|
FERRIC CARBOXYMALTOSE 50 MG IRON/ML INTRAVENOUS SOLUTION [129037]
|
Facility
|
IP
|
$186.80
|
|
|
Service Code
|
HCPCS J1439
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$117.12 |
| Max. Negotiated Rate |
$186.80 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$183.06
|
| Rate for Payer: Altius Auto/Workers Compensation |
$179.33
|
| Rate for Payer: Altius Commercial |
$179.33
|
| Rate for Payer: Beech Street Commercial |
$183.06
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$153.36
|
| Rate for Payer: Cash Price |
$130.76
|
| Rate for Payer: ChoiceCare Network Commercial |
$181.20
|
| Rate for Payer: Cigna of WY Commercial |
$183.06
|
| Rate for Payer: Entrust Commercial |
$177.46
|
| Rate for Payer: First Choice Health Commercial |
$177.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$177.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$123.29
|
| Rate for Payer: HealthUtah PPO |
$186.80
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$181.20
|
| Rate for Payer: Multiplan Medicare/VA |
$117.12
|
| Rate for Payer: One Health Plan of WY PPO |
$183.06
|
| Rate for Payer: PacificSource Commercial |
$168.12
|
| Rate for Payer: PHCS PPO |
$183.06
|
| Rate for Payer: Three Rivers PPO |
$140.10
|
| Rate for Payer: TriWest Veterans Administration |
$123.29
|
| Rate for Payer: United Healthcare Commercial |
$162.52
|
| Rate for Payer: United Healthcare Medicare |
$123.29
|
| Rate for Payer: WINHealth Partners Commercial |
$177.46
|
| Rate for Payer: Wise Provider Network Commercial |
$177.46
|
|
|
FERRIC CARBOXYMALTOSE 50 MG IRON/ML INTRAVENOUS SOLUTION [129037]
|
Facility
|
OP
|
$186.80
|
|
|
Service Code
|
HCPCS J1439
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$102.93 |
| Max. Negotiated Rate |
$186.80 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$183.06
|
| Rate for Payer: Aetna of WY Medicare |
$123.29
|
| Rate for Payer: Altius Auto/Workers Compensation |
$179.33
|
| Rate for Payer: Altius Commercial |
$179.33
|
| Rate for Payer: Beech Street Commercial |
$183.06
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$153.36
|
| Rate for Payer: Cash Price |
$130.76
|
| Rate for Payer: ChoiceCare Network Commercial |
$181.20
|
| Rate for Payer: Cigna of WY Commercial |
$183.06
|
| Rate for Payer: Entrust Commercial |
$177.46
|
| Rate for Payer: First Choice Health Commercial |
$177.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$177.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$108.34
|
| Rate for Payer: HealthUtah PPO |
$186.80
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$181.20
|
| Rate for Payer: Multiplan Medicare/VA |
$102.93
|
| Rate for Payer: One Health Plan of WY PPO |
$183.06
|
| Rate for Payer: PacificSource Commercial |
$168.12
|
| Rate for Payer: PHCS PPO |
$183.06
|
| Rate for Payer: Three Rivers PPO |
$140.10
|
| Rate for Payer: TriWest Veterans Administration |
$108.34
|
| Rate for Payer: United Healthcare Commercial |
$162.52
|
| Rate for Payer: United Healthcare Medicare |
$108.34
|
| Rate for Payer: WINHealth Partners Commercial |
$183.06
|
| Rate for Payer: Wise Provider Network Commercial |
$177.46
|
|
|
FERROUS SULFATE 325 MG (65 MG IRON) TABLET [12393]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 0904759160
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.10
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.10
|
| Rate for Payer: Altius Commercial |
$0.10
|
| Rate for Payer: Beech Street Commercial |
$0.10
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.08
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.10
|
| Rate for Payer: Cigna of WY Commercial |
$0.10
|
| Rate for Payer: Entrust Commercial |
$0.10
|
| Rate for Payer: First Choice Health Commercial |
$0.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.07
|
| Rate for Payer: HealthUtah PPO |
$0.10
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.10
|
| Rate for Payer: Multiplan Medicare/VA |
$0.06
|
| Rate for Payer: One Health Plan of WY PPO |
$0.10
|
| Rate for Payer: PacificSource Commercial |
$0.09
|
| Rate for Payer: PHCS PPO |
$0.10
|
| Rate for Payer: Three Rivers PPO |
$0.08
|
| Rate for Payer: TriWest Veterans Administration |
$0.07
|
| Rate for Payer: United Healthcare Commercial |
$0.09
|
| Rate for Payer: United Healthcare Medicare |
$0.07
|
| Rate for Payer: WINHealth Partners Commercial |
$0.10
|
| Rate for Payer: Wise Provider Network Commercial |
$0.10
|
|
|
FERROUS SULFATE 325 MG (65 MG IRON) TABLET [12393]
|
Facility
|
IP
|
$0.12
|
|
|
Service Code
|
NDC 0904759161
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.12
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.12
|
| Rate for Payer: Altius Commercial |
$0.12
|
| Rate for Payer: Beech Street Commercial |
$0.12
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.10
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.12
|
| Rate for Payer: Cigna of WY Commercial |
$0.12
|
| Rate for Payer: Entrust Commercial |
$0.11
|
| Rate for Payer: First Choice Health Commercial |
$0.11
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.11
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.08
|
| Rate for Payer: HealthUtah PPO |
$0.12
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.12
|
| Rate for Payer: Multiplan Medicare/VA |
$0.08
|
| Rate for Payer: One Health Plan of WY PPO |
$0.12
|
| Rate for Payer: PacificSource Commercial |
$0.11
|
| Rate for Payer: PHCS PPO |
$0.12
|
| Rate for Payer: Three Rivers PPO |
$0.09
|
| Rate for Payer: TriWest Veterans Administration |
$0.08
|
| Rate for Payer: United Healthcare Commercial |
$0.10
|
| Rate for Payer: United Healthcare Medicare |
$0.08
|
| Rate for Payer: WINHealth Partners Commercial |
$0.11
|
| Rate for Payer: Wise Provider Network Commercial |
$0.11
|
|
|
FERROUS SULFATE 325 MG (65 MG IRON) TABLET [12393]
|
Facility
|
OP
|
$0.12
|
|
|
Service Code
|
NDC 0904759161
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.12
|
| Rate for Payer: Aetna of WY Medicare |
$0.08
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.12
|
| Rate for Payer: Altius Commercial |
$0.12
|
| Rate for Payer: Beech Street Commercial |
$0.12
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.10
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.12
|
| Rate for Payer: Cigna of WY Commercial |
$0.12
|
| Rate for Payer: Entrust Commercial |
$0.11
|
| Rate for Payer: First Choice Health Commercial |
$0.11
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.11
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.07
|
| Rate for Payer: HealthUtah PPO |
$0.12
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.12
|
| Rate for Payer: Multiplan Medicare/VA |
$0.07
|
| Rate for Payer: One Health Plan of WY PPO |
$0.12
|
| Rate for Payer: PacificSource Commercial |
$0.11
|
| Rate for Payer: PHCS PPO |
$0.12
|
| Rate for Payer: Three Rivers PPO |
$0.09
|
| Rate for Payer: TriWest Veterans Administration |
$0.07
|
| Rate for Payer: United Healthcare Commercial |
$0.10
|
| Rate for Payer: United Healthcare Medicare |
$0.07
|
| Rate for Payer: WINHealth Partners Commercial |
$0.12
|
| Rate for Payer: Wise Provider Network Commercial |
$0.11
|
|
|
FERROUS SULFATE 325 MG (65 MG IRON) TABLET [12393]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 0904759160
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.10
|
| Rate for Payer: Aetna of WY Medicare |
$0.07
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.10
|
| Rate for Payer: Altius Commercial |
$0.10
|
| Rate for Payer: Beech Street Commercial |
$0.10
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.08
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.10
|
| Rate for Payer: Cigna of WY Commercial |
$0.10
|
| Rate for Payer: Entrust Commercial |
$0.10
|
| Rate for Payer: First Choice Health Commercial |
$0.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.06
|
| Rate for Payer: HealthUtah PPO |
$0.10
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.10
|
| Rate for Payer: Multiplan Medicare/VA |
$0.06
|
| Rate for Payer: One Health Plan of WY PPO |
$0.10
|
| Rate for Payer: PacificSource Commercial |
$0.09
|
| Rate for Payer: PHCS PPO |
$0.10
|
| Rate for Payer: Three Rivers PPO |
$0.08
|
| Rate for Payer: TriWest Veterans Administration |
$0.06
|
| Rate for Payer: United Healthcare Commercial |
$0.09
|
| Rate for Payer: United Healthcare Medicare |
$0.06
|
| Rate for Payer: WINHealth Partners Commercial |
$0.10
|
| Rate for Payer: Wise Provider Network Commercial |
$0.10
|
|
|
FERROUS SULFATE 325 MG (65 MG IRON) TABLET,DELAYED RELEASE [17937]
|
Facility
|
IP
|
$0.64
|
|
|
Service Code
|
NDC 0245010811
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$0.64 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.63
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.61
|
| 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 |
$0.53
|
| 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 |
$0.42
|
| Rate for Payer: HealthUtah PPO |
$0.64
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.62
|
| Rate for Payer: Multiplan Medicare/VA |
$0.40
|
| 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 |
$0.42
|
| Rate for Payer: United Healthcare Commercial |
$0.56
|
| Rate for Payer: United Healthcare Medicare |
$0.42
|
| Rate for Payer: WINHealth Partners Commercial |
$0.61
|
| Rate for Payer: Wise Provider Network Commercial |
$0.61
|
|
|
FERROUS SULFATE 325 MG (65 MG IRON) TABLET,DELAYED RELEASE [17937]
|
Facility
|
OP
|
$0.64
|
|
|
Service Code
|
NDC 0245010811
|
|
Hospital Revenue Code
|
250
|
| 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 Auto/Workers Compensation |
$0.61
|
| 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 |
$0.53
|
| 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 |
$0.37
|
| 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 |
$0.37
|
| Rate for Payer: United Healthcare Commercial |
$0.56
|
| Rate for Payer: United Healthcare Medicare |
$0.37
|
| Rate for Payer: WINHealth Partners Commercial |
$0.63
|
| Rate for Payer: Wise Provider Network Commercial |
$0.61
|
|
|
FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION [87295]
|
Facility
|
OP
|
$137.87
|
|
|
Service Code
|
HCPCS Q0138
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$75.97 |
| Max. Negotiated Rate |
$137.87 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$135.11
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$99.87
|
| Rate for Payer: Aetna of WY Medicare |
$90.99
|
| Rate for Payer: Aetna of WY Medicare |
$67.26
|
| Rate for Payer: Altius Auto/Workers Compensation |
$97.83
|
| Rate for Payer: Altius Auto/Workers Compensation |
$132.36
|
| Rate for Payer: Altius Commercial |
$132.36
|
| Rate for Payer: Altius Commercial |
$97.83
|
| Rate for Payer: Beech Street Commercial |
$99.87
|
| Rate for Payer: Beech Street Commercial |
$135.11
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$113.19
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$83.67
|
| Rate for Payer: Cash Price |
$71.34
|
| Rate for Payer: Cash Price |
$96.51
|
| Rate for Payer: ChoiceCare Network Commercial |
$133.73
|
| Rate for Payer: ChoiceCare Network Commercial |
$98.85
|
| Rate for Payer: Cigna of WY Commercial |
$99.87
|
| Rate for Payer: Cigna of WY Commercial |
$135.11
|
| Rate for Payer: Entrust Commercial |
$130.98
|
| Rate for Payer: Entrust Commercial |
$96.81
|
| Rate for Payer: First Choice Health Commercial |
$96.81
|
| Rate for Payer: First Choice Health Commercial |
$130.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$96.81
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$130.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$79.96
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$59.11
|
| Rate for Payer: HealthUtah PPO |
$101.91
|
| Rate for Payer: HealthUtah PPO |
$137.87
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$98.85
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$133.73
|
| Rate for Payer: Multiplan Medicare/VA |
$75.97
|
| Rate for Payer: Multiplan Medicare/VA |
$56.15
|
| Rate for Payer: One Health Plan of WY PPO |
$99.87
|
| Rate for Payer: One Health Plan of WY PPO |
$135.11
|
| Rate for Payer: PacificSource Commercial |
$124.08
|
| Rate for Payer: PacificSource Commercial |
$91.72
|
| Rate for Payer: PHCS PPO |
$99.87
|
| Rate for Payer: PHCS PPO |
$135.11
|
| Rate for Payer: Three Rivers PPO |
$76.43
|
| Rate for Payer: Three Rivers PPO |
$103.40
|
| Rate for Payer: TriWest Veterans Administration |
$79.96
|
| Rate for Payer: TriWest Veterans Administration |
$59.11
|
| Rate for Payer: United Healthcare Commercial |
$88.66
|
| Rate for Payer: United Healthcare Commercial |
$119.95
|
| Rate for Payer: United Healthcare Medicare |
$79.96
|
| Rate for Payer: United Healthcare Medicare |
$59.11
|
| Rate for Payer: WINHealth Partners Commercial |
$99.87
|
| Rate for Payer: WINHealth Partners Commercial |
$135.11
|
| Rate for Payer: Wise Provider Network Commercial |
$96.81
|
| Rate for Payer: Wise Provider Network Commercial |
$130.98
|
|
|
FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION [87295]
|
Facility
|
IP
|
$137.87
|
|
|
Service Code
|
HCPCS Q0138
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$86.44 |
| Max. Negotiated Rate |
$137.87 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$135.11
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$99.87
|
| Rate for Payer: Altius Auto/Workers Compensation |
$132.36
|
| Rate for Payer: Altius Auto/Workers Compensation |
$97.83
|
| Rate for Payer: Altius Commercial |
$97.83
|
| Rate for Payer: Altius Commercial |
$132.36
|
| Rate for Payer: Beech Street Commercial |
$135.11
|
| Rate for Payer: Beech Street Commercial |
$99.87
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$83.67
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$113.19
|
| Rate for Payer: Cash Price |
$96.51
|
| Rate for Payer: Cash Price |
$71.34
|
| Rate for Payer: ChoiceCare Network Commercial |
$98.85
|
| Rate for Payer: ChoiceCare Network Commercial |
$133.73
|
| Rate for Payer: Cigna of WY Commercial |
$135.11
|
| Rate for Payer: Cigna of WY Commercial |
$99.87
|
| Rate for Payer: Entrust Commercial |
$96.81
|
| Rate for Payer: Entrust Commercial |
$130.98
|
| Rate for Payer: First Choice Health Commercial |
$96.81
|
| Rate for Payer: First Choice Health Commercial |
$130.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$96.81
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$130.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$90.99
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$67.26
|
| Rate for Payer: HealthUtah PPO |
$137.87
|
| Rate for Payer: HealthUtah PPO |
$101.91
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$98.85
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$133.73
|
| Rate for Payer: Multiplan Medicare/VA |
$86.44
|
| Rate for Payer: Multiplan Medicare/VA |
$63.90
|
| Rate for Payer: One Health Plan of WY PPO |
$135.11
|
| Rate for Payer: One Health Plan of WY PPO |
$99.87
|
| Rate for Payer: PacificSource Commercial |
$124.08
|
| Rate for Payer: PacificSource Commercial |
$91.72
|
| Rate for Payer: PHCS PPO |
$99.87
|
| Rate for Payer: PHCS PPO |
$135.11
|
| Rate for Payer: Three Rivers PPO |
$76.43
|
| Rate for Payer: Three Rivers PPO |
$103.40
|
| Rate for Payer: TriWest Veterans Administration |
$90.99
|
| Rate for Payer: TriWest Veterans Administration |
$67.26
|
| Rate for Payer: United Healthcare Commercial |
$88.66
|
| Rate for Payer: United Healthcare Commercial |
$119.95
|
| Rate for Payer: United Healthcare Medicare |
$90.99
|
| Rate for Payer: United Healthcare Medicare |
$67.26
|
| Rate for Payer: WINHealth Partners Commercial |
$96.81
|
| Rate for Payer: WINHealth Partners Commercial |
$130.98
|
| Rate for Payer: Wise Provider Network Commercial |
$96.81
|
| Rate for Payer: Wise Provider Network Commercial |
$130.98
|
|
|
FETAL BIOPHYSICAL PROFILE NON-STRESS TESTING
|
Professional
|
Both
|
$777.00
|
|
|
Service Code
|
HCPCS 76818
|
| Hospital Charge Code |
76818
|
| Min. Negotiated Rate |
$98.72 |
| Max. Negotiated Rate |
$777.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$761.46
|
| Rate for Payer: Aetna of WY Medicare |
$116.14
|
| Rate for Payer: Beech Street Commercial |
$738.15
|
| Rate for Payer: Cash Price |
$543.90
|
| Rate for Payer: Cash Price |
$543.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$753.69
|
| Rate for Payer: Cigna of WY Commercial |
$761.46
|
| Rate for Payer: First Choice Health Commercial |
$699.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$738.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$116.14
|
| Rate for Payer: HealthUtah PPO |
$777.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$753.69
|
| Rate for Payer: Multiplan Medicare/VA |
$98.72
|
| Rate for Payer: One Health Plan of WY PPO |
$761.46
|
| Rate for Payer: PacificSource Commercial |
$699.30
|
| Rate for Payer: PHCS PPO |
$738.15
|
| Rate for Payer: Three Rivers PPO |
$582.75
|
| Rate for Payer: TriWest Veterans Administration |
$116.14
|
| Rate for Payer: United Healthcare Commercial |
$675.99
|
| Rate for Payer: United Healthcare Medicare |
$116.14
|
| Rate for Payer: WINHealth Partners Commercial |
$738.15
|
|
|
FETAL CONTRACTION STRESS TEST
|
Professional
|
Both
|
$209.00
|
|
|
Service Code
|
HCPCS 59020
|
| Hospital Charge Code |
59020
|
| Min. Negotiated Rate |
$58.46 |
| Max. Negotiated Rate |
$209.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$204.82
|
| Rate for Payer: Aetna of WY Medicare |
$68.78
|
| Rate for Payer: Beech Street Commercial |
$198.55
|
| Rate for Payer: Cash Price |
$146.30
|
| Rate for Payer: Cash Price |
$146.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$202.73
|
| Rate for Payer: Cigna of WY Commercial |
$204.82
|
| Rate for Payer: First Choice Health Commercial |
$188.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$198.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$68.78
|
| Rate for Payer: HealthUtah PPO |
$209.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$202.73
|
| Rate for Payer: Multiplan Medicare/VA |
$58.46
|
| Rate for Payer: One Health Plan of WY PPO |
$204.82
|
| Rate for Payer: PacificSource Commercial |
$188.10
|
| Rate for Payer: PHCS PPO |
$198.55
|
| Rate for Payer: Three Rivers PPO |
$156.75
|
| Rate for Payer: TriWest Veterans Administration |
$68.78
|
| Rate for Payer: United Healthcare Commercial |
$181.83
|
| Rate for Payer: United Healthcare Medicare |
$68.78
|
| Rate for Payer: WINHealth Partners Commercial |
$177.65
|
|
|
FETAL NONSTRESS TEST
|
Professional
|
Both
|
$143.00
|
|
|
Service Code
|
HCPCS 59025
|
| Hospital Charge Code |
59025
|
| Min. Negotiated Rate |
$40.17 |
| Max. Negotiated Rate |
$143.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$140.14
|
| Rate for Payer: Aetna of WY Medicare |
$47.26
|
| Rate for Payer: Beech Street Commercial |
$135.85
|
| Rate for Payer: Cash Price |
$100.10
|
| Rate for Payer: Cash Price |
$100.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$138.71
|
| Rate for Payer: Cigna of WY Commercial |
$140.14
|
| Rate for Payer: First Choice Health Commercial |
$128.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$135.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$47.26
|
| Rate for Payer: HealthUtah PPO |
$143.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$138.71
|
| Rate for Payer: Multiplan Medicare/VA |
$40.17
|
| Rate for Payer: One Health Plan of WY PPO |
$140.14
|
| Rate for Payer: PacificSource Commercial |
$128.70
|
| Rate for Payer: PHCS PPO |
$135.85
|
| Rate for Payer: Three Rivers PPO |
$107.25
|
| Rate for Payer: TriWest Veterans Administration |
$47.26
|
| Rate for Payer: United Healthcare Commercial |
$124.41
|
| Rate for Payer: United Healthcare Medicare |
$47.26
|
| Rate for Payer: WINHealth Partners Commercial |
$121.55
|
|
|
FIBERSTITCH 1.5 12° CURVED IMPLANT
|
Facility
|
OP
|
$1,925.00
|
|
| Hospital Charge Code |
27800000S1
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,060.68 |
| Max. Negotiated Rate |
$1,925.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,886.50
|
| Rate for Payer: Aetna of WY Medicare |
$1,270.50
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,848.00
|
| Rate for Payer: Altius Commercial |
$1,848.00
|
| Rate for Payer: Beech Street Commercial |
$1,886.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,580.42
|
| Rate for Payer: Cash Price |
$1,347.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,867.25
|
| Rate for Payer: Cigna of WY Commercial |
$1,886.50
|
| Rate for Payer: Entrust Commercial |
$1,828.75
|
| Rate for Payer: First Choice Health Commercial |
$1,828.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,828.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,116.50
|
| Rate for Payer: HealthUtah PPO |
$1,925.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,867.25
|
| Rate for Payer: Multiplan Medicare/VA |
$1,060.68
|
| Rate for Payer: One Health Plan of WY PPO |
$1,886.50
|
| Rate for Payer: PacificSource Commercial |
$1,732.50
|
| Rate for Payer: PHCS PPO |
$1,886.50
|
| Rate for Payer: Three Rivers PPO |
$1,443.75
|
| Rate for Payer: TriWest Veterans Administration |
$1,116.50
|
| Rate for Payer: United Healthcare Commercial |
$1,674.75
|
| Rate for Payer: United Healthcare Medicare |
$1,116.50
|
| Rate for Payer: WINHealth Partners Commercial |
$1,886.50
|
| Rate for Payer: Wise Provider Network Commercial |
$1,828.75
|
|
|
FIBERSTITCH 1.5 12° CURVED IMPLANT
|
Facility
|
IP
|
$1,925.00
|
|
| Hospital Charge Code |
27800000S1
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,206.98 |
| Max. Negotiated Rate |
$1,925.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,886.50
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,848.00
|
| Rate for Payer: Altius Commercial |
$1,848.00
|
| Rate for Payer: Beech Street Commercial |
$1,886.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,580.42
|
| Rate for Payer: Cash Price |
$1,347.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,867.25
|
| Rate for Payer: Cigna of WY Commercial |
$1,886.50
|
| Rate for Payer: Entrust Commercial |
$1,828.75
|
| Rate for Payer: First Choice Health Commercial |
$1,828.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,828.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,270.50
|
| Rate for Payer: HealthUtah PPO |
$1,925.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,867.25
|
| Rate for Payer: Multiplan Medicare/VA |
$1,206.98
|
| Rate for Payer: One Health Plan of WY PPO |
$1,886.50
|
| Rate for Payer: PacificSource Commercial |
$1,732.50
|
| Rate for Payer: PHCS PPO |
$1,886.50
|
| Rate for Payer: Three Rivers PPO |
$1,443.75
|
| Rate for Payer: TriWest Veterans Administration |
$1,270.50
|
| Rate for Payer: United Healthcare Commercial |
$1,674.75
|
| Rate for Payer: United Healthcare Medicare |
$1,270.50
|
| Rate for Payer: WINHealth Partners Commercial |
$1,828.75
|
| Rate for Payer: Wise Provider Network Commercial |
$1,828.75
|
|
|
FIBERSTITCH 1.5 24° CURVED IMPLANT
|
Facility
|
OP
|
$1,925.00
|
|
| Hospital Charge Code |
27800000S1
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,060.68 |
| Max. Negotiated Rate |
$1,925.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,886.50
|
| Rate for Payer: Aetna of WY Medicare |
$1,270.50
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,848.00
|
| Rate for Payer: Altius Commercial |
$1,848.00
|
| Rate for Payer: Beech Street Commercial |
$1,886.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,580.42
|
| Rate for Payer: Cash Price |
$1,347.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,867.25
|
| Rate for Payer: Cigna of WY Commercial |
$1,886.50
|
| Rate for Payer: Entrust Commercial |
$1,828.75
|
| Rate for Payer: First Choice Health Commercial |
$1,828.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,828.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,116.50
|
| Rate for Payer: HealthUtah PPO |
$1,925.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,867.25
|
| Rate for Payer: Multiplan Medicare/VA |
$1,060.68
|
| Rate for Payer: One Health Plan of WY PPO |
$1,886.50
|
| Rate for Payer: PacificSource Commercial |
$1,732.50
|
| Rate for Payer: PHCS PPO |
$1,886.50
|
| Rate for Payer: Three Rivers PPO |
$1,443.75
|
| Rate for Payer: TriWest Veterans Administration |
$1,116.50
|
| Rate for Payer: United Healthcare Commercial |
$1,674.75
|
| Rate for Payer: United Healthcare Medicare |
$1,116.50
|
| Rate for Payer: WINHealth Partners Commercial |
$1,886.50
|
| Rate for Payer: Wise Provider Network Commercial |
$1,828.75
|
|
|
FIBERSTITCH 1.5 24° CURVED IMPLANT
|
Facility
|
IP
|
$1,925.00
|
|
| Hospital Charge Code |
27800000S1
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,206.98 |
| Max. Negotiated Rate |
$1,925.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,886.50
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,848.00
|
| Rate for Payer: Altius Commercial |
$1,848.00
|
| Rate for Payer: Beech Street Commercial |
$1,886.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,580.42
|
| Rate for Payer: Cash Price |
$1,347.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,867.25
|
| Rate for Payer: Cigna of WY Commercial |
$1,886.50
|
| Rate for Payer: Entrust Commercial |
$1,828.75
|
| Rate for Payer: First Choice Health Commercial |
$1,828.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,828.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,270.50
|
| Rate for Payer: HealthUtah PPO |
$1,925.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,867.25
|
| Rate for Payer: Multiplan Medicare/VA |
$1,206.98
|
| Rate for Payer: One Health Plan of WY PPO |
$1,886.50
|
| Rate for Payer: PacificSource Commercial |
$1,732.50
|
| Rate for Payer: PHCS PPO |
$1,886.50
|
| Rate for Payer: Three Rivers PPO |
$1,443.75
|
| Rate for Payer: TriWest Veterans Administration |
$1,270.50
|
| Rate for Payer: United Healthcare Commercial |
$1,674.75
|
| Rate for Payer: United Healthcare Medicare |
$1,270.50
|
| Rate for Payer: WINHealth Partners Commercial |
$1,828.75
|
| Rate for Payer: Wise Provider Network Commercial |
$1,828.75
|
|
|
FIBERSTITCH 1.5 REVERSE CURVED IMPLANT
|
Facility
|
OP
|
$1,925.00
|
|
| Hospital Charge Code |
27800000S1
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,060.68 |
| Max. Negotiated Rate |
$1,925.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,886.50
|
| Rate for Payer: Aetna of WY Medicare |
$1,270.50
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,848.00
|
| Rate for Payer: Altius Commercial |
$1,848.00
|
| Rate for Payer: Beech Street Commercial |
$1,886.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,580.42
|
| Rate for Payer: Cash Price |
$1,347.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,867.25
|
| Rate for Payer: Cigna of WY Commercial |
$1,886.50
|
| Rate for Payer: Entrust Commercial |
$1,828.75
|
| Rate for Payer: First Choice Health Commercial |
$1,828.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,828.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,116.50
|
| Rate for Payer: HealthUtah PPO |
$1,925.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,867.25
|
| Rate for Payer: Multiplan Medicare/VA |
$1,060.68
|
| Rate for Payer: One Health Plan of WY PPO |
$1,886.50
|
| Rate for Payer: PacificSource Commercial |
$1,732.50
|
| Rate for Payer: PHCS PPO |
$1,886.50
|
| Rate for Payer: Three Rivers PPO |
$1,443.75
|
| Rate for Payer: TriWest Veterans Administration |
$1,116.50
|
| Rate for Payer: United Healthcare Commercial |
$1,674.75
|
| Rate for Payer: United Healthcare Medicare |
$1,116.50
|
| Rate for Payer: WINHealth Partners Commercial |
$1,886.50
|
| Rate for Payer: Wise Provider Network Commercial |
$1,828.75
|
|
|
FIBERSTITCH 1.5 REVERSE CURVED IMPLANT
|
Facility
|
IP
|
$1,925.00
|
|
| Hospital Charge Code |
27800000S1
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,206.98 |
| Max. Negotiated Rate |
$1,925.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,886.50
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,848.00
|
| Rate for Payer: Altius Commercial |
$1,848.00
|
| Rate for Payer: Beech Street Commercial |
$1,886.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,580.42
|
| Rate for Payer: Cash Price |
$1,347.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,867.25
|
| Rate for Payer: Cigna of WY Commercial |
$1,886.50
|
| Rate for Payer: Entrust Commercial |
$1,828.75
|
| Rate for Payer: First Choice Health Commercial |
$1,828.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,828.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,270.50
|
| Rate for Payer: HealthUtah PPO |
$1,925.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,867.25
|
| Rate for Payer: Multiplan Medicare/VA |
$1,206.98
|
| Rate for Payer: One Health Plan of WY PPO |
$1,886.50
|
| Rate for Payer: PacificSource Commercial |
$1,732.50
|
| Rate for Payer: PHCS PPO |
$1,886.50
|
| Rate for Payer: Three Rivers PPO |
$1,443.75
|
| Rate for Payer: TriWest Veterans Administration |
$1,270.50
|
| Rate for Payer: United Healthcare Commercial |
$1,674.75
|
| Rate for Payer: United Healthcare Medicare |
$1,270.50
|
| Rate for Payer: WINHealth Partners Commercial |
$1,828.75
|
| Rate for Payer: Wise Provider Network Commercial |
$1,828.75
|
|
|
FIBERTAPE CERCLAGE TENSIONER
|
Facility
|
OP
|
$1,124.41
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$619.55 |
| Max. Negotiated Rate |
$1,124.41 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,101.92
|
| Rate for Payer: Aetna of WY Medicare |
$742.11
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,079.43
|
| Rate for Payer: Altius Commercial |
$1,079.43
|
| Rate for Payer: Beech Street Commercial |
$1,101.92
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$923.14
|
| Rate for Payer: Cash Price |
$787.09
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,090.68
|
| Rate for Payer: Cigna of WY Commercial |
$1,101.92
|
| Rate for Payer: Entrust Commercial |
$1,068.19
|
| Rate for Payer: First Choice Health Commercial |
$1,068.19
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,068.19
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$652.16
|
| Rate for Payer: HealthUtah PPO |
$1,124.41
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,090.68
|
| Rate for Payer: Multiplan Medicare/VA |
$619.55
|
| Rate for Payer: One Health Plan of WY PPO |
$1,101.92
|
| Rate for Payer: PacificSource Commercial |
$1,011.97
|
| Rate for Payer: PHCS PPO |
$1,101.92
|
| Rate for Payer: Three Rivers PPO |
$843.31
|
| Rate for Payer: TriWest Veterans Administration |
$652.16
|
| Rate for Payer: United Healthcare Commercial |
$978.24
|
| Rate for Payer: United Healthcare Medicare |
$652.16
|
| Rate for Payer: WINHealth Partners Commercial |
$1,101.92
|
| Rate for Payer: Wise Provider Network Commercial |
$1,068.19
|
|
|
FIBERTAPE CERCLAGE TENSIONER
|
Facility
|
IP
|
$1,124.41
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$705.01 |
| Max. Negotiated Rate |
$1,124.41 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,101.92
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,079.43
|
| Rate for Payer: Altius Commercial |
$1,079.43
|
| Rate for Payer: Beech Street Commercial |
$1,101.92
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$923.14
|
| Rate for Payer: Cash Price |
$787.09
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,090.68
|
| Rate for Payer: Cigna of WY Commercial |
$1,101.92
|
| Rate for Payer: Entrust Commercial |
$1,068.19
|
| Rate for Payer: First Choice Health Commercial |
$1,068.19
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,068.19
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$742.11
|
| Rate for Payer: HealthUtah PPO |
$1,124.41
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,090.68
|
| Rate for Payer: Multiplan Medicare/VA |
$705.01
|
| Rate for Payer: One Health Plan of WY PPO |
$1,101.92
|
| Rate for Payer: PacificSource Commercial |
$1,011.97
|
| Rate for Payer: PHCS PPO |
$1,101.92
|
| Rate for Payer: Three Rivers PPO |
$843.31
|
| Rate for Payer: TriWest Veterans Administration |
$742.11
|
| Rate for Payer: United Healthcare Commercial |
$978.24
|
| Rate for Payer: United Healthcare Medicare |
$742.11
|
| Rate for Payer: WINHealth Partners Commercial |
$1,068.19
|
| Rate for Payer: Wise Provider Network Commercial |
$1,068.19
|
|
|
FIBULA SHAFT GRAFT
|
Facility
|
OP
|
$4,235.00
|
|
| Hospital Charge Code |
27800000S1
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,333.48 |
| Max. Negotiated Rate |
$4,235.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4,150.30
|
| Rate for Payer: Aetna of WY Medicare |
$2,795.10
|
| Rate for Payer: Altius Auto/Workers Compensation |
$4,065.60
|
| Rate for Payer: Altius Commercial |
$4,065.60
|
| Rate for Payer: Beech Street Commercial |
$4,150.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3,476.94
|
| Rate for Payer: Cash Price |
$2,964.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$4,107.95
|
| Rate for Payer: Cigna of WY Commercial |
$4,150.30
|
| Rate for Payer: Entrust Commercial |
$4,023.25
|
| Rate for Payer: First Choice Health Commercial |
$4,023.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,023.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2,456.30
|
| Rate for Payer: HealthUtah PPO |
$4,235.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4,107.95
|
| Rate for Payer: Multiplan Medicare/VA |
$2,333.48
|
| Rate for Payer: One Health Plan of WY PPO |
$4,150.30
|
| Rate for Payer: PacificSource Commercial |
$3,811.50
|
| Rate for Payer: PHCS PPO |
$4,150.30
|
| Rate for Payer: Three Rivers PPO |
$3,176.25
|
| Rate for Payer: TriWest Veterans Administration |
$2,456.30
|
| Rate for Payer: United Healthcare Commercial |
$3,684.45
|
| Rate for Payer: United Healthcare Medicare |
$2,456.30
|
| Rate for Payer: WINHealth Partners Commercial |
$4,150.30
|
| Rate for Payer: Wise Provider Network Commercial |
$4,023.25
|
|
|
FIBULA SHAFT GRAFT
|
Facility
|
IP
|
$4,235.00
|
|
| Hospital Charge Code |
27800000S1
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,655.34 |
| Max. Negotiated Rate |
$4,235.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4,150.30
|
| Rate for Payer: Altius Auto/Workers Compensation |
$4,065.60
|
| Rate for Payer: Altius Commercial |
$4,065.60
|
| Rate for Payer: Beech Street Commercial |
$4,150.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3,476.94
|
| Rate for Payer: Cash Price |
$2,964.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$4,107.95
|
| Rate for Payer: Cigna of WY Commercial |
$4,150.30
|
| Rate for Payer: Entrust Commercial |
$4,023.25
|
| Rate for Payer: First Choice Health Commercial |
$4,023.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,023.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2,795.10
|
| Rate for Payer: HealthUtah PPO |
$4,235.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4,107.95
|
| Rate for Payer: Multiplan Medicare/VA |
$2,655.34
|
| Rate for Payer: One Health Plan of WY PPO |
$4,150.30
|
| Rate for Payer: PacificSource Commercial |
$3,811.50
|
| Rate for Payer: PHCS PPO |
$4,150.30
|
| Rate for Payer: Three Rivers PPO |
$3,176.25
|
| Rate for Payer: TriWest Veterans Administration |
$2,795.10
|
| Rate for Payer: United Healthcare Commercial |
$3,684.45
|
| Rate for Payer: United Healthcare Medicare |
$2,795.10
|
| Rate for Payer: WINHealth Partners Commercial |
$4,023.25
|
| Rate for Payer: Wise Provider Network Commercial |
$4,023.25
|
|
|
FIDAXOMICIN 200 MG TABLET [92589]
|
Facility
|
OP
|
$325.31
|
|
|
Service Code
|
NDC 5201508001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$179.25 |
| Max. Negotiated Rate |
$325.31 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$318.80
|
| Rate for Payer: Aetna of WY Medicare |
$214.70
|
| Rate for Payer: Altius Auto/Workers Compensation |
$312.30
|
| Rate for Payer: Altius Commercial |
$312.30
|
| Rate for Payer: Beech Street Commercial |
$318.80
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$267.08
|
| Rate for Payer: Cash Price |
$227.72
|
| Rate for Payer: ChoiceCare Network Commercial |
$315.55
|
| Rate for Payer: Cigna of WY Commercial |
$318.80
|
| Rate for Payer: Entrust Commercial |
$309.04
|
| Rate for Payer: First Choice Health Commercial |
$309.04
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$309.04
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$188.68
|
| Rate for Payer: HealthUtah PPO |
$325.31
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$315.55
|
| Rate for Payer: Multiplan Medicare/VA |
$179.25
|
| Rate for Payer: One Health Plan of WY PPO |
$318.80
|
| Rate for Payer: PacificSource Commercial |
$292.78
|
| Rate for Payer: PHCS PPO |
$318.80
|
| Rate for Payer: Three Rivers PPO |
$243.98
|
| Rate for Payer: TriWest Veterans Administration |
$188.68
|
| Rate for Payer: United Healthcare Commercial |
$283.02
|
| Rate for Payer: United Healthcare Medicare |
$188.68
|
| Rate for Payer: WINHealth Partners Commercial |
$318.80
|
| Rate for Payer: Wise Provider Network Commercial |
$309.04
|
|
|
FIDAXOMICIN 200 MG TABLET [92589]
|
Facility
|
IP
|
$325.31
|
|
|
Service Code
|
NDC 5201508001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$203.97 |
| Max. Negotiated Rate |
$325.31 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$318.80
|
| Rate for Payer: Altius Auto/Workers Compensation |
$312.30
|
| Rate for Payer: Altius Commercial |
$312.30
|
| Rate for Payer: Beech Street Commercial |
$318.80
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$267.08
|
| Rate for Payer: Cash Price |
$227.72
|
| Rate for Payer: ChoiceCare Network Commercial |
$315.55
|
| Rate for Payer: Cigna of WY Commercial |
$318.80
|
| Rate for Payer: Entrust Commercial |
$309.04
|
| Rate for Payer: First Choice Health Commercial |
$309.04
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$309.04
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$214.70
|
| Rate for Payer: HealthUtah PPO |
$325.31
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$315.55
|
| Rate for Payer: Multiplan Medicare/VA |
$203.97
|
| Rate for Payer: One Health Plan of WY PPO |
$318.80
|
| Rate for Payer: PacificSource Commercial |
$292.78
|
| Rate for Payer: PHCS PPO |
$318.80
|
| Rate for Payer: Three Rivers PPO |
$243.98
|
| Rate for Payer: TriWest Veterans Administration |
$214.70
|
| Rate for Payer: United Healthcare Commercial |
$283.02
|
| Rate for Payer: United Healthcare Medicare |
$214.70
|
| Rate for Payer: WINHealth Partners Commercial |
$309.04
|
| Rate for Payer: Wise Provider Network Commercial |
$309.04
|
|
