|
COPPER 380 SQUARE MM INTRAUTERINE DEVICE [129166]
|
Facility
|
OP
|
$1,025.00
|
|
|
Service Code
|
NDC 5936551281
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$564.78 |
| Max. Negotiated Rate |
$1,025.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,004.50
|
| Rate for Payer: Aetna of WY Medicare |
$676.50
|
| Rate for Payer: Altius Auto/Workers Compensation |
$984.00
|
| Rate for Payer: Altius Commercial |
$984.00
|
| Rate for Payer: Beech Street Commercial |
$1,004.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$841.52
|
| Rate for Payer: Cash Price |
$717.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$994.25
|
| Rate for Payer: Cigna of WY Commercial |
$1,004.50
|
| Rate for Payer: Entrust Commercial |
$973.75
|
| Rate for Payer: First Choice Health Commercial |
$973.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$973.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$594.50
|
| Rate for Payer: HealthUtah PPO |
$1,025.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$994.25
|
| Rate for Payer: Multiplan Medicare/VA |
$564.78
|
| Rate for Payer: One Health Plan of WY PPO |
$1,004.50
|
| Rate for Payer: PacificSource Commercial |
$922.50
|
| Rate for Payer: PHCS PPO |
$1,004.50
|
| Rate for Payer: Three Rivers PPO |
$768.75
|
| Rate for Payer: TriWest Veterans Administration |
$594.50
|
| Rate for Payer: United Healthcare Commercial |
$891.75
|
| Rate for Payer: United Healthcare Medicare |
$594.50
|
| Rate for Payer: WINHealth Partners Commercial |
$1,004.50
|
| Rate for Payer: Wise Provider Network Commercial |
$973.75
|
|
|
COPPER 380 SQUARE MM INTRAUTERINE DEVICE [129166]
|
Facility
|
IP
|
$1,025.00
|
|
|
Service Code
|
NDC 5936551281
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$642.68 |
| Max. Negotiated Rate |
$1,025.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,004.50
|
| Rate for Payer: Altius Auto/Workers Compensation |
$984.00
|
| Rate for Payer: Altius Commercial |
$984.00
|
| Rate for Payer: Beech Street Commercial |
$1,004.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$841.52
|
| Rate for Payer: Cash Price |
$717.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$994.25
|
| Rate for Payer: Cigna of WY Commercial |
$1,004.50
|
| Rate for Payer: Entrust Commercial |
$973.75
|
| Rate for Payer: First Choice Health Commercial |
$973.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$973.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$676.50
|
| Rate for Payer: HealthUtah PPO |
$1,025.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$994.25
|
| Rate for Payer: Multiplan Medicare/VA |
$642.68
|
| Rate for Payer: One Health Plan of WY PPO |
$1,004.50
|
| Rate for Payer: PacificSource Commercial |
$922.50
|
| Rate for Payer: PHCS PPO |
$1,004.50
|
| Rate for Payer: Three Rivers PPO |
$768.75
|
| Rate for Payer: TriWest Veterans Administration |
$676.50
|
| Rate for Payer: United Healthcare Commercial |
$891.75
|
| Rate for Payer: United Healthcare Medicare |
$676.50
|
| Rate for Payer: WINHealth Partners Commercial |
$973.75
|
| Rate for Payer: Wise Provider Network Commercial |
$973.75
|
|
|
CORACOACROMIAL LIGAMENT RELEAS W/WOACROMIOPLASTY
|
Professional
|
Both
|
$3,572.00
|
|
|
Service Code
|
HCPCS 23415
|
| Hospital Charge Code |
23415
|
| Min. Negotiated Rate |
$578.14 |
| Max. Negotiated Rate |
$3,572.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,500.56
|
| Rate for Payer: Aetna of WY Medicare |
$680.16
|
| Rate for Payer: Beech Street Commercial |
$3,393.40
|
| Rate for Payer: Cash Price |
$2,500.40
|
| Rate for Payer: Cash Price |
$2,500.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,464.84
|
| Rate for Payer: Cigna of WY Commercial |
$3,500.56
|
| Rate for Payer: First Choice Health Commercial |
$3,214.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,393.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$680.16
|
| Rate for Payer: HealthUtah PPO |
$3,572.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,464.84
|
| Rate for Payer: Multiplan Medicare/VA |
$578.14
|
| Rate for Payer: One Health Plan of WY PPO |
$3,500.56
|
| Rate for Payer: PacificSource Commercial |
$3,214.80
|
| Rate for Payer: PHCS PPO |
$3,393.40
|
| Rate for Payer: Three Rivers PPO |
$2,679.00
|
| Rate for Payer: TriWest Veterans Administration |
$680.16
|
| Rate for Payer: United Healthcare Commercial |
$3,107.64
|
| Rate for Payer: United Healthcare Medicare |
$680.16
|
| Rate for Payer: WINHealth Partners Commercial |
$3,036.20
|
|
|
CORACOACROMIAL LIGAMENT RELEAS W/WOACROMIOPLASTY
|
Professional
|
Both
|
$3,572.00
|
|
|
Service Code
|
HCPCS 23415 AS
|
| Hospital Charge Code |
23415
|
| Min. Negotiated Rate |
$578.14 |
| Max. Negotiated Rate |
$3,572.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,500.56
|
| Rate for Payer: Aetna of WY Medicare |
$680.16
|
| Rate for Payer: Beech Street Commercial |
$3,393.40
|
| Rate for Payer: Cash Price |
$2,500.40
|
| Rate for Payer: Cash Price |
$2,500.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,464.84
|
| Rate for Payer: Cigna of WY Commercial |
$3,500.56
|
| Rate for Payer: First Choice Health Commercial |
$3,214.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,393.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$680.16
|
| Rate for Payer: HealthUtah PPO |
$3,572.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,464.84
|
| Rate for Payer: Multiplan Medicare/VA |
$578.14
|
| Rate for Payer: One Health Plan of WY PPO |
$3,500.56
|
| Rate for Payer: PacificSource Commercial |
$3,214.80
|
| Rate for Payer: PHCS PPO |
$3,393.40
|
| Rate for Payer: Three Rivers PPO |
$2,679.00
|
| Rate for Payer: TriWest Veterans Administration |
$680.16
|
| Rate for Payer: United Healthcare Commercial |
$3,107.64
|
| Rate for Payer: United Healthcare Medicare |
$680.16
|
| Rate for Payer: WINHealth Partners Commercial |
$3,036.20
|
|
|
CORACOACROMIAL LIGAMENT RELEAS W/WOACROMIOPLASTY
|
Professional
|
Both
|
$3,572.00
|
|
|
Service Code
|
HCPCS 23415 80
|
| Hospital Charge Code |
23415
|
| Min. Negotiated Rate |
$578.14 |
| Max. Negotiated Rate |
$3,572.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,500.56
|
| Rate for Payer: Aetna of WY Medicare |
$680.16
|
| Rate for Payer: Beech Street Commercial |
$3,393.40
|
| Rate for Payer: Cash Price |
$2,500.40
|
| Rate for Payer: Cash Price |
$2,500.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,464.84
|
| Rate for Payer: Cigna of WY Commercial |
$3,500.56
|
| Rate for Payer: First Choice Health Commercial |
$3,214.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,393.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$680.16
|
| Rate for Payer: HealthUtah PPO |
$3,572.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,464.84
|
| Rate for Payer: Multiplan Medicare/VA |
$578.14
|
| Rate for Payer: One Health Plan of WY PPO |
$3,500.56
|
| Rate for Payer: PacificSource Commercial |
$3,214.80
|
| Rate for Payer: PHCS PPO |
$3,393.40
|
| Rate for Payer: Three Rivers PPO |
$2,679.00
|
| Rate for Payer: TriWest Veterans Administration |
$680.16
|
| Rate for Payer: United Healthcare Commercial |
$3,107.64
|
| Rate for Payer: United Healthcare Medicare |
$680.16
|
| Rate for Payer: WINHealth Partners Commercial |
$3,036.20
|
|
|
CORING REAMER 10MM W/PIN 1224S
|
Facility
|
IP
|
$838.04
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$525.45 |
| Max. Negotiated Rate |
$838.04 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$821.28
|
| Rate for Payer: Altius Auto/Workers Compensation |
$804.52
|
| Rate for Payer: Altius Commercial |
$804.52
|
| Rate for Payer: Beech Street Commercial |
$821.28
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$688.03
|
| Rate for Payer: Cash Price |
$586.63
|
| Rate for Payer: ChoiceCare Network Commercial |
$812.90
|
| Rate for Payer: Cigna of WY Commercial |
$821.28
|
| Rate for Payer: Entrust Commercial |
$796.14
|
| Rate for Payer: First Choice Health Commercial |
$796.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$796.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$553.11
|
| Rate for Payer: HealthUtah PPO |
$838.04
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$812.90
|
| Rate for Payer: Multiplan Medicare/VA |
$525.45
|
| Rate for Payer: One Health Plan of WY PPO |
$821.28
|
| Rate for Payer: PacificSource Commercial |
$754.24
|
| Rate for Payer: PHCS PPO |
$821.28
|
| Rate for Payer: Three Rivers PPO |
$628.53
|
| Rate for Payer: TriWest Veterans Administration |
$553.11
|
| Rate for Payer: United Healthcare Commercial |
$729.09
|
| Rate for Payer: United Healthcare Medicare |
$553.11
|
| Rate for Payer: WINHealth Partners Commercial |
$796.14
|
| Rate for Payer: Wise Provider Network Commercial |
$796.14
|
|
|
CORING REAMER 10MM W/PIN 1224S
|
Facility
|
OP
|
$838.04
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$461.76 |
| Max. Negotiated Rate |
$838.04 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$821.28
|
| Rate for Payer: Aetna of WY Medicare |
$553.11
|
| Rate for Payer: Altius Auto/Workers Compensation |
$804.52
|
| Rate for Payer: Altius Commercial |
$804.52
|
| Rate for Payer: Beech Street Commercial |
$821.28
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$688.03
|
| Rate for Payer: Cash Price |
$586.63
|
| Rate for Payer: ChoiceCare Network Commercial |
$812.90
|
| Rate for Payer: Cigna of WY Commercial |
$821.28
|
| Rate for Payer: Entrust Commercial |
$796.14
|
| Rate for Payer: First Choice Health Commercial |
$796.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$796.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$486.06
|
| Rate for Payer: HealthUtah PPO |
$838.04
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$812.90
|
| Rate for Payer: Multiplan Medicare/VA |
$461.76
|
| Rate for Payer: One Health Plan of WY PPO |
$821.28
|
| Rate for Payer: PacificSource Commercial |
$754.24
|
| Rate for Payer: PHCS PPO |
$821.28
|
| Rate for Payer: Three Rivers PPO |
$628.53
|
| Rate for Payer: TriWest Veterans Administration |
$486.06
|
| Rate for Payer: United Healthcare Commercial |
$729.09
|
| Rate for Payer: United Healthcare Medicare |
$486.06
|
| Rate for Payer: WINHealth Partners Commercial |
$821.28
|
| Rate for Payer: Wise Provider Network Commercial |
$796.14
|
|
|
CORING REAMER 7MM PIN AR-1220S
|
Facility
|
OP
|
$838.04
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$461.76 |
| Max. Negotiated Rate |
$838.04 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$821.28
|
| Rate for Payer: Aetna of WY Medicare |
$553.11
|
| Rate for Payer: Altius Auto/Workers Compensation |
$804.52
|
| Rate for Payer: Altius Commercial |
$804.52
|
| Rate for Payer: Beech Street Commercial |
$821.28
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$688.03
|
| Rate for Payer: Cash Price |
$586.63
|
| Rate for Payer: ChoiceCare Network Commercial |
$812.90
|
| Rate for Payer: Cigna of WY Commercial |
$821.28
|
| Rate for Payer: Entrust Commercial |
$796.14
|
| Rate for Payer: First Choice Health Commercial |
$796.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$796.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$486.06
|
| Rate for Payer: HealthUtah PPO |
$838.04
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$812.90
|
| Rate for Payer: Multiplan Medicare/VA |
$461.76
|
| Rate for Payer: One Health Plan of WY PPO |
$821.28
|
| Rate for Payer: PacificSource Commercial |
$754.24
|
| Rate for Payer: PHCS PPO |
$821.28
|
| Rate for Payer: Three Rivers PPO |
$628.53
|
| Rate for Payer: TriWest Veterans Administration |
$486.06
|
| Rate for Payer: United Healthcare Commercial |
$729.09
|
| Rate for Payer: United Healthcare Medicare |
$486.06
|
| Rate for Payer: WINHealth Partners Commercial |
$821.28
|
| Rate for Payer: Wise Provider Network Commercial |
$796.14
|
|
|
CORING REAMER 7MM PIN AR-1220S
|
Facility
|
IP
|
$838.04
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$525.45 |
| Max. Negotiated Rate |
$838.04 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$821.28
|
| Rate for Payer: Altius Auto/Workers Compensation |
$804.52
|
| Rate for Payer: Altius Commercial |
$804.52
|
| Rate for Payer: Beech Street Commercial |
$821.28
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$688.03
|
| Rate for Payer: Cash Price |
$586.63
|
| Rate for Payer: ChoiceCare Network Commercial |
$812.90
|
| Rate for Payer: Cigna of WY Commercial |
$821.28
|
| Rate for Payer: Entrust Commercial |
$796.14
|
| Rate for Payer: First Choice Health Commercial |
$796.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$796.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$553.11
|
| Rate for Payer: HealthUtah PPO |
$838.04
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$812.90
|
| Rate for Payer: Multiplan Medicare/VA |
$525.45
|
| Rate for Payer: One Health Plan of WY PPO |
$821.28
|
| Rate for Payer: PacificSource Commercial |
$754.24
|
| Rate for Payer: PHCS PPO |
$821.28
|
| Rate for Payer: Three Rivers PPO |
$628.53
|
| Rate for Payer: TriWest Veterans Administration |
$553.11
|
| Rate for Payer: United Healthcare Commercial |
$729.09
|
| Rate for Payer: United Healthcare Medicare |
$553.11
|
| Rate for Payer: WINHealth Partners Commercial |
$796.14
|
| Rate for Payer: Wise Provider Network Commercial |
$796.14
|
|
|
CORING REAMER 8MM PIN AR-1222S
|
Facility
|
IP
|
$838.04
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$525.45 |
| Max. Negotiated Rate |
$838.04 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$821.28
|
| Rate for Payer: Altius Auto/Workers Compensation |
$804.52
|
| Rate for Payer: Altius Commercial |
$804.52
|
| Rate for Payer: Beech Street Commercial |
$821.28
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$688.03
|
| Rate for Payer: Cash Price |
$586.63
|
| Rate for Payer: ChoiceCare Network Commercial |
$812.90
|
| Rate for Payer: Cigna of WY Commercial |
$821.28
|
| Rate for Payer: Entrust Commercial |
$796.14
|
| Rate for Payer: First Choice Health Commercial |
$796.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$796.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$553.11
|
| Rate for Payer: HealthUtah PPO |
$838.04
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$812.90
|
| Rate for Payer: Multiplan Medicare/VA |
$525.45
|
| Rate for Payer: One Health Plan of WY PPO |
$821.28
|
| Rate for Payer: PacificSource Commercial |
$754.24
|
| Rate for Payer: PHCS PPO |
$821.28
|
| Rate for Payer: Three Rivers PPO |
$628.53
|
| Rate for Payer: TriWest Veterans Administration |
$553.11
|
| Rate for Payer: United Healthcare Commercial |
$729.09
|
| Rate for Payer: United Healthcare Medicare |
$553.11
|
| Rate for Payer: WINHealth Partners Commercial |
$796.14
|
| Rate for Payer: Wise Provider Network Commercial |
$796.14
|
|
|
CORING REAMER 8MM PIN AR-1222S
|
Facility
|
OP
|
$838.04
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$461.76 |
| Max. Negotiated Rate |
$838.04 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$821.28
|
| Rate for Payer: Aetna of WY Medicare |
$553.11
|
| Rate for Payer: Altius Auto/Workers Compensation |
$804.52
|
| Rate for Payer: Altius Commercial |
$804.52
|
| Rate for Payer: Beech Street Commercial |
$821.28
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$688.03
|
| Rate for Payer: Cash Price |
$586.63
|
| Rate for Payer: ChoiceCare Network Commercial |
$812.90
|
| Rate for Payer: Cigna of WY Commercial |
$821.28
|
| Rate for Payer: Entrust Commercial |
$796.14
|
| Rate for Payer: First Choice Health Commercial |
$796.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$796.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$486.06
|
| Rate for Payer: HealthUtah PPO |
$838.04
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$812.90
|
| Rate for Payer: Multiplan Medicare/VA |
$461.76
|
| Rate for Payer: One Health Plan of WY PPO |
$821.28
|
| Rate for Payer: PacificSource Commercial |
$754.24
|
| Rate for Payer: PHCS PPO |
$821.28
|
| Rate for Payer: Three Rivers PPO |
$628.53
|
| Rate for Payer: TriWest Veterans Administration |
$486.06
|
| Rate for Payer: United Healthcare Commercial |
$729.09
|
| Rate for Payer: United Healthcare Medicare |
$486.06
|
| Rate for Payer: WINHealth Partners Commercial |
$821.28
|
| Rate for Payer: Wise Provider Network Commercial |
$796.14
|
|
|
CORING REAMER 9MM PIN AR-1223S
|
Facility
|
OP
|
$838.04
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$461.76 |
| Max. Negotiated Rate |
$838.04 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$821.28
|
| Rate for Payer: Aetna of WY Medicare |
$553.11
|
| Rate for Payer: Altius Auto/Workers Compensation |
$804.52
|
| Rate for Payer: Altius Commercial |
$804.52
|
| Rate for Payer: Beech Street Commercial |
$821.28
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$688.03
|
| Rate for Payer: Cash Price |
$586.63
|
| Rate for Payer: ChoiceCare Network Commercial |
$812.90
|
| Rate for Payer: Cigna of WY Commercial |
$821.28
|
| Rate for Payer: Entrust Commercial |
$796.14
|
| Rate for Payer: First Choice Health Commercial |
$796.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$796.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$486.06
|
| Rate for Payer: HealthUtah PPO |
$838.04
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$812.90
|
| Rate for Payer: Multiplan Medicare/VA |
$461.76
|
| Rate for Payer: One Health Plan of WY PPO |
$821.28
|
| Rate for Payer: PacificSource Commercial |
$754.24
|
| Rate for Payer: PHCS PPO |
$821.28
|
| Rate for Payer: Three Rivers PPO |
$628.53
|
| Rate for Payer: TriWest Veterans Administration |
$486.06
|
| Rate for Payer: United Healthcare Commercial |
$729.09
|
| Rate for Payer: United Healthcare Medicare |
$486.06
|
| Rate for Payer: WINHealth Partners Commercial |
$821.28
|
| Rate for Payer: Wise Provider Network Commercial |
$796.14
|
|
|
CORING REAMER 9MM PIN AR-1223S
|
Facility
|
IP
|
$838.04
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$525.45 |
| Max. Negotiated Rate |
$838.04 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$821.28
|
| Rate for Payer: Altius Auto/Workers Compensation |
$804.52
|
| Rate for Payer: Altius Commercial |
$804.52
|
| Rate for Payer: Beech Street Commercial |
$821.28
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$688.03
|
| Rate for Payer: Cash Price |
$586.63
|
| Rate for Payer: ChoiceCare Network Commercial |
$812.90
|
| Rate for Payer: Cigna of WY Commercial |
$821.28
|
| Rate for Payer: Entrust Commercial |
$796.14
|
| Rate for Payer: First Choice Health Commercial |
$796.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$796.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$553.11
|
| Rate for Payer: HealthUtah PPO |
$838.04
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$812.90
|
| Rate for Payer: Multiplan Medicare/VA |
$525.45
|
| Rate for Payer: One Health Plan of WY PPO |
$821.28
|
| Rate for Payer: PacificSource Commercial |
$754.24
|
| Rate for Payer: PHCS PPO |
$821.28
|
| Rate for Payer: Three Rivers PPO |
$628.53
|
| Rate for Payer: TriWest Veterans Administration |
$553.11
|
| Rate for Payer: United Healthcare Commercial |
$729.09
|
| Rate for Payer: United Healthcare Medicare |
$553.11
|
| Rate for Payer: WINHealth Partners Commercial |
$796.14
|
| Rate for Payer: Wise Provider Network Commercial |
$796.14
|
|
|
CORRECTION HAMMERTOE
|
Professional
|
Both
|
$4,320.00
|
|
|
Service Code
|
HCPCS 28285 50
|
| Hospital Charge Code |
28285
|
| Min. Negotiated Rate |
$322.19 |
| Max. Negotiated Rate |
$4,320.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4,233.60
|
| Rate for Payer: Aetna of WY Medicare |
$379.05
|
| Rate for Payer: Beech Street Commercial |
$4,104.00
|
| Rate for Payer: Cash Price |
$3,024.00
|
| Rate for Payer: Cash Price |
$3,024.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$4,190.40
|
| Rate for Payer: Cigna of WY Commercial |
$4,233.60
|
| Rate for Payer: First Choice Health Commercial |
$3,888.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,104.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$379.05
|
| Rate for Payer: HealthUtah PPO |
$4,320.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4,190.40
|
| Rate for Payer: Multiplan Medicare/VA |
$322.19
|
| Rate for Payer: One Health Plan of WY PPO |
$4,233.60
|
| Rate for Payer: PacificSource Commercial |
$3,888.00
|
| Rate for Payer: PHCS PPO |
$4,104.00
|
| Rate for Payer: Three Rivers PPO |
$3,240.00
|
| Rate for Payer: TriWest Veterans Administration |
$379.05
|
| Rate for Payer: United Healthcare Commercial |
$3,758.40
|
| Rate for Payer: United Healthcare Medicare |
$379.05
|
| Rate for Payer: WINHealth Partners Commercial |
$3,672.00
|
|
|
CORRECTION HAMMERTOE
|
Professional
|
Both
|
$2,160.00
|
|
|
Service Code
|
HCPCS 28285 80
|
| Hospital Charge Code |
28285
|
| Min. Negotiated Rate |
$322.19 |
| Max. Negotiated Rate |
$2,160.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,116.80
|
| Rate for Payer: Aetna of WY Medicare |
$379.05
|
| Rate for Payer: Beech Street Commercial |
$2,052.00
|
| Rate for Payer: Cash Price |
$1,512.00
|
| Rate for Payer: Cash Price |
$1,512.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,095.20
|
| Rate for Payer: Cigna of WY Commercial |
$2,116.80
|
| Rate for Payer: First Choice Health Commercial |
$1,944.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,052.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$379.05
|
| Rate for Payer: HealthUtah PPO |
$2,160.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,095.20
|
| Rate for Payer: Multiplan Medicare/VA |
$322.19
|
| Rate for Payer: One Health Plan of WY PPO |
$2,116.80
|
| Rate for Payer: PacificSource Commercial |
$1,944.00
|
| Rate for Payer: PHCS PPO |
$2,052.00
|
| Rate for Payer: Three Rivers PPO |
$1,620.00
|
| Rate for Payer: TriWest Veterans Administration |
$379.05
|
| Rate for Payer: United Healthcare Commercial |
$1,879.20
|
| Rate for Payer: United Healthcare Medicare |
$379.05
|
| Rate for Payer: WINHealth Partners Commercial |
$1,836.00
|
|
|
CORRECTION HAMMERTOE
|
Professional
|
Both
|
$2,160.00
|
|
|
Service Code
|
HCPCS 28285
|
| Hospital Charge Code |
28285
|
| Min. Negotiated Rate |
$322.19 |
| Max. Negotiated Rate |
$2,160.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,116.80
|
| Rate for Payer: Aetna of WY Medicare |
$379.05
|
| Rate for Payer: Beech Street Commercial |
$2,052.00
|
| Rate for Payer: Cash Price |
$1,512.00
|
| Rate for Payer: Cash Price |
$1,512.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,095.20
|
| Rate for Payer: Cigna of WY Commercial |
$2,116.80
|
| Rate for Payer: First Choice Health Commercial |
$1,944.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,052.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$379.05
|
| Rate for Payer: HealthUtah PPO |
$2,160.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,095.20
|
| Rate for Payer: Multiplan Medicare/VA |
$322.19
|
| Rate for Payer: One Health Plan of WY PPO |
$2,116.80
|
| Rate for Payer: PacificSource Commercial |
$1,944.00
|
| Rate for Payer: PHCS PPO |
$2,052.00
|
| Rate for Payer: Three Rivers PPO |
$1,620.00
|
| Rate for Payer: TriWest Veterans Administration |
$379.05
|
| Rate for Payer: United Healthcare Commercial |
$1,879.20
|
| Rate for Payer: United Healthcare Medicare |
$379.05
|
| Rate for Payer: WINHealth Partners Commercial |
$1,836.00
|
|
|
CORRJ HLX VLGS BNCTY SESMDC DSTL METAR OSTEOT
|
Professional
|
Both
|
$5,451.00
|
|
|
Service Code
|
HCPCS 28296
|
| Hospital Charge Code |
28296
|
| Min. Negotiated Rate |
$426.65 |
| Max. Negotiated Rate |
$5,451.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5,341.98
|
| Rate for Payer: Aetna of WY Medicare |
$501.94
|
| Rate for Payer: Beech Street Commercial |
$5,178.45
|
| Rate for Payer: Cash Price |
$3,815.70
|
| Rate for Payer: Cash Price |
$3,815.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$5,287.47
|
| Rate for Payer: Cigna of WY Commercial |
$5,341.98
|
| Rate for Payer: First Choice Health Commercial |
$4,905.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5,178.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$501.94
|
| Rate for Payer: HealthUtah PPO |
$5,451.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5,287.47
|
| Rate for Payer: Multiplan Medicare/VA |
$426.65
|
| Rate for Payer: One Health Plan of WY PPO |
$5,341.98
|
| Rate for Payer: PacificSource Commercial |
$4,905.90
|
| Rate for Payer: PHCS PPO |
$5,178.45
|
| Rate for Payer: Three Rivers PPO |
$4,088.25
|
| Rate for Payer: TriWest Veterans Administration |
$501.94
|
| Rate for Payer: United Healthcare Commercial |
$4,742.37
|
| Rate for Payer: United Healthcare Medicare |
$501.94
|
| Rate for Payer: WINHealth Partners Commercial |
$4,633.35
|
|
|
CORRJ HLX VLGS BNCTY SESMDC DSTL METAR OSTEOT
|
Professional
|
Both
|
$5,451.00
|
|
|
Service Code
|
HCPCS 28296 80
|
| Hospital Charge Code |
28296
|
| Min. Negotiated Rate |
$426.65 |
| Max. Negotiated Rate |
$5,451.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5,341.98
|
| Rate for Payer: Aetna of WY Medicare |
$501.94
|
| Rate for Payer: Beech Street Commercial |
$5,178.45
|
| Rate for Payer: Cash Price |
$3,815.70
|
| Rate for Payer: Cash Price |
$3,815.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$5,287.47
|
| Rate for Payer: Cigna of WY Commercial |
$5,341.98
|
| Rate for Payer: First Choice Health Commercial |
$4,905.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5,178.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$501.94
|
| Rate for Payer: HealthUtah PPO |
$5,451.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5,287.47
|
| Rate for Payer: Multiplan Medicare/VA |
$426.65
|
| Rate for Payer: One Health Plan of WY PPO |
$5,341.98
|
| Rate for Payer: PacificSource Commercial |
$4,905.90
|
| Rate for Payer: PHCS PPO |
$5,178.45
|
| Rate for Payer: Three Rivers PPO |
$4,088.25
|
| Rate for Payer: TriWest Veterans Administration |
$501.94
|
| Rate for Payer: United Healthcare Commercial |
$4,742.37
|
| Rate for Payer: United Healthcare Medicare |
$501.94
|
| Rate for Payer: WINHealth Partners Commercial |
$4,633.35
|
|
|
CORRJ HLX VLGS BNCTY SESMDC DSTL METAR OSTEOT
|
Professional
|
Both
|
$5,451.00
|
|
|
Service Code
|
HCPCS 28296 AS
|
| Hospital Charge Code |
28296
|
| Min. Negotiated Rate |
$426.65 |
| Max. Negotiated Rate |
$5,451.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5,341.98
|
| Rate for Payer: Aetna of WY Medicare |
$501.94
|
| Rate for Payer: Beech Street Commercial |
$5,178.45
|
| Rate for Payer: Cash Price |
$3,815.70
|
| Rate for Payer: Cash Price |
$3,815.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$5,287.47
|
| Rate for Payer: Cigna of WY Commercial |
$5,341.98
|
| Rate for Payer: First Choice Health Commercial |
$4,905.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5,178.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$501.94
|
| Rate for Payer: HealthUtah PPO |
$5,451.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5,287.47
|
| Rate for Payer: Multiplan Medicare/VA |
$426.65
|
| Rate for Payer: One Health Plan of WY PPO |
$5,341.98
|
| Rate for Payer: PacificSource Commercial |
$4,905.90
|
| Rate for Payer: PHCS PPO |
$5,178.45
|
| Rate for Payer: Three Rivers PPO |
$4,088.25
|
| Rate for Payer: TriWest Veterans Administration |
$501.94
|
| Rate for Payer: United Healthcare Commercial |
$4,742.37
|
| Rate for Payer: United Healthcare Medicare |
$501.94
|
| Rate for Payer: WINHealth Partners Commercial |
$4,633.35
|
|
|
CORRJ HLX VLGS BNCTY SESMDC RESCJ PROX PHLX BASE
|
Professional
|
Both
|
$4,325.00
|
|
|
Service Code
|
HCPCS 28292
|
| Hospital Charge Code |
28292
|
| Min. Negotiated Rate |
$404.32 |
| Max. Negotiated Rate |
$4,325.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4,238.50
|
| Rate for Payer: Aetna of WY Medicare |
$475.67
|
| Rate for Payer: Beech Street Commercial |
$4,108.75
|
| Rate for Payer: Cash Price |
$3,027.50
|
| Rate for Payer: Cash Price |
$3,027.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$4,195.25
|
| Rate for Payer: Cigna of WY Commercial |
$4,238.50
|
| Rate for Payer: First Choice Health Commercial |
$3,892.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,108.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$475.67
|
| Rate for Payer: HealthUtah PPO |
$4,325.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4,195.25
|
| Rate for Payer: Multiplan Medicare/VA |
$404.32
|
| Rate for Payer: One Health Plan of WY PPO |
$4,238.50
|
| Rate for Payer: PacificSource Commercial |
$3,892.50
|
| Rate for Payer: PHCS PPO |
$4,108.75
|
| Rate for Payer: Three Rivers PPO |
$3,243.75
|
| Rate for Payer: TriWest Veterans Administration |
$475.67
|
| Rate for Payer: United Healthcare Commercial |
$3,762.75
|
| Rate for Payer: United Healthcare Medicare |
$475.67
|
| Rate for Payer: WINHealth Partners Commercial |
$3,676.25
|
|
|
CORRJ HLX VLGS BNCTY SESMDC RESCJ PROX PHLX BASE
|
Professional
|
Both
|
$4,325.00
|
|
|
Service Code
|
HCPCS 28292 80
|
| Hospital Charge Code |
28292
|
| Min. Negotiated Rate |
$404.32 |
| Max. Negotiated Rate |
$4,325.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4,238.50
|
| Rate for Payer: Aetna of WY Medicare |
$475.67
|
| Rate for Payer: Beech Street Commercial |
$4,108.75
|
| Rate for Payer: Cash Price |
$3,027.50
|
| Rate for Payer: Cash Price |
$3,027.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$4,195.25
|
| Rate for Payer: Cigna of WY Commercial |
$4,238.50
|
| Rate for Payer: First Choice Health Commercial |
$3,892.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,108.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$475.67
|
| Rate for Payer: HealthUtah PPO |
$4,325.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4,195.25
|
| Rate for Payer: Multiplan Medicare/VA |
$404.32
|
| Rate for Payer: One Health Plan of WY PPO |
$4,238.50
|
| Rate for Payer: PacificSource Commercial |
$3,892.50
|
| Rate for Payer: PHCS PPO |
$4,108.75
|
| Rate for Payer: Three Rivers PPO |
$3,243.75
|
| Rate for Payer: TriWest Veterans Administration |
$475.67
|
| Rate for Payer: United Healthcare Commercial |
$3,762.75
|
| Rate for Payer: United Healthcare Medicare |
$475.67
|
| Rate for Payer: WINHealth Partners Commercial |
$3,676.25
|
|
|
CORRJ HLX VLGS BNCTY SESMDC RESCJ PROX PHLX BASE
|
Professional
|
Both
|
$4,325.00
|
|
|
Service Code
|
HCPCS 28292 AS
|
| Hospital Charge Code |
28292
|
| Min. Negotiated Rate |
$404.32 |
| Max. Negotiated Rate |
$4,325.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4,238.50
|
| Rate for Payer: Aetna of WY Medicare |
$475.67
|
| Rate for Payer: Beech Street Commercial |
$4,108.75
|
| Rate for Payer: Cash Price |
$3,027.50
|
| Rate for Payer: Cash Price |
$3,027.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$4,195.25
|
| Rate for Payer: Cigna of WY Commercial |
$4,238.50
|
| Rate for Payer: First Choice Health Commercial |
$3,892.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,108.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$475.67
|
| Rate for Payer: HealthUtah PPO |
$4,325.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4,195.25
|
| Rate for Payer: Multiplan Medicare/VA |
$404.32
|
| Rate for Payer: One Health Plan of WY PPO |
$4,238.50
|
| Rate for Payer: PacificSource Commercial |
$3,892.50
|
| Rate for Payer: PHCS PPO |
$4,108.75
|
| Rate for Payer: Three Rivers PPO |
$3,243.75
|
| Rate for Payer: TriWest Veterans Administration |
$475.67
|
| Rate for Payer: United Healthcare Commercial |
$3,762.75
|
| Rate for Payer: United Healthcare Medicare |
$475.67
|
| Rate for Payer: WINHealth Partners Commercial |
$3,676.25
|
|
|
COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION [6641]
|
Facility
|
OP
|
$174.87
|
|
|
Service Code
|
HCPCS J0834
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$96.35 |
| Max. Negotiated Rate |
$174.87 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$171.37
|
| Rate for Payer: Aetna of WY Medicare |
$115.41
|
| Rate for Payer: Altius Auto/Workers Compensation |
$167.88
|
| Rate for Payer: Altius Commercial |
$167.88
|
| Rate for Payer: Beech Street Commercial |
$171.37
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$143.57
|
| Rate for Payer: Cash Price |
$122.41
|
| Rate for Payer: ChoiceCare Network Commercial |
$169.62
|
| Rate for Payer: Cigna of WY Commercial |
$171.37
|
| Rate for Payer: Entrust Commercial |
$166.13
|
| Rate for Payer: First Choice Health Commercial |
$166.13
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$166.13
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$101.42
|
| Rate for Payer: HealthUtah PPO |
$174.87
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$169.62
|
| Rate for Payer: Multiplan Medicare/VA |
$96.35
|
| Rate for Payer: One Health Plan of WY PPO |
$171.37
|
| Rate for Payer: PacificSource Commercial |
$157.38
|
| Rate for Payer: PHCS PPO |
$171.37
|
| Rate for Payer: Three Rivers PPO |
$131.15
|
| Rate for Payer: TriWest Veterans Administration |
$101.42
|
| Rate for Payer: United Healthcare Commercial |
$152.14
|
| Rate for Payer: United Healthcare Medicare |
$101.42
|
| Rate for Payer: WINHealth Partners Commercial |
$171.37
|
| Rate for Payer: Wise Provider Network Commercial |
$166.13
|
|
|
COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION [6641]
|
Facility
|
IP
|
$174.87
|
|
|
Service Code
|
HCPCS J0834
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$109.64 |
| Max. Negotiated Rate |
$174.87 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$171.37
|
| Rate for Payer: Altius Auto/Workers Compensation |
$167.88
|
| Rate for Payer: Altius Commercial |
$167.88
|
| Rate for Payer: Beech Street Commercial |
$171.37
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$143.57
|
| Rate for Payer: Cash Price |
$122.41
|
| Rate for Payer: ChoiceCare Network Commercial |
$169.62
|
| Rate for Payer: Cigna of WY Commercial |
$171.37
|
| Rate for Payer: Entrust Commercial |
$166.13
|
| Rate for Payer: First Choice Health Commercial |
$166.13
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$166.13
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$115.41
|
| Rate for Payer: HealthUtah PPO |
$174.87
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$169.62
|
| Rate for Payer: Multiplan Medicare/VA |
$109.64
|
| Rate for Payer: One Health Plan of WY PPO |
$171.37
|
| Rate for Payer: PacificSource Commercial |
$157.38
|
| Rate for Payer: PHCS PPO |
$171.37
|
| Rate for Payer: Three Rivers PPO |
$131.15
|
| Rate for Payer: TriWest Veterans Administration |
$115.41
|
| Rate for Payer: United Healthcare Commercial |
$152.14
|
| Rate for Payer: United Healthcare Medicare |
$115.41
|
| Rate for Payer: WINHealth Partners Commercial |
$166.13
|
| Rate for Payer: Wise Provider Network Commercial |
$166.13
|
|
|
COV-19 AMP PRB HGH THRUPUT
|
Professional
|
Both
|
$202.00
|
|
|
Service Code
|
HCPCS U0003
|
| Hospital Charge Code |
U0003
|
| Min. Negotiated Rate |
$151.50 |
| Max. Negotiated Rate |
$202.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$197.96
|
| Rate for Payer: Beech Street Commercial |
$191.90
|
| Rate for Payer: Cash Price |
$141.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$195.94
|
| Rate for Payer: Cigna of WY Commercial |
$197.96
|
| Rate for Payer: First Choice Health Commercial |
$181.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$191.90
|
| Rate for Payer: HealthUtah PPO |
$202.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$195.94
|
| Rate for Payer: One Health Plan of WY PPO |
$197.96
|
| Rate for Payer: PacificSource Commercial |
$181.80
|
| Rate for Payer: PHCS PPO |
$191.90
|
| Rate for Payer: Three Rivers PPO |
$151.50
|
| Rate for Payer: United Healthcare Commercial |
$175.74
|
| Rate for Payer: WINHealth Partners Commercial |
$191.90
|
|
