|
DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE [41766]
|
Facility
|
IP
|
$5,820.00
|
|
|
Service Code
|
HCPCS J0881
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,649.14 |
| Max. Negotiated Rate |
$5,820.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5,703.60
|
| Rate for Payer: Altius Auto/Workers Compensation |
$5,587.20
|
| Rate for Payer: Altius Commercial |
$5,587.20
|
| Rate for Payer: Beech Street Commercial |
$5,703.60
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$4,778.22
|
| Rate for Payer: Cash Price |
$4,074.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$5,645.40
|
| Rate for Payer: Cigna of WY Commercial |
$5,703.60
|
| Rate for Payer: Entrust Commercial |
$5,529.00
|
| Rate for Payer: First Choice Health Commercial |
$5,529.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5,529.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3,841.20
|
| Rate for Payer: HealthUtah PPO |
$5,820.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5,645.40
|
| Rate for Payer: Multiplan Medicare/VA |
$3,649.14
|
| Rate for Payer: One Health Plan of WY PPO |
$5,703.60
|
| Rate for Payer: PacificSource Commercial |
$5,238.00
|
| Rate for Payer: PHCS PPO |
$5,703.60
|
| Rate for Payer: Three Rivers PPO |
$4,365.00
|
| Rate for Payer: TriWest Veterans Administration |
$3,841.20
|
| Rate for Payer: United Healthcare Commercial |
$5,063.40
|
| Rate for Payer: United Healthcare Medicare |
$3,841.20
|
| Rate for Payer: WINHealth Partners Commercial |
$5,529.00
|
| Rate for Payer: Wise Provider Network Commercial |
$5,529.00
|
|
|
DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE [41764]
|
Facility
|
OP
|
$789.00
|
|
|
Service Code
|
HCPCS J0881
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$434.74 |
| Max. Negotiated Rate |
$789.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$773.22
|
| Rate for Payer: Aetna of WY Medicare |
$520.74
|
| Rate for Payer: Altius Auto/Workers Compensation |
$757.44
|
| Rate for Payer: Altius Commercial |
$757.44
|
| Rate for Payer: Beech Street Commercial |
$773.22
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$647.77
|
| Rate for Payer: Cash Price |
$552.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$765.33
|
| Rate for Payer: Cigna of WY Commercial |
$773.22
|
| Rate for Payer: Entrust Commercial |
$749.55
|
| Rate for Payer: First Choice Health Commercial |
$749.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$749.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$457.62
|
| Rate for Payer: HealthUtah PPO |
$789.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$765.33
|
| Rate for Payer: Multiplan Medicare/VA |
$434.74
|
| Rate for Payer: One Health Plan of WY PPO |
$773.22
|
| Rate for Payer: PacificSource Commercial |
$710.10
|
| Rate for Payer: PHCS PPO |
$773.22
|
| Rate for Payer: Three Rivers PPO |
$591.75
|
| Rate for Payer: TriWest Veterans Administration |
$457.62
|
| Rate for Payer: United Healthcare Commercial |
$686.43
|
| Rate for Payer: United Healthcare Medicare |
$457.62
|
| Rate for Payer: WINHealth Partners Commercial |
$773.22
|
| Rate for Payer: Wise Provider Network Commercial |
$749.55
|
|
|
DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE [41764]
|
Facility
|
IP
|
$789.00
|
|
|
Service Code
|
HCPCS J0881
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$494.70 |
| Max. Negotiated Rate |
$789.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$773.22
|
| Rate for Payer: Altius Auto/Workers Compensation |
$757.44
|
| Rate for Payer: Altius Commercial |
$757.44
|
| Rate for Payer: Beech Street Commercial |
$773.22
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$647.77
|
| Rate for Payer: Cash Price |
$552.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$765.33
|
| Rate for Payer: Cigna of WY Commercial |
$773.22
|
| Rate for Payer: Entrust Commercial |
$749.55
|
| Rate for Payer: First Choice Health Commercial |
$749.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$749.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$520.74
|
| Rate for Payer: HealthUtah PPO |
$789.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$765.33
|
| Rate for Payer: Multiplan Medicare/VA |
$494.70
|
| Rate for Payer: One Health Plan of WY PPO |
$773.22
|
| Rate for Payer: PacificSource Commercial |
$710.10
|
| Rate for Payer: PHCS PPO |
$773.22
|
| Rate for Payer: Three Rivers PPO |
$591.75
|
| Rate for Payer: TriWest Veterans Administration |
$520.74
|
| Rate for Payer: United Healthcare Commercial |
$686.43
|
| Rate for Payer: United Healthcare Medicare |
$520.74
|
| Rate for Payer: WINHealth Partners Commercial |
$749.55
|
| Rate for Payer: Wise Provider Network Commercial |
$749.55
|
|
|
DARBEPOETIN ALFA 500 MCG/ML IN POLYSORBATE INJECTION SYRINGE [41383]
|
Facility
|
OP
|
$5,820.00
|
|
|
Service Code
|
HCPCS J0881
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,206.82 |
| Max. Negotiated Rate |
$5,820.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5,703.60
|
| Rate for Payer: Aetna of WY Medicare |
$3,841.20
|
| Rate for Payer: Altius Auto/Workers Compensation |
$5,587.20
|
| Rate for Payer: Altius Commercial |
$5,587.20
|
| Rate for Payer: Beech Street Commercial |
$5,703.60
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$4,778.22
|
| Rate for Payer: Cash Price |
$4,074.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$5,645.40
|
| Rate for Payer: Cigna of WY Commercial |
$5,703.60
|
| Rate for Payer: Entrust Commercial |
$5,529.00
|
| Rate for Payer: First Choice Health Commercial |
$5,529.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5,529.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3,375.60
|
| Rate for Payer: HealthUtah PPO |
$5,820.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5,645.40
|
| Rate for Payer: Multiplan Medicare/VA |
$3,206.82
|
| Rate for Payer: One Health Plan of WY PPO |
$5,703.60
|
| Rate for Payer: PacificSource Commercial |
$5,238.00
|
| Rate for Payer: PHCS PPO |
$5,703.60
|
| Rate for Payer: Three Rivers PPO |
$4,365.00
|
| Rate for Payer: TriWest Veterans Administration |
$3,375.60
|
| Rate for Payer: United Healthcare Commercial |
$5,063.40
|
| Rate for Payer: United Healthcare Medicare |
$3,375.60
|
| Rate for Payer: WINHealth Partners Commercial |
$5,703.60
|
| Rate for Payer: Wise Provider Network Commercial |
$5,529.00
|
|
|
DARBEPOETIN ALFA 500 MCG/ML IN POLYSORBATE INJECTION SYRINGE [41383]
|
Facility
|
IP
|
$5,820.00
|
|
|
Service Code
|
HCPCS J0881
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,649.14 |
| Max. Negotiated Rate |
$5,820.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5,703.60
|
| Rate for Payer: Altius Auto/Workers Compensation |
$5,587.20
|
| Rate for Payer: Altius Commercial |
$5,587.20
|
| Rate for Payer: Beech Street Commercial |
$5,703.60
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$4,778.22
|
| Rate for Payer: Cash Price |
$4,074.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$5,645.40
|
| Rate for Payer: Cigna of WY Commercial |
$5,703.60
|
| Rate for Payer: Entrust Commercial |
$5,529.00
|
| Rate for Payer: First Choice Health Commercial |
$5,529.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5,529.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3,841.20
|
| Rate for Payer: HealthUtah PPO |
$5,820.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5,645.40
|
| Rate for Payer: Multiplan Medicare/VA |
$3,649.14
|
| Rate for Payer: One Health Plan of WY PPO |
$5,703.60
|
| Rate for Payer: PacificSource Commercial |
$5,238.00
|
| Rate for Payer: PHCS PPO |
$5,703.60
|
| Rate for Payer: Three Rivers PPO |
$4,365.00
|
| Rate for Payer: TriWest Veterans Administration |
$3,841.20
|
| Rate for Payer: United Healthcare Commercial |
$5,063.40
|
| Rate for Payer: United Healthcare Medicare |
$3,841.20
|
| Rate for Payer: WINHealth Partners Commercial |
$5,529.00
|
| Rate for Payer: Wise Provider Network Commercial |
$5,529.00
|
|
|
DAVINCI 12-8MM REDUCER
|
Facility
|
IP
|
$87.50
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$54.86 |
| Max. Negotiated Rate |
$87.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$85.75
|
| Rate for Payer: Altius Auto/Workers Compensation |
$84.00
|
| Rate for Payer: Altius Commercial |
$84.00
|
| Rate for Payer: Beech Street Commercial |
$85.75
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$71.84
|
| Rate for Payer: Cash Price |
$61.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$84.88
|
| Rate for Payer: Cigna of WY Commercial |
$85.75
|
| Rate for Payer: Entrust Commercial |
$83.12
|
| Rate for Payer: First Choice Health Commercial |
$83.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$83.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$57.75
|
| Rate for Payer: HealthUtah PPO |
$87.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$84.88
|
| Rate for Payer: Multiplan Medicare/VA |
$54.86
|
| Rate for Payer: One Health Plan of WY PPO |
$85.75
|
| Rate for Payer: PacificSource Commercial |
$78.75
|
| Rate for Payer: PHCS PPO |
$85.75
|
| Rate for Payer: Three Rivers PPO |
$65.62
|
| Rate for Payer: TriWest Veterans Administration |
$57.75
|
| Rate for Payer: United Healthcare Commercial |
$76.12
|
| Rate for Payer: United Healthcare Medicare |
$57.75
|
| Rate for Payer: WINHealth Partners Commercial |
$83.12
|
| Rate for Payer: Wise Provider Network Commercial |
$83.12
|
|
|
DAVINCI 12-8MM REDUCER
|
Facility
|
OP
|
$87.50
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$48.21 |
| Max. Negotiated Rate |
$87.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$85.75
|
| Rate for Payer: Aetna of WY Medicare |
$57.75
|
| Rate for Payer: Altius Auto/Workers Compensation |
$84.00
|
| Rate for Payer: Altius Commercial |
$84.00
|
| Rate for Payer: Beech Street Commercial |
$85.75
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$71.84
|
| Rate for Payer: Cash Price |
$61.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$84.88
|
| Rate for Payer: Cigna of WY Commercial |
$85.75
|
| Rate for Payer: Entrust Commercial |
$83.12
|
| Rate for Payer: First Choice Health Commercial |
$83.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$83.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$50.75
|
| Rate for Payer: HealthUtah PPO |
$87.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$84.88
|
| Rate for Payer: Multiplan Medicare/VA |
$48.21
|
| Rate for Payer: One Health Plan of WY PPO |
$85.75
|
| Rate for Payer: PacificSource Commercial |
$78.75
|
| Rate for Payer: PHCS PPO |
$85.75
|
| Rate for Payer: Three Rivers PPO |
$65.62
|
| Rate for Payer: TriWest Veterans Administration |
$50.75
|
| Rate for Payer: United Healthcare Commercial |
$76.12
|
| Rate for Payer: United Healthcare Medicare |
$50.75
|
| Rate for Payer: WINHealth Partners Commercial |
$85.75
|
| Rate for Payer: Wise Provider Network Commercial |
$83.12
|
|
|
DAVINCI 12MM & STAPLER SEAL
|
Facility
|
OP
|
$49.00
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$27.00 |
| Max. Negotiated Rate |
$49.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$48.02
|
| Rate for Payer: Aetna of WY Medicare |
$32.34
|
| Rate for Payer: Altius Auto/Workers Compensation |
$47.04
|
| Rate for Payer: Altius Commercial |
$47.04
|
| Rate for Payer: Beech Street Commercial |
$48.02
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$40.23
|
| Rate for Payer: Cash Price |
$34.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$47.53
|
| Rate for Payer: Cigna of WY Commercial |
$48.02
|
| Rate for Payer: Entrust Commercial |
$46.55
|
| Rate for Payer: First Choice Health Commercial |
$46.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$46.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$28.42
|
| Rate for Payer: HealthUtah PPO |
$49.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$47.53
|
| Rate for Payer: Multiplan Medicare/VA |
$27.00
|
| Rate for Payer: One Health Plan of WY PPO |
$48.02
|
| Rate for Payer: PacificSource Commercial |
$44.10
|
| Rate for Payer: PHCS PPO |
$48.02
|
| Rate for Payer: Three Rivers PPO |
$36.75
|
| Rate for Payer: TriWest Veterans Administration |
$28.42
|
| Rate for Payer: United Healthcare Commercial |
$42.63
|
| Rate for Payer: United Healthcare Medicare |
$28.42
|
| Rate for Payer: WINHealth Partners Commercial |
$48.02
|
| Rate for Payer: Wise Provider Network Commercial |
$46.55
|
|
|
DAVINCI 12MM & STAPLER SEAL
|
Facility
|
IP
|
$49.00
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$30.72 |
| Max. Negotiated Rate |
$49.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$48.02
|
| Rate for Payer: Altius Auto/Workers Compensation |
$47.04
|
| Rate for Payer: Altius Commercial |
$47.04
|
| Rate for Payer: Beech Street Commercial |
$48.02
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$40.23
|
| Rate for Payer: Cash Price |
$34.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$47.53
|
| Rate for Payer: Cigna of WY Commercial |
$48.02
|
| Rate for Payer: Entrust Commercial |
$46.55
|
| Rate for Payer: First Choice Health Commercial |
$46.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$46.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$32.34
|
| Rate for Payer: HealthUtah PPO |
$49.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$47.53
|
| Rate for Payer: Multiplan Medicare/VA |
$30.72
|
| Rate for Payer: One Health Plan of WY PPO |
$48.02
|
| Rate for Payer: PacificSource Commercial |
$44.10
|
| Rate for Payer: PHCS PPO |
$48.02
|
| Rate for Payer: Three Rivers PPO |
$36.75
|
| Rate for Payer: TriWest Veterans Administration |
$32.34
|
| Rate for Payer: United Healthcare Commercial |
$42.63
|
| Rate for Payer: United Healthcare Medicare |
$32.34
|
| Rate for Payer: WINHealth Partners Commercial |
$46.55
|
| Rate for Payer: Wise Provider Network Commercial |
$46.55
|
|
|
DAVINCI 8MM BLADELES OBTURATOR
|
Facility
|
OP
|
$87.50
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$48.21 |
| Max. Negotiated Rate |
$87.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$85.75
|
| Rate for Payer: Aetna of WY Medicare |
$57.75
|
| Rate for Payer: Altius Auto/Workers Compensation |
$84.00
|
| Rate for Payer: Altius Commercial |
$84.00
|
| Rate for Payer: Beech Street Commercial |
$85.75
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$71.84
|
| Rate for Payer: Cash Price |
$61.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$84.88
|
| Rate for Payer: Cigna of WY Commercial |
$85.75
|
| Rate for Payer: Entrust Commercial |
$83.12
|
| Rate for Payer: First Choice Health Commercial |
$83.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$83.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$50.75
|
| Rate for Payer: HealthUtah PPO |
$87.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$84.88
|
| Rate for Payer: Multiplan Medicare/VA |
$48.21
|
| Rate for Payer: One Health Plan of WY PPO |
$85.75
|
| Rate for Payer: PacificSource Commercial |
$78.75
|
| Rate for Payer: PHCS PPO |
$85.75
|
| Rate for Payer: Three Rivers PPO |
$65.62
|
| Rate for Payer: TriWest Veterans Administration |
$50.75
|
| Rate for Payer: United Healthcare Commercial |
$76.12
|
| Rate for Payer: United Healthcare Medicare |
$50.75
|
| Rate for Payer: WINHealth Partners Commercial |
$85.75
|
| Rate for Payer: Wise Provider Network Commercial |
$83.12
|
|
|
DAVINCI 8MM BLADELES OBTURATOR
|
Facility
|
IP
|
$87.50
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$54.86 |
| Max. Negotiated Rate |
$87.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$85.75
|
| Rate for Payer: Altius Auto/Workers Compensation |
$84.00
|
| Rate for Payer: Altius Commercial |
$84.00
|
| Rate for Payer: Beech Street Commercial |
$85.75
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$71.84
|
| Rate for Payer: Cash Price |
$61.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$84.88
|
| Rate for Payer: Cigna of WY Commercial |
$85.75
|
| Rate for Payer: Entrust Commercial |
$83.12
|
| Rate for Payer: First Choice Health Commercial |
$83.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$83.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$57.75
|
| Rate for Payer: HealthUtah PPO |
$87.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$84.88
|
| Rate for Payer: Multiplan Medicare/VA |
$54.86
|
| Rate for Payer: One Health Plan of WY PPO |
$85.75
|
| Rate for Payer: PacificSource Commercial |
$78.75
|
| Rate for Payer: PHCS PPO |
$85.75
|
| Rate for Payer: Three Rivers PPO |
$65.62
|
| Rate for Payer: TriWest Veterans Administration |
$57.75
|
| Rate for Payer: United Healthcare Commercial |
$76.12
|
| Rate for Payer: United Healthcare Medicare |
$57.75
|
| Rate for Payer: WINHealth Partners Commercial |
$83.12
|
| Rate for Payer: Wise Provider Network Commercial |
$83.12
|
|
|
DAVINCI DRAPE INSTRUMENT ARM
|
Facility
|
OP
|
$191.10
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$105.30 |
| Max. Negotiated Rate |
$191.10 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$187.28
|
| Rate for Payer: Aetna of WY Medicare |
$126.13
|
| Rate for Payer: Altius Auto/Workers Compensation |
$183.46
|
| Rate for Payer: Altius Commercial |
$183.46
|
| Rate for Payer: Beech Street Commercial |
$187.28
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$156.89
|
| Rate for Payer: Cash Price |
$133.77
|
| Rate for Payer: ChoiceCare Network Commercial |
$185.37
|
| Rate for Payer: Cigna of WY Commercial |
$187.28
|
| Rate for Payer: Entrust Commercial |
$181.54
|
| Rate for Payer: First Choice Health Commercial |
$181.54
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$181.54
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$110.84
|
| Rate for Payer: HealthUtah PPO |
$191.10
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$185.37
|
| Rate for Payer: Multiplan Medicare/VA |
$105.30
|
| Rate for Payer: One Health Plan of WY PPO |
$187.28
|
| Rate for Payer: PacificSource Commercial |
$171.99
|
| Rate for Payer: PHCS PPO |
$187.28
|
| Rate for Payer: Three Rivers PPO |
$143.32
|
| Rate for Payer: TriWest Veterans Administration |
$110.84
|
| Rate for Payer: United Healthcare Commercial |
$166.26
|
| Rate for Payer: United Healthcare Medicare |
$110.84
|
| Rate for Payer: WINHealth Partners Commercial |
$187.28
|
| Rate for Payer: Wise Provider Network Commercial |
$181.54
|
|
|
DAVINCI DRAPE INSTRUMENT ARM
|
Facility
|
IP
|
$191.10
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$119.82 |
| Max. Negotiated Rate |
$191.10 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$187.28
|
| Rate for Payer: Altius Auto/Workers Compensation |
$183.46
|
| Rate for Payer: Altius Commercial |
$183.46
|
| Rate for Payer: Beech Street Commercial |
$187.28
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$156.89
|
| Rate for Payer: Cash Price |
$133.77
|
| Rate for Payer: ChoiceCare Network Commercial |
$185.37
|
| Rate for Payer: Cigna of WY Commercial |
$187.28
|
| Rate for Payer: Entrust Commercial |
$181.54
|
| Rate for Payer: First Choice Health Commercial |
$181.54
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$181.54
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$126.13
|
| Rate for Payer: HealthUtah PPO |
$191.10
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$185.37
|
| Rate for Payer: Multiplan Medicare/VA |
$119.82
|
| Rate for Payer: One Health Plan of WY PPO |
$187.28
|
| Rate for Payer: PacificSource Commercial |
$171.99
|
| Rate for Payer: PHCS PPO |
$187.28
|
| Rate for Payer: Three Rivers PPO |
$143.32
|
| Rate for Payer: TriWest Veterans Administration |
$126.13
|
| Rate for Payer: United Healthcare Commercial |
$166.26
|
| Rate for Payer: United Healthcare Medicare |
$126.13
|
| Rate for Payer: WINHealth Partners Commercial |
$181.54
|
| Rate for Payer: Wise Provider Network Commercial |
$181.54
|
|
|
DAVINCI ENDOWRIST SUCTION
|
Facility
|
IP
|
$518.00
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$324.79 |
| Max. Negotiated Rate |
$518.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$507.64
|
| Rate for Payer: Altius Auto/Workers Compensation |
$497.28
|
| Rate for Payer: Altius Commercial |
$497.28
|
| Rate for Payer: Beech Street Commercial |
$507.64
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$425.28
|
| Rate for Payer: Cash Price |
$362.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$502.46
|
| Rate for Payer: Cigna of WY Commercial |
$507.64
|
| Rate for Payer: Entrust Commercial |
$492.10
|
| Rate for Payer: First Choice Health Commercial |
$492.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$492.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$341.88
|
| Rate for Payer: HealthUtah PPO |
$518.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$502.46
|
| Rate for Payer: Multiplan Medicare/VA |
$324.79
|
| Rate for Payer: One Health Plan of WY PPO |
$507.64
|
| Rate for Payer: PacificSource Commercial |
$466.20
|
| Rate for Payer: PHCS PPO |
$507.64
|
| Rate for Payer: Three Rivers PPO |
$388.50
|
| Rate for Payer: TriWest Veterans Administration |
$341.88
|
| Rate for Payer: United Healthcare Commercial |
$450.66
|
| Rate for Payer: United Healthcare Medicare |
$341.88
|
| Rate for Payer: WINHealth Partners Commercial |
$492.10
|
| Rate for Payer: Wise Provider Network Commercial |
$492.10
|
|
|
DAVINCI ENDOWRIST SUCTION
|
Facility
|
OP
|
$518.00
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$285.42 |
| Max. Negotiated Rate |
$518.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$507.64
|
| Rate for Payer: Aetna of WY Medicare |
$341.88
|
| Rate for Payer: Altius Auto/Workers Compensation |
$497.28
|
| Rate for Payer: Altius Commercial |
$497.28
|
| Rate for Payer: Beech Street Commercial |
$507.64
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$425.28
|
| Rate for Payer: Cash Price |
$362.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$502.46
|
| Rate for Payer: Cigna of WY Commercial |
$507.64
|
| Rate for Payer: Entrust Commercial |
$492.10
|
| Rate for Payer: First Choice Health Commercial |
$492.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$492.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$300.44
|
| Rate for Payer: HealthUtah PPO |
$518.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$502.46
|
| Rate for Payer: Multiplan Medicare/VA |
$285.42
|
| Rate for Payer: One Health Plan of WY PPO |
$507.64
|
| Rate for Payer: PacificSource Commercial |
$466.20
|
| Rate for Payer: PHCS PPO |
$507.64
|
| Rate for Payer: Three Rivers PPO |
$388.50
|
| Rate for Payer: TriWest Veterans Administration |
$300.44
|
| Rate for Payer: United Healthcare Commercial |
$450.66
|
| Rate for Payer: United Healthcare Medicare |
$300.44
|
| Rate for Payer: WINHealth Partners Commercial |
$507.64
|
| Rate for Payer: Wise Provider Network Commercial |
$492.10
|
|
|
DAVINCI HEMOLOK M/L GREEN LIGATING CLIP
|
Facility
|
IP
|
$112.16
|
|
| Hospital Charge Code |
27800000S1
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$70.32 |
| Max. Negotiated Rate |
$112.16 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$109.92
|
| Rate for Payer: Altius Auto/Workers Compensation |
$107.67
|
| Rate for Payer: Altius Commercial |
$107.67
|
| Rate for Payer: Beech Street Commercial |
$109.92
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$92.08
|
| Rate for Payer: Cash Price |
$78.51
|
| Rate for Payer: ChoiceCare Network Commercial |
$108.80
|
| Rate for Payer: Cigna of WY Commercial |
$109.92
|
| Rate for Payer: Entrust Commercial |
$106.55
|
| Rate for Payer: First Choice Health Commercial |
$106.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$106.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$74.03
|
| Rate for Payer: HealthUtah PPO |
$112.16
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$108.80
|
| Rate for Payer: Multiplan Medicare/VA |
$70.32
|
| Rate for Payer: One Health Plan of WY PPO |
$109.92
|
| Rate for Payer: PacificSource Commercial |
$100.94
|
| Rate for Payer: PHCS PPO |
$109.92
|
| Rate for Payer: Three Rivers PPO |
$84.12
|
| Rate for Payer: TriWest Veterans Administration |
$74.03
|
| Rate for Payer: United Healthcare Commercial |
$97.58
|
| Rate for Payer: United Healthcare Medicare |
$74.03
|
| Rate for Payer: WINHealth Partners Commercial |
$106.55
|
| Rate for Payer: Wise Provider Network Commercial |
$106.55
|
|
|
DAVINCI HEMOLOK M/L GREEN LIGATING CLIP
|
Facility
|
OP
|
$112.16
|
|
| Hospital Charge Code |
27800000S1
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$61.80 |
| Max. Negotiated Rate |
$112.16 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$109.92
|
| Rate for Payer: Aetna of WY Medicare |
$74.03
|
| Rate for Payer: Altius Auto/Workers Compensation |
$107.67
|
| Rate for Payer: Altius Commercial |
$107.67
|
| Rate for Payer: Beech Street Commercial |
$109.92
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$92.08
|
| Rate for Payer: Cash Price |
$78.51
|
| Rate for Payer: ChoiceCare Network Commercial |
$108.80
|
| Rate for Payer: Cigna of WY Commercial |
$109.92
|
| Rate for Payer: Entrust Commercial |
$106.55
|
| Rate for Payer: First Choice Health Commercial |
$106.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$106.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$65.05
|
| Rate for Payer: HealthUtah PPO |
$112.16
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$108.80
|
| Rate for Payer: Multiplan Medicare/VA |
$61.80
|
| Rate for Payer: One Health Plan of WY PPO |
$109.92
|
| Rate for Payer: PacificSource Commercial |
$100.94
|
| Rate for Payer: PHCS PPO |
$109.92
|
| Rate for Payer: Three Rivers PPO |
$84.12
|
| Rate for Payer: TriWest Veterans Administration |
$65.05
|
| Rate for Payer: United Healthcare Commercial |
$97.58
|
| Rate for Payer: United Healthcare Medicare |
$65.05
|
| Rate for Payer: WINHealth Partners Commercial |
$109.92
|
| Rate for Payer: Wise Provider Network Commercial |
$106.55
|
|
|
DAVINCI RELOAD 2.5 WHITE
|
Facility
|
IP
|
$845.25
|
|
| Hospital Charge Code |
27800000S1
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$529.97 |
| Max. Negotiated Rate |
$845.25 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$828.34
|
| Rate for Payer: Altius Auto/Workers Compensation |
$811.44
|
| Rate for Payer: Altius Commercial |
$811.44
|
| Rate for Payer: Beech Street Commercial |
$828.34
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$693.95
|
| Rate for Payer: Cash Price |
$591.68
|
| Rate for Payer: ChoiceCare Network Commercial |
$819.89
|
| Rate for Payer: Cigna of WY Commercial |
$828.34
|
| Rate for Payer: Entrust Commercial |
$802.99
|
| Rate for Payer: First Choice Health Commercial |
$802.99
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$802.99
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$557.86
|
| Rate for Payer: HealthUtah PPO |
$845.25
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$819.89
|
| Rate for Payer: Multiplan Medicare/VA |
$529.97
|
| Rate for Payer: One Health Plan of WY PPO |
$828.34
|
| Rate for Payer: PacificSource Commercial |
$760.72
|
| Rate for Payer: PHCS PPO |
$828.34
|
| Rate for Payer: Three Rivers PPO |
$633.94
|
| Rate for Payer: TriWest Veterans Administration |
$557.86
|
| Rate for Payer: United Healthcare Commercial |
$735.37
|
| Rate for Payer: United Healthcare Medicare |
$557.86
|
| Rate for Payer: WINHealth Partners Commercial |
$802.99
|
| Rate for Payer: Wise Provider Network Commercial |
$802.99
|
|
|
DAVINCI RELOAD 2.5 WHITE
|
Facility
|
OP
|
$845.25
|
|
| Hospital Charge Code |
27800000S1
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$465.73 |
| Max. Negotiated Rate |
$845.25 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$828.34
|
| Rate for Payer: Aetna of WY Medicare |
$557.86
|
| Rate for Payer: Altius Auto/Workers Compensation |
$811.44
|
| Rate for Payer: Altius Commercial |
$811.44
|
| Rate for Payer: Beech Street Commercial |
$828.34
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$693.95
|
| Rate for Payer: Cash Price |
$591.68
|
| Rate for Payer: ChoiceCare Network Commercial |
$819.89
|
| Rate for Payer: Cigna of WY Commercial |
$828.34
|
| Rate for Payer: Entrust Commercial |
$802.99
|
| Rate for Payer: First Choice Health Commercial |
$802.99
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$802.99
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$490.24
|
| Rate for Payer: HealthUtah PPO |
$845.25
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$819.89
|
| Rate for Payer: Multiplan Medicare/VA |
$465.73
|
| Rate for Payer: One Health Plan of WY PPO |
$828.34
|
| Rate for Payer: PacificSource Commercial |
$760.72
|
| Rate for Payer: PHCS PPO |
$828.34
|
| Rate for Payer: Three Rivers PPO |
$633.94
|
| Rate for Payer: TriWest Veterans Administration |
$490.24
|
| Rate for Payer: United Healthcare Commercial |
$735.37
|
| Rate for Payer: United Healthcare Medicare |
$490.24
|
| Rate for Payer: WINHealth Partners Commercial |
$828.34
|
| Rate for Payer: Wise Provider Network Commercial |
$802.99
|
|
|
DAVINCI RELOAD 3.5 BLUE
|
Facility
|
OP
|
$845.25
|
|
| Hospital Charge Code |
27800000S1
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$465.73 |
| Max. Negotiated Rate |
$845.25 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$828.34
|
| Rate for Payer: Aetna of WY Medicare |
$557.86
|
| Rate for Payer: Altius Auto/Workers Compensation |
$811.44
|
| Rate for Payer: Altius Commercial |
$811.44
|
| Rate for Payer: Beech Street Commercial |
$828.34
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$693.95
|
| Rate for Payer: Cash Price |
$591.68
|
| Rate for Payer: ChoiceCare Network Commercial |
$819.89
|
| Rate for Payer: Cigna of WY Commercial |
$828.34
|
| Rate for Payer: Entrust Commercial |
$802.99
|
| Rate for Payer: First Choice Health Commercial |
$802.99
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$802.99
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$490.24
|
| Rate for Payer: HealthUtah PPO |
$845.25
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$819.89
|
| Rate for Payer: Multiplan Medicare/VA |
$465.73
|
| Rate for Payer: One Health Plan of WY PPO |
$828.34
|
| Rate for Payer: PacificSource Commercial |
$760.72
|
| Rate for Payer: PHCS PPO |
$828.34
|
| Rate for Payer: Three Rivers PPO |
$633.94
|
| Rate for Payer: TriWest Veterans Administration |
$490.24
|
| Rate for Payer: United Healthcare Commercial |
$735.37
|
| Rate for Payer: United Healthcare Medicare |
$490.24
|
| Rate for Payer: WINHealth Partners Commercial |
$828.34
|
| Rate for Payer: Wise Provider Network Commercial |
$802.99
|
|
|
DAVINCI RELOAD 3.5 BLUE
|
Facility
|
IP
|
$845.25
|
|
| Hospital Charge Code |
27800000S1
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$529.97 |
| Max. Negotiated Rate |
$845.25 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$828.34
|
| Rate for Payer: Altius Auto/Workers Compensation |
$811.44
|
| Rate for Payer: Altius Commercial |
$811.44
|
| Rate for Payer: Beech Street Commercial |
$828.34
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$693.95
|
| Rate for Payer: Cash Price |
$591.68
|
| Rate for Payer: ChoiceCare Network Commercial |
$819.89
|
| Rate for Payer: Cigna of WY Commercial |
$828.34
|
| Rate for Payer: Entrust Commercial |
$802.99
|
| Rate for Payer: First Choice Health Commercial |
$802.99
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$802.99
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$557.86
|
| Rate for Payer: HealthUtah PPO |
$845.25
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$819.89
|
| Rate for Payer: Multiplan Medicare/VA |
$529.97
|
| Rate for Payer: One Health Plan of WY PPO |
$828.34
|
| Rate for Payer: PacificSource Commercial |
$760.72
|
| Rate for Payer: PHCS PPO |
$828.34
|
| Rate for Payer: Three Rivers PPO |
$633.94
|
| Rate for Payer: TriWest Veterans Administration |
$557.86
|
| Rate for Payer: United Healthcare Commercial |
$735.37
|
| Rate for Payer: United Healthcare Medicare |
$557.86
|
| Rate for Payer: WINHealth Partners Commercial |
$802.99
|
| Rate for Payer: Wise Provider Network Commercial |
$802.99
|
|
|
DAVINCI SEE SHARP SCOPE WARMER
|
Facility
|
IP
|
$157.50
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$98.75 |
| Max. Negotiated Rate |
$157.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$154.35
|
| Rate for Payer: Altius Auto/Workers Compensation |
$151.20
|
| Rate for Payer: Altius Commercial |
$151.20
|
| Rate for Payer: Beech Street Commercial |
$154.35
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$129.31
|
| Rate for Payer: Cash Price |
$110.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$152.78
|
| Rate for Payer: Cigna of WY Commercial |
$154.35
|
| Rate for Payer: Entrust Commercial |
$149.62
|
| Rate for Payer: First Choice Health Commercial |
$149.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$149.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$103.95
|
| Rate for Payer: HealthUtah PPO |
$157.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$152.78
|
| Rate for Payer: Multiplan Medicare/VA |
$98.75
|
| Rate for Payer: One Health Plan of WY PPO |
$154.35
|
| Rate for Payer: PacificSource Commercial |
$141.75
|
| Rate for Payer: PHCS PPO |
$154.35
|
| Rate for Payer: Three Rivers PPO |
$118.12
|
| Rate for Payer: TriWest Veterans Administration |
$103.95
|
| Rate for Payer: United Healthcare Commercial |
$137.02
|
| Rate for Payer: United Healthcare Medicare |
$103.95
|
| Rate for Payer: WINHealth Partners Commercial |
$149.62
|
| Rate for Payer: Wise Provider Network Commercial |
$149.62
|
|
|
DAVINCI SEE SHARP SCOPE WARMER
|
Facility
|
OP
|
$157.50
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$86.78 |
| Max. Negotiated Rate |
$157.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$154.35
|
| Rate for Payer: Aetna of WY Medicare |
$103.95
|
| Rate for Payer: Altius Auto/Workers Compensation |
$151.20
|
| Rate for Payer: Altius Commercial |
$151.20
|
| Rate for Payer: Beech Street Commercial |
$154.35
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$129.31
|
| Rate for Payer: Cash Price |
$110.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$152.78
|
| Rate for Payer: Cigna of WY Commercial |
$154.35
|
| Rate for Payer: Entrust Commercial |
$149.62
|
| Rate for Payer: First Choice Health Commercial |
$149.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$149.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$91.35
|
| Rate for Payer: HealthUtah PPO |
$157.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$152.78
|
| Rate for Payer: Multiplan Medicare/VA |
$86.78
|
| Rate for Payer: One Health Plan of WY PPO |
$154.35
|
| Rate for Payer: PacificSource Commercial |
$141.75
|
| Rate for Payer: PHCS PPO |
$154.35
|
| Rate for Payer: Three Rivers PPO |
$118.12
|
| Rate for Payer: TriWest Veterans Administration |
$91.35
|
| Rate for Payer: United Healthcare Commercial |
$137.02
|
| Rate for Payer: United Healthcare Medicare |
$91.35
|
| Rate for Payer: WINHealth Partners Commercial |
$154.35
|
| Rate for Payer: Wise Provider Network Commercial |
$149.62
|
|
|
DAVINCI STAPLER SUREFORM
|
Facility
|
OP
|
$1,400.00
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$771.40 |
| Max. Negotiated Rate |
$1,400.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,372.00
|
| Rate for Payer: Aetna of WY Medicare |
$924.00
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,344.00
|
| Rate for Payer: Altius Commercial |
$1,344.00
|
| Rate for Payer: Beech Street Commercial |
$1,372.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,149.40
|
| Rate for Payer: Cash Price |
$980.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,358.00
|
| Rate for Payer: Cigna of WY Commercial |
$1,372.00
|
| Rate for Payer: Entrust Commercial |
$1,330.00
|
| Rate for Payer: First Choice Health Commercial |
$1,330.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,330.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$812.00
|
| Rate for Payer: HealthUtah PPO |
$1,400.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,358.00
|
| Rate for Payer: Multiplan Medicare/VA |
$771.40
|
| Rate for Payer: One Health Plan of WY PPO |
$1,372.00
|
| Rate for Payer: PacificSource Commercial |
$1,260.00
|
| Rate for Payer: PHCS PPO |
$1,372.00
|
| Rate for Payer: Three Rivers PPO |
$1,050.00
|
| Rate for Payer: TriWest Veterans Administration |
$812.00
|
| Rate for Payer: United Healthcare Commercial |
$1,218.00
|
| Rate for Payer: United Healthcare Medicare |
$812.00
|
| Rate for Payer: WINHealth Partners Commercial |
$1,372.00
|
| Rate for Payer: Wise Provider Network Commercial |
$1,330.00
|
|
|
DAVINCI STAPLER SUREFORM
|
Facility
|
IP
|
$1,400.00
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$877.80 |
| Max. Negotiated Rate |
$1,400.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,372.00
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,344.00
|
| Rate for Payer: Altius Commercial |
$1,344.00
|
| Rate for Payer: Beech Street Commercial |
$1,372.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,149.40
|
| Rate for Payer: Cash Price |
$980.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,358.00
|
| Rate for Payer: Cigna of WY Commercial |
$1,372.00
|
| Rate for Payer: Entrust Commercial |
$1,330.00
|
| Rate for Payer: First Choice Health Commercial |
$1,330.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,330.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$924.00
|
| Rate for Payer: HealthUtah PPO |
$1,400.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,358.00
|
| Rate for Payer: Multiplan Medicare/VA |
$877.80
|
| Rate for Payer: One Health Plan of WY PPO |
$1,372.00
|
| Rate for Payer: PacificSource Commercial |
$1,260.00
|
| Rate for Payer: PHCS PPO |
$1,372.00
|
| Rate for Payer: Three Rivers PPO |
$1,050.00
|
| Rate for Payer: TriWest Veterans Administration |
$924.00
|
| Rate for Payer: United Healthcare Commercial |
$1,218.00
|
| Rate for Payer: United Healthcare Medicare |
$924.00
|
| Rate for Payer: WINHealth Partners Commercial |
$1,330.00
|
| Rate for Payer: Wise Provider Network Commercial |
$1,330.00
|
|
