|
CUBITAL TUNNEL SPLINT S/M
|
Facility
|
OP
|
$210.00
|
|
| Hospital Charge Code |
2200239
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$113.72 |
| Max. Negotiated Rate |
$210.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$205.80
|
| Rate for Payer: Aetna of WY Medicare |
$138.60
|
| Rate for Payer: Altius Commercial |
$201.60
|
| Rate for Payer: Beech Street Commercial |
$205.80
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$203.70
|
| Rate for Payer: Cash Price |
$147.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$203.70
|
| Rate for Payer: Cigna of WY Commercial |
$205.80
|
| Rate for Payer: Entrust Commercial |
$199.50
|
| Rate for Payer: First Choice Health Commercial |
$199.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$199.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$119.70
|
| Rate for Payer: HealthUtah PPO |
$210.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$203.70
|
| Rate for Payer: Multiplan Medicare/VA |
$113.72
|
| Rate for Payer: One Health Plan of WY PPO |
$205.80
|
| Rate for Payer: PacificSource Commercial |
$189.00
|
| Rate for Payer: PHCS PPO |
$205.80
|
| Rate for Payer: Three Rivers PPO |
$157.50
|
| Rate for Payer: TriWest Veterans Administration |
$119.70
|
| Rate for Payer: United Healthcare Commercial |
$200.55
|
| Rate for Payer: United Healthcare Medicare |
$119.70
|
| Rate for Payer: WINHealth Partners Commercial |
$205.80
|
| Rate for Payer: Wise Provider Network Commercial |
$199.50
|
|
|
CUBITAL TUNNEL SPLINT S/M
|
Facility
|
IP
|
$210.00
|
|
| Hospital Charge Code |
2200239
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$121.70 |
| Max. Negotiated Rate |
$210.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$205.80
|
| Rate for Payer: Aetna of WY Medicare |
$134.40
|
| Rate for Payer: Altius Commercial |
$201.60
|
| Rate for Payer: Beech Street Commercial |
$205.80
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$203.70
|
| Rate for Payer: Cash Price |
$147.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$203.70
|
| Rate for Payer: Cigna of WY Commercial |
$205.80
|
| Rate for Payer: Entrust Commercial |
$199.50
|
| Rate for Payer: First Choice Health Commercial |
$199.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$199.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$128.10
|
| Rate for Payer: HealthUtah PPO |
$210.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$203.70
|
| Rate for Payer: Multiplan Medicare/VA |
$121.70
|
| Rate for Payer: One Health Plan of WY PPO |
$205.80
|
| Rate for Payer: PacificSource Commercial |
$189.00
|
| Rate for Payer: PHCS PPO |
$205.80
|
| Rate for Payer: Three Rivers PPO |
$157.50
|
| Rate for Payer: TriWest Veterans Administration |
$128.10
|
| Rate for Payer: United Healthcare Commercial |
$200.55
|
| Rate for Payer: United Healthcare Medicare |
$128.10
|
| Rate for Payer: WINHealth Partners Commercial |
$199.50
|
| Rate for Payer: Wise Provider Network Commercial |
$199.50
|
|
|
CURETTAGE POSTPARTUM
|
Professional
|
Both
|
$469.00
|
|
|
Service Code
|
HCPCS 59160
|
| Min. Negotiated Rate |
$153.03 |
| Max. Negotiated Rate |
$469.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$459.62
|
| Rate for Payer: Aetna of WY Medicare |
$180.03
|
| Rate for Payer: Beech Street Commercial |
$445.55
|
| Rate for Payer: Cash Price |
$328.30
|
| Rate for Payer: Cash Price |
$328.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$454.93
|
| Rate for Payer: Cigna of WY Commercial |
$459.62
|
| Rate for Payer: First Choice Health Commercial |
$422.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$445.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$180.03
|
| Rate for Payer: HealthUtah PPO |
$469.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$454.93
|
| Rate for Payer: Multiplan Medicare/VA |
$153.03
|
| Rate for Payer: One Health Plan of WY PPO |
$459.62
|
| Rate for Payer: PacificSource Commercial |
$422.10
|
| Rate for Payer: PHCS PPO |
$445.55
|
| Rate for Payer: Three Rivers PPO |
$351.75
|
| Rate for Payer: TriWest Veterans Administration |
$180.03
|
| Rate for Payer: United Healthcare Commercial |
$445.55
|
| Rate for Payer: WINHealth Partners Commercial |
$398.65
|
|
|
CURETTE EAR LIGHTED FLEXLOOP
|
Facility
|
IP
|
$236.60
|
|
| Hospital Charge Code |
2400216
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$137.11 |
| Max. Negotiated Rate |
$236.60 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$231.87
|
| Rate for Payer: Aetna of WY Medicare |
$151.42
|
| Rate for Payer: Altius Commercial |
$227.14
|
| Rate for Payer: Beech Street Commercial |
$231.87
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$229.50
|
| Rate for Payer: Cash Price |
$165.62
|
| Rate for Payer: ChoiceCare Network Commercial |
$229.50
|
| Rate for Payer: Cigna of WY Commercial |
$231.87
|
| Rate for Payer: Entrust Commercial |
$224.77
|
| Rate for Payer: First Choice Health Commercial |
$224.77
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$224.77
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$144.33
|
| Rate for Payer: HealthUtah PPO |
$236.60
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$229.50
|
| Rate for Payer: Multiplan Medicare/VA |
$137.11
|
| Rate for Payer: One Health Plan of WY PPO |
$231.87
|
| Rate for Payer: PacificSource Commercial |
$212.94
|
| Rate for Payer: PHCS PPO |
$231.87
|
| Rate for Payer: Three Rivers PPO |
$177.45
|
| Rate for Payer: TriWest Veterans Administration |
$144.33
|
| Rate for Payer: United Healthcare Commercial |
$225.95
|
| Rate for Payer: United Healthcare Medicare |
$144.33
|
| Rate for Payer: WINHealth Partners Commercial |
$224.77
|
| Rate for Payer: Wise Provider Network Commercial |
$224.77
|
|
|
CURETTE EAR LIGHTED FLEXLOOP
|
Facility
|
OP
|
$236.60
|
|
| Hospital Charge Code |
2400216
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$128.12 |
| Max. Negotiated Rate |
$236.60 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$231.87
|
| Rate for Payer: Aetna of WY Medicare |
$156.16
|
| Rate for Payer: Altius Commercial |
$227.14
|
| Rate for Payer: Beech Street Commercial |
$231.87
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$229.50
|
| Rate for Payer: Cash Price |
$165.62
|
| Rate for Payer: ChoiceCare Network Commercial |
$229.50
|
| Rate for Payer: Cigna of WY Commercial |
$231.87
|
| Rate for Payer: Entrust Commercial |
$224.77
|
| Rate for Payer: First Choice Health Commercial |
$224.77
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$224.77
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$134.86
|
| Rate for Payer: HealthUtah PPO |
$236.60
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$229.50
|
| Rate for Payer: Multiplan Medicare/VA |
$128.12
|
| Rate for Payer: One Health Plan of WY PPO |
$231.87
|
| Rate for Payer: PacificSource Commercial |
$212.94
|
| Rate for Payer: PHCS PPO |
$231.87
|
| Rate for Payer: Three Rivers PPO |
$177.45
|
| Rate for Payer: TriWest Veterans Administration |
$134.86
|
| Rate for Payer: United Healthcare Commercial |
$225.95
|
| Rate for Payer: United Healthcare Medicare |
$134.86
|
| Rate for Payer: WINHealth Partners Commercial |
$231.87
|
| Rate for Payer: Wise Provider Network Commercial |
$224.77
|
|
|
CURETTE EAR LIGHTED MICROLOOP
|
Facility
|
OP
|
$5.27
|
|
| Hospital Charge Code |
2400279
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2.85 |
| Max. Negotiated Rate |
$5.27 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5.16
|
| Rate for Payer: Aetna of WY Medicare |
$3.48
|
| Rate for Payer: Altius Commercial |
$5.06
|
| Rate for Payer: Beech Street Commercial |
$5.16
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$5.11
|
| Rate for Payer: Cash Price |
$3.69
|
| Rate for Payer: ChoiceCare Network Commercial |
$5.11
|
| Rate for Payer: Cigna of WY Commercial |
$5.16
|
| Rate for Payer: Entrust Commercial |
$5.01
|
| Rate for Payer: First Choice Health Commercial |
$5.01
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5.01
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3.00
|
| Rate for Payer: HealthUtah PPO |
$5.27
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5.11
|
| Rate for Payer: Multiplan Medicare/VA |
$2.85
|
| Rate for Payer: One Health Plan of WY PPO |
$5.16
|
| Rate for Payer: PacificSource Commercial |
$4.74
|
| Rate for Payer: PHCS PPO |
$5.16
|
| Rate for Payer: Three Rivers PPO |
$3.95
|
| Rate for Payer: TriWest Veterans Administration |
$3.00
|
| Rate for Payer: United Healthcare Commercial |
$5.03
|
| Rate for Payer: United Healthcare Medicare |
$3.00
|
| Rate for Payer: WINHealth Partners Commercial |
$5.16
|
| Rate for Payer: Wise Provider Network Commercial |
$5.01
|
|
|
CURETTE EAR LIGHTED MICROLOOP
|
Facility
|
IP
|
$5.27
|
|
| Hospital Charge Code |
2400279
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3.05 |
| Max. Negotiated Rate |
$5.27 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5.16
|
| Rate for Payer: Aetna of WY Medicare |
$3.37
|
| Rate for Payer: Altius Commercial |
$5.06
|
| Rate for Payer: Beech Street Commercial |
$5.16
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$5.11
|
| Rate for Payer: Cash Price |
$3.69
|
| Rate for Payer: ChoiceCare Network Commercial |
$5.11
|
| Rate for Payer: Cigna of WY Commercial |
$5.16
|
| Rate for Payer: Entrust Commercial |
$5.01
|
| Rate for Payer: First Choice Health Commercial |
$5.01
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5.01
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3.21
|
| Rate for Payer: HealthUtah PPO |
$5.27
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5.11
|
| Rate for Payer: Multiplan Medicare/VA |
$3.05
|
| Rate for Payer: One Health Plan of WY PPO |
$5.16
|
| Rate for Payer: PacificSource Commercial |
$4.74
|
| Rate for Payer: PHCS PPO |
$5.16
|
| Rate for Payer: Three Rivers PPO |
$3.95
|
| Rate for Payer: TriWest Veterans Administration |
$3.21
|
| Rate for Payer: United Healthcare Commercial |
$5.03
|
| Rate for Payer: United Healthcare Medicare |
$3.21
|
| Rate for Payer: WINHealth Partners Commercial |
$5.01
|
| Rate for Payer: Wise Provider Network Commercial |
$5.01
|
|
|
CURETTE FLEXLOOP EAR 19-321
|
Facility
|
OP
|
$168.95
|
|
| Hospital Charge Code |
2400051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$91.49 |
| Max. Negotiated Rate |
$168.95 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$165.57
|
| Rate for Payer: Aetna of WY Medicare |
$111.51
|
| Rate for Payer: Altius Commercial |
$162.19
|
| Rate for Payer: Beech Street Commercial |
$165.57
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$163.88
|
| Rate for Payer: Cash Price |
$118.26
|
| Rate for Payer: ChoiceCare Network Commercial |
$163.88
|
| Rate for Payer: Cigna of WY Commercial |
$165.57
|
| Rate for Payer: Entrust Commercial |
$160.50
|
| Rate for Payer: First Choice Health Commercial |
$160.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$160.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$96.30
|
| Rate for Payer: HealthUtah PPO |
$168.95
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$163.88
|
| Rate for Payer: Multiplan Medicare/VA |
$91.49
|
| Rate for Payer: One Health Plan of WY PPO |
$165.57
|
| Rate for Payer: PacificSource Commercial |
$152.06
|
| Rate for Payer: PHCS PPO |
$165.57
|
| Rate for Payer: Three Rivers PPO |
$126.71
|
| Rate for Payer: TriWest Veterans Administration |
$96.30
|
| Rate for Payer: United Healthcare Commercial |
$161.35
|
| Rate for Payer: United Healthcare Medicare |
$96.30
|
| Rate for Payer: WINHealth Partners Commercial |
$165.57
|
| Rate for Payer: Wise Provider Network Commercial |
$160.50
|
|
|
CURETTE FLEXLOOP EAR 19-321
|
Facility
|
IP
|
$168.95
|
|
| Hospital Charge Code |
2400051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$97.91 |
| Max. Negotiated Rate |
$168.95 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$165.57
|
| Rate for Payer: Aetna of WY Medicare |
$108.13
|
| Rate for Payer: Altius Commercial |
$162.19
|
| Rate for Payer: Beech Street Commercial |
$165.57
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$163.88
|
| Rate for Payer: Cash Price |
$118.26
|
| Rate for Payer: ChoiceCare Network Commercial |
$163.88
|
| Rate for Payer: Cigna of WY Commercial |
$165.57
|
| Rate for Payer: Entrust Commercial |
$160.50
|
| Rate for Payer: First Choice Health Commercial |
$160.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$160.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$103.06
|
| Rate for Payer: HealthUtah PPO |
$168.95
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$163.88
|
| Rate for Payer: Multiplan Medicare/VA |
$97.91
|
| Rate for Payer: One Health Plan of WY PPO |
$165.57
|
| Rate for Payer: PacificSource Commercial |
$152.06
|
| Rate for Payer: PHCS PPO |
$165.57
|
| Rate for Payer: Three Rivers PPO |
$126.71
|
| Rate for Payer: TriWest Veterans Administration |
$103.06
|
| Rate for Payer: United Healthcare Commercial |
$161.35
|
| Rate for Payer: United Healthcare Medicare |
$103.06
|
| Rate for Payer: WINHealth Partners Commercial |
$160.50
|
| Rate for Payer: Wise Provider Network Commercial |
$160.50
|
|
|
CV STRS TST XERS&/OR RX CONT ECG I&R ONLY
|
Professional
|
Both
|
$141.00
|
|
|
Service Code
|
HCPCS 93018
|
| Min. Negotiated Rate |
$11.34 |
| Max. Negotiated Rate |
$141.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$138.18
|
| Rate for Payer: Aetna of WY Medicare |
$13.34
|
| Rate for Payer: Beech Street Commercial |
$133.95
|
| Rate for Payer: Cash Price |
$98.70
|
| Rate for Payer: Cash Price |
$98.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$136.77
|
| Rate for Payer: Cigna of WY Commercial |
$138.18
|
| Rate for Payer: First Choice Health Commercial |
$126.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$133.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$13.34
|
| Rate for Payer: HealthUtah PPO |
$141.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$136.77
|
| Rate for Payer: Multiplan Medicare/VA |
$11.34
|
| Rate for Payer: One Health Plan of WY PPO |
$138.18
|
| Rate for Payer: PacificSource Commercial |
$126.90
|
| Rate for Payer: PHCS PPO |
$133.95
|
| Rate for Payer: Three Rivers PPO |
$105.75
|
| Rate for Payer: TriWest Veterans Administration |
$13.34
|
| Rate for Payer: United Healthcare Commercial |
$133.95
|
| Rate for Payer: WINHealth Partners Commercial |
$133.95
|
|
|
CV STRS TST XERS&/OR RX CONT ECG W/O I&R
|
Professional
|
Both
|
$186.00
|
|
|
Service Code
|
HCPCS 93016
|
| Min. Negotiated Rate |
$17.19 |
| Max. Negotiated Rate |
$186.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$182.28
|
| Rate for Payer: Aetna of WY Medicare |
$20.22
|
| Rate for Payer: Beech Street Commercial |
$176.70
|
| Rate for Payer: Cash Price |
$130.20
|
| Rate for Payer: Cash Price |
$130.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$180.42
|
| Rate for Payer: Cigna of WY Commercial |
$182.28
|
| Rate for Payer: First Choice Health Commercial |
$167.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$176.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$20.22
|
| Rate for Payer: HealthUtah PPO |
$186.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$180.42
|
| Rate for Payer: Multiplan Medicare/VA |
$17.19
|
| Rate for Payer: One Health Plan of WY PPO |
$182.28
|
| Rate for Payer: PacificSource Commercial |
$167.40
|
| Rate for Payer: PHCS PPO |
$176.70
|
| Rate for Payer: Three Rivers PPO |
$139.50
|
| Rate for Payer: TriWest Veterans Administration |
$20.22
|
| Rate for Payer: United Healthcare Commercial |
$176.70
|
| Rate for Payer: WINHealth Partners Commercial |
$176.70
|
|
|
CV STRS TST XERS&/OR RX CONT ECG W/SI&R
|
Professional
|
Both
|
$434.00
|
|
|
Service Code
|
HCPCS 93015
|
| Min. Negotiated Rate |
$59.83 |
| Max. Negotiated Rate |
$434.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$425.32
|
| Rate for Payer: Aetna of WY Medicare |
$70.39
|
| Rate for Payer: Beech Street Commercial |
$412.30
|
| Rate for Payer: Cash Price |
$303.80
|
| Rate for Payer: Cash Price |
$303.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$420.98
|
| Rate for Payer: Cigna of WY Commercial |
$425.32
|
| Rate for Payer: First Choice Health Commercial |
$390.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$412.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$70.39
|
| Rate for Payer: HealthUtah PPO |
$434.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$420.98
|
| Rate for Payer: Multiplan Medicare/VA |
$59.83
|
| Rate for Payer: One Health Plan of WY PPO |
$425.32
|
| Rate for Payer: PacificSource Commercial |
$390.60
|
| Rate for Payer: PHCS PPO |
$412.30
|
| Rate for Payer: Three Rivers PPO |
$325.50
|
| Rate for Payer: TriWest Veterans Administration |
$70.39
|
| Rate for Payer: United Healthcare Commercial |
$412.30
|
| Rate for Payer: WINHealth Partners Commercial |
$412.30
|
|
|
CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION [12255]
|
Facility
|
IP
|
$39.47
|
|
|
Service Code
|
HCPCS J3420
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.87 |
| Max. Negotiated Rate |
$39.47 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$38.68
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$38.41
|
| Rate for Payer: Aetna of WY Medicare |
$25.08
|
| Rate for Payer: Aetna of WY Medicare |
$25.26
|
| Rate for Payer: Altius Commercial |
$37.62
|
| Rate for Payer: Altius Commercial |
$37.89
|
| Rate for Payer: Beech Street Commercial |
$38.68
|
| Rate for Payer: Beech Street Commercial |
$38.41
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$38.29
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$38.01
|
| Rate for Payer: Cash Price |
$27.43
|
| Rate for Payer: Cash Price |
$27.63
|
| Rate for Payer: ChoiceCare Network Commercial |
$38.29
|
| Rate for Payer: ChoiceCare Network Commercial |
$38.01
|
| Rate for Payer: Cigna of WY Commercial |
$38.68
|
| Rate for Payer: Cigna of WY Commercial |
$38.41
|
| Rate for Payer: Entrust Commercial |
$37.50
|
| Rate for Payer: Entrust Commercial |
$37.23
|
| Rate for Payer: First Choice Health Commercial |
$37.23
|
| Rate for Payer: First Choice Health Commercial |
$37.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$37.23
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$37.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$24.08
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$23.91
|
| Rate for Payer: HealthUtah PPO |
$39.47
|
| Rate for Payer: HealthUtah PPO |
$39.19
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$38.29
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$38.01
|
| Rate for Payer: Multiplan Medicare/VA |
$22.87
|
| Rate for Payer: Multiplan Medicare/VA |
$22.71
|
| Rate for Payer: One Health Plan of WY PPO |
$38.68
|
| Rate for Payer: One Health Plan of WY PPO |
$38.41
|
| Rate for Payer: PacificSource Commercial |
$35.52
|
| Rate for Payer: PacificSource Commercial |
$35.27
|
| Rate for Payer: PHCS PPO |
$38.41
|
| Rate for Payer: PHCS PPO |
$38.68
|
| Rate for Payer: Three Rivers PPO |
$29.60
|
| Rate for Payer: Three Rivers PPO |
$29.39
|
| Rate for Payer: TriWest Veterans Administration |
$24.08
|
| Rate for Payer: TriWest Veterans Administration |
$23.91
|
| Rate for Payer: United Healthcare Commercial |
$37.69
|
| Rate for Payer: United Healthcare Commercial |
$37.43
|
| Rate for Payer: United Healthcare Medicare |
$24.08
|
| Rate for Payer: United Healthcare Medicare |
$23.91
|
| Rate for Payer: WINHealth Partners Commercial |
$37.23
|
| Rate for Payer: WINHealth Partners Commercial |
$37.50
|
| Rate for Payer: Wise Provider Network Commercial |
$37.50
|
| Rate for Payer: Wise Provider Network Commercial |
$37.23
|
|
|
CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION [12255]
|
Facility
|
OP
|
$39.47
|
|
|
Service Code
|
HCPCS J3420
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.37 |
| Max. Negotiated Rate |
$39.47 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$38.68
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$38.41
|
| Rate for Payer: Aetna of WY Medicare |
$25.87
|
| Rate for Payer: Aetna of WY Medicare |
$26.05
|
| Rate for Payer: Altius Commercial |
$37.89
|
| Rate for Payer: Altius Commercial |
$37.62
|
| Rate for Payer: Beech Street Commercial |
$38.41
|
| Rate for Payer: Beech Street Commercial |
$38.68
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$38.01
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$38.29
|
| Rate for Payer: Cash Price |
$27.63
|
| Rate for Payer: Cash Price |
$27.43
|
| Rate for Payer: ChoiceCare Network Commercial |
$38.01
|
| Rate for Payer: ChoiceCare Network Commercial |
$38.29
|
| Rate for Payer: Cigna of WY Commercial |
$38.68
|
| Rate for Payer: Cigna of WY Commercial |
$38.41
|
| Rate for Payer: Entrust Commercial |
$37.23
|
| Rate for Payer: Entrust Commercial |
$37.50
|
| Rate for Payer: First Choice Health Commercial |
$37.50
|
| Rate for Payer: First Choice Health Commercial |
$37.23
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$37.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$37.23
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$22.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$22.34
|
| Rate for Payer: HealthUtah PPO |
$39.47
|
| Rate for Payer: HealthUtah PPO |
$39.19
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$38.01
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$38.29
|
| Rate for Payer: Multiplan Medicare/VA |
$21.22
|
| Rate for Payer: Multiplan Medicare/VA |
$21.37
|
| Rate for Payer: One Health Plan of WY PPO |
$38.41
|
| Rate for Payer: One Health Plan of WY PPO |
$38.68
|
| Rate for Payer: PacificSource Commercial |
$35.52
|
| Rate for Payer: PacificSource Commercial |
$35.27
|
| Rate for Payer: PHCS PPO |
$38.68
|
| Rate for Payer: PHCS PPO |
$38.41
|
| Rate for Payer: Three Rivers PPO |
$29.39
|
| Rate for Payer: Three Rivers PPO |
$29.60
|
| Rate for Payer: TriWest Veterans Administration |
$22.34
|
| Rate for Payer: TriWest Veterans Administration |
$22.50
|
| Rate for Payer: United Healthcare Commercial |
$37.69
|
| Rate for Payer: United Healthcare Commercial |
$37.43
|
| Rate for Payer: United Healthcare Medicare |
$22.34
|
| Rate for Payer: United Healthcare Medicare |
$22.50
|
| Rate for Payer: WINHealth Partners Commercial |
$38.68
|
| Rate for Payer: WINHealth Partners Commercial |
$38.41
|
| Rate for Payer: Wise Provider Network Commercial |
$37.50
|
| Rate for Payer: Wise Provider Network Commercial |
$37.23
|
|
|
CYANOCOBALAMIN (VIT B-12) 1,000 MCG TABLET [6084]
|
Facility
|
IP
|
$15.83
|
|
|
Service Code
|
NDC 5026885511
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.17 |
| Max. Negotiated Rate |
$15.83 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.51
|
| Rate for Payer: Aetna of WY Medicare |
$10.13
|
| Rate for Payer: Altius Commercial |
$15.20
|
| Rate for Payer: Beech Street Commercial |
$15.51
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.36
|
| Rate for Payer: Cash Price |
$11.08
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.36
|
| Rate for Payer: Cigna of WY Commercial |
$15.51
|
| Rate for Payer: Entrust Commercial |
$15.04
|
| Rate for Payer: First Choice Health Commercial |
$15.04
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.04
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.66
|
| Rate for Payer: HealthUtah PPO |
$15.83
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.36
|
| Rate for Payer: Multiplan Medicare/VA |
$9.17
|
| Rate for Payer: One Health Plan of WY PPO |
$15.51
|
| Rate for Payer: PacificSource Commercial |
$14.25
|
| Rate for Payer: PHCS PPO |
$15.51
|
| Rate for Payer: Three Rivers PPO |
$11.87
|
| Rate for Payer: TriWest Veterans Administration |
$9.66
|
| Rate for Payer: United Healthcare Commercial |
$15.12
|
| Rate for Payer: United Healthcare Medicare |
$9.66
|
| Rate for Payer: WINHealth Partners Commercial |
$15.04
|
| Rate for Payer: Wise Provider Network Commercial |
$15.04
|
|
|
CYANOCOBALAMIN (VIT B-12) 1,000 MCG TABLET [6084]
|
Facility
|
OP
|
$15.83
|
|
|
Service Code
|
NDC 5026885511
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.57 |
| Max. Negotiated Rate |
$15.83 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.51
|
| Rate for Payer: Aetna of WY Medicare |
$10.45
|
| Rate for Payer: Altius Commercial |
$15.20
|
| Rate for Payer: Beech Street Commercial |
$15.51
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.36
|
| Rate for Payer: Cash Price |
$11.08
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.36
|
| Rate for Payer: Cigna of WY Commercial |
$15.51
|
| Rate for Payer: Entrust Commercial |
$15.04
|
| Rate for Payer: First Choice Health Commercial |
$15.04
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.04
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.02
|
| Rate for Payer: HealthUtah PPO |
$15.83
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.36
|
| Rate for Payer: Multiplan Medicare/VA |
$8.57
|
| Rate for Payer: One Health Plan of WY PPO |
$15.51
|
| Rate for Payer: PacificSource Commercial |
$14.25
|
| Rate for Payer: PHCS PPO |
$15.51
|
| Rate for Payer: Three Rivers PPO |
$11.87
|
| Rate for Payer: TriWest Veterans Administration |
$9.02
|
| Rate for Payer: United Healthcare Commercial |
$15.12
|
| Rate for Payer: United Healthcare Medicare |
$9.02
|
| Rate for Payer: WINHealth Partners Commercial |
$15.51
|
| Rate for Payer: Wise Provider Network Commercial |
$15.04
|
|
|
CYANOCOBALAMIN (VIT B-12) 1,000 MCG TABLET [6084]
|
Facility
|
IP
|
$15.83
|
|
|
Service Code
|
NDC 5026885515
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.17 |
| Max. Negotiated Rate |
$15.83 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.51
|
| Rate for Payer: Aetna of WY Medicare |
$10.13
|
| Rate for Payer: Altius Commercial |
$15.20
|
| Rate for Payer: Beech Street Commercial |
$15.51
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.36
|
| Rate for Payer: Cash Price |
$11.08
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.36
|
| Rate for Payer: Cigna of WY Commercial |
$15.51
|
| Rate for Payer: Entrust Commercial |
$15.04
|
| Rate for Payer: First Choice Health Commercial |
$15.04
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.04
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.66
|
| Rate for Payer: HealthUtah PPO |
$15.83
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.36
|
| Rate for Payer: Multiplan Medicare/VA |
$9.17
|
| Rate for Payer: One Health Plan of WY PPO |
$15.51
|
| Rate for Payer: PacificSource Commercial |
$14.25
|
| Rate for Payer: PHCS PPO |
$15.51
|
| Rate for Payer: Three Rivers PPO |
$11.87
|
| Rate for Payer: TriWest Veterans Administration |
$9.66
|
| Rate for Payer: United Healthcare Commercial |
$15.12
|
| Rate for Payer: United Healthcare Medicare |
$9.66
|
| Rate for Payer: WINHealth Partners Commercial |
$15.04
|
| Rate for Payer: Wise Provider Network Commercial |
$15.04
|
|
|
CYANOCOBALAMIN (VIT B-12) 1,000 MCG TABLET [6084]
|
Facility
|
OP
|
$15.83
|
|
|
Service Code
|
NDC 5026885515
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.57 |
| Max. Negotiated Rate |
$15.83 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.51
|
| Rate for Payer: Aetna of WY Medicare |
$10.45
|
| Rate for Payer: Altius Commercial |
$15.20
|
| Rate for Payer: Beech Street Commercial |
$15.51
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.36
|
| Rate for Payer: Cash Price |
$11.08
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.36
|
| Rate for Payer: Cigna of WY Commercial |
$15.51
|
| Rate for Payer: Entrust Commercial |
$15.04
|
| Rate for Payer: First Choice Health Commercial |
$15.04
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.04
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.02
|
| Rate for Payer: HealthUtah PPO |
$15.83
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.36
|
| Rate for Payer: Multiplan Medicare/VA |
$8.57
|
| Rate for Payer: One Health Plan of WY PPO |
$15.51
|
| Rate for Payer: PacificSource Commercial |
$14.25
|
| Rate for Payer: PHCS PPO |
$15.51
|
| Rate for Payer: Three Rivers PPO |
$11.87
|
| Rate for Payer: TriWest Veterans Administration |
$9.02
|
| Rate for Payer: United Healthcare Commercial |
$15.12
|
| Rate for Payer: United Healthcare Medicare |
$9.02
|
| Rate for Payer: WINHealth Partners Commercial |
$15.51
|
| Rate for Payer: Wise Provider Network Commercial |
$15.04
|
|
|
CYCLOBENZAPRINE 10 MG TABLET [286]
|
Facility
|
IP
|
$15.71
|
|
|
Service Code
|
NDC 6068755811
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.10 |
| Max. Negotiated Rate |
$15.71 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.40
|
| Rate for Payer: Aetna of WY Medicare |
$10.05
|
| Rate for Payer: Altius Commercial |
$15.08
|
| Rate for Payer: Beech Street Commercial |
$15.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.24
|
| Rate for Payer: Cash Price |
$11.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.24
|
| Rate for Payer: Cigna of WY Commercial |
$15.40
|
| Rate for Payer: Entrust Commercial |
$14.92
|
| Rate for Payer: First Choice Health Commercial |
$14.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.58
|
| Rate for Payer: HealthUtah PPO |
$15.71
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.24
|
| Rate for Payer: Multiplan Medicare/VA |
$9.10
|
| Rate for Payer: One Health Plan of WY PPO |
$15.40
|
| Rate for Payer: PacificSource Commercial |
$14.14
|
| Rate for Payer: PHCS PPO |
$15.40
|
| Rate for Payer: Three Rivers PPO |
$11.78
|
| Rate for Payer: TriWest Veterans Administration |
$9.58
|
| Rate for Payer: United Healthcare Commercial |
$15.00
|
| Rate for Payer: United Healthcare Medicare |
$9.58
|
| Rate for Payer: WINHealth Partners Commercial |
$14.92
|
| Rate for Payer: Wise Provider Network Commercial |
$14.92
|
|
|
CYCLOBENZAPRINE 10 MG TABLET [286]
|
Facility
|
OP
|
$15.71
|
|
|
Service Code
|
NDC 6068755801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.51 |
| Max. Negotiated Rate |
$15.71 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.40
|
| Rate for Payer: Aetna of WY Medicare |
$10.37
|
| Rate for Payer: Altius Commercial |
$15.08
|
| Rate for Payer: Beech Street Commercial |
$15.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.24
|
| Rate for Payer: Cash Price |
$11.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.24
|
| Rate for Payer: Cigna of WY Commercial |
$15.40
|
| Rate for Payer: Entrust Commercial |
$14.92
|
| Rate for Payer: First Choice Health Commercial |
$14.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.95
|
| Rate for Payer: HealthUtah PPO |
$15.71
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.24
|
| Rate for Payer: Multiplan Medicare/VA |
$8.51
|
| Rate for Payer: One Health Plan of WY PPO |
$15.40
|
| Rate for Payer: PacificSource Commercial |
$14.14
|
| Rate for Payer: PHCS PPO |
$15.40
|
| Rate for Payer: Three Rivers PPO |
$11.78
|
| Rate for Payer: TriWest Veterans Administration |
$8.95
|
| Rate for Payer: United Healthcare Commercial |
$15.00
|
| Rate for Payer: United Healthcare Medicare |
$8.95
|
| Rate for Payer: WINHealth Partners Commercial |
$15.40
|
| Rate for Payer: Wise Provider Network Commercial |
$14.92
|
|
|
CYCLOBENZAPRINE 10 MG TABLET [286]
|
Facility
|
OP
|
$15.71
|
|
|
Service Code
|
NDC 6068755811
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.51 |
| Max. Negotiated Rate |
$15.71 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.40
|
| Rate for Payer: Aetna of WY Medicare |
$10.37
|
| Rate for Payer: Altius Commercial |
$15.08
|
| Rate for Payer: Beech Street Commercial |
$15.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.24
|
| Rate for Payer: Cash Price |
$11.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.24
|
| Rate for Payer: Cigna of WY Commercial |
$15.40
|
| Rate for Payer: Entrust Commercial |
$14.92
|
| Rate for Payer: First Choice Health Commercial |
$14.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.95
|
| Rate for Payer: HealthUtah PPO |
$15.71
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.24
|
| Rate for Payer: Multiplan Medicare/VA |
$8.51
|
| Rate for Payer: One Health Plan of WY PPO |
$15.40
|
| Rate for Payer: PacificSource Commercial |
$14.14
|
| Rate for Payer: PHCS PPO |
$15.40
|
| Rate for Payer: Three Rivers PPO |
$11.78
|
| Rate for Payer: TriWest Veterans Administration |
$8.95
|
| Rate for Payer: United Healthcare Commercial |
$15.00
|
| Rate for Payer: United Healthcare Medicare |
$8.95
|
| Rate for Payer: WINHealth Partners Commercial |
$15.40
|
| Rate for Payer: Wise Provider Network Commercial |
$14.92
|
|
|
CYCLOBENZAPRINE 10 MG TABLET [286]
|
Facility
|
IP
|
$15.71
|
|
|
Service Code
|
NDC 6068755801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.10 |
| Max. Negotiated Rate |
$15.71 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.40
|
| Rate for Payer: Aetna of WY Medicare |
$10.05
|
| Rate for Payer: Altius Commercial |
$15.08
|
| Rate for Payer: Beech Street Commercial |
$15.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.24
|
| Rate for Payer: Cash Price |
$11.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.24
|
| Rate for Payer: Cigna of WY Commercial |
$15.40
|
| Rate for Payer: Entrust Commercial |
$14.92
|
| Rate for Payer: First Choice Health Commercial |
$14.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.58
|
| Rate for Payer: HealthUtah PPO |
$15.71
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.24
|
| Rate for Payer: Multiplan Medicare/VA |
$9.10
|
| Rate for Payer: One Health Plan of WY PPO |
$15.40
|
| Rate for Payer: PacificSource Commercial |
$14.14
|
| Rate for Payer: PHCS PPO |
$15.40
|
| Rate for Payer: Three Rivers PPO |
$11.78
|
| Rate for Payer: TriWest Veterans Administration |
$9.58
|
| Rate for Payer: United Healthcare Commercial |
$15.00
|
| Rate for Payer: United Healthcare Medicare |
$9.58
|
| Rate for Payer: WINHealth Partners Commercial |
$14.92
|
| Rate for Payer: Wise Provider Network Commercial |
$14.92
|
|
|
CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION [19355]
|
Facility
|
IP
|
$344.63
|
|
|
Service Code
|
HCPCS J9070
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$199.71 |
| Max. Negotiated Rate |
$344.63 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$337.74
|
| Rate for Payer: Aetna of WY Medicare |
$220.56
|
| Rate for Payer: Altius Commercial |
$330.84
|
| Rate for Payer: Beech Street Commercial |
$337.74
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$334.29
|
| Rate for Payer: Cash Price |
$241.24
|
| Rate for Payer: ChoiceCare Network Commercial |
$334.29
|
| Rate for Payer: Cigna of WY Commercial |
$337.74
|
| Rate for Payer: Entrust Commercial |
$327.40
|
| Rate for Payer: First Choice Health Commercial |
$327.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$327.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$210.22
|
| Rate for Payer: HealthUtah PPO |
$344.63
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$334.29
|
| Rate for Payer: Multiplan Medicare/VA |
$199.71
|
| Rate for Payer: One Health Plan of WY PPO |
$337.74
|
| Rate for Payer: PacificSource Commercial |
$310.17
|
| Rate for Payer: PHCS PPO |
$337.74
|
| Rate for Payer: Three Rivers PPO |
$258.47
|
| Rate for Payer: TriWest Veterans Administration |
$210.22
|
| Rate for Payer: United Healthcare Commercial |
$329.12
|
| Rate for Payer: United Healthcare Medicare |
$210.22
|
| Rate for Payer: WINHealth Partners Commercial |
$327.40
|
| Rate for Payer: Wise Provider Network Commercial |
$327.40
|
|
|
CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION [19355]
|
Facility
|
OP
|
$344.63
|
|
|
Service Code
|
HCPCS J9070
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$186.62 |
| Max. Negotiated Rate |
$344.63 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$337.74
|
| Rate for Payer: Aetna of WY Medicare |
$227.46
|
| Rate for Payer: Altius Commercial |
$330.84
|
| Rate for Payer: Beech Street Commercial |
$337.74
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$334.29
|
| Rate for Payer: Cash Price |
$241.24
|
| Rate for Payer: ChoiceCare Network Commercial |
$334.29
|
| Rate for Payer: Cigna of WY Commercial |
$337.74
|
| Rate for Payer: Entrust Commercial |
$327.40
|
| Rate for Payer: First Choice Health Commercial |
$327.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$327.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$196.44
|
| Rate for Payer: HealthUtah PPO |
$344.63
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$334.29
|
| Rate for Payer: Multiplan Medicare/VA |
$186.62
|
| Rate for Payer: One Health Plan of WY PPO |
$337.74
|
| Rate for Payer: PacificSource Commercial |
$310.17
|
| Rate for Payer: PHCS PPO |
$337.74
|
| Rate for Payer: Three Rivers PPO |
$258.47
|
| Rate for Payer: TriWest Veterans Administration |
$196.44
|
| Rate for Payer: United Healthcare Commercial |
$329.12
|
| Rate for Payer: United Healthcare Medicare |
$196.44
|
| Rate for Payer: WINHealth Partners Commercial |
$337.74
|
| Rate for Payer: Wise Provider Network Commercial |
$327.40
|
|
|
CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE [27717]
|
Facility
|
OP
|
$30.75
|
|
|
Service Code
|
NDC 0023916360
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.65 |
| Max. Negotiated Rate |
$30.75 |
| Rate for Payer: WINHealth Partners Commercial |
$30.14
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$30.14
|
| Rate for Payer: Aetna of WY Medicare |
$20.30
|
| Rate for Payer: Altius Commercial |
$29.52
|
| Rate for Payer: Beech Street Commercial |
$30.14
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$29.83
|
| Rate for Payer: Cash Price |
$21.52
|
| Rate for Payer: ChoiceCare Network Commercial |
$29.83
|
| Rate for Payer: Cigna of WY Commercial |
$30.14
|
| Rate for Payer: Entrust Commercial |
$29.21
|
| Rate for Payer: First Choice Health Commercial |
$29.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$29.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$17.53
|
| Rate for Payer: HealthUtah PPO |
$30.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$29.83
|
| Rate for Payer: Multiplan Medicare/VA |
$16.65
|
| Rate for Payer: One Health Plan of WY PPO |
$30.14
|
| Rate for Payer: PacificSource Commercial |
$27.68
|
| Rate for Payer: PHCS PPO |
$30.14
|
| Rate for Payer: Three Rivers PPO |
$23.06
|
| Rate for Payer: TriWest Veterans Administration |
$17.53
|
| Rate for Payer: United Healthcare Commercial |
$29.37
|
| Rate for Payer: United Healthcare Medicare |
$17.53
|
| Rate for Payer: Wise Provider Network Commercial |
$29.21
|
|
