|
AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION [14310]
|
Facility
|
OP
|
$36.70
|
|
|
Service Code
|
HCPCS J0456
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.87 |
| Max. Negotiated Rate |
$36.70 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$35.97
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$33.08
|
| Rate for Payer: Aetna of WY Medicare |
$22.28
|
| Rate for Payer: Aetna of WY Medicare |
$24.22
|
| Rate for Payer: Altius Commercial |
$32.40
|
| Rate for Payer: Altius Commercial |
$35.23
|
| Rate for Payer: Beech Street Commercial |
$33.08
|
| Rate for Payer: Beech Street Commercial |
$35.97
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$35.60
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$32.74
|
| Rate for Payer: Cash Price |
$25.69
|
| Rate for Payer: Cash Price |
$23.62
|
| Rate for Payer: ChoiceCare Network Commercial |
$35.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$32.74
|
| Rate for Payer: Cigna of WY Commercial |
$33.08
|
| Rate for Payer: Cigna of WY Commercial |
$35.97
|
| Rate for Payer: Entrust Commercial |
$34.86
|
| Rate for Payer: Entrust Commercial |
$32.06
|
| Rate for Payer: First Choice Health Commercial |
$34.86
|
| Rate for Payer: First Choice Health Commercial |
$32.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$34.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$32.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$19.24
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$20.92
|
| Rate for Payer: HealthUtah PPO |
$33.75
|
| Rate for Payer: HealthUtah PPO |
$36.70
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$35.60
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$32.74
|
| Rate for Payer: Multiplan Medicare/VA |
$18.28
|
| Rate for Payer: Multiplan Medicare/VA |
$19.87
|
| Rate for Payer: One Health Plan of WY PPO |
$35.97
|
| Rate for Payer: One Health Plan of WY PPO |
$33.08
|
| Rate for Payer: PacificSource Commercial |
$30.38
|
| Rate for Payer: PacificSource Commercial |
$33.03
|
| Rate for Payer: PHCS PPO |
$33.08
|
| Rate for Payer: PHCS PPO |
$35.97
|
| Rate for Payer: Three Rivers PPO |
$27.52
|
| Rate for Payer: Three Rivers PPO |
$25.31
|
| Rate for Payer: TriWest Veterans Administration |
$20.92
|
| Rate for Payer: TriWest Veterans Administration |
$19.24
|
| Rate for Payer: United Healthcare Commercial |
$35.05
|
| Rate for Payer: United Healthcare Commercial |
$32.23
|
| Rate for Payer: United Healthcare Medicare |
$19.24
|
| Rate for Payer: United Healthcare Medicare |
$20.92
|
| Rate for Payer: WINHealth Partners Commercial |
$35.97
|
| Rate for Payer: WINHealth Partners Commercial |
$33.08
|
| Rate for Payer: Wise Provider Network Commercial |
$32.06
|
| Rate for Payer: Wise Provider Network Commercial |
$34.86
|
|
|
BA2X BONE GRAFT FOAM 005
|
Facility
|
OP
|
$6,930.00
|
|
| Hospital Charge Code |
3001475
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,752.60 |
| Max. Negotiated Rate |
$6,930.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$6,791.40
|
| Rate for Payer: Aetna of WY Medicare |
$4,573.80
|
| Rate for Payer: Altius Commercial |
$6,652.80
|
| Rate for Payer: Beech Street Commercial |
$6,791.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$6,722.10
|
| Rate for Payer: Cash Price |
$4,851.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$6,722.10
|
| Rate for Payer: Cigna of WY Commercial |
$6,791.40
|
| Rate for Payer: Entrust Commercial |
$6,583.50
|
| Rate for Payer: First Choice Health Commercial |
$6,583.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$6,583.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3,950.10
|
| Rate for Payer: HealthUtah PPO |
$6,930.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$6,722.10
|
| Rate for Payer: Multiplan Medicare/VA |
$3,752.60
|
| Rate for Payer: One Health Plan of WY PPO |
$6,791.40
|
| Rate for Payer: PacificSource Commercial |
$6,237.00
|
| Rate for Payer: PHCS PPO |
$6,791.40
|
| Rate for Payer: Three Rivers PPO |
$5,197.50
|
| Rate for Payer: TriWest Veterans Administration |
$3,950.10
|
| Rate for Payer: United Healthcare Commercial |
$6,618.15
|
| Rate for Payer: United Healthcare Medicare |
$3,950.10
|
| Rate for Payer: WINHealth Partners Commercial |
$6,791.40
|
| Rate for Payer: Wise Provider Network Commercial |
$6,583.50
|
|
|
BA2X BONE GRAFT FOAM 005
|
Facility
|
IP
|
$6,930.00
|
|
| Hospital Charge Code |
3001475
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,015.94 |
| Max. Negotiated Rate |
$6,930.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$6,791.40
|
| Rate for Payer: Aetna of WY Medicare |
$4,435.20
|
| Rate for Payer: Altius Commercial |
$6,652.80
|
| Rate for Payer: Beech Street Commercial |
$6,791.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$6,722.10
|
| Rate for Payer: Cash Price |
$4,851.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$6,722.10
|
| Rate for Payer: Cigna of WY Commercial |
$6,791.40
|
| Rate for Payer: Entrust Commercial |
$6,583.50
|
| Rate for Payer: First Choice Health Commercial |
$6,583.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$6,583.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$4,227.30
|
| Rate for Payer: HealthUtah PPO |
$6,930.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$6,722.10
|
| Rate for Payer: Multiplan Medicare/VA |
$4,015.94
|
| Rate for Payer: One Health Plan of WY PPO |
$6,791.40
|
| Rate for Payer: PacificSource Commercial |
$6,237.00
|
| Rate for Payer: PHCS PPO |
$6,791.40
|
| Rate for Payer: Three Rivers PPO |
$5,197.50
|
| Rate for Payer: TriWest Veterans Administration |
$4,227.30
|
| Rate for Payer: United Healthcare Commercial |
$6,618.15
|
| Rate for Payer: United Healthcare Medicare |
$4,227.30
|
| Rate for Payer: WINHealth Partners Commercial |
$6,583.50
|
| Rate for Payer: Wise Provider Network Commercial |
$6,583.50
|
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT [6246]
|
Facility
|
IP
|
$15.48
|
|
|
Service Code
|
NDC 6800147746
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.97 |
| Max. Negotiated Rate |
$15.48 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.17
|
| Rate for Payer: Aetna of WY Medicare |
$9.91
|
| Rate for Payer: Altius Commercial |
$14.86
|
| Rate for Payer: Beech Street Commercial |
$15.17
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.02
|
| Rate for Payer: Cash Price |
$10.84
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.02
|
| Rate for Payer: Cigna of WY Commercial |
$15.17
|
| Rate for Payer: Entrust Commercial |
$14.71
|
| Rate for Payer: First Choice Health Commercial |
$14.71
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.71
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.44
|
| Rate for Payer: HealthUtah PPO |
$15.48
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.02
|
| Rate for Payer: Multiplan Medicare/VA |
$8.97
|
| Rate for Payer: One Health Plan of WY PPO |
$15.17
|
| Rate for Payer: PacificSource Commercial |
$13.93
|
| Rate for Payer: PHCS PPO |
$15.17
|
| Rate for Payer: Three Rivers PPO |
$11.61
|
| Rate for Payer: TriWest Veterans Administration |
$9.44
|
| Rate for Payer: United Healthcare Commercial |
$14.78
|
| Rate for Payer: United Healthcare Medicare |
$9.44
|
| Rate for Payer: WINHealth Partners Commercial |
$14.71
|
| Rate for Payer: Wise Provider Network Commercial |
$14.71
|
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT [6246]
|
Facility
|
OP
|
$15.48
|
|
|
Service Code
|
NDC 6800147746
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.38 |
| Max. Negotiated Rate |
$15.48 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.17
|
| Rate for Payer: Aetna of WY Medicare |
$10.22
|
| Rate for Payer: Altius Commercial |
$14.86
|
| Rate for Payer: Beech Street Commercial |
$15.17
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.02
|
| Rate for Payer: Cash Price |
$10.84
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.02
|
| Rate for Payer: Cigna of WY Commercial |
$15.17
|
| Rate for Payer: Entrust Commercial |
$14.71
|
| Rate for Payer: First Choice Health Commercial |
$14.71
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.71
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.82
|
| Rate for Payer: HealthUtah PPO |
$15.48
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.02
|
| Rate for Payer: Multiplan Medicare/VA |
$8.38
|
| Rate for Payer: One Health Plan of WY PPO |
$15.17
|
| Rate for Payer: PacificSource Commercial |
$13.93
|
| Rate for Payer: PHCS PPO |
$15.17
|
| Rate for Payer: Three Rivers PPO |
$11.61
|
| Rate for Payer: TriWest Veterans Administration |
$8.82
|
| Rate for Payer: United Healthcare Commercial |
$14.78
|
| Rate for Payer: United Healthcare Medicare |
$8.82
|
| Rate for Payer: WINHealth Partners Commercial |
$15.17
|
| Rate for Payer: Wise Provider Network Commercial |
$14.71
|
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET [28964]
|
Facility
|
OP
|
$15.53
|
|
|
Service Code
|
NDC 4580206000
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.41 |
| Max. Negotiated Rate |
$15.53 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.22
|
| Rate for Payer: Aetna of WY Medicare |
$10.25
|
| Rate for Payer: Altius Commercial |
$14.91
|
| Rate for Payer: Beech Street Commercial |
$15.22
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.06
|
| Rate for Payer: Cash Price |
$10.87
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.06
|
| Rate for Payer: Cigna of WY Commercial |
$15.22
|
| Rate for Payer: Entrust Commercial |
$14.75
|
| Rate for Payer: First Choice Health Commercial |
$14.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.85
|
| Rate for Payer: HealthUtah PPO |
$15.53
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.06
|
| Rate for Payer: Multiplan Medicare/VA |
$8.41
|
| Rate for Payer: One Health Plan of WY PPO |
$15.22
|
| Rate for Payer: PacificSource Commercial |
$13.98
|
| Rate for Payer: PHCS PPO |
$15.22
|
| Rate for Payer: Three Rivers PPO |
$11.65
|
| Rate for Payer: TriWest Veterans Administration |
$8.85
|
| Rate for Payer: United Healthcare Commercial |
$14.83
|
| Rate for Payer: United Healthcare Medicare |
$8.85
|
| Rate for Payer: WINHealth Partners Commercial |
$15.22
|
| Rate for Payer: Wise Provider Network Commercial |
$14.75
|
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET [28964]
|
Facility
|
IP
|
$15.53
|
|
|
Service Code
|
NDC 4580206070
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.00 |
| Max. Negotiated Rate |
$15.53 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.22
|
| Rate for Payer: Aetna of WY Medicare |
$9.94
|
| Rate for Payer: Altius Commercial |
$14.91
|
| Rate for Payer: Beech Street Commercial |
$15.22
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.06
|
| Rate for Payer: Cash Price |
$10.87
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.06
|
| Rate for Payer: Cigna of WY Commercial |
$15.22
|
| Rate for Payer: Entrust Commercial |
$14.75
|
| Rate for Payer: First Choice Health Commercial |
$14.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.47
|
| Rate for Payer: HealthUtah PPO |
$15.53
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.06
|
| Rate for Payer: Multiplan Medicare/VA |
$9.00
|
| Rate for Payer: One Health Plan of WY PPO |
$15.22
|
| Rate for Payer: PacificSource Commercial |
$13.98
|
| Rate for Payer: PHCS PPO |
$15.22
|
| Rate for Payer: Three Rivers PPO |
$11.65
|
| Rate for Payer: TriWest Veterans Administration |
$9.47
|
| Rate for Payer: United Healthcare Commercial |
$14.83
|
| Rate for Payer: United Healthcare Medicare |
$9.47
|
| Rate for Payer: WINHealth Partners Commercial |
$14.75
|
| Rate for Payer: Wise Provider Network Commercial |
$14.75
|
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET [28964]
|
Facility
|
OP
|
$15.53
|
|
|
Service Code
|
NDC 6800147745
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.41 |
| Max. Negotiated Rate |
$15.53 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.22
|
| Rate for Payer: Aetna of WY Medicare |
$10.25
|
| Rate for Payer: Altius Commercial |
$14.91
|
| Rate for Payer: Beech Street Commercial |
$15.22
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.06
|
| Rate for Payer: Cash Price |
$10.87
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.06
|
| Rate for Payer: Cigna of WY Commercial |
$15.22
|
| Rate for Payer: Entrust Commercial |
$14.75
|
| Rate for Payer: First Choice Health Commercial |
$14.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.85
|
| Rate for Payer: HealthUtah PPO |
$15.53
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.06
|
| Rate for Payer: Multiplan Medicare/VA |
$8.41
|
| Rate for Payer: One Health Plan of WY PPO |
$15.22
|
| Rate for Payer: PacificSource Commercial |
$13.98
|
| Rate for Payer: PHCS PPO |
$15.22
|
| Rate for Payer: Three Rivers PPO |
$11.65
|
| Rate for Payer: TriWest Veterans Administration |
$8.85
|
| Rate for Payer: United Healthcare Commercial |
$14.83
|
| Rate for Payer: United Healthcare Medicare |
$8.85
|
| Rate for Payer: WINHealth Partners Commercial |
$15.22
|
| Rate for Payer: Wise Provider Network Commercial |
$14.75
|
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET [28964]
|
Facility
|
IP
|
$15.53
|
|
|
Service Code
|
NDC 4580206000
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.00 |
| Max. Negotiated Rate |
$15.53 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.22
|
| Rate for Payer: Aetna of WY Medicare |
$9.94
|
| Rate for Payer: Altius Commercial |
$14.91
|
| Rate for Payer: Beech Street Commercial |
$15.22
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.06
|
| Rate for Payer: Cash Price |
$10.87
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.06
|
| Rate for Payer: Cigna of WY Commercial |
$15.22
|
| Rate for Payer: Entrust Commercial |
$14.75
|
| Rate for Payer: First Choice Health Commercial |
$14.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.47
|
| Rate for Payer: HealthUtah PPO |
$15.53
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.06
|
| Rate for Payer: Multiplan Medicare/VA |
$9.00
|
| Rate for Payer: One Health Plan of WY PPO |
$15.22
|
| Rate for Payer: PacificSource Commercial |
$13.98
|
| Rate for Payer: PHCS PPO |
$15.22
|
| Rate for Payer: Three Rivers PPO |
$11.65
|
| Rate for Payer: TriWest Veterans Administration |
$9.47
|
| Rate for Payer: United Healthcare Commercial |
$14.83
|
| Rate for Payer: United Healthcare Medicare |
$9.47
|
| Rate for Payer: WINHealth Partners Commercial |
$14.75
|
| Rate for Payer: Wise Provider Network Commercial |
$14.75
|
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET [28964]
|
Facility
|
IP
|
$15.53
|
|
|
Service Code
|
NDC 6800147745
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.00 |
| Max. Negotiated Rate |
$15.53 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.22
|
| Rate for Payer: Aetna of WY Medicare |
$9.94
|
| Rate for Payer: Altius Commercial |
$14.91
|
| Rate for Payer: Beech Street Commercial |
$15.22
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.06
|
| Rate for Payer: Cash Price |
$10.87
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.06
|
| Rate for Payer: Cigna of WY Commercial |
$15.22
|
| Rate for Payer: Entrust Commercial |
$14.75
|
| Rate for Payer: First Choice Health Commercial |
$14.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.47
|
| Rate for Payer: HealthUtah PPO |
$15.53
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.06
|
| Rate for Payer: Multiplan Medicare/VA |
$9.00
|
| Rate for Payer: One Health Plan of WY PPO |
$15.22
|
| Rate for Payer: PacificSource Commercial |
$13.98
|
| Rate for Payer: PHCS PPO |
$15.22
|
| Rate for Payer: Three Rivers PPO |
$11.65
|
| Rate for Payer: TriWest Veterans Administration |
$9.47
|
| Rate for Payer: United Healthcare Commercial |
$14.83
|
| Rate for Payer: United Healthcare Medicare |
$9.47
|
| Rate for Payer: WINHealth Partners Commercial |
$14.75
|
| Rate for Payer: Wise Provider Network Commercial |
$14.75
|
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET [28964]
|
Facility
|
OP
|
$15.53
|
|
|
Service Code
|
NDC 4580206070
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.41 |
| Max. Negotiated Rate |
$15.53 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.22
|
| Rate for Payer: Aetna of WY Medicare |
$10.25
|
| Rate for Payer: Altius Commercial |
$14.91
|
| Rate for Payer: Beech Street Commercial |
$15.22
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.06
|
| Rate for Payer: Cash Price |
$10.87
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.06
|
| Rate for Payer: Cigna of WY Commercial |
$15.22
|
| Rate for Payer: Entrust Commercial |
$14.75
|
| Rate for Payer: First Choice Health Commercial |
$14.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.85
|
| Rate for Payer: HealthUtah PPO |
$15.53
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.06
|
| Rate for Payer: Multiplan Medicare/VA |
$8.41
|
| Rate for Payer: One Health Plan of WY PPO |
$15.22
|
| Rate for Payer: PacificSource Commercial |
$13.98
|
| Rate for Payer: PHCS PPO |
$15.22
|
| Rate for Payer: Three Rivers PPO |
$11.65
|
| Rate for Payer: TriWest Veterans Administration |
$8.85
|
| Rate for Payer: United Healthcare Commercial |
$14.83
|
| Rate for Payer: United Healthcare Medicare |
$8.85
|
| Rate for Payer: WINHealth Partners Commercial |
$15.22
|
| Rate for Payer: Wise Provider Network Commercial |
$14.75
|
|
|
BACK RAFT
|
Facility
|
OP
|
$95.52
|
|
| Hospital Charge Code |
2200238
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$51.72 |
| Max. Negotiated Rate |
$95.52 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$93.61
|
| Rate for Payer: Aetna of WY Medicare |
$63.04
|
| Rate for Payer: Altius Commercial |
$91.70
|
| Rate for Payer: Beech Street Commercial |
$93.61
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$92.65
|
| Rate for Payer: Cash Price |
$66.86
|
| Rate for Payer: ChoiceCare Network Commercial |
$92.65
|
| Rate for Payer: Cigna of WY Commercial |
$93.61
|
| Rate for Payer: Entrust Commercial |
$90.74
|
| Rate for Payer: First Choice Health Commercial |
$90.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$90.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$54.45
|
| Rate for Payer: HealthUtah PPO |
$95.52
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$92.65
|
| Rate for Payer: Multiplan Medicare/VA |
$51.72
|
| Rate for Payer: One Health Plan of WY PPO |
$93.61
|
| Rate for Payer: PacificSource Commercial |
$85.97
|
| Rate for Payer: PHCS PPO |
$93.61
|
| Rate for Payer: Three Rivers PPO |
$71.64
|
| Rate for Payer: TriWest Veterans Administration |
$54.45
|
| Rate for Payer: United Healthcare Commercial |
$91.22
|
| Rate for Payer: United Healthcare Medicare |
$54.45
|
| Rate for Payer: WINHealth Partners Commercial |
$93.61
|
| Rate for Payer: Wise Provider Network Commercial |
$90.74
|
|
|
BACK RAFT
|
Facility
|
IP
|
$95.52
|
|
| Hospital Charge Code |
2200238
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$55.35 |
| Max. Negotiated Rate |
$95.52 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$93.61
|
| Rate for Payer: Aetna of WY Medicare |
$61.13
|
| Rate for Payer: Altius Commercial |
$91.70
|
| Rate for Payer: Beech Street Commercial |
$93.61
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$92.65
|
| Rate for Payer: Cash Price |
$66.86
|
| Rate for Payer: ChoiceCare Network Commercial |
$92.65
|
| Rate for Payer: Cigna of WY Commercial |
$93.61
|
| Rate for Payer: Entrust Commercial |
$90.74
|
| Rate for Payer: First Choice Health Commercial |
$90.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$90.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$58.27
|
| Rate for Payer: HealthUtah PPO |
$95.52
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$92.65
|
| Rate for Payer: Multiplan Medicare/VA |
$55.35
|
| Rate for Payer: One Health Plan of WY PPO |
$93.61
|
| Rate for Payer: PacificSource Commercial |
$85.97
|
| Rate for Payer: PHCS PPO |
$93.61
|
| Rate for Payer: Three Rivers PPO |
$71.64
|
| Rate for Payer: TriWest Veterans Administration |
$58.27
|
| Rate for Payer: United Healthcare Commercial |
$91.22
|
| Rate for Payer: United Healthcare Medicare |
$58.27
|
| Rate for Payer: WINHealth Partners Commercial |
$90.74
|
| Rate for Payer: Wise Provider Network Commercial |
$90.74
|
|
|
BACLOFEN 10 MG TABLET [11710]
|
Facility
|
OP
|
$17.07
|
|
|
Service Code
|
NDC 5026810615
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.24 |
| Max. Negotiated Rate |
$17.07 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.73
|
| Rate for Payer: Aetna of WY Medicare |
$11.27
|
| Rate for Payer: Altius Commercial |
$16.39
|
| Rate for Payer: Beech Street Commercial |
$16.73
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.56
|
| Rate for Payer: Cash Price |
$11.95
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.56
|
| Rate for Payer: Cigna of WY Commercial |
$16.73
|
| Rate for Payer: Entrust Commercial |
$16.22
|
| Rate for Payer: First Choice Health Commercial |
$16.22
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.22
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.73
|
| Rate for Payer: HealthUtah PPO |
$17.07
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.56
|
| Rate for Payer: Multiplan Medicare/VA |
$9.24
|
| Rate for Payer: One Health Plan of WY PPO |
$16.73
|
| Rate for Payer: PacificSource Commercial |
$15.36
|
| Rate for Payer: PHCS PPO |
$16.73
|
| Rate for Payer: Three Rivers PPO |
$12.80
|
| Rate for Payer: TriWest Veterans Administration |
$9.73
|
| Rate for Payer: United Healthcare Commercial |
$16.30
|
| Rate for Payer: United Healthcare Medicare |
$9.73
|
| Rate for Payer: WINHealth Partners Commercial |
$16.73
|
| Rate for Payer: Wise Provider Network Commercial |
$16.22
|
|
|
BACLOFEN 10 MG TABLET [11710]
|
Facility
|
IP
|
$17.28
|
|
|
Service Code
|
NDC 6808485501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.01 |
| Max. Negotiated Rate |
$17.28 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.93
|
| Rate for Payer: Aetna of WY Medicare |
$11.06
|
| Rate for Payer: Altius Commercial |
$16.59
|
| Rate for Payer: Beech Street Commercial |
$16.93
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.76
|
| Rate for Payer: Cash Price |
$12.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.76
|
| Rate for Payer: Cigna of WY Commercial |
$16.93
|
| Rate for Payer: Entrust Commercial |
$16.42
|
| Rate for Payer: First Choice Health Commercial |
$16.42
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.42
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.54
|
| Rate for Payer: HealthUtah PPO |
$17.28
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.76
|
| Rate for Payer: Multiplan Medicare/VA |
$10.01
|
| Rate for Payer: One Health Plan of WY PPO |
$16.93
|
| Rate for Payer: PacificSource Commercial |
$15.55
|
| Rate for Payer: PHCS PPO |
$16.93
|
| Rate for Payer: Three Rivers PPO |
$12.96
|
| Rate for Payer: TriWest Veterans Administration |
$10.54
|
| Rate for Payer: United Healthcare Commercial |
$16.50
|
| Rate for Payer: United Healthcare Medicare |
$10.54
|
| Rate for Payer: WINHealth Partners Commercial |
$16.42
|
| Rate for Payer: Wise Provider Network Commercial |
$16.42
|
|
|
BACLOFEN 10 MG TABLET [11710]
|
Facility
|
OP
|
$17.28
|
|
|
Service Code
|
NDC 6808485501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.36 |
| Max. Negotiated Rate |
$17.28 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.93
|
| Rate for Payer: Aetna of WY Medicare |
$11.40
|
| Rate for Payer: Altius Commercial |
$16.59
|
| Rate for Payer: Beech Street Commercial |
$16.93
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.76
|
| Rate for Payer: Cash Price |
$12.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.76
|
| Rate for Payer: Cigna of WY Commercial |
$16.93
|
| Rate for Payer: Entrust Commercial |
$16.42
|
| Rate for Payer: First Choice Health Commercial |
$16.42
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.42
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.85
|
| Rate for Payer: HealthUtah PPO |
$17.28
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.76
|
| Rate for Payer: Multiplan Medicare/VA |
$9.36
|
| Rate for Payer: One Health Plan of WY PPO |
$16.93
|
| Rate for Payer: PacificSource Commercial |
$15.55
|
| Rate for Payer: PHCS PPO |
$16.93
|
| Rate for Payer: Three Rivers PPO |
$12.96
|
| Rate for Payer: TriWest Veterans Administration |
$9.85
|
| Rate for Payer: United Healthcare Commercial |
$16.50
|
| Rate for Payer: United Healthcare Medicare |
$9.85
|
| Rate for Payer: WINHealth Partners Commercial |
$16.93
|
| Rate for Payer: Wise Provider Network Commercial |
$16.42
|
|
|
BACLOFEN 10 MG TABLET [11710]
|
Facility
|
OP
|
$17.07
|
|
|
Service Code
|
NDC 5026810611
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.24 |
| Max. Negotiated Rate |
$17.07 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.73
|
| Rate for Payer: Aetna of WY Medicare |
$11.27
|
| Rate for Payer: Altius Commercial |
$16.39
|
| Rate for Payer: Beech Street Commercial |
$16.73
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.56
|
| Rate for Payer: Cash Price |
$11.95
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.56
|
| Rate for Payer: Cigna of WY Commercial |
$16.73
|
| Rate for Payer: Entrust Commercial |
$16.22
|
| Rate for Payer: First Choice Health Commercial |
$16.22
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.22
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.73
|
| Rate for Payer: HealthUtah PPO |
$17.07
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.56
|
| Rate for Payer: Multiplan Medicare/VA |
$9.24
|
| Rate for Payer: One Health Plan of WY PPO |
$16.73
|
| Rate for Payer: PacificSource Commercial |
$15.36
|
| Rate for Payer: PHCS PPO |
$16.73
|
| Rate for Payer: Three Rivers PPO |
$12.80
|
| Rate for Payer: TriWest Veterans Administration |
$9.73
|
| Rate for Payer: United Healthcare Commercial |
$16.30
|
| Rate for Payer: United Healthcare Medicare |
$9.73
|
| Rate for Payer: WINHealth Partners Commercial |
$16.73
|
| Rate for Payer: Wise Provider Network Commercial |
$16.22
|
|
|
BACLOFEN 10 MG TABLET [11710]
|
Facility
|
IP
|
$17.07
|
|
|
Service Code
|
NDC 5026810615
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.89 |
| Max. Negotiated Rate |
$17.07 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.73
|
| Rate for Payer: Aetna of WY Medicare |
$10.92
|
| Rate for Payer: Altius Commercial |
$16.39
|
| Rate for Payer: Beech Street Commercial |
$16.73
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.56
|
| Rate for Payer: Cash Price |
$11.95
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.56
|
| Rate for Payer: Cigna of WY Commercial |
$16.73
|
| Rate for Payer: Entrust Commercial |
$16.22
|
| Rate for Payer: First Choice Health Commercial |
$16.22
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.22
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.41
|
| Rate for Payer: HealthUtah PPO |
$17.07
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.56
|
| Rate for Payer: Multiplan Medicare/VA |
$9.89
|
| Rate for Payer: One Health Plan of WY PPO |
$16.73
|
| Rate for Payer: PacificSource Commercial |
$15.36
|
| Rate for Payer: PHCS PPO |
$16.73
|
| Rate for Payer: Three Rivers PPO |
$12.80
|
| Rate for Payer: TriWest Veterans Administration |
$10.41
|
| Rate for Payer: United Healthcare Commercial |
$16.30
|
| Rate for Payer: United Healthcare Medicare |
$10.41
|
| Rate for Payer: WINHealth Partners Commercial |
$16.22
|
| Rate for Payer: Wise Provider Network Commercial |
$16.22
|
|
|
BACLOFEN 10 MG TABLET [11710]
|
Facility
|
OP
|
$17.28
|
|
|
Service Code
|
NDC 6808485511
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.36 |
| Max. Negotiated Rate |
$17.28 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.93
|
| Rate for Payer: Aetna of WY Medicare |
$11.40
|
| Rate for Payer: Altius Commercial |
$16.59
|
| Rate for Payer: Beech Street Commercial |
$16.93
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.76
|
| Rate for Payer: Cash Price |
$12.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.76
|
| Rate for Payer: Cigna of WY Commercial |
$16.93
|
| Rate for Payer: Entrust Commercial |
$16.42
|
| Rate for Payer: First Choice Health Commercial |
$16.42
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.42
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.85
|
| Rate for Payer: HealthUtah PPO |
$17.28
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.76
|
| Rate for Payer: Multiplan Medicare/VA |
$9.36
|
| Rate for Payer: One Health Plan of WY PPO |
$16.93
|
| Rate for Payer: PacificSource Commercial |
$15.55
|
| Rate for Payer: PHCS PPO |
$16.93
|
| Rate for Payer: Three Rivers PPO |
$12.96
|
| Rate for Payer: TriWest Veterans Administration |
$9.85
|
| Rate for Payer: United Healthcare Commercial |
$16.50
|
| Rate for Payer: United Healthcare Medicare |
$9.85
|
| Rate for Payer: WINHealth Partners Commercial |
$16.93
|
| Rate for Payer: Wise Provider Network Commercial |
$16.42
|
|
|
BACLOFEN 10 MG TABLET [11710]
|
Facility
|
IP
|
$17.28
|
|
|
Service Code
|
NDC 6808485511
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.01 |
| Max. Negotiated Rate |
$17.28 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.93
|
| Rate for Payer: Aetna of WY Medicare |
$11.06
|
| Rate for Payer: Altius Commercial |
$16.59
|
| Rate for Payer: Beech Street Commercial |
$16.93
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.76
|
| Rate for Payer: Cash Price |
$12.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.76
|
| Rate for Payer: Cigna of WY Commercial |
$16.93
|
| Rate for Payer: Entrust Commercial |
$16.42
|
| Rate for Payer: First Choice Health Commercial |
$16.42
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.42
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.54
|
| Rate for Payer: HealthUtah PPO |
$17.28
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.76
|
| Rate for Payer: Multiplan Medicare/VA |
$10.01
|
| Rate for Payer: One Health Plan of WY PPO |
$16.93
|
| Rate for Payer: PacificSource Commercial |
$15.55
|
| Rate for Payer: PHCS PPO |
$16.93
|
| Rate for Payer: Three Rivers PPO |
$12.96
|
| Rate for Payer: TriWest Veterans Administration |
$10.54
|
| Rate for Payer: United Healthcare Commercial |
$16.50
|
| Rate for Payer: United Healthcare Medicare |
$10.54
|
| Rate for Payer: WINHealth Partners Commercial |
$16.42
|
| Rate for Payer: Wise Provider Network Commercial |
$16.42
|
|
|
BACLOFEN 10 MG TABLET [11710]
|
Facility
|
IP
|
$17.07
|
|
|
Service Code
|
NDC 5026810611
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.89 |
| Max. Negotiated Rate |
$17.07 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.73
|
| Rate for Payer: Aetna of WY Medicare |
$10.92
|
| Rate for Payer: Altius Commercial |
$16.39
|
| Rate for Payer: Beech Street Commercial |
$16.73
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.56
|
| Rate for Payer: Cash Price |
$11.95
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.56
|
| Rate for Payer: Cigna of WY Commercial |
$16.73
|
| Rate for Payer: Entrust Commercial |
$16.22
|
| Rate for Payer: First Choice Health Commercial |
$16.22
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.22
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.41
|
| Rate for Payer: HealthUtah PPO |
$17.07
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.56
|
| Rate for Payer: Multiplan Medicare/VA |
$9.89
|
| Rate for Payer: One Health Plan of WY PPO |
$16.73
|
| Rate for Payer: PacificSource Commercial |
$15.36
|
| Rate for Payer: PHCS PPO |
$16.73
|
| Rate for Payer: Three Rivers PPO |
$12.80
|
| Rate for Payer: TriWest Veterans Administration |
$10.41
|
| Rate for Payer: United Healthcare Commercial |
$16.30
|
| Rate for Payer: United Healthcare Medicare |
$10.41
|
| Rate for Payer: WINHealth Partners Commercial |
$16.22
|
| Rate for Payer: Wise Provider Network Commercial |
$16.22
|
|
|
BACLOFEN 40,000 MCG/20 ML (2,000 MCG/ML) INTRATHECAL SOLUTION [91337]
|
Facility
|
IP
|
$62.30
|
|
|
Service Code
|
HCPCS J0475
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.10 |
| Max. Negotiated Rate |
$62.30 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$61.05
|
| Rate for Payer: Aetna of WY Medicare |
$39.87
|
| Rate for Payer: Altius Commercial |
$59.81
|
| Rate for Payer: Beech Street Commercial |
$61.05
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$60.43
|
| Rate for Payer: Cash Price |
$43.61
|
| Rate for Payer: ChoiceCare Network Commercial |
$60.43
|
| Rate for Payer: Cigna of WY Commercial |
$61.05
|
| Rate for Payer: Entrust Commercial |
$59.18
|
| Rate for Payer: First Choice Health Commercial |
$59.18
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$59.18
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$38.00
|
| Rate for Payer: HealthUtah PPO |
$62.30
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$60.43
|
| Rate for Payer: Multiplan Medicare/VA |
$36.10
|
| Rate for Payer: One Health Plan of WY PPO |
$61.05
|
| Rate for Payer: PacificSource Commercial |
$56.07
|
| Rate for Payer: PHCS PPO |
$61.05
|
| Rate for Payer: Three Rivers PPO |
$46.72
|
| Rate for Payer: TriWest Veterans Administration |
$38.00
|
| Rate for Payer: United Healthcare Commercial |
$59.50
|
| Rate for Payer: United Healthcare Medicare |
$38.00
|
| Rate for Payer: WINHealth Partners Commercial |
$59.18
|
| Rate for Payer: Wise Provider Network Commercial |
$59.18
|
|
|
BACLOFEN 40,000 MCG/20 ML (2,000 MCG/ML) INTRATHECAL SOLUTION [91337]
|
Facility
|
OP
|
$62.30
|
|
|
Service Code
|
HCPCS J0475
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.74 |
| Max. Negotiated Rate |
$62.30 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$61.05
|
| Rate for Payer: Aetna of WY Medicare |
$41.12
|
| Rate for Payer: Altius Commercial |
$59.81
|
| Rate for Payer: Beech Street Commercial |
$61.05
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$60.43
|
| Rate for Payer: Cash Price |
$43.61
|
| Rate for Payer: ChoiceCare Network Commercial |
$60.43
|
| Rate for Payer: Cigna of WY Commercial |
$61.05
|
| Rate for Payer: Entrust Commercial |
$59.18
|
| Rate for Payer: First Choice Health Commercial |
$59.18
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$59.18
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$35.51
|
| Rate for Payer: HealthUtah PPO |
$62.30
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$60.43
|
| Rate for Payer: Multiplan Medicare/VA |
$33.74
|
| Rate for Payer: One Health Plan of WY PPO |
$61.05
|
| Rate for Payer: PacificSource Commercial |
$56.07
|
| Rate for Payer: PHCS PPO |
$61.05
|
| Rate for Payer: Three Rivers PPO |
$46.72
|
| Rate for Payer: TriWest Veterans Administration |
$35.51
|
| Rate for Payer: United Healthcare Commercial |
$59.50
|
| Rate for Payer: United Healthcare Medicare |
$35.51
|
| Rate for Payer: WINHealth Partners Commercial |
$61.05
|
| Rate for Payer: Wise Provider Network Commercial |
$59.18
|
|
|
BACTISURE WOUND LAVAGE
|
Facility
|
IP
|
$420.58
|
|
| Hospital Charge Code |
2650900
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$243.73 |
| Max. Negotiated Rate |
$420.58 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$412.17
|
| Rate for Payer: Aetna of WY Medicare |
$269.17
|
| Rate for Payer: Altius Commercial |
$403.76
|
| Rate for Payer: Beech Street Commercial |
$412.17
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$407.96
|
| Rate for Payer: Cash Price |
$294.41
|
| Rate for Payer: ChoiceCare Network Commercial |
$407.96
|
| Rate for Payer: Cigna of WY Commercial |
$412.17
|
| Rate for Payer: Entrust Commercial |
$399.55
|
| Rate for Payer: First Choice Health Commercial |
$399.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$399.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$256.55
|
| Rate for Payer: HealthUtah PPO |
$420.58
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$407.96
|
| Rate for Payer: Multiplan Medicare/VA |
$243.73
|
| Rate for Payer: One Health Plan of WY PPO |
$412.17
|
| Rate for Payer: PacificSource Commercial |
$378.52
|
| Rate for Payer: PHCS PPO |
$412.17
|
| Rate for Payer: Three Rivers PPO |
$315.44
|
| Rate for Payer: TriWest Veterans Administration |
$256.55
|
| Rate for Payer: United Healthcare Commercial |
$401.65
|
| Rate for Payer: United Healthcare Medicare |
$256.55
|
| Rate for Payer: WINHealth Partners Commercial |
$399.55
|
| Rate for Payer: Wise Provider Network Commercial |
$399.55
|
|
|
BACTISURE WOUND LAVAGE
|
Facility
|
OP
|
$420.58
|
|
| Hospital Charge Code |
2650900
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$227.74 |
| Max. Negotiated Rate |
$420.58 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$412.17
|
| Rate for Payer: Aetna of WY Medicare |
$277.58
|
| Rate for Payer: Altius Commercial |
$403.76
|
| Rate for Payer: Beech Street Commercial |
$412.17
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$407.96
|
| Rate for Payer: Cash Price |
$294.41
|
| Rate for Payer: ChoiceCare Network Commercial |
$407.96
|
| Rate for Payer: Cigna of WY Commercial |
$412.17
|
| Rate for Payer: Entrust Commercial |
$399.55
|
| Rate for Payer: First Choice Health Commercial |
$399.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$399.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$239.73
|
| Rate for Payer: HealthUtah PPO |
$420.58
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$407.96
|
| Rate for Payer: Multiplan Medicare/VA |
$227.74
|
| Rate for Payer: One Health Plan of WY PPO |
$412.17
|
| Rate for Payer: PacificSource Commercial |
$378.52
|
| Rate for Payer: PHCS PPO |
$412.17
|
| Rate for Payer: Three Rivers PPO |
$315.44
|
| Rate for Payer: TriWest Veterans Administration |
$239.73
|
| Rate for Payer: United Healthcare Commercial |
$401.65
|
| Rate for Payer: United Healthcare Medicare |
$239.73
|
| Rate for Payer: WINHealth Partners Commercial |
$412.17
|
| Rate for Payer: Wise Provider Network Commercial |
$399.55
|
|
