|
DERMABOND SKIN AFFIX ADHESIVE MINI
|
Facility
|
IP
|
$40.00
|
|
| Hospital Charge Code |
2150349
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$23.18 |
| Max. Negotiated Rate |
$40.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$39.20
|
| Rate for Payer: Aetna of WY Medicare |
$25.60
|
| Rate for Payer: Altius Commercial |
$38.40
|
| Rate for Payer: Beech Street Commercial |
$39.20
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$38.80
|
| Rate for Payer: Cash Price |
$28.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$38.80
|
| Rate for Payer: Cigna of WY Commercial |
$39.20
|
| Rate for Payer: Entrust Commercial |
$38.00
|
| Rate for Payer: First Choice Health Commercial |
$38.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$38.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$24.40
|
| Rate for Payer: HealthUtah PPO |
$40.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$38.80
|
| Rate for Payer: Multiplan Medicare/VA |
$23.18
|
| Rate for Payer: One Health Plan of WY PPO |
$39.20
|
| Rate for Payer: PacificSource Commercial |
$36.00
|
| Rate for Payer: PHCS PPO |
$39.20
|
| Rate for Payer: Three Rivers PPO |
$30.00
|
| Rate for Payer: TriWest Veterans Administration |
$24.40
|
| Rate for Payer: United Healthcare Commercial |
$38.20
|
| Rate for Payer: United Healthcare Medicare |
$24.40
|
| Rate for Payer: WINHealth Partners Commercial |
$38.00
|
| Rate for Payer: Wise Provider Network Commercial |
$38.00
|
|
|
DERMACARRIER II 1.5:1 ZIMMER
|
Facility
|
OP
|
$71.24
|
|
| Hospital Charge Code |
3003238
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$38.58 |
| Max. Negotiated Rate |
$71.24 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$69.82
|
| Rate for Payer: Aetna of WY Medicare |
$47.02
|
| Rate for Payer: Altius Commercial |
$68.39
|
| Rate for Payer: Beech Street Commercial |
$69.82
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$69.10
|
| Rate for Payer: Cash Price |
$49.87
|
| Rate for Payer: ChoiceCare Network Commercial |
$69.10
|
| Rate for Payer: Cigna of WY Commercial |
$69.82
|
| Rate for Payer: Entrust Commercial |
$67.68
|
| Rate for Payer: First Choice Health Commercial |
$67.68
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$67.68
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$40.61
|
| Rate for Payer: HealthUtah PPO |
$71.24
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$69.10
|
| Rate for Payer: Multiplan Medicare/VA |
$38.58
|
| Rate for Payer: One Health Plan of WY PPO |
$69.82
|
| Rate for Payer: PacificSource Commercial |
$64.12
|
| Rate for Payer: PHCS PPO |
$69.82
|
| Rate for Payer: Three Rivers PPO |
$53.43
|
| Rate for Payer: TriWest Veterans Administration |
$40.61
|
| Rate for Payer: United Healthcare Commercial |
$68.03
|
| Rate for Payer: United Healthcare Medicare |
$40.61
|
| Rate for Payer: WINHealth Partners Commercial |
$69.82
|
| Rate for Payer: Wise Provider Network Commercial |
$67.68
|
|
|
DERMACARRIER II 1.5:1 ZIMMER
|
Facility
|
IP
|
$71.24
|
|
| Hospital Charge Code |
3003238
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$41.28 |
| Max. Negotiated Rate |
$71.24 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$69.82
|
| Rate for Payer: Aetna of WY Medicare |
$45.59
|
| Rate for Payer: Altius Commercial |
$68.39
|
| Rate for Payer: Beech Street Commercial |
$69.82
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$69.10
|
| Rate for Payer: Cash Price |
$49.87
|
| Rate for Payer: ChoiceCare Network Commercial |
$69.10
|
| Rate for Payer: Cigna of WY Commercial |
$69.82
|
| Rate for Payer: Entrust Commercial |
$67.68
|
| Rate for Payer: First Choice Health Commercial |
$67.68
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$67.68
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$43.46
|
| Rate for Payer: HealthUtah PPO |
$71.24
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$69.10
|
| Rate for Payer: Multiplan Medicare/VA |
$41.28
|
| Rate for Payer: One Health Plan of WY PPO |
$69.82
|
| Rate for Payer: PacificSource Commercial |
$64.12
|
| Rate for Payer: PHCS PPO |
$69.82
|
| Rate for Payer: Three Rivers PPO |
$53.43
|
| Rate for Payer: TriWest Veterans Administration |
$43.46
|
| Rate for Payer: United Healthcare Commercial |
$68.03
|
| Rate for Payer: United Healthcare Medicare |
$43.46
|
| Rate for Payer: WINHealth Partners Commercial |
$67.68
|
| Rate for Payer: Wise Provider Network Commercial |
$67.68
|
|
|
DERMACARRIERS II
|
Facility
|
OP
|
$98.00
|
|
| Hospital Charge Code |
3000986
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$53.07 |
| Max. Negotiated Rate |
$98.00 |
| Rate for Payer: United Healthcare Commercial |
$93.59
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$96.04
|
| Rate for Payer: Aetna of WY Medicare |
$64.68
|
| Rate for Payer: Altius Commercial |
$94.08
|
| Rate for Payer: Beech Street Commercial |
$96.04
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$95.06
|
| 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: Entrust Commercial |
$93.10
|
| Rate for Payer: First Choice Health Commercial |
$93.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$93.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$55.86
|
| Rate for Payer: HealthUtah PPO |
$98.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$95.06
|
| Rate for Payer: Multiplan Medicare/VA |
$53.07
|
| Rate for Payer: One Health Plan of WY PPO |
$96.04
|
| Rate for Payer: PacificSource Commercial |
$88.20
|
| Rate for Payer: PHCS PPO |
$96.04
|
| Rate for Payer: Three Rivers PPO |
$73.50
|
| Rate for Payer: TriWest Veterans Administration |
$55.86
|
| Rate for Payer: United Healthcare Medicare |
$55.86
|
| Rate for Payer: WINHealth Partners Commercial |
$96.04
|
| Rate for Payer: Wise Provider Network Commercial |
$93.10
|
|
|
DERMACARRIERS II
|
Facility
|
IP
|
$98.00
|
|
| Hospital Charge Code |
3000986
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$56.79 |
| Max. Negotiated Rate |
$98.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$96.04
|
| Rate for Payer: Aetna of WY Medicare |
$62.72
|
| Rate for Payer: Altius Commercial |
$94.08
|
| Rate for Payer: Beech Street Commercial |
$96.04
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$95.06
|
| 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: Entrust Commercial |
$93.10
|
| Rate for Payer: First Choice Health Commercial |
$93.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$93.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$59.78
|
| Rate for Payer: HealthUtah PPO |
$98.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$95.06
|
| Rate for Payer: Multiplan Medicare/VA |
$56.79
|
| Rate for Payer: One Health Plan of WY PPO |
$96.04
|
| Rate for Payer: PacificSource Commercial |
$88.20
|
| Rate for Payer: PHCS PPO |
$96.04
|
| Rate for Payer: Three Rivers PPO |
$73.50
|
| Rate for Payer: TriWest Veterans Administration |
$59.78
|
| Rate for Payer: United Healthcare Commercial |
$93.59
|
| Rate for Payer: United Healthcare Medicare |
$59.78
|
| Rate for Payer: WINHealth Partners Commercial |
$93.10
|
| Rate for Payer: Wise Provider Network Commercial |
$93.10
|
|
|
DERMASAVER SHIN TUBE MED 12-15
|
Facility
|
OP
|
$88.44
|
|
| Hospital Charge Code |
2200433
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$47.89 |
| Max. Negotiated Rate |
$88.44 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$86.67
|
| Rate for Payer: Aetna of WY Medicare |
$58.37
|
| Rate for Payer: Altius Commercial |
$84.90
|
| Rate for Payer: Beech Street Commercial |
$86.67
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$85.79
|
| Rate for Payer: Cash Price |
$61.91
|
| Rate for Payer: ChoiceCare Network Commercial |
$85.79
|
| Rate for Payer: Cigna of WY Commercial |
$86.67
|
| Rate for Payer: Entrust Commercial |
$84.02
|
| Rate for Payer: First Choice Health Commercial |
$84.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$84.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$50.41
|
| Rate for Payer: HealthUtah PPO |
$88.44
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$85.79
|
| Rate for Payer: Multiplan Medicare/VA |
$47.89
|
| Rate for Payer: One Health Plan of WY PPO |
$86.67
|
| Rate for Payer: PacificSource Commercial |
$79.60
|
| Rate for Payer: PHCS PPO |
$86.67
|
| Rate for Payer: Three Rivers PPO |
$66.33
|
| Rate for Payer: TriWest Veterans Administration |
$50.41
|
| Rate for Payer: United Healthcare Commercial |
$84.46
|
| Rate for Payer: United Healthcare Medicare |
$50.41
|
| Rate for Payer: WINHealth Partners Commercial |
$86.67
|
| Rate for Payer: Wise Provider Network Commercial |
$84.02
|
|
|
DERMASAVER SHIN TUBE MED 12-15
|
Facility
|
IP
|
$88.44
|
|
| Hospital Charge Code |
2200433
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$51.25 |
| Max. Negotiated Rate |
$88.44 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$86.67
|
| Rate for Payer: Aetna of WY Medicare |
$56.60
|
| Rate for Payer: Altius Commercial |
$84.90
|
| Rate for Payer: Beech Street Commercial |
$86.67
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$85.79
|
| Rate for Payer: Cash Price |
$61.91
|
| Rate for Payer: ChoiceCare Network Commercial |
$85.79
|
| Rate for Payer: Cigna of WY Commercial |
$86.67
|
| Rate for Payer: Entrust Commercial |
$84.02
|
| Rate for Payer: First Choice Health Commercial |
$84.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$84.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$53.95
|
| Rate for Payer: HealthUtah PPO |
$88.44
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$85.79
|
| Rate for Payer: Multiplan Medicare/VA |
$51.25
|
| Rate for Payer: One Health Plan of WY PPO |
$86.67
|
| Rate for Payer: PacificSource Commercial |
$79.60
|
| Rate for Payer: PHCS PPO |
$86.67
|
| Rate for Payer: Three Rivers PPO |
$66.33
|
| Rate for Payer: TriWest Veterans Administration |
$53.95
|
| Rate for Payer: United Healthcare Commercial |
$84.46
|
| Rate for Payer: United Healthcare Medicare |
$53.95
|
| Rate for Payer: WINHealth Partners Commercial |
$84.02
|
| Rate for Payer: Wise Provider Network Commercial |
$84.02
|
|
|
DERMASAVER SHIN TUBE SM 9-12"
|
Facility
|
IP
|
$88.44
|
|
| Hospital Charge Code |
2200432
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$51.25 |
| Max. Negotiated Rate |
$88.44 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$86.67
|
| Rate for Payer: Aetna of WY Medicare |
$56.60
|
| Rate for Payer: Altius Commercial |
$84.90
|
| Rate for Payer: Beech Street Commercial |
$86.67
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$85.79
|
| Rate for Payer: Cash Price |
$61.91
|
| Rate for Payer: ChoiceCare Network Commercial |
$85.79
|
| Rate for Payer: Cigna of WY Commercial |
$86.67
|
| Rate for Payer: Entrust Commercial |
$84.02
|
| Rate for Payer: First Choice Health Commercial |
$84.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$84.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$53.95
|
| Rate for Payer: HealthUtah PPO |
$88.44
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$85.79
|
| Rate for Payer: Multiplan Medicare/VA |
$51.25
|
| Rate for Payer: One Health Plan of WY PPO |
$86.67
|
| Rate for Payer: PacificSource Commercial |
$79.60
|
| Rate for Payer: PHCS PPO |
$86.67
|
| Rate for Payer: Three Rivers PPO |
$66.33
|
| Rate for Payer: TriWest Veterans Administration |
$53.95
|
| Rate for Payer: United Healthcare Commercial |
$84.46
|
| Rate for Payer: United Healthcare Medicare |
$53.95
|
| Rate for Payer: WINHealth Partners Commercial |
$84.02
|
| Rate for Payer: Wise Provider Network Commercial |
$84.02
|
|
|
DERMASAVER SHIN TUBE SM 9-12"
|
Facility
|
OP
|
$88.44
|
|
| Hospital Charge Code |
2200432
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$47.89 |
| Max. Negotiated Rate |
$88.44 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$86.67
|
| Rate for Payer: Aetna of WY Medicare |
$58.37
|
| Rate for Payer: Altius Commercial |
$84.90
|
| Rate for Payer: Beech Street Commercial |
$86.67
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$85.79
|
| Rate for Payer: Cash Price |
$61.91
|
| Rate for Payer: ChoiceCare Network Commercial |
$85.79
|
| Rate for Payer: Cigna of WY Commercial |
$86.67
|
| Rate for Payer: Entrust Commercial |
$84.02
|
| Rate for Payer: First Choice Health Commercial |
$84.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$84.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$50.41
|
| Rate for Payer: HealthUtah PPO |
$88.44
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$85.79
|
| Rate for Payer: Multiplan Medicare/VA |
$47.89
|
| Rate for Payer: One Health Plan of WY PPO |
$86.67
|
| Rate for Payer: PacificSource Commercial |
$79.60
|
| Rate for Payer: PHCS PPO |
$86.67
|
| Rate for Payer: Three Rivers PPO |
$66.33
|
| Rate for Payer: TriWest Veterans Administration |
$50.41
|
| Rate for Payer: United Healthcare Commercial |
$84.46
|
| Rate for Payer: United Healthcare Medicare |
$50.41
|
| Rate for Payer: WINHealth Partners Commercial |
$86.67
|
| Rate for Payer: Wise Provider Network Commercial |
$84.02
|
|
|
DERMATOME BLADE 8800-000-10
|
Facility
|
OP
|
$161.00
|
|
| Hospital Charge Code |
3000985
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$87.18 |
| Max. Negotiated Rate |
$161.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$157.78
|
| Rate for Payer: Aetna of WY Medicare |
$106.26
|
| Rate for Payer: Altius Commercial |
$154.56
|
| Rate for Payer: Beech Street Commercial |
$157.78
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$156.17
|
| Rate for Payer: Cash Price |
$112.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$156.17
|
| Rate for Payer: Cigna of WY Commercial |
$157.78
|
| Rate for Payer: Entrust Commercial |
$152.95
|
| Rate for Payer: First Choice Health Commercial |
$152.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$152.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$91.77
|
| Rate for Payer: HealthUtah PPO |
$161.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$156.17
|
| Rate for Payer: Multiplan Medicare/VA |
$87.18
|
| Rate for Payer: One Health Plan of WY PPO |
$157.78
|
| Rate for Payer: PacificSource Commercial |
$144.90
|
| Rate for Payer: PHCS PPO |
$157.78
|
| Rate for Payer: Three Rivers PPO |
$120.75
|
| Rate for Payer: TriWest Veterans Administration |
$91.77
|
| Rate for Payer: United Healthcare Commercial |
$153.76
|
| Rate for Payer: United Healthcare Medicare |
$91.77
|
| Rate for Payer: WINHealth Partners Commercial |
$157.78
|
| Rate for Payer: Wise Provider Network Commercial |
$152.95
|
|
|
DERMATOME BLADE 8800-000-10
|
Facility
|
IP
|
$161.00
|
|
| Hospital Charge Code |
3000985
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$93.30 |
| Max. Negotiated Rate |
$161.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$157.78
|
| Rate for Payer: Aetna of WY Medicare |
$103.04
|
| Rate for Payer: Altius Commercial |
$154.56
|
| Rate for Payer: Beech Street Commercial |
$157.78
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$156.17
|
| Rate for Payer: Cash Price |
$112.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$156.17
|
| Rate for Payer: Cigna of WY Commercial |
$157.78
|
| Rate for Payer: Entrust Commercial |
$152.95
|
| Rate for Payer: First Choice Health Commercial |
$152.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$152.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$98.21
|
| Rate for Payer: HealthUtah PPO |
$161.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$156.17
|
| Rate for Payer: Multiplan Medicare/VA |
$93.30
|
| Rate for Payer: One Health Plan of WY PPO |
$157.78
|
| Rate for Payer: PacificSource Commercial |
$144.90
|
| Rate for Payer: PHCS PPO |
$157.78
|
| Rate for Payer: Three Rivers PPO |
$120.75
|
| Rate for Payer: TriWest Veterans Administration |
$98.21
|
| Rate for Payer: United Healthcare Commercial |
$153.76
|
| Rate for Payer: United Healthcare Medicare |
$98.21
|
| Rate for Payer: WINHealth Partners Commercial |
$152.95
|
| Rate for Payer: Wise Provider Network Commercial |
$152.95
|
|
|
DERMATOME BLADE ZIMMER
|
Facility
|
IP
|
$96.97
|
|
| Hospital Charge Code |
3003239
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$56.19 |
| Max. Negotiated Rate |
$96.97 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$95.03
|
| Rate for Payer: Aetna of WY Medicare |
$62.06
|
| Rate for Payer: Altius Commercial |
$93.09
|
| Rate for Payer: Beech Street Commercial |
$95.03
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$94.06
|
| Rate for Payer: Cash Price |
$67.88
|
| Rate for Payer: ChoiceCare Network Commercial |
$94.06
|
| Rate for Payer: Cigna of WY Commercial |
$95.03
|
| Rate for Payer: Entrust Commercial |
$92.12
|
| Rate for Payer: First Choice Health Commercial |
$92.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$92.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$59.15
|
| Rate for Payer: HealthUtah PPO |
$96.97
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$94.06
|
| Rate for Payer: Multiplan Medicare/VA |
$56.19
|
| Rate for Payer: One Health Plan of WY PPO |
$95.03
|
| Rate for Payer: PacificSource Commercial |
$87.27
|
| Rate for Payer: PHCS PPO |
$95.03
|
| Rate for Payer: Three Rivers PPO |
$72.73
|
| Rate for Payer: TriWest Veterans Administration |
$59.15
|
| Rate for Payer: United Healthcare Commercial |
$92.61
|
| Rate for Payer: United Healthcare Medicare |
$59.15
|
| Rate for Payer: WINHealth Partners Commercial |
$92.12
|
| Rate for Payer: Wise Provider Network Commercial |
$92.12
|
|
|
DERMATOME BLADE ZIMMER
|
Facility
|
OP
|
$96.97
|
|
| Hospital Charge Code |
3003239
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$52.51 |
| Max. Negotiated Rate |
$96.97 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$95.03
|
| Rate for Payer: Aetna of WY Medicare |
$64.00
|
| Rate for Payer: Altius Commercial |
$93.09
|
| Rate for Payer: Beech Street Commercial |
$95.03
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$94.06
|
| Rate for Payer: Cash Price |
$67.88
|
| Rate for Payer: ChoiceCare Network Commercial |
$94.06
|
| Rate for Payer: Cigna of WY Commercial |
$95.03
|
| Rate for Payer: Entrust Commercial |
$92.12
|
| Rate for Payer: First Choice Health Commercial |
$92.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$92.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$55.27
|
| Rate for Payer: HealthUtah PPO |
$96.97
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$94.06
|
| Rate for Payer: Multiplan Medicare/VA |
$52.51
|
| Rate for Payer: One Health Plan of WY PPO |
$95.03
|
| Rate for Payer: PacificSource Commercial |
$87.27
|
| Rate for Payer: PHCS PPO |
$95.03
|
| Rate for Payer: Three Rivers PPO |
$72.73
|
| Rate for Payer: TriWest Veterans Administration |
$55.27
|
| Rate for Payer: United Healthcare Commercial |
$92.61
|
| Rate for Payer: United Healthcare Medicare |
$55.27
|
| Rate for Payer: WINHealth Partners Commercial |
$95.03
|
| Rate for Payer: Wise Provider Network Commercial |
$92.12
|
|
|
DESFLURANE 100 % INHALATION LIQUID [6276]
|
Facility
|
OP
|
$17.67
|
|
|
Service Code
|
NDC 1001964164
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.57 |
| Max. Negotiated Rate |
$17.67 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$17.32
|
| Rate for Payer: Aetna of WY Medicare |
$11.66
|
| Rate for Payer: Altius Commercial |
$16.96
|
| Rate for Payer: Beech Street Commercial |
$17.32
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$17.14
|
| Rate for Payer: Cash Price |
$12.37
|
| Rate for Payer: ChoiceCare Network Commercial |
$17.14
|
| Rate for Payer: Cigna of WY Commercial |
$17.32
|
| Rate for Payer: Entrust Commercial |
$16.79
|
| Rate for Payer: First Choice Health Commercial |
$16.79
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.79
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.07
|
| Rate for Payer: HealthUtah PPO |
$17.67
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.14
|
| Rate for Payer: Multiplan Medicare/VA |
$9.57
|
| Rate for Payer: One Health Plan of WY PPO |
$17.32
|
| Rate for Payer: PacificSource Commercial |
$15.90
|
| Rate for Payer: PHCS PPO |
$17.32
|
| Rate for Payer: Three Rivers PPO |
$13.25
|
| Rate for Payer: TriWest Veterans Administration |
$10.07
|
| Rate for Payer: United Healthcare Commercial |
$16.87
|
| Rate for Payer: United Healthcare Medicare |
$10.07
|
| Rate for Payer: WINHealth Partners Commercial |
$17.32
|
| Rate for Payer: Wise Provider Network Commercial |
$16.79
|
|
|
DESFLURANE 100 % INHALATION LIQUID [6276]
|
Facility
|
IP
|
$17.67
|
|
|
Service Code
|
NDC 1001964164
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.24 |
| Max. Negotiated Rate |
$17.67 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$17.32
|
| Rate for Payer: Aetna of WY Medicare |
$11.31
|
| Rate for Payer: Altius Commercial |
$16.96
|
| Rate for Payer: Beech Street Commercial |
$17.32
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$17.14
|
| Rate for Payer: Cash Price |
$12.37
|
| Rate for Payer: ChoiceCare Network Commercial |
$17.14
|
| Rate for Payer: Cigna of WY Commercial |
$17.32
|
| Rate for Payer: Entrust Commercial |
$16.79
|
| Rate for Payer: First Choice Health Commercial |
$16.79
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.79
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.78
|
| Rate for Payer: HealthUtah PPO |
$17.67
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.14
|
| Rate for Payer: Multiplan Medicare/VA |
$10.24
|
| Rate for Payer: One Health Plan of WY PPO |
$17.32
|
| Rate for Payer: PacificSource Commercial |
$15.90
|
| Rate for Payer: PHCS PPO |
$17.32
|
| Rate for Payer: Three Rivers PPO |
$13.25
|
| Rate for Payer: TriWest Veterans Administration |
$10.78
|
| Rate for Payer: United Healthcare Commercial |
$16.87
|
| Rate for Payer: United Healthcare Medicare |
$10.78
|
| Rate for Payer: WINHealth Partners Commercial |
$16.79
|
| Rate for Payer: Wise Provider Network Commercial |
$16.79
|
|
|
DESIPRAMINE 50 MG TABLET [10820]
|
Facility
|
OP
|
$16.16
|
|
|
Service Code
|
NDC 5074211401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.75 |
| Max. Negotiated Rate |
$16.16 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.84
|
| Rate for Payer: Aetna of WY Medicare |
$10.67
|
| Rate for Payer: Altius Commercial |
$15.51
|
| Rate for Payer: Beech Street Commercial |
$15.84
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.68
|
| Rate for Payer: Cash Price |
$11.31
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.68
|
| Rate for Payer: Cigna of WY Commercial |
$15.84
|
| Rate for Payer: Entrust Commercial |
$15.35
|
| Rate for Payer: First Choice Health Commercial |
$15.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.21
|
| Rate for Payer: HealthUtah PPO |
$16.16
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.68
|
| Rate for Payer: Multiplan Medicare/VA |
$8.75
|
| Rate for Payer: One Health Plan of WY PPO |
$15.84
|
| Rate for Payer: PacificSource Commercial |
$14.54
|
| Rate for Payer: PHCS PPO |
$15.84
|
| Rate for Payer: Three Rivers PPO |
$12.12
|
| Rate for Payer: TriWest Veterans Administration |
$9.21
|
| Rate for Payer: United Healthcare Commercial |
$15.43
|
| Rate for Payer: United Healthcare Medicare |
$9.21
|
| Rate for Payer: WINHealth Partners Commercial |
$15.84
|
| Rate for Payer: Wise Provider Network Commercial |
$15.35
|
|
|
DESIPRAMINE 50 MG TABLET [10820]
|
Facility
|
OP
|
$16.99
|
|
|
Service Code
|
NDC 6923810571
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.20 |
| Max. Negotiated Rate |
$16.99 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.65
|
| Rate for Payer: Aetna of WY Medicare |
$11.21
|
| Rate for Payer: Altius Commercial |
$16.31
|
| Rate for Payer: Beech Street Commercial |
$16.65
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.48
|
| Rate for Payer: Cash Price |
$11.89
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.48
|
| Rate for Payer: Cigna of WY Commercial |
$16.65
|
| Rate for Payer: Entrust Commercial |
$16.14
|
| Rate for Payer: First Choice Health Commercial |
$16.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.68
|
| Rate for Payer: HealthUtah PPO |
$16.99
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.48
|
| Rate for Payer: Multiplan Medicare/VA |
$9.20
|
| Rate for Payer: One Health Plan of WY PPO |
$16.65
|
| Rate for Payer: PacificSource Commercial |
$15.29
|
| Rate for Payer: PHCS PPO |
$16.65
|
| Rate for Payer: Three Rivers PPO |
$12.74
|
| Rate for Payer: TriWest Veterans Administration |
$9.68
|
| Rate for Payer: United Healthcare Commercial |
$16.23
|
| Rate for Payer: United Healthcare Medicare |
$9.68
|
| Rate for Payer: WINHealth Partners Commercial |
$16.65
|
| Rate for Payer: Wise Provider Network Commercial |
$16.14
|
|
|
DESIPRAMINE 50 MG TABLET [10820]
|
Facility
|
IP
|
$16.16
|
|
|
Service Code
|
NDC 5074211401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.36 |
| Max. Negotiated Rate |
$16.16 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.84
|
| Rate for Payer: Aetna of WY Medicare |
$10.34
|
| Rate for Payer: Altius Commercial |
$15.51
|
| Rate for Payer: Beech Street Commercial |
$15.84
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.68
|
| Rate for Payer: Cash Price |
$11.31
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.68
|
| Rate for Payer: Cigna of WY Commercial |
$15.84
|
| Rate for Payer: Entrust Commercial |
$15.35
|
| Rate for Payer: First Choice Health Commercial |
$15.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.86
|
| Rate for Payer: HealthUtah PPO |
$16.16
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.68
|
| Rate for Payer: Multiplan Medicare/VA |
$9.36
|
| Rate for Payer: One Health Plan of WY PPO |
$15.84
|
| Rate for Payer: PacificSource Commercial |
$14.54
|
| Rate for Payer: PHCS PPO |
$15.84
|
| Rate for Payer: Three Rivers PPO |
$12.12
|
| Rate for Payer: TriWest Veterans Administration |
$9.86
|
| Rate for Payer: United Healthcare Commercial |
$15.43
|
| Rate for Payer: United Healthcare Medicare |
$9.86
|
| Rate for Payer: WINHealth Partners Commercial |
$15.35
|
| Rate for Payer: Wise Provider Network Commercial |
$15.35
|
|
|
DESIPRAMINE 50 MG TABLET [10820]
|
Facility
|
IP
|
$16.99
|
|
|
Service Code
|
NDC 6923810571
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.85 |
| Max. Negotiated Rate |
$16.99 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.65
|
| Rate for Payer: Aetna of WY Medicare |
$10.87
|
| Rate for Payer: Altius Commercial |
$16.31
|
| Rate for Payer: Beech Street Commercial |
$16.65
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.48
|
| Rate for Payer: Cash Price |
$11.89
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.48
|
| Rate for Payer: Cigna of WY Commercial |
$16.65
|
| Rate for Payer: Entrust Commercial |
$16.14
|
| Rate for Payer: First Choice Health Commercial |
$16.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.36
|
| Rate for Payer: HealthUtah PPO |
$16.99
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.48
|
| Rate for Payer: Multiplan Medicare/VA |
$9.85
|
| Rate for Payer: One Health Plan of WY PPO |
$16.65
|
| Rate for Payer: PacificSource Commercial |
$15.29
|
| Rate for Payer: PHCS PPO |
$16.65
|
| Rate for Payer: Three Rivers PPO |
$12.74
|
| Rate for Payer: TriWest Veterans Administration |
$10.36
|
| Rate for Payer: United Healthcare Commercial |
$16.23
|
| Rate for Payer: United Healthcare Medicare |
$10.36
|
| Rate for Payer: WINHealth Partners Commercial |
$16.14
|
| Rate for Payer: Wise Provider Network Commercial |
$16.14
|
|
|
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION [1442]
|
Facility
|
OP
|
$91.00
|
|
|
Service Code
|
HCPCS J2597
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$49.28 |
| Max. Negotiated Rate |
$91.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$89.18
|
| Rate for Payer: Aetna of WY Medicare |
$60.06
|
| Rate for Payer: Altius Commercial |
$87.36
|
| Rate for Payer: Beech Street Commercial |
$89.18
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$88.27
|
| Rate for Payer: Cash Price |
$63.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$88.27
|
| Rate for Payer: Cigna of WY Commercial |
$89.18
|
| Rate for Payer: Entrust Commercial |
$86.45
|
| Rate for Payer: First Choice Health Commercial |
$86.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$86.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$51.87
|
| Rate for Payer: HealthUtah PPO |
$91.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$88.27
|
| Rate for Payer: Multiplan Medicare/VA |
$49.28
|
| Rate for Payer: One Health Plan of WY PPO |
$89.18
|
| Rate for Payer: PacificSource Commercial |
$81.90
|
| Rate for Payer: PHCS PPO |
$89.18
|
| Rate for Payer: Three Rivers PPO |
$68.25
|
| Rate for Payer: TriWest Veterans Administration |
$51.87
|
| Rate for Payer: United Healthcare Commercial |
$86.90
|
| Rate for Payer: United Healthcare Medicare |
$51.87
|
| Rate for Payer: WINHealth Partners Commercial |
$89.18
|
| Rate for Payer: Wise Provider Network Commercial |
$86.45
|
|
|
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION [1442]
|
Facility
|
IP
|
$91.00
|
|
|
Service Code
|
HCPCS J2597
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$52.73 |
| Max. Negotiated Rate |
$91.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$89.18
|
| Rate for Payer: Aetna of WY Medicare |
$58.24
|
| Rate for Payer: Altius Commercial |
$87.36
|
| Rate for Payer: Beech Street Commercial |
$89.18
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$88.27
|
| Rate for Payer: Cash Price |
$63.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$88.27
|
| Rate for Payer: Cigna of WY Commercial |
$89.18
|
| Rate for Payer: Entrust Commercial |
$86.45
|
| Rate for Payer: First Choice Health Commercial |
$86.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$86.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$55.51
|
| Rate for Payer: HealthUtah PPO |
$91.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$88.27
|
| Rate for Payer: Multiplan Medicare/VA |
$52.73
|
| Rate for Payer: One Health Plan of WY PPO |
$89.18
|
| Rate for Payer: PacificSource Commercial |
$81.90
|
| Rate for Payer: PHCS PPO |
$89.18
|
| Rate for Payer: Three Rivers PPO |
$68.25
|
| Rate for Payer: TriWest Veterans Administration |
$55.51
|
| Rate for Payer: United Healthcare Commercial |
$86.90
|
| Rate for Payer: United Healthcare Medicare |
$55.51
|
| Rate for Payer: WINHealth Partners Commercial |
$86.45
|
| Rate for Payer: Wise Provider Network Commercial |
$86.45
|
|
|
DESTRUCTION BENIGN LESIONS 15/>
|
Professional
|
Both
|
$351.00
|
|
|
Service Code
|
HCPCS 17111
|
| Min. Negotiated Rate |
$263.25 |
| Max. Negotiated Rate |
$351.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$343.98
|
| Rate for Payer: Beech Street Commercial |
$333.45
|
| Rate for Payer: Cash Price |
$245.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$340.47
|
| Rate for Payer: Cigna of WY Commercial |
$343.98
|
| Rate for Payer: First Choice Health Commercial |
$315.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$333.45
|
| Rate for Payer: HealthUtah PPO |
$351.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$340.47
|
| Rate for Payer: One Health Plan of WY PPO |
$343.98
|
| Rate for Payer: PacificSource Commercial |
$315.90
|
| Rate for Payer: PHCS PPO |
$333.45
|
| Rate for Payer: Three Rivers PPO |
$263.25
|
| Rate for Payer: United Healthcare Commercial |
$333.45
|
| Rate for Payer: WINHealth Partners Commercial |
$298.35
|
|
|
DESTRUCTION BENIGN LESIONS UP TO 14
|
Professional
|
Both
|
$285.00
|
|
|
Service Code
|
HCPCS 17110
|
| Min. Negotiated Rate |
$57.10 |
| Max. Negotiated Rate |
$285.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$279.30
|
| Rate for Payer: Aetna of WY Medicare |
$67.18
|
| Rate for Payer: Beech Street Commercial |
$270.75
|
| Rate for Payer: Cash Price |
$199.50
|
| Rate for Payer: Cash Price |
$199.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$276.45
|
| Rate for Payer: Cigna of WY Commercial |
$279.30
|
| Rate for Payer: First Choice Health Commercial |
$256.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$270.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$67.18
|
| Rate for Payer: HealthUtah PPO |
$285.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$276.45
|
| Rate for Payer: Multiplan Medicare/VA |
$57.10
|
| Rate for Payer: One Health Plan of WY PPO |
$279.30
|
| Rate for Payer: PacificSource Commercial |
$256.50
|
| Rate for Payer: PHCS PPO |
$270.75
|
| Rate for Payer: Three Rivers PPO |
$213.75
|
| Rate for Payer: TriWest Veterans Administration |
$67.18
|
| Rate for Payer: United Healthcare Commercial |
$270.75
|
| Rate for Payer: WINHealth Partners Commercial |
$242.25
|
|
|
DESTRUCTION INTERNAL HEMORRHOID THERMAL ENERGY
|
Professional
|
Both
|
$664.00
|
|
|
Service Code
|
HCPCS 46930
|
| Min. Negotiated Rate |
$125.80 |
| Max. Negotiated Rate |
$664.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$650.72
|
| Rate for Payer: Aetna of WY Medicare |
$148.00
|
| Rate for Payer: Beech Street Commercial |
$630.80
|
| Rate for Payer: Cash Price |
$464.80
|
| Rate for Payer: Cash Price |
$464.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$644.08
|
| Rate for Payer: Cigna of WY Commercial |
$650.72
|
| Rate for Payer: First Choice Health Commercial |
$597.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$630.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$148.00
|
| Rate for Payer: HealthUtah PPO |
$664.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$644.08
|
| Rate for Payer: Multiplan Medicare/VA |
$125.80
|
| Rate for Payer: One Health Plan of WY PPO |
$650.72
|
| Rate for Payer: PacificSource Commercial |
$597.60
|
| Rate for Payer: PHCS PPO |
$630.80
|
| Rate for Payer: Three Rivers PPO |
$498.00
|
| Rate for Payer: TriWest Veterans Administration |
$148.00
|
| Rate for Payer: United Healthcare Commercial |
$630.80
|
| Rate for Payer: WINHealth Partners Commercial |
$564.40
|
|
|
DESTRUCTION LESIONS VULVA EXTENSIVE
|
Professional
|
Both
|
$1,372.00
|
|
|
Service Code
|
HCPCS 56515
|
| Min. Negotiated Rate |
$175.33 |
| Max. Negotiated Rate |
$1,372.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,344.56
|
| Rate for Payer: Aetna of WY Medicare |
$206.27
|
| Rate for Payer: Beech Street Commercial |
$1,303.40
|
| Rate for Payer: Cash Price |
$960.40
|
| Rate for Payer: Cash Price |
$960.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,330.84
|
| Rate for Payer: Cigna of WY Commercial |
$1,344.56
|
| Rate for Payer: First Choice Health Commercial |
$1,234.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,303.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$206.27
|
| Rate for Payer: HealthUtah PPO |
$1,372.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,330.84
|
| Rate for Payer: Multiplan Medicare/VA |
$175.33
|
| Rate for Payer: One Health Plan of WY PPO |
$1,344.56
|
| Rate for Payer: PacificSource Commercial |
$1,234.80
|
| Rate for Payer: PHCS PPO |
$1,303.40
|
| Rate for Payer: Three Rivers PPO |
$1,029.00
|
| Rate for Payer: TriWest Veterans Administration |
$206.27
|
| Rate for Payer: United Healthcare Commercial |
$1,303.40
|
| Rate for Payer: WINHealth Partners Commercial |
$1,166.20
|
|
