|
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
|
|
|
DISSECTOR SJ 3.0MMX7CM 93
|
Facility
|
IP
|
$269.82
|
|
| Hospital Charge Code |
2650863
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$156.36 |
| Max. Negotiated Rate |
$269.82 |
| Rate for Payer: United Healthcare Commercial |
$257.68
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$264.42
|
| Rate for Payer: Aetna of WY Medicare |
$172.68
|
| Rate for Payer: Altius Commercial |
$259.03
|
| Rate for Payer: Beech Street Commercial |
$264.42
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$261.73
|
| Rate for Payer: Cash Price |
$188.87
|
| Rate for Payer: ChoiceCare Network Commercial |
$261.73
|
| Rate for Payer: Cigna of WY Commercial |
$264.42
|
| Rate for Payer: Entrust Commercial |
$256.33
|
| Rate for Payer: First Choice Health Commercial |
$256.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$256.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$164.59
|
| Rate for Payer: HealthUtah PPO |
$269.82
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$261.73
|
| Rate for Payer: Multiplan Medicare/VA |
$156.36
|
| Rate for Payer: One Health Plan of WY PPO |
$264.42
|
| Rate for Payer: PacificSource Commercial |
$242.84
|
| Rate for Payer: PHCS PPO |
$264.42
|
| Rate for Payer: Three Rivers PPO |
$202.36
|
| Rate for Payer: TriWest Veterans Administration |
$164.59
|
| Rate for Payer: United Healthcare Medicare |
$164.59
|
| Rate for Payer: WINHealth Partners Commercial |
$256.33
|
| Rate for Payer: Wise Provider Network Commercial |
$256.33
|
|
|
DISSECTOR SJ 3.0MMX7CM 93
|
Facility
|
OP
|
$269.82
|
|
| Hospital Charge Code |
2650863
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$146.11 |
| Max. Negotiated Rate |
$269.82 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$264.42
|
| Rate for Payer: Aetna of WY Medicare |
$178.08
|
| Rate for Payer: Altius Commercial |
$259.03
|
| Rate for Payer: Beech Street Commercial |
$264.42
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$261.73
|
| Rate for Payer: Cash Price |
$188.87
|
| Rate for Payer: ChoiceCare Network Commercial |
$261.73
|
| Rate for Payer: Cigna of WY Commercial |
$264.42
|
| Rate for Payer: Entrust Commercial |
$256.33
|
| Rate for Payer: First Choice Health Commercial |
$256.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$256.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$153.80
|
| Rate for Payer: HealthUtah PPO |
$269.82
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$261.73
|
| Rate for Payer: Multiplan Medicare/VA |
$146.11
|
| Rate for Payer: One Health Plan of WY PPO |
$264.42
|
| Rate for Payer: PacificSource Commercial |
$242.84
|
| Rate for Payer: PHCS PPO |
$264.42
|
| Rate for Payer: Three Rivers PPO |
$202.36
|
| Rate for Payer: TriWest Veterans Administration |
$153.80
|
| Rate for Payer: United Healthcare Commercial |
$257.68
|
| Rate for Payer: United Healthcare Medicare |
$153.80
|
| Rate for Payer: WINHealth Partners Commercial |
$264.42
|
| Rate for Payer: Wise Provider Network Commercial |
$256.33
|
|
|
DISSECT TOOL MIDAS REX MC16
|
Facility
|
IP
|
$31.50
|
|
| Hospital Charge Code |
2800137
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$18.25 |
| Max. Negotiated Rate |
$31.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$30.87
|
| Rate for Payer: Aetna of WY Medicare |
$20.16
|
| Rate for Payer: Altius Commercial |
$30.24
|
| Rate for Payer: Beech Street Commercial |
$30.87
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$30.56
|
| Rate for Payer: Cash Price |
$22.05
|
| Rate for Payer: ChoiceCare Network Commercial |
$30.56
|
| Rate for Payer: Cigna of WY Commercial |
$30.87
|
| Rate for Payer: Entrust Commercial |
$29.92
|
| Rate for Payer: First Choice Health Commercial |
$29.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$29.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$19.22
|
| Rate for Payer: HealthUtah PPO |
$31.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$30.56
|
| Rate for Payer: Multiplan Medicare/VA |
$18.25
|
| Rate for Payer: One Health Plan of WY PPO |
$30.87
|
| Rate for Payer: PacificSource Commercial |
$28.35
|
| Rate for Payer: PHCS PPO |
$30.87
|
| Rate for Payer: Three Rivers PPO |
$23.62
|
| Rate for Payer: TriWest Veterans Administration |
$19.22
|
| Rate for Payer: United Healthcare Commercial |
$30.08
|
| Rate for Payer: United Healthcare Medicare |
$19.22
|
| Rate for Payer: WINHealth Partners Commercial |
$29.92
|
| Rate for Payer: Wise Provider Network Commercial |
$29.92
|
|
|
DISSECT TOOL MIDAS REX MC16
|
Facility
|
OP
|
$31.50
|
|
| Hospital Charge Code |
2800137
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$17.06 |
| Max. Negotiated Rate |
$31.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$30.87
|
| Rate for Payer: Aetna of WY Medicare |
$20.79
|
| Rate for Payer: Altius Commercial |
$30.24
|
| Rate for Payer: Beech Street Commercial |
$30.87
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$30.56
|
| Rate for Payer: Cash Price |
$22.05
|
| Rate for Payer: ChoiceCare Network Commercial |
$30.56
|
| Rate for Payer: Cigna of WY Commercial |
$30.87
|
| Rate for Payer: Entrust Commercial |
$29.92
|
| Rate for Payer: First Choice Health Commercial |
$29.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$29.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$17.96
|
| Rate for Payer: HealthUtah PPO |
$31.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$30.56
|
| Rate for Payer: Multiplan Medicare/VA |
$17.06
|
| Rate for Payer: One Health Plan of WY PPO |
$30.87
|
| Rate for Payer: PacificSource Commercial |
$28.35
|
| Rate for Payer: PHCS PPO |
$30.87
|
| Rate for Payer: Three Rivers PPO |
$23.62
|
| Rate for Payer: TriWest Veterans Administration |
$17.96
|
| Rate for Payer: United Healthcare Commercial |
$30.08
|
| Rate for Payer: United Healthcare Medicare |
$17.96
|
| Rate for Payer: WINHealth Partners Commercial |
$30.87
|
| Rate for Payer: Wise Provider Network Commercial |
$29.92
|
|
|
DISTAL BICEPS REPAIR SYS
|
Facility
|
OP
|
$2,975.00
|
|
| Hospital Charge Code |
3001410
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,610.96 |
| Max. Negotiated Rate |
$2,975.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,915.50
|
| Rate for Payer: Aetna of WY Medicare |
$1,963.50
|
| Rate for Payer: Altius Commercial |
$2,856.00
|
| Rate for Payer: Beech Street Commercial |
$2,915.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,885.75
|
| Rate for Payer: Cash Price |
$2,082.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,885.75
|
| Rate for Payer: Cigna of WY Commercial |
$2,915.50
|
| Rate for Payer: Entrust Commercial |
$2,826.25
|
| Rate for Payer: First Choice Health Commercial |
$2,826.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,826.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,695.75
|
| Rate for Payer: HealthUtah PPO |
$2,975.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,885.75
|
| Rate for Payer: Multiplan Medicare/VA |
$1,610.96
|
| Rate for Payer: One Health Plan of WY PPO |
$2,915.50
|
| Rate for Payer: PacificSource Commercial |
$2,677.50
|
| Rate for Payer: PHCS PPO |
$2,915.50
|
| Rate for Payer: Three Rivers PPO |
$2,231.25
|
| Rate for Payer: TriWest Veterans Administration |
$1,695.75
|
| Rate for Payer: United Healthcare Commercial |
$2,841.12
|
| Rate for Payer: United Healthcare Medicare |
$1,695.75
|
| Rate for Payer: WINHealth Partners Commercial |
$2,915.50
|
| Rate for Payer: Wise Provider Network Commercial |
$2,826.25
|
|
|
DISTAL BICEPS REPAIR SYS
|
Facility
|
IP
|
$2,975.00
|
|
| Hospital Charge Code |
3001410
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,724.01 |
| Max. Negotiated Rate |
$2,975.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,915.50
|
| Rate for Payer: Aetna of WY Medicare |
$1,904.00
|
| Rate for Payer: Altius Commercial |
$2,856.00
|
| Rate for Payer: Beech Street Commercial |
$2,915.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,885.75
|
| Rate for Payer: Cash Price |
$2,082.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,885.75
|
| Rate for Payer: Cigna of WY Commercial |
$2,915.50
|
| Rate for Payer: Entrust Commercial |
$2,826.25
|
| Rate for Payer: First Choice Health Commercial |
$2,826.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,826.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,814.75
|
| Rate for Payer: HealthUtah PPO |
$2,975.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,885.75
|
| Rate for Payer: Multiplan Medicare/VA |
$1,724.01
|
| Rate for Payer: One Health Plan of WY PPO |
$2,915.50
|
| Rate for Payer: PacificSource Commercial |
$2,677.50
|
| Rate for Payer: PHCS PPO |
$2,915.50
|
| Rate for Payer: Three Rivers PPO |
$2,231.25
|
| Rate for Payer: TriWest Veterans Administration |
$1,814.75
|
| Rate for Payer: United Healthcare Commercial |
$2,841.12
|
| Rate for Payer: United Healthcare Medicare |
$1,814.75
|
| Rate for Payer: WINHealth Partners Commercial |
$2,826.25
|
| Rate for Payer: Wise Provider Network Commercial |
$2,826.25
|
|
|
DISTAL RADIUS KIT STD HEAD RT
|
Facility
|
OP
|
$8,750.00
|
|
| Hospital Charge Code |
3001623
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,738.12 |
| Max. Negotiated Rate |
$8,750.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$8,575.00
|
| Rate for Payer: Aetna of WY Medicare |
$5,775.00
|
| Rate for Payer: Altius Commercial |
$8,400.00
|
| Rate for Payer: Beech Street Commercial |
$8,575.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$8,487.50
|
| Rate for Payer: Cash Price |
$6,125.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$8,487.50
|
| Rate for Payer: Cigna of WY Commercial |
$8,575.00
|
| Rate for Payer: Entrust Commercial |
$8,312.50
|
| Rate for Payer: First Choice Health Commercial |
$8,312.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$8,312.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$4,987.50
|
| Rate for Payer: HealthUtah PPO |
$8,750.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$8,487.50
|
| Rate for Payer: Multiplan Medicare/VA |
$4,738.12
|
| Rate for Payer: One Health Plan of WY PPO |
$8,575.00
|
| Rate for Payer: PacificSource Commercial |
$7,875.00
|
| Rate for Payer: PHCS PPO |
$8,575.00
|
| Rate for Payer: Three Rivers PPO |
$6,562.50
|
| Rate for Payer: TriWest Veterans Administration |
$4,987.50
|
| Rate for Payer: United Healthcare Commercial |
$8,356.25
|
| Rate for Payer: United Healthcare Medicare |
$4,987.50
|
| Rate for Payer: WINHealth Partners Commercial |
$8,575.00
|
| Rate for Payer: Wise Provider Network Commercial |
$8,312.50
|
|
|
DISTAL RADIUS KIT STD HEAD RT
|
Facility
|
IP
|
$8,750.00
|
|
| Hospital Charge Code |
3001623
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,070.62 |
| Max. Negotiated Rate |
$8,750.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$8,575.00
|
| Rate for Payer: Aetna of WY Medicare |
$5,600.00
|
| Rate for Payer: Altius Commercial |
$8,400.00
|
| Rate for Payer: Beech Street Commercial |
$8,575.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$8,487.50
|
| Rate for Payer: Cash Price |
$6,125.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$8,487.50
|
| Rate for Payer: Cigna of WY Commercial |
$8,575.00
|
| Rate for Payer: Entrust Commercial |
$8,312.50
|
| Rate for Payer: First Choice Health Commercial |
$8,312.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$8,312.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$5,337.50
|
| Rate for Payer: HealthUtah PPO |
$8,750.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$8,487.50
|
| Rate for Payer: Multiplan Medicare/VA |
$5,070.62
|
| Rate for Payer: One Health Plan of WY PPO |
$8,575.00
|
| Rate for Payer: PacificSource Commercial |
$7,875.00
|
| Rate for Payer: PHCS PPO |
$8,575.00
|
| Rate for Payer: Three Rivers PPO |
$6,562.50
|
| Rate for Payer: TriWest Veterans Administration |
$5,337.50
|
| Rate for Payer: United Healthcare Commercial |
$8,356.25
|
| Rate for Payer: United Healthcare Medicare |
$5,337.50
|
| Rate for Payer: WINHealth Partners Commercial |
$8,312.50
|
| Rate for Payer: Wise Provider Network Commercial |
$8,312.50
|
|
|
DISTRACTION PIN 14 MM
|
Facility
|
OP
|
$346.50
|
|
| Hospital Charge Code |
2800357
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$187.63 |
| Max. Negotiated Rate |
$346.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$339.57
|
| Rate for Payer: Aetna of WY Medicare |
$228.69
|
| Rate for Payer: Altius Commercial |
$332.64
|
| Rate for Payer: Beech Street Commercial |
$339.57
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$336.10
|
| Rate for Payer: Cash Price |
$242.55
|
| Rate for Payer: ChoiceCare Network Commercial |
$336.10
|
| Rate for Payer: Cigna of WY Commercial |
$339.57
|
| Rate for Payer: Entrust Commercial |
$329.18
|
| Rate for Payer: First Choice Health Commercial |
$329.18
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$329.18
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$197.50
|
| Rate for Payer: HealthUtah PPO |
$346.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$336.10
|
| Rate for Payer: Multiplan Medicare/VA |
$187.63
|
| Rate for Payer: One Health Plan of WY PPO |
$339.57
|
| Rate for Payer: PacificSource Commercial |
$311.85
|
| Rate for Payer: PHCS PPO |
$339.57
|
| Rate for Payer: Three Rivers PPO |
$259.88
|
| Rate for Payer: TriWest Veterans Administration |
$197.50
|
| Rate for Payer: United Healthcare Commercial |
$330.91
|
| Rate for Payer: United Healthcare Medicare |
$197.50
|
| Rate for Payer: WINHealth Partners Commercial |
$339.57
|
| Rate for Payer: Wise Provider Network Commercial |
$329.18
|
|
|
DISTRACTION PIN 14 MM
|
Facility
|
IP
|
$346.50
|
|
| Hospital Charge Code |
2800357
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$200.80 |
| Max. Negotiated Rate |
$346.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$339.57
|
| Rate for Payer: Aetna of WY Medicare |
$221.76
|
| Rate for Payer: Altius Commercial |
$332.64
|
| Rate for Payer: Beech Street Commercial |
$339.57
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$336.10
|
| Rate for Payer: Cash Price |
$242.55
|
| Rate for Payer: ChoiceCare Network Commercial |
$336.10
|
| Rate for Payer: Cigna of WY Commercial |
$339.57
|
| Rate for Payer: Entrust Commercial |
$329.18
|
| Rate for Payer: First Choice Health Commercial |
$329.18
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$329.18
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$211.36
|
| Rate for Payer: HealthUtah PPO |
$346.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$336.10
|
| Rate for Payer: Multiplan Medicare/VA |
$200.80
|
| Rate for Payer: One Health Plan of WY PPO |
$339.57
|
| Rate for Payer: PacificSource Commercial |
$311.85
|
| Rate for Payer: PHCS PPO |
$339.57
|
| Rate for Payer: Three Rivers PPO |
$259.88
|
| Rate for Payer: TriWest Veterans Administration |
$211.36
|
| Rate for Payer: United Healthcare Commercial |
$330.91
|
| Rate for Payer: United Healthcare Medicare |
$211.36
|
| Rate for Payer: WINHealth Partners Commercial |
$329.18
|
| Rate for Payer: Wise Provider Network Commercial |
$329.18
|
|
|
DISTRACTOR PIN 14MM
|
Facility
|
OP
|
$79.45
|
|
| Hospital Charge Code |
2800107
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$43.02 |
| Max. Negotiated Rate |
$79.45 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$77.86
|
| Rate for Payer: Aetna of WY Medicare |
$52.44
|
| Rate for Payer: Altius Commercial |
$76.27
|
| Rate for Payer: Beech Street Commercial |
$77.86
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$77.07
|
| Rate for Payer: Cash Price |
$55.62
|
| Rate for Payer: ChoiceCare Network Commercial |
$77.07
|
| Rate for Payer: Cigna of WY Commercial |
$77.86
|
| Rate for Payer: Entrust Commercial |
$75.48
|
| Rate for Payer: First Choice Health Commercial |
$75.48
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$75.48
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$45.29
|
| Rate for Payer: HealthUtah PPO |
$79.45
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$77.07
|
| Rate for Payer: Multiplan Medicare/VA |
$43.02
|
| Rate for Payer: One Health Plan of WY PPO |
$77.86
|
| Rate for Payer: PacificSource Commercial |
$71.50
|
| Rate for Payer: PHCS PPO |
$77.86
|
| Rate for Payer: Three Rivers PPO |
$59.59
|
| Rate for Payer: TriWest Veterans Administration |
$45.29
|
| Rate for Payer: United Healthcare Commercial |
$75.87
|
| Rate for Payer: United Healthcare Medicare |
$45.29
|
| Rate for Payer: WINHealth Partners Commercial |
$77.86
|
| Rate for Payer: Wise Provider Network Commercial |
$75.48
|
|
|
DISTRACTOR PIN 14MM
|
Facility
|
IP
|
$79.45
|
|
| Hospital Charge Code |
2800107
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$46.04 |
| Max. Negotiated Rate |
$79.45 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$77.86
|
| Rate for Payer: Aetna of WY Medicare |
$50.85
|
| Rate for Payer: Altius Commercial |
$76.27
|
| Rate for Payer: Beech Street Commercial |
$77.86
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$77.07
|
| Rate for Payer: Cash Price |
$55.62
|
| Rate for Payer: ChoiceCare Network Commercial |
$77.07
|
| Rate for Payer: Cigna of WY Commercial |
$77.86
|
| Rate for Payer: Entrust Commercial |
$75.48
|
| Rate for Payer: First Choice Health Commercial |
$75.48
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$75.48
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$48.46
|
| Rate for Payer: HealthUtah PPO |
$79.45
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$77.07
|
| Rate for Payer: Multiplan Medicare/VA |
$46.04
|
| Rate for Payer: One Health Plan of WY PPO |
$77.86
|
| Rate for Payer: PacificSource Commercial |
$71.50
|
| Rate for Payer: PHCS PPO |
$77.86
|
| Rate for Payer: Three Rivers PPO |
$59.59
|
| Rate for Payer: TriWest Veterans Administration |
$48.46
|
| Rate for Payer: United Healthcare Commercial |
$75.87
|
| Rate for Payer: United Healthcare Medicare |
$48.46
|
| Rate for Payer: WINHealth Partners Commercial |
$75.48
|
| Rate for Payer: Wise Provider Network Commercial |
$75.48
|
|
|
DIVALPROEX 250 MG TABLET,DELAYED RELEASE [2620]
|
Facility
|
IP
|
$15.88
|
|
|
Service Code
|
NDC 0832712389
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.20 |
| Max. Negotiated Rate |
$15.88 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.56
|
| Rate for Payer: Aetna of WY Medicare |
$10.16
|
| Rate for Payer: Altius Commercial |
$15.24
|
| Rate for Payer: Beech Street Commercial |
$15.56
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.40
|
| Rate for Payer: Cash Price |
$11.12
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.40
|
| Rate for Payer: Cigna of WY Commercial |
$15.56
|
| Rate for Payer: Entrust Commercial |
$15.09
|
| Rate for Payer: First Choice Health Commercial |
$15.09
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.09
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.69
|
| Rate for Payer: HealthUtah PPO |
$15.88
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.40
|
| Rate for Payer: Multiplan Medicare/VA |
$9.20
|
| Rate for Payer: One Health Plan of WY PPO |
$15.56
|
| Rate for Payer: PacificSource Commercial |
$14.29
|
| Rate for Payer: PHCS PPO |
$15.56
|
| Rate for Payer: Three Rivers PPO |
$11.91
|
| Rate for Payer: TriWest Veterans Administration |
$9.69
|
| Rate for Payer: United Healthcare Commercial |
$15.17
|
| Rate for Payer: United Healthcare Medicare |
$9.69
|
| Rate for Payer: WINHealth Partners Commercial |
$15.09
|
| Rate for Payer: Wise Provider Network Commercial |
$15.09
|
|
|
DIVALPROEX 250 MG TABLET,DELAYED RELEASE [2620]
|
Facility
|
OP
|
$15.88
|
|
|
Service Code
|
NDC 0832712389
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.60 |
| Max. Negotiated Rate |
$15.88 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.56
|
| Rate for Payer: Aetna of WY Medicare |
$10.48
|
| Rate for Payer: Altius Commercial |
$15.24
|
| Rate for Payer: Beech Street Commercial |
$15.56
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.40
|
| Rate for Payer: Cash Price |
$11.12
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.40
|
| Rate for Payer: Cigna of WY Commercial |
$15.56
|
| Rate for Payer: Entrust Commercial |
$15.09
|
| Rate for Payer: First Choice Health Commercial |
$15.09
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.09
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.05
|
| Rate for Payer: HealthUtah PPO |
$15.88
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.40
|
| Rate for Payer: Multiplan Medicare/VA |
$8.60
|
| Rate for Payer: One Health Plan of WY PPO |
$15.56
|
| Rate for Payer: PacificSource Commercial |
$14.29
|
| Rate for Payer: PHCS PPO |
$15.56
|
| Rate for Payer: Three Rivers PPO |
$11.91
|
| Rate for Payer: TriWest Veterans Administration |
$9.05
|
| Rate for Payer: United Healthcare Commercial |
$15.17
|
| Rate for Payer: United Healthcare Medicare |
$9.05
|
| Rate for Payer: WINHealth Partners Commercial |
$15.56
|
| Rate for Payer: Wise Provider Network Commercial |
$15.09
|
|
|
DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION [54830]
|
Facility
|
OP
|
$16.39
|
|
|
Service Code
|
HCPCS J1250
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.88 |
| Max. Negotiated Rate |
$16.39 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.06
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.19
|
| Rate for Payer: Aetna of WY Medicare |
$10.90
|
| Rate for Payer: Aetna of WY Medicare |
$10.82
|
| Rate for Payer: Altius Commercial |
$15.73
|
| Rate for Payer: Altius Commercial |
$15.86
|
| Rate for Payer: Beech Street Commercial |
$16.06
|
| Rate for Payer: Beech Street Commercial |
$16.19
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.90
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.02
|
| Rate for Payer: Cash Price |
$11.47
|
| Rate for Payer: Cash Price |
$11.57
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.02
|
| Rate for Payer: Cigna of WY Commercial |
$16.19
|
| Rate for Payer: Cigna of WY Commercial |
$16.06
|
| Rate for Payer: Entrust Commercial |
$15.57
|
| Rate for Payer: Entrust Commercial |
$15.69
|
| Rate for Payer: First Choice Health Commercial |
$15.57
|
| Rate for Payer: First Choice Health Commercial |
$15.69
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.69
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.42
|
| Rate for Payer: HealthUtah PPO |
$16.52
|
| Rate for Payer: HealthUtah PPO |
$16.39
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.90
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.02
|
| Rate for Payer: Multiplan Medicare/VA |
$8.95
|
| Rate for Payer: Multiplan Medicare/VA |
$8.88
|
| Rate for Payer: One Health Plan of WY PPO |
$16.06
|
| Rate for Payer: One Health Plan of WY PPO |
$16.19
|
| Rate for Payer: PacificSource Commercial |
$14.87
|
| Rate for Payer: PacificSource Commercial |
$14.75
|
| Rate for Payer: PHCS PPO |
$16.06
|
| Rate for Payer: PHCS PPO |
$16.19
|
| Rate for Payer: Three Rivers PPO |
$12.29
|
| Rate for Payer: Three Rivers PPO |
$12.39
|
| Rate for Payer: TriWest Veterans Administration |
$9.42
|
| Rate for Payer: TriWest Veterans Administration |
$9.34
|
| Rate for Payer: United Healthcare Commercial |
$15.65
|
| Rate for Payer: United Healthcare Commercial |
$15.78
|
| Rate for Payer: United Healthcare Medicare |
$9.42
|
| Rate for Payer: United Healthcare Medicare |
$9.34
|
| Rate for Payer: WINHealth Partners Commercial |
$16.06
|
| Rate for Payer: WINHealth Partners Commercial |
$16.19
|
| Rate for Payer: Wise Provider Network Commercial |
$15.69
|
| Rate for Payer: Wise Provider Network Commercial |
$15.57
|
|
|
DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION [54830]
|
Facility
|
IP
|
$16.39
|
|
|
Service Code
|
HCPCS J1250
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.50 |
| Max. Negotiated Rate |
$16.39 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.06
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.19
|
| Rate for Payer: Aetna of WY Medicare |
$10.57
|
| Rate for Payer: Aetna of WY Medicare |
$10.49
|
| Rate for Payer: Altius Commercial |
$15.73
|
| Rate for Payer: Altius Commercial |
$15.86
|
| Rate for Payer: Beech Street Commercial |
$16.19
|
| Rate for Payer: Beech Street Commercial |
$16.06
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.02
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.90
|
| Rate for Payer: Cash Price |
$11.57
|
| Rate for Payer: Cash Price |
$11.47
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.02
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.90
|
| Rate for Payer: Cigna of WY Commercial |
$16.06
|
| Rate for Payer: Cigna of WY Commercial |
$16.19
|
| Rate for Payer: Entrust Commercial |
$15.69
|
| Rate for Payer: Entrust Commercial |
$15.57
|
| Rate for Payer: First Choice Health Commercial |
$15.57
|
| Rate for Payer: First Choice Health Commercial |
$15.69
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.69
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.08
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.00
|
| Rate for Payer: HealthUtah PPO |
$16.52
|
| Rate for Payer: HealthUtah PPO |
$16.39
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.02
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.90
|
| Rate for Payer: Multiplan Medicare/VA |
$9.50
|
| Rate for Payer: Multiplan Medicare/VA |
$9.57
|
| Rate for Payer: One Health Plan of WY PPO |
$16.19
|
| Rate for Payer: One Health Plan of WY PPO |
$16.06
|
| Rate for Payer: PacificSource Commercial |
$14.75
|
| Rate for Payer: PacificSource Commercial |
$14.87
|
| Rate for Payer: PHCS PPO |
$16.19
|
| Rate for Payer: PHCS PPO |
$16.06
|
| Rate for Payer: Three Rivers PPO |
$12.29
|
| Rate for Payer: Three Rivers PPO |
$12.39
|
| Rate for Payer: TriWest Veterans Administration |
$10.00
|
| Rate for Payer: TriWest Veterans Administration |
$10.08
|
| Rate for Payer: United Healthcare Commercial |
$15.65
|
| Rate for Payer: United Healthcare Commercial |
$15.78
|
| Rate for Payer: United Healthcare Medicare |
$10.08
|
| Rate for Payer: United Healthcare Medicare |
$10.00
|
| Rate for Payer: WINHealth Partners Commercial |
$15.57
|
| Rate for Payer: WINHealth Partners Commercial |
$15.69
|
| Rate for Payer: Wise Provider Network Commercial |
$15.57
|
| Rate for Payer: Wise Provider Network Commercial |
$15.69
|
|
|
DOCETAXEL 10 MG/ML INTRAVENOUS SOLUTION (WRAPPED) [4000725]
|
Facility
|
OP
|
$57.66
|
|
|
Service Code
|
HCPCS J9171
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.22 |
| Max. Negotiated Rate |
$57.66 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$56.51
|
| Rate for Payer: Aetna of WY Medicare |
$38.06
|
| Rate for Payer: Altius Commercial |
$55.35
|
| Rate for Payer: Beech Street Commercial |
$56.51
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$55.93
|
| Rate for Payer: Cash Price |
$40.36
|
| Rate for Payer: ChoiceCare Network Commercial |
$55.93
|
| Rate for Payer: Cigna of WY Commercial |
$56.51
|
| Rate for Payer: Entrust Commercial |
$54.78
|
| Rate for Payer: First Choice Health Commercial |
$54.78
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$54.78
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$32.87
|
| Rate for Payer: HealthUtah PPO |
$57.66
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$55.93
|
| Rate for Payer: Multiplan Medicare/VA |
$31.22
|
| Rate for Payer: One Health Plan of WY PPO |
$56.51
|
| Rate for Payer: PacificSource Commercial |
$51.89
|
| Rate for Payer: PHCS PPO |
$56.51
|
| Rate for Payer: Three Rivers PPO |
$43.24
|
| Rate for Payer: TriWest Veterans Administration |
$32.87
|
| Rate for Payer: United Healthcare Commercial |
$55.07
|
| Rate for Payer: United Healthcare Medicare |
$32.87
|
| Rate for Payer: WINHealth Partners Commercial |
$56.51
|
| Rate for Payer: Wise Provider Network Commercial |
$54.78
|
|
|
DOCETAXEL 10 MG/ML INTRAVENOUS SOLUTION (WRAPPED) [4000725]
|
Facility
|
IP
|
$57.66
|
|
|
Service Code
|
HCPCS J9171
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.41 |
| Max. Negotiated Rate |
$57.66 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$56.51
|
| Rate for Payer: Aetna of WY Medicare |
$36.90
|
| Rate for Payer: Altius Commercial |
$55.35
|
| Rate for Payer: Beech Street Commercial |
$56.51
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$55.93
|
| Rate for Payer: Cash Price |
$40.36
|
| Rate for Payer: ChoiceCare Network Commercial |
$55.93
|
| Rate for Payer: Cigna of WY Commercial |
$56.51
|
| Rate for Payer: Entrust Commercial |
$54.78
|
| Rate for Payer: First Choice Health Commercial |
$54.78
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$54.78
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$35.17
|
| Rate for Payer: HealthUtah PPO |
$57.66
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$55.93
|
| Rate for Payer: Multiplan Medicare/VA |
$33.41
|
| Rate for Payer: One Health Plan of WY PPO |
$56.51
|
| Rate for Payer: PacificSource Commercial |
$51.89
|
| Rate for Payer: PHCS PPO |
$56.51
|
| Rate for Payer: Three Rivers PPO |
$43.24
|
| Rate for Payer: TriWest Veterans Administration |
$35.17
|
| Rate for Payer: United Healthcare Commercial |
$55.07
|
| Rate for Payer: United Healthcare Medicare |
$35.17
|
| Rate for Payer: WINHealth Partners Commercial |
$54.78
|
| Rate for Payer: Wise Provider Network Commercial |
$54.78
|
|
|
DOCETAXEL 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION [90791]
|
Facility
|
IP
|
$152.81
|
|
|
Service Code
|
HCPCS J9171
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$88.55 |
| Max. Negotiated Rate |
$152.81 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$149.75
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$56.35
|
| Rate for Payer: Aetna of WY Medicare |
$36.80
|
| Rate for Payer: Aetna of WY Medicare |
$97.80
|
| Rate for Payer: Altius Commercial |
$146.70
|
| Rate for Payer: Altius Commercial |
$55.20
|
| Rate for Payer: Beech Street Commercial |
$149.75
|
| Rate for Payer: Beech Street Commercial |
$56.35
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$148.23
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$55.78
|
| Rate for Payer: Cash Price |
$106.97
|
| Rate for Payer: Cash Price |
$40.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$148.23
|
| Rate for Payer: ChoiceCare Network Commercial |
$55.78
|
| Rate for Payer: Cigna of WY Commercial |
$149.75
|
| Rate for Payer: Cigna of WY Commercial |
$56.35
|
| Rate for Payer: Entrust Commercial |
$145.17
|
| Rate for Payer: Entrust Commercial |
$54.62
|
| Rate for Payer: First Choice Health Commercial |
$54.62
|
| Rate for Payer: First Choice Health Commercial |
$145.17
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$54.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$145.17
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$35.08
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$93.21
|
| Rate for Payer: HealthUtah PPO |
$152.81
|
| Rate for Payer: HealthUtah PPO |
$57.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$148.23
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$55.78
|
| Rate for Payer: Multiplan Medicare/VA |
$33.32
|
| Rate for Payer: Multiplan Medicare/VA |
$88.55
|
| Rate for Payer: One Health Plan of WY PPO |
$149.75
|
| Rate for Payer: One Health Plan of WY PPO |
$56.35
|
| Rate for Payer: PacificSource Commercial |
$51.75
|
| Rate for Payer: PacificSource Commercial |
$137.53
|
| Rate for Payer: PHCS PPO |
$149.75
|
| Rate for Payer: PHCS PPO |
$56.35
|
| Rate for Payer: Three Rivers PPO |
$43.12
|
| Rate for Payer: Three Rivers PPO |
$114.61
|
| Rate for Payer: TriWest Veterans Administration |
$35.08
|
| Rate for Payer: TriWest Veterans Administration |
$93.21
|
| Rate for Payer: United Healthcare Commercial |
$145.93
|
| Rate for Payer: United Healthcare Commercial |
$54.91
|
| Rate for Payer: United Healthcare Medicare |
$35.08
|
| Rate for Payer: United Healthcare Medicare |
$93.21
|
| Rate for Payer: WINHealth Partners Commercial |
$145.17
|
| Rate for Payer: WINHealth Partners Commercial |
$54.62
|
| Rate for Payer: Wise Provider Network Commercial |
$54.62
|
| Rate for Payer: Wise Provider Network Commercial |
$145.17
|
|
|
DOCETAXEL 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION [90791]
|
Facility
|
OP
|
$57.50
|
|
|
Service Code
|
HCPCS J9171
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.14 |
| Max. Negotiated Rate |
$57.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$56.35
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$149.75
|
| Rate for Payer: Aetna of WY Medicare |
$37.95
|
| Rate for Payer: Aetna of WY Medicare |
$100.85
|
| Rate for Payer: Altius Commercial |
$146.70
|
| Rate for Payer: Altius Commercial |
$55.20
|
| Rate for Payer: Beech Street Commercial |
$56.35
|
| Rate for Payer: Beech Street Commercial |
$149.75
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$55.78
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$148.23
|
| Rate for Payer: Cash Price |
$106.97
|
| Rate for Payer: Cash Price |
$40.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$148.23
|
| Rate for Payer: ChoiceCare Network Commercial |
$55.78
|
| Rate for Payer: Cigna of WY Commercial |
$149.75
|
| Rate for Payer: Cigna of WY Commercial |
$56.35
|
| Rate for Payer: Entrust Commercial |
$145.17
|
| Rate for Payer: Entrust Commercial |
$54.62
|
| Rate for Payer: First Choice Health Commercial |
$54.62
|
| Rate for Payer: First Choice Health Commercial |
$145.17
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$54.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$145.17
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$87.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$32.78
|
| Rate for Payer: HealthUtah PPO |
$57.50
|
| Rate for Payer: HealthUtah PPO |
$152.81
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$148.23
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$55.78
|
| Rate for Payer: Multiplan Medicare/VA |
$31.14
|
| Rate for Payer: Multiplan Medicare/VA |
$82.75
|
| Rate for Payer: One Health Plan of WY PPO |
$56.35
|
| Rate for Payer: One Health Plan of WY PPO |
$149.75
|
| Rate for Payer: PacificSource Commercial |
$137.53
|
| Rate for Payer: PacificSource Commercial |
$51.75
|
| Rate for Payer: PHCS PPO |
$56.35
|
| Rate for Payer: PHCS PPO |
$149.75
|
| Rate for Payer: Three Rivers PPO |
$43.12
|
| Rate for Payer: Three Rivers PPO |
$114.61
|
| Rate for Payer: TriWest Veterans Administration |
$87.10
|
| Rate for Payer: TriWest Veterans Administration |
$32.78
|
| Rate for Payer: United Healthcare Commercial |
$145.93
|
| Rate for Payer: United Healthcare Commercial |
$54.91
|
| Rate for Payer: United Healthcare Medicare |
$32.78
|
| Rate for Payer: United Healthcare Medicare |
$87.10
|
| Rate for Payer: WINHealth Partners Commercial |
$149.75
|
| Rate for Payer: WINHealth Partners Commercial |
$56.35
|
| Rate for Payer: Wise Provider Network Commercial |
$145.17
|
| Rate for Payer: Wise Provider Network Commercial |
$54.62
|
|
|
DOCUSATE SODIUM 100 MG CAPSULE [14921]
|
Facility
|
OP
|
$15.08
|
|
|
Service Code
|
NDC 0904728060
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.17 |
| Max. Negotiated Rate |
$15.08 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.78
|
| Rate for Payer: Aetna of WY Medicare |
$9.95
|
| Rate for Payer: Altius Commercial |
$14.48
|
| Rate for Payer: Beech Street Commercial |
$14.78
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.63
|
| Rate for Payer: Cash Price |
$10.55
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.63
|
| Rate for Payer: Cigna of WY Commercial |
$14.78
|
| Rate for Payer: Entrust Commercial |
$14.33
|
| Rate for Payer: First Choice Health Commercial |
$14.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.60
|
| Rate for Payer: HealthUtah PPO |
$15.08
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.63
|
| Rate for Payer: Multiplan Medicare/VA |
$8.17
|
| Rate for Payer: One Health Plan of WY PPO |
$14.78
|
| Rate for Payer: PacificSource Commercial |
$13.57
|
| Rate for Payer: PHCS PPO |
$14.78
|
| Rate for Payer: Three Rivers PPO |
$11.31
|
| Rate for Payer: TriWest Veterans Administration |
$8.60
|
| Rate for Payer: United Healthcare Commercial |
$14.40
|
| Rate for Payer: United Healthcare Medicare |
$8.60
|
| Rate for Payer: WINHealth Partners Commercial |
$14.78
|
| Rate for Payer: Wise Provider Network Commercial |
$14.33
|
|
|
DOCUSATE SODIUM 100 MG CAPSULE [14921]
|
Facility
|
IP
|
$15.08
|
|
|
Service Code
|
NDC 0904728060
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.74 |
| Max. Negotiated Rate |
$15.08 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.78
|
| Rate for Payer: Aetna of WY Medicare |
$9.65
|
| Rate for Payer: Altius Commercial |
$14.48
|
| Rate for Payer: Beech Street Commercial |
$14.78
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.63
|
| Rate for Payer: Cash Price |
$10.55
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.63
|
| Rate for Payer: Cigna of WY Commercial |
$14.78
|
| Rate for Payer: Entrust Commercial |
$14.33
|
| Rate for Payer: First Choice Health Commercial |
$14.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.20
|
| Rate for Payer: HealthUtah PPO |
$15.08
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.63
|
| Rate for Payer: Multiplan Medicare/VA |
$8.74
|
| Rate for Payer: One Health Plan of WY PPO |
$14.78
|
| Rate for Payer: PacificSource Commercial |
$13.57
|
| Rate for Payer: PHCS PPO |
$14.78
|
| Rate for Payer: Three Rivers PPO |
$11.31
|
| Rate for Payer: TriWest Veterans Administration |
$9.20
|
| Rate for Payer: United Healthcare Commercial |
$14.40
|
| Rate for Payer: United Healthcare Medicare |
$9.20
|
| Rate for Payer: WINHealth Partners Commercial |
$14.33
|
| Rate for Payer: Wise Provider Network Commercial |
$14.33
|
|
|
DOCUSATE SODIUM 100 MG CAPSULE [14921]
|
Facility
|
OP
|
$15.06
|
|
|
Service Code
|
NDC 0904718361
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.15 |
| Max. Negotiated Rate |
$15.06 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.76
|
| Rate for Payer: Aetna of WY Medicare |
$9.94
|
| Rate for Payer: Altius Commercial |
$14.46
|
| Rate for Payer: Beech Street Commercial |
$14.76
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.61
|
| Rate for Payer: Cash Price |
$10.54
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.61
|
| Rate for Payer: Cigna of WY Commercial |
$14.76
|
| Rate for Payer: Entrust Commercial |
$14.31
|
| Rate for Payer: First Choice Health Commercial |
$14.31
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.31
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.58
|
| Rate for Payer: HealthUtah PPO |
$15.06
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.61
|
| Rate for Payer: Multiplan Medicare/VA |
$8.15
|
| Rate for Payer: One Health Plan of WY PPO |
$14.76
|
| Rate for Payer: PacificSource Commercial |
$13.55
|
| Rate for Payer: PHCS PPO |
$14.76
|
| Rate for Payer: Three Rivers PPO |
$11.30
|
| Rate for Payer: TriWest Veterans Administration |
$8.58
|
| Rate for Payer: United Healthcare Commercial |
$14.38
|
| Rate for Payer: United Healthcare Medicare |
$8.58
|
| Rate for Payer: WINHealth Partners Commercial |
$14.76
|
| Rate for Payer: Wise Provider Network Commercial |
$14.31
|
|
|
DOCUSATE SODIUM 100 MG CAPSULE [14921]
|
Facility
|
IP
|
$15.20
|
|
|
Service Code
|
NDC 0904728080
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.81 |
| Max. Negotiated Rate |
$15.20 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.90
|
| Rate for Payer: Aetna of WY Medicare |
$9.73
|
| Rate for Payer: Altius Commercial |
$14.59
|
| Rate for Payer: Beech Street Commercial |
$14.90
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.74
|
| Rate for Payer: Cash Price |
$10.64
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.74
|
| Rate for Payer: Cigna of WY Commercial |
$14.90
|
| Rate for Payer: Entrust Commercial |
$14.44
|
| Rate for Payer: First Choice Health Commercial |
$14.44
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.44
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.27
|
| Rate for Payer: HealthUtah PPO |
$15.20
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.74
|
| Rate for Payer: Multiplan Medicare/VA |
$8.81
|
| Rate for Payer: One Health Plan of WY PPO |
$14.90
|
| Rate for Payer: PacificSource Commercial |
$13.68
|
| Rate for Payer: PHCS PPO |
$14.90
|
| Rate for Payer: Three Rivers PPO |
$11.40
|
| Rate for Payer: TriWest Veterans Administration |
$9.27
|
| Rate for Payer: United Healthcare Commercial |
$14.52
|
| Rate for Payer: United Healthcare Medicare |
$9.27
|
| Rate for Payer: WINHealth Partners Commercial |
$14.44
|
| Rate for Payer: Wise Provider Network Commercial |
$14.44
|
|
