|
DIAPER SZ 3 16-28 LBS
|
Facility
|
IP
|
$1.82
|
|
| Hospital Charge Code |
2450012
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1.05 |
| Max. Negotiated Rate |
$1.82 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.78
|
| Rate for Payer: Aetna of WY Medicare |
$1.16
|
| Rate for Payer: Altius Commercial |
$1.75
|
| Rate for Payer: Beech Street Commercial |
$1.78
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.77
|
| Rate for Payer: Cash Price |
$1.27
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.77
|
| Rate for Payer: Cigna of WY Commercial |
$1.78
|
| Rate for Payer: Entrust Commercial |
$1.73
|
| Rate for Payer: First Choice Health Commercial |
$1.73
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.73
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.11
|
| Rate for Payer: HealthUtah PPO |
$1.82
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.77
|
| Rate for Payer: Multiplan Medicare/VA |
$1.05
|
| Rate for Payer: One Health Plan of WY PPO |
$1.78
|
| Rate for Payer: PacificSource Commercial |
$1.64
|
| Rate for Payer: PHCS PPO |
$1.78
|
| Rate for Payer: Three Rivers PPO |
$1.36
|
| Rate for Payer: TriWest Veterans Administration |
$1.11
|
| Rate for Payer: United Healthcare Commercial |
$1.74
|
| Rate for Payer: United Healthcare Medicare |
$1.11
|
| Rate for Payer: WINHealth Partners Commercial |
$1.73
|
| Rate for Payer: Wise Provider Network Commercial |
$1.73
|
|
|
DIAPER SZ 3 16-28 LBS
|
Facility
|
OP
|
$1.82
|
|
| Hospital Charge Code |
2450012
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$0.99 |
| Max. Negotiated Rate |
$1.82 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.78
|
| Rate for Payer: Aetna of WY Medicare |
$1.20
|
| Rate for Payer: Altius Commercial |
$1.75
|
| Rate for Payer: Beech Street Commercial |
$1.78
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.77
|
| Rate for Payer: Cash Price |
$1.27
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.77
|
| Rate for Payer: Cigna of WY Commercial |
$1.78
|
| Rate for Payer: Entrust Commercial |
$1.73
|
| Rate for Payer: First Choice Health Commercial |
$1.73
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.73
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.04
|
| Rate for Payer: HealthUtah PPO |
$1.82
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.77
|
| Rate for Payer: Multiplan Medicare/VA |
$0.99
|
| Rate for Payer: One Health Plan of WY PPO |
$1.78
|
| Rate for Payer: PacificSource Commercial |
$1.64
|
| Rate for Payer: PHCS PPO |
$1.78
|
| Rate for Payer: Three Rivers PPO |
$1.36
|
| Rate for Payer: TriWest Veterans Administration |
$1.04
|
| Rate for Payer: United Healthcare Commercial |
$1.74
|
| Rate for Payer: United Healthcare Medicare |
$1.04
|
| Rate for Payer: WINHealth Partners Commercial |
$1.78
|
| Rate for Payer: Wise Provider Network Commercial |
$1.73
|
|
|
DIAPER SZ 5 27LBS +
|
Facility
|
IP
|
$3.09
|
|
| Hospital Charge Code |
2450015
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1.79 |
| Max. Negotiated Rate |
$3.09 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3.03
|
| Rate for Payer: Aetna of WY Medicare |
$1.98
|
| Rate for Payer: Altius Commercial |
$2.97
|
| Rate for Payer: Beech Street Commercial |
$3.03
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3.00
|
| Rate for Payer: Cash Price |
$2.16
|
| Rate for Payer: ChoiceCare Network Commercial |
$3.00
|
| Rate for Payer: Cigna of WY Commercial |
$3.03
|
| Rate for Payer: Entrust Commercial |
$2.94
|
| Rate for Payer: First Choice Health Commercial |
$2.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.88
|
| Rate for Payer: HealthUtah PPO |
$3.09
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3.00
|
| Rate for Payer: Multiplan Medicare/VA |
$1.79
|
| Rate for Payer: One Health Plan of WY PPO |
$3.03
|
| Rate for Payer: PacificSource Commercial |
$2.78
|
| Rate for Payer: PHCS PPO |
$3.03
|
| Rate for Payer: Three Rivers PPO |
$2.32
|
| Rate for Payer: TriWest Veterans Administration |
$1.88
|
| Rate for Payer: United Healthcare Commercial |
$2.95
|
| Rate for Payer: United Healthcare Medicare |
$1.88
|
| Rate for Payer: WINHealth Partners Commercial |
$2.94
|
| Rate for Payer: Wise Provider Network Commercial |
$2.94
|
|
|
DIAPER SZ 5 27LBS +
|
Facility
|
OP
|
$3.09
|
|
| Hospital Charge Code |
2450015
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1.67 |
| Max. Negotiated Rate |
$3.09 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3.03
|
| Rate for Payer: Aetna of WY Medicare |
$2.04
|
| Rate for Payer: Altius Commercial |
$2.97
|
| Rate for Payer: Beech Street Commercial |
$3.03
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3.00
|
| Rate for Payer: Cash Price |
$2.16
|
| Rate for Payer: ChoiceCare Network Commercial |
$3.00
|
| Rate for Payer: Cigna of WY Commercial |
$3.03
|
| Rate for Payer: Entrust Commercial |
$2.94
|
| Rate for Payer: First Choice Health Commercial |
$2.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.76
|
| Rate for Payer: HealthUtah PPO |
$3.09
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3.00
|
| Rate for Payer: Multiplan Medicare/VA |
$1.67
|
| Rate for Payer: One Health Plan of WY PPO |
$3.03
|
| Rate for Payer: PacificSource Commercial |
$2.78
|
| Rate for Payer: PHCS PPO |
$3.03
|
| Rate for Payer: Three Rivers PPO |
$2.32
|
| Rate for Payer: TriWest Veterans Administration |
$1.76
|
| Rate for Payer: United Healthcare Commercial |
$2.95
|
| Rate for Payer: United Healthcare Medicare |
$1.76
|
| Rate for Payer: WINHealth Partners Commercial |
$3.03
|
| Rate for Payer: Wise Provider Network Commercial |
$2.94
|
|
|
DIAPER SZ NEWBORN 10LBS
|
Facility
|
IP
|
$0.64
|
|
| Hospital Charge Code |
2450014
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$0.64 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.63
|
| Rate for Payer: Aetna of WY Medicare |
$0.41
|
| Rate for Payer: Altius Commercial |
$0.61
|
| Rate for Payer: Beech Street Commercial |
$0.63
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.62
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.62
|
| Rate for Payer: Cigna of WY Commercial |
$0.63
|
| Rate for Payer: Entrust Commercial |
$0.61
|
| Rate for Payer: First Choice Health Commercial |
$0.61
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.61
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.39
|
| Rate for Payer: HealthUtah PPO |
$0.64
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.62
|
| Rate for Payer: Multiplan Medicare/VA |
$0.37
|
| Rate for Payer: One Health Plan of WY PPO |
$0.63
|
| Rate for Payer: PacificSource Commercial |
$0.58
|
| Rate for Payer: PHCS PPO |
$0.63
|
| Rate for Payer: Three Rivers PPO |
$0.48
|
| Rate for Payer: TriWest Veterans Administration |
$0.39
|
| Rate for Payer: United Healthcare Commercial |
$0.61
|
| Rate for Payer: United Healthcare Medicare |
$0.39
|
| Rate for Payer: WINHealth Partners Commercial |
$0.61
|
| Rate for Payer: Wise Provider Network Commercial |
$0.61
|
|
|
DIAPER SZ NEWBORN 10LBS
|
Facility
|
OP
|
$0.64
|
|
| Hospital Charge Code |
2450014
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$0.64 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.63
|
| Rate for Payer: Aetna of WY Medicare |
$0.42
|
| Rate for Payer: Altius Commercial |
$0.61
|
| Rate for Payer: Beech Street Commercial |
$0.63
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.62
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.62
|
| Rate for Payer: Cigna of WY Commercial |
$0.63
|
| Rate for Payer: Entrust Commercial |
$0.61
|
| Rate for Payer: First Choice Health Commercial |
$0.61
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.61
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.36
|
| Rate for Payer: HealthUtah PPO |
$0.64
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.62
|
| Rate for Payer: Multiplan Medicare/VA |
$0.35
|
| Rate for Payer: One Health Plan of WY PPO |
$0.63
|
| Rate for Payer: PacificSource Commercial |
$0.58
|
| Rate for Payer: PHCS PPO |
$0.63
|
| Rate for Payer: Three Rivers PPO |
$0.48
|
| Rate for Payer: TriWest Veterans Administration |
$0.36
|
| Rate for Payer: United Healthcare Commercial |
$0.61
|
| Rate for Payer: United Healthcare Medicare |
$0.36
|
| Rate for Payer: WINHealth Partners Commercial |
$0.63
|
| Rate for Payer: Wise Provider Network Commercial |
$0.61
|
|
|
DIAPER SZ PREEMIE UP TO 6LBS
|
Facility
|
IP
|
$0.40
|
|
| Hospital Charge Code |
2450058
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.39
|
| Rate for Payer: Aetna of WY Medicare |
$0.26
|
| Rate for Payer: Altius Commercial |
$0.38
|
| Rate for Payer: Beech Street Commercial |
$0.39
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.39
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.39
|
| Rate for Payer: Cigna of WY Commercial |
$0.39
|
| Rate for Payer: Entrust Commercial |
$0.38
|
| Rate for Payer: First Choice Health Commercial |
$0.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.24
|
| Rate for Payer: HealthUtah PPO |
$0.40
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.39
|
| Rate for Payer: Multiplan Medicare/VA |
$0.23
|
| Rate for Payer: One Health Plan of WY PPO |
$0.39
|
| Rate for Payer: PacificSource Commercial |
$0.36
|
| Rate for Payer: PHCS PPO |
$0.39
|
| Rate for Payer: Three Rivers PPO |
$0.30
|
| Rate for Payer: TriWest Veterans Administration |
$0.24
|
| Rate for Payer: United Healthcare Commercial |
$0.38
|
| Rate for Payer: United Healthcare Medicare |
$0.24
|
| Rate for Payer: WINHealth Partners Commercial |
$0.38
|
| Rate for Payer: Wise Provider Network Commercial |
$0.38
|
|
|
DIAPER SZ PREEMIE UP TO 6LBS
|
Facility
|
OP
|
$0.40
|
|
| Hospital Charge Code |
2450058
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.39
|
| Rate for Payer: Aetna of WY Medicare |
$0.26
|
| Rate for Payer: Altius Commercial |
$0.38
|
| Rate for Payer: Beech Street Commercial |
$0.39
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.39
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.39
|
| Rate for Payer: Cigna of WY Commercial |
$0.39
|
| Rate for Payer: Entrust Commercial |
$0.38
|
| Rate for Payer: First Choice Health Commercial |
$0.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.23
|
| Rate for Payer: HealthUtah PPO |
$0.40
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.39
|
| Rate for Payer: Multiplan Medicare/VA |
$0.22
|
| Rate for Payer: One Health Plan of WY PPO |
$0.39
|
| Rate for Payer: PacificSource Commercial |
$0.36
|
| Rate for Payer: PHCS PPO |
$0.39
|
| Rate for Payer: Three Rivers PPO |
$0.30
|
| Rate for Payer: TriWest Veterans Administration |
$0.23
|
| Rate for Payer: United Healthcare Commercial |
$0.38
|
| Rate for Payer: United Healthcare Medicare |
$0.23
|
| Rate for Payer: WINHealth Partners Commercial |
$0.39
|
| Rate for Payer: Wise Provider Network Commercial |
$0.38
|
|
|
DIAPHRAGM/CERVICAL CAP FITTING W/INSTRUCTIONS
|
Professional
|
Both
|
$178.00
|
|
|
Service Code
|
HCPCS 57170
|
| Min. Negotiated Rate |
$38.16 |
| Max. Negotiated Rate |
$178.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$174.44
|
| Rate for Payer: Aetna of WY Medicare |
$44.89
|
| Rate for Payer: Beech Street Commercial |
$169.10
|
| Rate for Payer: Cash Price |
$124.60
|
| Rate for Payer: Cash Price |
$124.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$172.66
|
| Rate for Payer: Cigna of WY Commercial |
$174.44
|
| Rate for Payer: First Choice Health Commercial |
$160.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$169.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$44.89
|
| Rate for Payer: HealthUtah PPO |
$178.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$172.66
|
| Rate for Payer: Multiplan Medicare/VA |
$38.16
|
| Rate for Payer: One Health Plan of WY PPO |
$174.44
|
| Rate for Payer: PacificSource Commercial |
$160.20
|
| Rate for Payer: PHCS PPO |
$169.10
|
| Rate for Payer: Three Rivers PPO |
$133.50
|
| Rate for Payer: TriWest Veterans Administration |
$44.89
|
| Rate for Payer: United Healthcare Commercial |
$169.10
|
| Rate for Payer: WINHealth Partners Commercial |
$151.30
|
|
|
DIATRIZOATE MEGLUMINE 30 % URETHRAL SOLUTION [11706]
|
Facility
|
IP
|
$15.74
|
|
|
Service Code
|
HCPCS Q9958
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.12 |
| Max. Negotiated Rate |
$15.74 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.43
|
| Rate for Payer: Aetna of WY Medicare |
$10.07
|
| Rate for Payer: Altius Commercial |
$15.11
|
| Rate for Payer: Beech Street Commercial |
$15.43
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.27
|
| Rate for Payer: Cash Price |
$11.02
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.27
|
| Rate for Payer: Cigna of WY Commercial |
$15.43
|
| Rate for Payer: Entrust Commercial |
$14.95
|
| Rate for Payer: First Choice Health Commercial |
$14.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.60
|
| Rate for Payer: HealthUtah PPO |
$15.74
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.27
|
| Rate for Payer: Multiplan Medicare/VA |
$9.12
|
| Rate for Payer: One Health Plan of WY PPO |
$15.43
|
| Rate for Payer: PacificSource Commercial |
$14.17
|
| Rate for Payer: PHCS PPO |
$15.43
|
| Rate for Payer: Three Rivers PPO |
$11.80
|
| Rate for Payer: TriWest Veterans Administration |
$9.60
|
| Rate for Payer: United Healthcare Commercial |
$15.03
|
| Rate for Payer: United Healthcare Medicare |
$9.60
|
| Rate for Payer: WINHealth Partners Commercial |
$14.95
|
| Rate for Payer: Wise Provider Network Commercial |
$14.95
|
|
|
DIATRIZOATE MEGLUMINE 30 % URETHRAL SOLUTION [11706]
|
Facility
|
OP
|
$15.74
|
|
|
Service Code
|
HCPCS Q9958
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.52 |
| Max. Negotiated Rate |
$15.74 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.43
|
| Rate for Payer: Aetna of WY Medicare |
$10.39
|
| Rate for Payer: Altius Commercial |
$15.11
|
| Rate for Payer: Beech Street Commercial |
$15.43
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.27
|
| Rate for Payer: Cash Price |
$11.02
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.27
|
| Rate for Payer: Cigna of WY Commercial |
$15.43
|
| Rate for Payer: Entrust Commercial |
$14.95
|
| Rate for Payer: First Choice Health Commercial |
$14.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.97
|
| Rate for Payer: HealthUtah PPO |
$15.74
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.27
|
| Rate for Payer: Multiplan Medicare/VA |
$8.52
|
| Rate for Payer: One Health Plan of WY PPO |
$15.43
|
| Rate for Payer: PacificSource Commercial |
$14.17
|
| Rate for Payer: PHCS PPO |
$15.43
|
| Rate for Payer: Three Rivers PPO |
$11.80
|
| Rate for Payer: TriWest Veterans Administration |
$8.97
|
| Rate for Payer: United Healthcare Commercial |
$15.03
|
| Rate for Payer: United Healthcare Medicare |
$8.97
|
| Rate for Payer: WINHealth Partners Commercial |
$15.43
|
| Rate for Payer: Wise Provider Network Commercial |
$14.95
|
|
|
DIATRIZOATE MEGLUMINE-DIATRIZOATE SODIUM 66 %-10 % ORAL SOLUTION [3636]
|
Facility
|
OP
|
$18.08
|
|
|
Service Code
|
HCPCS Q9963
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.79 |
| Max. Negotiated Rate |
$18.08 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$17.72
|
| Rate for Payer: Aetna of WY Medicare |
$11.93
|
| Rate for Payer: Altius Commercial |
$17.36
|
| Rate for Payer: Beech Street Commercial |
$17.72
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$17.54
|
| Rate for Payer: Cash Price |
$12.65
|
| Rate for Payer: ChoiceCare Network Commercial |
$17.54
|
| Rate for Payer: Cigna of WY Commercial |
$17.72
|
| Rate for Payer: Entrust Commercial |
$17.18
|
| Rate for Payer: First Choice Health Commercial |
$17.18
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.18
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.31
|
| Rate for Payer: HealthUtah PPO |
$18.08
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.54
|
| Rate for Payer: Multiplan Medicare/VA |
$9.79
|
| Rate for Payer: One Health Plan of WY PPO |
$17.72
|
| Rate for Payer: PacificSource Commercial |
$16.27
|
| Rate for Payer: PHCS PPO |
$17.72
|
| Rate for Payer: Three Rivers PPO |
$13.56
|
| Rate for Payer: TriWest Veterans Administration |
$10.31
|
| Rate for Payer: United Healthcare Commercial |
$17.27
|
| Rate for Payer: United Healthcare Medicare |
$10.31
|
| Rate for Payer: WINHealth Partners Commercial |
$17.72
|
| Rate for Payer: Wise Provider Network Commercial |
$17.18
|
|
|
DIATRIZOATE MEGLUMINE-DIATRIZOATE SODIUM 66 %-10 % ORAL SOLUTION [3636]
|
Facility
|
IP
|
$18.08
|
|
|
Service Code
|
HCPCS Q9963
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.48 |
| Max. Negotiated Rate |
$18.08 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$17.72
|
| Rate for Payer: Aetna of WY Medicare |
$11.57
|
| Rate for Payer: Altius Commercial |
$17.36
|
| Rate for Payer: Beech Street Commercial |
$17.72
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$17.54
|
| Rate for Payer: Cash Price |
$12.65
|
| Rate for Payer: ChoiceCare Network Commercial |
$17.54
|
| Rate for Payer: Cigna of WY Commercial |
$17.72
|
| Rate for Payer: Entrust Commercial |
$17.18
|
| Rate for Payer: First Choice Health Commercial |
$17.18
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.18
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.03
|
| Rate for Payer: HealthUtah PPO |
$18.08
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.54
|
| Rate for Payer: Multiplan Medicare/VA |
$10.48
|
| Rate for Payer: One Health Plan of WY PPO |
$17.72
|
| Rate for Payer: PacificSource Commercial |
$16.27
|
| Rate for Payer: PHCS PPO |
$17.72
|
| Rate for Payer: Three Rivers PPO |
$13.56
|
| Rate for Payer: TriWest Veterans Administration |
$11.03
|
| Rate for Payer: United Healthcare Commercial |
$17.27
|
| Rate for Payer: United Healthcare Medicare |
$11.03
|
| Rate for Payer: WINHealth Partners Commercial |
$17.18
|
| Rate for Payer: Wise Provider Network Commercial |
$17.18
|
|
|
DIAZEPAM 5 MG/ML INJECTION SOLUTION [2738]
|
Facility
|
OP
|
$32.90
|
|
|
Service Code
|
HCPCS J3360
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.82 |
| Max. Negotiated Rate |
$32.90 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$32.24
|
| Rate for Payer: Aetna of WY Medicare |
$21.71
|
| Rate for Payer: Altius Commercial |
$31.58
|
| Rate for Payer: Beech Street Commercial |
$32.24
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$31.91
|
| Rate for Payer: Cash Price |
$23.03
|
| Rate for Payer: ChoiceCare Network Commercial |
$31.91
|
| Rate for Payer: Cigna of WY Commercial |
$32.24
|
| Rate for Payer: Entrust Commercial |
$31.26
|
| Rate for Payer: First Choice Health Commercial |
$31.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$31.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$18.75
|
| Rate for Payer: HealthUtah PPO |
$32.90
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$31.91
|
| Rate for Payer: Multiplan Medicare/VA |
$17.82
|
| Rate for Payer: One Health Plan of WY PPO |
$32.24
|
| Rate for Payer: PacificSource Commercial |
$29.61
|
| Rate for Payer: PHCS PPO |
$32.24
|
| Rate for Payer: Three Rivers PPO |
$24.68
|
| Rate for Payer: TriWest Veterans Administration |
$18.75
|
| Rate for Payer: United Healthcare Commercial |
$31.42
|
| Rate for Payer: United Healthcare Medicare |
$18.75
|
| Rate for Payer: WINHealth Partners Commercial |
$32.24
|
| Rate for Payer: Wise Provider Network Commercial |
$31.26
|
|
|
DIAZEPAM 5 MG/ML INJECTION SOLUTION [2738]
|
Facility
|
IP
|
$32.90
|
|
|
Service Code
|
HCPCS J3360
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.07 |
| Max. Negotiated Rate |
$32.90 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$32.24
|
| Rate for Payer: Aetna of WY Medicare |
$21.06
|
| Rate for Payer: Altius Commercial |
$31.58
|
| Rate for Payer: Beech Street Commercial |
$32.24
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$31.91
|
| Rate for Payer: Cash Price |
$23.03
|
| Rate for Payer: ChoiceCare Network Commercial |
$31.91
|
| Rate for Payer: Cigna of WY Commercial |
$32.24
|
| Rate for Payer: Entrust Commercial |
$31.26
|
| Rate for Payer: First Choice Health Commercial |
$31.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$31.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$20.07
|
| Rate for Payer: HealthUtah PPO |
$32.90
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$31.91
|
| Rate for Payer: Multiplan Medicare/VA |
$19.07
|
| Rate for Payer: One Health Plan of WY PPO |
$32.24
|
| Rate for Payer: PacificSource Commercial |
$29.61
|
| Rate for Payer: PHCS PPO |
$32.24
|
| Rate for Payer: Three Rivers PPO |
$24.68
|
| Rate for Payer: TriWest Veterans Administration |
$20.07
|
| Rate for Payer: United Healthcare Commercial |
$31.42
|
| Rate for Payer: United Healthcare Medicare |
$20.07
|
| Rate for Payer: WINHealth Partners Commercial |
$31.26
|
| Rate for Payer: Wise Provider Network Commercial |
$31.26
|
|
|
DIAZEPAM 5 MG/ML INJECTION SYRINGE [25511]
|
Facility
|
IP
|
$51.92
|
|
|
Service Code
|
HCPCS J3360
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.09 |
| Max. Negotiated Rate |
$51.92 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$50.88
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$50.86
|
| Rate for Payer: Aetna of WY Medicare |
$33.23
|
| Rate for Payer: Aetna of WY Medicare |
$33.22
|
| Rate for Payer: Altius Commercial |
$49.84
|
| Rate for Payer: Altius Commercial |
$49.82
|
| Rate for Payer: Beech Street Commercial |
$50.86
|
| Rate for Payer: Beech Street Commercial |
$50.88
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$50.34
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$50.36
|
| Rate for Payer: Cash Price |
$36.33
|
| Rate for Payer: Cash Price |
$36.34
|
| Rate for Payer: ChoiceCare Network Commercial |
$50.36
|
| Rate for Payer: ChoiceCare Network Commercial |
$50.34
|
| Rate for Payer: Cigna of WY Commercial |
$50.86
|
| Rate for Payer: Cigna of WY Commercial |
$50.88
|
| Rate for Payer: Entrust Commercial |
$49.30
|
| Rate for Payer: Entrust Commercial |
$49.32
|
| Rate for Payer: First Choice Health Commercial |
$49.30
|
| Rate for Payer: First Choice Health Commercial |
$49.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$49.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$49.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$31.66
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$31.67
|
| Rate for Payer: HealthUtah PPO |
$51.90
|
| Rate for Payer: HealthUtah PPO |
$51.92
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$50.34
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$50.36
|
| Rate for Payer: Multiplan Medicare/VA |
$30.09
|
| Rate for Payer: Multiplan Medicare/VA |
$30.08
|
| Rate for Payer: One Health Plan of WY PPO |
$50.86
|
| Rate for Payer: One Health Plan of WY PPO |
$50.88
|
| Rate for Payer: PacificSource Commercial |
$46.73
|
| Rate for Payer: PacificSource Commercial |
$46.71
|
| Rate for Payer: PHCS PPO |
$50.86
|
| Rate for Payer: PHCS PPO |
$50.88
|
| Rate for Payer: Three Rivers PPO |
$38.94
|
| Rate for Payer: Three Rivers PPO |
$38.92
|
| Rate for Payer: TriWest Veterans Administration |
$31.67
|
| Rate for Payer: TriWest Veterans Administration |
$31.66
|
| Rate for Payer: United Healthcare Commercial |
$49.56
|
| Rate for Payer: United Healthcare Commercial |
$49.58
|
| Rate for Payer: United Healthcare Medicare |
$31.67
|
| Rate for Payer: United Healthcare Medicare |
$31.66
|
| Rate for Payer: WINHealth Partners Commercial |
$49.30
|
| Rate for Payer: WINHealth Partners Commercial |
$49.32
|
| Rate for Payer: Wise Provider Network Commercial |
$49.30
|
| Rate for Payer: Wise Provider Network Commercial |
$49.32
|
|
|
DIAZEPAM 5 MG/ML INJECTION SYRINGE [25511]
|
Facility
|
OP
|
$51.90
|
|
|
Service Code
|
HCPCS J3360
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.10 |
| Max. Negotiated Rate |
$51.90 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$50.86
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$50.88
|
| Rate for Payer: Aetna of WY Medicare |
$34.25
|
| Rate for Payer: Aetna of WY Medicare |
$34.27
|
| Rate for Payer: Altius Commercial |
$49.82
|
| Rate for Payer: Altius Commercial |
$49.84
|
| Rate for Payer: Beech Street Commercial |
$50.86
|
| Rate for Payer: Beech Street Commercial |
$50.88
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$50.36
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$50.34
|
| Rate for Payer: Cash Price |
$36.33
|
| Rate for Payer: Cash Price |
$36.34
|
| Rate for Payer: ChoiceCare Network Commercial |
$50.34
|
| Rate for Payer: ChoiceCare Network Commercial |
$50.36
|
| Rate for Payer: Cigna of WY Commercial |
$50.88
|
| Rate for Payer: Cigna of WY Commercial |
$50.86
|
| Rate for Payer: Entrust Commercial |
$49.30
|
| Rate for Payer: Entrust Commercial |
$49.32
|
| Rate for Payer: First Choice Health Commercial |
$49.32
|
| Rate for Payer: First Choice Health Commercial |
$49.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$49.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$49.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$29.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$29.59
|
| Rate for Payer: HealthUtah PPO |
$51.92
|
| Rate for Payer: HealthUtah PPO |
$51.90
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$50.34
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$50.36
|
| Rate for Payer: Multiplan Medicare/VA |
$28.11
|
| Rate for Payer: Multiplan Medicare/VA |
$28.10
|
| Rate for Payer: One Health Plan of WY PPO |
$50.86
|
| Rate for Payer: One Health Plan of WY PPO |
$50.88
|
| Rate for Payer: PacificSource Commercial |
$46.71
|
| Rate for Payer: PacificSource Commercial |
$46.73
|
| Rate for Payer: PHCS PPO |
$50.88
|
| Rate for Payer: PHCS PPO |
$50.86
|
| Rate for Payer: Three Rivers PPO |
$38.92
|
| Rate for Payer: Three Rivers PPO |
$38.94
|
| Rate for Payer: TriWest Veterans Administration |
$29.59
|
| Rate for Payer: TriWest Veterans Administration |
$29.58
|
| Rate for Payer: United Healthcare Commercial |
$49.56
|
| Rate for Payer: United Healthcare Commercial |
$49.58
|
| Rate for Payer: United Healthcare Medicare |
$29.58
|
| Rate for Payer: United Healthcare Medicare |
$29.59
|
| Rate for Payer: WINHealth Partners Commercial |
$50.86
|
| Rate for Payer: WINHealth Partners Commercial |
$50.88
|
| Rate for Payer: Wise Provider Network Commercial |
$49.30
|
| Rate for Payer: Wise Provider Network Commercial |
$49.32
|
|
|
DIAZEPAM 5 MG TABLET [20121]
|
Facility
|
IP
|
$15.27
|
|
|
Service Code
|
NDC 5107928501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.85 |
| Max. Negotiated Rate |
$15.27 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.96
|
| Rate for Payer: Aetna of WY Medicare |
$9.77
|
| Rate for Payer: Altius Commercial |
$14.66
|
| Rate for Payer: Beech Street Commercial |
$14.96
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.81
|
| Rate for Payer: Cash Price |
$10.69
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.81
|
| Rate for Payer: Cigna of WY Commercial |
$14.96
|
| Rate for Payer: Entrust Commercial |
$14.51
|
| Rate for Payer: First Choice Health Commercial |
$14.51
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.51
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.31
|
| Rate for Payer: HealthUtah PPO |
$15.27
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.81
|
| Rate for Payer: Multiplan Medicare/VA |
$8.85
|
| Rate for Payer: One Health Plan of WY PPO |
$14.96
|
| Rate for Payer: PacificSource Commercial |
$13.74
|
| Rate for Payer: PHCS PPO |
$14.96
|
| Rate for Payer: Three Rivers PPO |
$11.45
|
| Rate for Payer: TriWest Veterans Administration |
$9.31
|
| Rate for Payer: United Healthcare Commercial |
$14.58
|
| Rate for Payer: United Healthcare Medicare |
$9.31
|
| Rate for Payer: WINHealth Partners Commercial |
$14.51
|
| Rate for Payer: Wise Provider Network Commercial |
$14.51
|
|
|
DIAZEPAM 5 MG TABLET [20121]
|
Facility
|
OP
|
$15.27
|
|
|
Service Code
|
NDC 5107928501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.27 |
| Max. Negotiated Rate |
$15.27 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.96
|
| Rate for Payer: Aetna of WY Medicare |
$10.08
|
| Rate for Payer: Altius Commercial |
$14.66
|
| Rate for Payer: Beech Street Commercial |
$14.96
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.81
|
| Rate for Payer: Cash Price |
$10.69
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.81
|
| Rate for Payer: Cigna of WY Commercial |
$14.96
|
| Rate for Payer: Entrust Commercial |
$14.51
|
| Rate for Payer: First Choice Health Commercial |
$14.51
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.51
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.70
|
| Rate for Payer: HealthUtah PPO |
$15.27
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.81
|
| Rate for Payer: Multiplan Medicare/VA |
$8.27
|
| Rate for Payer: One Health Plan of WY PPO |
$14.96
|
| Rate for Payer: PacificSource Commercial |
$13.74
|
| Rate for Payer: PHCS PPO |
$14.96
|
| Rate for Payer: Three Rivers PPO |
$11.45
|
| Rate for Payer: TriWest Veterans Administration |
$8.70
|
| Rate for Payer: United Healthcare Commercial |
$14.58
|
| Rate for Payer: United Healthcare Medicare |
$8.70
|
| Rate for Payer: WINHealth Partners Commercial |
$14.96
|
| Rate for Payer: Wise Provider Network Commercial |
$14.51
|
|
|
DIAZEPAM INJECTION
|
Professional
|
Both
|
$14.00
|
|
|
Service Code
|
HCPCS J3360
|
| Min. Negotiated Rate |
$5.56 |
| Max. Negotiated Rate |
$14.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$13.72
|
| Rate for Payer: Aetna of WY Medicare |
$6.54
|
| Rate for Payer: Beech Street Commercial |
$13.30
|
| Rate for Payer: Cash Price |
$9.80
|
| Rate for Payer: Cash Price |
$9.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$13.58
|
| Rate for Payer: Cigna of WY Commercial |
$13.72
|
| Rate for Payer: First Choice Health Commercial |
$12.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$13.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$6.54
|
| Rate for Payer: HealthUtah PPO |
$14.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$13.58
|
| Rate for Payer: Multiplan Medicare/VA |
$5.56
|
| Rate for Payer: One Health Plan of WY PPO |
$13.72
|
| Rate for Payer: PacificSource Commercial |
$12.60
|
| Rate for Payer: PHCS PPO |
$13.30
|
| Rate for Payer: Three Rivers PPO |
$10.50
|
| Rate for Payer: TriWest Veterans Administration |
$6.54
|
| Rate for Payer: United Healthcare Commercial |
$13.30
|
| Rate for Payer: WINHealth Partners Commercial |
$13.30
|
|
|
DIBUCAINE 1 % TOPICAL OINTMENT [9568]
|
Facility
|
OP
|
$15.70
|
|
|
Service Code
|
NDC 0536121195
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.50 |
| Max. Negotiated Rate |
$15.70 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.39
|
| Rate for Payer: Aetna of WY Medicare |
$10.36
|
| Rate for Payer: Altius Commercial |
$15.07
|
| Rate for Payer: Beech Street Commercial |
$15.39
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.23
|
| Rate for Payer: Cash Price |
$10.99
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.23
|
| Rate for Payer: Cigna of WY Commercial |
$15.39
|
| Rate for Payer: Entrust Commercial |
$14.92
|
| Rate for Payer: First Choice Health Commercial |
$14.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.95
|
| Rate for Payer: HealthUtah PPO |
$15.70
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.23
|
| Rate for Payer: Multiplan Medicare/VA |
$8.50
|
| Rate for Payer: One Health Plan of WY PPO |
$15.39
|
| Rate for Payer: PacificSource Commercial |
$14.13
|
| Rate for Payer: PHCS PPO |
$15.39
|
| Rate for Payer: Three Rivers PPO |
$11.78
|
| Rate for Payer: TriWest Veterans Administration |
$8.95
|
| Rate for Payer: United Healthcare Commercial |
$14.99
|
| Rate for Payer: United Healthcare Medicare |
$8.95
|
| Rate for Payer: WINHealth Partners Commercial |
$15.39
|
| Rate for Payer: Wise Provider Network Commercial |
$14.92
|
|
|
DIBUCAINE 1 % TOPICAL OINTMENT [9568]
|
Facility
|
IP
|
$15.70
|
|
|
Service Code
|
NDC 0536121195
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.10 |
| Max. Negotiated Rate |
$15.70 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.39
|
| Rate for Payer: Aetna of WY Medicare |
$10.05
|
| Rate for Payer: Altius Commercial |
$15.07
|
| Rate for Payer: Beech Street Commercial |
$15.39
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.23
|
| Rate for Payer: Cash Price |
$10.99
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.23
|
| Rate for Payer: Cigna of WY Commercial |
$15.39
|
| Rate for Payer: Entrust Commercial |
$14.92
|
| Rate for Payer: First Choice Health Commercial |
$14.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.58
|
| Rate for Payer: HealthUtah PPO |
$15.70
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.23
|
| Rate for Payer: Multiplan Medicare/VA |
$9.10
|
| Rate for Payer: One Health Plan of WY PPO |
$15.39
|
| Rate for Payer: PacificSource Commercial |
$14.13
|
| Rate for Payer: PHCS PPO |
$15.39
|
| Rate for Payer: Three Rivers PPO |
$11.78
|
| Rate for Payer: TriWest Veterans Administration |
$9.58
|
| Rate for Payer: United Healthcare Commercial |
$14.99
|
| Rate for Payer: United Healthcare Medicare |
$9.58
|
| Rate for Payer: WINHealth Partners Commercial |
$14.92
|
| Rate for Payer: Wise Provider Network Commercial |
$14.92
|
|
|
DICLOFENAC 1 % TOPICAL GEL [52825]
|
Facility
|
IP
|
$15.80
|
|
|
Service Code
|
NDC 6909752444
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.16 |
| Max. Negotiated Rate |
$15.80 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.48
|
| Rate for Payer: Aetna of WY Medicare |
$10.11
|
| Rate for Payer: Altius Commercial |
$15.17
|
| Rate for Payer: Beech Street Commercial |
$15.48
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.33
|
| Rate for Payer: Cash Price |
$11.06
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.33
|
| Rate for Payer: Cigna of WY Commercial |
$15.48
|
| Rate for Payer: Entrust Commercial |
$15.01
|
| Rate for Payer: First Choice Health Commercial |
$15.01
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.01
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.64
|
| Rate for Payer: HealthUtah PPO |
$15.80
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.33
|
| Rate for Payer: Multiplan Medicare/VA |
$9.16
|
| Rate for Payer: One Health Plan of WY PPO |
$15.48
|
| Rate for Payer: PacificSource Commercial |
$14.22
|
| Rate for Payer: PHCS PPO |
$15.48
|
| Rate for Payer: Three Rivers PPO |
$11.85
|
| Rate for Payer: TriWest Veterans Administration |
$9.64
|
| Rate for Payer: United Healthcare Commercial |
$15.09
|
| Rate for Payer: United Healthcare Medicare |
$9.64
|
| Rate for Payer: WINHealth Partners Commercial |
$15.01
|
| Rate for Payer: Wise Provider Network Commercial |
$15.01
|
|
|
DICLOFENAC 1 % TOPICAL GEL [52825]
|
Facility
|
OP
|
$15.39
|
|
|
Service Code
|
NDC 0067815203
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.33 |
| Max. Negotiated Rate |
$15.39 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.08
|
| Rate for Payer: Aetna of WY Medicare |
$10.16
|
| Rate for Payer: Altius Commercial |
$14.77
|
| Rate for Payer: Beech Street Commercial |
$15.08
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.93
|
| Rate for Payer: Cash Price |
$10.77
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.93
|
| Rate for Payer: Cigna of WY Commercial |
$15.08
|
| Rate for Payer: Entrust Commercial |
$14.62
|
| Rate for Payer: First Choice Health Commercial |
$14.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.77
|
| Rate for Payer: HealthUtah PPO |
$15.39
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.93
|
| Rate for Payer: Multiplan Medicare/VA |
$8.33
|
| Rate for Payer: One Health Plan of WY PPO |
$15.08
|
| Rate for Payer: PacificSource Commercial |
$13.85
|
| Rate for Payer: PHCS PPO |
$15.08
|
| Rate for Payer: Three Rivers PPO |
$11.54
|
| Rate for Payer: TriWest Veterans Administration |
$8.77
|
| Rate for Payer: United Healthcare Commercial |
$14.70
|
| Rate for Payer: United Healthcare Medicare |
$8.77
|
| Rate for Payer: WINHealth Partners Commercial |
$15.08
|
| Rate for Payer: Wise Provider Network Commercial |
$14.62
|
|
|
DICLOFENAC 1 % TOPICAL GEL [52825]
|
Facility
|
IP
|
$15.39
|
|
|
Service Code
|
NDC 0067815203
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.92 |
| Max. Negotiated Rate |
$15.39 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.08
|
| Rate for Payer: Aetna of WY Medicare |
$9.85
|
| Rate for Payer: Altius Commercial |
$14.77
|
| Rate for Payer: Beech Street Commercial |
$15.08
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.93
|
| Rate for Payer: Cash Price |
$10.77
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.93
|
| Rate for Payer: Cigna of WY Commercial |
$15.08
|
| Rate for Payer: Entrust Commercial |
$14.62
|
| Rate for Payer: First Choice Health Commercial |
$14.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.39
|
| Rate for Payer: HealthUtah PPO |
$15.39
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.93
|
| Rate for Payer: Multiplan Medicare/VA |
$8.92
|
| Rate for Payer: One Health Plan of WY PPO |
$15.08
|
| Rate for Payer: PacificSource Commercial |
$13.85
|
| Rate for Payer: PHCS PPO |
$15.08
|
| Rate for Payer: Three Rivers PPO |
$11.54
|
| Rate for Payer: TriWest Veterans Administration |
$9.39
|
| Rate for Payer: United Healthcare Commercial |
$14.70
|
| Rate for Payer: United Healthcare Medicare |
$9.39
|
| Rate for Payer: WINHealth Partners Commercial |
$14.62
|
| Rate for Payer: Wise Provider Network Commercial |
$14.62
|
|
