|
FINGER TRAP SINGLE MEDIUM YELLOW
|
Facility
|
IP
|
$84.00
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$52.67 |
| Max. Negotiated Rate |
$84.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$82.32
|
| Rate for Payer: Altius Auto/Workers Compensation |
$80.64
|
| Rate for Payer: Altius Commercial |
$80.64
|
| Rate for Payer: Beech Street Commercial |
$82.32
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$68.96
|
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$81.48
|
| Rate for Payer: Cigna of WY Commercial |
$82.32
|
| Rate for Payer: Entrust Commercial |
$79.80
|
| Rate for Payer: First Choice Health Commercial |
$79.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$79.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$55.44
|
| Rate for Payer: HealthUtah PPO |
$84.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$81.48
|
| Rate for Payer: Multiplan Medicare/VA |
$52.67
|
| Rate for Payer: One Health Plan of WY PPO |
$82.32
|
| Rate for Payer: PacificSource Commercial |
$75.60
|
| Rate for Payer: PHCS PPO |
$82.32
|
| Rate for Payer: Three Rivers PPO |
$63.00
|
| Rate for Payer: TriWest Veterans Administration |
$55.44
|
| Rate for Payer: United Healthcare Commercial |
$73.08
|
| Rate for Payer: United Healthcare Medicare |
$55.44
|
| Rate for Payer: WINHealth Partners Commercial |
$79.80
|
| Rate for Payer: Wise Provider Network Commercial |
$79.80
|
|
|
FINGER TRAP SINGLE MEDIUM YELLOW
|
Facility
|
OP
|
$84.00
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$46.28 |
| Max. Negotiated Rate |
$84.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$82.32
|
| Rate for Payer: Aetna of WY Medicare |
$55.44
|
| Rate for Payer: Altius Auto/Workers Compensation |
$80.64
|
| Rate for Payer: Altius Commercial |
$80.64
|
| Rate for Payer: Beech Street Commercial |
$82.32
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$68.96
|
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$81.48
|
| Rate for Payer: Cigna of WY Commercial |
$82.32
|
| Rate for Payer: Entrust Commercial |
$79.80
|
| Rate for Payer: First Choice Health Commercial |
$79.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$79.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$48.72
|
| Rate for Payer: HealthUtah PPO |
$84.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$81.48
|
| Rate for Payer: Multiplan Medicare/VA |
$46.28
|
| Rate for Payer: One Health Plan of WY PPO |
$82.32
|
| Rate for Payer: PacificSource Commercial |
$75.60
|
| Rate for Payer: PHCS PPO |
$82.32
|
| Rate for Payer: Three Rivers PPO |
$63.00
|
| Rate for Payer: TriWest Veterans Administration |
$48.72
|
| Rate for Payer: United Healthcare Commercial |
$73.08
|
| Rate for Payer: United Healthcare Medicare |
$48.72
|
| Rate for Payer: WINHealth Partners Commercial |
$82.32
|
| Rate for Payer: Wise Provider Network Commercial |
$79.80
|
|
|
FINGER TRAP SINGLE X-LARGE GREEN
|
Facility
|
IP
|
$84.00
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$52.67 |
| Max. Negotiated Rate |
$84.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$82.32
|
| Rate for Payer: Altius Auto/Workers Compensation |
$80.64
|
| Rate for Payer: Altius Commercial |
$80.64
|
| Rate for Payer: Beech Street Commercial |
$82.32
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$68.96
|
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$81.48
|
| Rate for Payer: Cigna of WY Commercial |
$82.32
|
| Rate for Payer: Entrust Commercial |
$79.80
|
| Rate for Payer: First Choice Health Commercial |
$79.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$79.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$55.44
|
| Rate for Payer: HealthUtah PPO |
$84.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$81.48
|
| Rate for Payer: Multiplan Medicare/VA |
$52.67
|
| Rate for Payer: One Health Plan of WY PPO |
$82.32
|
| Rate for Payer: PacificSource Commercial |
$75.60
|
| Rate for Payer: PHCS PPO |
$82.32
|
| Rate for Payer: Three Rivers PPO |
$63.00
|
| Rate for Payer: TriWest Veterans Administration |
$55.44
|
| Rate for Payer: United Healthcare Commercial |
$73.08
|
| Rate for Payer: United Healthcare Medicare |
$55.44
|
| Rate for Payer: WINHealth Partners Commercial |
$79.80
|
| Rate for Payer: Wise Provider Network Commercial |
$79.80
|
|
|
FINGER TRAP SINGLE X-LARGE GREEN
|
Facility
|
OP
|
$84.00
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$46.28 |
| Max. Negotiated Rate |
$84.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$82.32
|
| Rate for Payer: Aetna of WY Medicare |
$55.44
|
| Rate for Payer: Altius Auto/Workers Compensation |
$80.64
|
| Rate for Payer: Altius Commercial |
$80.64
|
| Rate for Payer: Beech Street Commercial |
$82.32
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$68.96
|
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$81.48
|
| Rate for Payer: Cigna of WY Commercial |
$82.32
|
| Rate for Payer: Entrust Commercial |
$79.80
|
| Rate for Payer: First Choice Health Commercial |
$79.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$79.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$48.72
|
| Rate for Payer: HealthUtah PPO |
$84.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$81.48
|
| Rate for Payer: Multiplan Medicare/VA |
$46.28
|
| Rate for Payer: One Health Plan of WY PPO |
$82.32
|
| Rate for Payer: PacificSource Commercial |
$75.60
|
| Rate for Payer: PHCS PPO |
$82.32
|
| Rate for Payer: Three Rivers PPO |
$63.00
|
| Rate for Payer: TriWest Veterans Administration |
$48.72
|
| Rate for Payer: United Healthcare Commercial |
$73.08
|
| Rate for Payer: United Healthcare Medicare |
$48.72
|
| Rate for Payer: WINHealth Partners Commercial |
$82.32
|
| Rate for Payer: Wise Provider Network Commercial |
$79.80
|
|
|
FISSURECTOMY INCL SPHINCTEROTOMY WHEN PERFORMED
|
Professional
|
Both
|
$6,523.00
|
|
|
Service Code
|
HCPCS 46200
|
| Hospital Charge Code |
46200
|
| Min. Negotiated Rate |
$281.13 |
| Max. Negotiated Rate |
$6,523.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$6,392.54
|
| Rate for Payer: Aetna of WY Medicare |
$330.74
|
| Rate for Payer: Beech Street Commercial |
$6,196.85
|
| Rate for Payer: Cash Price |
$4,566.10
|
| Rate for Payer: Cash Price |
$4,566.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$6,327.31
|
| Rate for Payer: Cigna of WY Commercial |
$6,392.54
|
| Rate for Payer: First Choice Health Commercial |
$5,870.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$6,196.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$330.74
|
| Rate for Payer: HealthUtah PPO |
$6,523.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$6,327.31
|
| Rate for Payer: Multiplan Medicare/VA |
$281.13
|
| Rate for Payer: One Health Plan of WY PPO |
$6,392.54
|
| Rate for Payer: PacificSource Commercial |
$5,870.70
|
| Rate for Payer: PHCS PPO |
$6,196.85
|
| Rate for Payer: Three Rivers PPO |
$4,892.25
|
| Rate for Payer: TriWest Veterans Administration |
$330.74
|
| Rate for Payer: United Healthcare Commercial |
$5,675.01
|
| Rate for Payer: United Healthcare Medicare |
$330.74
|
| Rate for Payer: WINHealth Partners Commercial |
$5,544.55
|
|
|
FIT&INSJ PESSARY/OTH INTRAVAGINAL SUPPORT DEVI
|
Professional
|
Both
|
$234.00
|
|
|
Service Code
|
HCPCS 57160
|
| Hospital Charge Code |
57160
|
| Min. Negotiated Rate |
$37.11 |
| Max. Negotiated Rate |
$234.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$229.32
|
| Rate for Payer: Aetna of WY Medicare |
$43.66
|
| Rate for Payer: Beech Street Commercial |
$222.30
|
| Rate for Payer: Cash Price |
$163.80
|
| Rate for Payer: Cash Price |
$163.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$226.98
|
| Rate for Payer: Cigna of WY Commercial |
$229.32
|
| Rate for Payer: First Choice Health Commercial |
$210.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$222.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$43.66
|
| Rate for Payer: HealthUtah PPO |
$234.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$226.98
|
| Rate for Payer: Multiplan Medicare/VA |
$37.11
|
| Rate for Payer: One Health Plan of WY PPO |
$229.32
|
| Rate for Payer: PacificSource Commercial |
$210.60
|
| Rate for Payer: PHCS PPO |
$222.30
|
| Rate for Payer: Three Rivers PPO |
$175.50
|
| Rate for Payer: TriWest Veterans Administration |
$43.66
|
| Rate for Payer: United Healthcare Commercial |
$203.58
|
| Rate for Payer: United Healthcare Medicare |
$43.66
|
| Rate for Payer: WINHealth Partners Commercial |
$198.90
|
|
|
FLAP ISLAND PEDICLE ANATOMIC NAMED AXIAL ARTERY
|
Professional
|
Both
|
$4,179.00
|
|
|
Service Code
|
HCPCS 15740
|
| Hospital Charge Code |
15740
|
| Min. Negotiated Rate |
$690.94 |
| Max. Negotiated Rate |
$4,179.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4,095.42
|
| Rate for Payer: Aetna of WY Medicare |
$812.87
|
| Rate for Payer: Beech Street Commercial |
$3,970.05
|
| Rate for Payer: Cash Price |
$2,925.30
|
| Rate for Payer: Cash Price |
$2,925.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$4,053.63
|
| Rate for Payer: Cigna of WY Commercial |
$4,095.42
|
| Rate for Payer: First Choice Health Commercial |
$3,761.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,970.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$812.87
|
| Rate for Payer: HealthUtah PPO |
$4,179.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4,053.63
|
| Rate for Payer: Multiplan Medicare/VA |
$690.94
|
| Rate for Payer: One Health Plan of WY PPO |
$4,095.42
|
| Rate for Payer: PacificSource Commercial |
$3,761.10
|
| Rate for Payer: PHCS PPO |
$3,970.05
|
| Rate for Payer: Three Rivers PPO |
$3,134.25
|
| Rate for Payer: TriWest Veterans Administration |
$812.87
|
| Rate for Payer: United Healthcare Commercial |
$3,635.73
|
| Rate for Payer: United Healthcare Medicare |
$812.87
|
| Rate for Payer: WINHealth Partners Commercial |
$3,552.15
|
|
|
FLECAINIDE 100 MG TABLET [14034]
|
Facility
|
OP
|
$0.80
|
|
|
Service Code
|
NDC 6255938101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.44 |
| Max. Negotiated Rate |
$0.80 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.78
|
| Rate for Payer: Aetna of WY Medicare |
$0.53
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.77
|
| Rate for Payer: Altius Commercial |
$0.77
|
| Rate for Payer: Beech Street Commercial |
$0.78
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.66
|
| Rate for Payer: Cash Price |
$0.56
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.78
|
| Rate for Payer: Cigna of WY Commercial |
$0.78
|
| Rate for Payer: Entrust Commercial |
$0.76
|
| Rate for Payer: First Choice Health Commercial |
$0.76
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.76
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.46
|
| Rate for Payer: HealthUtah PPO |
$0.80
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.78
|
| Rate for Payer: Multiplan Medicare/VA |
$0.44
|
| Rate for Payer: One Health Plan of WY PPO |
$0.78
|
| Rate for Payer: PacificSource Commercial |
$0.72
|
| Rate for Payer: PHCS PPO |
$0.78
|
| Rate for Payer: Three Rivers PPO |
$0.60
|
| Rate for Payer: TriWest Veterans Administration |
$0.46
|
| Rate for Payer: United Healthcare Commercial |
$0.70
|
| Rate for Payer: United Healthcare Medicare |
$0.46
|
| Rate for Payer: WINHealth Partners Commercial |
$0.78
|
| Rate for Payer: Wise Provider Network Commercial |
$0.76
|
|
|
FLECAINIDE 100 MG TABLET [14034]
|
Facility
|
IP
|
$0.80
|
|
|
Service Code
|
NDC 6255938101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$0.80 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.78
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.77
|
| Rate for Payer: Altius Commercial |
$0.77
|
| Rate for Payer: Beech Street Commercial |
$0.78
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.66
|
| Rate for Payer: Cash Price |
$0.56
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.78
|
| Rate for Payer: Cigna of WY Commercial |
$0.78
|
| Rate for Payer: Entrust Commercial |
$0.76
|
| Rate for Payer: First Choice Health Commercial |
$0.76
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.76
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.53
|
| Rate for Payer: HealthUtah PPO |
$0.80
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.78
|
| Rate for Payer: Multiplan Medicare/VA |
$0.50
|
| Rate for Payer: One Health Plan of WY PPO |
$0.78
|
| Rate for Payer: PacificSource Commercial |
$0.72
|
| Rate for Payer: PHCS PPO |
$0.78
|
| Rate for Payer: Three Rivers PPO |
$0.60
|
| Rate for Payer: TriWest Veterans Administration |
$0.53
|
| Rate for Payer: United Healthcare Commercial |
$0.70
|
| Rate for Payer: United Healthcare Medicare |
$0.53
|
| Rate for Payer: WINHealth Partners Commercial |
$0.76
|
| Rate for Payer: Wise Provider Network Commercial |
$0.76
|
|
|
FLECAINIDE 100 MG TABLET [14034]
|
Facility
|
OP
|
$3.57
|
|
|
Service Code
|
NDC 5026832111
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.97 |
| Max. Negotiated Rate |
$3.57 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3.50
|
| Rate for Payer: Aetna of WY Medicare |
$2.36
|
| Rate for Payer: Altius Auto/Workers Compensation |
$3.43
|
| Rate for Payer: Altius Commercial |
$3.43
|
| Rate for Payer: Beech Street Commercial |
$3.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.93
|
| Rate for Payer: Cash Price |
$2.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$3.46
|
| Rate for Payer: Cigna of WY Commercial |
$3.50
|
| Rate for Payer: Entrust Commercial |
$3.39
|
| Rate for Payer: First Choice Health Commercial |
$3.39
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3.39
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2.07
|
| Rate for Payer: HealthUtah PPO |
$3.57
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3.46
|
| Rate for Payer: Multiplan Medicare/VA |
$1.97
|
| Rate for Payer: One Health Plan of WY PPO |
$3.50
|
| Rate for Payer: PacificSource Commercial |
$3.21
|
| Rate for Payer: PHCS PPO |
$3.50
|
| Rate for Payer: Three Rivers PPO |
$2.68
|
| Rate for Payer: TriWest Veterans Administration |
$2.07
|
| Rate for Payer: United Healthcare Commercial |
$3.11
|
| Rate for Payer: United Healthcare Medicare |
$2.07
|
| Rate for Payer: WINHealth Partners Commercial |
$3.50
|
| Rate for Payer: Wise Provider Network Commercial |
$3.39
|
|
|
FLECAINIDE 100 MG TABLET [14034]
|
Facility
|
IP
|
$3.57
|
|
|
Service Code
|
NDC 5026832111
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.24 |
| Max. Negotiated Rate |
$3.57 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3.50
|
| Rate for Payer: Altius Auto/Workers Compensation |
$3.43
|
| Rate for Payer: Altius Commercial |
$3.43
|
| Rate for Payer: Beech Street Commercial |
$3.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.93
|
| Rate for Payer: Cash Price |
$2.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$3.46
|
| Rate for Payer: Cigna of WY Commercial |
$3.50
|
| Rate for Payer: Entrust Commercial |
$3.39
|
| Rate for Payer: First Choice Health Commercial |
$3.39
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3.39
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2.36
|
| Rate for Payer: HealthUtah PPO |
$3.57
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3.46
|
| Rate for Payer: Multiplan Medicare/VA |
$2.24
|
| Rate for Payer: One Health Plan of WY PPO |
$3.50
|
| Rate for Payer: PacificSource Commercial |
$3.21
|
| Rate for Payer: PHCS PPO |
$3.50
|
| Rate for Payer: Three Rivers PPO |
$2.68
|
| Rate for Payer: TriWest Veterans Administration |
$2.36
|
| Rate for Payer: United Healthcare Commercial |
$3.11
|
| Rate for Payer: United Healthcare Medicare |
$2.36
|
| Rate for Payer: WINHealth Partners Commercial |
$3.39
|
| Rate for Payer: Wise Provider Network Commercial |
$3.39
|
|
|
FLIPCUTTER III DRILL AR-1204FF
|
Facility
|
IP
|
$1,696.52
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,063.72 |
| Max. Negotiated Rate |
$1,696.52 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,662.59
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,628.66
|
| Rate for Payer: Altius Commercial |
$1,628.66
|
| Rate for Payer: Beech Street Commercial |
$1,662.59
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,392.84
|
| Rate for Payer: Cash Price |
$1,187.56
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,645.62
|
| Rate for Payer: Cigna of WY Commercial |
$1,662.59
|
| Rate for Payer: Entrust Commercial |
$1,611.69
|
| Rate for Payer: First Choice Health Commercial |
$1,611.69
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,611.69
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,119.70
|
| Rate for Payer: HealthUtah PPO |
$1,696.52
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,645.62
|
| Rate for Payer: Multiplan Medicare/VA |
$1,063.72
|
| Rate for Payer: One Health Plan of WY PPO |
$1,662.59
|
| Rate for Payer: PacificSource Commercial |
$1,526.87
|
| Rate for Payer: PHCS PPO |
$1,662.59
|
| Rate for Payer: Three Rivers PPO |
$1,272.39
|
| Rate for Payer: TriWest Veterans Administration |
$1,119.70
|
| Rate for Payer: United Healthcare Commercial |
$1,475.97
|
| Rate for Payer: United Healthcare Medicare |
$1,119.70
|
| Rate for Payer: WINHealth Partners Commercial |
$1,611.69
|
| Rate for Payer: Wise Provider Network Commercial |
$1,611.69
|
|
|
FLIPCUTTER III DRILL AR-1204FF
|
Facility
|
OP
|
$1,696.52
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$934.78 |
| Max. Negotiated Rate |
$1,696.52 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,662.59
|
| Rate for Payer: Aetna of WY Medicare |
$1,119.70
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,628.66
|
| Rate for Payer: Altius Commercial |
$1,628.66
|
| Rate for Payer: Beech Street Commercial |
$1,662.59
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,392.84
|
| Rate for Payer: Cash Price |
$1,187.56
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,645.62
|
| Rate for Payer: Cigna of WY Commercial |
$1,662.59
|
| Rate for Payer: Entrust Commercial |
$1,611.69
|
| Rate for Payer: First Choice Health Commercial |
$1,611.69
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,611.69
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$983.98
|
| Rate for Payer: HealthUtah PPO |
$1,696.52
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,645.62
|
| Rate for Payer: Multiplan Medicare/VA |
$934.78
|
| Rate for Payer: One Health Plan of WY PPO |
$1,662.59
|
| Rate for Payer: PacificSource Commercial |
$1,526.87
|
| Rate for Payer: PHCS PPO |
$1,662.59
|
| Rate for Payer: Three Rivers PPO |
$1,272.39
|
| Rate for Payer: TriWest Veterans Administration |
$983.98
|
| Rate for Payer: United Healthcare Commercial |
$1,475.97
|
| Rate for Payer: United Healthcare Medicare |
$983.98
|
| Rate for Payer: WINHealth Partners Commercial |
$1,662.59
|
| Rate for Payer: Wise Provider Network Commercial |
$1,611.69
|
|
|
FLOSEAL HEMOSTATIC MATRIX 5ML
|
Facility
|
IP
|
$786.04
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$492.85 |
| Max. Negotiated Rate |
$786.04 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$770.32
|
| Rate for Payer: Altius Auto/Workers Compensation |
$754.60
|
| Rate for Payer: Altius Commercial |
$754.60
|
| Rate for Payer: Beech Street Commercial |
$770.32
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$645.34
|
| Rate for Payer: Cash Price |
$550.23
|
| Rate for Payer: ChoiceCare Network Commercial |
$762.46
|
| Rate for Payer: Cigna of WY Commercial |
$770.32
|
| Rate for Payer: Entrust Commercial |
$746.74
|
| Rate for Payer: First Choice Health Commercial |
$746.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$746.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$518.79
|
| Rate for Payer: HealthUtah PPO |
$786.04
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$762.46
|
| Rate for Payer: Multiplan Medicare/VA |
$492.85
|
| Rate for Payer: One Health Plan of WY PPO |
$770.32
|
| Rate for Payer: PacificSource Commercial |
$707.44
|
| Rate for Payer: PHCS PPO |
$770.32
|
| Rate for Payer: Three Rivers PPO |
$589.53
|
| Rate for Payer: TriWest Veterans Administration |
$518.79
|
| Rate for Payer: United Healthcare Commercial |
$683.85
|
| Rate for Payer: United Healthcare Medicare |
$518.79
|
| Rate for Payer: WINHealth Partners Commercial |
$746.74
|
| Rate for Payer: Wise Provider Network Commercial |
$746.74
|
|
|
FLOSEAL HEMOSTATIC MATRIX 5ML
|
Facility
|
OP
|
$786.04
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$433.11 |
| Max. Negotiated Rate |
$786.04 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$770.32
|
| Rate for Payer: Aetna of WY Medicare |
$518.79
|
| Rate for Payer: Altius Auto/Workers Compensation |
$754.60
|
| Rate for Payer: Altius Commercial |
$754.60
|
| Rate for Payer: Beech Street Commercial |
$770.32
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$645.34
|
| Rate for Payer: Cash Price |
$550.23
|
| Rate for Payer: ChoiceCare Network Commercial |
$762.46
|
| Rate for Payer: Cigna of WY Commercial |
$770.32
|
| Rate for Payer: Entrust Commercial |
$746.74
|
| Rate for Payer: First Choice Health Commercial |
$746.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$746.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$455.90
|
| Rate for Payer: HealthUtah PPO |
$786.04
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$762.46
|
| Rate for Payer: Multiplan Medicare/VA |
$433.11
|
| Rate for Payer: One Health Plan of WY PPO |
$770.32
|
| Rate for Payer: PacificSource Commercial |
$707.44
|
| Rate for Payer: PHCS PPO |
$770.32
|
| Rate for Payer: Three Rivers PPO |
$589.53
|
| Rate for Payer: TriWest Veterans Administration |
$455.90
|
| Rate for Payer: United Healthcare Commercial |
$683.85
|
| Rate for Payer: United Healthcare Medicare |
$455.90
|
| Rate for Payer: WINHealth Partners Commercial |
$770.32
|
| Rate for Payer: Wise Provider Network Commercial |
$746.74
|
|
|
FLOXURIDINE 0.5 GRAM SOLUTION FOR INJECTION [3294]
|
Facility
|
OP
|
$5,864.86
|
|
|
Service Code
|
HCPCS J9200
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,231.54 |
| Max. Negotiated Rate |
$5,864.86 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5,747.56
|
| Rate for Payer: Aetna of WY Medicare |
$3,870.81
|
| Rate for Payer: Altius Auto/Workers Compensation |
$5,630.27
|
| Rate for Payer: Altius Commercial |
$5,630.27
|
| Rate for Payer: Beech Street Commercial |
$5,747.56
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$4,815.05
|
| Rate for Payer: Cash Price |
$4,105.41
|
| Rate for Payer: ChoiceCare Network Commercial |
$5,688.91
|
| Rate for Payer: Cigna of WY Commercial |
$5,747.56
|
| Rate for Payer: Entrust Commercial |
$5,571.62
|
| Rate for Payer: First Choice Health Commercial |
$5,571.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5,571.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3,401.62
|
| Rate for Payer: HealthUtah PPO |
$5,864.86
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5,688.91
|
| Rate for Payer: Multiplan Medicare/VA |
$3,231.54
|
| Rate for Payer: One Health Plan of WY PPO |
$5,747.56
|
| Rate for Payer: PacificSource Commercial |
$5,278.37
|
| Rate for Payer: PHCS PPO |
$5,747.56
|
| Rate for Payer: Three Rivers PPO |
$4,398.64
|
| Rate for Payer: TriWest Veterans Administration |
$3,401.62
|
| Rate for Payer: United Healthcare Commercial |
$5,102.43
|
| Rate for Payer: United Healthcare Medicare |
$3,401.62
|
| Rate for Payer: WINHealth Partners Commercial |
$5,747.56
|
| Rate for Payer: Wise Provider Network Commercial |
$5,571.62
|
|
|
FLOXURIDINE 0.5 GRAM SOLUTION FOR INJECTION [3294]
|
Facility
|
IP
|
$5,864.86
|
|
|
Service Code
|
HCPCS J9200
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,677.27 |
| Max. Negotiated Rate |
$5,864.86 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5,747.56
|
| Rate for Payer: Altius Auto/Workers Compensation |
$5,630.27
|
| Rate for Payer: Altius Commercial |
$5,630.27
|
| Rate for Payer: Beech Street Commercial |
$5,747.56
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$4,815.05
|
| Rate for Payer: Cash Price |
$4,105.41
|
| Rate for Payer: ChoiceCare Network Commercial |
$5,688.91
|
| Rate for Payer: Cigna of WY Commercial |
$5,747.56
|
| Rate for Payer: Entrust Commercial |
$5,571.62
|
| Rate for Payer: First Choice Health Commercial |
$5,571.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5,571.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3,870.81
|
| Rate for Payer: HealthUtah PPO |
$5,864.86
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5,688.91
|
| Rate for Payer: Multiplan Medicare/VA |
$3,677.27
|
| Rate for Payer: One Health Plan of WY PPO |
$5,747.56
|
| Rate for Payer: PacificSource Commercial |
$5,278.37
|
| Rate for Payer: PHCS PPO |
$5,747.56
|
| Rate for Payer: Three Rivers PPO |
$4,398.64
|
| Rate for Payer: TriWest Veterans Administration |
$3,870.81
|
| Rate for Payer: United Healthcare Commercial |
$5,102.43
|
| Rate for Payer: United Healthcare Medicare |
$3,870.81
|
| Rate for Payer: WINHealth Partners Commercial |
$5,571.62
|
| Rate for Payer: Wise Provider Network Commercial |
$5,571.62
|
|
|
FLUCONAZOLE 100 MG TABLET [706]
|
Facility
|
IP
|
$6.80
|
|
|
Service Code
|
NDC 5026833715
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.26 |
| Max. Negotiated Rate |
$6.80 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$6.66
|
| Rate for Payer: Altius Auto/Workers Compensation |
$6.53
|
| Rate for Payer: Altius Commercial |
$6.53
|
| Rate for Payer: Beech Street Commercial |
$6.66
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$5.58
|
| Rate for Payer: Cash Price |
$4.76
|
| Rate for Payer: ChoiceCare Network Commercial |
$6.60
|
| Rate for Payer: Cigna of WY Commercial |
$6.66
|
| Rate for Payer: Entrust Commercial |
$6.46
|
| Rate for Payer: First Choice Health Commercial |
$6.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$6.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$4.49
|
| Rate for Payer: HealthUtah PPO |
$6.80
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$6.60
|
| Rate for Payer: Multiplan Medicare/VA |
$4.26
|
| Rate for Payer: One Health Plan of WY PPO |
$6.66
|
| Rate for Payer: PacificSource Commercial |
$6.12
|
| Rate for Payer: PHCS PPO |
$6.66
|
| Rate for Payer: Three Rivers PPO |
$5.10
|
| Rate for Payer: TriWest Veterans Administration |
$4.49
|
| Rate for Payer: United Healthcare Commercial |
$5.92
|
| Rate for Payer: United Healthcare Medicare |
$4.49
|
| Rate for Payer: WINHealth Partners Commercial |
$6.46
|
| Rate for Payer: Wise Provider Network Commercial |
$6.46
|
|
|
FLUCONAZOLE 100 MG TABLET [706]
|
Facility
|
OP
|
$6.80
|
|
|
Service Code
|
NDC 5026833711
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.75 |
| Max. Negotiated Rate |
$6.80 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$6.66
|
| Rate for Payer: Aetna of WY Medicare |
$4.49
|
| Rate for Payer: Altius Auto/Workers Compensation |
$6.53
|
| Rate for Payer: Altius Commercial |
$6.53
|
| Rate for Payer: Beech Street Commercial |
$6.66
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$5.58
|
| Rate for Payer: Cash Price |
$4.76
|
| Rate for Payer: ChoiceCare Network Commercial |
$6.60
|
| Rate for Payer: Cigna of WY Commercial |
$6.66
|
| Rate for Payer: Entrust Commercial |
$6.46
|
| Rate for Payer: First Choice Health Commercial |
$6.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$6.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3.94
|
| Rate for Payer: HealthUtah PPO |
$6.80
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$6.60
|
| Rate for Payer: Multiplan Medicare/VA |
$3.75
|
| Rate for Payer: One Health Plan of WY PPO |
$6.66
|
| Rate for Payer: PacificSource Commercial |
$6.12
|
| Rate for Payer: PHCS PPO |
$6.66
|
| Rate for Payer: Three Rivers PPO |
$5.10
|
| Rate for Payer: TriWest Veterans Administration |
$3.94
|
| Rate for Payer: United Healthcare Commercial |
$5.92
|
| Rate for Payer: United Healthcare Medicare |
$3.94
|
| Rate for Payer: WINHealth Partners Commercial |
$6.66
|
| Rate for Payer: Wise Provider Network Commercial |
$6.46
|
|
|
FLUCONAZOLE 100 MG TABLET [706]
|
Facility
|
OP
|
$5.98
|
|
|
Service Code
|
NDC 6800125204
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.29 |
| Max. Negotiated Rate |
$5.98 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5.86
|
| Rate for Payer: Aetna of WY Medicare |
$3.95
|
| Rate for Payer: Altius Auto/Workers Compensation |
$5.74
|
| Rate for Payer: Altius Commercial |
$5.74
|
| Rate for Payer: Beech Street Commercial |
$5.86
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$4.91
|
| Rate for Payer: Cash Price |
$4.19
|
| Rate for Payer: ChoiceCare Network Commercial |
$5.80
|
| Rate for Payer: Cigna of WY Commercial |
$5.86
|
| Rate for Payer: Entrust Commercial |
$5.68
|
| Rate for Payer: First Choice Health Commercial |
$5.68
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5.68
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3.47
|
| Rate for Payer: HealthUtah PPO |
$5.98
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5.80
|
| Rate for Payer: Multiplan Medicare/VA |
$3.29
|
| Rate for Payer: One Health Plan of WY PPO |
$5.86
|
| Rate for Payer: PacificSource Commercial |
$5.38
|
| Rate for Payer: PHCS PPO |
$5.86
|
| Rate for Payer: Three Rivers PPO |
$4.48
|
| Rate for Payer: TriWest Veterans Administration |
$3.47
|
| Rate for Payer: United Healthcare Commercial |
$5.20
|
| Rate for Payer: United Healthcare Medicare |
$3.47
|
| Rate for Payer: WINHealth Partners Commercial |
$5.86
|
| Rate for Payer: Wise Provider Network Commercial |
$5.68
|
|
|
FLUCONAZOLE 100 MG TABLET [706]
|
Facility
|
IP
|
$5.98
|
|
|
Service Code
|
NDC 6800125204
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.75 |
| Max. Negotiated Rate |
$5.98 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5.86
|
| Rate for Payer: Altius Auto/Workers Compensation |
$5.74
|
| Rate for Payer: Altius Commercial |
$5.74
|
| Rate for Payer: Beech Street Commercial |
$5.86
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$4.91
|
| Rate for Payer: Cash Price |
$4.19
|
| Rate for Payer: ChoiceCare Network Commercial |
$5.80
|
| Rate for Payer: Cigna of WY Commercial |
$5.86
|
| Rate for Payer: Entrust Commercial |
$5.68
|
| Rate for Payer: First Choice Health Commercial |
$5.68
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5.68
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3.95
|
| Rate for Payer: HealthUtah PPO |
$5.98
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5.80
|
| Rate for Payer: Multiplan Medicare/VA |
$3.75
|
| Rate for Payer: One Health Plan of WY PPO |
$5.86
|
| Rate for Payer: PacificSource Commercial |
$5.38
|
| Rate for Payer: PHCS PPO |
$5.86
|
| Rate for Payer: Three Rivers PPO |
$4.48
|
| Rate for Payer: TriWest Veterans Administration |
$3.95
|
| Rate for Payer: United Healthcare Commercial |
$5.20
|
| Rate for Payer: United Healthcare Medicare |
$3.95
|
| Rate for Payer: WINHealth Partners Commercial |
$5.68
|
| Rate for Payer: Wise Provider Network Commercial |
$5.68
|
|
|
FLUCONAZOLE 100 MG TABLET [706]
|
Facility
|
OP
|
$6.80
|
|
|
Service Code
|
NDC 5026833715
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.75 |
| Max. Negotiated Rate |
$6.80 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$6.66
|
| Rate for Payer: Aetna of WY Medicare |
$4.49
|
| Rate for Payer: Altius Auto/Workers Compensation |
$6.53
|
| Rate for Payer: Altius Commercial |
$6.53
|
| Rate for Payer: Beech Street Commercial |
$6.66
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$5.58
|
| Rate for Payer: Cash Price |
$4.76
|
| Rate for Payer: ChoiceCare Network Commercial |
$6.60
|
| Rate for Payer: Cigna of WY Commercial |
$6.66
|
| Rate for Payer: Entrust Commercial |
$6.46
|
| Rate for Payer: First Choice Health Commercial |
$6.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$6.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3.94
|
| Rate for Payer: HealthUtah PPO |
$6.80
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$6.60
|
| Rate for Payer: Multiplan Medicare/VA |
$3.75
|
| Rate for Payer: One Health Plan of WY PPO |
$6.66
|
| Rate for Payer: PacificSource Commercial |
$6.12
|
| Rate for Payer: PHCS PPO |
$6.66
|
| Rate for Payer: Three Rivers PPO |
$5.10
|
| Rate for Payer: TriWest Veterans Administration |
$3.94
|
| Rate for Payer: United Healthcare Commercial |
$5.92
|
| Rate for Payer: United Healthcare Medicare |
$3.94
|
| Rate for Payer: WINHealth Partners Commercial |
$6.66
|
| Rate for Payer: Wise Provider Network Commercial |
$6.46
|
|
|
FLUCONAZOLE 100 MG TABLET [706]
|
Facility
|
IP
|
$6.80
|
|
|
Service Code
|
NDC 5026833711
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.26 |
| Max. Negotiated Rate |
$6.80 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$6.66
|
| Rate for Payer: Altius Auto/Workers Compensation |
$6.53
|
| Rate for Payer: Altius Commercial |
$6.53
|
| Rate for Payer: Beech Street Commercial |
$6.66
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$5.58
|
| Rate for Payer: Cash Price |
$4.76
|
| Rate for Payer: ChoiceCare Network Commercial |
$6.60
|
| Rate for Payer: Cigna of WY Commercial |
$6.66
|
| Rate for Payer: Entrust Commercial |
$6.46
|
| Rate for Payer: First Choice Health Commercial |
$6.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$6.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$4.49
|
| Rate for Payer: HealthUtah PPO |
$6.80
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$6.60
|
| Rate for Payer: Multiplan Medicare/VA |
$4.26
|
| Rate for Payer: One Health Plan of WY PPO |
$6.66
|
| Rate for Payer: PacificSource Commercial |
$6.12
|
| Rate for Payer: PHCS PPO |
$6.66
|
| Rate for Payer: Three Rivers PPO |
$5.10
|
| Rate for Payer: TriWest Veterans Administration |
$4.49
|
| Rate for Payer: United Healthcare Commercial |
$5.92
|
| Rate for Payer: United Healthcare Medicare |
$4.49
|
| Rate for Payer: WINHealth Partners Commercial |
$6.46
|
| Rate for Payer: Wise Provider Network Commercial |
$6.46
|
|
|
FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK [9173]
|
Facility
|
IP
|
$15.36
|
|
|
Service Code
|
HCPCS J1450
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.63 |
| Max. Negotiated Rate |
$15.36 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.05
|
| Rate for Payer: Altius Auto/Workers Compensation |
$14.75
|
| Rate for Payer: Altius Commercial |
$14.75
|
| Rate for Payer: Beech Street Commercial |
$15.05
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.61
|
| Rate for Payer: Cash Price |
$10.75
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.90
|
| Rate for Payer: Cigna of WY Commercial |
$15.05
|
| Rate for Payer: Entrust Commercial |
$14.59
|
| Rate for Payer: First Choice Health Commercial |
$14.59
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.59
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.14
|
| Rate for Payer: HealthUtah PPO |
$15.36
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.90
|
| Rate for Payer: Multiplan Medicare/VA |
$9.63
|
| Rate for Payer: One Health Plan of WY PPO |
$15.05
|
| Rate for Payer: PacificSource Commercial |
$13.82
|
| Rate for Payer: PHCS PPO |
$15.05
|
| Rate for Payer: Three Rivers PPO |
$11.52
|
| Rate for Payer: TriWest Veterans Administration |
$10.14
|
| Rate for Payer: United Healthcare Commercial |
$13.36
|
| Rate for Payer: United Healthcare Medicare |
$10.14
|
| Rate for Payer: WINHealth Partners Commercial |
$14.59
|
| Rate for Payer: Wise Provider Network Commercial |
$14.59
|
|
|
FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK [9173]
|
Facility
|
OP
|
$15.36
|
|
|
Service Code
|
HCPCS J1450
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.46 |
| Max. Negotiated Rate |
$15.36 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.05
|
| Rate for Payer: Aetna of WY Medicare |
$10.14
|
| Rate for Payer: Altius Auto/Workers Compensation |
$14.75
|
| Rate for Payer: Altius Commercial |
$14.75
|
| Rate for Payer: Beech Street Commercial |
$15.05
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.61
|
| Rate for Payer: Cash Price |
$10.75
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.90
|
| Rate for Payer: Cigna of WY Commercial |
$15.05
|
| Rate for Payer: Entrust Commercial |
$14.59
|
| Rate for Payer: First Choice Health Commercial |
$14.59
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.59
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.91
|
| Rate for Payer: HealthUtah PPO |
$15.36
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.90
|
| Rate for Payer: Multiplan Medicare/VA |
$8.46
|
| Rate for Payer: One Health Plan of WY PPO |
$15.05
|
| Rate for Payer: PacificSource Commercial |
$13.82
|
| Rate for Payer: PHCS PPO |
$15.05
|
| Rate for Payer: Three Rivers PPO |
$11.52
|
| Rate for Payer: TriWest Veterans Administration |
$8.91
|
| Rate for Payer: United Healthcare Commercial |
$13.36
|
| Rate for Payer: United Healthcare Medicare |
$8.91
|
| Rate for Payer: WINHealth Partners Commercial |
$15.05
|
| Rate for Payer: Wise Provider Network Commercial |
$14.59
|
|
