PacificSource Commercial |
$2,394.00
|
| Rate for Payer: PHCS PPO |
$2,606.80
|
| Rate for Payer: Three Rivers PPO |
$1,995.00
|
| Rate for Payer: TriWest Veterans Administration |
$1,755.60
|
| Rate for Payer: United Healthcare Commercial |
$2,314.20
|
| Rate for Payer: United Healthcare Medicare |
$1,755.60
|
| Rate for Payer: WINHealth Partners Commercial |
$2,527.00
|
| Rate for Payer: Wise Provider Network Commercial |
$2,527.00
|
|
|
WOLVERINE CUTTING BALLOON 3.0MM X 10MM
|
Facility
|
OP
|
$2,660.00
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,465.66 |
| Max. Negotiated Rate |
$2,660.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,606.80
|
| Rate for Payer: Aetna of WY Medicare |
$1,755.60
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2,553.60
|
| Rate for Payer: Altius Commercial |
$2,553.60
|
| Rate for Payer: Beech Street Commercial |
$2,606.80
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,183.86
|
| Rate for Payer: Cash Price |
$1,862.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,580.20
|
| Rate for Payer: Cigna of WY Commercial |
$2,606.80
|
| Rate for Payer: Entrust Commercial |
$2,527.00
|
| Rate for Payer: First Choice Health Commercial |
$2,527.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,527.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,542.80
|
| Rate for Payer: HealthUtah PPO |
$2,660.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,580.20
|
| Rate for Payer: Multiplan Medicare/VA |
$1,465.66
|
| Rate for Payer: One Health Plan of WY PPO |
$2,606.80
|
| Rate for Payer: PacificSource Commercial |
$2,394.00
|
| Rate for Payer: PHCS PPO |
$2,606.80
|
| Rate for Payer: Three Rivers PPO |
$1,995.00
|
| Rate for Payer: TriWest Veterans Administration |
$1,542.80
|
| Rate for Payer: United Healthcare Commercial |
$2,314.20
|
| Rate for Payer: United Healthcare Medicare |
$1,542.80
|
| Rate for Payer: WINHealth Partners Commercial |
$2,606.80
|
| Rate for Payer: Wise Provider Network Commercial |
$2,527.00
|
|
|
WOLVERINE CUTTING BALLOON 3.0MM X 10MM
|
Facility
|
IP
|
$2,660.00
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,667.82 |
| Max. Negotiated Rate |
$2,660.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,606.80
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2,553.60
|
| Rate for Payer: Altius Commercial |
$2,553.60
|
| Rate for Payer: Beech Street Commercial |
$2,606.80
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,183.86
|
| Rate for Payer: Cash Price |
$1,862.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,580.20
|
| Rate for Payer: Cigna of WY Commercial |
$2,606.80
|
| Rate for Payer: Entrust Commercial |
$2,527.00
|
| Rate for Payer: First Choice Health Commercial |
$2,527.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,527.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,755.60
|
| Rate for Payer: HealthUtah PPO |
$2,660.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,580.20
|
| Rate for Payer: Multiplan Medicare/VA |
$1,667.82
|
| Rate for Payer: One Health Plan of WY PPO |
$2,606.80
|
| Rate for Payer: PacificSource Commercial |
$2,394.00
|
| Rate for Payer: PHCS PPO |
$2,606.80
|
| Rate for Payer: Three Rivers PPO |
$1,995.00
|
| Rate for Payer: TriWest Veterans Administration |
$1,755.60
|
| Rate for Payer: United Healthcare Commercial |
$2,314.20
|
| Rate for Payer: United Healthcare Medicare |
$1,755.60
|
| Rate for Payer: WINHealth Partners Commercial |
$2,527.00
|
| Rate for Payer: Wise Provider Network Commercial |
$2,527.00
|
|
|
WOLVERINE CUTTING BALLOON 3.5MM X 10MM
|
Facility
|
IP
|
$2,660.00
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,667.82 |
| Max. Negotiated Rate |
$2,660.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,606.80
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2,553.60
|
| Rate for Payer: Altius Commercial |
$2,553.60
|
| Rate for Payer: Beech Street Commercial |
$2,606.80
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,183.86
|
| Rate for Payer: Cash Price |
$1,862.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,580.20
|
| Rate for Payer: Cigna of WY Commercial |
$2,606.80
|
| Rate for Payer: Entrust Commercial |
$2,527.00
|
| Rate for Payer: First Choice Health Commercial |
$2,527.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,527.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,755.60
|
| Rate for Payer: HealthUtah PPO |
$2,660.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,580.20
|
| Rate for Payer: Multiplan Medicare/VA |
$1,667.82
|
| Rate for Payer: One Health Plan of WY PPO |
$2,606.80
|
| Rate for Payer: PacificSource Commercial |
$2,394.00
|
| Rate for Payer: PHCS PPO |
$2,606.80
|
| Rate for Payer: Three Rivers PPO |
$1,995.00
|
| Rate for Payer: TriWest Veterans Administration |
$1,755.60
|
| Rate for Payer: United Healthcare Commercial |
$2,314.20
|
| Rate for Payer: United Healthcare Medicare |
$1,755.60
|
| Rate for Payer: WINHealth Partners Commercial |
$2,527.00
|
| Rate for Payer: Wise Provider Network Commercial |
$2,527.00
|
|
|
WOLVERINE CUTTING BALLOON 3.5MM X 10MM
|
Facility
|
OP
|
$2,660.00
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,465.66 |
| Max. Negotiated Rate |
$2,660.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,606.80
|
| Rate for Payer: Aetna of WY Medicare |
$1,755.60
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2,553.60
|
| Rate for Payer: Altius Commercial |
$2,553.60
|
| Rate for Payer: Beech Street Commercial |
$2,606.80
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,183.86
|
| Rate for Payer: Cash Price |
$1,862.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,580.20
|
| Rate for Payer: Cigna of WY Commercial |
$2,606.80
|
| Rate for Payer: Entrust Commercial |
$2,527.00
|
| Rate for Payer: First Choice Health Commercial |
$2,527.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,527.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,542.80
|
| Rate for Payer: HealthUtah PPO |
$2,660.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,580.20
|
| Rate for Payer: Multiplan Medicare/VA |
$1,465.66
|
| Rate for Payer: One Health Plan of WY PPO |
$2,606.80
|
| Rate for Payer: PacificSource Commercial |
$2,394.00
|
| Rate for Payer: PHCS PPO |
$2,606.80
|
| Rate for Payer: Three Rivers PPO |
$1,995.00
|
| Rate for Payer: TriWest Veterans Administration |
$1,542.80
|
| Rate for Payer: United Healthcare Commercial |
$2,314.20
|
| Rate for Payer: United Healthcare Medicare |
$1,542.80
|
| Rate for Payer: WINHealth Partners Commercial |
$2,606.80
|
| Rate for Payer: Wise Provider Network Commercial |
$2,527.00
|
|
|
WOLVERINE CUTTING BALLOON 4.0MM X 10MM
|
Facility
|
IP
|
$2,660.00
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,667.82 |
| Max. Negotiated Rate |
$2,660.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,606.80
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2,553.60
|
| Rate for Payer: Altius Commercial |
$2,553.60
|
| Rate for Payer: Beech Street Commercial |
$2,606.80
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,183.86
|
| Rate for Payer: Cash Price |
$1,862.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,580.20
|
| Rate for Payer: Cigna of WY Commercial |
$2,606.80
|
| Rate for Payer: Entrust Commercial |
$2,527.00
|
| Rate for Payer: First Choice Health Commercial |
$2,527.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,527.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,755.60
|
| Rate for Payer: HealthUtah PPO |
$2,660.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,580.20
|
| Rate for Payer: Multiplan Medicare/VA |
$1,667.82
|
| Rate for Payer: One Health Plan of WY PPO |
$2,606.80
|
| Rate for Payer: PacificSource Commercial |
$2,394.00
|
| Rate for Payer: PHCS PPO |
$2,606.80
|
| Rate for Payer: Three Rivers PPO |
$1,995.00
|
| Rate for Payer: TriWest Veterans Administration |
$1,755.60
|
| Rate for Payer: United Healthcare Commercial |
$2,314.20
|
| Rate for Payer: United Healthcare Medicare |
$1,755.60
|
| Rate for Payer: WINHealth Partners Commercial |
$2,527.00
|
| Rate for Payer: Wise Provider Network Commercial |
$2,527.00
|
|
|
WOLVERINE CUTTING BALLOON 4.0MM X 10MM
|
Facility
|
OP
|
$2,660.00
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,465.66 |
| Max. Negotiated Rate |
$2,660.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,606.80
|
| Rate for Payer: Aetna of WY Medicare |
$1,755.60
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2,553.60
|
| Rate for Payer: Altius Commercial |
$2,553.60
|
| Rate for Payer: Beech Street Commercial |
$2,606.80
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,183.86
|
| Rate for Payer: Cash Price |
$1,862.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,580.20
|
| Rate for Payer: Cigna of WY Commercial |
$2,606.80
|
| Rate for Payer: Entrust Commercial |
$2,527.00
|
| Rate for Payer: First Choice Health Commercial |
$2,527.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,527.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,542.80
|
| Rate for Payer: HealthUtah PPO |
$2,660.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,580.20
|
| Rate for Payer: Multiplan Medicare/VA |
$1,465.66
|
| Rate for Payer: One Health Plan of WY PPO |
$2,606.80
|
| Rate for Payer: PacificSource Commercial |
$2,394.00
|
| Rate for Payer: PHCS PPO |
$2,606.80
|
| Rate for Payer: Three Rivers PPO |
$1,995.00
|
| Rate for Payer: TriWest Veterans Administration |
$1,542.80
|
| Rate for Payer: United Healthcare Commercial |
$2,314.20
|
| Rate for Payer: United Healthcare Medicare |
$1,542.80
|
| Rate for Payer: WINHealth Partners Commercial |
$2,606.80
|
| Rate for Payer: Wise Provider Network Commercial |
$2,527.00
|
|
|
WOUND VAC PREVENA PEEL & PLACE 20 CM
|
Facility
|
IP
|
$869.09
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$544.92 |
| Max. Negotiated Rate |
$869.09 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$851.71
|
| Rate for Payer: Altius Auto/Workers Compensation |
$834.33
|
| Rate for Payer: Altius Commercial |
$834.33
|
| Rate for Payer: Beech Street Commercial |
$851.71
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$713.52
|
| Rate for Payer: Cash Price |
$608.36
|
| Rate for Payer: ChoiceCare Network Commercial |
$843.02
|
| Rate for Payer: Cigna of WY Commercial |
$851.71
|
| Rate for Payer: Entrust Commercial |
$825.64
|
| Rate for Payer: First Choice Health Commercial |
$825.64
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$825.64
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$573.60
|
| Rate for Payer: HealthUtah PPO |
$869.09
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$843.02
|
| Rate for Payer: Multiplan Medicare/VA |
$544.92
|
| Rate for Payer: One Health Plan of WY PPO |
$851.71
|
| Rate for Payer: PacificSource Commercial |
$782.18
|
| Rate for Payer: PHCS PPO |
$851.71
|
| Rate for Payer: Three Rivers PPO |
$651.82
|
| Rate for Payer: TriWest Veterans Administration |
$573.60
|
| Rate for Payer: United Healthcare Commercial |
$756.11
|
| Rate for Payer: United Healthcare Medicare |
$573.60
|
| Rate for Payer: WINHealth Partners Commercial |
$825.64
|
| Rate for Payer: Wise Provider Network Commercial |
$825.64
|
|
|
WOUND VAC PREVENA PEEL & PLACE 20 CM
|
Facility
|
OP
|
$869.09
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$478.87 |
| Max. Negotiated Rate |
$869.09 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$851.71
|
| Rate for Payer: Aetna of WY Medicare |
$573.60
|
| Rate for Payer: Altius Auto/Workers Compensation |
$834.33
|
| Rate for Payer: Altius Commercial |
$834.33
|
| Rate for Payer: Beech Street Commercial |
$851.71
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$713.52
|
| Rate for Payer: Cash Price |
$608.36
|
| Rate for Payer: ChoiceCare Network Commercial |
$843.02
|
| Rate for Payer: Cigna of WY Commercial |
$851.71
|
| Rate for Payer: Entrust Commercial |
$825.64
|
| Rate for Payer: First Choice Health Commercial |
$825.64
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$825.64
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$504.07
|
| Rate for Payer: HealthUtah PPO |
$869.09
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$843.02
|
| Rate for Payer: Multiplan Medicare/VA |
$478.87
|
| Rate for Payer: One Health Plan of WY PPO |
$851.71
|
| Rate for Payer: PacificSource Commercial |
$782.18
|
| Rate for Payer: PHCS PPO |
$851.71
|
| Rate for Payer: Three Rivers PPO |
$651.82
|
| Rate for Payer: TriWest Veterans Administration |
$504.07
|
| Rate for Payer: United Healthcare Commercial |
$756.11
|
| Rate for Payer: United Healthcare Medicare |
$504.07
|
| Rate for Payer: WINHealth Partners Commercial |
$851.71
|
| Rate for Payer: Wise Provider Network Commercial |
$825.64
|
|
|
WOUND VAC PREVENA PLUS 14 DAY UNIT
|
Facility
|
OP
|
$1,435.28
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$790.84 |
| Max. Negotiated Rate |
$1,435.28 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,406.57
|
| Rate for Payer: Aetna of WY Medicare |
$947.28
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,377.87
|
| Rate for Payer: Altius Commercial |
$1,377.87
|
| Rate for Payer: Beech Street Commercial |
$1,406.57
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,178.36
|
| Rate for Payer: Cash Price |
$1,004.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,392.22
|
| Rate for Payer: Cigna of WY Commercial |
$1,406.57
|
| Rate for Payer: Entrust Commercial |
$1,363.52
|
| Rate for Payer: First Choice Health Commercial |
$1,363.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,363.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$832.46
|
| Rate for Payer: HealthUtah PPO |
$1,435.28
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,392.22
|
| Rate for Payer: Multiplan Medicare/VA |
$790.84
|
| Rate for Payer: One Health Plan of WY PPO |
$1,406.57
|
| Rate for Payer: PacificSource Commercial |
$1,291.75
|
| Rate for Payer: PHCS PPO |
$1,406.57
|
| Rate for Payer: Three Rivers PPO |
$1,076.46
|
| Rate for Payer: TriWest Veterans Administration |
$832.46
|
| Rate for Payer: United Healthcare Commercial |
$1,248.69
|
| Rate for Payer: United Healthcare Medicare |
$832.46
|
| Rate for Payer: WINHealth Partners Commercial |
$1,406.57
|
| Rate for Payer: Wise Provider Network Commercial |
$1,363.52
|
|
|
WOUND VAC PREVENA PLUS 14 DAY UNIT
|
Facility
|
IP
|
$1,435.28
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$899.92 |
| Max. Negotiated Rate |
$1,435.28 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,406.57
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,377.87
|
| Rate for Payer: Altius Commercial |
$1,377.87
|
| Rate for Payer: Beech Street Commercial |
$1,406.57
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,178.36
|
| Rate for Payer: Cash Price |
$1,004.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,392.22
|
| Rate for Payer: Cigna of WY Commercial |
$1,406.57
|
| Rate for Payer: Entrust Commercial |
$1,363.52
|
| Rate for Payer: First Choice Health Commercial |
$1,363.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,363.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$947.28
|
| Rate for Payer: HealthUtah PPO |
$1,435.28
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,392.22
|
| Rate for Payer: Multiplan Medicare/VA |
$899.92
|
| Rate for Payer: One Health Plan of WY PPO |
$1,406.57
|
| Rate for Payer: PacificSource Commercial |
$1,291.75
|
| Rate for Payer: PHCS PPO |
$1,406.57
|
| Rate for Payer: Three Rivers PPO |
$1,076.46
|
| Rate for Payer: TriWest Veterans Administration |
$947.28
|
| Rate for Payer: United Healthcare Commercial |
$1,248.69
|
| Rate for Payer: United Healthcare Medicare |
$947.28
|
| Rate for Payer: WINHealth Partners Commercial |
$1,363.52
|
| Rate for Payer: Wise Provider Network Commercial |
$1,363.52
|
|
|
X-RAY FEMUR 2 VW
|
Professional
|
Both
|
$234.00
|
|
|
Service Code
|
HCPCS 73550 TC
|
| Hospital Charge Code |
73550
|
| Min. Negotiated Rate |
$175.50 |
| Max. Negotiated Rate |
$234.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$229.32
|
| Rate for Payer: Beech Street Commercial |
$222.30
|
| Rate for Payer: Cash Price |
$163.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$226.98
|
| Rate for Payer: Cigna of WY Commercial |
$229.32
|
| Rate for Payer: First Choice Health Commercial |
$210.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$222.30
|
| Rate for Payer: HealthUtah PPO |
$234.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$226.98
|
| Rate for Payer: One Health Plan of WY PPO |
$229.32
|
| Rate for Payer: PacificSource Commercial |
$210.60
|
| Rate for Payer: PHCS PPO |
$222.30
|
| Rate for Payer: Three Rivers PPO |
$175.50
|
| Rate for Payer: United Healthcare Commercial |
$203.58
|
| Rate for Payer: WINHealth Partners Commercial |
$222.30
|
|
|
X-RAY FEMUR 2 VW
|
Professional
|
Both
|
$64.00
|
|
|
Service Code
|
HCPCS 73550 26
|
| Hospital Charge Code |
73550
|
| Min. Negotiated Rate |
$48.00 |
| Max. Negotiated Rate |
$64.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$62.72
|
| Rate for Payer: Beech Street Commercial |
$60.80
|
| Rate for Payer: Cash Price |
$44.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$62.08
|
| Rate for Payer: Cigna of WY Commercial |
$62.72
|
| Rate for Payer: First Choice Health Commercial |
$57.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$60.80
|
| Rate for Payer: HealthUtah PPO |
$64.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$62.08
|
| Rate for Payer: One Health Plan of WY PPO |
$62.72
|
| Rate for Payer: PacificSource Commercial |
$57.60
|
| Rate for Payer: PHCS PPO |
$60.80
|
| Rate for Payer: Three Rivers PPO |
$48.00
|
| Rate for Payer: United Healthcare Commercial |
$55.68
|
| Rate for Payer: WINHealth Partners Commercial |
$60.80
|
|
|
X-RAY HIPS 4 VW + PELVIS
|
Professional
|
Both
|
$289.00
|
|
|
Service Code
|
HCPCS 73520
|
| Hospital Charge Code |
73520
|
| Min. Negotiated Rate |
$216.75 |
| Max. Negotiated Rate |
$289.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$283.22
|
| Rate for Payer: Beech Street Commercial |
$274.55
|
| Rate for Payer: Cash Price |
$202.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$280.33
|
| Rate for Payer: Cigna of WY Commercial |
$283.22
|
| Rate for Payer: First Choice Health Commercial |
$260.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$274.55
|
| Rate for Payer: HealthUtah PPO |
$289.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$280.33
|
| Rate for Payer: One Health Plan of WY PPO |
$283.22
|
| Rate for Payer: PacificSource Commercial |
$260.10
|
| Rate for Payer: PHCS PPO |
$274.55
|
| Rate for Payer: Three Rivers PPO |
$216.75
|
| Rate for Payer: United Healthcare Commercial |
$251.43
|
| Rate for Payer: WINHealth Partners Commercial |
$274.55
|
|
|
X-RAY HIP UNI 2+ VW
|
Professional
|
Both
|
$297.00
|
|
|
Service Code
|
HCPCS 73510
|
| Hospital Charge Code |
73510
|
| Min. Negotiated Rate |
$222.75 |
| Max. Negotiated Rate |
$297.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$291.06
|
| Rate for Payer: Beech Street Commercial |
$282.15
|
| Rate for Payer: Cash Price |
$207.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$288.09
|
| Rate for Payer: Cigna of WY Commercial |
$291.06
|
| Rate for Payer: First Choice Health Commercial |
$267.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$282.15
|
| Rate for Payer: HealthUtah PPO |
$297.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$288.09
|
| Rate for Payer: One Health Plan of WY PPO |
$291.06
|
| Rate for Payer: PacificSource Commercial |
$267.30
|
| Rate for Payer: PHCS PPO |
$282.15
|
| Rate for Payer: Three Rivers PPO |
$222.75
|
| Rate for Payer: United Healthcare Commercial |
$258.39
|
| Rate for Payer: WINHealth Partners Commercial |
$282.15
|
|
|
X-RAY HIP UNILAT 1 VW
|
Professional
|
Both
|
$192.00
|
|
|
Service Code
|
HCPCS 73500 TC
|
| Hospital Charge Code |
73500
|
| Min. Negotiated Rate |
$144.00 |
| Max. Negotiated Rate |
$192.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$188.16
|
| Rate for Payer: Beech Street Commercial |
$182.40
|
| Rate for Payer: Cash Price |
$134.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$186.24
|
| Rate for Payer: Cigna of WY Commercial |
$188.16
|
| Rate for Payer: First Choice Health Commercial |
$172.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$182.40
|
| Rate for Payer: HealthUtah PPO |
$192.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$186.24
|
| Rate for Payer: One Health Plan of WY PPO |
$188.16
|
| Rate for Payer: PacificSource Commercial |
$172.80
|
| Rate for Payer: PHCS PPO |
$182.40
|
| Rate for Payer: Three Rivers PPO |
$144.00
|
| Rate for Payer: United Healthcare Commercial |
$167.04
|
| Rate for Payer: WINHealth Partners Commercial |
$182.40
|
|
|
X-RAY HIP UNILAT 1 VW
|
Professional
|
Both
|
$227.00
|
|
|
Service Code
|
HCPCS 73500
|
| Hospital Charge Code |
73500
|
| Min. Negotiated Rate |
$170.25 |
| Max. Negotiated Rate |
$227.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$222.46
|
| Rate for Payer: Beech Street Commercial |
$215.65
|
| Rate for Payer: Cash Price |
$158.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$220.19
|
| Rate for Payer: Cigna of WY Commercial |
$222.46
|
| Rate for Payer: First Choice Health Commercial |
$204.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$215.65
|
| Rate for Payer: HealthUtah PPO |
$227.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$220.19
|
| Rate for Payer: One Health Plan of WY PPO |
$222.46
|
| Rate for Payer: PacificSource Commercial |
$204.30
|
| Rate for Payer: PHCS PPO |
$215.65
|
| Rate for Payer: Three Rivers PPO |
$170.25
|
| Rate for Payer: United Healthcare Commercial |
$197.49
|
| Rate for Payer: WINHealth Partners Commercial |
$215.65
|
|
|
XTRNL ECG REC<48 HRS RVW&INTERPJ PHYS/QHP
|
Professional
|
Both
|
$185.00
|
|
|
Service Code
|
HCPCS 93227
|
| Hospital Charge Code |
93227
|
| Min. Negotiated Rate |
$14.96 |
| Max. Negotiated Rate |
$185.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$181.30
|
| Rate for Payer: Aetna of WY Medicare |
$17.60
|
| Rate for Payer: Beech Street Commercial |
$175.75
|
| Rate for Payer: Cash Price |
$129.50
|
| Rate for Payer: Cash Price |
$129.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$179.45
|
| Rate for Payer: Cigna of WY Commercial |
$181.30
|
| Rate for Payer: First Choice Health Commercial |
$166.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$175.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$17.60
|
| Rate for Payer: HealthUtah PPO |
$185.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$179.45
|
| Rate for Payer: Multiplan Medicare/VA |
$14.96
|
| Rate for Payer: One Health Plan of WY PPO |
$181.30
|
| Rate for Payer: PacificSource Commercial |
$166.50
|
| Rate for Payer: PHCS PPO |
$175.75
|
| Rate for Payer: Three Rivers PPO |
$138.75
|
| Rate for Payer: TriWest Veterans Administration |
$17.60
|
| Rate for Payer: United Healthcare Commercial |
$160.95
|
| Rate for Payer: United Healthcare Medicare |
$17.60
|
| Rate for Payer: WINHealth Partners Commercial |
$175.75
|
|
|
XTRNL PT ACTIVTD ECG DWNLD W/R&I </30 DAYS
|
Professional
|
Both
|
$164.00
|
|
|
Service Code
|
HCPCS 93272
|
| Hospital Charge Code |
93272
|
| Min. Negotiated Rate |
$19.62 |
| Max. Negotiated Rate |
$164.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$160.72
|
| Rate for Payer: Aetna of WY Medicare |
$23.08
|
| Rate for Payer: Beech Street Commercial |
$155.80
|
| Rate for Payer: Cash Price |
$114.80
|
| Rate for Payer: Cash Price |
$114.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$159.08
|
| Rate for Payer: Cigna of WY Commercial |
$160.72
|
| Rate for Payer: First Choice Health Commercial |
$147.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$155.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$23.08
|
| Rate for Payer: HealthUtah PPO |
$164.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$159.08
|
| Rate for Payer: Multiplan Medicare/VA |
$19.62
|
| Rate for Payer: One Health Plan of WY PPO |
$160.72
|
| Rate for Payer: PacificSource Commercial |
$147.60
|
| Rate for Payer: PHCS PPO |
$155.80
|
| Rate for Payer: Three Rivers PPO |
$123.00
|
| Rate for Payer: TriWest Veterans Administration |
$23.08
|
| Rate for Payer: United Healthcare Commercial |
$142.68
|
| Rate for Payer: United Healthcare Medicare |
$23.08
|
| Rate for Payer: WINHealth Partners Commercial |
$155.80
|
|
|
YELLOW FEVER VACCINE LIVE SUBQ
|
Professional
|
Both
|
$219.00
|
|
|
Service Code
|
HCPCS 90717
|
| Hospital Charge Code |
90717
|
| Min. Negotiated Rate |
$164.25 |
| Max. Negotiated Rate |
$219.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$214.62
|
| Rate for Payer: Beech Street Commercial |
$208.05
|
| Rate for Payer: Cash Price |
$153.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$212.43
|
| Rate for Payer: Cigna of WY Commercial |
$214.62
|
| Rate for Payer: First Choice Health Commercial |
$197.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$208.05
|
| Rate for Payer: HealthUtah PPO |
$219.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$212.43
|
| Rate for Payer: One Health Plan of WY PPO |
$214.62
|
| Rate for Payer: PacificSource Commercial |
$197.10
|
| Rate for Payer: PHCS PPO |
$208.05
|
| Rate for Payer: Three Rivers PPO |
$164.25
|
| Rate for Payer: United Healthcare Commercial |
$190.53
|
| Rate for Payer: WINHealth Partners Commercial |
$219.00
|
|
|
ZINC OXIDE-VITAMIN B5-VIT E 11.3% TOPICAL CREAM [53324]
|
Facility
|
IP
|
$0.12
|
|
|
Service Code
|
NDC 3010304100
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.12
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.12
|
| Rate for Payer: Altius Commercial |
$0.12
|
| Rate for Payer: Beech Street Commercial |
$0.12
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.10
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.12
|
| Rate for Payer: Cigna of WY Commercial |
$0.12
|
| Rate for Payer: Entrust Commercial |
$0.11
|
| Rate for Payer: First Choice Health Commercial |
$0.11
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.11
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.08
|
| Rate for Payer: HealthUtah PPO |
$0.12
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.12
|
| Rate for Payer: Multiplan Medicare/VA |
$0.08
|
| Rate for Payer: One Health Plan of WY PPO |
$0.12
|
| Rate for Payer: PacificSource Commercial |
$0.11
|
| Rate for Payer: PHCS PPO |
$0.12
|
| Rate for Payer: Three Rivers PPO |
$0.09
|
| Rate for Payer: TriWest Veterans Administration |
$0.08
|
| Rate for Payer: United Healthcare Commercial |
$0.10
|
| Rate for Payer: United Healthcare Medicare |
$0.08
|
| Rate for Payer: WINHealth Partners Commercial |
$0.11
|
| Rate for Payer: Wise Provider Network Commercial |
$0.11
|
|
|
ZINC OXIDE-VITAMIN B5-VIT E 11.3% TOPICAL CREAM [53324]
|
Facility
|
OP
|
$0.12
|
|
|
Service Code
|
NDC 3010304100
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.12
|
| Rate for Payer: Aetna of WY Medicare |
$0.08
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.12
|
| Rate for Payer: Altius Commercial |
$0.12
|
| Rate for Payer: Beech Street Commercial |
$0.12
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.10
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.12
|
| Rate for Payer: Cigna of WY Commercial |
$0.12
|
| Rate for Payer: Entrust Commercial |
$0.11
|
| Rate for Payer: First Choice Health Commercial |
$0.11
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.11
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.07
|
| Rate for Payer: HealthUtah PPO |
$0.12
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.12
|
| Rate for Payer: Multiplan Medicare/VA |
$0.07
|
| Rate for Payer: One Health Plan of WY PPO |
$0.12
|
| Rate for Payer: PacificSource Commercial |
$0.11
|
| Rate for Payer: PHCS PPO |
$0.12
|
| Rate for Payer: Three Rivers PPO |
$0.09
|
| Rate for Payer: TriWest Veterans Administration |
$0.07
|
| Rate for Payer: United Healthcare Commercial |
$0.10
|
| Rate for Payer: United Healthcare Medicare |
$0.07
|
| Rate for Payer: WINHealth Partners Commercial |
$0.12
|
| Rate for Payer: Wise Provider Network Commercial |
$0.11
|
|
|
ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE [41933]
|
Facility
|
IP
|
$0.39
|
|
|
Service Code
|
NDC 6858500801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.39 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.38
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.37
|
| Rate for Payer: Altius Commercial |
$0.37
|
| Rate for Payer: Beech Street Commercial |
$0.38
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.32
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.38
|
| Rate for Payer: Cigna of WY Commercial |
$0.38
|
| Rate for Payer: Entrust Commercial |
$0.37
|
| Rate for Payer: First Choice Health Commercial |
$0.37
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.37
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.26
|
| Rate for Payer: HealthUtah PPO |
$0.39
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.38
|
| Rate for Payer: Multiplan Medicare/VA |
$0.24
|
| Rate for Payer: One Health Plan of WY PPO |
$0.38
|
| Rate for Payer: PacificSource Commercial |
$0.35
|
| Rate for Payer: PHCS PPO |
$0.38
|
| Rate for Payer: Three Rivers PPO |
$0.29
|
| Rate for Payer: TriWest Veterans Administration |
$0.26
|
| Rate for Payer: United Healthcare Commercial |
$0.34
|
| Rate for Payer: United Healthcare Medicare |
$0.26
|
| Rate for Payer: WINHealth Partners Commercial |
$0.37
|
| Rate for Payer: Wise Provider Network Commercial |
$0.37
|
|
|
ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE [41933]
|
Facility
|
OP
|
$0.39
|
|
|
Service Code
|
NDC 6858500801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.39 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.38
|
| Rate for Payer: Aetna of WY Medicare |
$0.26
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.37
|
| Rate for Payer: Altius Commercial |
$0.37
|
| Rate for Payer: Beech Street Commercial |
$0.38
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.32
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.38
|
| Rate for Payer: Cigna of WY Commercial |
$0.38
|
| Rate for Payer: Entrust Commercial |
$0.37
|
| Rate for Payer: First Choice Health Commercial |
$0.37
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.37
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.23
|
| Rate for Payer: HealthUtah PPO |
$0.39
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.38
|
| Rate for Payer: Multiplan Medicare/VA |
$0.21
|
| Rate for Payer: One Health Plan of WY PPO |
$0.38
|
| Rate for Payer: PacificSource Commercial |
$0.35
|
| Rate for Payer: PHCS PPO |
$0.38
|
| Rate for Payer: Three Rivers PPO |
$0.29
|
| Rate for Payer: TriWest Veterans Administration |
$0.23
|
| Rate for Payer: United Healthcare Commercial |
$0.34
|
| Rate for Payer: United Healthcare Medicare |
$0.23
|
| Rate for Payer: WINHealth Partners Commercial |
$0.38
|
| Rate for Payer: Wise Provider Network Commercial |
$0.37
|
|
|
ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE [41933]
|
Facility
|
IP
|
$0.94
|
|
|
Service Code
|
NDC 7733398310
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$0.94 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.92
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.90
|
| Rate for Payer: Altius Commercial |
$0.90
|
| Rate for Payer: Beech Street Commercial |
$0.92
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.77
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.91
|
| Rate for Payer: Cigna of WY Commercial |
$0.92
|
| Rate for Payer: Entrust Commercial |
$0.89
|
| Rate for Payer: First Choice Health Commercial |
$0.89
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.89
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.62
|
| Rate for Payer: HealthUtah PPO |
$0.94
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.91
|
| Rate for Payer: Multiplan Medicare/VA |
$0.59
|
| Rate for Payer: One Health Plan of WY PPO |
$0.92
|
| Rate for Payer: PacificSource Commercial |
$0.85
|
| Rate for Payer: PHCS PPO |
$0.92
|
| Rate for Payer: Three Rivers PPO |
$0.71
|
| Rate for Payer: TriWest Veterans Administration |
$0.62
|
| Rate for Payer: United Healthcare Commercial |
$0.82
|
| Rate for Payer: United Healthcare Medicare |
$0.62
|
| Rate for Payer: WINHealth Partners Commercial |
$0.89
|
| Rate for Payer: Wise Provider Network Commercial |
$0.89
|
|
