|
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
|
|
|
CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE [27717]
|
Facility
|
OP
|
$47.28
|
|
|
Service Code
|
NDC 6050562022
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.60 |
| Max. Negotiated Rate |
$47.28 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$46.33
|
| Rate for Payer: Aetna of WY Medicare |
$31.20
|
| Rate for Payer: Altius Commercial |
$45.39
|
| Rate for Payer: Beech Street Commercial |
$46.33
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$45.86
|
| Rate for Payer: Cash Price |
$33.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$45.86
|
| Rate for Payer: Cigna of WY Commercial |
$46.33
|
| Rate for Payer: Entrust Commercial |
$44.92
|
| Rate for Payer: First Choice Health Commercial |
$44.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$44.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$26.95
|
| Rate for Payer: HealthUtah PPO |
$47.28
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$45.86
|
| Rate for Payer: Multiplan Medicare/VA |
$25.60
|
| Rate for Payer: One Health Plan of WY PPO |
$46.33
|
| Rate for Payer: PacificSource Commercial |
$42.55
|
| Rate for Payer: PHCS PPO |
$46.33
|
| Rate for Payer: Three Rivers PPO |
$35.46
|
| Rate for Payer: TriWest Veterans Administration |
$26.95
|
| Rate for Payer: United Healthcare Commercial |
$45.15
|
| Rate for Payer: United Healthcare Medicare |
$26.95
|
| Rate for Payer: WINHealth Partners Commercial |
$46.33
|
| Rate for Payer: Wise Provider Network Commercial |
$44.92
|
|
|
CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE [27717]
|
Facility
|
IP
|
$47.28
|
|
|
Service Code
|
NDC 6050562022
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.40 |
| Max. Negotiated Rate |
$47.28 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$46.33
|
| Rate for Payer: Aetna of WY Medicare |
$30.26
|
| Rate for Payer: Altius Commercial |
$45.39
|
| Rate for Payer: Beech Street Commercial |
$46.33
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$45.86
|
| Rate for Payer: Cash Price |
$33.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$45.86
|
| Rate for Payer: Cigna of WY Commercial |
$46.33
|
| Rate for Payer: Entrust Commercial |
$44.92
|
| Rate for Payer: First Choice Health Commercial |
$44.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$44.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$28.84
|
| Rate for Payer: HealthUtah PPO |
$47.28
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$45.86
|
| Rate for Payer: Multiplan Medicare/VA |
$27.40
|
| Rate for Payer: One Health Plan of WY PPO |
$46.33
|
| Rate for Payer: PacificSource Commercial |
$42.55
|
| Rate for Payer: PHCS PPO |
$46.33
|
| Rate for Payer: Three Rivers PPO |
$35.46
|
| Rate for Payer: TriWest Veterans Administration |
$28.84
|
| Rate for Payer: United Healthcare Commercial |
$45.15
|
| Rate for Payer: United Healthcare Medicare |
$28.84
|
| Rate for Payer: WINHealth Partners Commercial |
$44.92
|
| Rate for Payer: Wise Provider Network Commercial |
$44.92
|
|
|
CYGNUS, PER SQ CM
|
Professional
|
Both
|
$368.00
|
|
|
Service Code
|
HCPCS Q4170
|
| Min. Negotiated Rate |
$48.22 |
| Max. Negotiated Rate |
$368.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$360.64
|
| Rate for Payer: Aetna of WY Medicare |
$56.73
|
| Rate for Payer: Beech Street Commercial |
$349.60
|
| Rate for Payer: Cash Price |
$257.60
|
| Rate for Payer: Cash Price |
$257.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$356.96
|
| Rate for Payer: Cigna of WY Commercial |
$360.64
|
| Rate for Payer: First Choice Health Commercial |
$331.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$349.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$56.73
|
| Rate for Payer: HealthUtah PPO |
$368.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$356.96
|
| Rate for Payer: Multiplan Medicare/VA |
$48.22
|
| Rate for Payer: One Health Plan of WY PPO |
$360.64
|
| Rate for Payer: PacificSource Commercial |
$331.20
|
| Rate for Payer: PHCS PPO |
$349.60
|
| Rate for Payer: Three Rivers PPO |
$276.00
|
| Rate for Payer: TriWest Veterans Administration |
$56.73
|
| Rate for Payer: United Healthcare Commercial |
$349.60
|
| Rate for Payer: WINHealth Partners Commercial |
$349.60
|
|
|
CYSTORRHAPHY SUTR BLDR WND INJ/RPT SIMPLE
|
Professional
|
Both
|
$3,296.00
|
|
|
Service Code
|
HCPCS 51860
|
| Min. Negotiated Rate |
$607.84 |
| Max. Negotiated Rate |
$3,296.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,230.08
|
| Rate for Payer: Aetna of WY Medicare |
$715.10
|
| Rate for Payer: Beech Street Commercial |
$3,131.20
|
| Rate for Payer: Cash Price |
$2,307.20
|
| Rate for Payer: Cash Price |
$2,307.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,197.12
|
| Rate for Payer: Cigna of WY Commercial |
$3,230.08
|
| Rate for Payer: First Choice Health Commercial |
$2,966.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,131.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$715.10
|
| Rate for Payer: HealthUtah PPO |
$3,296.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,197.12
|
| Rate for Payer: Multiplan Medicare/VA |
$607.84
|
| Rate for Payer: One Health Plan of WY PPO |
$3,230.08
|
| Rate for Payer: PacificSource Commercial |
$2,966.40
|
| Rate for Payer: PHCS PPO |
$3,131.20
|
| Rate for Payer: Three Rivers PPO |
$2,472.00
|
| Rate for Payer: TriWest Veterans Administration |
$715.10
|
| Rate for Payer: United Healthcare Commercial |
$3,131.20
|
| Rate for Payer: WINHealth Partners Commercial |
$2,801.60
|
|
|
CYSTORRHAPHY SUTR BLDR WND INJ/RPT SIMPLE
|
Professional
|
Both
|
$3,296.00
|
|
|
Service Code
|
HCPCS 51860 AS
|
| Min. Negotiated Rate |
$607.84 |
| Max. Negotiated Rate |
$3,296.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,230.08
|
| Rate for Payer: Beech Street Commercial |
$3,131.20
|
| Rate for Payer: Cash Price |
$2,307.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,197.12
|
| Rate for Payer: Cigna of WY Commercial |
$3,230.08
|
| Rate for Payer: First Choice Health Commercial |
$2,966.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,131.20
|
| Rate for Payer: HealthUtah PPO |
$3,296.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,197.12
|
| Rate for Payer: One Health Plan of WY PPO |
$3,230.08
|
| Rate for Payer: PacificSource Commercial |
$2,966.40
|
| Rate for Payer: PHCS PPO |
$3,131.20
|
| Rate for Payer: Three Rivers PPO |
$2,472.00
|
| Rate for Payer: United Healthcare Commercial |
$3,131.20
|
| Rate for Payer: WINHealth Partners Commercial |
$2,801.60
|
|
|
CYSTORRHAPHY SUTR BLDR WND INJ/RPT SIMPLE
|
Professional
|
Both
|
$3,296.00
|
|
|
Service Code
|
HCPCS 51860 80
|
| Min. Negotiated Rate |
$607.84 |
| Max. Negotiated Rate |
$3,296.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,230.08
|
| Rate for Payer: Beech Street Commercial |
$3,131.20
|
| Rate for Payer: Cash Price |
$2,307.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,197.12
|
| Rate for Payer: Cigna of WY Commercial |
$3,230.08
|
| Rate for Payer: First Choice Health Commercial |
$2,966.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,131.20
|
| Rate for Payer: HealthUtah PPO |
$3,296.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,197.12
|
| Rate for Payer: One Health Plan of WY PPO |
$3,230.08
|
| Rate for Payer: PacificSource Commercial |
$2,966.40
|
| Rate for Payer: PHCS PPO |
$3,131.20
|
| Rate for Payer: Three Rivers PPO |
$2,472.00
|
| Rate for Payer: United Healthcare Commercial |
$3,131.20
|
| Rate for Payer: WINHealth Partners Commercial |
$2,801.60
|
|
|
CYSTO W/SIMPLE REMOVAL STONE & STENT
|
Professional
|
Both
|
$1,746.00
|
|
|
Service Code
|
HCPCS 52310
|
| Min. Negotiated Rate |
$122.14 |
| Max. Negotiated Rate |
$1,746.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,711.08
|
| Rate for Payer: Aetna of WY Medicare |
$143.70
|
| Rate for Payer: Beech Street Commercial |
$1,658.70
|
| Rate for Payer: Cash Price |
$1,222.20
|
| Rate for Payer: Cash Price |
$1,222.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,693.62
|
| Rate for Payer: Cigna of WY Commercial |
$1,711.08
|
| Rate for Payer: First Choice Health Commercial |
$1,571.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,658.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$143.70
|
| Rate for Payer: HealthUtah PPO |
$1,746.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,693.62
|
| Rate for Payer: Multiplan Medicare/VA |
$122.14
|
| Rate for Payer: One Health Plan of WY PPO |
$1,711.08
|
| Rate for Payer: PacificSource Commercial |
$1,571.40
|
| Rate for Payer: PHCS PPO |
$1,658.70
|
| Rate for Payer: Three Rivers PPO |
$1,309.50
|
| Rate for Payer: TriWest Veterans Administration |
$143.70
|
| Rate for Payer: United Healthcare Commercial |
$1,658.70
|
| Rate for Payer: WINHealth Partners Commercial |
$1,484.10
|
|
|
CYTAL, PER SQUARE CENTIMETER
|
Professional
|
Both
|
$194.00
|
|
|
Service Code
|
HCPCS Q4166
|
| Min. Negotiated Rate |
$16.32 |
| Max. Negotiated Rate |
$194.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$190.12
|
| Rate for Payer: Aetna of WY Medicare |
$19.20
|
| Rate for Payer: Beech Street Commercial |
$184.30
|
| Rate for Payer: Cash Price |
$135.80
|
| Rate for Payer: Cash Price |
$135.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$188.18
|
| Rate for Payer: Cigna of WY Commercial |
$190.12
|
| Rate for Payer: First Choice Health Commercial |
$174.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$184.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$19.20
|
| Rate for Payer: HealthUtah PPO |
$194.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$188.18
|
| Rate for Payer: Multiplan Medicare/VA |
$16.32
|
| Rate for Payer: One Health Plan of WY PPO |
$190.12
|
| Rate for Payer: PacificSource Commercial |
$174.60
|
| Rate for Payer: PHCS PPO |
$184.30
|
| Rate for Payer: Three Rivers PPO |
$145.50
|
| Rate for Payer: TriWest Veterans Administration |
$19.20
|
| Rate for Payer: United Healthcare Commercial |
$184.30
|
| Rate for Payer: WINHealth Partners Commercial |
$184.30
|
|
|
CYTARABINE (PF) 100 MG/5 ML (20 MG/ML) INJECTION SOLUTION [87075]
|
Facility
|
OP
|
$20.08
|
|
|
Service Code
|
HCPCS J9100
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.87 |
| Max. Negotiated Rate |
$20.08 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$19.68
|
| Rate for Payer: Aetna of WY Medicare |
$13.25
|
| Rate for Payer: Altius Commercial |
$19.28
|
| Rate for Payer: Beech Street Commercial |
$19.68
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$19.48
|
| Rate for Payer: Cash Price |
$14.05
|
| Rate for Payer: ChoiceCare Network Commercial |
$19.48
|
| Rate for Payer: Cigna of WY Commercial |
$19.68
|
| Rate for Payer: Entrust Commercial |
$19.08
|
| Rate for Payer: First Choice Health Commercial |
$19.08
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$19.08
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.45
|
| Rate for Payer: HealthUtah PPO |
$20.08
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$19.48
|
| Rate for Payer: Multiplan Medicare/VA |
$10.87
|
| Rate for Payer: One Health Plan of WY PPO |
$19.68
|
| Rate for Payer: PacificSource Commercial |
$18.07
|
| Rate for Payer: PHCS PPO |
$19.68
|
| Rate for Payer: Three Rivers PPO |
$15.06
|
| Rate for Payer: TriWest Veterans Administration |
$11.45
|
| Rate for Payer: United Healthcare Commercial |
$19.18
|
| Rate for Payer: United Healthcare Medicare |
$11.45
|
| Rate for Payer: WINHealth Partners Commercial |
$19.68
|
| Rate for Payer: Wise Provider Network Commercial |
$19.08
|
|
|
CYTARABINE (PF) 100 MG/5 ML (20 MG/ML) INJECTION SOLUTION [87075]
|
Facility
|
IP
|
$20.08
|
|
|
Service Code
|
HCPCS J9100
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.64 |
| Max. Negotiated Rate |
$20.08 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$19.68
|
| Rate for Payer: Aetna of WY Medicare |
$12.85
|
| Rate for Payer: Altius Commercial |
$19.28
|
| Rate for Payer: Beech Street Commercial |
$19.68
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$19.48
|
| Rate for Payer: Cash Price |
$14.05
|
| Rate for Payer: ChoiceCare Network Commercial |
$19.48
|
| Rate for Payer: Cigna of WY Commercial |
$19.68
|
| Rate for Payer: Entrust Commercial |
$19.08
|
| Rate for Payer: First Choice Health Commercial |
$19.08
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$19.08
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$12.25
|
| Rate for Payer: HealthUtah PPO |
$20.08
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$19.48
|
| Rate for Payer: Multiplan Medicare/VA |
$11.64
|
| Rate for Payer: One Health Plan of WY PPO |
$19.68
|
| Rate for Payer: PacificSource Commercial |
$18.07
|
| Rate for Payer: PHCS PPO |
$19.68
|
| Rate for Payer: Three Rivers PPO |
$15.06
|
| Rate for Payer: TriWest Veterans Administration |
$12.25
|
| Rate for Payer: United Healthcare Commercial |
$19.18
|
| Rate for Payer: United Healthcare Medicare |
$12.25
|
| Rate for Payer: WINHealth Partners Commercial |
$19.08
|
| Rate for Payer: Wise Provider Network Commercial |
$19.08
|
|
|
CYTOSOLIC 5 NUCLEOTIDASE 1A (CN-1A) ANTIBODY (IGG)
|
Professional
|
Both
|
$171.00
|
|
|
Service Code
|
HCPCS 83516
|
| Min. Negotiated Rate |
$9.80 |
| Max. Negotiated Rate |
$171.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$167.58
|
| Rate for Payer: Aetna of WY Medicare |
$11.53
|
| Rate for Payer: Beech Street Commercial |
$162.45
|
| Rate for Payer: Cash Price |
$119.70
|
| Rate for Payer: Cash Price |
$119.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$165.87
|
| Rate for Payer: Cigna of WY Commercial |
$167.58
|
| Rate for Payer: First Choice Health Commercial |
$153.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$162.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.53
|
| Rate for Payer: HealthUtah PPO |
$171.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$165.87
|
| Rate for Payer: Multiplan Medicare/VA |
$9.80
|
| Rate for Payer: One Health Plan of WY PPO |
$167.58
|
| Rate for Payer: PacificSource Commercial |
$153.90
|
| Rate for Payer: PHCS PPO |
$162.45
|
| Rate for Payer: Three Rivers PPO |
$128.25
|
| Rate for Payer: TriWest Veterans Administration |
$11.53
|
| Rate for Payer: United Healthcare Commercial |
$162.45
|
| Rate for Payer: WINHealth Partners Commercial |
$162.45
|
|
|
CYTP CONCENTRATION SMEARS & INTERPRETATION
|
Professional
|
Both
|
$98.00
|
|
|
Service Code
|
HCPCS 88108
|
| Min. Negotiated Rate |
$73.50 |
| Max. Negotiated Rate |
$98.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$96.04
|
| Rate for Payer: Beech Street Commercial |
$93.10
|
| Rate for Payer: Cash Price |
$68.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$95.06
|
| Rate for Payer: Cigna of WY Commercial |
$96.04
|
| Rate for Payer: First Choice Health Commercial |
$88.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$93.10
|
| Rate for Payer: HealthUtah PPO |
$98.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$95.06
|
| Rate for Payer: One Health Plan of WY PPO |
$96.04
|
| Rate for Payer: PacificSource Commercial |
$88.20
|
| Rate for Payer: PHCS PPO |
$93.10
|
| Rate for Payer: Three Rivers PPO |
$73.50
|
| Rate for Payer: United Healthcare Commercial |
$93.10
|
| Rate for Payer: WINHealth Partners Commercial |
$93.10
|
|
|
CYTP C/V AUTO THIN LYR PREPJ SCR SYS PHYS
|
Professional
|
Both
|
$51.00
|
|
|
Service Code
|
HCPCS 88174
|
| Min. Negotiated Rate |
$21.56 |
| Max. Negotiated Rate |
$51.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$49.98
|
| Rate for Payer: Aetna of WY Medicare |
$25.37
|
| Rate for Payer: Beech Street Commercial |
$48.45
|
| Rate for Payer: Cash Price |
$35.70
|
| Rate for Payer: Cash Price |
$35.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$49.47
|
| Rate for Payer: Cigna of WY Commercial |
$49.98
|
| Rate for Payer: First Choice Health Commercial |
$45.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$48.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$25.37
|
| Rate for Payer: HealthUtah PPO |
$51.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$49.47
|
| Rate for Payer: Multiplan Medicare/VA |
$21.56
|
| Rate for Payer: One Health Plan of WY PPO |
$49.98
|
| Rate for Payer: PacificSource Commercial |
$45.90
|
| Rate for Payer: PHCS PPO |
$48.45
|
| Rate for Payer: Three Rivers PPO |
$38.25
|
| Rate for Payer: TriWest Veterans Administration |
$25.37
|
| Rate for Payer: United Healthcare Commercial |
$48.45
|
| Rate for Payer: WINHealth Partners Commercial |
$48.45
|
|
|
CYTP SLIDES CERV/VAG MNL SCRN PHYSICIAN SUPV
|
Professional
|
Both
|
$51.00
|
|
|
Service Code
|
HCPCS 88164
|
| Min. Negotiated Rate |
$15.10 |
| Max. Negotiated Rate |
$51.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$49.98
|
| Rate for Payer: Aetna of WY Medicare |
$17.76
|
| Rate for Payer: Beech Street Commercial |
$48.45
|
| Rate for Payer: Cash Price |
$35.70
|
| Rate for Payer: Cash Price |
$35.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$49.47
|
| Rate for Payer: Cigna of WY Commercial |
$49.98
|
| Rate for Payer: First Choice Health Commercial |
$45.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$48.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$17.76
|
| Rate for Payer: HealthUtah PPO |
$51.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$49.47
|
| Rate for Payer: Multiplan Medicare/VA |
$15.10
|
| Rate for Payer: One Health Plan of WY PPO |
$49.98
|
| Rate for Payer: PacificSource Commercial |
$45.90
|
| Rate for Payer: PHCS PPO |
$48.45
|
| Rate for Payer: Three Rivers PPO |
$38.25
|
| Rate for Payer: TriWest Veterans Administration |
$17.76
|
| Rate for Payer: United Healthcare Commercial |
$48.45
|
| Rate for Payer: WINHealth Partners Commercial |
$48.45
|
|
|
DANTROLENE 20 MG INTRAVENOUS SOLUTION [3097]
|
Facility
|
IP
|
$137.50
|
|
|
Service Code
|
NDC 2750500367
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$79.68 |
| Max. Negotiated Rate |
$137.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$134.75
|
| Rate for Payer: Aetna of WY Medicare |
$88.00
|
| Rate for Payer: Altius Commercial |
$132.00
|
| Rate for Payer: Beech Street Commercial |
$134.75
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$133.38
|
| Rate for Payer: Cash Price |
$96.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$133.38
|
| Rate for Payer: Cigna of WY Commercial |
$134.75
|
| Rate for Payer: Entrust Commercial |
$130.62
|
| Rate for Payer: First Choice Health Commercial |
$130.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$130.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$83.88
|
| Rate for Payer: HealthUtah PPO |
$137.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$133.38
|
| Rate for Payer: Multiplan Medicare/VA |
$79.68
|
| Rate for Payer: One Health Plan of WY PPO |
$134.75
|
| Rate for Payer: PacificSource Commercial |
$123.75
|
| Rate for Payer: PHCS PPO |
$134.75
|
| Rate for Payer: Three Rivers PPO |
$103.12
|
| Rate for Payer: TriWest Veterans Administration |
$83.88
|
| Rate for Payer: United Healthcare Commercial |
$131.31
|
| Rate for Payer: United Healthcare Medicare |
$83.88
|
| Rate for Payer: WINHealth Partners Commercial |
$130.62
|
| Rate for Payer: Wise Provider Network Commercial |
$130.62
|
|
|
DANTROLENE 20 MG INTRAVENOUS SOLUTION [3097]
|
Facility
|
OP
|
$137.50
|
|
|
Service Code
|
NDC 2750500367
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$74.46 |
| Max. Negotiated Rate |
$137.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$134.75
|
| Rate for Payer: Aetna of WY Medicare |
$90.75
|
| Rate for Payer: Altius Commercial |
$132.00
|
| Rate for Payer: Beech Street Commercial |
$134.75
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$133.38
|
| Rate for Payer: Cash Price |
$96.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$133.38
|
| Rate for Payer: Cigna of WY Commercial |
$134.75
|
| Rate for Payer: Entrust Commercial |
$130.62
|
| Rate for Payer: First Choice Health Commercial |
$130.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$130.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$78.38
|
| Rate for Payer: HealthUtah PPO |
$137.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$133.38
|
| Rate for Payer: Multiplan Medicare/VA |
$74.46
|
| Rate for Payer: One Health Plan of WY PPO |
$134.75
|
| Rate for Payer: PacificSource Commercial |
$123.75
|
| Rate for Payer: PHCS PPO |
$134.75
|
| Rate for Payer: Three Rivers PPO |
$103.12
|
| Rate for Payer: TriWest Veterans Administration |
$78.38
|
| Rate for Payer: United Healthcare Commercial |
$131.31
|
| Rate for Payer: United Healthcare Medicare |
$78.38
|
| Rate for Payer: WINHealth Partners Commercial |
$134.75
|
| Rate for Payer: Wise Provider Network Commercial |
$130.62
|
|
|
DANTROLENE 20MG VIALS
|
Facility
|
OP
|
$247.64
|
|
| Hospital Charge Code |
2050002
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$134.10 |
| Max. Negotiated Rate |
$247.64 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$242.69
|
| Rate for Payer: Aetna of WY Medicare |
$163.44
|
| Rate for Payer: Altius Commercial |
$237.73
|
| Rate for Payer: Beech Street Commercial |
$242.69
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$240.21
|
| Rate for Payer: Cash Price |
$173.35
|
| Rate for Payer: ChoiceCare Network Commercial |
$240.21
|
| Rate for Payer: Cigna of WY Commercial |
$242.69
|
| Rate for Payer: Entrust Commercial |
$235.26
|
| Rate for Payer: First Choice Health Commercial |
$235.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$235.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$141.15
|
| Rate for Payer: HealthUtah PPO |
$247.64
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$240.21
|
| Rate for Payer: Multiplan Medicare/VA |
$134.10
|
| Rate for Payer: One Health Plan of WY PPO |
$242.69
|
| Rate for Payer: PacificSource Commercial |
$222.88
|
| Rate for Payer: PHCS PPO |
$242.69
|
| Rate for Payer: Three Rivers PPO |
$185.73
|
| Rate for Payer: TriWest Veterans Administration |
$141.15
|
| Rate for Payer: United Healthcare Commercial |
$236.50
|
| Rate for Payer: United Healthcare Medicare |
$141.15
|
| Rate for Payer: WINHealth Partners Commercial |
$242.69
|
| Rate for Payer: Wise Provider Network Commercial |
$235.26
|
|
|
DANTROLENE 20MG VIALS
|
Facility
|
IP
|
$247.64
|
|
| Hospital Charge Code |
2050002
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$143.51 |
| Max. Negotiated Rate |
$247.64 |
| Rate for Payer: United Healthcare Commercial |
$236.50
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$242.69
|
| Rate for Payer: Aetna of WY Medicare |
$158.49
|
| Rate for Payer: Altius Commercial |
$237.73
|
| Rate for Payer: Beech Street Commercial |
$242.69
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$240.21
|
| Rate for Payer: Cash Price |
$173.35
|
| Rate for Payer: ChoiceCare Network Commercial |
$240.21
|
| Rate for Payer: Cigna of WY Commercial |
$242.69
|
| Rate for Payer: Entrust Commercial |
$235.26
|
| Rate for Payer: First Choice Health Commercial |
$235.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$235.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$151.06
|
| Rate for Payer: HealthUtah PPO |
$247.64
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$240.21
|
| Rate for Payer: Multiplan Medicare/VA |
$143.51
|
| Rate for Payer: One Health Plan of WY PPO |
$242.69
|
| Rate for Payer: PacificSource Commercial |
$222.88
|
| Rate for Payer: PHCS PPO |
$242.69
|
| Rate for Payer: Three Rivers PPO |
$185.73
|
| Rate for Payer: TriWest Veterans Administration |
$151.06
|
| Rate for Payer: United Healthcare Medicare |
$151.06
|
| Rate for Payer: WINHealth Partners Commercial |
$235.26
|
| Rate for Payer: Wise Provider Network Commercial |
$235.26
|
|
|
DAPAGLIFLOZIN PROPANEDIOL 10 MG TABLET [131704]
|
Facility
|
IP
|
$49.69
|
|
|
Service Code
|
NDC 0310621030
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.80 |
| Max. Negotiated Rate |
$49.69 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$48.70
|
| Rate for Payer: Aetna of WY Medicare |
$31.80
|
| Rate for Payer: Altius Commercial |
$47.70
|
| Rate for Payer: Beech Street Commercial |
$48.70
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$48.20
|
| Rate for Payer: Cash Price |
$34.78
|
| Rate for Payer: ChoiceCare Network Commercial |
$48.20
|
| Rate for Payer: Cigna of WY Commercial |
$48.70
|
| Rate for Payer: Entrust Commercial |
$47.21
|
| Rate for Payer: First Choice Health Commercial |
$47.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$47.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$30.31
|
| Rate for Payer: HealthUtah PPO |
$49.69
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$48.20
|
| Rate for Payer: Multiplan Medicare/VA |
$28.80
|
| Rate for Payer: One Health Plan of WY PPO |
$48.70
|
| Rate for Payer: PacificSource Commercial |
$44.72
|
| Rate for Payer: PHCS PPO |
$48.70
|
| Rate for Payer: Three Rivers PPO |
$37.27
|
| Rate for Payer: TriWest Veterans Administration |
$30.31
|
| Rate for Payer: United Healthcare Commercial |
$47.45
|
| Rate for Payer: United Healthcare Medicare |
$30.31
|
| Rate for Payer: WINHealth Partners Commercial |
$47.21
|
| Rate for Payer: Wise Provider Network Commercial |
$47.21
|
|
|
DAPAGLIFLOZIN PROPANEDIOL 10 MG TABLET [131704]
|
Facility
|
IP
|
$58.67
|
|
|
Service Code
|
NDC 6699345730
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$34.00 |
| Max. Negotiated Rate |
$58.67 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$57.50
|
| Rate for Payer: Aetna of WY Medicare |
$37.55
|
| Rate for Payer: Altius Commercial |
$56.32
|
| Rate for Payer: Beech Street Commercial |
$57.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$56.91
|
| Rate for Payer: Cash Price |
$41.07
|
| Rate for Payer: ChoiceCare Network Commercial |
$56.91
|
| Rate for Payer: Cigna of WY Commercial |
$57.50
|
| Rate for Payer: Entrust Commercial |
$55.74
|
| Rate for Payer: First Choice Health Commercial |
$55.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$55.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$35.79
|
| Rate for Payer: HealthUtah PPO |
$58.67
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$56.91
|
| Rate for Payer: Multiplan Medicare/VA |
$34.00
|
| Rate for Payer: One Health Plan of WY PPO |
$57.50
|
| Rate for Payer: PacificSource Commercial |
$52.80
|
| Rate for Payer: PHCS PPO |
$57.50
|
| Rate for Payer: Three Rivers PPO |
$44.00
|
| Rate for Payer: TriWest Veterans Administration |
$35.79
|
| Rate for Payer: United Healthcare Commercial |
$56.03
|
| Rate for Payer: United Healthcare Medicare |
$35.79
|
| Rate for Payer: WINHealth Partners Commercial |
$55.74
|
| Rate for Payer: Wise Provider Network Commercial |
$55.74
|
|
|
DAPAGLIFLOZIN PROPANEDIOL 10 MG TABLET [131704]
|
Facility
|
IP
|
$58.67
|
|
|
Service Code
|
NDC 0310621039
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$34.00 |
| Max. Negotiated Rate |
$58.67 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$57.50
|
| Rate for Payer: Aetna of WY Medicare |
$37.55
|
| Rate for Payer: Altius Commercial |
$56.32
|
| Rate for Payer: Beech Street Commercial |
$57.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$56.91
|
| Rate for Payer: Cash Price |
$41.07
|
| Rate for Payer: ChoiceCare Network Commercial |
$56.91
|
| Rate for Payer: Cigna of WY Commercial |
$57.50
|
| Rate for Payer: Entrust Commercial |
$55.74
|
| Rate for Payer: First Choice Health Commercial |
$55.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$55.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$35.79
|
| Rate for Payer: HealthUtah PPO |
$58.67
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$56.91
|
| Rate for Payer: Multiplan Medicare/VA |
$34.00
|
| Rate for Payer: One Health Plan of WY PPO |
$57.50
|
| Rate for Payer: PacificSource Commercial |
$52.80
|
| Rate for Payer: PHCS PPO |
$57.50
|
| Rate for Payer: Three Rivers PPO |
$44.00
|
| Rate for Payer: TriWest Veterans Administration |
$35.79
|
| Rate for Payer: United Healthcare Commercial |
$56.03
|
| Rate for Payer: United Healthcare Medicare |
$35.79
|
| Rate for Payer: WINHealth Partners Commercial |
$55.74
|
| Rate for Payer: Wise Provider Network Commercial |
$55.74
|
|
|
DAPAGLIFLOZIN PROPANEDIOL 10 MG TABLET [131704]
|
Facility
|
OP
|
$49.69
|
|
|
Service Code
|
NDC 0310621030
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.91 |
| Max. Negotiated Rate |
$49.69 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$48.70
|
| Rate for Payer: Aetna of WY Medicare |
$32.80
|
| Rate for Payer: Altius Commercial |
$47.70
|
| Rate for Payer: Beech Street Commercial |
$48.70
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$48.20
|
| Rate for Payer: Cash Price |
$34.78
|
| Rate for Payer: ChoiceCare Network Commercial |
$48.20
|
| Rate for Payer: Cigna of WY Commercial |
$48.70
|
| Rate for Payer: Entrust Commercial |
$47.21
|
| Rate for Payer: First Choice Health Commercial |
$47.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$47.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$28.32
|
| Rate for Payer: HealthUtah PPO |
$49.69
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$48.20
|
| Rate for Payer: Multiplan Medicare/VA |
$26.91
|
| Rate for Payer: One Health Plan of WY PPO |
$48.70
|
| Rate for Payer: PacificSource Commercial |
$44.72
|
| Rate for Payer: PHCS PPO |
$48.70
|
| Rate for Payer: Three Rivers PPO |
$37.27
|
| Rate for Payer: TriWest Veterans Administration |
$28.32
|
| Rate for Payer: United Healthcare Commercial |
$47.45
|
| Rate for Payer: United Healthcare Medicare |
$28.32
|
| Rate for Payer: WINHealth Partners Commercial |
$48.70
|
| Rate for Payer: Wise Provider Network Commercial |
$47.21
|
|
|
DAPAGLIFLOZIN PROPANEDIOL 10 MG TABLET [131704]
|
Facility
|
OP
|
$58.67
|
|
|
Service Code
|
NDC 0310621039
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$31.77 |
| Max. Negotiated Rate |
$58.67 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$57.50
|
| Rate for Payer: Aetna of WY Medicare |
$38.72
|
| Rate for Payer: Altius Commercial |
$56.32
|
| Rate for Payer: Beech Street Commercial |
$57.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$56.91
|
| Rate for Payer: Cash Price |
$41.07
|
| Rate for Payer: ChoiceCare Network Commercial |
$56.91
|
| Rate for Payer: Cigna of WY Commercial |
$57.50
|
| Rate for Payer: Entrust Commercial |
$55.74
|
| Rate for Payer: First Choice Health Commercial |
$55.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$55.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$33.44
|
| Rate for Payer: HealthUtah PPO |
$58.67
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$56.91
|
| Rate for Payer: Multiplan Medicare/VA |
$31.77
|
| Rate for Payer: One Health Plan of WY PPO |
$57.50
|
| Rate for Payer: PacificSource Commercial |
$52.80
|
| Rate for Payer: PHCS PPO |
$57.50
|
| Rate for Payer: Three Rivers PPO |
$44.00
|
| Rate for Payer: TriWest Veterans Administration |
$33.44
|
| Rate for Payer: United Healthcare Commercial |
$56.03
|
| Rate for Payer: United Healthcare Medicare |
$33.44
|
| Rate for Payer: WINHealth Partners Commercial |
$57.50
|
| Rate for Payer: Wise Provider Network Commercial |
$55.74
|
|
|
DAPAGLIFLOZIN PROPANEDIOL 10 MG TABLET [131704]
|
Facility
|
OP
|
$58.67
|
|
|
Service Code
|
NDC 6699345730
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$31.77 |
| Max. Negotiated Rate |
$58.67 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$57.50
|
| Rate for Payer: Aetna of WY Medicare |
$38.72
|
| Rate for Payer: Altius Commercial |
$56.32
|
| Rate for Payer: Beech Street Commercial |
$57.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$56.91
|
| Rate for Payer: Cash Price |
$41.07
|
| Rate for Payer: ChoiceCare Network Commercial |
$56.91
|
| Rate for Payer: Cigna of WY Commercial |
$57.50
|
| Rate for Payer: Entrust Commercial |
$55.74
|
| Rate for Payer: First Choice Health Commercial |
$55.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$55.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$33.44
|
| Rate for Payer: HealthUtah PPO |
$58.67
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$56.91
|
| Rate for Payer: Multiplan Medicare/VA |
$31.77
|
| Rate for Payer: One Health Plan of WY PPO |
$57.50
|
| Rate for Payer: PacificSource Commercial |
$52.80
|
| Rate for Payer: PHCS PPO |
$57.50
|
| Rate for Payer: Three Rivers PPO |
$44.00
|
| Rate for Payer: TriWest Veterans Administration |
$33.44
|
| Rate for Payer: United Healthcare Commercial |
$56.03
|
| Rate for Payer: United Healthcare Medicare |
$33.44
|
| Rate for Payer: WINHealth Partners Commercial |
$57.50
|
| Rate for Payer: Wise Provider Network Commercial |
$55.74
|
|
