|
CERVICAL MIAMI J MJ300 SHORT
|
Facility
|
OP
|
$134.33
|
|
| Hospital Charge Code |
2200374
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$72.74 |
| Max. Negotiated Rate |
$134.33 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$131.64
|
| Rate for Payer: Aetna of WY Medicare |
$88.66
|
| Rate for Payer: Altius Commercial |
$128.96
|
| Rate for Payer: Beech Street Commercial |
$131.64
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$130.30
|
| Rate for Payer: Cash Price |
$94.03
|
| Rate for Payer: ChoiceCare Network Commercial |
$130.30
|
| Rate for Payer: Cigna of WY Commercial |
$131.64
|
| Rate for Payer: Entrust Commercial |
$127.61
|
| Rate for Payer: First Choice Health Commercial |
$127.61
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$127.61
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$76.57
|
| Rate for Payer: HealthUtah PPO |
$134.33
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$130.30
|
| Rate for Payer: Multiplan Medicare/VA |
$72.74
|
| Rate for Payer: One Health Plan of WY PPO |
$131.64
|
| Rate for Payer: PacificSource Commercial |
$120.90
|
| Rate for Payer: PHCS PPO |
$131.64
|
| Rate for Payer: Three Rivers PPO |
$100.75
|
| Rate for Payer: TriWest Veterans Administration |
$76.57
|
| Rate for Payer: United Healthcare Commercial |
$128.29
|
| Rate for Payer: United Healthcare Medicare |
$76.57
|
| Rate for Payer: WINHealth Partners Commercial |
$131.64
|
| Rate for Payer: Wise Provider Network Commercial |
$127.61
|
|
|
CERVICAL MIAMI J MJ300 SHORT
|
Facility
|
IP
|
$134.33
|
|
| Hospital Charge Code |
2200374
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$77.84 |
| Max. Negotiated Rate |
$134.33 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$131.64
|
| Rate for Payer: Aetna of WY Medicare |
$85.97
|
| Rate for Payer: Altius Commercial |
$128.96
|
| Rate for Payer: Beech Street Commercial |
$131.64
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$130.30
|
| Rate for Payer: Cash Price |
$94.03
|
| Rate for Payer: ChoiceCare Network Commercial |
$130.30
|
| Rate for Payer: Cigna of WY Commercial |
$131.64
|
| Rate for Payer: Entrust Commercial |
$127.61
|
| Rate for Payer: First Choice Health Commercial |
$127.61
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$127.61
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$81.94
|
| Rate for Payer: HealthUtah PPO |
$134.33
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$130.30
|
| Rate for Payer: Multiplan Medicare/VA |
$77.84
|
| Rate for Payer: One Health Plan of WY PPO |
$131.64
|
| Rate for Payer: PacificSource Commercial |
$120.90
|
| Rate for Payer: PHCS PPO |
$131.64
|
| Rate for Payer: Three Rivers PPO |
$100.75
|
| Rate for Payer: TriWest Veterans Administration |
$81.94
|
| Rate for Payer: United Healthcare Commercial |
$128.29
|
| Rate for Payer: United Healthcare Medicare |
$81.94
|
| Rate for Payer: WINHealth Partners Commercial |
$127.61
|
| Rate for Payer: Wise Provider Network Commercial |
$127.61
|
|
|
CERVICAL MIAMI J MJ400 REG
|
Facility
|
OP
|
$134.33
|
|
| Hospital Charge Code |
2200373
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$72.74 |
| Max. Negotiated Rate |
$134.33 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$131.64
|
| Rate for Payer: Aetna of WY Medicare |
$88.66
|
| Rate for Payer: Altius Commercial |
$128.96
|
| Rate for Payer: Beech Street Commercial |
$131.64
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$130.30
|
| Rate for Payer: Cash Price |
$94.03
|
| Rate for Payer: ChoiceCare Network Commercial |
$130.30
|
| Rate for Payer: Cigna of WY Commercial |
$131.64
|
| Rate for Payer: Entrust Commercial |
$127.61
|
| Rate for Payer: First Choice Health Commercial |
$127.61
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$127.61
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$76.57
|
| Rate for Payer: HealthUtah PPO |
$134.33
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$130.30
|
| Rate for Payer: Multiplan Medicare/VA |
$72.74
|
| Rate for Payer: One Health Plan of WY PPO |
$131.64
|
| Rate for Payer: PacificSource Commercial |
$120.90
|
| Rate for Payer: PHCS PPO |
$131.64
|
| Rate for Payer: Three Rivers PPO |
$100.75
|
| Rate for Payer: TriWest Veterans Administration |
$76.57
|
| Rate for Payer: United Healthcare Commercial |
$128.29
|
| Rate for Payer: United Healthcare Medicare |
$76.57
|
| Rate for Payer: WINHealth Partners Commercial |
$131.64
|
| Rate for Payer: Wise Provider Network Commercial |
$127.61
|
|
|
CERVICAL MIAMI J MJ400 REG
|
Facility
|
IP
|
$134.33
|
|
| Hospital Charge Code |
2200373
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$77.84 |
| Max. Negotiated Rate |
$134.33 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$131.64
|
| Rate for Payer: Aetna of WY Medicare |
$85.97
|
| Rate for Payer: Altius Commercial |
$128.96
|
| Rate for Payer: Beech Street Commercial |
$131.64
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$130.30
|
| Rate for Payer: Cash Price |
$94.03
|
| Rate for Payer: ChoiceCare Network Commercial |
$130.30
|
| Rate for Payer: Cigna of WY Commercial |
$131.64
|
| Rate for Payer: Entrust Commercial |
$127.61
|
| Rate for Payer: First Choice Health Commercial |
$127.61
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$127.61
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$81.94
|
| Rate for Payer: HealthUtah PPO |
$134.33
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$130.30
|
| Rate for Payer: Multiplan Medicare/VA |
$77.84
|
| Rate for Payer: One Health Plan of WY PPO |
$131.64
|
| Rate for Payer: PacificSource Commercial |
$120.90
|
| Rate for Payer: PHCS PPO |
$131.64
|
| Rate for Payer: Three Rivers PPO |
$100.75
|
| Rate for Payer: TriWest Veterans Administration |
$81.94
|
| Rate for Payer: United Healthcare Commercial |
$128.29
|
| Rate for Payer: United Healthcare Medicare |
$81.94
|
| Rate for Payer: WINHealth Partners Commercial |
$127.61
|
| Rate for Payer: Wise Provider Network Commercial |
$127.61
|
|
|
CERVICAL MIAMI J MJ500 TALL
|
Facility
|
IP
|
$122.92
|
|
| Hospital Charge Code |
2200265
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$71.23 |
| Max. Negotiated Rate |
$122.92 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$120.46
|
| Rate for Payer: Aetna of WY Medicare |
$78.67
|
| Rate for Payer: Altius Commercial |
$118.00
|
| Rate for Payer: Beech Street Commercial |
$120.46
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$119.23
|
| Rate for Payer: Cash Price |
$86.04
|
| Rate for Payer: ChoiceCare Network Commercial |
$119.23
|
| Rate for Payer: Cigna of WY Commercial |
$120.46
|
| Rate for Payer: Entrust Commercial |
$116.77
|
| Rate for Payer: First Choice Health Commercial |
$116.77
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$116.77
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$74.98
|
| Rate for Payer: HealthUtah PPO |
$122.92
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$119.23
|
| Rate for Payer: Multiplan Medicare/VA |
$71.23
|
| Rate for Payer: One Health Plan of WY PPO |
$120.46
|
| Rate for Payer: PacificSource Commercial |
$110.63
|
| Rate for Payer: PHCS PPO |
$120.46
|
| Rate for Payer: Three Rivers PPO |
$92.19
|
| Rate for Payer: TriWest Veterans Administration |
$74.98
|
| Rate for Payer: United Healthcare Commercial |
$117.39
|
| Rate for Payer: United Healthcare Medicare |
$74.98
|
| Rate for Payer: WINHealth Partners Commercial |
$116.77
|
| Rate for Payer: Wise Provider Network Commercial |
$116.77
|
|
|
CERVICAL MIAMI J MJ500 TALL
|
Facility
|
OP
|
$122.92
|
|
| Hospital Charge Code |
2200265
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$66.56 |
| Max. Negotiated Rate |
$122.92 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$120.46
|
| Rate for Payer: Aetna of WY Medicare |
$81.13
|
| Rate for Payer: Altius Commercial |
$118.00
|
| Rate for Payer: Beech Street Commercial |
$120.46
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$119.23
|
| Rate for Payer: Cash Price |
$86.04
|
| Rate for Payer: ChoiceCare Network Commercial |
$119.23
|
| Rate for Payer: Cigna of WY Commercial |
$120.46
|
| Rate for Payer: Entrust Commercial |
$116.77
|
| Rate for Payer: First Choice Health Commercial |
$116.77
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$116.77
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$70.06
|
| Rate for Payer: HealthUtah PPO |
$122.92
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$119.23
|
| Rate for Payer: Multiplan Medicare/VA |
$66.56
|
| Rate for Payer: One Health Plan of WY PPO |
$120.46
|
| Rate for Payer: PacificSource Commercial |
$110.63
|
| Rate for Payer: PHCS PPO |
$120.46
|
| Rate for Payer: Three Rivers PPO |
$92.19
|
| Rate for Payer: TriWest Veterans Administration |
$70.06
|
| Rate for Payer: United Healthcare Commercial |
$117.39
|
| Rate for Payer: United Healthcare Medicare |
$70.06
|
| Rate for Payer: WINHealth Partners Commercial |
$120.46
|
| Rate for Payer: Wise Provider Network Commercial |
$116.77
|
|
|
CESAREAN DELIVERY ATTEMPTED VBAC
|
Professional
|
Both
|
$2,430.00
|
|
|
Service Code
|
HCPCS 59620
|
| Min. Negotiated Rate |
$747.48 |
| Max. Negotiated Rate |
$2,430.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,381.40
|
| Rate for Payer: Aetna of WY Medicare |
$879.39
|
| Rate for Payer: Beech Street Commercial |
$2,308.50
|
| Rate for Payer: Cash Price |
$1,701.00
|
| Rate for Payer: Cash Price |
$1,701.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,357.10
|
| Rate for Payer: Cigna of WY Commercial |
$2,381.40
|
| Rate for Payer: First Choice Health Commercial |
$2,187.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,308.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$879.39
|
| Rate for Payer: HealthUtah PPO |
$2,430.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,357.10
|
| Rate for Payer: Multiplan Medicare/VA |
$747.48
|
| Rate for Payer: One Health Plan of WY PPO |
$2,381.40
|
| Rate for Payer: PacificSource Commercial |
$2,187.00
|
| Rate for Payer: PHCS PPO |
$2,308.50
|
| Rate for Payer: Three Rivers PPO |
$1,822.50
|
| Rate for Payer: TriWest Veterans Administration |
$879.39
|
| Rate for Payer: United Healthcare Commercial |
$2,308.50
|
| Rate for Payer: WINHealth Partners Commercial |
$2,065.50
|
|
|
CESAREAN DELIVERY ATTEMPTED VBAC
|
Professional
|
Both
|
$2,430.00
|
|
|
Service Code
|
HCPCS 59620 80
|
| Min. Negotiated Rate |
$747.48 |
| Max. Negotiated Rate |
$2,430.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,381.40
|
| Rate for Payer: Beech Street Commercial |
$2,308.50
|
| Rate for Payer: Cash Price |
$1,701.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,357.10
|
| Rate for Payer: Cigna of WY Commercial |
$2,381.40
|
| Rate for Payer: First Choice Health Commercial |
$2,187.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,308.50
|
| Rate for Payer: HealthUtah PPO |
$2,430.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,357.10
|
| Rate for Payer: One Health Plan of WY PPO |
$2,381.40
|
| Rate for Payer: PacificSource Commercial |
$2,187.00
|
| Rate for Payer: PHCS PPO |
$2,308.50
|
| Rate for Payer: Three Rivers PPO |
$1,822.50
|
| Rate for Payer: United Healthcare Commercial |
$2,308.50
|
| Rate for Payer: WINHealth Partners Commercial |
$2,065.50
|
|
|
CESAREAN DELIVERY ONLY
|
Professional
|
Both
|
$2,346.00
|
|
|
Service Code
|
HCPCS 59514 80
|
| Min. Negotiated Rate |
$723.15 |
| Max. Negotiated Rate |
$2,346.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,299.08
|
| Rate for Payer: Beech Street Commercial |
$2,228.70
|
| Rate for Payer: Cash Price |
$1,642.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,275.62
|
| Rate for Payer: Cigna of WY Commercial |
$2,299.08
|
| Rate for Payer: First Choice Health Commercial |
$2,111.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,228.70
|
| Rate for Payer: HealthUtah PPO |
$2,346.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,275.62
|
| Rate for Payer: One Health Plan of WY PPO |
$2,299.08
|
| Rate for Payer: PacificSource Commercial |
$2,111.40
|
| Rate for Payer: PHCS PPO |
$2,228.70
|
| Rate for Payer: Three Rivers PPO |
$1,759.50
|
| Rate for Payer: United Healthcare Commercial |
$2,228.70
|
| Rate for Payer: WINHealth Partners Commercial |
$1,994.10
|
|
|
CESAREAN DELIVERY ONLY
|
Professional
|
Both
|
$2,346.00
|
|
|
Service Code
|
HCPCS 59514
|
| Min. Negotiated Rate |
$723.15 |
| Max. Negotiated Rate |
$2,346.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,299.08
|
| Rate for Payer: Aetna of WY Medicare |
$850.77
|
| Rate for Payer: Beech Street Commercial |
$2,228.70
|
| Rate for Payer: Cash Price |
$1,642.20
|
| Rate for Payer: Cash Price |
$1,642.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,275.62
|
| Rate for Payer: Cigna of WY Commercial |
$2,299.08
|
| Rate for Payer: First Choice Health Commercial |
$2,111.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,228.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$850.77
|
| Rate for Payer: HealthUtah PPO |
$1,762.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,275.62
|
| Rate for Payer: Multiplan Medicare/VA |
$723.15
|
| Rate for Payer: One Health Plan of WY PPO |
$2,299.08
|
| Rate for Payer: PacificSource Commercial |
$2,111.40
|
| Rate for Payer: PHCS PPO |
$2,228.70
|
| Rate for Payer: Three Rivers PPO |
$1,759.50
|
| Rate for Payer: TriWest Veterans Administration |
$850.77
|
| Rate for Payer: United Healthcare Commercial |
$2,228.70
|
| Rate for Payer: WINHealth Partners Commercial |
$1,994.10
|
|
|
CESAREAN DELIVERY ONLY
|
Professional
|
Both
|
$2,346.00
|
|
|
Service Code
|
HCPCS 59514 AS
|
| Min. Negotiated Rate |
$723.15 |
| Max. Negotiated Rate |
$2,346.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,299.08
|
| Rate for Payer: Beech Street Commercial |
$2,228.70
|
| Rate for Payer: Cash Price |
$1,642.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,275.62
|
| Rate for Payer: Cigna of WY Commercial |
$2,299.08
|
| Rate for Payer: First Choice Health Commercial |
$2,111.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,228.70
|
| Rate for Payer: HealthUtah PPO |
$2,346.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,275.62
|
| Rate for Payer: One Health Plan of WY PPO |
$2,299.08
|
| Rate for Payer: PacificSource Commercial |
$2,111.40
|
| Rate for Payer: PHCS PPO |
$2,228.70
|
| Rate for Payer: Three Rivers PPO |
$1,759.50
|
| Rate for Payer: United Healthcare Commercial |
$2,228.70
|
| Rate for Payer: WINHealth Partners Commercial |
$1,994.10
|
|
|
CESAREAN DELIVERY ONLY W/POSTPARTUM CARE
|
Professional
|
Both
|
$3,257.00
|
|
|
Service Code
|
HCPCS 59515
|
| Min. Negotiated Rate |
$1,073.55 |
| Max. Negotiated Rate |
$3,257.00 |
| Rate for Payer: ChoiceCare Network Commercial |
$3,159.29
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,191.86
|
| Rate for Payer: Aetna of WY Medicare |
$1,263.00
|
| Rate for Payer: Beech Street Commercial |
$3,094.15
|
| Rate for Payer: Cash Price |
$2,279.90
|
| Rate for Payer: Cash Price |
$2,279.90
|
| Rate for Payer: Cigna of WY Commercial |
$3,191.86
|
| Rate for Payer: First Choice Health Commercial |
$2,931.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,094.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,263.00
|
| Rate for Payer: HealthUtah PPO |
$3,257.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,159.29
|
| Rate for Payer: Multiplan Medicare/VA |
$1,073.55
|
| Rate for Payer: One Health Plan of WY PPO |
$3,191.86
|
| Rate for Payer: PacificSource Commercial |
$2,931.30
|
| Rate for Payer: PHCS PPO |
$3,094.15
|
| Rate for Payer: Three Rivers PPO |
$2,442.75
|
| Rate for Payer: TriWest Veterans Administration |
$1,263.00
|
| Rate for Payer: United Healthcare Commercial |
$3,094.15
|
| Rate for Payer: WINHealth Partners Commercial |
$2,768.45
|
|
|
CESAREAN DLVRY & POSTPARTUM CARE ATTEMPTED VBA
|
Professional
|
Both
|
$2,707.00
|
|
|
Service Code
|
HCPCS 59622
|
| Min. Negotiated Rate |
$1,112.71 |
| Max. Negotiated Rate |
$2,707.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,652.86
|
| Rate for Payer: Aetna of WY Medicare |
$1,309.07
|
| Rate for Payer: Beech Street Commercial |
$2,571.65
|
| Rate for Payer: Cash Price |
$1,894.90
|
| Rate for Payer: Cash Price |
$1,894.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,625.79
|
| Rate for Payer: Cigna of WY Commercial |
$2,652.86
|
| Rate for Payer: First Choice Health Commercial |
$2,436.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,571.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,309.07
|
| Rate for Payer: HealthUtah PPO |
$2,707.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,625.79
|
| Rate for Payer: Multiplan Medicare/VA |
$1,112.71
|
| Rate for Payer: One Health Plan of WY PPO |
$2,652.86
|
| Rate for Payer: PacificSource Commercial |
$2,436.30
|
| Rate for Payer: PHCS PPO |
$2,571.65
|
| Rate for Payer: Three Rivers PPO |
$2,030.25
|
| Rate for Payer: TriWest Veterans Administration |
$1,309.07
|
| Rate for Payer: United Healthcare Commercial |
$2,571.65
|
| Rate for Payer: WINHealth Partners Commercial |
$2,300.95
|
|
|
CETIRIZINE 10 MG TABLET [2857]
|
Facility
|
OP
|
$15.58
|
|
|
Service Code
|
NDC 6800143696
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.44 |
| Max. Negotiated Rate |
$15.58 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.27
|
| Rate for Payer: Aetna of WY Medicare |
$10.28
|
| Rate for Payer: Altius Commercial |
$14.96
|
| Rate for Payer: Beech Street Commercial |
$15.27
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.11
|
| Rate for Payer: Cash Price |
$10.91
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.11
|
| Rate for Payer: Cigna of WY Commercial |
$15.27
|
| Rate for Payer: Entrust Commercial |
$14.80
|
| Rate for Payer: First Choice Health Commercial |
$14.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.88
|
| Rate for Payer: HealthUtah PPO |
$15.58
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.11
|
| Rate for Payer: Multiplan Medicare/VA |
$8.44
|
| Rate for Payer: One Health Plan of WY PPO |
$15.27
|
| Rate for Payer: PacificSource Commercial |
$14.02
|
| Rate for Payer: PHCS PPO |
$15.27
|
| Rate for Payer: Three Rivers PPO |
$11.68
|
| Rate for Payer: TriWest Veterans Administration |
$8.88
|
| Rate for Payer: United Healthcare Commercial |
$14.88
|
| Rate for Payer: United Healthcare Medicare |
$8.88
|
| Rate for Payer: WINHealth Partners Commercial |
$15.27
|
| Rate for Payer: Wise Provider Network Commercial |
$14.80
|
|
|
CETIRIZINE 10 MG TABLET [2857]
|
Facility
|
OP
|
$15.58
|
|
|
Service Code
|
NDC 6800143616
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.44 |
| Max. Negotiated Rate |
$15.58 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.27
|
| Rate for Payer: Aetna of WY Medicare |
$10.28
|
| Rate for Payer: Altius Commercial |
$14.96
|
| Rate for Payer: Beech Street Commercial |
$15.27
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.11
|
| Rate for Payer: Cash Price |
$10.91
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.11
|
| Rate for Payer: Cigna of WY Commercial |
$15.27
|
| Rate for Payer: Entrust Commercial |
$14.80
|
| Rate for Payer: First Choice Health Commercial |
$14.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.88
|
| Rate for Payer: HealthUtah PPO |
$15.58
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.11
|
| Rate for Payer: Multiplan Medicare/VA |
$8.44
|
| Rate for Payer: One Health Plan of WY PPO |
$15.27
|
| Rate for Payer: PacificSource Commercial |
$14.02
|
| Rate for Payer: PHCS PPO |
$15.27
|
| Rate for Payer: Three Rivers PPO |
$11.68
|
| Rate for Payer: TriWest Veterans Administration |
$8.88
|
| Rate for Payer: United Healthcare Commercial |
$14.88
|
| Rate for Payer: United Healthcare Medicare |
$8.88
|
| Rate for Payer: WINHealth Partners Commercial |
$15.27
|
| Rate for Payer: Wise Provider Network Commercial |
$14.80
|
|
|
CETIRIZINE 10 MG TABLET [2857]
|
Facility
|
IP
|
$15.58
|
|
|
Service Code
|
NDC 6800143696
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.03 |
| Max. Negotiated Rate |
$15.58 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.27
|
| Rate for Payer: Aetna of WY Medicare |
$9.97
|
| Rate for Payer: Altius Commercial |
$14.96
|
| Rate for Payer: Beech Street Commercial |
$15.27
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.11
|
| Rate for Payer: Cash Price |
$10.91
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.11
|
| Rate for Payer: Cigna of WY Commercial |
$15.27
|
| Rate for Payer: Entrust Commercial |
$14.80
|
| Rate for Payer: First Choice Health Commercial |
$14.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.50
|
| Rate for Payer: HealthUtah PPO |
$15.58
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.11
|
| Rate for Payer: Multiplan Medicare/VA |
$9.03
|
| Rate for Payer: One Health Plan of WY PPO |
$15.27
|
| Rate for Payer: PacificSource Commercial |
$14.02
|
| Rate for Payer: PHCS PPO |
$15.27
|
| Rate for Payer: Three Rivers PPO |
$11.68
|
| Rate for Payer: TriWest Veterans Administration |
$9.50
|
| Rate for Payer: United Healthcare Commercial |
$14.88
|
| Rate for Payer: United Healthcare Medicare |
$9.50
|
| Rate for Payer: WINHealth Partners Commercial |
$14.80
|
| Rate for Payer: Wise Provider Network Commercial |
$14.80
|
|
|
CETIRIZINE 10 MG TABLET [2857]
|
Facility
|
IP
|
$15.58
|
|
|
Service Code
|
NDC 6800143616
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.03 |
| Max. Negotiated Rate |
$15.58 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.27
|
| Rate for Payer: Aetna of WY Medicare |
$9.97
|
| Rate for Payer: Altius Commercial |
$14.96
|
| Rate for Payer: Beech Street Commercial |
$15.27
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.11
|
| Rate for Payer: Cash Price |
$10.91
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.11
|
| Rate for Payer: Cigna of WY Commercial |
$15.27
|
| Rate for Payer: Entrust Commercial |
$14.80
|
| Rate for Payer: First Choice Health Commercial |
$14.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.50
|
| Rate for Payer: HealthUtah PPO |
$15.58
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.11
|
| Rate for Payer: Multiplan Medicare/VA |
$9.03
|
| Rate for Payer: One Health Plan of WY PPO |
$15.27
|
| Rate for Payer: PacificSource Commercial |
$14.02
|
| Rate for Payer: PHCS PPO |
$15.27
|
| Rate for Payer: Three Rivers PPO |
$11.68
|
| Rate for Payer: TriWest Veterans Administration |
$9.50
|
| Rate for Payer: United Healthcare Commercial |
$14.88
|
| Rate for Payer: United Healthcare Medicare |
$9.50
|
| Rate for Payer: WINHealth Partners Commercial |
$14.80
|
| Rate for Payer: Wise Provider Network Commercial |
$14.80
|
|
|
CETIRIZINE 10 MG TABLET [2857]
|
Facility
|
IP
|
$15.36
|
|
|
Service Code
|
NDC 8770140653
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.90 |
| Max. Negotiated Rate |
$15.36 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.05
|
| Rate for Payer: Aetna of WY Medicare |
$9.83
|
| Rate for Payer: Altius Commercial |
$14.75
|
| Rate for Payer: Beech Street Commercial |
$15.05
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.90
|
| Rate for Payer: Cash Price |
$10.75
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.90
|
| Rate for Payer: Cigna of WY Commercial |
$15.05
|
| Rate for Payer: Entrust Commercial |
$14.59
|
| Rate for Payer: First Choice Health Commercial |
$14.59
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.59
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.37
|
| Rate for Payer: HealthUtah PPO |
$15.36
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.90
|
| Rate for Payer: Multiplan Medicare/VA |
$8.90
|
| Rate for Payer: One Health Plan of WY PPO |
$15.05
|
| Rate for Payer: PacificSource Commercial |
$13.82
|
| Rate for Payer: PHCS PPO |
$15.05
|
| Rate for Payer: Three Rivers PPO |
$11.52
|
| Rate for Payer: TriWest Veterans Administration |
$9.37
|
| Rate for Payer: United Healthcare Commercial |
$14.67
|
| Rate for Payer: United Healthcare Medicare |
$9.37
|
| Rate for Payer: WINHealth Partners Commercial |
$14.59
|
| Rate for Payer: Wise Provider Network Commercial |
$14.59
|
|
|
CETIRIZINE 10 MG TABLET [2857]
|
Facility
|
IP
|
$15.36
|
|
|
Service Code
|
NDC 2438599875
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.90 |
| Max. Negotiated Rate |
$15.36 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.05
|
| Rate for Payer: Aetna of WY Medicare |
$9.83
|
| Rate for Payer: Altius Commercial |
$14.75
|
| Rate for Payer: Beech Street Commercial |
$15.05
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.90
|
| Rate for Payer: Cash Price |
$10.75
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.90
|
| Rate for Payer: Cigna of WY Commercial |
$15.05
|
| Rate for Payer: Entrust Commercial |
$14.59
|
| Rate for Payer: First Choice Health Commercial |
$14.59
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.59
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.37
|
| Rate for Payer: HealthUtah PPO |
$15.36
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.90
|
| Rate for Payer: Multiplan Medicare/VA |
$8.90
|
| Rate for Payer: One Health Plan of WY PPO |
$15.05
|
| Rate for Payer: PacificSource Commercial |
$13.82
|
| Rate for Payer: PHCS PPO |
$15.05
|
| Rate for Payer: Three Rivers PPO |
$11.52
|
| Rate for Payer: TriWest Veterans Administration |
$9.37
|
| Rate for Payer: United Healthcare Commercial |
$14.67
|
| Rate for Payer: United Healthcare Medicare |
$9.37
|
| Rate for Payer: WINHealth Partners Commercial |
$14.59
|
| Rate for Payer: Wise Provider Network Commercial |
$14.59
|
|
|
CETIRIZINE 10 MG TABLET [2857]
|
Facility
|
OP
|
$15.36
|
|
|
Service Code
|
NDC 8770140653
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.32 |
| Max. Negotiated Rate |
$15.36 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.05
|
| Rate for Payer: Aetna of WY Medicare |
$10.14
|
| Rate for Payer: Altius Commercial |
$14.75
|
| Rate for Payer: Beech Street Commercial |
$15.05
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.90
|
| Rate for Payer: Cash Price |
$10.75
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.90
|
| Rate for Payer: Cigna of WY Commercial |
$15.05
|
| Rate for Payer: Entrust Commercial |
$14.59
|
| Rate for Payer: First Choice Health Commercial |
$14.59
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.59
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.76
|
| Rate for Payer: HealthUtah PPO |
$15.36
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.90
|
| Rate for Payer: Multiplan Medicare/VA |
$8.32
|
| Rate for Payer: One Health Plan of WY PPO |
$15.05
|
| Rate for Payer: PacificSource Commercial |
$13.82
|
| Rate for Payer: PHCS PPO |
$15.05
|
| Rate for Payer: Three Rivers PPO |
$11.52
|
| Rate for Payer: TriWest Veterans Administration |
$8.76
|
| Rate for Payer: United Healthcare Commercial |
$14.67
|
| Rate for Payer: United Healthcare Medicare |
$8.76
|
| Rate for Payer: WINHealth Partners Commercial |
$15.05
|
| Rate for Payer: Wise Provider Network Commercial |
$14.59
|
|
|
CETIRIZINE 10 MG TABLET [2857]
|
Facility
|
OP
|
$15.36
|
|
|
Service Code
|
NDC 2438599875
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.32 |
| Max. Negotiated Rate |
$15.36 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.05
|
| Rate for Payer: Aetna of WY Medicare |
$10.14
|
| Rate for Payer: Altius Commercial |
$14.75
|
| Rate for Payer: Beech Street Commercial |
$15.05
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.90
|
| Rate for Payer: Cash Price |
$10.75
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.90
|
| Rate for Payer: Cigna of WY Commercial |
$15.05
|
| Rate for Payer: Entrust Commercial |
$14.59
|
| Rate for Payer: First Choice Health Commercial |
$14.59
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.59
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.76
|
| Rate for Payer: HealthUtah PPO |
$15.36
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.90
|
| Rate for Payer: Multiplan Medicare/VA |
$8.32
|
| Rate for Payer: One Health Plan of WY PPO |
$15.05
|
| Rate for Payer: PacificSource Commercial |
$13.82
|
| Rate for Payer: PHCS PPO |
$15.05
|
| Rate for Payer: Three Rivers PPO |
$11.52
|
| Rate for Payer: TriWest Veterans Administration |
$8.76
|
| Rate for Payer: United Healthcare Commercial |
$14.67
|
| Rate for Payer: United Healthcare Medicare |
$8.76
|
| Rate for Payer: WINHealth Partners Commercial |
$15.05
|
| Rate for Payer: Wise Provider Network Commercial |
$14.59
|
|
|
CETIRIZINE 5 MG TABLET [3234]
|
Facility
|
IP
|
$15.53
|
|
|
Service Code
|
NDC 0378363501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.00 |
| Max. Negotiated Rate |
$15.53 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.22
|
| Rate for Payer: Aetna of WY Medicare |
$9.94
|
| Rate for Payer: Altius Commercial |
$14.91
|
| Rate for Payer: Beech Street Commercial |
$15.22
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.06
|
| Rate for Payer: Cash Price |
$10.87
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.06
|
| Rate for Payer: Cigna of WY Commercial |
$15.22
|
| Rate for Payer: Entrust Commercial |
$14.75
|
| Rate for Payer: First Choice Health Commercial |
$14.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.47
|
| Rate for Payer: HealthUtah PPO |
$15.53
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.06
|
| Rate for Payer: Multiplan Medicare/VA |
$9.00
|
| Rate for Payer: One Health Plan of WY PPO |
$15.22
|
| Rate for Payer: PacificSource Commercial |
$13.98
|
| Rate for Payer: PHCS PPO |
$15.22
|
| Rate for Payer: Three Rivers PPO |
$11.65
|
| Rate for Payer: TriWest Veterans Administration |
$9.47
|
| Rate for Payer: United Healthcare Commercial |
$14.83
|
| Rate for Payer: United Healthcare Medicare |
$9.47
|
| Rate for Payer: WINHealth Partners Commercial |
$14.75
|
| Rate for Payer: Wise Provider Network Commercial |
$14.75
|
|
|
CETIRIZINE 5 MG TABLET [3234]
|
Facility
|
OP
|
$15.53
|
|
|
Service Code
|
NDC 0378363501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.41 |
| Max. Negotiated Rate |
$15.53 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.22
|
| Rate for Payer: Aetna of WY Medicare |
$10.25
|
| Rate for Payer: Altius Commercial |
$14.91
|
| Rate for Payer: Beech Street Commercial |
$15.22
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.06
|
| Rate for Payer: Cash Price |
$10.87
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.06
|
| Rate for Payer: Cigna of WY Commercial |
$15.22
|
| Rate for Payer: Entrust Commercial |
$14.75
|
| Rate for Payer: First Choice Health Commercial |
$14.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.85
|
| Rate for Payer: HealthUtah PPO |
$15.53
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.06
|
| Rate for Payer: Multiplan Medicare/VA |
$8.41
|
| Rate for Payer: One Health Plan of WY PPO |
$15.22
|
| Rate for Payer: PacificSource Commercial |
$13.98
|
| Rate for Payer: PHCS PPO |
$15.22
|
| Rate for Payer: Three Rivers PPO |
$11.65
|
| Rate for Payer: TriWest Veterans Administration |
$8.85
|
| Rate for Payer: United Healthcare Commercial |
$14.83
|
| Rate for Payer: United Healthcare Medicare |
$8.85
|
| Rate for Payer: WINHealth Partners Commercial |
$15.22
|
| Rate for Payer: Wise Provider Network Commercial |
$14.75
|
|
|
CHANGE GASTROSTOMY TUBE PERCUTANEOUS W/O GUIDE
|
Professional
|
Both
|
$266.00
|
|
|
Service Code
|
HCPCS 43760
|
| Min. Negotiated Rate |
$199.50 |
| Max. Negotiated Rate |
$266.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$260.68
|
| Rate for Payer: Beech Street Commercial |
$252.70
|
| Rate for Payer: Cash Price |
$186.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$258.02
|
| Rate for Payer: Cigna of WY Commercial |
$260.68
|
| Rate for Payer: First Choice Health Commercial |
$239.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$252.70
|
| Rate for Payer: HealthUtah PPO |
$266.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$258.02
|
| Rate for Payer: One Health Plan of WY PPO |
$260.68
|
| Rate for Payer: PacificSource Commercial |
$239.40
|
| Rate for Payer: PHCS PPO |
$252.70
|
| Rate for Payer: Three Rivers PPO |
$199.50
|
| Rate for Payer: United Healthcare Commercial |
$252.70
|
| Rate for Payer: WINHealth Partners Commercial |
$226.10
|
|
|
CHARGING SYSTEM KIT SC-6412-3
|
Facility
|
OP
|
$8,575.00
|
|
| Hospital Charge Code |
2800188
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$4,643.36 |
| Max. Negotiated Rate |
$8,575.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$8,403.50
|
| Rate for Payer: Aetna of WY Medicare |
$5,659.50
|
| Rate for Payer: Altius Commercial |
$8,232.00
|
| Rate for Payer: Beech Street Commercial |
$8,403.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$8,317.75
|
| Rate for Payer: Cash Price |
$6,002.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$8,317.75
|
| Rate for Payer: Cigna of WY Commercial |
$8,403.50
|
| Rate for Payer: Entrust Commercial |
$8,146.25
|
| Rate for Payer: First Choice Health Commercial |
$8,146.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$8,146.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$4,887.75
|
| Rate for Payer: HealthUtah PPO |
$8,575.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$8,317.75
|
| Rate for Payer: Multiplan Medicare/VA |
$4,643.36
|
| Rate for Payer: One Health Plan of WY PPO |
$8,403.50
|
| Rate for Payer: PacificSource Commercial |
$7,717.50
|
| Rate for Payer: PHCS PPO |
$8,403.50
|
| Rate for Payer: Three Rivers PPO |
$6,431.25
|
| Rate for Payer: TriWest Veterans Administration |
$4,887.75
|
| Rate for Payer: United Healthcare Commercial |
$8,189.12
|
| Rate for Payer: United Healthcare Medicare |
$4,887.75
|
| Rate for Payer: WINHealth Partners Commercial |
$8,403.50
|
| Rate for Payer: Wise Provider Network Commercial |
$8,146.25
|
|
