|
DIAGNOSTIC ARTHROSCOPY SHOULDER +- SYNOVIAL BX
|
Professional
|
Both
|
$2,424.00
|
|
|
Service Code
|
HCPCS 29805 80
|
| Hospital Charge Code |
29805
|
| Min. Negotiated Rate |
$388.32 |
| Max. Negotiated Rate |
$2,424.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,375.52
|
| Rate for Payer: Aetna of WY Medicare |
$456.85
|
| Rate for Payer: Beech Street Commercial |
$2,302.80
|
| Rate for Payer: Cash Price |
$1,696.80
|
| Rate for Payer: Cash Price |
$1,696.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,351.28
|
| Rate for Payer: Cigna of WY Commercial |
$2,375.52
|
| Rate for Payer: First Choice Health Commercial |
$2,181.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,302.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$456.85
|
| Rate for Payer: HealthUtah PPO |
$2,424.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,351.28
|
| Rate for Payer: Multiplan Medicare/VA |
$388.32
|
| Rate for Payer: One Health Plan of WY PPO |
$2,375.52
|
| Rate for Payer: PacificSource Commercial |
$2,181.60
|
| Rate for Payer: PHCS PPO |
$2,302.80
|
| Rate for Payer: Three Rivers PPO |
$1,818.00
|
| Rate for Payer: TriWest Veterans Administration |
$456.85
|
| Rate for Payer: United Healthcare Commercial |
$2,108.88
|
| Rate for Payer: United Healthcare Medicare |
$456.85
|
| Rate for Payer: WINHealth Partners Commercial |
$2,060.40
|
|
|
DIAGNOSTIC ARTHROSCOPY SHOULDER +- SYNOVIAL BX
|
Professional
|
Both
|
$2,424.00
|
|
|
Service Code
|
HCPCS 29805
|
| Hospital Charge Code |
29805
|
| Min. Negotiated Rate |
$388.32 |
| Max. Negotiated Rate |
$2,424.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,375.52
|
| Rate for Payer: Aetna of WY Medicare |
$456.85
|
| Rate for Payer: Beech Street Commercial |
$2,302.80
|
| Rate for Payer: Cash Price |
$1,696.80
|
| Rate for Payer: Cash Price |
$1,696.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,351.28
|
| Rate for Payer: Cigna of WY Commercial |
$2,375.52
|
| Rate for Payer: First Choice Health Commercial |
$2,181.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,302.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$456.85
|
| Rate for Payer: HealthUtah PPO |
$2,424.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,351.28
|
| Rate for Payer: Multiplan Medicare/VA |
$388.32
|
| Rate for Payer: One Health Plan of WY PPO |
$2,375.52
|
| Rate for Payer: PacificSource Commercial |
$2,181.60
|
| Rate for Payer: PHCS PPO |
$2,302.80
|
| Rate for Payer: Three Rivers PPO |
$1,818.00
|
| Rate for Payer: TriWest Veterans Administration |
$456.85
|
| Rate for Payer: United Healthcare Commercial |
$2,108.88
|
| Rate for Payer: United Healthcare Medicare |
$456.85
|
| Rate for Payer: WINHealth Partners Commercial |
$2,060.40
|
|
|
DIAGNOSTIC BONE MARROW ASPIRATION
|
Professional
|
Both
|
$942.00
|
|
|
Service Code
|
HCPCS 38220 80
|
| Hospital Charge Code |
38220
|
| Min. Negotiated Rate |
$54.66 |
| Max. Negotiated Rate |
$942.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$923.16
|
| Rate for Payer: Aetna of WY Medicare |
$64.31
|
| Rate for Payer: Beech Street Commercial |
$894.90
|
| Rate for Payer: Cash Price |
$659.40
|
| Rate for Payer: Cash Price |
$659.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$913.74
|
| Rate for Payer: Cigna of WY Commercial |
$923.16
|
| Rate for Payer: First Choice Health Commercial |
$847.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$894.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$64.31
|
| Rate for Payer: HealthUtah PPO |
$942.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$913.74
|
| Rate for Payer: Multiplan Medicare/VA |
$54.66
|
| Rate for Payer: One Health Plan of WY PPO |
$923.16
|
| Rate for Payer: PacificSource Commercial |
$847.80
|
| Rate for Payer: PHCS PPO |
$894.90
|
| Rate for Payer: Three Rivers PPO |
$706.50
|
| Rate for Payer: TriWest Veterans Administration |
$64.31
|
| Rate for Payer: United Healthcare Commercial |
$819.54
|
| Rate for Payer: United Healthcare Medicare |
$64.31
|
| Rate for Payer: WINHealth Partners Commercial |
$800.70
|
|
|
DIAGNOSTIC BONE MARROW ASPIRATION
|
Professional
|
Both
|
$942.00
|
|
|
Service Code
|
HCPCS 38220
|
| Hospital Charge Code |
38220
|
| Min. Negotiated Rate |
$54.66 |
| Max. Negotiated Rate |
$942.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$923.16
|
| Rate for Payer: Aetna of WY Medicare |
$64.31
|
| Rate for Payer: Beech Street Commercial |
$894.90
|
| Rate for Payer: Cash Price |
$659.40
|
| Rate for Payer: Cash Price |
$659.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$913.74
|
| Rate for Payer: Cigna of WY Commercial |
$923.16
|
| Rate for Payer: First Choice Health Commercial |
$847.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$894.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$64.31
|
| Rate for Payer: HealthUtah PPO |
$942.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$913.74
|
| Rate for Payer: Multiplan Medicare/VA |
$54.66
|
| Rate for Payer: One Health Plan of WY PPO |
$923.16
|
| Rate for Payer: PacificSource Commercial |
$847.80
|
| Rate for Payer: PHCS PPO |
$894.90
|
| Rate for Payer: Three Rivers PPO |
$706.50
|
| Rate for Payer: TriWest Veterans Administration |
$64.31
|
| Rate for Payer: United Healthcare Commercial |
$819.54
|
| Rate for Payer: United Healthcare Medicare |
$64.31
|
| Rate for Payer: WINHealth Partners Commercial |
$800.70
|
|
|
DIAGNOSTIC LUMBAR SPINAL PUNCTURE
|
Professional
|
Both
|
$321.00
|
|
|
Service Code
|
HCPCS 62270
|
| Hospital Charge Code |
62270
|
| Min. Negotiated Rate |
$50.92 |
| Max. Negotiated Rate |
$321.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$314.58
|
| Rate for Payer: Aetna of WY Medicare |
$59.91
|
| Rate for Payer: Beech Street Commercial |
$304.95
|
| Rate for Payer: Cash Price |
$224.70
|
| Rate for Payer: Cash Price |
$224.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$311.37
|
| Rate for Payer: Cigna of WY Commercial |
$314.58
|
| Rate for Payer: First Choice Health Commercial |
$288.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$304.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$59.91
|
| Rate for Payer: HealthUtah PPO |
$321.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$311.37
|
| Rate for Payer: Multiplan Medicare/VA |
$50.92
|
| Rate for Payer: One Health Plan of WY PPO |
$314.58
|
| Rate for Payer: PacificSource Commercial |
$288.90
|
| Rate for Payer: PHCS PPO |
$304.95
|
| Rate for Payer: Three Rivers PPO |
$240.75
|
| Rate for Payer: TriWest Veterans Administration |
$59.91
|
| Rate for Payer: United Healthcare Commercial |
$279.27
|
| Rate for Payer: United Healthcare Medicare |
$59.91
|
| Rate for Payer: WINHealth Partners Commercial |
$272.85
|
|
|
DIAPHRAGM/CERVICAL CAP FITTING W/INSTRUCTIONS
|
Professional
|
Both
|
$208.00
|
|
|
Service Code
|
HCPCS 57170
|
| Hospital Charge Code |
57170
|
| Min. Negotiated Rate |
$38.16 |
| Max. Negotiated Rate |
$208.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$203.84
|
| Rate for Payer: Aetna of WY Medicare |
$44.89
|
| Rate for Payer: Beech Street Commercial |
$197.60
|
| Rate for Payer: Cash Price |
$145.60
|
| Rate for Payer: Cash Price |
$145.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$201.76
|
| Rate for Payer: Cigna of WY Commercial |
$203.84
|
| Rate for Payer: First Choice Health Commercial |
$187.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$197.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$44.89
|
| Rate for Payer: HealthUtah PPO |
$208.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$201.76
|
| Rate for Payer: Multiplan Medicare/VA |
$38.16
|
| Rate for Payer: One Health Plan of WY PPO |
$203.84
|
| Rate for Payer: PacificSource Commercial |
$187.20
|
| Rate for Payer: PHCS PPO |
$197.60
|
| Rate for Payer: Three Rivers PPO |
$156.00
|
| Rate for Payer: TriWest Veterans Administration |
$44.89
|
| Rate for Payer: United Healthcare Commercial |
$180.96
|
| Rate for Payer: United Healthcare Medicare |
$44.89
|
| Rate for Payer: WINHealth Partners Commercial |
$176.80
|
|
|
DIATRIZOATE MEGLUMINE 30 % URETHRAL SOLUTION [11706]
|
Facility
|
IP
|
$0.74
|
|
|
Service Code
|
HCPCS Q9958
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$0.74 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.73
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.71
|
| Rate for Payer: Altius Commercial |
$0.71
|
| Rate for Payer: Beech Street Commercial |
$0.73
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.61
|
| Rate for Payer: Cash Price |
$0.52
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.72
|
| Rate for Payer: Cigna of WY Commercial |
$0.73
|
| Rate for Payer: Entrust Commercial |
$0.70
|
| Rate for Payer: First Choice Health Commercial |
$0.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.49
|
| Rate for Payer: HealthUtah PPO |
$0.74
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.72
|
| Rate for Payer: Multiplan Medicare/VA |
$0.46
|
| Rate for Payer: One Health Plan of WY PPO |
$0.73
|
| Rate for Payer: PacificSource Commercial |
$0.67
|
| Rate for Payer: PHCS PPO |
$0.73
|
| Rate for Payer: Three Rivers PPO |
$0.56
|
| Rate for Payer: TriWest Veterans Administration |
$0.49
|
| Rate for Payer: United Healthcare Commercial |
$0.64
|
| Rate for Payer: United Healthcare Medicare |
$0.49
|
| Rate for Payer: WINHealth Partners Commercial |
$0.70
|
| Rate for Payer: Wise Provider Network Commercial |
$0.70
|
|
|
DIATRIZOATE MEGLUMINE 30 % URETHRAL SOLUTION [11706]
|
Facility
|
OP
|
$0.74
|
|
|
Service Code
|
HCPCS Q9958
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$0.74 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.73
|
| Rate for Payer: Aetna of WY Medicare |
$0.49
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.71
|
| Rate for Payer: Altius Commercial |
$0.71
|
| Rate for Payer: Beech Street Commercial |
$0.73
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.61
|
| Rate for Payer: Cash Price |
$0.52
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.72
|
| Rate for Payer: Cigna of WY Commercial |
$0.73
|
| Rate for Payer: Entrust Commercial |
$0.70
|
| Rate for Payer: First Choice Health Commercial |
$0.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.43
|
| Rate for Payer: HealthUtah PPO |
$0.74
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.72
|
| Rate for Payer: Multiplan Medicare/VA |
$0.41
|
| Rate for Payer: One Health Plan of WY PPO |
$0.73
|
| Rate for Payer: PacificSource Commercial |
$0.67
|
| Rate for Payer: PHCS PPO |
$0.73
|
| Rate for Payer: Three Rivers PPO |
$0.56
|
| Rate for Payer: TriWest Veterans Administration |
$0.43
|
| Rate for Payer: United Healthcare Commercial |
$0.64
|
| Rate for Payer: United Healthcare Medicare |
$0.43
|
| Rate for Payer: WINHealth Partners Commercial |
$0.73
|
| Rate for Payer: Wise Provider Network Commercial |
$0.70
|
|
|
DIATRIZOATE MEGLUMINE-DIATRIZOATE SODIUM 66 %-10 % ORAL SOLUTION [3636]
|
Facility
|
IP
|
$3.08
|
|
|
Service Code
|
HCPCS Q9963
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.93 |
| Max. Negotiated Rate |
$3.08 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3.02
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.96
|
| Rate for Payer: Altius Commercial |
$2.96
|
| Rate for Payer: Beech Street Commercial |
$3.02
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.53
|
| Rate for Payer: Cash Price |
$2.15
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.99
|
| Rate for Payer: Cigna of WY Commercial |
$3.02
|
| Rate for Payer: Entrust Commercial |
$2.93
|
| Rate for Payer: First Choice Health Commercial |
$2.93
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.93
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2.03
|
| Rate for Payer: HealthUtah PPO |
$3.08
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.99
|
| Rate for Payer: Multiplan Medicare/VA |
$1.93
|
| Rate for Payer: One Health Plan of WY PPO |
$3.02
|
| Rate for Payer: PacificSource Commercial |
$2.77
|
| Rate for Payer: PHCS PPO |
$3.02
|
| Rate for Payer: Three Rivers PPO |
$2.31
|
| Rate for Payer: TriWest Veterans Administration |
$2.03
|
| Rate for Payer: United Healthcare Commercial |
$2.68
|
| Rate for Payer: United Healthcare Medicare |
$2.03
|
| Rate for Payer: WINHealth Partners Commercial |
$2.93
|
| Rate for Payer: Wise Provider Network Commercial |
$2.93
|
|
|
DIATRIZOATE MEGLUMINE-DIATRIZOATE SODIUM 66 %-10 % ORAL SOLUTION [3636]
|
Facility
|
OP
|
$3.08
|
|
|
Service Code
|
HCPCS Q9963
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$3.08 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3.02
|
| Rate for Payer: Aetna of WY Medicare |
$2.03
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.96
|
| Rate for Payer: Altius Commercial |
$2.96
|
| Rate for Payer: Beech Street Commercial |
$3.02
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.53
|
| Rate for Payer: Cash Price |
$2.15
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.99
|
| Rate for Payer: Cigna of WY Commercial |
$3.02
|
| Rate for Payer: Entrust Commercial |
$2.93
|
| Rate for Payer: First Choice Health Commercial |
$2.93
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.93
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.79
|
| Rate for Payer: HealthUtah PPO |
$3.08
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.99
|
| Rate for Payer: Multiplan Medicare/VA |
$1.70
|
| Rate for Payer: One Health Plan of WY PPO |
$3.02
|
| Rate for Payer: PacificSource Commercial |
$2.77
|
| Rate for Payer: PHCS PPO |
$3.02
|
| Rate for Payer: Three Rivers PPO |
$2.31
|
| Rate for Payer: TriWest Veterans Administration |
$1.79
|
| Rate for Payer: United Healthcare Commercial |
$2.68
|
| Rate for Payer: United Healthcare Medicare |
$1.79
|
| Rate for Payer: WINHealth Partners Commercial |
$3.02
|
| Rate for Payer: Wise Provider Network Commercial |
$2.93
|
|
|
DIAZEPAM 5 MG/ML INJECTION SOLUTION [2738]
|
Facility
|
IP
|
$34.29
|
|
|
Service Code
|
HCPCS J3360
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.50 |
| Max. Negotiated Rate |
$34.29 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$33.60
|
| Rate for Payer: Altius Auto/Workers Compensation |
$32.92
|
| Rate for Payer: Altius Commercial |
$32.92
|
| Rate for Payer: Beech Street Commercial |
$33.60
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$28.15
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$33.26
|
| Rate for Payer: Cigna of WY Commercial |
$33.60
|
| Rate for Payer: Entrust Commercial |
$32.58
|
| Rate for Payer: First Choice Health Commercial |
$32.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$32.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$22.63
|
| Rate for Payer: HealthUtah PPO |
$34.29
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$33.26
|
| Rate for Payer: Multiplan Medicare/VA |
$21.50
|
| Rate for Payer: One Health Plan of WY PPO |
$33.60
|
| Rate for Payer: PacificSource Commercial |
$30.86
|
| Rate for Payer: PHCS PPO |
$33.60
|
| Rate for Payer: Three Rivers PPO |
$25.72
|
| Rate for Payer: TriWest Veterans Administration |
$22.63
|
| Rate for Payer: United Healthcare Commercial |
$29.83
|
| Rate for Payer: United Healthcare Medicare |
$22.63
|
| Rate for Payer: WINHealth Partners Commercial |
$32.58
|
| Rate for Payer: Wise Provider Network Commercial |
$32.58
|
|
|
DIAZEPAM 5 MG/ML INJECTION SOLUTION [2738]
|
Facility
|
OP
|
$34.29
|
|
|
Service Code
|
HCPCS J3360
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.89 |
| Max. Negotiated Rate |
$34.29 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$33.60
|
| Rate for Payer: Aetna of WY Medicare |
$22.63
|
| Rate for Payer: Altius Auto/Workers Compensation |
$32.92
|
| Rate for Payer: Altius Commercial |
$32.92
|
| Rate for Payer: Beech Street Commercial |
$33.60
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$28.15
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$33.26
|
| Rate for Payer: Cigna of WY Commercial |
$33.60
|
| Rate for Payer: Entrust Commercial |
$32.58
|
| Rate for Payer: First Choice Health Commercial |
$32.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$32.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$19.89
|
| Rate for Payer: HealthUtah PPO |
$34.29
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$33.26
|
| Rate for Payer: Multiplan Medicare/VA |
$18.89
|
| Rate for Payer: One Health Plan of WY PPO |
$33.60
|
| Rate for Payer: PacificSource Commercial |
$30.86
|
| Rate for Payer: PHCS PPO |
$33.60
|
| Rate for Payer: Three Rivers PPO |
$25.72
|
| Rate for Payer: TriWest Veterans Administration |
$19.89
|
| Rate for Payer: United Healthcare Commercial |
$29.83
|
| Rate for Payer: United Healthcare Medicare |
$19.89
|
| Rate for Payer: WINHealth Partners Commercial |
$33.60
|
| Rate for Payer: Wise Provider Network Commercial |
$32.58
|
|
|
DIAZEPAM 5 MG/ML INJECTION SYRINGE [25511]
|
Facility
|
OP
|
$51.92
|
|
|
Service Code
|
HCPCS J3360
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.61 |
| Max. Negotiated Rate |
$51.92 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$50.88
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$50.86
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$55.94
|
| Rate for Payer: Aetna of WY Medicare |
$34.27
|
| Rate for Payer: Aetna of WY Medicare |
$37.67
|
| Rate for Payer: Aetna of WY Medicare |
$34.25
|
| Rate for Payer: Altius Auto/Workers Compensation |
$49.84
|
| Rate for Payer: Altius Auto/Workers Compensation |
$49.82
|
| Rate for Payer: Altius Auto/Workers Compensation |
$54.80
|
| Rate for Payer: Altius Commercial |
$49.84
|
| Rate for Payer: Altius Commercial |
$54.80
|
| Rate for Payer: Altius Commercial |
$49.82
|
| Rate for Payer: Beech Street Commercial |
$50.88
|
| Rate for Payer: Beech Street Commercial |
$55.94
|
| Rate for Payer: Beech Street Commercial |
$50.86
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$42.63
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$42.61
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$46.86
|
| Rate for Payer: Cash Price |
$36.34
|
| Rate for Payer: Cash Price |
$36.33
|
| Rate for Payer: Cash Price |
$39.95
|
| Rate for Payer: ChoiceCare Network Commercial |
$50.36
|
| Rate for Payer: ChoiceCare Network Commercial |
$55.37
|
| Rate for Payer: ChoiceCare Network Commercial |
$50.34
|
| Rate for Payer: Cigna of WY Commercial |
$55.94
|
| Rate for Payer: Cigna of WY Commercial |
$50.86
|
| Rate for Payer: Cigna of WY Commercial |
$50.88
|
| Rate for Payer: Entrust Commercial |
$54.23
|
| Rate for Payer: Entrust Commercial |
$49.32
|
| Rate for Payer: Entrust Commercial |
$49.30
|
| Rate for Payer: First Choice Health Commercial |
$49.32
|
| Rate for Payer: First Choice Health Commercial |
$49.30
|
| Rate for Payer: First Choice Health Commercial |
$54.23
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$49.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$54.23
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$49.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$30.11
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$30.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$33.11
|
| Rate for Payer: HealthUtah PPO |
$51.90
|
| Rate for Payer: HealthUtah PPO |
$57.08
|
| Rate for Payer: HealthUtah PPO |
$51.92
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$55.37
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$50.34
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$50.36
|
| Rate for Payer: Multiplan Medicare/VA |
$28.60
|
| Rate for Payer: Multiplan Medicare/VA |
$28.61
|
| Rate for Payer: Multiplan Medicare/VA |
$31.45
|
| Rate for Payer: One Health Plan of WY PPO |
$50.86
|
| Rate for Payer: One Health Plan of WY PPO |
$55.94
|
| Rate for Payer: One Health Plan of WY PPO |
$50.88
|
| Rate for Payer: PacificSource Commercial |
$51.37
|
| Rate for Payer: PacificSource Commercial |
$46.73
|
| Rate for Payer: PacificSource Commercial |
$46.71
|
| Rate for Payer: PHCS PPO |
$50.88
|
| Rate for Payer: PHCS PPO |
$50.86
|
| Rate for Payer: PHCS PPO |
$55.94
|
| Rate for Payer: Three Rivers PPO |
$38.94
|
| Rate for Payer: Three Rivers PPO |
$38.92
|
| Rate for Payer: Three Rivers PPO |
$42.81
|
| Rate for Payer: TriWest Veterans Administration |
$33.11
|
| Rate for Payer: TriWest Veterans Administration |
$30.11
|
| Rate for Payer: TriWest Veterans Administration |
$30.10
|
| Rate for Payer: United Healthcare Commercial |
$45.15
|
| Rate for Payer: United Healthcare Commercial |
$45.17
|
| Rate for Payer: United Healthcare Commercial |
$49.66
|
| Rate for Payer: United Healthcare Medicare |
$33.11
|
| Rate for Payer: United Healthcare Medicare |
$30.10
|
| Rate for Payer: United Healthcare Medicare |
$30.11
|
| Rate for Payer: WINHealth Partners Commercial |
$55.94
|
| Rate for Payer: WINHealth Partners Commercial |
$50.86
|
| Rate for Payer: WINHealth Partners Commercial |
$50.88
|
| Rate for Payer: Wise Provider Network Commercial |
$49.30
|
| Rate for Payer: Wise Provider Network Commercial |
$54.23
|
| Rate for Payer: Wise Provider Network Commercial |
$49.32
|
|
|
DIAZEPAM 5 MG/ML INJECTION SYRINGE [25511]
|
Facility
|
IP
|
$51.90
|
|
|
Service Code
|
HCPCS J3360
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.54 |
| Max. Negotiated Rate |
$51.90 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$50.86
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$50.88
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$55.94
|
| Rate for Payer: Altius Auto/Workers Compensation |
$49.82
|
| Rate for Payer: Altius Auto/Workers Compensation |
$49.84
|
| Rate for Payer: Altius Auto/Workers Compensation |
$54.80
|
| Rate for Payer: Altius Commercial |
$49.84
|
| Rate for Payer: Altius Commercial |
$49.82
|
| Rate for Payer: Altius Commercial |
$54.80
|
| Rate for Payer: Beech Street Commercial |
$55.94
|
| Rate for Payer: Beech Street Commercial |
$50.88
|
| Rate for Payer: Beech Street Commercial |
$50.86
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$42.61
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$46.86
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$42.63
|
| Rate for Payer: Cash Price |
$36.34
|
| Rate for Payer: Cash Price |
$36.33
|
| Rate for Payer: Cash Price |
$39.95
|
| Rate for Payer: ChoiceCare Network Commercial |
$50.34
|
| Rate for Payer: ChoiceCare Network Commercial |
$55.37
|
| Rate for Payer: ChoiceCare Network Commercial |
$50.36
|
| Rate for Payer: Cigna of WY Commercial |
$50.88
|
| Rate for Payer: Cigna of WY Commercial |
$55.94
|
| Rate for Payer: Cigna of WY Commercial |
$50.86
|
| Rate for Payer: Entrust Commercial |
$54.23
|
| Rate for Payer: Entrust Commercial |
$49.30
|
| Rate for Payer: Entrust Commercial |
$49.32
|
| Rate for Payer: First Choice Health Commercial |
$49.32
|
| Rate for Payer: First Choice Health Commercial |
$54.23
|
| Rate for Payer: First Choice Health Commercial |
$49.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$49.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$54.23
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$49.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$34.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$34.27
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$37.67
|
| Rate for Payer: HealthUtah PPO |
$51.90
|
| Rate for Payer: HealthUtah PPO |
$51.92
|
| Rate for Payer: HealthUtah PPO |
$57.08
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$55.37
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$50.36
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$50.34
|
| Rate for Payer: Multiplan Medicare/VA |
$35.79
|
| Rate for Payer: Multiplan Medicare/VA |
$32.54
|
| Rate for Payer: Multiplan Medicare/VA |
$32.55
|
| Rate for Payer: One Health Plan of WY PPO |
$50.86
|
| Rate for Payer: One Health Plan of WY PPO |
$50.88
|
| Rate for Payer: One Health Plan of WY PPO |
$55.94
|
| Rate for Payer: PacificSource Commercial |
$51.37
|
| Rate for Payer: PacificSource Commercial |
$46.71
|
| Rate for Payer: PacificSource Commercial |
$46.73
|
| Rate for Payer: PHCS PPO |
$50.88
|
| Rate for Payer: PHCS PPO |
$50.86
|
| Rate for Payer: PHCS PPO |
$55.94
|
| Rate for Payer: Three Rivers PPO |
$38.94
|
| Rate for Payer: Three Rivers PPO |
$38.92
|
| Rate for Payer: Three Rivers PPO |
$42.81
|
| Rate for Payer: TriWest Veterans Administration |
$34.27
|
| Rate for Payer: TriWest Veterans Administration |
$34.25
|
| Rate for Payer: TriWest Veterans Administration |
$37.67
|
| Rate for Payer: United Healthcare Commercial |
$45.15
|
| Rate for Payer: United Healthcare Commercial |
$49.66
|
| Rate for Payer: United Healthcare Commercial |
$45.17
|
| Rate for Payer: United Healthcare Medicare |
$34.25
|
| Rate for Payer: United Healthcare Medicare |
$37.67
|
| Rate for Payer: United Healthcare Medicare |
$34.27
|
| Rate for Payer: WINHealth Partners Commercial |
$49.32
|
| Rate for Payer: WINHealth Partners Commercial |
$49.30
|
| Rate for Payer: WINHealth Partners Commercial |
$54.23
|
| Rate for Payer: Wise Provider Network Commercial |
$54.23
|
| Rate for Payer: Wise Provider Network Commercial |
$49.30
|
| Rate for Payer: Wise Provider Network Commercial |
$49.32
|
|
|
DIAZEPAM 5 MG TABLET [20121]
|
Facility
|
IP
|
$0.27
|
|
|
Service Code
|
NDC 5107928501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.26
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.26
|
| Rate for Payer: Altius Commercial |
$0.26
|
| Rate for Payer: Beech Street Commercial |
$0.26
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.22
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.26
|
| Rate for Payer: Cigna of WY Commercial |
$0.26
|
| Rate for Payer: Entrust Commercial |
$0.26
|
| Rate for Payer: First Choice Health Commercial |
$0.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.18
|
| Rate for Payer: HealthUtah PPO |
$0.27
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.26
|
| Rate for Payer: Multiplan Medicare/VA |
$0.17
|
| Rate for Payer: One Health Plan of WY PPO |
$0.26
|
| Rate for Payer: PacificSource Commercial |
$0.24
|
| Rate for Payer: PHCS PPO |
$0.26
|
| Rate for Payer: Three Rivers PPO |
$0.20
|
| Rate for Payer: TriWest Veterans Administration |
$0.18
|
| Rate for Payer: United Healthcare Commercial |
$0.23
|
| Rate for Payer: United Healthcare Medicare |
$0.18
|
| Rate for Payer: WINHealth Partners Commercial |
$0.26
|
| Rate for Payer: Wise Provider Network Commercial |
$0.26
|
|
|
DIAZEPAM 5 MG TABLET [20121]
|
Facility
|
OP
|
$0.27
|
|
|
Service Code
|
NDC 5107928501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.26
|
| Rate for Payer: Aetna of WY Medicare |
$0.18
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.26
|
| Rate for Payer: Altius Commercial |
$0.26
|
| Rate for Payer: Beech Street Commercial |
$0.26
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.22
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.26
|
| Rate for Payer: Cigna of WY Commercial |
$0.26
|
| Rate for Payer: Entrust Commercial |
$0.26
|
| Rate for Payer: First Choice Health Commercial |
$0.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.16
|
| Rate for Payer: HealthUtah PPO |
$0.27
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.26
|
| Rate for Payer: Multiplan Medicare/VA |
$0.15
|
| Rate for Payer: One Health Plan of WY PPO |
$0.26
|
| Rate for Payer: PacificSource Commercial |
$0.24
|
| Rate for Payer: PHCS PPO |
$0.26
|
| Rate for Payer: Three Rivers PPO |
$0.20
|
| Rate for Payer: TriWest Veterans Administration |
$0.16
|
| Rate for Payer: United Healthcare Commercial |
$0.23
|
| Rate for Payer: United Healthcare Medicare |
$0.16
|
| Rate for Payer: WINHealth Partners Commercial |
$0.26
|
| Rate for Payer: Wise Provider Network Commercial |
$0.26
|
|
|
DIAZEPAM INJECTION
|
Professional
|
Both
|
$16.00
|
|
|
Service Code
|
HCPCS J3360
|
| Hospital Charge Code |
J3360
|
| Min. Negotiated Rate |
$5.56 |
| Max. Negotiated Rate |
$16.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.68
|
| Rate for Payer: Aetna of WY Medicare |
$6.54
|
| Rate for Payer: Beech Street Commercial |
$15.20
|
| Rate for Payer: Cash Price |
$11.20
|
| Rate for Payer: Cash Price |
$11.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.52
|
| Rate for Payer: Cigna of WY Commercial |
$15.68
|
| Rate for Payer: First Choice Health Commercial |
$14.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$6.54
|
| Rate for Payer: HealthUtah PPO |
$16.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.52
|
| Rate for Payer: Multiplan Medicare/VA |
$5.56
|
| Rate for Payer: One Health Plan of WY PPO |
$15.68
|
| Rate for Payer: PacificSource Commercial |
$14.40
|
| Rate for Payer: PHCS PPO |
$15.20
|
| Rate for Payer: Three Rivers PPO |
$12.00
|
| Rate for Payer: TriWest Veterans Administration |
$6.54
|
| Rate for Payer: United Healthcare Commercial |
$13.92
|
| Rate for Payer: United Healthcare Medicare |
$6.54
|
| Rate for Payer: WINHealth Partners Commercial |
$15.20
|
|
|
DIBUCAINE 1 % TOPICAL OINTMENT [9568]
|
Facility
|
OP
|
$0.70
|
|
|
Service Code
|
NDC 0536121195
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$0.70 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.69
|
| Rate for Payer: Aetna of WY Medicare |
$0.46
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.67
|
| Rate for Payer: Altius Commercial |
$0.67
|
| Rate for Payer: Beech Street Commercial |
$0.69
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.57
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.68
|
| Rate for Payer: Cigna of WY Commercial |
$0.69
|
| Rate for Payer: Entrust Commercial |
$0.67
|
| Rate for Payer: First Choice Health Commercial |
$0.67
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.67
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.41
|
| Rate for Payer: HealthUtah PPO |
$0.70
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.68
|
| Rate for Payer: Multiplan Medicare/VA |
$0.39
|
| Rate for Payer: One Health Plan of WY PPO |
$0.69
|
| Rate for Payer: PacificSource Commercial |
$0.63
|
| Rate for Payer: PHCS PPO |
$0.69
|
| Rate for Payer: Three Rivers PPO |
$0.53
|
| Rate for Payer: TriWest Veterans Administration |
$0.41
|
| Rate for Payer: United Healthcare Commercial |
$0.61
|
| Rate for Payer: United Healthcare Medicare |
$0.41
|
| Rate for Payer: WINHealth Partners Commercial |
$0.69
|
| Rate for Payer: Wise Provider Network Commercial |
$0.67
|
|
|
DIBUCAINE 1 % TOPICAL OINTMENT [9568]
|
Facility
|
IP
|
$0.70
|
|
|
Service Code
|
NDC 0536121195
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.44 |
| Max. Negotiated Rate |
$0.70 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.69
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.67
|
| Rate for Payer: Altius Commercial |
$0.67
|
| Rate for Payer: Beech Street Commercial |
$0.69
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.57
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.68
|
| Rate for Payer: Cigna of WY Commercial |
$0.69
|
| Rate for Payer: Entrust Commercial |
$0.67
|
| Rate for Payer: First Choice Health Commercial |
$0.67
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.67
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.46
|
| Rate for Payer: HealthUtah PPO |
$0.70
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.68
|
| Rate for Payer: Multiplan Medicare/VA |
$0.44
|
| Rate for Payer: One Health Plan of WY PPO |
$0.69
|
| Rate for Payer: PacificSource Commercial |
$0.63
|
| Rate for Payer: PHCS PPO |
$0.69
|
| Rate for Payer: Three Rivers PPO |
$0.53
|
| Rate for Payer: TriWest Veterans Administration |
$0.46
|
| Rate for Payer: United Healthcare Commercial |
$0.61
|
| Rate for Payer: United Healthcare Medicare |
$0.46
|
| Rate for Payer: WINHealth Partners Commercial |
$0.67
|
| Rate for Payer: Wise Provider Network Commercial |
$0.67
|
|
|
DICLOFENAC 1 % TOPICAL GEL [52825]
|
Facility
|
IP
|
$0.39
|
|
|
Service Code
|
NDC 4612275252
|
|
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
|
|
|
DICLOFENAC 1 % TOPICAL GEL [52825]
|
Facility
|
IP
|
$0.57
|
|
|
Service Code
|
NDC 0067815203
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$0.57 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.56
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.55
|
| Rate for Payer: Altius Commercial |
$0.55
|
| Rate for Payer: Beech Street Commercial |
$0.56
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.47
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.55
|
| Rate for Payer: Cigna of WY Commercial |
$0.56
|
| Rate for Payer: Entrust Commercial |
$0.54
|
| Rate for Payer: First Choice Health Commercial |
$0.54
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.54
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.38
|
| Rate for Payer: HealthUtah PPO |
$0.57
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.55
|
| Rate for Payer: Multiplan Medicare/VA |
$0.36
|
| Rate for Payer: One Health Plan of WY PPO |
$0.56
|
| Rate for Payer: PacificSource Commercial |
$0.51
|
| Rate for Payer: PHCS PPO |
$0.56
|
| Rate for Payer: Three Rivers PPO |
$0.43
|
| Rate for Payer: TriWest Veterans Administration |
$0.38
|
| Rate for Payer: United Healthcare Commercial |
$0.50
|
| Rate for Payer: United Healthcare Medicare |
$0.38
|
| Rate for Payer: WINHealth Partners Commercial |
$0.54
|
| Rate for Payer: Wise Provider Network Commercial |
$0.54
|
|
|
DICLOFENAC 1 % TOPICAL GEL [52825]
|
Facility
|
OP
|
$0.57
|
|
|
Service Code
|
NDC 0067815203
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.57 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.56
|
| Rate for Payer: Aetna of WY Medicare |
$0.38
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.55
|
| Rate for Payer: Altius Commercial |
$0.55
|
| Rate for Payer: Beech Street Commercial |
$0.56
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.47
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.55
|
| Rate for Payer: Cigna of WY Commercial |
$0.56
|
| Rate for Payer: Entrust Commercial |
$0.54
|
| Rate for Payer: First Choice Health Commercial |
$0.54
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.54
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.33
|
| Rate for Payer: HealthUtah PPO |
$0.57
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.55
|
| Rate for Payer: Multiplan Medicare/VA |
$0.31
|
| Rate for Payer: One Health Plan of WY PPO |
$0.56
|
| Rate for Payer: PacificSource Commercial |
$0.51
|
| Rate for Payer: PHCS PPO |
$0.56
|
| Rate for Payer: Three Rivers PPO |
$0.43
|
| Rate for Payer: TriWest Veterans Administration |
$0.33
|
| Rate for Payer: United Healthcare Commercial |
$0.50
|
| Rate for Payer: United Healthcare Medicare |
$0.33
|
| Rate for Payer: WINHealth Partners Commercial |
$0.56
|
| Rate for Payer: Wise Provider Network Commercial |
$0.54
|
|
|
DICLOFENAC 1 % TOPICAL GEL [52825]
|
Facility
|
IP
|
$0.60
|
|
|
Service Code
|
NDC 6909752444
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.59
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.58
|
| Rate for Payer: Altius Commercial |
$0.58
|
| Rate for Payer: Beech Street Commercial |
$0.59
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.49
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.58
|
| Rate for Payer: Cigna of WY Commercial |
$0.59
|
| Rate for Payer: Entrust Commercial |
$0.57
|
| Rate for Payer: First Choice Health Commercial |
$0.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.40
|
| Rate for Payer: HealthUtah PPO |
$0.60
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.58
|
| Rate for Payer: Multiplan Medicare/VA |
$0.38
|
| Rate for Payer: One Health Plan of WY PPO |
$0.59
|
| Rate for Payer: PacificSource Commercial |
$0.54
|
| Rate for Payer: PHCS PPO |
$0.59
|
| Rate for Payer: Three Rivers PPO |
$0.45
|
| Rate for Payer: TriWest Veterans Administration |
$0.40
|
| Rate for Payer: United Healthcare Commercial |
$0.52
|
| Rate for Payer: United Healthcare Medicare |
$0.40
|
| Rate for Payer: WINHealth Partners Commercial |
$0.57
|
| Rate for Payer: Wise Provider Network Commercial |
$0.57
|
|
|
DICLOFENAC 1 % TOPICAL GEL [52825]
|
Facility
|
IP
|
$0.60
|
|
|
Service Code
|
NDC 4580216000
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.59
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.58
|
| Rate for Payer: Altius Commercial |
$0.58
|
| Rate for Payer: Beech Street Commercial |
$0.59
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.49
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.58
|
| Rate for Payer: Cigna of WY Commercial |
$0.59
|
| Rate for Payer: Entrust Commercial |
$0.57
|
| Rate for Payer: First Choice Health Commercial |
$0.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.40
|
| Rate for Payer: HealthUtah PPO |
$0.60
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.58
|
| Rate for Payer: Multiplan Medicare/VA |
$0.38
|
| Rate for Payer: One Health Plan of WY PPO |
$0.59
|
| Rate for Payer: PacificSource Commercial |
$0.54
|
| Rate for Payer: PHCS PPO |
$0.59
|
| Rate for Payer: Three Rivers PPO |
$0.45
|
| Rate for Payer: TriWest Veterans Administration |
$0.40
|
| Rate for Payer: United Healthcare Commercial |
$0.52
|
| Rate for Payer: United Healthcare Medicare |
$0.40
|
| Rate for Payer: WINHealth Partners Commercial |
$0.57
|
| Rate for Payer: Wise Provider Network Commercial |
$0.57
|
|
|
DICLOFENAC 1 % TOPICAL GEL [52825]
|
Facility
|
OP
|
$0.39
|
|
|
Service Code
|
NDC 4612275252
|
|
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
|
|
