|
SUCTION TUBING
|
Facility
|
IP
|
$0.90
|
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: SELF PAY |
$0.45
|
|
|
SUCTION TUBING CONNECTOR
|
Facility
|
IP
|
$0.38
|
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: SELF PAY |
$0.19
|
|
|
SUCTION TUBING WP
|
Facility
|
IP
|
$0.90
|
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: SELF PAY |
$0.45
|
|
|
SURGICAL CLIPPER BLADE
|
Facility
|
IP
|
$9.16
|
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$4.58 |
| Max. Negotiated Rate |
$4.58 |
| Rate for Payer: SELF PAY |
$4.58
|
|
|
SURGICAL CLIPPER BLADE WP
|
Facility
|
IP
|
$9.16
|
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$4.58 |
| Max. Negotiated Rate |
$4.58 |
| Rate for Payer: SELF PAY |
$4.58
|
|
|
SURGICAL MASK
|
Facility
|
IP
|
$13.10
|
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$6.55 |
| Max. Negotiated Rate |
$6.55 |
| Rate for Payer: SELF PAY |
$6.55
|
|
|
SURGICAL MASK WITH EYE SHIELD
|
Facility
|
IP
|
$2.48
|
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$1.24 |
| Rate for Payer: SELF PAY |
$1.24
|
|
|
SURGICAL MASK WP
|
Facility
|
IP
|
$13.10
|
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$6.55 |
| Max. Negotiated Rate |
$6.55 |
| Rate for Payer: SELF PAY |
$6.55
|
|
|
SURGINET DRESSING
|
Facility
|
IP
|
$0.74
|
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: SELF PAY |
$0.37
|
|
|
SUTURE REMOVAL TRAY
|
Facility
|
IP
|
$2.32
|
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1.16 |
| Max. Negotiated Rate |
$1.16 |
| Rate for Payer: SELF PAY |
$1.16
|
|
|
SUTURE REMOVAL TRAY WP
|
Facility
|
IP
|
$2.32
|
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1.16 |
| Max. Negotiated Rate |
$1.16 |
| Rate for Payer: SELF PAY |
$1.16
|
|
|
SVN NEBULIZER KIT
|
Facility
|
IP
|
$1.54
|
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$0.77 |
| Max. Negotiated Rate |
$0.77 |
| Rate for Payer: SELF PAY |
$0.77
|
|
|
SVN NEBULIZER KIT WP
|
Facility
|
IP
|
$1.54
|
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$0.77 |
| Max. Negotiated Rate |
$0.77 |
| Rate for Payer: SELF PAY |
$0.77
|
|
|
Swallowing Treatment-1 U
|
Facility
|
IP
|
$127.00
|
|
|
Service Code
|
CPT 92526
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$63.50 |
| Max. Negotiated Rate |
$63.50 |
| Rate for Payer: SELF PAY |
$63.50
|
|
|
Syncope and collapse
|
Facility
|
IP
|
$60,800.00
|
|
|
Service Code
|
MSDRG 312
|
| Min. Negotiated Rate |
$24,374.11 |
| Max. Negotiated Rate |
$27,082.35 |
| Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS |
$27,082.35
|
| Rate for Payer: American Health Plans Medicare Advantage |
$27,082.35
|
| Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage |
$27,082.35
|
| Rate for Payer: CIGNA Medicare Advantage |
$27,082.35
|
| Rate for Payer: HealthChoice Utah Medicare Advantage |
$27,082.35
|
| Rate for Payer: Humana Medicare Advantage |
$27,082.35
|
| Rate for Payer: Medicare |
$27,082.35
|
| Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL |
$27,082.35
|
| Rate for Payer: MOLINA MEDICARE |
$27,082.35
|
| Rate for Payer: Pacific Source Medicare Advantage |
$27,082.35
|
| Rate for Payer: Select Health Medicare Advantage |
$27,082.35
|
| Rate for Payer: SELF PAY |
$30,400.00
|
| Rate for Payer: Tricare West Military |
$24,374.11
|
|
|
T3
|
Facility
|
IP
|
$14.18
|
|
|
Service Code
|
CPT 84480
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$7.09 |
| Max. Negotiated Rate |
$7.09 |
| Rate for Payer: SELF PAY |
$7.09
|
|
|
T3 FREE
|
Facility
|
IP
|
$25.00
|
|
|
Service Code
|
CPT 84481
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.50 |
| Max. Negotiated Rate |
$12.50 |
| Rate for Payer: SELF PAY |
$12.50
|
|
|
T4
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
CPT 84479
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$7.50 |
| Max. Negotiated Rate |
$7.50 |
| Rate for Payer: SELF PAY |
$7.50
|
|
|
T4 FREE
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
CPT 84439
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$7.50 |
| Max. Negotiated Rate |
$7.50 |
| Rate for Payer: SELF PAY |
$7.50
|
|
|
T7
|
Facility
|
IP
|
$6.87
|
|
|
Service Code
|
CPT 84436
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$3.44 |
| Max. Negotiated Rate |
$3.44 |
| Rate for Payer: SELF PAY |
$3.44
|
|
|
Tampon
|
Facility
|
IP
|
$1.06
|
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: SELF PAY |
$0.53
|
|
|
TAPE DURAPORE 1x10
|
Facility
|
IP
|
$1.60
|
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$0.80 |
| Rate for Payer: SELF PAY |
$0.80
|
|
|
TAPE DURAPORE 1X10 WP
|
Facility
|
IP
|
$1.60
|
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$0.80 |
| Rate for Payer: SELF PAY |
$0.80
|
|
|
TAPE MICROPORE 1
|
Facility
|
IP
|
$0.88
|
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$0.44 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: SELF PAY |
$0.44
|
|
|
TAPE MICROPORE 1 WP
|
Facility
|
IP
|
$0.88
|
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$0.44 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: SELF PAY |
$0.44
|
|
