|
ESCITALOPRAM 20 MG TABLET [25996]
|
Facility
|
OP
|
$16.27
|
|
|
Service Code
|
NDC 6808461801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.81 |
| Max. Negotiated Rate |
$16.27 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.94
|
| Rate for Payer: Aetna of WY Medicare |
$10.74
|
| Rate for Payer: Altius Commercial |
$15.62
|
| Rate for Payer: Beech Street Commercial |
$15.94
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.78
|
| Rate for Payer: Cash Price |
$11.39
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.78
|
| Rate for Payer: Cigna of WY Commercial |
$15.94
|
| Rate for Payer: Entrust Commercial |
$15.46
|
| Rate for Payer: First Choice Health Commercial |
$15.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.27
|
| Rate for Payer: HealthUtah PPO |
$16.27
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.78
|
| Rate for Payer: Multiplan Medicare/VA |
$8.81
|
| Rate for Payer: One Health Plan of WY PPO |
$15.94
|
| Rate for Payer: PacificSource Commercial |
$14.64
|
| Rate for Payer: PHCS PPO |
$15.94
|
| Rate for Payer: Three Rivers PPO |
$12.20
|
| Rate for Payer: TriWest Veterans Administration |
$9.27
|
| Rate for Payer: United Healthcare Commercial |
$15.54
|
| Rate for Payer: United Healthcare Medicare |
$9.27
|
| Rate for Payer: WINHealth Partners Commercial |
$15.94
|
| Rate for Payer: Wise Provider Network Commercial |
$15.46
|
|
|
ESCITALOPRAM 20 MG TABLET [25996]
|
Facility
|
IP
|
$16.27
|
|
|
Service Code
|
NDC 6808461811
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.43 |
| Max. Negotiated Rate |
$16.27 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.94
|
| Rate for Payer: Aetna of WY Medicare |
$10.41
|
| Rate for Payer: Altius Commercial |
$15.62
|
| Rate for Payer: Beech Street Commercial |
$15.94
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.78
|
| Rate for Payer: Cash Price |
$11.39
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.78
|
| Rate for Payer: Cigna of WY Commercial |
$15.94
|
| Rate for Payer: Entrust Commercial |
$15.46
|
| Rate for Payer: First Choice Health Commercial |
$15.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.92
|
| Rate for Payer: HealthUtah PPO |
$16.27
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.78
|
| Rate for Payer: Multiplan Medicare/VA |
$9.43
|
| Rate for Payer: One Health Plan of WY PPO |
$15.94
|
| Rate for Payer: PacificSource Commercial |
$14.64
|
| Rate for Payer: PHCS PPO |
$15.94
|
| Rate for Payer: Three Rivers PPO |
$12.20
|
| Rate for Payer: TriWest Veterans Administration |
$9.92
|
| Rate for Payer: United Healthcare Commercial |
$15.54
|
| Rate for Payer: United Healthcare Medicare |
$9.92
|
| Rate for Payer: WINHealth Partners Commercial |
$15.46
|
| Rate for Payer: Wise Provider Network Commercial |
$15.46
|
|
|
ESCITALOPRAM 20 MG TABLET [25996]
|
Facility
|
IP
|
$16.27
|
|
|
Service Code
|
NDC 6808461801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.43 |
| Max. Negotiated Rate |
$16.27 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.94
|
| Rate for Payer: Aetna of WY Medicare |
$10.41
|
| Rate for Payer: Altius Commercial |
$15.62
|
| Rate for Payer: Beech Street Commercial |
$15.94
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.78
|
| Rate for Payer: Cash Price |
$11.39
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.78
|
| Rate for Payer: Cigna of WY Commercial |
$15.94
|
| Rate for Payer: Entrust Commercial |
$15.46
|
| Rate for Payer: First Choice Health Commercial |
$15.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.92
|
| Rate for Payer: HealthUtah PPO |
$16.27
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.78
|
| Rate for Payer: Multiplan Medicare/VA |
$9.43
|
| Rate for Payer: One Health Plan of WY PPO |
$15.94
|
| Rate for Payer: PacificSource Commercial |
$14.64
|
| Rate for Payer: PHCS PPO |
$15.94
|
| Rate for Payer: Three Rivers PPO |
$12.20
|
| Rate for Payer: TriWest Veterans Administration |
$9.92
|
| Rate for Payer: United Healthcare Commercial |
$15.54
|
| Rate for Payer: United Healthcare Medicare |
$9.92
|
| Rate for Payer: WINHealth Partners Commercial |
$15.46
|
| Rate for Payer: Wise Provider Network Commercial |
$15.46
|
|
|
ESCITALOPRAM 20 MG TABLET [25996]
|
Facility
|
OP
|
$16.27
|
|
|
Service Code
|
NDC 6808461811
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.81 |
| Max. Negotiated Rate |
$16.27 |
| Rate for Payer: WINHealth Partners Commercial |
$15.94
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.94
|
| Rate for Payer: Aetna of WY Medicare |
$10.74
|
| Rate for Payer: Altius Commercial |
$15.62
|
| Rate for Payer: Beech Street Commercial |
$15.94
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.78
|
| Rate for Payer: Cash Price |
$11.39
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.78
|
| Rate for Payer: Cigna of WY Commercial |
$15.94
|
| Rate for Payer: Entrust Commercial |
$15.46
|
| Rate for Payer: First Choice Health Commercial |
$15.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.27
|
| Rate for Payer: HealthUtah PPO |
$16.27
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.78
|
| Rate for Payer: Multiplan Medicare/VA |
$8.81
|
| Rate for Payer: One Health Plan of WY PPO |
$15.94
|
| Rate for Payer: PacificSource Commercial |
$14.64
|
| Rate for Payer: PHCS PPO |
$15.94
|
| Rate for Payer: Three Rivers PPO |
$12.20
|
| Rate for Payer: TriWest Veterans Administration |
$9.27
|
| Rate for Payer: United Healthcare Commercial |
$15.54
|
| Rate for Payer: United Healthcare Medicare |
$9.27
|
| Rate for Payer: Wise Provider Network Commercial |
$15.46
|
|
|
ESMARK BANDAGE 4" STERILE
|
Facility
|
IP
|
$7.56
|
|
| Hospital Charge Code |
2650135
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$4.38 |
| Max. Negotiated Rate |
$7.56 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$7.41
|
| Rate for Payer: Aetna of WY Medicare |
$4.84
|
| Rate for Payer: Altius Commercial |
$7.26
|
| Rate for Payer: Beech Street Commercial |
$7.41
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$7.33
|
| Rate for Payer: Cash Price |
$5.29
|
| Rate for Payer: ChoiceCare Network Commercial |
$7.33
|
| Rate for Payer: Cigna of WY Commercial |
$7.41
|
| Rate for Payer: Entrust Commercial |
$7.18
|
| Rate for Payer: First Choice Health Commercial |
$7.18
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$7.18
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$4.61
|
| Rate for Payer: HealthUtah PPO |
$7.56
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$7.33
|
| Rate for Payer: Multiplan Medicare/VA |
$4.38
|
| Rate for Payer: One Health Plan of WY PPO |
$7.41
|
| Rate for Payer: PacificSource Commercial |
$6.80
|
| Rate for Payer: PHCS PPO |
$7.41
|
| Rate for Payer: Three Rivers PPO |
$5.67
|
| Rate for Payer: TriWest Veterans Administration |
$4.61
|
| Rate for Payer: United Healthcare Commercial |
$7.22
|
| Rate for Payer: United Healthcare Medicare |
$4.61
|
| Rate for Payer: WINHealth Partners Commercial |
$7.18
|
| Rate for Payer: Wise Provider Network Commercial |
$7.18
|
|
|
ESMARK BANDAGE 4" STERILE
|
Facility
|
OP
|
$7.56
|
|
| Hospital Charge Code |
2650135
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$4.09 |
| Max. Negotiated Rate |
$7.56 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$7.41
|
| Rate for Payer: Aetna of WY Medicare |
$4.99
|
| Rate for Payer: Altius Commercial |
$7.26
|
| Rate for Payer: Beech Street Commercial |
$7.41
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$7.33
|
| Rate for Payer: Cash Price |
$5.29
|
| Rate for Payer: ChoiceCare Network Commercial |
$7.33
|
| Rate for Payer: Cigna of WY Commercial |
$7.41
|
| Rate for Payer: Entrust Commercial |
$7.18
|
| Rate for Payer: First Choice Health Commercial |
$7.18
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$7.18
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$4.31
|
| Rate for Payer: HealthUtah PPO |
$7.56
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$7.33
|
| Rate for Payer: Multiplan Medicare/VA |
$4.09
|
| Rate for Payer: One Health Plan of WY PPO |
$7.41
|
| Rate for Payer: PacificSource Commercial |
$6.80
|
| Rate for Payer: PHCS PPO |
$7.41
|
| Rate for Payer: Three Rivers PPO |
$5.67
|
| Rate for Payer: TriWest Veterans Administration |
$4.31
|
| Rate for Payer: United Healthcare Commercial |
$7.22
|
| Rate for Payer: United Healthcare Medicare |
$4.31
|
| Rate for Payer: WINHealth Partners Commercial |
$7.41
|
| Rate for Payer: Wise Provider Network Commercial |
$7.18
|
|
|
ESMARK BANDAGE 6" STERILE
|
Facility
|
IP
|
$9.54
|
|
| Hospital Charge Code |
2650136
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$5.53 |
| Max. Negotiated Rate |
$9.54 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$9.35
|
| Rate for Payer: Aetna of WY Medicare |
$6.11
|
| Rate for Payer: Altius Commercial |
$9.16
|
| Rate for Payer: Beech Street Commercial |
$9.35
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$9.25
|
| Rate for Payer: Cash Price |
$6.68
|
| Rate for Payer: ChoiceCare Network Commercial |
$9.25
|
| Rate for Payer: Cigna of WY Commercial |
$9.35
|
| Rate for Payer: Entrust Commercial |
$9.06
|
| Rate for Payer: First Choice Health Commercial |
$9.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$9.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$5.82
|
| Rate for Payer: HealthUtah PPO |
$9.54
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$9.25
|
| Rate for Payer: Multiplan Medicare/VA |
$5.53
|
| Rate for Payer: One Health Plan of WY PPO |
$9.35
|
| Rate for Payer: PacificSource Commercial |
$8.59
|
| Rate for Payer: PHCS PPO |
$9.35
|
| Rate for Payer: Three Rivers PPO |
$7.16
|
| Rate for Payer: TriWest Veterans Administration |
$5.82
|
| Rate for Payer: United Healthcare Commercial |
$9.11
|
| Rate for Payer: United Healthcare Medicare |
$5.82
|
| Rate for Payer: WINHealth Partners Commercial |
$9.06
|
| Rate for Payer: Wise Provider Network Commercial |
$9.06
|
|
|
ESMARK BANDAGE 6" STERILE
|
Facility
|
OP
|
$9.54
|
|
| Hospital Charge Code |
2650136
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$5.17 |
| Max. Negotiated Rate |
$9.54 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$9.35
|
| Rate for Payer: Aetna of WY Medicare |
$6.30
|
| Rate for Payer: Altius Commercial |
$9.16
|
| Rate for Payer: Beech Street Commercial |
$9.35
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$9.25
|
| Rate for Payer: Cash Price |
$6.68
|
| Rate for Payer: ChoiceCare Network Commercial |
$9.25
|
| Rate for Payer: Cigna of WY Commercial |
$9.35
|
| Rate for Payer: Entrust Commercial |
$9.06
|
| Rate for Payer: First Choice Health Commercial |
$9.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$9.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$5.44
|
| Rate for Payer: HealthUtah PPO |
$9.54
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$9.25
|
| Rate for Payer: Multiplan Medicare/VA |
$5.17
|
| Rate for Payer: One Health Plan of WY PPO |
$9.35
|
| Rate for Payer: PacificSource Commercial |
$8.59
|
| Rate for Payer: PHCS PPO |
$9.35
|
| Rate for Payer: Three Rivers PPO |
$7.16
|
| Rate for Payer: TriWest Veterans Administration |
$5.44
|
| Rate for Payer: United Healthcare Commercial |
$9.11
|
| Rate for Payer: United Healthcare Medicare |
$5.44
|
| Rate for Payer: WINHealth Partners Commercial |
$9.35
|
| Rate for Payer: Wise Provider Network Commercial |
$9.06
|
|
|
ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION [10165]
|
Facility
|
OP
|
$16.76
|
|
|
Service Code
|
NDC 5515019410
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.08 |
| Max. Negotiated Rate |
$16.76 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.42
|
| Rate for Payer: Aetna of WY Medicare |
$11.06
|
| Rate for Payer: Altius Commercial |
$16.09
|
| Rate for Payer: Beech Street Commercial |
$16.42
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.26
|
| Rate for Payer: Cash Price |
$11.73
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.26
|
| Rate for Payer: Cigna of WY Commercial |
$16.42
|
| Rate for Payer: Entrust Commercial |
$15.92
|
| Rate for Payer: First Choice Health Commercial |
$15.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.55
|
| Rate for Payer: HealthUtah PPO |
$16.76
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.26
|
| Rate for Payer: Multiplan Medicare/VA |
$9.08
|
| Rate for Payer: One Health Plan of WY PPO |
$16.42
|
| Rate for Payer: PacificSource Commercial |
$15.08
|
| Rate for Payer: PHCS PPO |
$16.42
|
| Rate for Payer: Three Rivers PPO |
$12.57
|
| Rate for Payer: TriWest Veterans Administration |
$9.55
|
| Rate for Payer: United Healthcare Commercial |
$16.01
|
| Rate for Payer: United Healthcare Medicare |
$9.55
|
| Rate for Payer: WINHealth Partners Commercial |
$16.42
|
| Rate for Payer: Wise Provider Network Commercial |
$15.92
|
|
|
ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION [10165]
|
Facility
|
IP
|
$16.76
|
|
|
Service Code
|
NDC 5515019410
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.71 |
| Max. Negotiated Rate |
$16.76 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.42
|
| Rate for Payer: Aetna of WY Medicare |
$10.73
|
| Rate for Payer: Altius Commercial |
$16.09
|
| Rate for Payer: Beech Street Commercial |
$16.42
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.26
|
| Rate for Payer: Cash Price |
$11.73
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.26
|
| Rate for Payer: Cigna of WY Commercial |
$16.42
|
| Rate for Payer: Entrust Commercial |
$15.92
|
| Rate for Payer: First Choice Health Commercial |
$15.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.22
|
| Rate for Payer: HealthUtah PPO |
$16.76
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.26
|
| Rate for Payer: Multiplan Medicare/VA |
$9.71
|
| Rate for Payer: One Health Plan of WY PPO |
$16.42
|
| Rate for Payer: PacificSource Commercial |
$15.08
|
| Rate for Payer: PHCS PPO |
$16.42
|
| Rate for Payer: Three Rivers PPO |
$12.57
|
| Rate for Payer: TriWest Veterans Administration |
$10.22
|
| Rate for Payer: United Healthcare Commercial |
$16.01
|
| Rate for Payer: United Healthcare Medicare |
$10.22
|
| Rate for Payer: WINHealth Partners Commercial |
$15.92
|
| Rate for Payer: Wise Provider Network Commercial |
$15.92
|
|
|
ESOPHAGOGASTRODUODENOSCOPY TRANSORAL DIAGNOSTIC
|
Professional
|
Both
|
$543.00
|
|
|
Service Code
|
HCPCS 43235
|
| Min. Negotiated Rate |
$99.14 |
| Max. Negotiated Rate |
$543.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$532.14
|
| Rate for Payer: Aetna of WY Medicare |
$116.64
|
| Rate for Payer: Beech Street Commercial |
$515.85
|
| Rate for Payer: Cash Price |
$380.10
|
| Rate for Payer: Cash Price |
$380.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$526.71
|
| Rate for Payer: Cigna of WY Commercial |
$532.14
|
| Rate for Payer: First Choice Health Commercial |
$488.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$515.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$116.64
|
| Rate for Payer: HealthUtah PPO |
$543.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$526.71
|
| Rate for Payer: Multiplan Medicare/VA |
$99.14
|
| Rate for Payer: One Health Plan of WY PPO |
$532.14
|
| Rate for Payer: PacificSource Commercial |
$488.70
|
| Rate for Payer: PHCS PPO |
$515.85
|
| Rate for Payer: Three Rivers PPO |
$407.25
|
| Rate for Payer: TriWest Veterans Administration |
$116.64
|
| Rate for Payer: United Healthcare Commercial |
$515.85
|
| Rate for Payer: WINHealth Partners Commercial |
$461.55
|
|
|
ESOPHAGOSCOPY FLEX BALLOON DILAT <30 MM DIAM
|
Professional
|
Both
|
$1,393.00
|
|
|
Service Code
|
HCPCS 43220
|
| Min. Negotiated Rate |
$95.46 |
| Max. Negotiated Rate |
$1,393.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,365.14
|
| Rate for Payer: Aetna of WY Medicare |
$112.30
|
| Rate for Payer: Beech Street Commercial |
$1,323.35
|
| Rate for Payer: Cash Price |
$975.10
|
| Rate for Payer: Cash Price |
$975.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,351.21
|
| Rate for Payer: Cigna of WY Commercial |
$1,365.14
|
| Rate for Payer: First Choice Health Commercial |
$1,253.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,323.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$112.30
|
| Rate for Payer: HealthUtah PPO |
$1,393.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,351.21
|
| Rate for Payer: Multiplan Medicare/VA |
$95.46
|
| Rate for Payer: One Health Plan of WY PPO |
$1,365.14
|
| Rate for Payer: PacificSource Commercial |
$1,253.70
|
| Rate for Payer: PHCS PPO |
$1,323.35
|
| Rate for Payer: Three Rivers PPO |
$1,044.75
|
| Rate for Payer: TriWest Veterans Administration |
$112.30
|
| Rate for Payer: United Healthcare Commercial |
$1,323.35
|
| Rate for Payer: WINHealth Partners Commercial |
$1,184.05
|
|
|
ESOPHAGOSCOPY FLEXIBLE REMOVAL FOREIGN BODY
|
Professional
|
Both
|
$624.00
|
|
|
Service Code
|
HCPCS 43215
|
| Min. Negotiated Rate |
$113.86 |
| Max. Negotiated Rate |
$624.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$611.52
|
| Rate for Payer: Aetna of WY Medicare |
$133.95
|
| Rate for Payer: Beech Street Commercial |
$592.80
|
| Rate for Payer: Cash Price |
$436.80
|
| Rate for Payer: Cash Price |
$436.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$605.28
|
| Rate for Payer: Cigna of WY Commercial |
$611.52
|
| Rate for Payer: First Choice Health Commercial |
$561.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$592.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$133.95
|
| Rate for Payer: HealthUtah PPO |
$624.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$605.28
|
| Rate for Payer: Multiplan Medicare/VA |
$113.86
|
| Rate for Payer: One Health Plan of WY PPO |
$611.52
|
| Rate for Payer: PacificSource Commercial |
$561.60
|
| Rate for Payer: PHCS PPO |
$592.80
|
| Rate for Payer: Three Rivers PPO |
$468.00
|
| Rate for Payer: TriWest Veterans Administration |
$133.95
|
| Rate for Payer: United Healthcare Commercial |
$592.80
|
| Rate for Payer: WINHealth Partners Commercial |
$530.40
|
|
|
ESOPHAGOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC
|
Professional
|
Both
|
$1,563.00
|
|
|
Service Code
|
HCPCS 43200
|
| Min. Negotiated Rate |
$71.32 |
| Max. Negotiated Rate |
$1,563.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,531.74
|
| Rate for Payer: Aetna of WY Medicare |
$83.91
|
| Rate for Payer: Beech Street Commercial |
$1,484.85
|
| Rate for Payer: Cash Price |
$1,094.10
|
| Rate for Payer: Cash Price |
$1,094.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,516.11
|
| Rate for Payer: Cigna of WY Commercial |
$1,531.74
|
| Rate for Payer: First Choice Health Commercial |
$1,406.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,484.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$83.91
|
| Rate for Payer: HealthUtah PPO |
$1,563.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,516.11
|
| Rate for Payer: Multiplan Medicare/VA |
$71.32
|
| Rate for Payer: One Health Plan of WY PPO |
$1,531.74
|
| Rate for Payer: PacificSource Commercial |
$1,406.70
|
| Rate for Payer: PHCS PPO |
$1,484.85
|
| Rate for Payer: Three Rivers PPO |
$1,172.25
|
| Rate for Payer: TriWest Veterans Administration |
$83.91
|
| Rate for Payer: United Healthcare Commercial |
$1,484.85
|
| Rate for Payer: WINHealth Partners Commercial |
$1,328.55
|
|
|
ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY
|
Professional
|
Both
|
$1,237.00
|
|
|
Service Code
|
HCPCS 43202
|
| Min. Negotiated Rate |
$83.50 |
| Max. Negotiated Rate |
$1,237.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,212.26
|
| Rate for Payer: Aetna of WY Medicare |
$98.23
|
| Rate for Payer: Beech Street Commercial |
$1,175.15
|
| Rate for Payer: Cash Price |
$865.90
|
| Rate for Payer: Cash Price |
$865.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,199.89
|
| Rate for Payer: Cigna of WY Commercial |
$1,212.26
|
| Rate for Payer: First Choice Health Commercial |
$1,113.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,175.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$98.23
|
| Rate for Payer: HealthUtah PPO |
$1,237.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,199.89
|
| Rate for Payer: Multiplan Medicare/VA |
$83.50
|
| Rate for Payer: One Health Plan of WY PPO |
$1,212.26
|
| Rate for Payer: PacificSource Commercial |
$1,113.30
|
| Rate for Payer: PHCS PPO |
$1,175.15
|
| Rate for Payer: Three Rivers PPO |
$927.75
|
| Rate for Payer: TriWest Veterans Administration |
$98.23
|
| Rate for Payer: United Healthcare Commercial |
$1,175.15
|
| Rate for Payer: WINHealth Partners Commercial |
$1,051.45
|
|
|
ESOPHAGOSCOPY RIGID TRANSORAL BALLOON DILATION
|
Professional
|
Both
|
$808.00
|
|
|
Service Code
|
HCPCS 43195
|
| Min. Negotiated Rate |
$150.93 |
| Max. Negotiated Rate |
$808.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$791.84
|
| Rate for Payer: Aetna of WY Medicare |
$177.56
|
| Rate for Payer: Beech Street Commercial |
$767.60
|
| Rate for Payer: Cash Price |
$565.60
|
| Rate for Payer: Cash Price |
$565.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$783.76
|
| Rate for Payer: Cigna of WY Commercial |
$791.84
|
| Rate for Payer: First Choice Health Commercial |
$727.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$767.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$177.56
|
| Rate for Payer: HealthUtah PPO |
$808.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$783.76
|
| Rate for Payer: Multiplan Medicare/VA |
$150.93
|
| Rate for Payer: One Health Plan of WY PPO |
$791.84
|
| Rate for Payer: PacificSource Commercial |
$727.20
|
| Rate for Payer: PHCS PPO |
$767.60
|
| Rate for Payer: Three Rivers PPO |
$606.00
|
| Rate for Payer: TriWest Veterans Administration |
$177.56
|
| Rate for Payer: United Healthcare Commercial |
$767.60
|
| Rate for Payer: WINHealth Partners Commercial |
$686.80
|
|
|
ESOPHAGOSCOPY RIGID TRANSORAL DIAGNOSTIC BRUSH
|
Professional
|
Both
|
$463.00
|
|
|
Service Code
|
HCPCS 43191
|
| Min. Negotiated Rate |
$126.94 |
| Max. Negotiated Rate |
$463.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$453.74
|
| Rate for Payer: Aetna of WY Medicare |
$149.34
|
| Rate for Payer: Beech Street Commercial |
$439.85
|
| Rate for Payer: Cash Price |
$324.10
|
| Rate for Payer: Cash Price |
$324.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$449.11
|
| Rate for Payer: Cigna of WY Commercial |
$453.74
|
| Rate for Payer: First Choice Health Commercial |
$416.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$439.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$149.34
|
| Rate for Payer: HealthUtah PPO |
$463.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$449.11
|
| Rate for Payer: Multiplan Medicare/VA |
$126.94
|
| Rate for Payer: One Health Plan of WY PPO |
$453.74
|
| Rate for Payer: PacificSource Commercial |
$416.70
|
| Rate for Payer: PHCS PPO |
$439.85
|
| Rate for Payer: Three Rivers PPO |
$347.25
|
| Rate for Payer: TriWest Veterans Administration |
$149.34
|
| Rate for Payer: United Healthcare Commercial |
$439.85
|
| Rate for Payer: WINHealth Partners Commercial |
$393.55
|
|
|
ESOPH PROBE TEMP 12FR 81040412
|
Facility
|
IP
|
$5.90
|
|
| Hospital Charge Code |
2500022
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3.42 |
| Max. Negotiated Rate |
$5.90 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5.78
|
| Rate for Payer: Aetna of WY Medicare |
$3.78
|
| Rate for Payer: Altius Commercial |
$5.66
|
| Rate for Payer: Beech Street Commercial |
$5.78
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$5.72
|
| Rate for Payer: Cash Price |
$4.13
|
| Rate for Payer: ChoiceCare Network Commercial |
$5.72
|
| Rate for Payer: Cigna of WY Commercial |
$5.78
|
| Rate for Payer: Entrust Commercial |
$5.60
|
| Rate for Payer: First Choice Health Commercial |
$5.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3.60
|
| Rate for Payer: HealthUtah PPO |
$5.90
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5.72
|
| Rate for Payer: Multiplan Medicare/VA |
$3.42
|
| Rate for Payer: One Health Plan of WY PPO |
$5.78
|
| Rate for Payer: PacificSource Commercial |
$5.31
|
| Rate for Payer: PHCS PPO |
$5.78
|
| Rate for Payer: Three Rivers PPO |
$4.42
|
| Rate for Payer: TriWest Veterans Administration |
$3.60
|
| Rate for Payer: United Healthcare Commercial |
$5.63
|
| Rate for Payer: United Healthcare Medicare |
$3.60
|
| Rate for Payer: WINHealth Partners Commercial |
$5.60
|
| Rate for Payer: Wise Provider Network Commercial |
$5.60
|
|
|
ESOPH PROBE TEMP 12FR 81040412
|
Facility
|
OP
|
$5.90
|
|
| Hospital Charge Code |
2500022
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3.19 |
| Max. Negotiated Rate |
$5.90 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5.78
|
| Rate for Payer: Aetna of WY Medicare |
$3.89
|
| Rate for Payer: Altius Commercial |
$5.66
|
| Rate for Payer: Beech Street Commercial |
$5.78
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$5.72
|
| Rate for Payer: Cash Price |
$4.13
|
| Rate for Payer: ChoiceCare Network Commercial |
$5.72
|
| Rate for Payer: Cigna of WY Commercial |
$5.78
|
| Rate for Payer: Entrust Commercial |
$5.60
|
| Rate for Payer: First Choice Health Commercial |
$5.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3.36
|
| Rate for Payer: HealthUtah PPO |
$5.90
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5.72
|
| Rate for Payer: Multiplan Medicare/VA |
$3.19
|
| Rate for Payer: One Health Plan of WY PPO |
$5.78
|
| Rate for Payer: PacificSource Commercial |
$5.31
|
| Rate for Payer: PHCS PPO |
$5.78
|
| Rate for Payer: Three Rivers PPO |
$4.42
|
| Rate for Payer: TriWest Veterans Administration |
$3.36
|
| Rate for Payer: United Healthcare Commercial |
$5.63
|
| Rate for Payer: United Healthcare Medicare |
$3.36
|
| Rate for Payer: WINHealth Partners Commercial |
$5.78
|
| Rate for Payer: Wise Provider Network Commercial |
$5.60
|
|
|
ESOPH PROBE W/ TEMP 18 FR
|
Facility
|
OP
|
$11.79
|
|
| Hospital Charge Code |
2500021
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$6.38 |
| Max. Negotiated Rate |
$11.79 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$11.55
|
| Rate for Payer: Aetna of WY Medicare |
$7.78
|
| Rate for Payer: Altius Commercial |
$11.32
|
| Rate for Payer: Beech Street Commercial |
$11.55
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$11.44
|
| Rate for Payer: Cash Price |
$8.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$11.44
|
| Rate for Payer: Cigna of WY Commercial |
$11.55
|
| Rate for Payer: Entrust Commercial |
$11.20
|
| Rate for Payer: First Choice Health Commercial |
$11.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$11.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$6.72
|
| Rate for Payer: HealthUtah PPO |
$11.79
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$11.44
|
| Rate for Payer: Multiplan Medicare/VA |
$6.38
|
| Rate for Payer: One Health Plan of WY PPO |
$11.55
|
| Rate for Payer: PacificSource Commercial |
$10.61
|
| Rate for Payer: PHCS PPO |
$11.55
|
| Rate for Payer: Three Rivers PPO |
$8.84
|
| Rate for Payer: TriWest Veterans Administration |
$6.72
|
| Rate for Payer: United Healthcare Commercial |
$11.26
|
| Rate for Payer: United Healthcare Medicare |
$6.72
|
| Rate for Payer: WINHealth Partners Commercial |
$11.55
|
| Rate for Payer: Wise Provider Network Commercial |
$11.20
|
|
|
ESOPH PROBE W/ TEMP 18 FR
|
Facility
|
IP
|
$11.79
|
|
| Hospital Charge Code |
2500021
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$6.83 |
| Max. Negotiated Rate |
$11.79 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$11.55
|
| Rate for Payer: Aetna of WY Medicare |
$7.55
|
| Rate for Payer: Altius Commercial |
$11.32
|
| Rate for Payer: Beech Street Commercial |
$11.55
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$11.44
|
| Rate for Payer: Cash Price |
$8.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$11.44
|
| Rate for Payer: Cigna of WY Commercial |
$11.55
|
| Rate for Payer: Entrust Commercial |
$11.20
|
| Rate for Payer: First Choice Health Commercial |
$11.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$11.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$7.19
|
| Rate for Payer: HealthUtah PPO |
$11.79
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$11.44
|
| Rate for Payer: Multiplan Medicare/VA |
$6.83
|
| Rate for Payer: One Health Plan of WY PPO |
$11.55
|
| Rate for Payer: PacificSource Commercial |
$10.61
|
| Rate for Payer: PHCS PPO |
$11.55
|
| Rate for Payer: Three Rivers PPO |
$8.84
|
| Rate for Payer: TriWest Veterans Administration |
$7.19
|
| Rate for Payer: United Healthcare Commercial |
$11.26
|
| Rate for Payer: United Healthcare Medicare |
$7.19
|
| Rate for Payer: WINHealth Partners Commercial |
$11.20
|
| Rate for Payer: Wise Provider Network Commercial |
$11.20
|
|
|
ESTRADIOL 1 MG TABLET [10391]
|
Facility
|
OP
|
$15.35
|
|
|
Service Code
|
NDC 4280608801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.31 |
| Max. Negotiated Rate |
$15.35 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.04
|
| Rate for Payer: Aetna of WY Medicare |
$10.13
|
| Rate for Payer: Altius Commercial |
$14.74
|
| Rate for Payer: Beech Street Commercial |
$15.04
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.89
|
| Rate for Payer: Cash Price |
$10.74
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.89
|
| Rate for Payer: Cigna of WY Commercial |
$15.04
|
| Rate for Payer: Entrust Commercial |
$14.58
|
| Rate for Payer: First Choice Health Commercial |
$14.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.75
|
| Rate for Payer: HealthUtah PPO |
$15.35
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.89
|
| Rate for Payer: Multiplan Medicare/VA |
$8.31
|
| Rate for Payer: One Health Plan of WY PPO |
$15.04
|
| Rate for Payer: PacificSource Commercial |
$13.82
|
| Rate for Payer: PHCS PPO |
$15.04
|
| Rate for Payer: Three Rivers PPO |
$11.51
|
| Rate for Payer: TriWest Veterans Administration |
$8.75
|
| Rate for Payer: United Healthcare Commercial |
$14.66
|
| Rate for Payer: United Healthcare Medicare |
$8.75
|
| Rate for Payer: WINHealth Partners Commercial |
$15.04
|
| Rate for Payer: Wise Provider Network Commercial |
$14.58
|
|
|
ESTRADIOL 1 MG TABLET [10391]
|
Facility
|
IP
|
$15.35
|
|
|
Service Code
|
NDC 7095456510
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.90 |
| Max. Negotiated Rate |
$15.35 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.04
|
| Rate for Payer: Aetna of WY Medicare |
$9.82
|
| Rate for Payer: Altius Commercial |
$14.74
|
| Rate for Payer: Beech Street Commercial |
$15.04
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.89
|
| Rate for Payer: Cash Price |
$10.74
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.89
|
| Rate for Payer: Cigna of WY Commercial |
$15.04
|
| Rate for Payer: Entrust Commercial |
$14.58
|
| Rate for Payer: First Choice Health Commercial |
$14.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.36
|
| Rate for Payer: HealthUtah PPO |
$15.35
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.89
|
| Rate for Payer: Multiplan Medicare/VA |
$8.90
|
| Rate for Payer: One Health Plan of WY PPO |
$15.04
|
| Rate for Payer: PacificSource Commercial |
$13.82
|
| Rate for Payer: PHCS PPO |
$15.04
|
| Rate for Payer: Three Rivers PPO |
$11.51
|
| Rate for Payer: TriWest Veterans Administration |
$9.36
|
| Rate for Payer: United Healthcare Commercial |
$14.66
|
| Rate for Payer: United Healthcare Medicare |
$9.36
|
| Rate for Payer: WINHealth Partners Commercial |
$14.58
|
| Rate for Payer: Wise Provider Network Commercial |
$14.58
|
|
|
ESTRADIOL 1 MG TABLET [10391]
|
Facility
|
IP
|
$15.35
|
|
|
Service Code
|
NDC 4280608801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.90 |
| Max. Negotiated Rate |
$15.35 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.04
|
| Rate for Payer: Aetna of WY Medicare |
$9.82
|
| Rate for Payer: Altius Commercial |
$14.74
|
| Rate for Payer: Beech Street Commercial |
$15.04
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.89
|
| Rate for Payer: Cash Price |
$10.74
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.89
|
| Rate for Payer: Cigna of WY Commercial |
$15.04
|
| Rate for Payer: Entrust Commercial |
$14.58
|
| Rate for Payer: First Choice Health Commercial |
$14.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.36
|
| Rate for Payer: HealthUtah PPO |
$15.35
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.89
|
| Rate for Payer: Multiplan Medicare/VA |
$8.90
|
| Rate for Payer: One Health Plan of WY PPO |
$15.04
|
| Rate for Payer: PacificSource Commercial |
$13.82
|
| Rate for Payer: PHCS PPO |
$15.04
|
| Rate for Payer: Three Rivers PPO |
$11.51
|
| Rate for Payer: TriWest Veterans Administration |
$9.36
|
| Rate for Payer: United Healthcare Commercial |
$14.66
|
| Rate for Payer: United Healthcare Medicare |
$9.36
|
| Rate for Payer: WINHealth Partners Commercial |
$14.58
|
| Rate for Payer: Wise Provider Network Commercial |
$14.58
|
|
|
ESTRADIOL 1 MG TABLET [10391]
|
Facility
|
OP
|
$15.35
|
|
|
Service Code
|
NDC 7095456510
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.31 |
| Max. Negotiated Rate |
$15.35 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.04
|
| Rate for Payer: Aetna of WY Medicare |
$10.13
|
| Rate for Payer: Altius Commercial |
$14.74
|
| Rate for Payer: Beech Street Commercial |
$15.04
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.89
|
| Rate for Payer: Cash Price |
$10.74
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.89
|
| Rate for Payer: Cigna of WY Commercial |
$15.04
|
| Rate for Payer: Entrust Commercial |
$14.58
|
| Rate for Payer: First Choice Health Commercial |
$14.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.75
|
| Rate for Payer: HealthUtah PPO |
$15.35
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.89
|
| Rate for Payer: Multiplan Medicare/VA |
$8.31
|
| Rate for Payer: One Health Plan of WY PPO |
$15.04
|
| Rate for Payer: PacificSource Commercial |
$13.82
|
| Rate for Payer: PHCS PPO |
$15.04
|
| Rate for Payer: Three Rivers PPO |
$11.51
|
| Rate for Payer: TriWest Veterans Administration |
$8.75
|
| Rate for Payer: United Healthcare Commercial |
$14.66
|
| Rate for Payer: United Healthcare Medicare |
$8.75
|
| Rate for Payer: WINHealth Partners Commercial |
$15.04
|
| Rate for Payer: Wise Provider Network Commercial |
$14.58
|
|
