|
DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM [8707]
|
Facility
|
IP
|
$15.31
|
|
|
Service Code
|
NDC 4580235803
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.87 |
| Max. Negotiated Rate |
$15.31 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.00
|
| Rate for Payer: Aetna of WY Medicare |
$9.80
|
| Rate for Payer: Altius Commercial |
$14.70
|
| Rate for Payer: Beech Street Commercial |
$15.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.85
|
| Rate for Payer: Cash Price |
$10.71
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.85
|
| Rate for Payer: Cigna of WY Commercial |
$15.00
|
| Rate for Payer: Entrust Commercial |
$14.54
|
| Rate for Payer: First Choice Health Commercial |
$14.54
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.54
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.34
|
| Rate for Payer: HealthUtah PPO |
$15.31
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.85
|
| Rate for Payer: Multiplan Medicare/VA |
$8.87
|
| Rate for Payer: One Health Plan of WY PPO |
$15.00
|
| Rate for Payer: PacificSource Commercial |
$13.78
|
| Rate for Payer: PHCS PPO |
$15.00
|
| Rate for Payer: Three Rivers PPO |
$11.48
|
| Rate for Payer: TriWest Veterans Administration |
$9.34
|
| Rate for Payer: United Healthcare Commercial |
$14.62
|
| Rate for Payer: United Healthcare Medicare |
$9.34
|
| Rate for Payer: WINHealth Partners Commercial |
$14.54
|
| Rate for Payer: Wise Provider Network Commercial |
$14.54
|
|
|
DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM [8707]
|
Facility
|
OP
|
$15.25
|
|
|
Service Code
|
NDC 0904535431
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.26 |
| Max. Negotiated Rate |
$15.25 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.94
|
| Rate for Payer: Aetna of WY Medicare |
$10.06
|
| Rate for Payer: Altius Commercial |
$14.64
|
| Rate for Payer: Beech Street Commercial |
$14.94
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.79
|
| Rate for Payer: Cash Price |
$10.68
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.79
|
| Rate for Payer: Cigna of WY Commercial |
$14.94
|
| Rate for Payer: Entrust Commercial |
$14.49
|
| Rate for Payer: First Choice Health Commercial |
$14.49
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.49
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.69
|
| Rate for Payer: HealthUtah PPO |
$15.25
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.79
|
| Rate for Payer: Multiplan Medicare/VA |
$8.26
|
| Rate for Payer: One Health Plan of WY PPO |
$14.94
|
| Rate for Payer: PacificSource Commercial |
$13.72
|
| Rate for Payer: PHCS PPO |
$14.94
|
| Rate for Payer: Three Rivers PPO |
$11.44
|
| Rate for Payer: TriWest Veterans Administration |
$8.69
|
| Rate for Payer: United Healthcare Commercial |
$14.56
|
| Rate for Payer: United Healthcare Medicare |
$8.69
|
| Rate for Payer: WINHealth Partners Commercial |
$14.94
|
| Rate for Payer: Wise Provider Network Commercial |
$14.49
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET [6299]
|
Facility
|
OP
|
$15.68
|
|
|
Service Code
|
NDC 6255949001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.49 |
| Max. Negotiated Rate |
$15.68 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.37
|
| Rate for Payer: Aetna of WY Medicare |
$10.35
|
| Rate for Payer: Altius Commercial |
$15.05
|
| Rate for Payer: Beech Street Commercial |
$15.37
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.21
|
| Rate for Payer: Cash Price |
$10.98
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.21
|
| Rate for Payer: Cigna of WY Commercial |
$15.37
|
| Rate for Payer: Entrust Commercial |
$14.90
|
| Rate for Payer: First Choice Health Commercial |
$14.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.94
|
| Rate for Payer: HealthUtah PPO |
$15.68
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.21
|
| Rate for Payer: Multiplan Medicare/VA |
$8.49
|
| Rate for Payer: One Health Plan of WY PPO |
$15.37
|
| Rate for Payer: PacificSource Commercial |
$14.11
|
| Rate for Payer: PHCS PPO |
$15.37
|
| Rate for Payer: Three Rivers PPO |
$11.76
|
| Rate for Payer: TriWest Veterans Administration |
$8.94
|
| Rate for Payer: United Healthcare Commercial |
$14.97
|
| Rate for Payer: United Healthcare Medicare |
$8.94
|
| Rate for Payer: WINHealth Partners Commercial |
$15.37
|
| Rate for Payer: Wise Provider Network Commercial |
$14.90
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET [6299]
|
Facility
|
IP
|
$15.68
|
|
|
Service Code
|
NDC 6255949001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.09 |
| Max. Negotiated Rate |
$15.68 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.37
|
| Rate for Payer: Aetna of WY Medicare |
$10.04
|
| Rate for Payer: Altius Commercial |
$15.05
|
| Rate for Payer: Beech Street Commercial |
$15.37
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.21
|
| Rate for Payer: Cash Price |
$10.98
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.21
|
| Rate for Payer: Cigna of WY Commercial |
$15.37
|
| Rate for Payer: Entrust Commercial |
$14.90
|
| Rate for Payer: First Choice Health Commercial |
$14.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.56
|
| Rate for Payer: HealthUtah PPO |
$15.68
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.21
|
| Rate for Payer: Multiplan Medicare/VA |
$9.09
|
| Rate for Payer: One Health Plan of WY PPO |
$15.37
|
| Rate for Payer: PacificSource Commercial |
$14.11
|
| Rate for Payer: PHCS PPO |
$15.37
|
| Rate for Payer: Three Rivers PPO |
$11.76
|
| Rate for Payer: TriWest Veterans Administration |
$9.56
|
| Rate for Payer: United Healthcare Commercial |
$14.97
|
| Rate for Payer: United Healthcare Medicare |
$9.56
|
| Rate for Payer: WINHealth Partners Commercial |
$14.90
|
| Rate for Payer: Wise Provider Network Commercial |
$14.90
|
|
|
DIPH,PERTUS(ACELL),TET,POLIO (PF) 25 LF-58 MCG-10 LF/0.5 ML IM SYRINGE [53510]
|
Facility
|
IP
|
$189.24
|
|
|
Service Code
|
NDC 5816081252
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$109.66 |
| Max. Negotiated Rate |
$189.24 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$185.46
|
| Rate for Payer: Aetna of WY Medicare |
$121.11
|
| Rate for Payer: Altius Commercial |
$181.67
|
| Rate for Payer: Beech Street Commercial |
$185.46
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$183.56
|
| Rate for Payer: Cash Price |
$132.47
|
| Rate for Payer: ChoiceCare Network Commercial |
$183.56
|
| Rate for Payer: Cigna of WY Commercial |
$185.46
|
| Rate for Payer: Entrust Commercial |
$179.78
|
| Rate for Payer: First Choice Health Commercial |
$179.78
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$179.78
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$115.44
|
| Rate for Payer: HealthUtah PPO |
$189.24
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$183.56
|
| Rate for Payer: Multiplan Medicare/VA |
$109.66
|
| Rate for Payer: One Health Plan of WY PPO |
$185.46
|
| Rate for Payer: PacificSource Commercial |
$170.32
|
| Rate for Payer: PHCS PPO |
$185.46
|
| Rate for Payer: Three Rivers PPO |
$141.93
|
| Rate for Payer: TriWest Veterans Administration |
$115.44
|
| Rate for Payer: United Healthcare Commercial |
$180.72
|
| Rate for Payer: United Healthcare Medicare |
$115.44
|
| Rate for Payer: WINHealth Partners Commercial |
$179.78
|
| Rate for Payer: Wise Provider Network Commercial |
$179.78
|
|
|
DIPH,PERTUS(ACELL),TET,POLIO (PF) 25 LF-58 MCG-10 LF/0.5 ML IM SYRINGE [53510]
|
Facility
|
OP
|
$189.24
|
|
|
Service Code
|
NDC 5816081243
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$102.47 |
| Max. Negotiated Rate |
$189.24 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$185.46
|
| Rate for Payer: Aetna of WY Medicare |
$124.90
|
| Rate for Payer: Altius Commercial |
$181.67
|
| Rate for Payer: Beech Street Commercial |
$185.46
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$183.56
|
| Rate for Payer: Cash Price |
$132.47
|
| Rate for Payer: ChoiceCare Network Commercial |
$183.56
|
| Rate for Payer: Cigna of WY Commercial |
$185.46
|
| Rate for Payer: Entrust Commercial |
$179.78
|
| Rate for Payer: First Choice Health Commercial |
$179.78
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$179.78
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$107.87
|
| Rate for Payer: HealthUtah PPO |
$189.24
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$183.56
|
| Rate for Payer: Multiplan Medicare/VA |
$102.47
|
| Rate for Payer: One Health Plan of WY PPO |
$185.46
|
| Rate for Payer: PacificSource Commercial |
$170.32
|
| Rate for Payer: PHCS PPO |
$185.46
|
| Rate for Payer: Three Rivers PPO |
$141.93
|
| Rate for Payer: TriWest Veterans Administration |
$107.87
|
| Rate for Payer: United Healthcare Commercial |
$180.72
|
| Rate for Payer: United Healthcare Medicare |
$107.87
|
| Rate for Payer: WINHealth Partners Commercial |
$185.46
|
| Rate for Payer: Wise Provider Network Commercial |
$179.78
|
|
|
DIPH,PERTUS(ACELL),TET,POLIO (PF) 25 LF-58 MCG-10 LF/0.5 ML IM SYRINGE [53510]
|
Facility
|
OP
|
$189.24
|
|
|
Service Code
|
NDC 5816081252
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$102.47 |
| Max. Negotiated Rate |
$189.24 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$185.46
|
| Rate for Payer: Aetna of WY Medicare |
$124.90
|
| Rate for Payer: Altius Commercial |
$181.67
|
| Rate for Payer: Beech Street Commercial |
$185.46
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$183.56
|
| Rate for Payer: Cash Price |
$132.47
|
| Rate for Payer: ChoiceCare Network Commercial |
$183.56
|
| Rate for Payer: Cigna of WY Commercial |
$185.46
|
| Rate for Payer: Entrust Commercial |
$179.78
|
| Rate for Payer: First Choice Health Commercial |
$179.78
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$179.78
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$107.87
|
| Rate for Payer: HealthUtah PPO |
$189.24
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$183.56
|
| Rate for Payer: Multiplan Medicare/VA |
$102.47
|
| Rate for Payer: One Health Plan of WY PPO |
$185.46
|
| Rate for Payer: PacificSource Commercial |
$170.32
|
| Rate for Payer: PHCS PPO |
$185.46
|
| Rate for Payer: Three Rivers PPO |
$141.93
|
| Rate for Payer: TriWest Veterans Administration |
$107.87
|
| Rate for Payer: United Healthcare Commercial |
$180.72
|
| Rate for Payer: United Healthcare Medicare |
$107.87
|
| Rate for Payer: WINHealth Partners Commercial |
$185.46
|
| Rate for Payer: Wise Provider Network Commercial |
$179.78
|
|
|
DIPH,PERTUS(ACELL),TET,POLIO (PF) 25 LF-58 MCG-10 LF/0.5 ML IM SYRINGE [53510]
|
Facility
|
IP
|
$189.24
|
|
|
Service Code
|
NDC 5816081243
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$109.66 |
| Max. Negotiated Rate |
$189.24 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$185.46
|
| Rate for Payer: Aetna of WY Medicare |
$121.11
|
| Rate for Payer: Altius Commercial |
$181.67
|
| Rate for Payer: Beech Street Commercial |
$185.46
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$183.56
|
| Rate for Payer: Cash Price |
$132.47
|
| Rate for Payer: ChoiceCare Network Commercial |
$183.56
|
| Rate for Payer: Cigna of WY Commercial |
$185.46
|
| Rate for Payer: Entrust Commercial |
$179.78
|
| Rate for Payer: First Choice Health Commercial |
$179.78
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$179.78
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$115.44
|
| Rate for Payer: HealthUtah PPO |
$189.24
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$183.56
|
| Rate for Payer: Multiplan Medicare/VA |
$109.66
|
| Rate for Payer: One Health Plan of WY PPO |
$185.46
|
| Rate for Payer: PacificSource Commercial |
$170.32
|
| Rate for Payer: PHCS PPO |
$185.46
|
| Rate for Payer: Three Rivers PPO |
$141.93
|
| Rate for Payer: TriWest Veterans Administration |
$115.44
|
| Rate for Payer: United Healthcare Commercial |
$180.72
|
| Rate for Payer: United Healthcare Medicare |
$115.44
|
| Rate for Payer: WINHealth Partners Commercial |
$179.78
|
| Rate for Payer: Wise Provider Network Commercial |
$179.78
|
|
|
DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE [45972]
|
Facility
|
IP
|
$107.91
|
|
|
Service Code
|
NDC 5816081043
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$62.53 |
| Max. Negotiated Rate |
$107.91 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$105.75
|
| Rate for Payer: Aetna of WY Medicare |
$69.06
|
| Rate for Payer: Altius Commercial |
$103.59
|
| Rate for Payer: Beech Street Commercial |
$105.75
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$104.67
|
| Rate for Payer: Cash Price |
$75.54
|
| Rate for Payer: ChoiceCare Network Commercial |
$104.67
|
| Rate for Payer: Cigna of WY Commercial |
$105.75
|
| Rate for Payer: Entrust Commercial |
$102.51
|
| Rate for Payer: First Choice Health Commercial |
$102.51
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$102.51
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$65.83
|
| Rate for Payer: HealthUtah PPO |
$107.91
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$104.67
|
| Rate for Payer: Multiplan Medicare/VA |
$62.53
|
| Rate for Payer: One Health Plan of WY PPO |
$105.75
|
| Rate for Payer: PacificSource Commercial |
$97.12
|
| Rate for Payer: PHCS PPO |
$105.75
|
| Rate for Payer: Three Rivers PPO |
$80.93
|
| Rate for Payer: TriWest Veterans Administration |
$65.83
|
| Rate for Payer: United Healthcare Commercial |
$103.05
|
| Rate for Payer: United Healthcare Medicare |
$65.83
|
| Rate for Payer: WINHealth Partners Commercial |
$102.51
|
| Rate for Payer: Wise Provider Network Commercial |
$102.51
|
|
|
DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE [45972]
|
Facility
|
OP
|
$107.91
|
|
|
Service Code
|
NDC 5816081043
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$58.43 |
| Max. Negotiated Rate |
$107.91 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$105.75
|
| Rate for Payer: Aetna of WY Medicare |
$71.22
|
| Rate for Payer: Altius Commercial |
$103.59
|
| Rate for Payer: Beech Street Commercial |
$105.75
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$104.67
|
| Rate for Payer: Cash Price |
$75.54
|
| Rate for Payer: ChoiceCare Network Commercial |
$104.67
|
| Rate for Payer: Cigna of WY Commercial |
$105.75
|
| Rate for Payer: Entrust Commercial |
$102.51
|
| Rate for Payer: First Choice Health Commercial |
$102.51
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$102.51
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$61.51
|
| Rate for Payer: HealthUtah PPO |
$107.91
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$104.67
|
| Rate for Payer: Multiplan Medicare/VA |
$58.43
|
| Rate for Payer: One Health Plan of WY PPO |
$105.75
|
| Rate for Payer: PacificSource Commercial |
$97.12
|
| Rate for Payer: PHCS PPO |
$105.75
|
| Rate for Payer: Three Rivers PPO |
$80.93
|
| Rate for Payer: TriWest Veterans Administration |
$61.51
|
| Rate for Payer: United Healthcare Commercial |
$103.05
|
| Rate for Payer: United Healthcare Medicare |
$61.51
|
| Rate for Payer: WINHealth Partners Commercial |
$105.75
|
| Rate for Payer: Wise Provider Network Commercial |
$102.51
|
|
|
DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE [45972]
|
Facility
|
OP
|
$107.91
|
|
|
Service Code
|
NDC 5816081052
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$58.43 |
| Max. Negotiated Rate |
$107.91 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$105.75
|
| Rate for Payer: Aetna of WY Medicare |
$71.22
|
| Rate for Payer: Altius Commercial |
$103.59
|
| Rate for Payer: Beech Street Commercial |
$105.75
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$104.67
|
| Rate for Payer: Cash Price |
$75.54
|
| Rate for Payer: ChoiceCare Network Commercial |
$104.67
|
| Rate for Payer: Cigna of WY Commercial |
$105.75
|
| Rate for Payer: Entrust Commercial |
$102.51
|
| Rate for Payer: First Choice Health Commercial |
$102.51
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$102.51
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$61.51
|
| Rate for Payer: HealthUtah PPO |
$107.91
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$104.67
|
| Rate for Payer: Multiplan Medicare/VA |
$58.43
|
| Rate for Payer: One Health Plan of WY PPO |
$105.75
|
| Rate for Payer: PacificSource Commercial |
$97.12
|
| Rate for Payer: PHCS PPO |
$105.75
|
| Rate for Payer: Three Rivers PPO |
$80.93
|
| Rate for Payer: TriWest Veterans Administration |
$61.51
|
| Rate for Payer: United Healthcare Commercial |
$103.05
|
| Rate for Payer: United Healthcare Medicare |
$61.51
|
| Rate for Payer: WINHealth Partners Commercial |
$105.75
|
| Rate for Payer: Wise Provider Network Commercial |
$102.51
|
|
|
DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE [45972]
|
Facility
|
IP
|
$107.91
|
|
|
Service Code
|
NDC 5816081052
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$62.53 |
| Max. Negotiated Rate |
$107.91 |
| Rate for Payer: United Healthcare Commercial |
$103.05
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$105.75
|
| Rate for Payer: Aetna of WY Medicare |
$69.06
|
| Rate for Payer: Altius Commercial |
$103.59
|
| Rate for Payer: Beech Street Commercial |
$105.75
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$104.67
|
| Rate for Payer: Cash Price |
$75.54
|
| Rate for Payer: ChoiceCare Network Commercial |
$104.67
|
| Rate for Payer: Cigna of WY Commercial |
$105.75
|
| Rate for Payer: Entrust Commercial |
$102.51
|
| Rate for Payer: First Choice Health Commercial |
$102.51
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$102.51
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$65.83
|
| Rate for Payer: HealthUtah PPO |
$107.91
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$104.67
|
| Rate for Payer: Multiplan Medicare/VA |
$62.53
|
| Rate for Payer: One Health Plan of WY PPO |
$105.75
|
| Rate for Payer: PacificSource Commercial |
$97.12
|
| Rate for Payer: PHCS PPO |
$105.75
|
| Rate for Payer: Three Rivers PPO |
$80.93
|
| Rate for Payer: TriWest Veterans Administration |
$65.83
|
| Rate for Payer: United Healthcare Medicare |
$65.83
|
| Rate for Payer: WINHealth Partners Commercial |
$102.51
|
| Rate for Payer: Wise Provider Network Commercial |
$102.51
|
|
|
DIPHTH,PERTUS(AC)TETANUS(PF)2 LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SYRINGE [52987]
|
Facility
|
IP
|
$174.54
|
|
|
Service Code
|
HCPCS 90715
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$101.15 |
| Max. Negotiated Rate |
$174.54 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$171.05
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$171.04
|
| Rate for Payer: Aetna of WY Medicare |
$111.70
|
| Rate for Payer: Aetna of WY Medicare |
$111.71
|
| Rate for Payer: Altius Commercial |
$167.55
|
| Rate for Payer: Altius Commercial |
$167.56
|
| Rate for Payer: Beech Street Commercial |
$171.04
|
| Rate for Payer: Beech Street Commercial |
$171.05
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$169.29
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$169.30
|
| Rate for Payer: Cash Price |
$122.18
|
| Rate for Payer: Cash Price |
$122.17
|
| Rate for Payer: ChoiceCare Network Commercial |
$169.29
|
| Rate for Payer: ChoiceCare Network Commercial |
$169.30
|
| Rate for Payer: Cigna of WY Commercial |
$171.05
|
| Rate for Payer: Cigna of WY Commercial |
$171.04
|
| Rate for Payer: Entrust Commercial |
$165.80
|
| Rate for Payer: Entrust Commercial |
$165.81
|
| Rate for Payer: First Choice Health Commercial |
$165.80
|
| Rate for Payer: First Choice Health Commercial |
$165.81
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$165.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$165.81
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$106.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$106.47
|
| Rate for Payer: HealthUtah PPO |
$174.54
|
| Rate for Payer: HealthUtah PPO |
$174.53
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$169.30
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$169.29
|
| Rate for Payer: Multiplan Medicare/VA |
$101.14
|
| Rate for Payer: Multiplan Medicare/VA |
$101.15
|
| Rate for Payer: One Health Plan of WY PPO |
$171.05
|
| Rate for Payer: One Health Plan of WY PPO |
$171.04
|
| Rate for Payer: PacificSource Commercial |
$157.08
|
| Rate for Payer: PacificSource Commercial |
$157.09
|
| Rate for Payer: PHCS PPO |
$171.05
|
| Rate for Payer: PHCS PPO |
$171.04
|
| Rate for Payer: Three Rivers PPO |
$130.90
|
| Rate for Payer: Three Rivers PPO |
$130.90
|
| Rate for Payer: TriWest Veterans Administration |
$106.46
|
| Rate for Payer: TriWest Veterans Administration |
$106.47
|
| Rate for Payer: United Healthcare Commercial |
$166.68
|
| Rate for Payer: United Healthcare Commercial |
$166.69
|
| Rate for Payer: United Healthcare Medicare |
$106.47
|
| Rate for Payer: United Healthcare Medicare |
$106.46
|
| Rate for Payer: WINHealth Partners Commercial |
$165.80
|
| Rate for Payer: WINHealth Partners Commercial |
$165.81
|
| Rate for Payer: Wise Provider Network Commercial |
$165.80
|
| Rate for Payer: Wise Provider Network Commercial |
$165.81
|
|
|
DIPHTH,PERTUS(AC)TETANUS(PF)2 LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SYRINGE [52987]
|
Facility
|
OP
|
$174.54
|
|
|
Service Code
|
HCPCS 90715
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$94.51 |
| Max. Negotiated Rate |
$174.54 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$171.05
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$171.04
|
| Rate for Payer: Aetna of WY Medicare |
$115.20
|
| Rate for Payer: Aetna of WY Medicare |
$115.19
|
| Rate for Payer: Altius Commercial |
$167.56
|
| Rate for Payer: Altius Commercial |
$167.55
|
| Rate for Payer: Beech Street Commercial |
$171.05
|
| Rate for Payer: Beech Street Commercial |
$171.04
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$169.29
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$169.30
|
| Rate for Payer: Cash Price |
$122.18
|
| Rate for Payer: Cash Price |
$122.17
|
| Rate for Payer: ChoiceCare Network Commercial |
$169.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$169.29
|
| Rate for Payer: Cigna of WY Commercial |
$171.05
|
| Rate for Payer: Cigna of WY Commercial |
$171.04
|
| Rate for Payer: Entrust Commercial |
$165.81
|
| Rate for Payer: Entrust Commercial |
$165.80
|
| Rate for Payer: First Choice Health Commercial |
$165.80
|
| Rate for Payer: First Choice Health Commercial |
$165.81
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$165.81
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$165.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$99.48
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$99.49
|
| Rate for Payer: HealthUtah PPO |
$174.54
|
| Rate for Payer: HealthUtah PPO |
$174.53
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$169.30
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$169.29
|
| Rate for Payer: Multiplan Medicare/VA |
$94.51
|
| Rate for Payer: Multiplan Medicare/VA |
$94.51
|
| Rate for Payer: One Health Plan of WY PPO |
$171.05
|
| Rate for Payer: One Health Plan of WY PPO |
$171.04
|
| Rate for Payer: PacificSource Commercial |
$157.09
|
| Rate for Payer: PacificSource Commercial |
$157.08
|
| Rate for Payer: PHCS PPO |
$171.05
|
| Rate for Payer: PHCS PPO |
$171.04
|
| Rate for Payer: Three Rivers PPO |
$130.90
|
| Rate for Payer: Three Rivers PPO |
$130.90
|
| Rate for Payer: TriWest Veterans Administration |
$99.48
|
| Rate for Payer: TriWest Veterans Administration |
$99.49
|
| Rate for Payer: United Healthcare Commercial |
$166.69
|
| Rate for Payer: United Healthcare Commercial |
$166.68
|
| Rate for Payer: United Healthcare Medicare |
$99.49
|
| Rate for Payer: United Healthcare Medicare |
$99.48
|
| Rate for Payer: WINHealth Partners Commercial |
$171.04
|
| Rate for Payer: WINHealth Partners Commercial |
$171.05
|
| Rate for Payer: Wise Provider Network Commercial |
$165.80
|
| Rate for Payer: Wise Provider Network Commercial |
$165.81
|
|
|
DIPHTH TETANUS TOX ACELL PERTUSSIS VACC<7 YR IM
|
Professional
|
Both
|
$86.00
|
|
|
Service Code
|
HCPCS 90700
|
| Min. Negotiated Rate |
$64.50 |
| Max. Negotiated Rate |
$86.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$84.28
|
| Rate for Payer: Beech Street Commercial |
$81.70
|
| Rate for Payer: Cash Price |
$60.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$83.42
|
| Rate for Payer: Cigna of WY Commercial |
$84.28
|
| Rate for Payer: First Choice Health Commercial |
$77.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$81.70
|
| Rate for Payer: HealthUtah PPO |
$86.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$83.42
|
| Rate for Payer: One Health Plan of WY PPO |
$84.28
|
| Rate for Payer: PacificSource Commercial |
$77.40
|
| Rate for Payer: PHCS PPO |
$81.70
|
| Rate for Payer: Three Rivers PPO |
$64.50
|
| Rate for Payer: United Healthcare Commercial |
$81.70
|
| Rate for Payer: WINHealth Partners Commercial |
$86.00
|
|
|
DISCECTOMY ANT DCMPRN CORD CERVICAL 1 NTRSPC
|
Professional
|
Both
|
$5,928.00
|
|
|
Service Code
|
HCPCS 63075 AS
|
| Min. Negotiated Rate |
$4,446.00 |
| Max. Negotiated Rate |
$5,928.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5,809.44
|
| Rate for Payer: Beech Street Commercial |
$5,631.60
|
| Rate for Payer: Cash Price |
$4,149.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$5,750.16
|
| Rate for Payer: Cigna of WY Commercial |
$5,809.44
|
| Rate for Payer: First Choice Health Commercial |
$5,335.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5,631.60
|
| Rate for Payer: HealthUtah PPO |
$5,928.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5,750.16
|
| Rate for Payer: One Health Plan of WY PPO |
$5,809.44
|
| Rate for Payer: PacificSource Commercial |
$5,335.20
|
| Rate for Payer: PHCS PPO |
$5,631.60
|
| Rate for Payer: Three Rivers PPO |
$4,446.00
|
| Rate for Payer: United Healthcare Commercial |
$5,631.60
|
| Rate for Payer: WINHealth Partners Commercial |
$5,038.80
|
|
|
DISCECTOMY ANT DCMPRN CORD CERVICAL 1 NTRSPC
|
Professional
|
Both
|
$5,928.00
|
|
|
Service Code
|
HCPCS 63075 80
|
| Min. Negotiated Rate |
$4,446.00 |
| Max. Negotiated Rate |
$5,928.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5,809.44
|
| Rate for Payer: Beech Street Commercial |
$5,631.60
|
| Rate for Payer: Cash Price |
$4,149.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$5,750.16
|
| Rate for Payer: Cigna of WY Commercial |
$5,809.44
|
| Rate for Payer: First Choice Health Commercial |
$5,335.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5,631.60
|
| Rate for Payer: HealthUtah PPO |
$5,928.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5,750.16
|
| Rate for Payer: One Health Plan of WY PPO |
$5,809.44
|
| Rate for Payer: PacificSource Commercial |
$5,335.20
|
| Rate for Payer: PHCS PPO |
$5,631.60
|
| Rate for Payer: Three Rivers PPO |
$4,446.00
|
| Rate for Payer: United Healthcare Commercial |
$5,631.60
|
| Rate for Payer: WINHealth Partners Commercial |
$5,038.80
|
|
|
DISCECTOMY ANT DCMPRN CORD CERVICAL EA NTRSPC
|
Professional
|
Both
|
$1,079.00
|
|
|
Service Code
|
HCPCS 63076 AS
|
| Min. Negotiated Rate |
$809.25 |
| Max. Negotiated Rate |
$1,079.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,057.42
|
| Rate for Payer: Beech Street Commercial |
$1,025.05
|
| Rate for Payer: Cash Price |
$755.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,046.63
|
| Rate for Payer: Cigna of WY Commercial |
$1,057.42
|
| Rate for Payer: First Choice Health Commercial |
$971.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,025.05
|
| Rate for Payer: HealthUtah PPO |
$1,079.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,046.63
|
| Rate for Payer: One Health Plan of WY PPO |
$1,057.42
|
| Rate for Payer: PacificSource Commercial |
$971.10
|
| Rate for Payer: PHCS PPO |
$1,025.05
|
| Rate for Payer: Three Rivers PPO |
$809.25
|
| Rate for Payer: United Healthcare Commercial |
$1,025.05
|
| Rate for Payer: WINHealth Partners Commercial |
$917.15
|
|
|
DISCECTOMY ANT DCMPRN CORD CERVICAL EA NTRSPC
|
Professional
|
Both
|
$1,079.00
|
|
|
Service Code
|
HCPCS 63076 80
|
| Min. Negotiated Rate |
$809.25 |
| Max. Negotiated Rate |
$1,079.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,057.42
|
| Rate for Payer: Beech Street Commercial |
$1,025.05
|
| Rate for Payer: Cash Price |
$755.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,046.63
|
| Rate for Payer: Cigna of WY Commercial |
$1,057.42
|
| Rate for Payer: First Choice Health Commercial |
$971.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,025.05
|
| Rate for Payer: HealthUtah PPO |
$1,079.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,046.63
|
| Rate for Payer: One Health Plan of WY PPO |
$1,057.42
|
| Rate for Payer: PacificSource Commercial |
$971.10
|
| Rate for Payer: PHCS PPO |
$1,025.05
|
| Rate for Payer: Three Rivers PPO |
$809.25
|
| Rate for Payer: United Healthcare Commercial |
$1,025.05
|
| Rate for Payer: WINHealth Partners Commercial |
$917.15
|
|
|
DISE DYN EVAL SLEEP DISORDERED BREATHING FLX DX
|
Professional
|
Both
|
$285.00
|
|
|
Service Code
|
HCPCS 42975
|
| Min. Negotiated Rate |
$79.32 |
| Max. Negotiated Rate |
$285.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$279.30
|
| Rate for Payer: Aetna of WY Medicare |
$93.32
|
| Rate for Payer: Beech Street Commercial |
$270.75
|
| Rate for Payer: Cash Price |
$199.50
|
| Rate for Payer: Cash Price |
$199.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$276.45
|
| Rate for Payer: Cigna of WY Commercial |
$279.30
|
| Rate for Payer: First Choice Health Commercial |
$256.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$270.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$93.32
|
| Rate for Payer: HealthUtah PPO |
$285.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$276.45
|
| Rate for Payer: Multiplan Medicare/VA |
$79.32
|
| Rate for Payer: One Health Plan of WY PPO |
$279.30
|
| Rate for Payer: PacificSource Commercial |
$256.50
|
| Rate for Payer: PHCS PPO |
$270.75
|
| Rate for Payer: Three Rivers PPO |
$213.75
|
| Rate for Payer: TriWest Veterans Administration |
$93.32
|
| Rate for Payer: United Healthcare Commercial |
$270.75
|
| Rate for Payer: WINHealth Partners Commercial |
$242.25
|
|
|
DISSECTING TOOL MIDAS REX MC30
|
Facility
|
IP
|
$140.00
|
|
| Hospital Charge Code |
2800113
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$81.13 |
| Max. Negotiated Rate |
$140.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$137.20
|
| Rate for Payer: Aetna of WY Medicare |
$89.60
|
| Rate for Payer: Altius Commercial |
$134.40
|
| Rate for Payer: Beech Street Commercial |
$137.20
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$135.80
|
| Rate for Payer: Cash Price |
$98.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$135.80
|
| Rate for Payer: Cigna of WY Commercial |
$137.20
|
| Rate for Payer: Entrust Commercial |
$133.00
|
| Rate for Payer: First Choice Health Commercial |
$133.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$133.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$85.40
|
| Rate for Payer: HealthUtah PPO |
$140.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$135.80
|
| Rate for Payer: Multiplan Medicare/VA |
$81.13
|
| Rate for Payer: One Health Plan of WY PPO |
$137.20
|
| Rate for Payer: PacificSource Commercial |
$126.00
|
| Rate for Payer: PHCS PPO |
$137.20
|
| Rate for Payer: Three Rivers PPO |
$105.00
|
| Rate for Payer: TriWest Veterans Administration |
$85.40
|
| Rate for Payer: United Healthcare Commercial |
$133.70
|
| Rate for Payer: United Healthcare Medicare |
$85.40
|
| Rate for Payer: WINHealth Partners Commercial |
$133.00
|
| Rate for Payer: Wise Provider Network Commercial |
$133.00
|
|
|
DISSECTING TOOL MIDAS REX MC30
|
Facility
|
OP
|
$140.00
|
|
| Hospital Charge Code |
2800113
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$75.81 |
| Max. Negotiated Rate |
$140.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$137.20
|
| Rate for Payer: Aetna of WY Medicare |
$92.40
|
| Rate for Payer: Altius Commercial |
$134.40
|
| Rate for Payer: Beech Street Commercial |
$137.20
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$135.80
|
| Rate for Payer: Cash Price |
$98.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$135.80
|
| Rate for Payer: Cigna of WY Commercial |
$137.20
|
| Rate for Payer: Entrust Commercial |
$133.00
|
| Rate for Payer: First Choice Health Commercial |
$133.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$133.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$79.80
|
| Rate for Payer: HealthUtah PPO |
$140.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$135.80
|
| Rate for Payer: Multiplan Medicare/VA |
$75.81
|
| Rate for Payer: One Health Plan of WY PPO |
$137.20
|
| Rate for Payer: PacificSource Commercial |
$126.00
|
| Rate for Payer: PHCS PPO |
$137.20
|
| Rate for Payer: Three Rivers PPO |
$105.00
|
| Rate for Payer: TriWest Veterans Administration |
$79.80
|
| Rate for Payer: United Healthcare Commercial |
$133.70
|
| Rate for Payer: United Healthcare Medicare |
$79.80
|
| Rate for Payer: WINHealth Partners Commercial |
$137.20
|
| Rate for Payer: Wise Provider Network Commercial |
$133.00
|
|
|
DISSECTOR 4.0MM X 13CM
|
Facility
|
IP
|
$241.18
|
|
| Hospital Charge Code |
3004603
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$139.76 |
| Max. Negotiated Rate |
$241.18 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$236.36
|
| Rate for Payer: Aetna of WY Medicare |
$154.36
|
| Rate for Payer: Altius Commercial |
$231.53
|
| Rate for Payer: Beech Street Commercial |
$236.36
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$233.94
|
| Rate for Payer: Cash Price |
$168.83
|
| Rate for Payer: ChoiceCare Network Commercial |
$233.94
|
| Rate for Payer: Cigna of WY Commercial |
$236.36
|
| Rate for Payer: Entrust Commercial |
$229.12
|
| Rate for Payer: First Choice Health Commercial |
$229.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$229.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$147.12
|
| Rate for Payer: HealthUtah PPO |
$241.18
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$233.94
|
| Rate for Payer: Multiplan Medicare/VA |
$139.76
|
| Rate for Payer: One Health Plan of WY PPO |
$236.36
|
| Rate for Payer: PacificSource Commercial |
$217.06
|
| Rate for Payer: PHCS PPO |
$236.36
|
| Rate for Payer: Three Rivers PPO |
$180.88
|
| Rate for Payer: TriWest Veterans Administration |
$147.12
|
| Rate for Payer: United Healthcare Commercial |
$230.33
|
| Rate for Payer: United Healthcare Medicare |
$147.12
|
| Rate for Payer: WINHealth Partners Commercial |
$229.12
|
| Rate for Payer: Wise Provider Network Commercial |
$229.12
|
|
|
DISSECTOR 4.0MM X 13CM
|
Facility
|
OP
|
$241.18
|
|
| Hospital Charge Code |
3004603
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$130.60 |
| Max. Negotiated Rate |
$241.18 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$236.36
|
| Rate for Payer: Aetna of WY Medicare |
$159.18
|
| Rate for Payer: Altius Commercial |
$231.53
|
| Rate for Payer: Beech Street Commercial |
$236.36
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$233.94
|
| Rate for Payer: Cash Price |
$168.83
|
| Rate for Payer: ChoiceCare Network Commercial |
$233.94
|
| Rate for Payer: Cigna of WY Commercial |
$236.36
|
| Rate for Payer: Entrust Commercial |
$229.12
|
| Rate for Payer: First Choice Health Commercial |
$229.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$229.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$137.47
|
| Rate for Payer: HealthUtah PPO |
$241.18
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$233.94
|
| Rate for Payer: Multiplan Medicare/VA |
$130.60
|
| Rate for Payer: One Health Plan of WY PPO |
$236.36
|
| Rate for Payer: PacificSource Commercial |
$217.06
|
| Rate for Payer: PHCS PPO |
$236.36
|
| Rate for Payer: Three Rivers PPO |
$180.88
|
| Rate for Payer: TriWest Veterans Administration |
$137.47
|
| Rate for Payer: United Healthcare Commercial |
$230.33
|
| Rate for Payer: United Healthcare Medicare |
$137.47
|
| Rate for Payer: WINHealth Partners Commercial |
$236.36
|
| Rate for Payer: Wise Provider Network Commercial |
$229.12
|
|
|
DISSECTOR CURVED 3.5MM 8350CDS
|
Facility
|
OP
|
$140.00
|
|
| Hospital Charge Code |
3003878
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$75.81 |
| Max. Negotiated Rate |
$140.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$137.20
|
| Rate for Payer: Aetna of WY Medicare |
$92.40
|
| Rate for Payer: Altius Commercial |
$134.40
|
| Rate for Payer: Beech Street Commercial |
$137.20
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$135.80
|
| Rate for Payer: Cash Price |
$98.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$135.80
|
| Rate for Payer: Cigna of WY Commercial |
$137.20
|
| Rate for Payer: Entrust Commercial |
$133.00
|
| Rate for Payer: First Choice Health Commercial |
$133.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$133.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$79.80
|
| Rate for Payer: HealthUtah PPO |
$140.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$135.80
|
| Rate for Payer: Multiplan Medicare/VA |
$75.81
|
| Rate for Payer: One Health Plan of WY PPO |
$137.20
|
| Rate for Payer: PacificSource Commercial |
$126.00
|
| Rate for Payer: PHCS PPO |
$137.20
|
| Rate for Payer: Three Rivers PPO |
$105.00
|
| Rate for Payer: TriWest Veterans Administration |
$79.80
|
| Rate for Payer: United Healthcare Commercial |
$133.70
|
| Rate for Payer: United Healthcare Medicare |
$79.80
|
| Rate for Payer: WINHealth Partners Commercial |
$137.20
|
| Rate for Payer: Wise Provider Network Commercial |
$133.00
|
|
