|
DOT PHYSICAL
|
Professional
|
Both
|
$100.00
|
|
|
Service Code
|
HCPCS TY019
|
| Hospital Charge Code |
TY019
|
| Min. Negotiated Rate |
$75.00 |
| Max. Negotiated Rate |
$100.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$98.00
|
| Rate for Payer: Beech Street Commercial |
$95.00
|
| Rate for Payer: Cash Price |
$70.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$97.00
|
| Rate for Payer: Cigna of WY Commercial |
$98.00
|
| Rate for Payer: First Choice Health Commercial |
$90.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$95.00
|
| Rate for Payer: HealthUtah PPO |
$100.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$97.00
|
| Rate for Payer: One Health Plan of WY PPO |
$98.00
|
| Rate for Payer: PacificSource Commercial |
$90.00
|
| Rate for Payer: PHCS PPO |
$95.00
|
| Rate for Payer: Three Rivers PPO |
$75.00
|
| Rate for Payer: United Healthcare Commercial |
$87.00
|
| Rate for Payer: WINHealth Partners Commercial |
$95.00
|
|
|
DOXEPIN 10 MG/ML ORAL CONCENTRATE [14198]
|
Facility
|
IP
|
$1.90
|
|
|
Service Code
|
NDC 5483851240
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.19 |
| Max. Negotiated Rate |
$1.90 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.86
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.82
|
| Rate for Payer: Altius Commercial |
$1.82
|
| Rate for Payer: Beech Street Commercial |
$1.86
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.56
|
| Rate for Payer: Cash Price |
$1.33
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.84
|
| Rate for Payer: Cigna of WY Commercial |
$1.86
|
| Rate for Payer: Entrust Commercial |
$1.80
|
| Rate for Payer: First Choice Health Commercial |
$1.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.25
|
| Rate for Payer: HealthUtah PPO |
$1.90
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.84
|
| Rate for Payer: Multiplan Medicare/VA |
$1.19
|
| Rate for Payer: One Health Plan of WY PPO |
$1.86
|
| Rate for Payer: PacificSource Commercial |
$1.71
|
| Rate for Payer: PHCS PPO |
$1.86
|
| Rate for Payer: Three Rivers PPO |
$1.42
|
| Rate for Payer: TriWest Veterans Administration |
$1.25
|
| Rate for Payer: United Healthcare Commercial |
$1.65
|
| Rate for Payer: United Healthcare Medicare |
$1.25
|
| Rate for Payer: WINHealth Partners Commercial |
$1.80
|
| Rate for Payer: Wise Provider Network Commercial |
$1.80
|
|
|
DOXEPIN 10 MG/ML ORAL CONCENTRATE [14198]
|
Facility
|
OP
|
$1.90
|
|
|
Service Code
|
NDC 5483851240
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.05 |
| Max. Negotiated Rate |
$1.90 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.86
|
| Rate for Payer: Aetna of WY Medicare |
$1.25
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.82
|
| Rate for Payer: Altius Commercial |
$1.82
|
| Rate for Payer: Beech Street Commercial |
$1.86
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.56
|
| Rate for Payer: Cash Price |
$1.33
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.84
|
| Rate for Payer: Cigna of WY Commercial |
$1.86
|
| Rate for Payer: Entrust Commercial |
$1.80
|
| Rate for Payer: First Choice Health Commercial |
$1.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.10
|
| Rate for Payer: HealthUtah PPO |
$1.90
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.84
|
| Rate for Payer: Multiplan Medicare/VA |
$1.05
|
| Rate for Payer: One Health Plan of WY PPO |
$1.86
|
| Rate for Payer: PacificSource Commercial |
$1.71
|
| Rate for Payer: PHCS PPO |
$1.86
|
| Rate for Payer: Three Rivers PPO |
$1.42
|
| Rate for Payer: TriWest Veterans Administration |
$1.10
|
| Rate for Payer: United Healthcare Commercial |
$1.65
|
| Rate for Payer: United Healthcare Medicare |
$1.10
|
| Rate for Payer: WINHealth Partners Commercial |
$1.86
|
| Rate for Payer: Wise Provider Network Commercial |
$1.80
|
|
|
DOXORUBICIN 2 MG/ML INTRAVENOUS SOLUTION (WRAPPED) [4000713]
|
Facility
|
IP
|
$18.93
|
|
|
Service Code
|
HCPCS J9000
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.87 |
| Max. Negotiated Rate |
$18.93 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18.55
|
| Rate for Payer: Altius Auto/Workers Compensation |
$18.17
|
| Rate for Payer: Altius Commercial |
$18.17
|
| Rate for Payer: Beech Street Commercial |
$18.55
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.54
|
| Rate for Payer: Cash Price |
$13.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$18.36
|
| Rate for Payer: Cigna of WY Commercial |
$18.55
|
| Rate for Payer: Entrust Commercial |
$17.98
|
| Rate for Payer: First Choice Health Commercial |
$17.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$12.49
|
| Rate for Payer: HealthUtah PPO |
$18.93
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$18.36
|
| Rate for Payer: Multiplan Medicare/VA |
$11.87
|
| Rate for Payer: One Health Plan of WY PPO |
$18.55
|
| Rate for Payer: PacificSource Commercial |
$17.04
|
| Rate for Payer: PHCS PPO |
$18.55
|
| Rate for Payer: Three Rivers PPO |
$14.20
|
| Rate for Payer: TriWest Veterans Administration |
$12.49
|
| Rate for Payer: United Healthcare Commercial |
$16.47
|
| Rate for Payer: United Healthcare Medicare |
$12.49
|
| Rate for Payer: WINHealth Partners Commercial |
$17.98
|
| Rate for Payer: Wise Provider Network Commercial |
$17.98
|
|
|
DOXORUBICIN 2 MG/ML INTRAVENOUS SOLUTION (WRAPPED) [4000713]
|
Facility
|
OP
|
$18.93
|
|
|
Service Code
|
HCPCS J9000
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.43 |
| Max. Negotiated Rate |
$18.93 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18.55
|
| Rate for Payer: Aetna of WY Medicare |
$12.49
|
| Rate for Payer: Altius Auto/Workers Compensation |
$18.17
|
| Rate for Payer: Altius Commercial |
$18.17
|
| Rate for Payer: Beech Street Commercial |
$18.55
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.54
|
| Rate for Payer: Cash Price |
$13.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$18.36
|
| Rate for Payer: Cigna of WY Commercial |
$18.55
|
| Rate for Payer: Entrust Commercial |
$17.98
|
| Rate for Payer: First Choice Health Commercial |
$17.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.98
|
| Rate for Payer: HealthUtah PPO |
$18.93
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$18.36
|
| Rate for Payer: Multiplan Medicare/VA |
$10.43
|
| Rate for Payer: One Health Plan of WY PPO |
$18.55
|
| Rate for Payer: PacificSource Commercial |
$17.04
|
| Rate for Payer: PHCS PPO |
$18.55
|
| Rate for Payer: Three Rivers PPO |
$14.20
|
| Rate for Payer: TriWest Veterans Administration |
$10.98
|
| Rate for Payer: United Healthcare Commercial |
$16.47
|
| Rate for Payer: United Healthcare Medicare |
$10.98
|
| Rate for Payer: WINHealth Partners Commercial |
$18.55
|
| Rate for Payer: Wise Provider Network Commercial |
$17.98
|
|
|
DOXORUBICIN 50 MG/25 ML INTRAVENOUS SOLUTION [54482]
|
Facility
|
OP
|
$18.93
|
|
|
Service Code
|
HCPCS J9000
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.43 |
| Max. Negotiated Rate |
$18.93 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18.55
|
| Rate for Payer: Aetna of WY Medicare |
$12.49
|
| Rate for Payer: Altius Auto/Workers Compensation |
$18.17
|
| Rate for Payer: Altius Commercial |
$18.17
|
| Rate for Payer: Beech Street Commercial |
$18.55
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.54
|
| Rate for Payer: Cash Price |
$13.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$18.36
|
| Rate for Payer: Cigna of WY Commercial |
$18.55
|
| Rate for Payer: Entrust Commercial |
$17.98
|
| Rate for Payer: First Choice Health Commercial |
$17.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.98
|
| Rate for Payer: HealthUtah PPO |
$18.93
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$18.36
|
| Rate for Payer: Multiplan Medicare/VA |
$10.43
|
| Rate for Payer: One Health Plan of WY PPO |
$18.55
|
| Rate for Payer: PacificSource Commercial |
$17.04
|
| Rate for Payer: PHCS PPO |
$18.55
|
| Rate for Payer: Three Rivers PPO |
$14.20
|
| Rate for Payer: TriWest Veterans Administration |
$10.98
|
| Rate for Payer: United Healthcare Commercial |
$16.47
|
| Rate for Payer: United Healthcare Medicare |
$10.98
|
| Rate for Payer: WINHealth Partners Commercial |
$18.55
|
| Rate for Payer: Wise Provider Network Commercial |
$17.98
|
|
|
DOXORUBICIN 50 MG/25 ML INTRAVENOUS SOLUTION [54482]
|
Facility
|
IP
|
$18.93
|
|
|
Service Code
|
HCPCS J9000
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.87 |
| Max. Negotiated Rate |
$18.93 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18.55
|
| Rate for Payer: Altius Auto/Workers Compensation |
$18.17
|
| Rate for Payer: Altius Commercial |
$18.17
|
| Rate for Payer: Beech Street Commercial |
$18.55
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.54
|
| Rate for Payer: Cash Price |
$13.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$18.36
|
| Rate for Payer: Cigna of WY Commercial |
$18.55
|
| Rate for Payer: Entrust Commercial |
$17.98
|
| Rate for Payer: First Choice Health Commercial |
$17.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$12.49
|
| Rate for Payer: HealthUtah PPO |
$18.93
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$18.36
|
| Rate for Payer: Multiplan Medicare/VA |
$11.87
|
| Rate for Payer: One Health Plan of WY PPO |
$18.55
|
| Rate for Payer: PacificSource Commercial |
$17.04
|
| Rate for Payer: PHCS PPO |
$18.55
|
| Rate for Payer: Three Rivers PPO |
$14.20
|
| Rate for Payer: TriWest Veterans Administration |
$12.49
|
| Rate for Payer: United Healthcare Commercial |
$16.47
|
| Rate for Payer: United Healthcare Medicare |
$12.49
|
| Rate for Payer: WINHealth Partners Commercial |
$17.98
|
| Rate for Payer: Wise Provider Network Commercial |
$17.98
|
|
|
DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION [11178]
|
Facility
|
IP
|
$63.32
|
|
|
Service Code
|
NDC 6838291010
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.70 |
| Max. Negotiated Rate |
$63.32 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$62.05
|
| Rate for Payer: Altius Auto/Workers Compensation |
$60.79
|
| Rate for Payer: Altius Commercial |
$60.79
|
| Rate for Payer: Beech Street Commercial |
$62.05
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$51.99
|
| Rate for Payer: Cash Price |
$44.32
|
| Rate for Payer: ChoiceCare Network Commercial |
$61.42
|
| Rate for Payer: Cigna of WY Commercial |
$62.05
|
| Rate for Payer: Entrust Commercial |
$60.15
|
| Rate for Payer: First Choice Health Commercial |
$60.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$60.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$41.79
|
| Rate for Payer: HealthUtah PPO |
$63.32
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$61.42
|
| Rate for Payer: Multiplan Medicare/VA |
$39.70
|
| Rate for Payer: One Health Plan of WY PPO |
$62.05
|
| Rate for Payer: PacificSource Commercial |
$56.99
|
| Rate for Payer: PHCS PPO |
$62.05
|
| Rate for Payer: Three Rivers PPO |
$47.49
|
| Rate for Payer: TriWest Veterans Administration |
$41.79
|
| Rate for Payer: United Healthcare Commercial |
$55.09
|
| Rate for Payer: United Healthcare Medicare |
$41.79
|
| Rate for Payer: WINHealth Partners Commercial |
$60.15
|
| Rate for Payer: Wise Provider Network Commercial |
$60.15
|
|
|
DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION [11178]
|
Facility
|
OP
|
$63.32
|
|
|
Service Code
|
NDC 6838291001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$34.89 |
| Max. Negotiated Rate |
$63.32 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$62.05
|
| Rate for Payer: Aetna of WY Medicare |
$41.79
|
| Rate for Payer: Altius Auto/Workers Compensation |
$60.79
|
| Rate for Payer: Altius Commercial |
$60.79
|
| Rate for Payer: Beech Street Commercial |
$62.05
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$51.99
|
| Rate for Payer: Cash Price |
$44.32
|
| Rate for Payer: ChoiceCare Network Commercial |
$61.42
|
| Rate for Payer: Cigna of WY Commercial |
$62.05
|
| Rate for Payer: Entrust Commercial |
$60.15
|
| Rate for Payer: First Choice Health Commercial |
$60.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$60.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$36.73
|
| Rate for Payer: HealthUtah PPO |
$63.32
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$61.42
|
| Rate for Payer: Multiplan Medicare/VA |
$34.89
|
| Rate for Payer: One Health Plan of WY PPO |
$62.05
|
| Rate for Payer: PacificSource Commercial |
$56.99
|
| Rate for Payer: PHCS PPO |
$62.05
|
| Rate for Payer: Three Rivers PPO |
$47.49
|
| Rate for Payer: TriWest Veterans Administration |
$36.73
|
| Rate for Payer: United Healthcare Commercial |
$55.09
|
| Rate for Payer: United Healthcare Medicare |
$36.73
|
| Rate for Payer: WINHealth Partners Commercial |
$62.05
|
| Rate for Payer: Wise Provider Network Commercial |
$60.15
|
|
|
DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION [11178]
|
Facility
|
IP
|
$63.32
|
|
|
Service Code
|
NDC 6838291001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.70 |
| Max. Negotiated Rate |
$63.32 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$62.05
|
| Rate for Payer: Altius Auto/Workers Compensation |
$60.79
|
| Rate for Payer: Altius Commercial |
$60.79
|
| Rate for Payer: Beech Street Commercial |
$62.05
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$51.99
|
| Rate for Payer: Cash Price |
$44.32
|
| Rate for Payer: ChoiceCare Network Commercial |
$61.42
|
| Rate for Payer: Cigna of WY Commercial |
$62.05
|
| Rate for Payer: Entrust Commercial |
$60.15
|
| Rate for Payer: First Choice Health Commercial |
$60.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$60.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$41.79
|
| Rate for Payer: HealthUtah PPO |
$63.32
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$61.42
|
| Rate for Payer: Multiplan Medicare/VA |
$39.70
|
| Rate for Payer: One Health Plan of WY PPO |
$62.05
|
| Rate for Payer: PacificSource Commercial |
$56.99
|
| Rate for Payer: PHCS PPO |
$62.05
|
| Rate for Payer: Three Rivers PPO |
$47.49
|
| Rate for Payer: TriWest Veterans Administration |
$41.79
|
| Rate for Payer: United Healthcare Commercial |
$55.09
|
| Rate for Payer: United Healthcare Medicare |
$41.79
|
| Rate for Payer: WINHealth Partners Commercial |
$60.15
|
| Rate for Payer: Wise Provider Network Commercial |
$60.15
|
|
|
DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION [11178]
|
Facility
|
OP
|
$63.32
|
|
|
Service Code
|
NDC 6838291010
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$34.89 |
| Max. Negotiated Rate |
$63.32 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$62.05
|
| Rate for Payer: Aetna of WY Medicare |
$41.79
|
| Rate for Payer: Altius Auto/Workers Compensation |
$60.79
|
| Rate for Payer: Altius Commercial |
$60.79
|
| Rate for Payer: Beech Street Commercial |
$62.05
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$51.99
|
| Rate for Payer: Cash Price |
$44.32
|
| Rate for Payer: ChoiceCare Network Commercial |
$61.42
|
| Rate for Payer: Cigna of WY Commercial |
$62.05
|
| Rate for Payer: Entrust Commercial |
$60.15
|
| Rate for Payer: First Choice Health Commercial |
$60.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$60.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$36.73
|
| Rate for Payer: HealthUtah PPO |
$63.32
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$61.42
|
| Rate for Payer: Multiplan Medicare/VA |
$34.89
|
| Rate for Payer: One Health Plan of WY PPO |
$62.05
|
| Rate for Payer: PacificSource Commercial |
$56.99
|
| Rate for Payer: PHCS PPO |
$62.05
|
| Rate for Payer: Three Rivers PPO |
$47.49
|
| Rate for Payer: TriWest Veterans Administration |
$36.73
|
| Rate for Payer: United Healthcare Commercial |
$55.09
|
| Rate for Payer: United Healthcare Medicare |
$36.73
|
| Rate for Payer: WINHealth Partners Commercial |
$62.05
|
| Rate for Payer: Wise Provider Network Commercial |
$60.15
|
|
|
DOXYCYCLINE HYCLATE 100 MG TABLET [19334]
|
Facility
|
IP
|
$1.12
|
|
|
Service Code
|
NDC 0143211205
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.70 |
| Max. Negotiated Rate |
$1.12 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.10
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.08
|
| Rate for Payer: Altius Commercial |
$1.08
|
| Rate for Payer: Beech Street Commercial |
$1.10
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.92
|
| Rate for Payer: Cash Price |
$0.78
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.09
|
| Rate for Payer: Cigna of WY Commercial |
$1.10
|
| Rate for Payer: Entrust Commercial |
$1.06
|
| Rate for Payer: First Choice Health Commercial |
$1.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.74
|
| Rate for Payer: HealthUtah PPO |
$1.12
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.09
|
| Rate for Payer: Multiplan Medicare/VA |
$0.70
|
| Rate for Payer: One Health Plan of WY PPO |
$1.10
|
| Rate for Payer: PacificSource Commercial |
$1.01
|
| Rate for Payer: PHCS PPO |
$1.10
|
| Rate for Payer: Three Rivers PPO |
$0.84
|
| Rate for Payer: TriWest Veterans Administration |
$0.74
|
| Rate for Payer: United Healthcare Commercial |
$0.97
|
| Rate for Payer: United Healthcare Medicare |
$0.74
|
| Rate for Payer: WINHealth Partners Commercial |
$1.06
|
| Rate for Payer: Wise Provider Network Commercial |
$1.06
|
|
|
DOXYCYCLINE HYCLATE 100 MG TABLET [19334]
|
Facility
|
OP
|
$1.12
|
|
|
Service Code
|
NDC 0143211205
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$1.12 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.10
|
| Rate for Payer: Aetna of WY Medicare |
$0.74
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.08
|
| Rate for Payer: Altius Commercial |
$1.08
|
| Rate for Payer: Beech Street Commercial |
$1.10
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.92
|
| Rate for Payer: Cash Price |
$0.78
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.09
|
| Rate for Payer: Cigna of WY Commercial |
$1.10
|
| Rate for Payer: Entrust Commercial |
$1.06
|
| Rate for Payer: First Choice Health Commercial |
$1.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.65
|
| Rate for Payer: HealthUtah PPO |
$1.12
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.09
|
| Rate for Payer: Multiplan Medicare/VA |
$0.62
|
| Rate for Payer: One Health Plan of WY PPO |
$1.10
|
| Rate for Payer: PacificSource Commercial |
$1.01
|
| Rate for Payer: PHCS PPO |
$1.10
|
| Rate for Payer: Three Rivers PPO |
$0.84
|
| Rate for Payer: TriWest Veterans Administration |
$0.65
|
| Rate for Payer: United Healthcare Commercial |
$0.97
|
| Rate for Payer: United Healthcare Medicare |
$0.65
|
| Rate for Payer: WINHealth Partners Commercial |
$1.10
|
| Rate for Payer: Wise Provider Network Commercial |
$1.06
|
|
|
DOXYCYCLINE MONOHYDRATE 100 MG TABLET [7737]
|
Facility
|
IP
|
$8.80
|
|
|
Service Code
|
NDC 6068734495
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.52 |
| Max. Negotiated Rate |
$8.80 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$8.62
|
| Rate for Payer: Altius Auto/Workers Compensation |
$8.45
|
| Rate for Payer: Altius Commercial |
$8.45
|
| Rate for Payer: Beech Street Commercial |
$8.62
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$7.22
|
| Rate for Payer: Cash Price |
$6.16
|
| Rate for Payer: ChoiceCare Network Commercial |
$8.54
|
| Rate for Payer: Cigna of WY Commercial |
$8.62
|
| Rate for Payer: Entrust Commercial |
$8.36
|
| Rate for Payer: First Choice Health Commercial |
$8.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$8.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$5.81
|
| Rate for Payer: HealthUtah PPO |
$8.80
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$8.54
|
| Rate for Payer: Multiplan Medicare/VA |
$5.52
|
| Rate for Payer: One Health Plan of WY PPO |
$8.62
|
| Rate for Payer: PacificSource Commercial |
$7.92
|
| Rate for Payer: PHCS PPO |
$8.62
|
| Rate for Payer: Three Rivers PPO |
$6.60
|
| Rate for Payer: TriWest Veterans Administration |
$5.81
|
| Rate for Payer: United Healthcare Commercial |
$7.66
|
| Rate for Payer: United Healthcare Medicare |
$5.81
|
| Rate for Payer: WINHealth Partners Commercial |
$8.36
|
| Rate for Payer: Wise Provider Network Commercial |
$8.36
|
|
|
DOXYCYCLINE MONOHYDRATE 100 MG TABLET [7737]
|
Facility
|
OP
|
$8.80
|
|
|
Service Code
|
NDC 6068734495
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.85 |
| Max. Negotiated Rate |
$8.80 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$8.62
|
| Rate for Payer: Aetna of WY Medicare |
$5.81
|
| Rate for Payer: Altius Auto/Workers Compensation |
$8.45
|
| Rate for Payer: Altius Commercial |
$8.45
|
| Rate for Payer: Beech Street Commercial |
$8.62
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$7.22
|
| Rate for Payer: Cash Price |
$6.16
|
| Rate for Payer: ChoiceCare Network Commercial |
$8.54
|
| Rate for Payer: Cigna of WY Commercial |
$8.62
|
| Rate for Payer: Entrust Commercial |
$8.36
|
| Rate for Payer: First Choice Health Commercial |
$8.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$8.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$5.10
|
| Rate for Payer: HealthUtah PPO |
$8.80
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$8.54
|
| Rate for Payer: Multiplan Medicare/VA |
$4.85
|
| Rate for Payer: One Health Plan of WY PPO |
$8.62
|
| Rate for Payer: PacificSource Commercial |
$7.92
|
| Rate for Payer: PHCS PPO |
$8.62
|
| Rate for Payer: Three Rivers PPO |
$6.60
|
| Rate for Payer: TriWest Veterans Administration |
$5.10
|
| Rate for Payer: United Healthcare Commercial |
$7.66
|
| Rate for Payer: United Healthcare Medicare |
$5.10
|
| Rate for Payer: WINHealth Partners Commercial |
$8.62
|
| Rate for Payer: Wise Provider Network Commercial |
$8.36
|
|
|
DOXYCYCLINE MONOHYDRATE 100 MG TABLET [7737]
|
Facility
|
OP
|
$8.80
|
|
|
Service Code
|
NDC 6068734425
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.85 |
| Max. Negotiated Rate |
$8.80 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$8.62
|
| Rate for Payer: Aetna of WY Medicare |
$5.81
|
| Rate for Payer: Altius Auto/Workers Compensation |
$8.45
|
| Rate for Payer: Altius Commercial |
$8.45
|
| Rate for Payer: Beech Street Commercial |
$8.62
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$7.22
|
| Rate for Payer: Cash Price |
$6.16
|
| Rate for Payer: ChoiceCare Network Commercial |
$8.54
|
| Rate for Payer: Cigna of WY Commercial |
$8.62
|
| Rate for Payer: Entrust Commercial |
$8.36
|
| Rate for Payer: First Choice Health Commercial |
$8.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$8.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$5.10
|
| Rate for Payer: HealthUtah PPO |
$8.80
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$8.54
|
| Rate for Payer: Multiplan Medicare/VA |
$4.85
|
| Rate for Payer: One Health Plan of WY PPO |
$8.62
|
| Rate for Payer: PacificSource Commercial |
$7.92
|
| Rate for Payer: PHCS PPO |
$8.62
|
| Rate for Payer: Three Rivers PPO |
$6.60
|
| Rate for Payer: TriWest Veterans Administration |
$5.10
|
| Rate for Payer: United Healthcare Commercial |
$7.66
|
| Rate for Payer: United Healthcare Medicare |
$5.10
|
| Rate for Payer: WINHealth Partners Commercial |
$8.62
|
| Rate for Payer: Wise Provider Network Commercial |
$8.36
|
|
|
DOXYCYCLINE MONOHYDRATE 100 MG TABLET [7737]
|
Facility
|
IP
|
$8.80
|
|
|
Service Code
|
NDC 6068734425
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.52 |
| Max. Negotiated Rate |
$8.80 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$8.62
|
| Rate for Payer: Altius Auto/Workers Compensation |
$8.45
|
| Rate for Payer: Altius Commercial |
$8.45
|
| Rate for Payer: Beech Street Commercial |
$8.62
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$7.22
|
| Rate for Payer: Cash Price |
$6.16
|
| Rate for Payer: ChoiceCare Network Commercial |
$8.54
|
| Rate for Payer: Cigna of WY Commercial |
$8.62
|
| Rate for Payer: Entrust Commercial |
$8.36
|
| Rate for Payer: First Choice Health Commercial |
$8.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$8.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$5.81
|
| Rate for Payer: HealthUtah PPO |
$8.80
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$8.54
|
| Rate for Payer: Multiplan Medicare/VA |
$5.52
|
| Rate for Payer: One Health Plan of WY PPO |
$8.62
|
| Rate for Payer: PacificSource Commercial |
$7.92
|
| Rate for Payer: PHCS PPO |
$8.62
|
| Rate for Payer: Three Rivers PPO |
$6.60
|
| Rate for Payer: TriWest Veterans Administration |
$5.81
|
| Rate for Payer: United Healthcare Commercial |
$7.66
|
| Rate for Payer: United Healthcare Medicare |
$5.81
|
| Rate for Payer: WINHealth Partners Commercial |
$8.36
|
| Rate for Payer: Wise Provider Network Commercial |
$8.36
|
|
|
DOXYCYCLINE MONOHYDRATE 50 MG CAPSULE [9791]
|
Facility
|
IP
|
$2.17
|
|
|
Service Code
|
NDC 5026828015
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$2.17 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.13
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.08
|
| Rate for Payer: Altius Commercial |
$2.08
|
| Rate for Payer: Beech Street Commercial |
$2.13
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.78
|
| Rate for Payer: Cash Price |
$1.52
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.10
|
| Rate for Payer: Cigna of WY Commercial |
$2.13
|
| Rate for Payer: Entrust Commercial |
$2.06
|
| Rate for Payer: First Choice Health Commercial |
$2.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.43
|
| Rate for Payer: HealthUtah PPO |
$2.17
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.10
|
| Rate for Payer: Multiplan Medicare/VA |
$1.36
|
| Rate for Payer: One Health Plan of WY PPO |
$2.13
|
| Rate for Payer: PacificSource Commercial |
$1.95
|
| Rate for Payer: PHCS PPO |
$2.13
|
| Rate for Payer: Three Rivers PPO |
$1.63
|
| Rate for Payer: TriWest Veterans Administration |
$1.43
|
| Rate for Payer: United Healthcare Commercial |
$1.89
|
| Rate for Payer: United Healthcare Medicare |
$1.43
|
| Rate for Payer: WINHealth Partners Commercial |
$2.06
|
| Rate for Payer: Wise Provider Network Commercial |
$2.06
|
|
|
DOXYCYCLINE MONOHYDRATE 50 MG CAPSULE [9791]
|
Facility
|
OP
|
$2.17
|
|
|
Service Code
|
NDC 5026828015
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$2.17 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.13
|
| Rate for Payer: Aetna of WY Medicare |
$1.43
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.08
|
| Rate for Payer: Altius Commercial |
$2.08
|
| Rate for Payer: Beech Street Commercial |
$2.13
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.78
|
| Rate for Payer: Cash Price |
$1.52
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.10
|
| Rate for Payer: Cigna of WY Commercial |
$2.13
|
| Rate for Payer: Entrust Commercial |
$2.06
|
| Rate for Payer: First Choice Health Commercial |
$2.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.26
|
| Rate for Payer: HealthUtah PPO |
$2.17
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.10
|
| Rate for Payer: Multiplan Medicare/VA |
$1.20
|
| Rate for Payer: One Health Plan of WY PPO |
$2.13
|
| Rate for Payer: PacificSource Commercial |
$1.95
|
| Rate for Payer: PHCS PPO |
$2.13
|
| Rate for Payer: Three Rivers PPO |
$1.63
|
| Rate for Payer: TriWest Veterans Administration |
$1.26
|
| Rate for Payer: United Healthcare Commercial |
$1.89
|
| Rate for Payer: United Healthcare Medicare |
$1.26
|
| Rate for Payer: WINHealth Partners Commercial |
$2.13
|
| Rate for Payer: Wise Provider Network Commercial |
$2.06
|
|
|
DOXYCYCLINE MONOHYDRATE 50 MG CAPSULE [9791]
|
Facility
|
IP
|
$2.17
|
|
|
Service Code
|
NDC 5026828011
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$2.17 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.13
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.08
|
| Rate for Payer: Altius Commercial |
$2.08
|
| Rate for Payer: Beech Street Commercial |
$2.13
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.78
|
| Rate for Payer: Cash Price |
$1.52
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.10
|
| Rate for Payer: Cigna of WY Commercial |
$2.13
|
| Rate for Payer: Entrust Commercial |
$2.06
|
| Rate for Payer: First Choice Health Commercial |
$2.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.43
|
| Rate for Payer: HealthUtah PPO |
$2.17
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.10
|
| Rate for Payer: Multiplan Medicare/VA |
$1.36
|
| Rate for Payer: One Health Plan of WY PPO |
$2.13
|
| Rate for Payer: PacificSource Commercial |
$1.95
|
| Rate for Payer: PHCS PPO |
$2.13
|
| Rate for Payer: Three Rivers PPO |
$1.63
|
| Rate for Payer: TriWest Veterans Administration |
$1.43
|
| Rate for Payer: United Healthcare Commercial |
$1.89
|
| Rate for Payer: United Healthcare Medicare |
$1.43
|
| Rate for Payer: WINHealth Partners Commercial |
$2.06
|
| Rate for Payer: Wise Provider Network Commercial |
$2.06
|
|
|
DOXYCYCLINE MONOHYDRATE 50 MG CAPSULE [9791]
|
Facility
|
OP
|
$2.17
|
|
|
Service Code
|
NDC 5026828011
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$2.17 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.13
|
| Rate for Payer: Aetna of WY Medicare |
$1.43
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.08
|
| Rate for Payer: Altius Commercial |
$2.08
|
| Rate for Payer: Beech Street Commercial |
$2.13
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.78
|
| Rate for Payer: Cash Price |
$1.52
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.10
|
| Rate for Payer: Cigna of WY Commercial |
$2.13
|
| Rate for Payer: Entrust Commercial |
$2.06
|
| Rate for Payer: First Choice Health Commercial |
$2.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.26
|
| Rate for Payer: HealthUtah PPO |
$2.17
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.10
|
| Rate for Payer: Multiplan Medicare/VA |
$1.20
|
| Rate for Payer: One Health Plan of WY PPO |
$2.13
|
| Rate for Payer: PacificSource Commercial |
$1.95
|
| Rate for Payer: PHCS PPO |
$2.13
|
| Rate for Payer: Three Rivers PPO |
$1.63
|
| Rate for Payer: TriWest Veterans Administration |
$1.26
|
| Rate for Payer: United Healthcare Commercial |
$1.89
|
| Rate for Payer: United Healthcare Medicare |
$1.26
|
| Rate for Payer: WINHealth Partners Commercial |
$2.13
|
| Rate for Payer: Wise Provider Network Commercial |
$2.06
|
|
|
DRAINAGE EXTERNAL AUDITORY CANAL ABSCESS
|
Professional
|
Both
|
$721.00
|
|
|
Service Code
|
HCPCS 69020
|
| Hospital Charge Code |
69020
|
| Min. Negotiated Rate |
$119.75 |
| Max. Negotiated Rate |
$721.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$706.58
|
| Rate for Payer: Aetna of WY Medicare |
$140.88
|
| Rate for Payer: Beech Street Commercial |
$684.95
|
| Rate for Payer: Cash Price |
$504.70
|
| Rate for Payer: Cash Price |
$504.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$699.37
|
| Rate for Payer: Cigna of WY Commercial |
$706.58
|
| Rate for Payer: First Choice Health Commercial |
$648.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$684.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$140.88
|
| Rate for Payer: HealthUtah PPO |
$721.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$699.37
|
| Rate for Payer: Multiplan Medicare/VA |
$119.75
|
| Rate for Payer: One Health Plan of WY PPO |
$706.58
|
| Rate for Payer: PacificSource Commercial |
$648.90
|
| Rate for Payer: PHCS PPO |
$684.95
|
| Rate for Payer: Three Rivers PPO |
$540.75
|
| Rate for Payer: TriWest Veterans Administration |
$140.88
|
| Rate for Payer: United Healthcare Commercial |
$627.27
|
| Rate for Payer: United Healthcare Medicare |
$140.88
|
| Rate for Payer: WINHealth Partners Commercial |
$612.85
|
|
|
DRAINAGE EXTERNAL EAR ABSCESS/HEMATOMA COMP
|
Professional
|
Both
|
$808.00
|
|
|
Service Code
|
HCPCS 69005
|
| Hospital Charge Code |
69005
|
| Min. Negotiated Rate |
$133.70 |
| Max. Negotiated Rate |
$808.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$791.84
|
| Rate for Payer: Aetna of WY Medicare |
$157.30
|
| Rate for Payer: Beech Street Commercial |
$767.60
|
| Rate for Payer: Cash Price |
$565.60
|
| Rate for Payer: Cash Price |
$565.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$783.76
|
| Rate for Payer: Cigna of WY Commercial |
$791.84
|
| Rate for Payer: First Choice Health Commercial |
$727.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$767.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$157.30
|
| Rate for Payer: HealthUtah PPO |
$808.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$783.76
|
| Rate for Payer: Multiplan Medicare/VA |
$133.70
|
| Rate for Payer: One Health Plan of WY PPO |
$791.84
|
| Rate for Payer: PacificSource Commercial |
$727.20
|
| Rate for Payer: PHCS PPO |
$767.60
|
| Rate for Payer: Three Rivers PPO |
$606.00
|
| Rate for Payer: TriWest Veterans Administration |
$157.30
|
| Rate for Payer: United Healthcare Commercial |
$702.96
|
| Rate for Payer: United Healthcare Medicare |
$157.30
|
| Rate for Payer: WINHealth Partners Commercial |
$686.80
|
|
|
DRAINAGE EXTERNAL EAR ABSCESS/HEMATOMA SIMPLE
|
Professional
|
Both
|
$621.00
|
|
|
Service Code
|
HCPCS 69000
|
| Hospital Charge Code |
69000
|
| Min. Negotiated Rate |
$104.09 |
| Max. Negotiated Rate |
$621.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$608.58
|
| Rate for Payer: Aetna of WY Medicare |
$122.46
|
| Rate for Payer: Beech Street Commercial |
$589.95
|
| Rate for Payer: Cash Price |
$434.70
|
| Rate for Payer: Cash Price |
$434.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$602.37
|
| Rate for Payer: Cigna of WY Commercial |
$608.58
|
| Rate for Payer: First Choice Health Commercial |
$558.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$589.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$122.46
|
| Rate for Payer: HealthUtah PPO |
$621.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$602.37
|
| Rate for Payer: Multiplan Medicare/VA |
$104.09
|
| Rate for Payer: One Health Plan of WY PPO |
$608.58
|
| Rate for Payer: PacificSource Commercial |
$558.90
|
| Rate for Payer: PHCS PPO |
$589.95
|
| Rate for Payer: Three Rivers PPO |
$465.75
|
| Rate for Payer: TriWest Veterans Administration |
$122.46
|
| Rate for Payer: United Healthcare Commercial |
$540.27
|
| Rate for Payer: United Healthcare Medicare |
$122.46
|
| Rate for Payer: WINHealth Partners Commercial |
$527.85
|
|
|
DRAINAGE FINGER ABSCESS COMPLICATED
|
Professional
|
Both
|
$1,663.00
|
|
|
Service Code
|
HCPCS 26011
|
| Hospital Charge Code |
26011
|
| Min. Negotiated Rate |
$153.72 |
| Max. Negotiated Rate |
$1,663.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,629.74
|
| Rate for Payer: Aetna of WY Medicare |
$180.85
|
| Rate for Payer: Beech Street Commercial |
$1,579.85
|
| Rate for Payer: Cash Price |
$1,164.10
|
| Rate for Payer: Cash Price |
$1,164.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,613.11
|
| Rate for Payer: Cigna of WY Commercial |
$1,629.74
|
| Rate for Payer: First Choice Health Commercial |
$1,496.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,579.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$180.85
|
| Rate for Payer: HealthUtah PPO |
$1,663.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,613.11
|
| Rate for Payer: Multiplan Medicare/VA |
$153.72
|
| Rate for Payer: One Health Plan of WY PPO |
$1,629.74
|
| Rate for Payer: PacificSource Commercial |
$1,496.70
|
| Rate for Payer: PHCS PPO |
$1,579.85
|
| Rate for Payer: Three Rivers PPO |
$1,247.25
|
| Rate for Payer: TriWest Veterans Administration |
$180.85
|
| Rate for Payer: United Healthcare Commercial |
$1,446.81
|
| Rate for Payer: United Healthcare Medicare |
$180.85
|
| Rate for Payer: WINHealth Partners Commercial |
$1,413.55
|
|
