|
Trauma to the skin, subcutaneous tissue and breast without MCC
|
Facility
|
IP
|
$60,800.00
|
|
|
Service Code
|
MSDRG 605
|
| 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
|
|
|
TRAVEL
|
Facility
|
IP
|
$9.48
|
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$4.74 |
| Max. Negotiated Rate |
$4.74 |
| Rate for Payer: SELF PAY |
$4.74
|
|
|
TRAVEL WP
|
Facility
|
IP
|
$9.48
|
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$4.74 |
| Max. Negotiated Rate |
$4.74 |
| Rate for Payer: SELF PAY |
$4.74
|
|
|
TREPONEMA PALLIUM ANITBODY
|
Facility
|
IP
|
$63.00
|
|
|
Service Code
|
CPT 86780
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$31.50 |
| Max. Negotiated Rate |
$31.50 |
| Rate for Payer: SELF PAY |
$31.50
|
|
|
TRIGLYCERIDES
|
Facility
|
IP
|
$34.00
|
|
|
Service Code
|
CPT 84478
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.00 |
| Max. Negotiated Rate |
$17.00 |
| Rate for Payer: SELF PAY |
$17.00
|
|
|
TRIPLE ANTIBIOTIC OINTMENT
|
Facility
|
IP
|
$0.14
|
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: SELF PAY |
$0.07
|
|
|
TRIPLE ANTIBIOTIC OINTMENT WP
|
Facility
|
IP
|
$0.14
|
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: SELF PAY |
$0.07
|
|
|
TROPONIN T
|
Facility
|
IP
|
$149.00
|
|
|
Service Code
|
CPT 84484
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$74.50 |
| Max. Negotiated Rate |
$74.50 |
| Rate for Payer: SELF PAY |
$74.50
|
|
|
TSH
|
Facility
|
IP
|
$197.69
|
|
|
Service Code
|
CPT 84443
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$98.84 |
| Max. Negotiated Rate |
$98.84 |
| Rate for Payer: SELF PAY |
$98.84
|
|
|
TSH 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
|
|
|
TUBIGRIP BANDAGE B
|
Facility
|
IP
|
$8.46
|
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$4.23 |
| Max. Negotiated Rate |
$4.23 |
| Rate for Payer: SELF PAY |
$4.23
|
|
|
TUBIGRIP BANDAGE B WP
|
Facility
|
IP
|
$8.46
|
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$4.23 |
| Max. Negotiated Rate |
$4.23 |
| Rate for Payer: SELF PAY |
$4.23
|
|
|
TUBIGRIP BANDAGE C
|
Facility
|
IP
|
$6.02
|
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$3.01 |
| Max. Negotiated Rate |
$3.01 |
| Rate for Payer: SELF PAY |
$3.01
|
|
|
TUBIGRIP BANDAGE C WP
|
Facility
|
IP
|
$6.02
|
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$3.01 |
| Max. Negotiated Rate |
$3.01 |
| Rate for Payer: SELF PAY |
$3.01
|
|
|
TUBIGRIP BANDAGE D
|
Facility
|
IP
|
$7.32
|
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$3.66 |
| Max. Negotiated Rate |
$3.66 |
| Rate for Payer: SELF PAY |
$3.66
|
|
|
TUBIGRIP BANDAGE D WP
|
Facility
|
IP
|
$7.32
|
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$3.66 |
| Max. Negotiated Rate |
$3.66 |
| Rate for Payer: SELF PAY |
$3.66
|
|
|
TUBIGRIP BANDAGE E
|
Facility
|
IP
|
$8.52
|
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$4.26 |
| Max. Negotiated Rate |
$4.26 |
| Rate for Payer: SELF PAY |
$4.26
|
|
|
TUBIGRIP BANDAGE E WP
|
Facility
|
IP
|
$8.52
|
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$4.26 |
| Max. Negotiated Rate |
$4.26 |
| Rate for Payer: SELF PAY |
$4.26
|
|
|
TUBIGRIP BANDAGE F
|
Facility
|
IP
|
$9.28
|
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$4.64 |
| Max. Negotiated Rate |
$4.64 |
| Rate for Payer: SELF PAY |
$4.64
|
|
|
TUBIGRIP BANDAGE F WP
|
Facility
|
IP
|
$9.28
|
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$4.64 |
| Max. Negotiated Rate |
$4.64 |
| Rate for Payer: SELF PAY |
$4.64
|
|
|
TUBIGRIP BANDAGE G
|
Facility
|
IP
|
$10.94
|
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$5.47 |
| Max. Negotiated Rate |
$5.47 |
| Rate for Payer: SELF PAY |
$5.47
|
|
|
TUBIGRIP BANDAGE G WP
|
Facility
|
IP
|
$10.94
|
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$5.47 |
| Max. Negotiated Rate |
$5.47 |
| Rate for Payer: SELF PAY |
$5.47
|
|
|
TUBING CAP
|
Facility
|
IP
|
$52.20
|
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$26.10 |
| Max. Negotiated Rate |
$26.10 |
| Rate for Payer: SELF PAY |
$26.10
|
|
|
TUBING CAP WP
|
Facility
|
IP
|
$4.64
|
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$2.32 |
| Max. Negotiated Rate |
$2.32 |
| Rate for Payer: SELF PAY |
$2.32
|
|
|
TUBING CONNECTOR 5IN1
|
Facility
|
IP
|
$1.52
|
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$0.76 |
| Max. Negotiated Rate |
$0.76 |
| Rate for Payer: SELF PAY |
$0.76
|
|
