|
BALOXAVIR MARBOXIL 40 MG TABLET [154455]
|
Facility
|
OP
|
$253.71
|
|
|
Service Code
|
NDC 5009041040
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$137.38 |
| Max. Negotiated Rate |
$253.71 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$248.64
|
| Rate for Payer: Aetna of WY Medicare |
$167.45
|
| Rate for Payer: Altius Commercial |
$243.56
|
| Rate for Payer: Beech Street Commercial |
$248.64
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$246.10
|
| Rate for Payer: Cash Price |
$177.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$246.10
|
| Rate for Payer: Cigna of WY Commercial |
$248.64
|
| Rate for Payer: Entrust Commercial |
$241.02
|
| Rate for Payer: First Choice Health Commercial |
$241.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$241.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$144.61
|
| Rate for Payer: HealthUtah PPO |
$253.71
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$246.10
|
| Rate for Payer: Multiplan Medicare/VA |
$137.38
|
| Rate for Payer: One Health Plan of WY PPO |
$248.64
|
| Rate for Payer: PacificSource Commercial |
$228.34
|
| Rate for Payer: PHCS PPO |
$248.64
|
| Rate for Payer: Three Rivers PPO |
$190.28
|
| Rate for Payer: TriWest Veterans Administration |
$144.61
|
| Rate for Payer: United Healthcare Commercial |
$242.29
|
| Rate for Payer: United Healthcare Medicare |
$144.61
|
| Rate for Payer: WINHealth Partners Commercial |
$248.64
|
| Rate for Payer: Wise Provider Network Commercial |
$241.02
|
|
|
BANDAGE COVERLET WING
|
Facility
|
IP
|
$0.57
|
|
| Hospital Charge Code |
2000075
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$0.57 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.56
|
| Rate for Payer: Aetna of WY Medicare |
$0.36
|
| Rate for Payer: Altius Commercial |
$0.55
|
| Rate for Payer: Beech Street Commercial |
$0.56
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.55
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.55
|
| Rate for Payer: Cigna of WY Commercial |
$0.56
|
| Rate for Payer: Entrust Commercial |
$0.54
|
| Rate for Payer: First Choice Health Commercial |
$0.54
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.54
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.35
|
| Rate for Payer: HealthUtah PPO |
$0.57
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.55
|
| Rate for Payer: Multiplan Medicare/VA |
$0.33
|
| Rate for Payer: One Health Plan of WY PPO |
$0.56
|
| Rate for Payer: PacificSource Commercial |
$0.51
|
| Rate for Payer: PHCS PPO |
$0.56
|
| Rate for Payer: Three Rivers PPO |
$0.43
|
| Rate for Payer: TriWest Veterans Administration |
$0.35
|
| Rate for Payer: United Healthcare Commercial |
$0.54
|
| Rate for Payer: United Healthcare Medicare |
$0.35
|
| Rate for Payer: WINHealth Partners Commercial |
$0.54
|
| Rate for Payer: Wise Provider Network Commercial |
$0.54
|
|
|
BANDAGE COVERLET WING
|
Facility
|
OP
|
$0.57
|
|
| Hospital Charge Code |
2000075
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.57 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.56
|
| Rate for Payer: Aetna of WY Medicare |
$0.38
|
| Rate for Payer: Altius Commercial |
$0.55
|
| Rate for Payer: Beech Street Commercial |
$0.56
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.55
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.55
|
| Rate for Payer: Cigna of WY Commercial |
$0.56
|
| Rate for Payer: Entrust Commercial |
$0.54
|
| Rate for Payer: First Choice Health Commercial |
$0.54
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.54
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.32
|
| Rate for Payer: HealthUtah PPO |
$0.57
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.55
|
| Rate for Payer: Multiplan Medicare/VA |
$0.31
|
| Rate for Payer: One Health Plan of WY PPO |
$0.56
|
| Rate for Payer: PacificSource Commercial |
$0.51
|
| Rate for Payer: PHCS PPO |
$0.56
|
| Rate for Payer: Three Rivers PPO |
$0.43
|
| Rate for Payer: TriWest Veterans Administration |
$0.32
|
| Rate for Payer: United Healthcare Commercial |
$0.54
|
| Rate for Payer: United Healthcare Medicare |
$0.32
|
| Rate for Payer: WINHealth Partners Commercial |
$0.56
|
| Rate for Payer: Wise Provider Network Commercial |
$0.54
|
|
|
BANDAGE FOURFLEX MSC4400
|
Facility
|
IP
|
$29.51
|
|
| Hospital Charge Code |
2000067
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$17.10 |
| Max. Negotiated Rate |
$29.51 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$28.92
|
| Rate for Payer: Aetna of WY Medicare |
$18.89
|
| Rate for Payer: Altius Commercial |
$28.33
|
| Rate for Payer: Beech Street Commercial |
$28.92
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$28.62
|
| Rate for Payer: Cash Price |
$20.66
|
| Rate for Payer: ChoiceCare Network Commercial |
$28.62
|
| Rate for Payer: Cigna of WY Commercial |
$28.92
|
| Rate for Payer: Entrust Commercial |
$28.03
|
| Rate for Payer: First Choice Health Commercial |
$28.03
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$28.03
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$18.00
|
| Rate for Payer: HealthUtah PPO |
$29.51
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$28.62
|
| Rate for Payer: Multiplan Medicare/VA |
$17.10
|
| Rate for Payer: One Health Plan of WY PPO |
$28.92
|
| Rate for Payer: PacificSource Commercial |
$26.56
|
| Rate for Payer: PHCS PPO |
$28.92
|
| Rate for Payer: Three Rivers PPO |
$22.13
|
| Rate for Payer: TriWest Veterans Administration |
$18.00
|
| Rate for Payer: United Healthcare Commercial |
$28.18
|
| Rate for Payer: United Healthcare Medicare |
$18.00
|
| Rate for Payer: WINHealth Partners Commercial |
$28.03
|
| Rate for Payer: Wise Provider Network Commercial |
$28.03
|
|
|
BANDAGE FOURFLEX MSC4400
|
Facility
|
OP
|
$29.51
|
|
| Hospital Charge Code |
2000067
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$15.98 |
| Max. Negotiated Rate |
$29.51 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$28.92
|
| Rate for Payer: Aetna of WY Medicare |
$19.48
|
| Rate for Payer: Altius Commercial |
$28.33
|
| Rate for Payer: Beech Street Commercial |
$28.92
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$28.62
|
| Rate for Payer: Cash Price |
$20.66
|
| Rate for Payer: ChoiceCare Network Commercial |
$28.62
|
| Rate for Payer: Cigna of WY Commercial |
$28.92
|
| Rate for Payer: Entrust Commercial |
$28.03
|
| Rate for Payer: First Choice Health Commercial |
$28.03
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$28.03
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$16.82
|
| Rate for Payer: HealthUtah PPO |
$29.51
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$28.62
|
| Rate for Payer: Multiplan Medicare/VA |
$15.98
|
| Rate for Payer: One Health Plan of WY PPO |
$28.92
|
| Rate for Payer: PacificSource Commercial |
$26.56
|
| Rate for Payer: PHCS PPO |
$28.92
|
| Rate for Payer: Three Rivers PPO |
$22.13
|
| Rate for Payer: TriWest Veterans Administration |
$16.82
|
| Rate for Payer: United Healthcare Commercial |
$28.18
|
| Rate for Payer: United Healthcare Medicare |
$16.82
|
| Rate for Payer: WINHealth Partners Commercial |
$28.92
|
| Rate for Payer: Wise Provider Network Commercial |
$28.03
|
|
|
BANDAGE UNNA BOOT W/CALAMINE
|
Facility
|
IP
|
$13.24
|
|
| Hospital Charge Code |
2000007
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$7.67 |
| Max. Negotiated Rate |
$13.24 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$12.98
|
| Rate for Payer: Aetna of WY Medicare |
$8.47
|
| Rate for Payer: Altius Commercial |
$12.71
|
| Rate for Payer: Beech Street Commercial |
$12.98
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.84
|
| Rate for Payer: Cash Price |
$9.27
|
| Rate for Payer: ChoiceCare Network Commercial |
$12.84
|
| Rate for Payer: Cigna of WY Commercial |
$12.98
|
| Rate for Payer: Entrust Commercial |
$12.58
|
| Rate for Payer: First Choice Health Commercial |
$12.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$12.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.08
|
| Rate for Payer: HealthUtah PPO |
$13.24
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$12.84
|
| Rate for Payer: Multiplan Medicare/VA |
$7.67
|
| Rate for Payer: One Health Plan of WY PPO |
$12.98
|
| Rate for Payer: PacificSource Commercial |
$11.92
|
| Rate for Payer: PHCS PPO |
$12.98
|
| Rate for Payer: Three Rivers PPO |
$9.93
|
| Rate for Payer: TriWest Veterans Administration |
$8.08
|
| Rate for Payer: United Healthcare Commercial |
$12.64
|
| Rate for Payer: United Healthcare Medicare |
$8.08
|
| Rate for Payer: WINHealth Partners Commercial |
$12.58
|
| Rate for Payer: Wise Provider Network Commercial |
$12.58
|
|
|
BANDAGE UNNA BOOT W/CALAMINE
|
Facility
|
OP
|
$13.24
|
|
| Hospital Charge Code |
2000007
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$7.17 |
| Max. Negotiated Rate |
$13.24 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$12.98
|
| Rate for Payer: Aetna of WY Medicare |
$8.74
|
| Rate for Payer: Altius Commercial |
$12.71
|
| Rate for Payer: Beech Street Commercial |
$12.98
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.84
|
| Rate for Payer: Cash Price |
$9.27
|
| Rate for Payer: ChoiceCare Network Commercial |
$12.84
|
| Rate for Payer: Cigna of WY Commercial |
$12.98
|
| Rate for Payer: Entrust Commercial |
$12.58
|
| Rate for Payer: First Choice Health Commercial |
$12.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$12.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$7.55
|
| Rate for Payer: HealthUtah PPO |
$13.24
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$12.84
|
| Rate for Payer: Multiplan Medicare/VA |
$7.17
|
| Rate for Payer: One Health Plan of WY PPO |
$12.98
|
| Rate for Payer: PacificSource Commercial |
$11.92
|
| Rate for Payer: PHCS PPO |
$12.98
|
| Rate for Payer: Three Rivers PPO |
$9.93
|
| Rate for Payer: TriWest Veterans Administration |
$7.55
|
| Rate for Payer: United Healthcare Commercial |
$12.64
|
| Rate for Payer: United Healthcare Medicare |
$7.55
|
| Rate for Payer: WINHealth Partners Commercial |
$12.98
|
| Rate for Payer: Wise Provider Network Commercial |
$12.58
|
|
|
BARICITINIB 2 MG TABLET [152721]
|
Facility
|
OP
|
$174.83
|
|
|
Service Code
|
NDC 0002418230
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$94.67 |
| Max. Negotiated Rate |
$174.83 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$171.33
|
| Rate for Payer: Aetna of WY Medicare |
$115.39
|
| Rate for Payer: Altius Commercial |
$167.84
|
| Rate for Payer: Beech Street Commercial |
$171.33
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$169.59
|
| Rate for Payer: Cash Price |
$122.38
|
| Rate for Payer: ChoiceCare Network Commercial |
$169.59
|
| Rate for Payer: Cigna of WY Commercial |
$171.33
|
| Rate for Payer: Entrust Commercial |
$166.09
|
| Rate for Payer: First Choice Health Commercial |
$166.09
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$166.09
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$99.65
|
| Rate for Payer: HealthUtah PPO |
$174.83
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$169.59
|
| Rate for Payer: Multiplan Medicare/VA |
$94.67
|
| Rate for Payer: One Health Plan of WY PPO |
$171.33
|
| Rate for Payer: PacificSource Commercial |
$157.35
|
| Rate for Payer: PHCS PPO |
$171.33
|
| Rate for Payer: Three Rivers PPO |
$131.12
|
| Rate for Payer: TriWest Veterans Administration |
$99.65
|
| Rate for Payer: United Healthcare Commercial |
$166.96
|
| Rate for Payer: United Healthcare Medicare |
$99.65
|
| Rate for Payer: WINHealth Partners Commercial |
$171.33
|
| Rate for Payer: Wise Provider Network Commercial |
$166.09
|
|
|
BARICITINIB 2 MG TABLET [152721]
|
Facility
|
IP
|
$174.83
|
|
|
Service Code
|
NDC 0002418230
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$101.31 |
| Max. Negotiated Rate |
$174.83 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$171.33
|
| Rate for Payer: Aetna of WY Medicare |
$111.89
|
| Rate for Payer: Altius Commercial |
$167.84
|
| Rate for Payer: Beech Street Commercial |
$171.33
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$169.59
|
| Rate for Payer: Cash Price |
$122.38
|
| Rate for Payer: ChoiceCare Network Commercial |
$169.59
|
| Rate for Payer: Cigna of WY Commercial |
$171.33
|
| Rate for Payer: Entrust Commercial |
$166.09
|
| Rate for Payer: First Choice Health Commercial |
$166.09
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$166.09
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$106.65
|
| Rate for Payer: HealthUtah PPO |
$174.83
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$169.59
|
| Rate for Payer: Multiplan Medicare/VA |
$101.31
|
| Rate for Payer: One Health Plan of WY PPO |
$171.33
|
| Rate for Payer: PacificSource Commercial |
$157.35
|
| Rate for Payer: PHCS PPO |
$171.33
|
| Rate for Payer: Three Rivers PPO |
$131.12
|
| Rate for Payer: TriWest Veterans Administration |
$106.65
|
| Rate for Payer: United Healthcare Commercial |
$166.96
|
| Rate for Payer: United Healthcare Medicare |
$106.65
|
| Rate for Payer: WINHealth Partners Commercial |
$166.09
|
| Rate for Payer: Wise Provider Network Commercial |
$166.09
|
|
|
BARIUM SULFATE 105 % (W/V), 58 % (W/W) ORAL SUSPENSION [43229]
|
Facility
|
IP
|
$15.12
|
|
|
Service Code
|
NDC 3290916755
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.76 |
| Max. Negotiated Rate |
$15.12 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.82
|
| Rate for Payer: Aetna of WY Medicare |
$9.68
|
| Rate for Payer: Altius Commercial |
$14.52
|
| Rate for Payer: Beech Street Commercial |
$14.82
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.67
|
| Rate for Payer: Cash Price |
$10.58
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.67
|
| Rate for Payer: Cigna of WY Commercial |
$14.82
|
| Rate for Payer: Entrust Commercial |
$14.36
|
| Rate for Payer: First Choice Health Commercial |
$14.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.22
|
| Rate for Payer: HealthUtah PPO |
$15.12
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.67
|
| Rate for Payer: Multiplan Medicare/VA |
$8.76
|
| Rate for Payer: One Health Plan of WY PPO |
$14.82
|
| Rate for Payer: PacificSource Commercial |
$13.61
|
| Rate for Payer: PHCS PPO |
$14.82
|
| Rate for Payer: Three Rivers PPO |
$11.34
|
| Rate for Payer: TriWest Veterans Administration |
$9.22
|
| Rate for Payer: United Healthcare Commercial |
$14.44
|
| Rate for Payer: United Healthcare Medicare |
$9.22
|
| Rate for Payer: WINHealth Partners Commercial |
$14.36
|
| Rate for Payer: Wise Provider Network Commercial |
$14.36
|
|
|
BARIUM SULFATE 105 % (W/V), 58 % (W/W) ORAL SUSPENSION [43229]
|
Facility
|
OP
|
$15.12
|
|
|
Service Code
|
NDC 3290916755
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.19 |
| Max. Negotiated Rate |
$15.12 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.82
|
| Rate for Payer: Aetna of WY Medicare |
$9.98
|
| Rate for Payer: Altius Commercial |
$14.52
|
| Rate for Payer: Beech Street Commercial |
$14.82
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.67
|
| Rate for Payer: Cash Price |
$10.58
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.67
|
| Rate for Payer: Cigna of WY Commercial |
$14.82
|
| Rate for Payer: Entrust Commercial |
$14.36
|
| Rate for Payer: First Choice Health Commercial |
$14.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.62
|
| Rate for Payer: HealthUtah PPO |
$15.12
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.67
|
| Rate for Payer: Multiplan Medicare/VA |
$8.19
|
| Rate for Payer: One Health Plan of WY PPO |
$14.82
|
| Rate for Payer: PacificSource Commercial |
$13.61
|
| Rate for Payer: PHCS PPO |
$14.82
|
| Rate for Payer: Three Rivers PPO |
$11.34
|
| Rate for Payer: TriWest Veterans Administration |
$8.62
|
| Rate for Payer: United Healthcare Commercial |
$14.44
|
| Rate for Payer: United Healthcare Medicare |
$8.62
|
| Rate for Payer: WINHealth Partners Commercial |
$14.82
|
| Rate for Payer: Wise Provider Network Commercial |
$14.36
|
|
|
BARIUM SULFATE 40 % (W/V), 30% (W/W) ORAL PASTE [87036]
|
Facility
|
IP
|
$17.20
|
|
|
Service Code
|
NDC 3290912522
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.97 |
| Max. Negotiated Rate |
$17.20 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.86
|
| Rate for Payer: Aetna of WY Medicare |
$11.01
|
| Rate for Payer: Altius Commercial |
$16.51
|
| Rate for Payer: Beech Street Commercial |
$16.86
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.68
|
| Rate for Payer: Cash Price |
$12.04
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.68
|
| Rate for Payer: Cigna of WY Commercial |
$16.86
|
| Rate for Payer: Entrust Commercial |
$16.34
|
| Rate for Payer: First Choice Health Commercial |
$16.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.49
|
| Rate for Payer: HealthUtah PPO |
$17.20
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.68
|
| Rate for Payer: Multiplan Medicare/VA |
$9.97
|
| Rate for Payer: One Health Plan of WY PPO |
$16.86
|
| Rate for Payer: PacificSource Commercial |
$15.48
|
| Rate for Payer: PHCS PPO |
$16.86
|
| Rate for Payer: Three Rivers PPO |
$12.90
|
| Rate for Payer: TriWest Veterans Administration |
$10.49
|
| Rate for Payer: United Healthcare Commercial |
$16.43
|
| Rate for Payer: United Healthcare Medicare |
$10.49
|
| Rate for Payer: WINHealth Partners Commercial |
$16.34
|
| Rate for Payer: Wise Provider Network Commercial |
$16.34
|
|
|
BARIUM SULFATE 40 % (W/V), 30% (W/W) ORAL PASTE [87036]
|
Facility
|
OP
|
$17.20
|
|
|
Service Code
|
NDC 3290912522
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.31 |
| Max. Negotiated Rate |
$17.20 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.86
|
| Rate for Payer: Aetna of WY Medicare |
$11.35
|
| Rate for Payer: Altius Commercial |
$16.51
|
| Rate for Payer: Beech Street Commercial |
$16.86
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.68
|
| Rate for Payer: Cash Price |
$12.04
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.68
|
| Rate for Payer: Cigna of WY Commercial |
$16.86
|
| Rate for Payer: Entrust Commercial |
$16.34
|
| Rate for Payer: First Choice Health Commercial |
$16.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.80
|
| Rate for Payer: HealthUtah PPO |
$17.20
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.68
|
| Rate for Payer: Multiplan Medicare/VA |
$9.31
|
| Rate for Payer: One Health Plan of WY PPO |
$16.86
|
| Rate for Payer: PacificSource Commercial |
$15.48
|
| Rate for Payer: PHCS PPO |
$16.86
|
| Rate for Payer: Three Rivers PPO |
$12.90
|
| Rate for Payer: TriWest Veterans Administration |
$9.80
|
| Rate for Payer: United Healthcare Commercial |
$16.43
|
| Rate for Payer: United Healthcare Medicare |
$9.80
|
| Rate for Payer: WINHealth Partners Commercial |
$16.86
|
| Rate for Payer: Wise Provider Network Commercial |
$16.34
|
|
|
BARIUM SULFATE 40 % (W/V), 30 % (W/W) ORAL SUSPENSION [39338]
|
Facility
|
OP
|
$15.26
|
|
|
Service Code
|
NDC 3290911600
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.26 |
| Max. Negotiated Rate |
$15.26 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.95
|
| Rate for Payer: Aetna of WY Medicare |
$10.07
|
| Rate for Payer: Altius Commercial |
$14.65
|
| Rate for Payer: Beech Street Commercial |
$14.95
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.80
|
| Rate for Payer: Cash Price |
$10.68
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.80
|
| Rate for Payer: Cigna of WY Commercial |
$14.95
|
| Rate for Payer: Entrust Commercial |
$14.50
|
| Rate for Payer: First Choice Health Commercial |
$14.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.70
|
| Rate for Payer: HealthUtah PPO |
$15.26
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.80
|
| Rate for Payer: Multiplan Medicare/VA |
$8.26
|
| Rate for Payer: One Health Plan of WY PPO |
$14.95
|
| Rate for Payer: PacificSource Commercial |
$13.73
|
| Rate for Payer: PHCS PPO |
$14.95
|
| Rate for Payer: Three Rivers PPO |
$11.44
|
| Rate for Payer: TriWest Veterans Administration |
$8.70
|
| Rate for Payer: United Healthcare Commercial |
$14.57
|
| Rate for Payer: United Healthcare Medicare |
$8.70
|
| Rate for Payer: WINHealth Partners Commercial |
$14.95
|
| Rate for Payer: Wise Provider Network Commercial |
$14.50
|
|
|
BARIUM SULFATE 40 % (W/V), 30 % (W/W) ORAL SUSPENSION [39338]
|
Facility
|
IP
|
$15.26
|
|
|
Service Code
|
NDC 3290911600
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.84 |
| Max. Negotiated Rate |
$15.26 |
| Rate for Payer: WINHealth Partners Commercial |
$14.50
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.95
|
| Rate for Payer: Aetna of WY Medicare |
$9.77
|
| Rate for Payer: Altius Commercial |
$14.65
|
| Rate for Payer: Beech Street Commercial |
$14.95
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.80
|
| Rate for Payer: Cash Price |
$10.68
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.80
|
| Rate for Payer: Cigna of WY Commercial |
$14.95
|
| Rate for Payer: Entrust Commercial |
$14.50
|
| Rate for Payer: First Choice Health Commercial |
$14.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.31
|
| Rate for Payer: HealthUtah PPO |
$15.26
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.80
|
| Rate for Payer: Multiplan Medicare/VA |
$8.84
|
| Rate for Payer: One Health Plan of WY PPO |
$14.95
|
| Rate for Payer: PacificSource Commercial |
$13.73
|
| Rate for Payer: PHCS PPO |
$14.95
|
| Rate for Payer: Three Rivers PPO |
$11.44
|
| Rate for Payer: TriWest Veterans Administration |
$9.31
|
| Rate for Payer: United Healthcare Commercial |
$14.57
|
| Rate for Payer: United Healthcare Medicare |
$9.31
|
| Rate for Payer: Wise Provider Network Commercial |
$14.50
|
|
|
BARIUM SULFATE 60 % (W/V) ORAL SUSPENSION [18865]
|
Facility
|
IP
|
$15.06
|
|
|
Service Code
|
NDC 3290918602
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.73 |
| Max. Negotiated Rate |
$15.06 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.76
|
| Rate for Payer: Aetna of WY Medicare |
$9.64
|
| 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 |
$9.19
|
| Rate for Payer: HealthUtah PPO |
$15.06
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.61
|
| Rate for Payer: Multiplan Medicare/VA |
$8.73
|
| 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 |
$9.19
|
| Rate for Payer: United Healthcare Commercial |
$14.38
|
| Rate for Payer: United Healthcare Medicare |
$9.19
|
| Rate for Payer: WINHealth Partners Commercial |
$14.31
|
| Rate for Payer: Wise Provider Network Commercial |
$14.31
|
|
|
BARIUM SULFATE 60 % (W/V) ORAL SUSPENSION [18865]
|
Facility
|
OP
|
$15.08
|
|
|
Service Code
|
NDC 3290918702
|
|
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 |
$10.56
|
| 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
|
|
|
BARIUM SULFATE 60 % (W/V) ORAL SUSPENSION [18865]
|
Facility
|
IP
|
$15.08
|
|
|
Service Code
|
NDC 3290918702
|
|
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 |
$10.56
|
| 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
|
|
|
BARIUM SULFATE 60 % (W/V) ORAL SUSPENSION [18865]
|
Facility
|
OP
|
$15.06
|
|
|
Service Code
|
NDC 3290918602
|
|
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
|
|
|
BARIUM SULFATE 700 MG TABLET [88713]
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
NDC 1036177831
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.33 |
| Max. Negotiated Rate |
$23.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$22.54
|
| Rate for Payer: Aetna of WY Medicare |
$14.72
|
| Rate for Payer: Altius Commercial |
$22.08
|
| Rate for Payer: Beech Street Commercial |
$22.54
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$22.31
|
| Rate for Payer: Cash Price |
$16.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$22.31
|
| Rate for Payer: Cigna of WY Commercial |
$22.54
|
| Rate for Payer: Entrust Commercial |
$21.85
|
| Rate for Payer: First Choice Health Commercial |
$21.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$21.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$14.03
|
| Rate for Payer: HealthUtah PPO |
$23.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$22.31
|
| Rate for Payer: Multiplan Medicare/VA |
$13.33
|
| Rate for Payer: One Health Plan of WY PPO |
$22.54
|
| Rate for Payer: PacificSource Commercial |
$20.70
|
| Rate for Payer: PHCS PPO |
$22.54
|
| Rate for Payer: Three Rivers PPO |
$17.25
|
| Rate for Payer: TriWest Veterans Administration |
$14.03
|
| Rate for Payer: United Healthcare Commercial |
$21.96
|
| Rate for Payer: United Healthcare Medicare |
$14.03
|
| Rate for Payer: WINHealth Partners Commercial |
$21.85
|
| Rate for Payer: Wise Provider Network Commercial |
$21.85
|
|
|
BARIUM SULFATE 700 MG TABLET [88713]
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
NDC 1036177831
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.45 |
| Max. Negotiated Rate |
$23.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$22.54
|
| Rate for Payer: Aetna of WY Medicare |
$15.18
|
| Rate for Payer: Altius Commercial |
$22.08
|
| Rate for Payer: Beech Street Commercial |
$22.54
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$22.31
|
| Rate for Payer: Cash Price |
$16.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$22.31
|
| Rate for Payer: Cigna of WY Commercial |
$22.54
|
| Rate for Payer: Entrust Commercial |
$21.85
|
| Rate for Payer: First Choice Health Commercial |
$21.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$21.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$13.11
|
| Rate for Payer: HealthUtah PPO |
$23.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$22.31
|
| Rate for Payer: Multiplan Medicare/VA |
$12.45
|
| Rate for Payer: One Health Plan of WY PPO |
$22.54
|
| Rate for Payer: PacificSource Commercial |
$20.70
|
| Rate for Payer: PHCS PPO |
$22.54
|
| Rate for Payer: Three Rivers PPO |
$17.25
|
| Rate for Payer: TriWest Veterans Administration |
$13.11
|
| Rate for Payer: United Healthcare Commercial |
$21.96
|
| Rate for Payer: United Healthcare Medicare |
$13.11
|
| Rate for Payer: WINHealth Partners Commercial |
$22.54
|
| Rate for Payer: Wise Provider Network Commercial |
$21.85
|
|
|
BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION [43230]
|
Facility
|
IP
|
$36.06
|
|
|
Service Code
|
NDC 3290976401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.90 |
| Max. Negotiated Rate |
$36.06 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$35.34
|
| Rate for Payer: Aetna of WY Medicare |
$23.08
|
| Rate for Payer: Altius Commercial |
$34.62
|
| Rate for Payer: Beech Street Commercial |
$35.34
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$34.98
|
| Rate for Payer: Cash Price |
$25.24
|
| Rate for Payer: ChoiceCare Network Commercial |
$34.98
|
| Rate for Payer: Cigna of WY Commercial |
$35.34
|
| Rate for Payer: Entrust Commercial |
$34.26
|
| Rate for Payer: First Choice Health Commercial |
$34.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$34.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$22.00
|
| Rate for Payer: HealthUtah PPO |
$36.06
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$34.98
|
| Rate for Payer: Multiplan Medicare/VA |
$20.90
|
| Rate for Payer: One Health Plan of WY PPO |
$35.34
|
| Rate for Payer: PacificSource Commercial |
$32.45
|
| Rate for Payer: PHCS PPO |
$35.34
|
| Rate for Payer: Three Rivers PPO |
$27.04
|
| Rate for Payer: TriWest Veterans Administration |
$22.00
|
| Rate for Payer: United Healthcare Commercial |
$34.44
|
| Rate for Payer: United Healthcare Medicare |
$22.00
|
| Rate for Payer: WINHealth Partners Commercial |
$34.26
|
| Rate for Payer: Wise Provider Network Commercial |
$34.26
|
|
|
BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION [43230]
|
Facility
|
OP
|
$36.06
|
|
|
Service Code
|
NDC 3290976401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.53 |
| Max. Negotiated Rate |
$36.06 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$35.34
|
| Rate for Payer: Aetna of WY Medicare |
$23.80
|
| Rate for Payer: Altius Commercial |
$34.62
|
| Rate for Payer: Beech Street Commercial |
$35.34
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$34.98
|
| Rate for Payer: Cash Price |
$25.24
|
| Rate for Payer: ChoiceCare Network Commercial |
$34.98
|
| Rate for Payer: Cigna of WY Commercial |
$35.34
|
| Rate for Payer: Entrust Commercial |
$34.26
|
| Rate for Payer: First Choice Health Commercial |
$34.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$34.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$20.55
|
| Rate for Payer: HealthUtah PPO |
$36.06
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$34.98
|
| Rate for Payer: Multiplan Medicare/VA |
$19.53
|
| Rate for Payer: One Health Plan of WY PPO |
$35.34
|
| Rate for Payer: PacificSource Commercial |
$32.45
|
| Rate for Payer: PHCS PPO |
$35.34
|
| Rate for Payer: Three Rivers PPO |
$27.04
|
| Rate for Payer: TriWest Veterans Administration |
$20.55
|
| Rate for Payer: United Healthcare Commercial |
$34.44
|
| Rate for Payer: United Healthcare Medicare |
$20.55
|
| Rate for Payer: WINHealth Partners Commercial |
$35.34
|
| Rate for Payer: Wise Provider Network Commercial |
$34.26
|
|
|
BASIC METABOLIC PANEL CALCIUM TOTAL
|
Professional
|
Both
|
$99.00
|
|
|
Service Code
|
HCPCS 80048
|
| Min. Negotiated Rate |
$7.19 |
| Max. Negotiated Rate |
$99.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$97.02
|
| Rate for Payer: Aetna of WY Medicare |
$8.46
|
| Rate for Payer: Beech Street Commercial |
$94.05
|
| Rate for Payer: Cash Price |
$69.30
|
| Rate for Payer: Cash Price |
$69.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$96.03
|
| Rate for Payer: Cigna of WY Commercial |
$97.02
|
| Rate for Payer: First Choice Health Commercial |
$89.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$94.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.46
|
| Rate for Payer: HealthUtah PPO |
$99.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$96.03
|
| Rate for Payer: Multiplan Medicare/VA |
$7.19
|
| Rate for Payer: One Health Plan of WY PPO |
$97.02
|
| Rate for Payer: PacificSource Commercial |
$89.10
|
| Rate for Payer: PHCS PPO |
$94.05
|
| Rate for Payer: Three Rivers PPO |
$74.25
|
| Rate for Payer: TriWest Veterans Administration |
$8.46
|
| Rate for Payer: United Healthcare Commercial |
$94.05
|
| Rate for Payer: WINHealth Partners Commercial |
$94.05
|
|
|
BATTERY FLYTE HOOD STRYKER
|
Facility
|
IP
|
$933.62
|
|
| Hospital Charge Code |
2650906
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$541.03 |
| Max. Negotiated Rate |
$933.62 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$914.95
|
| Rate for Payer: Aetna of WY Medicare |
$597.52
|
| Rate for Payer: Altius Commercial |
$896.28
|
| Rate for Payer: Beech Street Commercial |
$914.95
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$905.61
|
| Rate for Payer: Cash Price |
$653.54
|
| Rate for Payer: ChoiceCare Network Commercial |
$905.61
|
| Rate for Payer: Cigna of WY Commercial |
$914.95
|
| Rate for Payer: Entrust Commercial |
$886.94
|
| Rate for Payer: First Choice Health Commercial |
$886.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$886.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$569.51
|
| Rate for Payer: HealthUtah PPO |
$933.62
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$905.61
|
| Rate for Payer: Multiplan Medicare/VA |
$541.03
|
| Rate for Payer: One Health Plan of WY PPO |
$914.95
|
| Rate for Payer: PacificSource Commercial |
$840.26
|
| Rate for Payer: PHCS PPO |
$914.95
|
| Rate for Payer: Three Rivers PPO |
$700.22
|
| Rate for Payer: TriWest Veterans Administration |
$569.51
|
| Rate for Payer: United Healthcare Commercial |
$891.61
|
| Rate for Payer: United Healthcare Medicare |
$569.51
|
| Rate for Payer: WINHealth Partners Commercial |
$886.94
|
| Rate for Payer: Wise Provider Network Commercial |
$886.94
|
|
