|
DESTRUCTION MALIGNANT LESION F/E/E/N/L/M 0.5CM/<
|
Professional
|
Both
|
$370.00
|
|
|
Service Code
|
HCPCS 17280
|
| Min. Negotiated Rate |
$71.70 |
| Max. Negotiated Rate |
$370.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$362.60
|
| Rate for Payer: Aetna of WY Medicare |
$84.35
|
| Rate for Payer: Beech Street Commercial |
$351.50
|
| Rate for Payer: Cash Price |
$259.00
|
| Rate for Payer: Cash Price |
$259.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$358.90
|
| Rate for Payer: Cigna of WY Commercial |
$362.60
|
| Rate for Payer: First Choice Health Commercial |
$333.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$351.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$84.35
|
| Rate for Payer: HealthUtah PPO |
$370.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$358.90
|
| Rate for Payer: Multiplan Medicare/VA |
$71.70
|
| Rate for Payer: One Health Plan of WY PPO |
$362.60
|
| Rate for Payer: PacificSource Commercial |
$333.00
|
| Rate for Payer: PHCS PPO |
$351.50
|
| Rate for Payer: Three Rivers PPO |
$277.50
|
| Rate for Payer: TriWest Veterans Administration |
$84.35
|
| Rate for Payer: United Healthcare Commercial |
$351.50
|
| Rate for Payer: WINHealth Partners Commercial |
$314.50
|
|
|
DESTRUCTION MALIGNANT LESION S/N/H/F/G 0.5 CM/<
|
Professional
|
Both
|
$601.00
|
|
|
Service Code
|
HCPCS 17270
|
| Min. Negotiated Rate |
$78.79 |
| Max. Negotiated Rate |
$601.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$588.98
|
| Rate for Payer: Aetna of WY Medicare |
$92.69
|
| Rate for Payer: Beech Street Commercial |
$570.95
|
| Rate for Payer: Cash Price |
$420.70
|
| Rate for Payer: Cash Price |
$420.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$582.97
|
| Rate for Payer: Cigna of WY Commercial |
$588.98
|
| Rate for Payer: First Choice Health Commercial |
$540.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$570.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$92.69
|
| Rate for Payer: HealthUtah PPO |
$601.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$582.97
|
| Rate for Payer: Multiplan Medicare/VA |
$78.79
|
| Rate for Payer: One Health Plan of WY PPO |
$588.98
|
| Rate for Payer: PacificSource Commercial |
$540.90
|
| Rate for Payer: PHCS PPO |
$570.95
|
| Rate for Payer: Three Rivers PPO |
$450.75
|
| Rate for Payer: TriWest Veterans Administration |
$92.69
|
| Rate for Payer: United Healthcare Commercial |
$570.95
|
| Rate for Payer: WINHealth Partners Commercial |
$510.85
|
|
|
DESTRUCTION MALIGNANT LESION T/A/L 0.5 CM/<
|
Professional
|
Both
|
$299.00
|
|
|
Service Code
|
HCPCS 17260
|
| Min. Negotiated Rate |
$58.28 |
| Max. Negotiated Rate |
$299.00 |
| Rate for Payer: HealthUtah PPO |
$299.00
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$293.02
|
| Rate for Payer: Aetna of WY Medicare |
$68.56
|
| Rate for Payer: Beech Street Commercial |
$284.05
|
| Rate for Payer: Cash Price |
$209.30
|
| Rate for Payer: Cash Price |
$209.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$290.03
|
| Rate for Payer: Cigna of WY Commercial |
$293.02
|
| Rate for Payer: First Choice Health Commercial |
$269.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$284.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$68.56
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$290.03
|
| Rate for Payer: Multiplan Medicare/VA |
$58.28
|
| Rate for Payer: One Health Plan of WY PPO |
$293.02
|
| Rate for Payer: PacificSource Commercial |
$269.10
|
| Rate for Payer: PHCS PPO |
$284.05
|
| Rate for Payer: Three Rivers PPO |
$224.25
|
| Rate for Payer: TriWest Veterans Administration |
$68.56
|
| Rate for Payer: United Healthcare Commercial |
$284.05
|
| Rate for Payer: WINHealth Partners Commercial |
$254.15
|
|
|
DESTRUCTION MAL LESION TRUNK/ARM/LEG 0.6-1.0 CM
|
Professional
|
Both
|
$371.00
|
|
|
Service Code
|
HCPCS 17261
|
| Min. Negotiated Rate |
$71.98 |
| Max. Negotiated Rate |
$371.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$363.58
|
| Rate for Payer: Aetna of WY Medicare |
$84.68
|
| Rate for Payer: Beech Street Commercial |
$352.45
|
| Rate for Payer: Cash Price |
$259.70
|
| Rate for Payer: Cash Price |
$259.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$359.87
|
| Rate for Payer: Cigna of WY Commercial |
$363.58
|
| Rate for Payer: First Choice Health Commercial |
$333.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$352.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$84.68
|
| Rate for Payer: HealthUtah PPO |
$371.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$359.87
|
| Rate for Payer: Multiplan Medicare/VA |
$71.98
|
| Rate for Payer: One Health Plan of WY PPO |
$363.58
|
| Rate for Payer: PacificSource Commercial |
$333.90
|
| Rate for Payer: PHCS PPO |
$352.45
|
| Rate for Payer: Three Rivers PPO |
$278.25
|
| Rate for Payer: TriWest Veterans Administration |
$84.68
|
| Rate for Payer: United Healthcare Commercial |
$352.45
|
| Rate for Payer: WINHealth Partners Commercial |
$315.35
|
|
|
DESTRUCTION MAL LESION TRUNK/ARM/LEG 1.1-2.0CM
|
Professional
|
Both
|
$477.00
|
|
|
Service Code
|
HCPCS 17262
|
| Min. Negotiated Rate |
$90.89 |
| Max. Negotiated Rate |
$477.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$467.46
|
| Rate for Payer: Aetna of WY Medicare |
$106.93
|
| Rate for Payer: Beech Street Commercial |
$453.15
|
| Rate for Payer: Cash Price |
$333.90
|
| Rate for Payer: Cash Price |
$333.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$462.69
|
| Rate for Payer: Cigna of WY Commercial |
$467.46
|
| Rate for Payer: First Choice Health Commercial |
$429.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$453.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$106.93
|
| Rate for Payer: HealthUtah PPO |
$477.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$462.69
|
| Rate for Payer: Multiplan Medicare/VA |
$90.89
|
| Rate for Payer: One Health Plan of WY PPO |
$467.46
|
| Rate for Payer: PacificSource Commercial |
$429.30
|
| Rate for Payer: PHCS PPO |
$453.15
|
| Rate for Payer: Three Rivers PPO |
$357.75
|
| Rate for Payer: TriWest Veterans Administration |
$106.93
|
| Rate for Payer: United Healthcare Commercial |
$453.15
|
| Rate for Payer: WINHealth Partners Commercial |
$405.45
|
|
|
DESTRUCTION MAL LESION TRUNK/ARM/LEG 2.1-3.0CM
|
Professional
|
Both
|
$531.00
|
|
|
Service Code
|
HCPCS 17263
|
| Min. Negotiated Rate |
$100.49 |
| Max. Negotiated Rate |
$531.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$520.38
|
| Rate for Payer: Aetna of WY Medicare |
$118.22
|
| Rate for Payer: Beech Street Commercial |
$504.45
|
| Rate for Payer: Cash Price |
$371.70
|
| Rate for Payer: Cash Price |
$371.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$515.07
|
| Rate for Payer: Cigna of WY Commercial |
$520.38
|
| Rate for Payer: First Choice Health Commercial |
$477.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$504.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$118.22
|
| Rate for Payer: HealthUtah PPO |
$531.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$515.07
|
| Rate for Payer: Multiplan Medicare/VA |
$100.49
|
| Rate for Payer: One Health Plan of WY PPO |
$520.38
|
| Rate for Payer: PacificSource Commercial |
$477.90
|
| Rate for Payer: PHCS PPO |
$504.45
|
| Rate for Payer: Three Rivers PPO |
$398.25
|
| Rate for Payer: TriWest Veterans Administration |
$118.22
|
| Rate for Payer: United Healthcare Commercial |
$504.45
|
| Rate for Payer: WINHealth Partners Commercial |
$451.35
|
|
|
DESTRUCTION MAL LESION TRUNK/ARM/LEG 3.1-4.0CM
|
Professional
|
Both
|
$565.00
|
|
|
Service Code
|
HCPCS 17264
|
| Min. Negotiated Rate |
$107.30 |
| Max. Negotiated Rate |
$565.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$553.70
|
| Rate for Payer: Aetna of WY Medicare |
$126.24
|
| Rate for Payer: Beech Street Commercial |
$536.75
|
| Rate for Payer: Cash Price |
$395.50
|
| Rate for Payer: Cash Price |
$395.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$548.05
|
| Rate for Payer: Cigna of WY Commercial |
$553.70
|
| Rate for Payer: First Choice Health Commercial |
$508.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$536.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$126.24
|
| Rate for Payer: HealthUtah PPO |
$565.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$548.05
|
| Rate for Payer: Multiplan Medicare/VA |
$107.30
|
| Rate for Payer: One Health Plan of WY PPO |
$553.70
|
| Rate for Payer: PacificSource Commercial |
$508.50
|
| Rate for Payer: PHCS PPO |
$536.75
|
| Rate for Payer: Three Rivers PPO |
$423.75
|
| Rate for Payer: TriWest Veterans Administration |
$126.24
|
| Rate for Payer: United Healthcare Commercial |
$536.75
|
| Rate for Payer: WINHealth Partners Commercial |
$480.25
|
|
|
DESTRUCTION MAL LESION TRUNK/ARM/LEG > 4.0 CM
|
Professional
|
Both
|
$668.00
|
|
|
Service Code
|
HCPCS 17266
|
| Min. Negotiated Rate |
$125.66 |
| Max. Negotiated Rate |
$668.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$654.64
|
| Rate for Payer: Aetna of WY Medicare |
$147.83
|
| Rate for Payer: Beech Street Commercial |
$634.60
|
| Rate for Payer: Cash Price |
$467.60
|
| Rate for Payer: Cash Price |
$467.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$647.96
|
| Rate for Payer: Cigna of WY Commercial |
$654.64
|
| Rate for Payer: First Choice Health Commercial |
$601.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$634.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$147.83
|
| Rate for Payer: HealthUtah PPO |
$668.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$647.96
|
| Rate for Payer: Multiplan Medicare/VA |
$125.66
|
| Rate for Payer: One Health Plan of WY PPO |
$654.64
|
| Rate for Payer: PacificSource Commercial |
$601.20
|
| Rate for Payer: PHCS PPO |
$634.60
|
| Rate for Payer: Three Rivers PPO |
$501.00
|
| Rate for Payer: TriWest Veterans Administration |
$147.83
|
| Rate for Payer: United Healthcare Commercial |
$634.60
|
| Rate for Payer: WINHealth Partners Commercial |
$567.80
|
|
|
DESTRUCTION PREMALIGNANT LESION 15/>
|
Professional
|
Both
|
$416.00
|
|
|
Service Code
|
HCPCS 17004
|
| Min. Negotiated Rate |
$81.01 |
| Max. Negotiated Rate |
$416.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$407.68
|
| Rate for Payer: Aetna of WY Medicare |
$95.31
|
| Rate for Payer: Beech Street Commercial |
$395.20
|
| Rate for Payer: Cash Price |
$291.20
|
| Rate for Payer: Cash Price |
$291.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$403.52
|
| Rate for Payer: Cigna of WY Commercial |
$407.68
|
| Rate for Payer: First Choice Health Commercial |
$374.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$395.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$95.31
|
| Rate for Payer: HealthUtah PPO |
$416.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$403.52
|
| Rate for Payer: Multiplan Medicare/VA |
$81.01
|
| Rate for Payer: One Health Plan of WY PPO |
$407.68
|
| Rate for Payer: PacificSource Commercial |
$374.40
|
| Rate for Payer: PHCS PPO |
$395.20
|
| Rate for Payer: Three Rivers PPO |
$312.00
|
| Rate for Payer: TriWest Veterans Administration |
$95.31
|
| Rate for Payer: United Healthcare Commercial |
$395.20
|
| Rate for Payer: WINHealth Partners Commercial |
$353.60
|
|
|
DESTRUCTION PREMALIGNANT LESION 1ST
|
Professional
|
Both
|
$229.00
|
|
|
Service Code
|
HCPCS 17000
|
| Min. Negotiated Rate |
$45.76 |
| Max. Negotiated Rate |
$229.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$224.42
|
| Rate for Payer: Aetna of WY Medicare |
$53.84
|
| Rate for Payer: Beech Street Commercial |
$217.55
|
| Rate for Payer: Cash Price |
$160.30
|
| Rate for Payer: Cash Price |
$160.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$222.13
|
| Rate for Payer: Cigna of WY Commercial |
$224.42
|
| Rate for Payer: First Choice Health Commercial |
$206.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$217.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$53.84
|
| Rate for Payer: HealthUtah PPO |
$229.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$222.13
|
| Rate for Payer: Multiplan Medicare/VA |
$45.76
|
| Rate for Payer: One Health Plan of WY PPO |
$224.42
|
| Rate for Payer: PacificSource Commercial |
$206.10
|
| Rate for Payer: PHCS PPO |
$217.55
|
| Rate for Payer: Three Rivers PPO |
$171.75
|
| Rate for Payer: TriWest Veterans Administration |
$53.84
|
| Rate for Payer: United Healthcare Commercial |
$217.55
|
| Rate for Payer: WINHealth Partners Commercial |
$194.65
|
|
|
DESTRUCTION PREMALIGNANT LESION 2-14 EA
|
Professional
|
Both
|
$9.00
|
|
|
Service Code
|
HCPCS 17003
|
| Min. Negotiated Rate |
$1.67 |
| Max. Negotiated Rate |
$9.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$8.82
|
| Rate for Payer: Aetna of WY Medicare |
$1.96
|
| Rate for Payer: Beech Street Commercial |
$8.55
|
| Rate for Payer: Cash Price |
$6.30
|
| Rate for Payer: Cash Price |
$6.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$8.73
|
| Rate for Payer: Cigna of WY Commercial |
$8.82
|
| Rate for Payer: First Choice Health Commercial |
$8.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$8.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.96
|
| Rate for Payer: HealthUtah PPO |
$9.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$8.73
|
| Rate for Payer: Multiplan Medicare/VA |
$1.67
|
| Rate for Payer: One Health Plan of WY PPO |
$8.82
|
| Rate for Payer: PacificSource Commercial |
$8.10
|
| Rate for Payer: PHCS PPO |
$8.55
|
| Rate for Payer: Three Rivers PPO |
$6.75
|
| Rate for Payer: TriWest Veterans Administration |
$1.96
|
| Rate for Payer: United Healthcare Commercial |
$8.55
|
| Rate for Payer: WINHealth Partners Commercial |
$7.65
|
|
|
DESTRUCTION RECTAL TUMOR TRANSANAL APPROACH
|
Professional
|
Both
|
$2,855.00
|
|
|
Service Code
|
HCPCS 45190
|
| Min. Negotiated Rate |
$572.17 |
| Max. Negotiated Rate |
$2,855.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,797.90
|
| Rate for Payer: Aetna of WY Medicare |
$673.14
|
| Rate for Payer: Beech Street Commercial |
$2,712.25
|
| Rate for Payer: Cash Price |
$1,998.50
|
| Rate for Payer: Cash Price |
$1,998.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,769.35
|
| Rate for Payer: Cigna of WY Commercial |
$2,797.90
|
| Rate for Payer: First Choice Health Commercial |
$2,569.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,712.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$673.14
|
| Rate for Payer: HealthUtah PPO |
$2,855.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,769.35
|
| Rate for Payer: Multiplan Medicare/VA |
$572.17
|
| Rate for Payer: One Health Plan of WY PPO |
$2,797.90
|
| Rate for Payer: PacificSource Commercial |
$2,569.50
|
| Rate for Payer: PHCS PPO |
$2,712.25
|
| Rate for Payer: Three Rivers PPO |
$2,141.25
|
| Rate for Payer: TriWest Veterans Administration |
$673.14
|
| Rate for Payer: United Healthcare Commercial |
$2,712.25
|
| Rate for Payer: WINHealth Partners Commercial |
$2,426.75
|
|
|
DESTRUCTION VAGINAL LESIONS SIMPLE
|
Professional
|
Both
|
$2,441.00
|
|
|
Service Code
|
HCPCS 57061
|
| Min. Negotiated Rate |
$95.81 |
| Max. Negotiated Rate |
$2,441.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,392.18
|
| Rate for Payer: Aetna of WY Medicare |
$112.72
|
| Rate for Payer: Beech Street Commercial |
$2,318.95
|
| Rate for Payer: Cash Price |
$1,708.70
|
| Rate for Payer: Cash Price |
$1,708.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,367.77
|
| Rate for Payer: Cigna of WY Commercial |
$2,392.18
|
| Rate for Payer: First Choice Health Commercial |
$2,196.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,318.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$112.72
|
| Rate for Payer: HealthUtah PPO |
$2,441.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,367.77
|
| Rate for Payer: Multiplan Medicare/VA |
$95.81
|
| Rate for Payer: One Health Plan of WY PPO |
$2,392.18
|
| Rate for Payer: PacificSource Commercial |
$2,196.90
|
| Rate for Payer: PHCS PPO |
$2,318.95
|
| Rate for Payer: Three Rivers PPO |
$1,830.75
|
| Rate for Payer: TriWest Veterans Administration |
$112.72
|
| Rate for Payer: United Healthcare Commercial |
$2,318.95
|
| Rate for Payer: WINHealth Partners Commercial |
$2,074.85
|
|
|
DEXAMETHASONE SODIUM PHOS
|
Professional
|
Both
|
$8.00
|
|
|
Service Code
|
HCPCS J1100
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$8.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$7.84
|
| Rate for Payer: Aetna of WY Medicare |
$0.12
|
| Rate for Payer: Beech Street Commercial |
$7.60
|
| Rate for Payer: Cash Price |
$5.60
|
| Rate for Payer: Cash Price |
$5.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$7.76
|
| Rate for Payer: Cigna of WY Commercial |
$7.84
|
| Rate for Payer: First Choice Health Commercial |
$7.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$7.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.12
|
| Rate for Payer: HealthUtah PPO |
$8.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$7.76
|
| Rate for Payer: Multiplan Medicare/VA |
$0.10
|
| Rate for Payer: One Health Plan of WY PPO |
$7.84
|
| Rate for Payer: PacificSource Commercial |
$7.20
|
| Rate for Payer: PHCS PPO |
$7.60
|
| Rate for Payer: Three Rivers PPO |
$6.00
|
| Rate for Payer: TriWest Veterans Administration |
$0.12
|
| Rate for Payer: United Healthcare Commercial |
$7.60
|
| Rate for Payer: WINHealth Partners Commercial |
$7.60
|
|
|
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION [17072]
|
Facility
|
OP
|
$25.80
|
|
|
Service Code
|
HCPCS J1100
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.97 |
| Max. Negotiated Rate |
$25.80 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$25.28
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18.49
|
| Rate for Payer: Aetna of WY Medicare |
$12.45
|
| Rate for Payer: Aetna of WY Medicare |
$17.03
|
| Rate for Payer: Altius Commercial |
$24.77
|
| Rate for Payer: Altius Commercial |
$18.12
|
| Rate for Payer: Beech Street Commercial |
$25.28
|
| Rate for Payer: Beech Street Commercial |
$18.49
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$25.03
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$18.30
|
| Rate for Payer: Cash Price |
$18.06
|
| Rate for Payer: Cash Price |
$13.21
|
| Rate for Payer: ChoiceCare Network Commercial |
$18.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$25.03
|
| Rate for Payer: Cigna of WY Commercial |
$18.49
|
| Rate for Payer: Cigna of WY Commercial |
$25.28
|
| Rate for Payer: Entrust Commercial |
$24.51
|
| Rate for Payer: Entrust Commercial |
$17.93
|
| Rate for Payer: First Choice Health Commercial |
$24.51
|
| Rate for Payer: First Choice Health Commercial |
$17.93
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.93
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$24.51
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.76
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$14.71
|
| Rate for Payer: HealthUtah PPO |
$25.80
|
| Rate for Payer: HealthUtah PPO |
$18.87
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$18.30
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$25.03
|
| Rate for Payer: Multiplan Medicare/VA |
$13.97
|
| Rate for Payer: Multiplan Medicare/VA |
$10.22
|
| Rate for Payer: One Health Plan of WY PPO |
$25.28
|
| Rate for Payer: One Health Plan of WY PPO |
$18.49
|
| Rate for Payer: PacificSource Commercial |
$16.98
|
| Rate for Payer: PacificSource Commercial |
$23.22
|
| Rate for Payer: PHCS PPO |
$25.28
|
| Rate for Payer: PHCS PPO |
$18.49
|
| Rate for Payer: Three Rivers PPO |
$19.35
|
| Rate for Payer: Three Rivers PPO |
$14.15
|
| Rate for Payer: TriWest Veterans Administration |
$14.71
|
| Rate for Payer: TriWest Veterans Administration |
$10.76
|
| Rate for Payer: United Healthcare Commercial |
$24.64
|
| Rate for Payer: United Healthcare Commercial |
$18.02
|
| Rate for Payer: United Healthcare Medicare |
$10.76
|
| Rate for Payer: United Healthcare Medicare |
$14.71
|
| Rate for Payer: WINHealth Partners Commercial |
$25.28
|
| Rate for Payer: WINHealth Partners Commercial |
$18.49
|
| Rate for Payer: Wise Provider Network Commercial |
$17.93
|
| Rate for Payer: Wise Provider Network Commercial |
$24.51
|
|
|
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION [17072]
|
Facility
|
IP
|
$18.87
|
|
|
Service Code
|
HCPCS J1100
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.94 |
| Max. Negotiated Rate |
$18.87 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18.49
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$25.28
|
| Rate for Payer: Aetna of WY Medicare |
$16.51
|
| Rate for Payer: Aetna of WY Medicare |
$12.08
|
| Rate for Payer: Altius Commercial |
$18.12
|
| Rate for Payer: Altius Commercial |
$24.77
|
| Rate for Payer: Beech Street Commercial |
$18.49
|
| Rate for Payer: Beech Street Commercial |
$25.28
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$18.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$25.03
|
| Rate for Payer: Cash Price |
$13.21
|
| Rate for Payer: Cash Price |
$18.06
|
| Rate for Payer: ChoiceCare Network Commercial |
$25.03
|
| Rate for Payer: ChoiceCare Network Commercial |
$18.30
|
| Rate for Payer: Cigna of WY Commercial |
$25.28
|
| Rate for Payer: Cigna of WY Commercial |
$18.49
|
| Rate for Payer: Entrust Commercial |
$17.93
|
| Rate for Payer: Entrust Commercial |
$24.51
|
| Rate for Payer: First Choice Health Commercial |
$24.51
|
| Rate for Payer: First Choice Health Commercial |
$17.93
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$24.51
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.93
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.51
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$15.74
|
| Rate for Payer: HealthUtah PPO |
$25.80
|
| Rate for Payer: HealthUtah PPO |
$18.87
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$18.30
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$25.03
|
| Rate for Payer: Multiplan Medicare/VA |
$14.95
|
| Rate for Payer: Multiplan Medicare/VA |
$10.94
|
| Rate for Payer: One Health Plan of WY PPO |
$18.49
|
| Rate for Payer: One Health Plan of WY PPO |
$25.28
|
| Rate for Payer: PacificSource Commercial |
$16.98
|
| Rate for Payer: PacificSource Commercial |
$23.22
|
| Rate for Payer: PHCS PPO |
$25.28
|
| Rate for Payer: PHCS PPO |
$18.49
|
| Rate for Payer: Three Rivers PPO |
$19.35
|
| Rate for Payer: Three Rivers PPO |
$14.15
|
| Rate for Payer: TriWest Veterans Administration |
$11.51
|
| Rate for Payer: TriWest Veterans Administration |
$15.74
|
| Rate for Payer: United Healthcare Commercial |
$24.64
|
| Rate for Payer: United Healthcare Commercial |
$18.02
|
| Rate for Payer: United Healthcare Medicare |
$15.74
|
| Rate for Payer: United Healthcare Medicare |
$11.51
|
| Rate for Payer: WINHealth Partners Commercial |
$17.93
|
| Rate for Payer: WINHealth Partners Commercial |
$24.51
|
| Rate for Payer: Wise Provider Network Commercial |
$17.93
|
| Rate for Payer: Wise Provider Network Commercial |
$24.51
|
|
|
DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION [42773]
|
Facility
|
IP
|
$22.00
|
|
|
Service Code
|
HCPCS J1100
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.75 |
| Max. Negotiated Rate |
$22.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$21.56
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$40.42
|
| Rate for Payer: Aetna of WY Medicare |
$14.08
|
| Rate for Payer: Aetna of WY Medicare |
$26.40
|
| Rate for Payer: Altius Commercial |
$39.60
|
| Rate for Payer: Altius Commercial |
$21.12
|
| Rate for Payer: Beech Street Commercial |
$21.56
|
| Rate for Payer: Beech Street Commercial |
$40.42
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$21.34
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$40.01
|
| Rate for Payer: Cash Price |
$28.87
|
| Rate for Payer: Cash Price |
$15.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$21.34
|
| Rate for Payer: ChoiceCare Network Commercial |
$40.01
|
| Rate for Payer: Cigna of WY Commercial |
$40.42
|
| Rate for Payer: Cigna of WY Commercial |
$21.56
|
| Rate for Payer: Entrust Commercial |
$39.19
|
| Rate for Payer: Entrust Commercial |
$20.90
|
| Rate for Payer: First Choice Health Commercial |
$39.19
|
| Rate for Payer: First Choice Health Commercial |
$20.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$20.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$39.19
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$13.42
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$25.16
|
| Rate for Payer: HealthUtah PPO |
$22.00
|
| Rate for Payer: HealthUtah PPO |
$41.25
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$21.34
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$40.01
|
| Rate for Payer: Multiplan Medicare/VA |
$23.90
|
| Rate for Payer: Multiplan Medicare/VA |
$12.75
|
| Rate for Payer: One Health Plan of WY PPO |
$40.42
|
| Rate for Payer: One Health Plan of WY PPO |
$21.56
|
| Rate for Payer: PacificSource Commercial |
$19.80
|
| Rate for Payer: PacificSource Commercial |
$37.12
|
| Rate for Payer: PHCS PPO |
$40.42
|
| Rate for Payer: PHCS PPO |
$21.56
|
| Rate for Payer: Three Rivers PPO |
$16.50
|
| Rate for Payer: Three Rivers PPO |
$30.94
|
| Rate for Payer: TriWest Veterans Administration |
$13.42
|
| Rate for Payer: TriWest Veterans Administration |
$25.16
|
| Rate for Payer: United Healthcare Commercial |
$21.01
|
| Rate for Payer: United Healthcare Commercial |
$39.39
|
| Rate for Payer: United Healthcare Medicare |
$13.42
|
| Rate for Payer: United Healthcare Medicare |
$25.16
|
| Rate for Payer: WINHealth Partners Commercial |
$39.19
|
| Rate for Payer: WINHealth Partners Commercial |
$20.90
|
| Rate for Payer: Wise Provider Network Commercial |
$20.90
|
| Rate for Payer: Wise Provider Network Commercial |
$39.19
|
|
|
DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION [42773]
|
Facility
|
OP
|
$22.00
|
|
|
Service Code
|
HCPCS J1100
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.91 |
| Max. Negotiated Rate |
$22.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$21.56
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$40.42
|
| Rate for Payer: Aetna of WY Medicare |
$14.52
|
| Rate for Payer: Aetna of WY Medicare |
$27.22
|
| Rate for Payer: Altius Commercial |
$21.12
|
| Rate for Payer: Altius Commercial |
$39.60
|
| Rate for Payer: Beech Street Commercial |
$21.56
|
| Rate for Payer: Beech Street Commercial |
$40.42
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$40.01
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$21.34
|
| Rate for Payer: Cash Price |
$15.40
|
| Rate for Payer: Cash Price |
$28.87
|
| Rate for Payer: ChoiceCare Network Commercial |
$40.01
|
| Rate for Payer: ChoiceCare Network Commercial |
$21.34
|
| Rate for Payer: Cigna of WY Commercial |
$21.56
|
| Rate for Payer: Cigna of WY Commercial |
$40.42
|
| Rate for Payer: Entrust Commercial |
$39.19
|
| Rate for Payer: Entrust Commercial |
$20.90
|
| Rate for Payer: First Choice Health Commercial |
$20.90
|
| Rate for Payer: First Choice Health Commercial |
$39.19
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$20.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$39.19
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$12.54
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$23.51
|
| Rate for Payer: HealthUtah PPO |
$41.25
|
| Rate for Payer: HealthUtah PPO |
$22.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$21.34
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$40.01
|
| Rate for Payer: Multiplan Medicare/VA |
$11.91
|
| Rate for Payer: Multiplan Medicare/VA |
$22.34
|
| Rate for Payer: One Health Plan of WY PPO |
$21.56
|
| Rate for Payer: One Health Plan of WY PPO |
$40.42
|
| Rate for Payer: PacificSource Commercial |
$37.12
|
| Rate for Payer: PacificSource Commercial |
$19.80
|
| Rate for Payer: PHCS PPO |
$21.56
|
| Rate for Payer: PHCS PPO |
$40.42
|
| Rate for Payer: Three Rivers PPO |
$16.50
|
| Rate for Payer: Three Rivers PPO |
$30.94
|
| Rate for Payer: TriWest Veterans Administration |
$23.51
|
| Rate for Payer: TriWest Veterans Administration |
$12.54
|
| Rate for Payer: United Healthcare Commercial |
$21.01
|
| Rate for Payer: United Healthcare Commercial |
$39.39
|
| Rate for Payer: United Healthcare Medicare |
$23.51
|
| Rate for Payer: United Healthcare Medicare |
$12.54
|
| Rate for Payer: WINHealth Partners Commercial |
$21.56
|
| Rate for Payer: WINHealth Partners Commercial |
$40.42
|
| Rate for Payer: Wise Provider Network Commercial |
$20.90
|
| Rate for Payer: Wise Provider Network Commercial |
$39.19
|
|
|
DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [13530]
|
Facility
|
IP
|
$25.12
|
|
|
Service Code
|
NDC 1672923930
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.56 |
| Max. Negotiated Rate |
$25.12 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$24.62
|
| Rate for Payer: Aetna of WY Medicare |
$16.08
|
| Rate for Payer: Altius Commercial |
$24.12
|
| Rate for Payer: Beech Street Commercial |
$24.62
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$24.37
|
| Rate for Payer: Cash Price |
$17.59
|
| Rate for Payer: ChoiceCare Network Commercial |
$24.37
|
| Rate for Payer: Cigna of WY Commercial |
$24.62
|
| Rate for Payer: Entrust Commercial |
$23.86
|
| Rate for Payer: First Choice Health Commercial |
$23.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$23.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$15.32
|
| Rate for Payer: HealthUtah PPO |
$25.12
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.37
|
| Rate for Payer: Multiplan Medicare/VA |
$14.56
|
| Rate for Payer: One Health Plan of WY PPO |
$24.62
|
| Rate for Payer: PacificSource Commercial |
$22.61
|
| Rate for Payer: PHCS PPO |
$24.62
|
| Rate for Payer: Three Rivers PPO |
$18.84
|
| Rate for Payer: TriWest Veterans Administration |
$15.32
|
| Rate for Payer: United Healthcare Commercial |
$23.99
|
| Rate for Payer: United Healthcare Medicare |
$15.32
|
| Rate for Payer: WINHealth Partners Commercial |
$23.86
|
| Rate for Payer: Wise Provider Network Commercial |
$23.86
|
|
|
DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [13530]
|
Facility
|
OP
|
$25.12
|
|
|
Service Code
|
NDC 1672923930
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.60 |
| Max. Negotiated Rate |
$25.12 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$24.62
|
| Rate for Payer: Aetna of WY Medicare |
$16.58
|
| Rate for Payer: Altius Commercial |
$24.12
|
| Rate for Payer: Beech Street Commercial |
$24.62
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$24.37
|
| Rate for Payer: Cash Price |
$17.59
|
| Rate for Payer: ChoiceCare Network Commercial |
$24.37
|
| Rate for Payer: Cigna of WY Commercial |
$24.62
|
| Rate for Payer: Entrust Commercial |
$23.86
|
| Rate for Payer: First Choice Health Commercial |
$23.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$23.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$14.32
|
| Rate for Payer: HealthUtah PPO |
$25.12
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.37
|
| Rate for Payer: Multiplan Medicare/VA |
$13.60
|
| Rate for Payer: One Health Plan of WY PPO |
$24.62
|
| Rate for Payer: PacificSource Commercial |
$22.61
|
| Rate for Payer: PHCS PPO |
$24.62
|
| Rate for Payer: Three Rivers PPO |
$18.84
|
| Rate for Payer: TriWest Veterans Administration |
$14.32
|
| Rate for Payer: United Healthcare Commercial |
$23.99
|
| Rate for Payer: United Healthcare Medicare |
$14.32
|
| Rate for Payer: WINHealth Partners Commercial |
$24.62
|
| Rate for Payer: Wise Provider Network Commercial |
$23.86
|
|
|
DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [13530]
|
Facility
|
OP
|
$25.12
|
|
|
Service Code
|
NDC 1672923993
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.60 |
| Max. Negotiated Rate |
$25.12 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$24.62
|
| Rate for Payer: Aetna of WY Medicare |
$16.58
|
| Rate for Payer: Altius Commercial |
$24.12
|
| Rate for Payer: Beech Street Commercial |
$24.62
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$24.37
|
| Rate for Payer: Cash Price |
$17.59
|
| Rate for Payer: ChoiceCare Network Commercial |
$24.37
|
| Rate for Payer: Cigna of WY Commercial |
$24.62
|
| Rate for Payer: Entrust Commercial |
$23.86
|
| Rate for Payer: First Choice Health Commercial |
$23.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$23.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$14.32
|
| Rate for Payer: HealthUtah PPO |
$25.12
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.37
|
| Rate for Payer: Multiplan Medicare/VA |
$13.60
|
| Rate for Payer: One Health Plan of WY PPO |
$24.62
|
| Rate for Payer: PacificSource Commercial |
$22.61
|
| Rate for Payer: PHCS PPO |
$24.62
|
| Rate for Payer: Three Rivers PPO |
$18.84
|
| Rate for Payer: TriWest Veterans Administration |
$14.32
|
| Rate for Payer: United Healthcare Commercial |
$23.99
|
| Rate for Payer: United Healthcare Medicare |
$14.32
|
| Rate for Payer: WINHealth Partners Commercial |
$24.62
|
| Rate for Payer: Wise Provider Network Commercial |
$23.86
|
|
|
DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [13530]
|
Facility
|
IP
|
$25.12
|
|
|
Service Code
|
NDC 1672923993
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.56 |
| Max. Negotiated Rate |
$25.12 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$24.62
|
| Rate for Payer: Aetna of WY Medicare |
$16.08
|
| Rate for Payer: Altius Commercial |
$24.12
|
| Rate for Payer: Beech Street Commercial |
$24.62
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$24.37
|
| Rate for Payer: Cash Price |
$17.59
|
| Rate for Payer: ChoiceCare Network Commercial |
$24.37
|
| Rate for Payer: Cigna of WY Commercial |
$24.62
|
| Rate for Payer: Entrust Commercial |
$23.86
|
| Rate for Payer: First Choice Health Commercial |
$23.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$23.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$15.32
|
| Rate for Payer: HealthUtah PPO |
$25.12
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.37
|
| Rate for Payer: Multiplan Medicare/VA |
$14.56
|
| Rate for Payer: One Health Plan of WY PPO |
$24.62
|
| Rate for Payer: PacificSource Commercial |
$22.61
|
| Rate for Payer: PHCS PPO |
$24.62
|
| Rate for Payer: Three Rivers PPO |
$18.84
|
| Rate for Payer: TriWest Veterans Administration |
$15.32
|
| Rate for Payer: United Healthcare Commercial |
$23.99
|
| Rate for Payer: United Healthcare Medicare |
$15.32
|
| Rate for Payer: WINHealth Partners Commercial |
$23.86
|
| Rate for Payer: Wise Provider Network Commercial |
$23.86
|
|
|
DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [13530]
|
Facility
|
IP
|
$25.12
|
|
|
Service Code
|
NDC 5515020902
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.56 |
| Max. Negotiated Rate |
$25.12 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$24.62
|
| Rate for Payer: Aetna of WY Medicare |
$16.08
|
| Rate for Payer: Altius Commercial |
$24.12
|
| Rate for Payer: Beech Street Commercial |
$24.62
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$24.37
|
| Rate for Payer: Cash Price |
$17.59
|
| Rate for Payer: ChoiceCare Network Commercial |
$24.37
|
| Rate for Payer: Cigna of WY Commercial |
$24.62
|
| Rate for Payer: Entrust Commercial |
$23.86
|
| Rate for Payer: First Choice Health Commercial |
$23.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$23.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$15.32
|
| Rate for Payer: HealthUtah PPO |
$25.12
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.37
|
| Rate for Payer: Multiplan Medicare/VA |
$14.56
|
| Rate for Payer: One Health Plan of WY PPO |
$24.62
|
| Rate for Payer: PacificSource Commercial |
$22.61
|
| Rate for Payer: PHCS PPO |
$24.62
|
| Rate for Payer: Three Rivers PPO |
$18.84
|
| Rate for Payer: TriWest Veterans Administration |
$15.32
|
| Rate for Payer: United Healthcare Commercial |
$23.99
|
| Rate for Payer: United Healthcare Medicare |
$15.32
|
| Rate for Payer: WINHealth Partners Commercial |
$23.86
|
| Rate for Payer: Wise Provider Network Commercial |
$23.86
|
|
|
DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [13530]
|
Facility
|
IP
|
$28.50
|
|
|
Service Code
|
NDC 7128850502
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.52 |
| Max. Negotiated Rate |
$28.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$27.93
|
| Rate for Payer: Aetna of WY Medicare |
$18.24
|
| Rate for Payer: Altius Commercial |
$27.36
|
| Rate for Payer: Beech Street Commercial |
$27.93
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$27.64
|
| Rate for Payer: Cash Price |
$19.95
|
| Rate for Payer: ChoiceCare Network Commercial |
$27.64
|
| Rate for Payer: Cigna of WY Commercial |
$27.93
|
| Rate for Payer: Entrust Commercial |
$27.08
|
| Rate for Payer: First Choice Health Commercial |
$27.08
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$27.08
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$17.38
|
| Rate for Payer: HealthUtah PPO |
$28.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$27.64
|
| Rate for Payer: Multiplan Medicare/VA |
$16.52
|
| Rate for Payer: One Health Plan of WY PPO |
$27.93
|
| Rate for Payer: PacificSource Commercial |
$25.65
|
| Rate for Payer: PHCS PPO |
$27.93
|
| Rate for Payer: Three Rivers PPO |
$21.38
|
| Rate for Payer: TriWest Veterans Administration |
$17.38
|
| Rate for Payer: United Healthcare Commercial |
$27.22
|
| Rate for Payer: United Healthcare Medicare |
$17.38
|
| Rate for Payer: WINHealth Partners Commercial |
$27.08
|
| Rate for Payer: Wise Provider Network Commercial |
$27.08
|
|
|
DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [13530]
|
Facility
|
OP
|
$25.12
|
|
|
Service Code
|
NDC 5515020902
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.60 |
| Max. Negotiated Rate |
$25.12 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$24.62
|
| Rate for Payer: Aetna of WY Medicare |
$16.58
|
| Rate for Payer: Altius Commercial |
$24.12
|
| Rate for Payer: Beech Street Commercial |
$24.62
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$24.37
|
| Rate for Payer: Cash Price |
$17.59
|
| Rate for Payer: ChoiceCare Network Commercial |
$24.37
|
| Rate for Payer: Cigna of WY Commercial |
$24.62
|
| Rate for Payer: Entrust Commercial |
$23.86
|
| Rate for Payer: First Choice Health Commercial |
$23.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$23.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$14.32
|
| Rate for Payer: HealthUtah PPO |
$25.12
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.37
|
| Rate for Payer: Multiplan Medicare/VA |
$13.60
|
| Rate for Payer: One Health Plan of WY PPO |
$24.62
|
| Rate for Payer: PacificSource Commercial |
$22.61
|
| Rate for Payer: PHCS PPO |
$24.62
|
| Rate for Payer: Three Rivers PPO |
$18.84
|
| Rate for Payer: TriWest Veterans Administration |
$14.32
|
| Rate for Payer: United Healthcare Commercial |
$23.99
|
| Rate for Payer: United Healthcare Medicare |
$14.32
|
| Rate for Payer: WINHealth Partners Commercial |
$24.62
|
| Rate for Payer: Wise Provider Network Commercial |
$23.86
|
|
