|
DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE [45972]
|
Facility
|
OP
|
$110.69
|
|
|
Service Code
|
NDC 5816081043
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$60.99 |
| Max. Negotiated Rate |
$110.69 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$108.48
|
| Rate for Payer: Aetna of WY Medicare |
$73.06
|
| Rate for Payer: Altius Auto/Workers Compensation |
$106.26
|
| Rate for Payer: Altius Commercial |
$106.26
|
| Rate for Payer: Beech Street Commercial |
$108.48
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$90.88
|
| Rate for Payer: Cash Price |
$77.49
|
| Rate for Payer: ChoiceCare Network Commercial |
$107.37
|
| Rate for Payer: Cigna of WY Commercial |
$108.48
|
| Rate for Payer: Entrust Commercial |
$105.16
|
| Rate for Payer: First Choice Health Commercial |
$105.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$105.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$64.20
|
| Rate for Payer: HealthUtah PPO |
$110.69
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$107.37
|
| Rate for Payer: Multiplan Medicare/VA |
$60.99
|
| Rate for Payer: One Health Plan of WY PPO |
$108.48
|
| Rate for Payer: PacificSource Commercial |
$99.62
|
| Rate for Payer: PHCS PPO |
$108.48
|
| Rate for Payer: Three Rivers PPO |
$83.02
|
| Rate for Payer: TriWest Veterans Administration |
$64.20
|
| Rate for Payer: United Healthcare Commercial |
$96.30
|
| Rate for Payer: United Healthcare Medicare |
$64.20
|
| Rate for Payer: WINHealth Partners Commercial |
$108.48
|
| Rate for Payer: Wise Provider Network Commercial |
$105.16
|
|
|
DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE [45972]
|
Facility
|
IP
|
$110.69
|
|
|
Service Code
|
NDC 5816081043
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$69.40 |
| Max. Negotiated Rate |
$110.69 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$108.48
|
| Rate for Payer: Altius Auto/Workers Compensation |
$106.26
|
| Rate for Payer: Altius Commercial |
$106.26
|
| Rate for Payer: Beech Street Commercial |
$108.48
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$90.88
|
| Rate for Payer: Cash Price |
$77.49
|
| Rate for Payer: ChoiceCare Network Commercial |
$107.37
|
| Rate for Payer: Cigna of WY Commercial |
$108.48
|
| Rate for Payer: Entrust Commercial |
$105.16
|
| Rate for Payer: First Choice Health Commercial |
$105.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$105.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$73.06
|
| Rate for Payer: HealthUtah PPO |
$110.69
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$107.37
|
| Rate for Payer: Multiplan Medicare/VA |
$69.40
|
| Rate for Payer: One Health Plan of WY PPO |
$108.48
|
| Rate for Payer: PacificSource Commercial |
$99.62
|
| Rate for Payer: PHCS PPO |
$108.48
|
| Rate for Payer: Three Rivers PPO |
$83.02
|
| Rate for Payer: TriWest Veterans Administration |
$73.06
|
| Rate for Payer: United Healthcare Commercial |
$96.30
|
| Rate for Payer: United Healthcare Medicare |
$73.06
|
| Rate for Payer: WINHealth Partners Commercial |
$105.16
|
| Rate for Payer: Wise Provider Network Commercial |
$105.16
|
|
|
DIPHTH,PERTUS(AC)TETANUS(PF)2 LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SYRINGE [52987]
|
Facility
|
IP
|
$179.32
|
|
|
Service Code
|
HCPCS 90715
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$112.43 |
| Max. Negotiated Rate |
$179.32 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$175.73
|
| Rate for Payer: Altius Auto/Workers Compensation |
$172.15
|
| Rate for Payer: Altius Commercial |
$172.15
|
| Rate for Payer: Beech Street Commercial |
$175.73
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$147.22
|
| Rate for Payer: Cash Price |
$125.53
|
| Rate for Payer: ChoiceCare Network Commercial |
$173.94
|
| Rate for Payer: Cigna of WY Commercial |
$175.73
|
| Rate for Payer: Entrust Commercial |
$170.35
|
| Rate for Payer: First Choice Health Commercial |
$170.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$170.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$118.35
|
| Rate for Payer: HealthUtah PPO |
$179.32
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$173.94
|
| Rate for Payer: Multiplan Medicare/VA |
$112.43
|
| Rate for Payer: One Health Plan of WY PPO |
$175.73
|
| Rate for Payer: PacificSource Commercial |
$161.39
|
| Rate for Payer: PHCS PPO |
$175.73
|
| Rate for Payer: Three Rivers PPO |
$134.49
|
| Rate for Payer: TriWest Veterans Administration |
$118.35
|
| Rate for Payer: United Healthcare Commercial |
$156.01
|
| Rate for Payer: United Healthcare Medicare |
$118.35
|
| Rate for Payer: WINHealth Partners Commercial |
$170.35
|
| Rate for Payer: Wise Provider Network Commercial |
$170.35
|
|
|
DIPHTH,PERTUS(AC)TETANUS(PF)2 LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SYRINGE [52987]
|
Facility
|
OP
|
$179.32
|
|
|
Service Code
|
HCPCS 90715
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$98.81 |
| Max. Negotiated Rate |
$179.32 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$175.73
|
| Rate for Payer: Aetna of WY Medicare |
$118.35
|
| Rate for Payer: Altius Auto/Workers Compensation |
$172.15
|
| Rate for Payer: Altius Commercial |
$172.15
|
| Rate for Payer: Beech Street Commercial |
$175.73
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$147.22
|
| Rate for Payer: Cash Price |
$125.53
|
| Rate for Payer: ChoiceCare Network Commercial |
$173.94
|
| Rate for Payer: Cigna of WY Commercial |
$175.73
|
| Rate for Payer: Entrust Commercial |
$170.35
|
| Rate for Payer: First Choice Health Commercial |
$170.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$170.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$104.01
|
| Rate for Payer: HealthUtah PPO |
$179.32
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$173.94
|
| Rate for Payer: Multiplan Medicare/VA |
$98.81
|
| Rate for Payer: One Health Plan of WY PPO |
$175.73
|
| Rate for Payer: PacificSource Commercial |
$161.39
|
| Rate for Payer: PHCS PPO |
$175.73
|
| Rate for Payer: Three Rivers PPO |
$134.49
|
| Rate for Payer: TriWest Veterans Administration |
$104.01
|
| Rate for Payer: United Healthcare Commercial |
$156.01
|
| Rate for Payer: United Healthcare Medicare |
$104.01
|
| Rate for Payer: WINHealth Partners Commercial |
$175.73
|
| Rate for Payer: Wise Provider Network Commercial |
$170.35
|
|
|
DIPHTH TETANUS TOX ACELL PERTUSSIS VACC<7 YR IM
|
Professional
|
Both
|
$101.00
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
90700
|
| Min. Negotiated Rate |
$75.75 |
| Max. Negotiated Rate |
$101.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$98.98
|
| Rate for Payer: Beech Street Commercial |
$95.95
|
| Rate for Payer: Cash Price |
$70.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$97.97
|
| Rate for Payer: Cigna of WY Commercial |
$98.98
|
| Rate for Payer: First Choice Health Commercial |
$90.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$95.95
|
| Rate for Payer: HealthUtah PPO |
$101.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$97.97
|
| Rate for Payer: One Health Plan of WY PPO |
$98.98
|
| Rate for Payer: PacificSource Commercial |
$90.90
|
| Rate for Payer: PHCS PPO |
$95.95
|
| Rate for Payer: Three Rivers PPO |
$75.75
|
| Rate for Payer: United Healthcare Commercial |
$87.87
|
| Rate for Payer: WINHealth Partners Commercial |
$101.00
|
|
|
DIP,PERT(A)TET-HEPB-POLIO-HIB PED(PF) 15-5 UNIT-10 MCG/0.5 ML IM SYRNG [160794]
|
Facility
|
OP
|
$304.41
|
|
|
Service Code
|
NDC 6336124315
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$167.73 |
| Max. Negotiated Rate |
$304.41 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$298.32
|
| Rate for Payer: Aetna of WY Medicare |
$200.91
|
| Rate for Payer: Altius Auto/Workers Compensation |
$292.23
|
| Rate for Payer: Altius Commercial |
$292.23
|
| Rate for Payer: Beech Street Commercial |
$298.32
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$249.92
|
| Rate for Payer: Cash Price |
$213.09
|
| Rate for Payer: ChoiceCare Network Commercial |
$295.28
|
| Rate for Payer: Cigna of WY Commercial |
$298.32
|
| Rate for Payer: Entrust Commercial |
$289.19
|
| Rate for Payer: First Choice Health Commercial |
$289.19
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$289.19
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$176.56
|
| Rate for Payer: HealthUtah PPO |
$304.41
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$295.28
|
| Rate for Payer: Multiplan Medicare/VA |
$167.73
|
| Rate for Payer: One Health Plan of WY PPO |
$298.32
|
| Rate for Payer: PacificSource Commercial |
$273.97
|
| Rate for Payer: PHCS PPO |
$298.32
|
| Rate for Payer: Three Rivers PPO |
$228.31
|
| Rate for Payer: TriWest Veterans Administration |
$176.56
|
| Rate for Payer: United Healthcare Commercial |
$264.84
|
| Rate for Payer: United Healthcare Medicare |
$176.56
|
| Rate for Payer: WINHealth Partners Commercial |
$298.32
|
| Rate for Payer: Wise Provider Network Commercial |
$289.19
|
|
|
DIP,PERT(A)TET-HEPB-POLIO-HIB PED(PF) 15-5 UNIT-10 MCG/0.5 ML IM SYRNG [160794]
|
Facility
|
IP
|
$304.41
|
|
|
Service Code
|
NDC 6336124315
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$190.87 |
| Max. Negotiated Rate |
$304.41 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$298.32
|
| Rate for Payer: Altius Auto/Workers Compensation |
$292.23
|
| Rate for Payer: Altius Commercial |
$292.23
|
| Rate for Payer: Beech Street Commercial |
$298.32
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$249.92
|
| Rate for Payer: Cash Price |
$213.09
|
| Rate for Payer: ChoiceCare Network Commercial |
$295.28
|
| Rate for Payer: Cigna of WY Commercial |
$298.32
|
| Rate for Payer: Entrust Commercial |
$289.19
|
| Rate for Payer: First Choice Health Commercial |
$289.19
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$289.19
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$200.91
|
| Rate for Payer: HealthUtah PPO |
$304.41
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$295.28
|
| Rate for Payer: Multiplan Medicare/VA |
$190.87
|
| Rate for Payer: One Health Plan of WY PPO |
$298.32
|
| Rate for Payer: PacificSource Commercial |
$273.97
|
| Rate for Payer: PHCS PPO |
$298.32
|
| Rate for Payer: Three Rivers PPO |
$228.31
|
| Rate for Payer: TriWest Veterans Administration |
$200.91
|
| Rate for Payer: United Healthcare Commercial |
$264.84
|
| Rate for Payer: United Healthcare Medicare |
$200.91
|
| Rate for Payer: WINHealth Partners Commercial |
$289.19
|
| Rate for Payer: Wise Provider Network Commercial |
$289.19
|
|
|
DIP,PERT(A)TET-HEPB-POLIO-HIB PED(PF) 15-5 UNIT-10 MCG/0.5 ML IM SYRNG [160794]
|
Facility
|
IP
|
$304.24
|
|
|
Service Code
|
NDC 6336124388
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$190.76 |
| Max. Negotiated Rate |
$304.24 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$298.16
|
| Rate for Payer: Altius Auto/Workers Compensation |
$292.07
|
| Rate for Payer: Altius Commercial |
$292.07
|
| Rate for Payer: Beech Street Commercial |
$298.16
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$249.78
|
| Rate for Payer: Cash Price |
$212.97
|
| Rate for Payer: ChoiceCare Network Commercial |
$295.11
|
| Rate for Payer: Cigna of WY Commercial |
$298.16
|
| Rate for Payer: Entrust Commercial |
$289.03
|
| Rate for Payer: First Choice Health Commercial |
$289.03
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$289.03
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$200.80
|
| Rate for Payer: HealthUtah PPO |
$304.24
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$295.11
|
| Rate for Payer: Multiplan Medicare/VA |
$190.76
|
| Rate for Payer: One Health Plan of WY PPO |
$298.16
|
| Rate for Payer: PacificSource Commercial |
$273.82
|
| Rate for Payer: PHCS PPO |
$298.16
|
| Rate for Payer: Three Rivers PPO |
$228.18
|
| Rate for Payer: TriWest Veterans Administration |
$200.80
|
| Rate for Payer: United Healthcare Commercial |
$264.69
|
| Rate for Payer: United Healthcare Medicare |
$200.80
|
| Rate for Payer: WINHealth Partners Commercial |
$289.03
|
| Rate for Payer: Wise Provider Network Commercial |
$289.03
|
|
|
DIP,PERT(A)TET-HEPB-POLIO-HIB PED(PF) 15-5 UNIT-10 MCG/0.5 ML IM SYRNG [160794]
|
Facility
|
OP
|
$304.24
|
|
|
Service Code
|
NDC 6336124388
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$167.64 |
| Max. Negotiated Rate |
$304.24 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$298.16
|
| Rate for Payer: Aetna of WY Medicare |
$200.80
|
| Rate for Payer: Altius Auto/Workers Compensation |
$292.07
|
| Rate for Payer: Altius Commercial |
$292.07
|
| Rate for Payer: Beech Street Commercial |
$298.16
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$249.78
|
| Rate for Payer: Cash Price |
$212.97
|
| Rate for Payer: ChoiceCare Network Commercial |
$295.11
|
| Rate for Payer: Cigna of WY Commercial |
$298.16
|
| Rate for Payer: Entrust Commercial |
$289.03
|
| Rate for Payer: First Choice Health Commercial |
$289.03
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$289.03
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$176.46
|
| Rate for Payer: HealthUtah PPO |
$304.24
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$295.11
|
| Rate for Payer: Multiplan Medicare/VA |
$167.64
|
| Rate for Payer: One Health Plan of WY PPO |
$298.16
|
| Rate for Payer: PacificSource Commercial |
$273.82
|
| Rate for Payer: PHCS PPO |
$298.16
|
| Rate for Payer: Three Rivers PPO |
$228.18
|
| Rate for Payer: TriWest Veterans Administration |
$176.46
|
| Rate for Payer: United Healthcare Commercial |
$264.69
|
| Rate for Payer: United Healthcare Medicare |
$176.46
|
| Rate for Payer: WINHealth Partners Commercial |
$298.16
|
| Rate for Payer: Wise Provider Network Commercial |
$289.03
|
|
|
DISCECTOMY ANT DCMPRN CORD CERVICAL 1 NTRSPC
|
Professional
|
Both
|
$6,936.00
|
|
|
Service Code
|
HCPCS 63075 AS
|
| Hospital Charge Code |
63075
|
| Min. Negotiated Rate |
$1,096.12 |
| Max. Negotiated Rate |
$6,936.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$6,797.28
|
| Rate for Payer: Aetna of WY Medicare |
$1,289.55
|
| Rate for Payer: Beech Street Commercial |
$6,589.20
|
| Rate for Payer: Cash Price |
$4,855.20
|
| Rate for Payer: Cash Price |
$4,855.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$6,727.92
|
| Rate for Payer: Cigna of WY Commercial |
$6,797.28
|
| Rate for Payer: First Choice Health Commercial |
$6,242.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$6,589.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,289.55
|
| Rate for Payer: HealthUtah PPO |
$6,936.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$6,727.92
|
| Rate for Payer: Multiplan Medicare/VA |
$1,096.12
|
| Rate for Payer: One Health Plan of WY PPO |
$6,797.28
|
| Rate for Payer: PacificSource Commercial |
$6,242.40
|
| Rate for Payer: PHCS PPO |
$6,589.20
|
| Rate for Payer: Three Rivers PPO |
$5,202.00
|
| Rate for Payer: TriWest Veterans Administration |
$1,289.55
|
| Rate for Payer: United Healthcare Commercial |
$6,034.32
|
| Rate for Payer: United Healthcare Medicare |
$1,289.55
|
| Rate for Payer: WINHealth Partners Commercial |
$5,895.60
|
|
|
DISCECTOMY ANT DCMPRN CORD CERVICAL 1 NTRSPC
|
Professional
|
Both
|
$6,936.00
|
|
|
Service Code
|
HCPCS 63075
|
| Hospital Charge Code |
63075
|
| Min. Negotiated Rate |
$1,096.12 |
| Max. Negotiated Rate |
$6,936.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$6,797.28
|
| Rate for Payer: Aetna of WY Medicare |
$1,289.55
|
| Rate for Payer: Beech Street Commercial |
$6,589.20
|
| Rate for Payer: Cash Price |
$4,855.20
|
| Rate for Payer: Cash Price |
$4,855.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$6,727.92
|
| Rate for Payer: Cigna of WY Commercial |
$6,797.28
|
| Rate for Payer: First Choice Health Commercial |
$6,242.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$6,589.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,289.55
|
| Rate for Payer: HealthUtah PPO |
$6,936.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$6,727.92
|
| Rate for Payer: Multiplan Medicare/VA |
$1,096.12
|
| Rate for Payer: One Health Plan of WY PPO |
$6,797.28
|
| Rate for Payer: PacificSource Commercial |
$6,242.40
|
| Rate for Payer: PHCS PPO |
$6,589.20
|
| Rate for Payer: Three Rivers PPO |
$5,202.00
|
| Rate for Payer: TriWest Veterans Administration |
$1,289.55
|
| Rate for Payer: United Healthcare Commercial |
$6,034.32
|
| Rate for Payer: United Healthcare Medicare |
$1,289.55
|
| Rate for Payer: WINHealth Partners Commercial |
$5,895.60
|
|
|
DISCECTOMY ANT DCMPRN CORD CERVICAL EA NTRSPC
|
Professional
|
Both
|
$1,262.00
|
|
|
Service Code
|
HCPCS 63076 AS
|
| Hospital Charge Code |
63076
|
| Min. Negotiated Rate |
$192.38 |
| Max. Negotiated Rate |
$1,262.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,236.76
|
| Rate for Payer: Aetna of WY Medicare |
$226.33
|
| Rate for Payer: Beech Street Commercial |
$1,198.90
|
| Rate for Payer: Cash Price |
$883.40
|
| Rate for Payer: Cash Price |
$883.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,224.14
|
| Rate for Payer: Cigna of WY Commercial |
$1,236.76
|
| Rate for Payer: First Choice Health Commercial |
$1,135.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,198.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$226.33
|
| Rate for Payer: HealthUtah PPO |
$1,262.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,224.14
|
| Rate for Payer: Multiplan Medicare/VA |
$192.38
|
| Rate for Payer: One Health Plan of WY PPO |
$1,236.76
|
| Rate for Payer: PacificSource Commercial |
$1,135.80
|
| Rate for Payer: PHCS PPO |
$1,198.90
|
| Rate for Payer: Three Rivers PPO |
$946.50
|
| Rate for Payer: TriWest Veterans Administration |
$226.33
|
| Rate for Payer: United Healthcare Commercial |
$1,097.94
|
| Rate for Payer: United Healthcare Medicare |
$226.33
|
| Rate for Payer: WINHealth Partners Commercial |
$1,072.70
|
|
|
DISCECTOMY ANT DCMPRN CORD CERVICAL EA NTRSPC
|
Professional
|
Both
|
$1,262.00
|
|
|
Service Code
|
HCPCS 63076
|
| Hospital Charge Code |
63076
|
| Min. Negotiated Rate |
$192.38 |
| Max. Negotiated Rate |
$1,262.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,236.76
|
| Rate for Payer: Aetna of WY Medicare |
$226.33
|
| Rate for Payer: Beech Street Commercial |
$1,198.90
|
| Rate for Payer: Cash Price |
$883.40
|
| Rate for Payer: Cash Price |
$883.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,224.14
|
| Rate for Payer: Cigna of WY Commercial |
$1,236.76
|
| Rate for Payer: First Choice Health Commercial |
$1,135.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,198.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$226.33
|
| Rate for Payer: HealthUtah PPO |
$1,262.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,224.14
|
| Rate for Payer: Multiplan Medicare/VA |
$192.38
|
| Rate for Payer: One Health Plan of WY PPO |
$1,236.76
|
| Rate for Payer: PacificSource Commercial |
$1,135.80
|
| Rate for Payer: PHCS PPO |
$1,198.90
|
| Rate for Payer: Three Rivers PPO |
$946.50
|
| Rate for Payer: TriWest Veterans Administration |
$226.33
|
| Rate for Payer: United Healthcare Commercial |
$1,097.94
|
| Rate for Payer: United Healthcare Medicare |
$226.33
|
| Rate for Payer: WINHealth Partners Commercial |
$1,072.70
|
|
|
DISE DYN EVAL SLEEP DISORDERED BREATHING FLX DX
|
Professional
|
Both
|
$333.00
|
|
|
Service Code
|
HCPCS 42975
|
| Hospital Charge Code |
42975
|
| Min. Negotiated Rate |
$79.32 |
| Max. Negotiated Rate |
$333.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$326.34
|
| Rate for Payer: Aetna of WY Medicare |
$93.32
|
| Rate for Payer: Beech Street Commercial |
$316.35
|
| Rate for Payer: Cash Price |
$233.10
|
| Rate for Payer: Cash Price |
$233.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$323.01
|
| Rate for Payer: Cigna of WY Commercial |
$326.34
|
| Rate for Payer: First Choice Health Commercial |
$299.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$316.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$93.32
|
| Rate for Payer: HealthUtah PPO |
$333.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$323.01
|
| Rate for Payer: Multiplan Medicare/VA |
$79.32
|
| Rate for Payer: One Health Plan of WY PPO |
$326.34
|
| Rate for Payer: PacificSource Commercial |
$299.70
|
| Rate for Payer: PHCS PPO |
$316.35
|
| Rate for Payer: Three Rivers PPO |
$249.75
|
| Rate for Payer: TriWest Veterans Administration |
$93.32
|
| Rate for Payer: United Healthcare Commercial |
$289.71
|
| Rate for Payer: United Healthcare Medicare |
$93.32
|
| Rate for Payer: WINHealth Partners Commercial |
$283.05
|
|
|
DISPENSING FEE BINAURAL
|
Professional
|
Both
|
$200.00
|
|
|
Service Code
|
HCPCS V5160
|
| Hospital Charge Code |
V5160
|
| Min. Negotiated Rate |
$150.00 |
| Max. Negotiated Rate |
$200.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$196.00
|
| Rate for Payer: Beech Street Commercial |
$190.00
|
| Rate for Payer: Cash Price |
$140.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$194.00
|
| Rate for Payer: Cigna of WY Commercial |
$196.00
|
| Rate for Payer: First Choice Health Commercial |
$180.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$190.00
|
| Rate for Payer: HealthUtah PPO |
$200.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$194.00
|
| Rate for Payer: One Health Plan of WY PPO |
$196.00
|
| Rate for Payer: PacificSource Commercial |
$180.00
|
| Rate for Payer: PHCS PPO |
$190.00
|
| Rate for Payer: Three Rivers PPO |
$150.00
|
| Rate for Payer: United Healthcare Commercial |
$174.00
|
| Rate for Payer: WINHealth Partners Commercial |
$190.00
|
|
|
DISSECTOR CURVED 3.5MM 8350CDS
|
Facility
|
IP
|
$269.82
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$169.18 |
| Max. Negotiated Rate |
$269.82 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$264.42
|
| Rate for Payer: Altius Auto/Workers Compensation |
$259.03
|
| Rate for Payer: Altius Commercial |
$259.03
|
| Rate for Payer: Beech Street Commercial |
$264.42
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$221.52
|
| Rate for Payer: Cash Price |
$188.87
|
| Rate for Payer: ChoiceCare Network Commercial |
$261.73
|
| Rate for Payer: Cigna of WY Commercial |
$264.42
|
| Rate for Payer: Entrust Commercial |
$256.33
|
| Rate for Payer: First Choice Health Commercial |
$256.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$256.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$178.08
|
| Rate for Payer: HealthUtah PPO |
$269.82
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$261.73
|
| Rate for Payer: Multiplan Medicare/VA |
$169.18
|
| Rate for Payer: One Health Plan of WY PPO |
$264.42
|
| Rate for Payer: PacificSource Commercial |
$242.84
|
| Rate for Payer: PHCS PPO |
$264.42
|
| Rate for Payer: Three Rivers PPO |
$202.36
|
| Rate for Payer: TriWest Veterans Administration |
$178.08
|
| Rate for Payer: United Healthcare Commercial |
$234.74
|
| Rate for Payer: United Healthcare Medicare |
$178.08
|
| Rate for Payer: WINHealth Partners Commercial |
$256.33
|
| Rate for Payer: Wise Provider Network Commercial |
$256.33
|
|
|
DISSECTOR CURVED 3.5MM 8350CDS
|
Facility
|
OP
|
$269.82
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$148.67 |
| Max. Negotiated Rate |
$269.82 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$264.42
|
| Rate for Payer: Aetna of WY Medicare |
$178.08
|
| Rate for Payer: Altius Auto/Workers Compensation |
$259.03
|
| Rate for Payer: Altius Commercial |
$259.03
|
| Rate for Payer: Beech Street Commercial |
$264.42
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$221.52
|
| Rate for Payer: Cash Price |
$188.87
|
| Rate for Payer: ChoiceCare Network Commercial |
$261.73
|
| Rate for Payer: Cigna of WY Commercial |
$264.42
|
| Rate for Payer: Entrust Commercial |
$256.33
|
| Rate for Payer: First Choice Health Commercial |
$256.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$256.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$156.50
|
| Rate for Payer: HealthUtah PPO |
$269.82
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$261.73
|
| Rate for Payer: Multiplan Medicare/VA |
$148.67
|
| Rate for Payer: One Health Plan of WY PPO |
$264.42
|
| Rate for Payer: PacificSource Commercial |
$242.84
|
| Rate for Payer: PHCS PPO |
$264.42
|
| Rate for Payer: Three Rivers PPO |
$202.36
|
| Rate for Payer: TriWest Veterans Administration |
$156.50
|
| Rate for Payer: United Healthcare Commercial |
$234.74
|
| Rate for Payer: United Healthcare Medicare |
$156.50
|
| Rate for Payer: WINHealth Partners Commercial |
$264.42
|
| Rate for Payer: Wise Provider Network Commercial |
$256.33
|
|
|
DISSECTOR SMALL HUB 3.0MM X 7CM
|
Facility
|
OP
|
$269.82
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$148.67 |
| Max. Negotiated Rate |
$269.82 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$264.42
|
| Rate for Payer: Aetna of WY Medicare |
$178.08
|
| Rate for Payer: Altius Auto/Workers Compensation |
$259.03
|
| Rate for Payer: Altius Commercial |
$259.03
|
| Rate for Payer: Beech Street Commercial |
$264.42
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$221.52
|
| Rate for Payer: Cash Price |
$188.87
|
| Rate for Payer: ChoiceCare Network Commercial |
$261.73
|
| Rate for Payer: Cigna of WY Commercial |
$264.42
|
| Rate for Payer: Entrust Commercial |
$256.33
|
| Rate for Payer: First Choice Health Commercial |
$256.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$256.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$156.50
|
| Rate for Payer: HealthUtah PPO |
$269.82
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$261.73
|
| Rate for Payer: Multiplan Medicare/VA |
$148.67
|
| Rate for Payer: One Health Plan of WY PPO |
$264.42
|
| Rate for Payer: PacificSource Commercial |
$242.84
|
| Rate for Payer: PHCS PPO |
$264.42
|
| Rate for Payer: Three Rivers PPO |
$202.36
|
| Rate for Payer: TriWest Veterans Administration |
$156.50
|
| Rate for Payer: United Healthcare Commercial |
$234.74
|
| Rate for Payer: United Healthcare Medicare |
$156.50
|
| Rate for Payer: WINHealth Partners Commercial |
$264.42
|
| Rate for Payer: Wise Provider Network Commercial |
$256.33
|
|
|
DISSECTOR SMALL HUB 3.0MM X 7CM
|
Facility
|
IP
|
$269.82
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$169.18 |
| Max. Negotiated Rate |
$269.82 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$264.42
|
| Rate for Payer: Altius Auto/Workers Compensation |
$259.03
|
| Rate for Payer: Altius Commercial |
$259.03
|
| Rate for Payer: Beech Street Commercial |
$264.42
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$221.52
|
| Rate for Payer: Cash Price |
$188.87
|
| Rate for Payer: ChoiceCare Network Commercial |
$261.73
|
| Rate for Payer: Cigna of WY Commercial |
$264.42
|
| Rate for Payer: Entrust Commercial |
$256.33
|
| Rate for Payer: First Choice Health Commercial |
$256.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$256.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$178.08
|
| Rate for Payer: HealthUtah PPO |
$269.82
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$261.73
|
| Rate for Payer: Multiplan Medicare/VA |
$169.18
|
| Rate for Payer: One Health Plan of WY PPO |
$264.42
|
| Rate for Payer: PacificSource Commercial |
$242.84
|
| Rate for Payer: PHCS PPO |
$264.42
|
| Rate for Payer: Three Rivers PPO |
$202.36
|
| Rate for Payer: TriWest Veterans Administration |
$178.08
|
| Rate for Payer: United Healthcare Commercial |
$234.74
|
| Rate for Payer: United Healthcare Medicare |
$178.08
|
| Rate for Payer: WINHealth Partners Commercial |
$256.33
|
| Rate for Payer: Wise Provider Network Commercial |
$256.33
|
|
|
DISTRACTOR PIN 14MM
|
Facility
|
OP
|
$79.45
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$43.78 |
| Max. Negotiated Rate |
$79.45 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$77.86
|
| Rate for Payer: Aetna of WY Medicare |
$52.44
|
| Rate for Payer: Altius Auto/Workers Compensation |
$76.27
|
| Rate for Payer: Altius Commercial |
$76.27
|
| Rate for Payer: Beech Street Commercial |
$77.86
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$65.23
|
| Rate for Payer: Cash Price |
$55.62
|
| Rate for Payer: ChoiceCare Network Commercial |
$77.07
|
| Rate for Payer: Cigna of WY Commercial |
$77.86
|
| Rate for Payer: Entrust Commercial |
$75.48
|
| Rate for Payer: First Choice Health Commercial |
$75.48
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$75.48
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$46.08
|
| Rate for Payer: HealthUtah PPO |
$79.45
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$77.07
|
| Rate for Payer: Multiplan Medicare/VA |
$43.78
|
| Rate for Payer: One Health Plan of WY PPO |
$77.86
|
| Rate for Payer: PacificSource Commercial |
$71.50
|
| Rate for Payer: PHCS PPO |
$77.86
|
| Rate for Payer: Three Rivers PPO |
$59.59
|
| Rate for Payer: TriWest Veterans Administration |
$46.08
|
| Rate for Payer: United Healthcare Commercial |
$69.12
|
| Rate for Payer: United Healthcare Medicare |
$46.08
|
| Rate for Payer: WINHealth Partners Commercial |
$77.86
|
| Rate for Payer: Wise Provider Network Commercial |
$75.48
|
|
|
DISTRACTOR PIN 14MM
|
Facility
|
IP
|
$79.45
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$49.82 |
| Max. Negotiated Rate |
$79.45 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$77.86
|
| Rate for Payer: Altius Auto/Workers Compensation |
$76.27
|
| Rate for Payer: Altius Commercial |
$76.27
|
| Rate for Payer: Beech Street Commercial |
$77.86
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$65.23
|
| Rate for Payer: Cash Price |
$55.62
|
| Rate for Payer: ChoiceCare Network Commercial |
$77.07
|
| Rate for Payer: Cigna of WY Commercial |
$77.86
|
| Rate for Payer: Entrust Commercial |
$75.48
|
| Rate for Payer: First Choice Health Commercial |
$75.48
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$75.48
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$52.44
|
| Rate for Payer: HealthUtah PPO |
$79.45
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$77.07
|
| Rate for Payer: Multiplan Medicare/VA |
$49.82
|
| Rate for Payer: One Health Plan of WY PPO |
$77.86
|
| Rate for Payer: PacificSource Commercial |
$71.50
|
| Rate for Payer: PHCS PPO |
$77.86
|
| Rate for Payer: Three Rivers PPO |
$59.59
|
| Rate for Payer: TriWest Veterans Administration |
$52.44
|
| Rate for Payer: United Healthcare Commercial |
$69.12
|
| Rate for Payer: United Healthcare Medicare |
$52.44
|
| Rate for Payer: WINHealth Partners Commercial |
$75.48
|
| Rate for Payer: Wise Provider Network Commercial |
$75.48
|
|
|
DIVALPROEX 250 MG TABLET,DELAYED RELEASE [2620]
|
Facility
|
OP
|
$0.88
|
|
|
Service Code
|
NDC 0832712389
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$0.88 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.86
|
| Rate for Payer: Aetna of WY Medicare |
$0.58
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.84
|
| Rate for Payer: Altius Commercial |
$0.84
|
| Rate for Payer: Beech Street Commercial |
$0.86
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.72
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.85
|
| Rate for Payer: Cigna of WY Commercial |
$0.86
|
| Rate for Payer: Entrust Commercial |
$0.84
|
| Rate for Payer: First Choice Health Commercial |
$0.84
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.84
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.51
|
| Rate for Payer: HealthUtah PPO |
$0.88
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.85
|
| Rate for Payer: Multiplan Medicare/VA |
$0.48
|
| Rate for Payer: One Health Plan of WY PPO |
$0.86
|
| Rate for Payer: PacificSource Commercial |
$0.79
|
| Rate for Payer: PHCS PPO |
$0.86
|
| Rate for Payer: Three Rivers PPO |
$0.66
|
| Rate for Payer: TriWest Veterans Administration |
$0.51
|
| Rate for Payer: United Healthcare Commercial |
$0.77
|
| Rate for Payer: United Healthcare Medicare |
$0.51
|
| Rate for Payer: WINHealth Partners Commercial |
$0.86
|
| Rate for Payer: Wise Provider Network Commercial |
$0.84
|
|
|
DIVALPROEX 250 MG TABLET,DELAYED RELEASE [2620]
|
Facility
|
IP
|
$0.88
|
|
|
Service Code
|
NDC 0832712389
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$0.88 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.86
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.84
|
| Rate for Payer: Altius Commercial |
$0.84
|
| Rate for Payer: Beech Street Commercial |
$0.86
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.72
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.85
|
| Rate for Payer: Cigna of WY Commercial |
$0.86
|
| Rate for Payer: Entrust Commercial |
$0.84
|
| Rate for Payer: First Choice Health Commercial |
$0.84
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.84
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.58
|
| Rate for Payer: HealthUtah PPO |
$0.88
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.85
|
| Rate for Payer: Multiplan Medicare/VA |
$0.55
|
| Rate for Payer: One Health Plan of WY PPO |
$0.86
|
| Rate for Payer: PacificSource Commercial |
$0.79
|
| Rate for Payer: PHCS PPO |
$0.86
|
| Rate for Payer: Three Rivers PPO |
$0.66
|
| Rate for Payer: TriWest Veterans Administration |
$0.58
|
| Rate for Payer: United Healthcare Commercial |
$0.77
|
| Rate for Payer: United Healthcare Medicare |
$0.58
|
| Rate for Payer: WINHealth Partners Commercial |
$0.84
|
| Rate for Payer: Wise Provider Network Commercial |
$0.84
|
|
|
DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION [54830]
|
Facility
|
OP
|
$16.52
|
|
|
Service Code
|
HCPCS J1250
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.10 |
| Max. Negotiated Rate |
$16.52 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.19
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.06
|
| Rate for Payer: Aetna of WY Medicare |
$10.90
|
| Rate for Payer: Aetna of WY Medicare |
$10.82
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.73
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.86
|
| Rate for Payer: Altius Commercial |
$15.86
|
| Rate for Payer: Altius Commercial |
$15.73
|
| Rate for Payer: Beech Street Commercial |
$16.06
|
| Rate for Payer: Beech Street Commercial |
$16.19
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.56
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.46
|
| Rate for Payer: Cash Price |
$11.47
|
| Rate for Payer: Cash Price |
$11.57
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.02
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.90
|
| Rate for Payer: Cigna of WY Commercial |
$16.06
|
| Rate for Payer: Cigna of WY Commercial |
$16.19
|
| Rate for Payer: Entrust Commercial |
$15.69
|
| Rate for Payer: Entrust Commercial |
$15.57
|
| Rate for Payer: First Choice Health Commercial |
$15.57
|
| Rate for Payer: First Choice Health Commercial |
$15.69
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.69
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.51
|
| Rate for Payer: HealthUtah PPO |
$16.39
|
| Rate for Payer: HealthUtah PPO |
$16.52
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.90
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.02
|
| Rate for Payer: Multiplan Medicare/VA |
$9.10
|
| Rate for Payer: Multiplan Medicare/VA |
$9.03
|
| Rate for Payer: One Health Plan of WY PPO |
$16.06
|
| Rate for Payer: One Health Plan of WY PPO |
$16.19
|
| Rate for Payer: PacificSource Commercial |
$14.87
|
| Rate for Payer: PacificSource Commercial |
$14.75
|
| Rate for Payer: PHCS PPO |
$16.06
|
| Rate for Payer: PHCS PPO |
$16.19
|
| Rate for Payer: Three Rivers PPO |
$12.29
|
| Rate for Payer: Three Rivers PPO |
$12.39
|
| Rate for Payer: TriWest Veterans Administration |
$9.58
|
| Rate for Payer: TriWest Veterans Administration |
$9.51
|
| Rate for Payer: United Healthcare Commercial |
$14.26
|
| Rate for Payer: United Healthcare Commercial |
$14.37
|
| Rate for Payer: United Healthcare Medicare |
$9.58
|
| Rate for Payer: United Healthcare Medicare |
$9.51
|
| Rate for Payer: WINHealth Partners Commercial |
$16.06
|
| Rate for Payer: WINHealth Partners Commercial |
$16.19
|
| Rate for Payer: Wise Provider Network Commercial |
$15.57
|
| Rate for Payer: Wise Provider Network Commercial |
$15.69
|
|
|
DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION [54830]
|
Facility
|
IP
|
$16.52
|
|
|
Service Code
|
HCPCS J1250
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.36 |
| Max. Negotiated Rate |
$16.52 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.19
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.06
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.86
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.73
|
| Rate for Payer: Altius Commercial |
$15.73
|
| Rate for Payer: Altius Commercial |
$15.86
|
| Rate for Payer: Beech Street Commercial |
$16.19
|
| Rate for Payer: Beech Street Commercial |
$16.06
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.46
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.56
|
| Rate for Payer: Cash Price |
$11.57
|
| Rate for Payer: Cash Price |
$11.47
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.02
|
| Rate for Payer: Cigna of WY Commercial |
$16.19
|
| Rate for Payer: Cigna of WY Commercial |
$16.06
|
| Rate for Payer: Entrust Commercial |
$15.57
|
| Rate for Payer: Entrust Commercial |
$15.69
|
| Rate for Payer: First Choice Health Commercial |
$15.57
|
| Rate for Payer: First Choice Health Commercial |
$15.69
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.69
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.82
|
| Rate for Payer: HealthUtah PPO |
$16.52
|
| Rate for Payer: HealthUtah PPO |
$16.39
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.90
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.02
|
| Rate for Payer: Multiplan Medicare/VA |
$10.36
|
| Rate for Payer: Multiplan Medicare/VA |
$10.28
|
| Rate for Payer: One Health Plan of WY PPO |
$16.19
|
| Rate for Payer: One Health Plan of WY PPO |
$16.06
|
| Rate for Payer: PacificSource Commercial |
$14.87
|
| Rate for Payer: PacificSource Commercial |
$14.75
|
| Rate for Payer: PHCS PPO |
$16.06
|
| Rate for Payer: PHCS PPO |
$16.19
|
| Rate for Payer: Three Rivers PPO |
$12.29
|
| Rate for Payer: Three Rivers PPO |
$12.39
|
| Rate for Payer: TriWest Veterans Administration |
$10.90
|
| Rate for Payer: TriWest Veterans Administration |
$10.82
|
| Rate for Payer: United Healthcare Commercial |
$14.26
|
| Rate for Payer: United Healthcare Commercial |
$14.37
|
| Rate for Payer: United Healthcare Medicare |
$10.90
|
| Rate for Payer: United Healthcare Medicare |
$10.82
|
| Rate for Payer: WINHealth Partners Commercial |
$15.57
|
| Rate for Payer: WINHealth Partners Commercial |
$15.69
|
| Rate for Payer: Wise Provider Network Commercial |
$15.57
|
| Rate for Payer: Wise Provider Network Commercial |
$15.69
|
|
