ACYCLOVIR 400 MG TABLET [7394]
|
Facility
|
OP
|
$1.18
|
|
Service Code
|
NDC 5026806115
|
Hospital Revenue Code
|
250
|
Min. Negotiated Rate |
$0.65 |
Max. Negotiated Rate |
$1.18 |
Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.16
|
Rate for Payer: Aetna of WY Medicare |
$0.78
|
Rate for Payer: Altius Auto/Workers Compensation |
$1.13
|
Rate for Payer: Altius Commercial |
$1.13
|
Rate for Payer: Beech Street Commercial |
$1.16
|
Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.97
|
Rate for Payer: Cash Price |
$0.82
|
Rate for Payer: ChoiceCare Network Commercial |
$1.14
|
Rate for Payer: Cigna of WY Commercial |
$1.16
|
Rate for Payer: Entrust Commercial |
$1.12
|
Rate for Payer: First Choice Health Commercial |
$1.12
|
Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.12
|
Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.68
|
Rate for Payer: HealthUtah PPO |
$1.18
|
Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.14
|
Rate for Payer: Multiplan Medicare/VA |
$0.65
|
Rate for Payer: One Health Plan of WY PPO |
$1.16
|
Rate for Payer: PacificSource Commercial |
$1.06
|
Rate for Payer: PHCS PPO |
$1.16
|
Rate for Payer: Three Rivers PPO |
$0.89
|
Rate for Payer: TriWest Veterans Administration |
$0.68
|
Rate for Payer: United Healthcare Commercial |
$1.03
|
Rate for Payer: United Healthcare Medicare |
$0.68
|
Rate for Payer: WINHealth Partners Commercial |
$1.16
|
Rate for Payer: Wise Provider Network Commercial |
$1.12
|
|
ACYCLOVIR 400 MG TABLET [7394]
|
Facility
|
OP
|
$1.55
|
|
Service Code
|
NDC 6808410811
|
Hospital Revenue Code
|
250
|
Min. Negotiated Rate |
$0.85 |
Max. Negotiated Rate |
$1.55 |
Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.52
|
Rate for Payer: Aetna of WY Medicare |
$1.02
|
Rate for Payer: Altius Auto/Workers Compensation |
$1.49
|
Rate for Payer: Altius Commercial |
$1.49
|
Rate for Payer: Beech Street Commercial |
$1.52
|
Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.27
|
Rate for Payer: Cash Price |
$1.09
|
Rate for Payer: ChoiceCare Network Commercial |
$1.50
|
Rate for Payer: Cigna of WY Commercial |
$1.52
|
Rate for Payer: Entrust Commercial |
$1.47
|
Rate for Payer: First Choice Health Commercial |
$1.47
|
Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.47
|
Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.90
|
Rate for Payer: HealthUtah PPO |
$1.55
|
Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.50
|
Rate for Payer: Multiplan Medicare/VA |
$0.85
|
Rate for Payer: One Health Plan of WY PPO |
$1.52
|
Rate for Payer: PacificSource Commercial |
$1.40
|
Rate for Payer: PHCS PPO |
$1.52
|
Rate for Payer: Three Rivers PPO |
$1.16
|
Rate for Payer: TriWest Veterans Administration |
$0.90
|
Rate for Payer: United Healthcare Commercial |
$1.35
|
Rate for Payer: United Healthcare Medicare |
$0.90
|
Rate for Payer: WINHealth Partners Commercial |
$1.52
|
Rate for Payer: Wise Provider Network Commercial |
$1.47
|
|
ACYCLOVIR 400 MG TABLET [7394]
|
Facility
|
IP
|
$1.18
|
|
Service Code
|
NDC 5026806111
|
Hospital Revenue Code
|
250
|
Min. Negotiated Rate |
$0.74 |
Max. Negotiated Rate |
$1.18 |
Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.16
|
Rate for Payer: Altius Auto/Workers Compensation |
$1.13
|
Rate for Payer: Altius Commercial |
$1.13
|
Rate for Payer: Beech Street Commercial |
$1.16
|
Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.97
|
Rate for Payer: Cash Price |
$0.82
|
Rate for Payer: ChoiceCare Network Commercial |
$1.14
|
Rate for Payer: Cigna of WY Commercial |
$1.16
|
Rate for Payer: Entrust Commercial |
$1.12
|
Rate for Payer: First Choice Health Commercial |
$1.12
|
Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.12
|
Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.78
|
Rate for Payer: HealthUtah PPO |
$1.18
|
Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.14
|
Rate for Payer: Multiplan Medicare/VA |
$0.74
|
Rate for Payer: One Health Plan of WY PPO |
$1.16
|
Rate for Payer: PacificSource Commercial |
$1.06
|
Rate for Payer: PHCS PPO |
$1.16
|
Rate for Payer: Three Rivers PPO |
$0.89
|
Rate for Payer: TriWest Veterans Administration |
$0.78
|
Rate for Payer: United Healthcare Commercial |
$1.03
|
Rate for Payer: United Healthcare Medicare |
$0.78
|
Rate for Payer: WINHealth Partners Commercial |
$1.12
|
Rate for Payer: Wise Provider Network Commercial |
$1.12
|
|
ACYCLOVIR 400 MG TABLET [7394]
|
Facility
|
IP
|
$1.18
|
|
Service Code
|
NDC 5026806115
|
Hospital Revenue Code
|
250
|
Min. Negotiated Rate |
$0.74 |
Max. Negotiated Rate |
$1.18 |
Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.16
|
Rate for Payer: Altius Auto/Workers Compensation |
$1.13
|
Rate for Payer: Altius Commercial |
$1.13
|
Rate for Payer: Beech Street Commercial |
$1.16
|
Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.97
|
Rate for Payer: Cash Price |
$0.82
|
Rate for Payer: ChoiceCare Network Commercial |
$1.14
|
Rate for Payer: Cigna of WY Commercial |
$1.16
|
Rate for Payer: Entrust Commercial |
$1.12
|
Rate for Payer: First Choice Health Commercial |
$1.12
|
Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.12
|
Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.78
|
Rate for Payer: HealthUtah PPO |
$1.18
|
Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.14
|
Rate for Payer: Multiplan Medicare/VA |
$0.74
|
Rate for Payer: One Health Plan of WY PPO |
$1.16
|
Rate for Payer: PacificSource Commercial |
$1.06
|
Rate for Payer: PHCS PPO |
$1.16
|
Rate for Payer: Three Rivers PPO |
$0.89
|
Rate for Payer: TriWest Veterans Administration |
$0.78
|
Rate for Payer: United Healthcare Commercial |
$1.03
|
Rate for Payer: United Healthcare Medicare |
$0.78
|
Rate for Payer: WINHealth Partners Commercial |
$1.12
|
Rate for Payer: Wise Provider Network Commercial |
$1.12
|
|
ACYCLOVIR 400 MG TABLET [7394]
|
Facility
|
OP
|
$1.18
|
|
Service Code
|
NDC 5026806111
|
Hospital Revenue Code
|
250
|
Min. Negotiated Rate |
$0.65 |
Max. Negotiated Rate |
$1.18 |
Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.16
|
Rate for Payer: Aetna of WY Medicare |
$0.78
|
Rate for Payer: Altius Auto/Workers Compensation |
$1.13
|
Rate for Payer: Altius Commercial |
$1.13
|
Rate for Payer: Beech Street Commercial |
$1.16
|
Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.97
|
Rate for Payer: Cash Price |
$0.82
|
Rate for Payer: ChoiceCare Network Commercial |
$1.14
|
Rate for Payer: Cigna of WY Commercial |
$1.16
|
Rate for Payer: Entrust Commercial |
$1.12
|
Rate for Payer: First Choice Health Commercial |
$1.12
|
Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.12
|
Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.68
|
Rate for Payer: HealthUtah PPO |
$1.18
|
Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.14
|
Rate for Payer: Multiplan Medicare/VA |
$0.65
|
Rate for Payer: One Health Plan of WY PPO |
$1.16
|
Rate for Payer: PacificSource Commercial |
$1.06
|
Rate for Payer: PHCS PPO |
$1.16
|
Rate for Payer: Three Rivers PPO |
$0.89
|
Rate for Payer: TriWest Veterans Administration |
$0.68
|
Rate for Payer: United Healthcare Commercial |
$1.03
|
Rate for Payer: United Healthcare Medicare |
$0.68
|
Rate for Payer: WINHealth Partners Commercial |
$1.16
|
Rate for Payer: Wise Provider Network Commercial |
$1.12
|
|
ACYCLOVIR 400 MG TABLET [7394]
|
Facility
|
IP
|
$1.55
|
|
Service Code
|
NDC 6808410811
|
Hospital Revenue Code
|
250
|
Min. Negotiated Rate |
$0.97 |
Max. Negotiated Rate |
$1.55 |
Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.52
|
Rate for Payer: Altius Auto/Workers Compensation |
$1.49
|
Rate for Payer: Altius Commercial |
$1.49
|
Rate for Payer: Beech Street Commercial |
$1.52
|
Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.27
|
Rate for Payer: Cash Price |
$1.09
|
Rate for Payer: ChoiceCare Network Commercial |
$1.50
|
Rate for Payer: Cigna of WY Commercial |
$1.52
|
Rate for Payer: Entrust Commercial |
$1.47
|
Rate for Payer: First Choice Health Commercial |
$1.47
|
Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.47
|
Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.02
|
Rate for Payer: HealthUtah PPO |
$1.55
|
Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.50
|
Rate for Payer: Multiplan Medicare/VA |
$0.97
|
Rate for Payer: One Health Plan of WY PPO |
$1.52
|
Rate for Payer: PacificSource Commercial |
$1.40
|
Rate for Payer: PHCS PPO |
$1.52
|
Rate for Payer: Three Rivers PPO |
$1.16
|
Rate for Payer: TriWest Veterans Administration |
$1.02
|
Rate for Payer: United Healthcare Commercial |
$1.35
|
Rate for Payer: United Healthcare Medicare |
$1.02
|
Rate for Payer: WINHealth Partners Commercial |
$1.47
|
Rate for Payer: Wise Provider Network Commercial |
$1.47
|
|
ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION [4235]
|
Facility
|
OP
|
$19.20
|
|
Service Code
|
HCPCS J0133
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$10.58 |
Max. Negotiated Rate |
$19.20 |
Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18.82
|
Rate for Payer: Aetna of WY Medicare |
$12.67
|
Rate for Payer: Altius Auto/Workers Compensation |
$18.43
|
Rate for Payer: Altius Commercial |
$18.43
|
Rate for Payer: Beech Street Commercial |
$18.82
|
Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.76
|
Rate for Payer: Cash Price |
$13.44
|
Rate for Payer: ChoiceCare Network Commercial |
$18.62
|
Rate for Payer: Cigna of WY Commercial |
$18.82
|
Rate for Payer: Entrust Commercial |
$18.24
|
Rate for Payer: First Choice Health Commercial |
$18.24
|
Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$18.24
|
Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.14
|
Rate for Payer: HealthUtah PPO |
$19.20
|
Rate for Payer: Idaho Integrated Healthcare Commercial |
$18.62
|
Rate for Payer: Multiplan Medicare/VA |
$10.58
|
Rate for Payer: One Health Plan of WY PPO |
$18.82
|
Rate for Payer: PacificSource Commercial |
$17.28
|
Rate for Payer: PHCS PPO |
$18.82
|
Rate for Payer: Three Rivers PPO |
$14.40
|
Rate for Payer: TriWest Veterans Administration |
$11.14
|
Rate for Payer: United Healthcare Commercial |
$16.70
|
Rate for Payer: United Healthcare Medicare |
$11.14
|
Rate for Payer: WINHealth Partners Commercial |
$18.82
|
Rate for Payer: Wise Provider Network Commercial |
$18.24
|
|
ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION [4235]
|
Facility
|
IP
|
$19.20
|
|
Service Code
|
HCPCS J0133
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$12.04 |
Max. Negotiated Rate |
$19.20 |
Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18.82
|
Rate for Payer: Altius Auto/Workers Compensation |
$18.43
|
Rate for Payer: Altius Commercial |
$18.43
|
Rate for Payer: Beech Street Commercial |
$18.82
|
Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.76
|
Rate for Payer: Cash Price |
$13.44
|
Rate for Payer: ChoiceCare Network Commercial |
$18.62
|
Rate for Payer: Cigna of WY Commercial |
$18.82
|
Rate for Payer: Entrust Commercial |
$18.24
|
Rate for Payer: First Choice Health Commercial |
$18.24
|
Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$18.24
|
Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$12.67
|
Rate for Payer: HealthUtah PPO |
$19.20
|
Rate for Payer: Idaho Integrated Healthcare Commercial |
$18.62
|
Rate for Payer: Multiplan Medicare/VA |
$12.04
|
Rate for Payer: One Health Plan of WY PPO |
$18.82
|
Rate for Payer: PacificSource Commercial |
$17.28
|
Rate for Payer: PHCS PPO |
$18.82
|
Rate for Payer: Three Rivers PPO |
$14.40
|
Rate for Payer: TriWest Veterans Administration |
$12.67
|
Rate for Payer: United Healthcare Commercial |
$16.70
|
Rate for Payer: United Healthcare Medicare |
$12.67
|
Rate for Payer: WINHealth Partners Commercial |
$18.24
|
Rate for Payer: Wise Provider Network Commercial |
$18.24
|
|
ADAPTER VALVED TEE 15MM OD
|
Facility
|
IP
|
$14.70
|
|
Hospital Charge Code |
27000000S1
|
Hospital Revenue Code
|
270
|
Min. Negotiated Rate |
$9.22 |
Max. Negotiated Rate |
$14.70 |
Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.41
|
Rate for Payer: Altius Auto/Workers Compensation |
$14.11
|
Rate for Payer: Altius Commercial |
$14.11
|
Rate for Payer: Beech Street Commercial |
$14.41
|
Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.07
|
Rate for Payer: Cash Price |
$10.29
|
Rate for Payer: ChoiceCare Network Commercial |
$14.26
|
Rate for Payer: Cigna of WY Commercial |
$14.41
|
Rate for Payer: Entrust Commercial |
$13.96
|
Rate for Payer: First Choice Health Commercial |
$13.96
|
Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$13.96
|
Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.70
|
Rate for Payer: HealthUtah PPO |
$14.70
|
Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.26
|
Rate for Payer: Multiplan Medicare/VA |
$9.22
|
Rate for Payer: One Health Plan of WY PPO |
$14.41
|
Rate for Payer: PacificSource Commercial |
$13.23
|
Rate for Payer: PHCS PPO |
$14.41
|
Rate for Payer: Three Rivers PPO |
$11.02
|
Rate for Payer: TriWest Veterans Administration |
$9.70
|
Rate for Payer: United Healthcare Commercial |
$12.79
|
Rate for Payer: United Healthcare Medicare |
$9.70
|
Rate for Payer: WINHealth Partners Commercial |
$13.96
|
Rate for Payer: Wise Provider Network Commercial |
$13.96
|
|
ADAPTER VALVED TEE 15MM OD
|
Facility
|
OP
|
$14.70
|
|
Hospital Charge Code |
27000000S1
|
Hospital Revenue Code
|
270
|
Min. Negotiated Rate |
$8.10 |
Max. Negotiated Rate |
$14.70 |
Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.41
|
Rate for Payer: Aetna of WY Medicare |
$9.70
|
Rate for Payer: Altius Auto/Workers Compensation |
$14.11
|
Rate for Payer: Altius Commercial |
$14.11
|
Rate for Payer: Beech Street Commercial |
$14.41
|
Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.07
|
Rate for Payer: Cash Price |
$10.29
|
Rate for Payer: ChoiceCare Network Commercial |
$14.26
|
Rate for Payer: Cigna of WY Commercial |
$14.41
|
Rate for Payer: Entrust Commercial |
$13.96
|
Rate for Payer: First Choice Health Commercial |
$13.96
|
Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$13.96
|
Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.53
|
Rate for Payer: HealthUtah PPO |
$14.70
|
Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.26
|
Rate for Payer: Multiplan Medicare/VA |
$8.10
|
Rate for Payer: One Health Plan of WY PPO |
$14.41
|
Rate for Payer: PacificSource Commercial |
$13.23
|
Rate for Payer: PHCS PPO |
$14.41
|
Rate for Payer: Three Rivers PPO |
$11.02
|
Rate for Payer: TriWest Veterans Administration |
$8.53
|
Rate for Payer: United Healthcare Commercial |
$12.79
|
Rate for Payer: United Healthcare Medicare |
$8.53
|
Rate for Payer: WINHealth Partners Commercial |
$14.41
|
Rate for Payer: Wise Provider Network Commercial |
$13.96
|
|
ADENOIDECTOMY PRIMARY <AGE 12
|
Professional
|
Both
|
$1,068.00
|
|
Service Code
|
HCPCS 42830
|
Hospital Charge Code |
42830
|
Min. Negotiated Rate |
$177.80 |
Max. Negotiated Rate |
$1,068.00 |
Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,046.64
|
Rate for Payer: Aetna of WY Medicare |
$209.18
|
Rate for Payer: Beech Street Commercial |
$1,014.60
|
Rate for Payer: Cash Price |
$747.60
|
Rate for Payer: Cash Price |
$747.60
|
Rate for Payer: ChoiceCare Network Commercial |
$1,035.96
|
Rate for Payer: Cigna of WY Commercial |
$1,046.64
|
Rate for Payer: First Choice Health Commercial |
$961.20
|
Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,014.60
|
Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$209.18
|
Rate for Payer: HealthUtah PPO |
$1,068.00
|
Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,035.96
|
Rate for Payer: Multiplan Medicare/VA |
$177.80
|
Rate for Payer: One Health Plan of WY PPO |
$1,046.64
|
Rate for Payer: PacificSource Commercial |
$961.20
|
Rate for Payer: PHCS PPO |
$1,014.60
|
Rate for Payer: Three Rivers PPO |
$801.00
|
Rate for Payer: TriWest Veterans Administration |
$209.18
|
Rate for Payer: United Healthcare Commercial |
$929.16
|
Rate for Payer: United Healthcare Medicare |
$209.18
|
Rate for Payer: WINHealth Partners Commercial |
$907.80
|
|
ADENOIDECTOMY PRIMARY AGE 12/>
|
Professional
|
Both
|
$1,156.00
|
|
Service Code
|
HCPCS 42831
|
Hospital Charge Code |
42831
|
Min. Negotiated Rate |
$193.32 |
Max. Negotiated Rate |
$1,156.00 |
Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,132.88
|
Rate for Payer: Aetna of WY Medicare |
$227.43
|
Rate for Payer: Beech Street Commercial |
$1,098.20
|
Rate for Payer: Cash Price |
$809.20
|
Rate for Payer: Cash Price |
$809.20
|
Rate for Payer: ChoiceCare Network Commercial |
$1,121.32
|
Rate for Payer: Cigna of WY Commercial |
$1,132.88
|
Rate for Payer: First Choice Health Commercial |
$1,040.40
|
Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,098.20
|
Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$227.43
|
Rate for Payer: HealthUtah PPO |
$1,156.00
|
Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,121.32
|
Rate for Payer: Multiplan Medicare/VA |
$193.32
|
Rate for Payer: One Health Plan of WY PPO |
$1,132.88
|
Rate for Payer: PacificSource Commercial |
$1,040.40
|
Rate for Payer: PHCS PPO |
$1,098.20
|
Rate for Payer: Three Rivers PPO |
$867.00
|
Rate for Payer: TriWest Veterans Administration |
$227.43
|
Rate for Payer: United Healthcare Commercial |
$1,005.72
|
Rate for Payer: United Healthcare Medicare |
$227.43
|
Rate for Payer: WINHealth Partners Commercial |
$982.60
|
|
ADENOIDECTOMY SECONDARY AGE 12/>
|
Professional
|
Both
|
$1,237.00
|
|
Service Code
|
HCPCS 42836
|
Hospital Charge Code |
42836
|
Min. Negotiated Rate |
$204.49 |
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 |
$240.58
|
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 |
$240.58
|
Rate for Payer: HealthUtah PPO |
$1,237.00
|
Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,199.89
|
Rate for Payer: Multiplan Medicare/VA |
$204.49
|
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 |
$240.58
|
Rate for Payer: United Healthcare Commercial |
$1,076.19
|
Rate for Payer: United Healthcare Medicare |
$240.58
|
Rate for Payer: WINHealth Partners Commercial |
$1,051.45
|
|
ADENOIDECTOMY SECONDARY<AGE 12
|
Professional
|
Both
|
$990.00
|
|
Service Code
|
HCPCS 42835
|
Hospital Charge Code |
42835
|
Min. Negotiated Rate |
$166.12 |
Max. Negotiated Rate |
$990.00 |
Rate for Payer: Aetna of WY Commercial/Medical Rental |
$970.20
|
Rate for Payer: Aetna of WY Medicare |
$195.44
|
Rate for Payer: Beech Street Commercial |
$940.50
|
Rate for Payer: Cash Price |
$693.00
|
Rate for Payer: Cash Price |
$693.00
|
Rate for Payer: ChoiceCare Network Commercial |
$960.30
|
Rate for Payer: Cigna of WY Commercial |
$970.20
|
Rate for Payer: First Choice Health Commercial |
$891.00
|
Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$940.50
|
Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$195.44
|
Rate for Payer: HealthUtah PPO |
$990.00
|
Rate for Payer: Idaho Integrated Healthcare Commercial |
$960.30
|
Rate for Payer: Multiplan Medicare/VA |
$166.12
|
Rate for Payer: One Health Plan of WY PPO |
$970.20
|
Rate for Payer: PacificSource Commercial |
$891.00
|
Rate for Payer: PHCS PPO |
$940.50
|
Rate for Payer: Three Rivers PPO |
$742.50
|
Rate for Payer: TriWest Veterans Administration |
$195.44
|
Rate for Payer: United Healthcare Commercial |
$861.30
|
Rate for Payer: United Healthcare Medicare |
$195.44
|
Rate for Payer: WINHealth Partners Commercial |
$841.50
|
|
ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION [12914]
|
Facility
|
OP
|
$26.25
|
|
Service Code
|
HCPCS J0153
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$14.46 |
Max. Negotiated Rate |
$26.25 |
Rate for Payer: Aetna of WY Commercial/Medical Rental |
$25.72
|
Rate for Payer: Aetna of WY Commercial/Medical Rental |
$25.64
|
Rate for Payer: Aetna of WY Commercial/Medical Rental |
$33.48
|
Rate for Payer: Aetna of WY Medicare |
$17.32
|
Rate for Payer: Aetna of WY Medicare |
$22.55
|
Rate for Payer: Aetna of WY Medicare |
$17.27
|
Rate for Payer: Altius Auto/Workers Compensation |
$25.20
|
Rate for Payer: Altius Auto/Workers Compensation |
$25.11
|
Rate for Payer: Altius Auto/Workers Compensation |
$32.79
|
Rate for Payer: Altius Commercial |
$25.20
|
Rate for Payer: Altius Commercial |
$32.79
|
Rate for Payer: Altius Commercial |
$25.11
|
Rate for Payer: Beech Street Commercial |
$25.72
|
Rate for Payer: Beech Street Commercial |
$33.48
|
Rate for Payer: Beech Street Commercial |
$25.64
|
Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$21.55
|
Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$21.48
|
Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$28.05
|
Rate for Payer: Cash Price |
$18.38
|
Rate for Payer: Cash Price |
$18.31
|
Rate for Payer: Cash Price |
$23.91
|
Rate for Payer: ChoiceCare Network Commercial |
$25.46
|
Rate for Payer: ChoiceCare Network Commercial |
$33.14
|
Rate for Payer: ChoiceCare Network Commercial |
$25.38
|
Rate for Payer: Cigna of WY Commercial |
$33.48
|
Rate for Payer: Cigna of WY Commercial |
$25.64
|
Rate for Payer: Cigna of WY Commercial |
$25.72
|
Rate for Payer: Entrust Commercial |
$32.45
|
Rate for Payer: Entrust Commercial |
$24.94
|
Rate for Payer: Entrust Commercial |
$24.85
|
Rate for Payer: First Choice Health Commercial |
$24.94
|
Rate for Payer: First Choice Health Commercial |
$24.85
|
Rate for Payer: First Choice Health Commercial |
$32.45
|
Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$24.85
|
Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$32.45
|
Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$24.94
|
Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$15.22
|
Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$15.17
|
Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$19.81
|
Rate for Payer: HealthUtah PPO |
$26.16
|
Rate for Payer: HealthUtah PPO |
$34.16
|
Rate for Payer: HealthUtah PPO |
$26.25
|
Rate for Payer: Idaho Integrated Healthcare Commercial |
$33.14
|
Rate for Payer: Idaho Integrated Healthcare Commercial |
$25.38
|
Rate for Payer: Idaho Integrated Healthcare Commercial |
$25.46
|
Rate for Payer: Multiplan Medicare/VA |
$14.41
|
Rate for Payer: Multiplan Medicare/VA |
$14.46
|
Rate for Payer: Multiplan Medicare/VA |
$18.82
|
Rate for Payer: One Health Plan of WY PPO |
$25.64
|
Rate for Payer: One Health Plan of WY PPO |
$33.48
|
Rate for Payer: One Health Plan of WY PPO |
$25.72
|
Rate for Payer: PacificSource Commercial |
$30.74
|
Rate for Payer: PacificSource Commercial |
$23.62
|
Rate for Payer: PacificSource Commercial |
$23.54
|
Rate for Payer: PHCS PPO |
$25.72
|
Rate for Payer: PHCS PPO |
$25.64
|
Rate for Payer: PHCS PPO |
$33.48
|
Rate for Payer: Three Rivers PPO |
$19.69
|
Rate for Payer: Three Rivers PPO |
$19.62
|
Rate for Payer: Three Rivers PPO |
$25.62
|
Rate for Payer: TriWest Veterans Administration |
$19.81
|
Rate for Payer: TriWest Veterans Administration |
$15.22
|
Rate for Payer: TriWest Veterans Administration |
$15.17
|
Rate for Payer: United Healthcare Commercial |
$22.76
|
Rate for Payer: United Healthcare Commercial |
$22.84
|
Rate for Payer: United Healthcare Commercial |
$29.72
|
Rate for Payer: United Healthcare Medicare |
$19.81
|
Rate for Payer: United Healthcare Medicare |
$15.17
|
Rate for Payer: United Healthcare Medicare |
$15.22
|
Rate for Payer: WINHealth Partners Commercial |
$33.48
|
Rate for Payer: WINHealth Partners Commercial |
$25.64
|
Rate for Payer: WINHealth Partners Commercial |
$25.72
|
Rate for Payer: Wise Provider Network Commercial |
$24.85
|
Rate for Payer: Wise Provider Network Commercial |
$32.45
|
Rate for Payer: Wise Provider Network Commercial |
$24.94
|
|
ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION [12914]
|
Facility
|
IP
|
$26.16
|
|
Service Code
|
HCPCS J0153
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$16.40 |
Max. Negotiated Rate |
$26.16 |
Rate for Payer: Aetna of WY Commercial/Medical Rental |
$25.64
|
Rate for Payer: Aetna of WY Commercial/Medical Rental |
$25.72
|
Rate for Payer: Aetna of WY Commercial/Medical Rental |
$33.48
|
Rate for Payer: Altius Auto/Workers Compensation |
$25.11
|
Rate for Payer: Altius Auto/Workers Compensation |
$25.20
|
Rate for Payer: Altius Auto/Workers Compensation |
$32.79
|
Rate for Payer: Altius Commercial |
$25.20
|
Rate for Payer: Altius Commercial |
$25.11
|
Rate for Payer: Altius Commercial |
$32.79
|
Rate for Payer: Beech Street Commercial |
$33.48
|
Rate for Payer: Beech Street Commercial |
$25.72
|
Rate for Payer: Beech Street Commercial |
$25.64
|
Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$21.48
|
Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$28.05
|
Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$21.55
|
Rate for Payer: Cash Price |
$18.38
|
Rate for Payer: Cash Price |
$18.31
|
Rate for Payer: Cash Price |
$23.91
|
Rate for Payer: ChoiceCare Network Commercial |
$25.38
|
Rate for Payer: ChoiceCare Network Commercial |
$33.14
|
Rate for Payer: ChoiceCare Network Commercial |
$25.46
|
Rate for Payer: Cigna of WY Commercial |
$25.72
|
Rate for Payer: Cigna of WY Commercial |
$33.48
|
Rate for Payer: Cigna of WY Commercial |
$25.64
|
Rate for Payer: Entrust Commercial |
$32.45
|
Rate for Payer: Entrust Commercial |
$24.85
|
Rate for Payer: Entrust Commercial |
$24.94
|
Rate for Payer: First Choice Health Commercial |
$24.94
|
Rate for Payer: First Choice Health Commercial |
$32.45
|
Rate for Payer: First Choice Health Commercial |
$24.85
|
Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$24.85
|
Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$32.45
|
Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$24.94
|
Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$17.27
|
Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$17.32
|
Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$22.55
|
Rate for Payer: HealthUtah PPO |
$26.16
|
Rate for Payer: HealthUtah PPO |
$26.25
|
Rate for Payer: HealthUtah PPO |
$34.16
|
Rate for Payer: Idaho Integrated Healthcare Commercial |
$33.14
|
Rate for Payer: Idaho Integrated Healthcare Commercial |
$25.46
|
Rate for Payer: Idaho Integrated Healthcare Commercial |
$25.38
|
Rate for Payer: Multiplan Medicare/VA |
$21.42
|
Rate for Payer: Multiplan Medicare/VA |
$16.40
|
Rate for Payer: Multiplan Medicare/VA |
$16.46
|
Rate for Payer: One Health Plan of WY PPO |
$25.64
|
Rate for Payer: One Health Plan of WY PPO |
$25.72
|
Rate for Payer: One Health Plan of WY PPO |
$33.48
|
Rate for Payer: PacificSource Commercial |
$30.74
|
Rate for Payer: PacificSource Commercial |
$23.54
|
Rate for Payer: PacificSource Commercial |
$23.62
|
Rate for Payer: PHCS PPO |
$25.72
|
Rate for Payer: PHCS PPO |
$25.64
|
Rate for Payer: PHCS PPO |
$33.48
|
Rate for Payer: Three Rivers PPO |
$19.69
|
Rate for Payer: Three Rivers PPO |
$19.62
|
Rate for Payer: Three Rivers PPO |
$25.62
|
Rate for Payer: TriWest Veterans Administration |
$17.32
|
Rate for Payer: TriWest Veterans Administration |
$17.27
|
Rate for Payer: TriWest Veterans Administration |
$22.55
|
Rate for Payer: United Healthcare Commercial |
$22.76
|
Rate for Payer: United Healthcare Commercial |
$29.72
|
Rate for Payer: United Healthcare Commercial |
$22.84
|
Rate for Payer: United Healthcare Medicare |
$17.27
|
Rate for Payer: United Healthcare Medicare |
$22.55
|
Rate for Payer: United Healthcare Medicare |
$17.32
|
Rate for Payer: WINHealth Partners Commercial |
$24.94
|
Rate for Payer: WINHealth Partners Commercial |
$24.85
|
Rate for Payer: WINHealth Partners Commercial |
$32.45
|
Rate for Payer: Wise Provider Network Commercial |
$32.45
|
Rate for Payer: Wise Provider Network Commercial |
$24.85
|
Rate for Payer: Wise Provider Network Commercial |
$24.94
|
|
ADENOSINE INJ 1MG
|
Professional
|
Both
|
$12.00
|
|
Service Code
|
HCPCS J0153
|
Hospital Charge Code |
J0153
|
Min. Negotiated Rate |
$0.47 |
Max. Negotiated Rate |
$12.00 |
Rate for Payer: Aetna of WY Commercial/Medical Rental |
$11.76
|
Rate for Payer: Aetna of WY Medicare |
$0.56
|
Rate for Payer: Beech Street Commercial |
$11.40
|
Rate for Payer: Cash Price |
$8.40
|
Rate for Payer: Cash Price |
$8.40
|
Rate for Payer: ChoiceCare Network Commercial |
$11.64
|
Rate for Payer: Cigna of WY Commercial |
$11.76
|
Rate for Payer: First Choice Health Commercial |
$10.80
|
Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$11.40
|
Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.56
|
Rate for Payer: HealthUtah PPO |
$12.00
|
Rate for Payer: Idaho Integrated Healthcare Commercial |
$11.64
|
Rate for Payer: Multiplan Medicare/VA |
$0.47
|
Rate for Payer: One Health Plan of WY PPO |
$11.76
|
Rate for Payer: PacificSource Commercial |
$10.80
|
Rate for Payer: PHCS PPO |
$11.40
|
Rate for Payer: Three Rivers PPO |
$9.00
|
Rate for Payer: TriWest Veterans Administration |
$0.56
|
Rate for Payer: United Healthcare Commercial |
$10.44
|
Rate for Payer: United Healthcare Medicare |
$0.56
|
Rate for Payer: WINHealth Partners Commercial |
$11.40
|
|
ADJNT TIS TRNSFR/REARGMT ANY AREA 30.1-60 SQ CM
|
Professional
|
Both
|
$4,357.00
|
|
Service Code
|
HCPCS 14301
|
Hospital Charge Code |
14301
|
Min. Negotiated Rate |
$710.15 |
Max. Negotiated Rate |
$4,357.00 |
Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4,269.86
|
Rate for Payer: Aetna of WY Medicare |
$835.47
|
Rate for Payer: Beech Street Commercial |
$4,139.15
|
Rate for Payer: Cash Price |
$3,049.90
|
Rate for Payer: Cash Price |
$3,049.90
|
Rate for Payer: ChoiceCare Network Commercial |
$4,226.29
|
Rate for Payer: Cigna of WY Commercial |
$4,269.86
|
Rate for Payer: First Choice Health Commercial |
$3,921.30
|
Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,139.15
|
Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$835.47
|
Rate for Payer: HealthUtah PPO |
$4,357.00
|
Rate for Payer: Idaho Integrated Healthcare Commercial |
$4,226.29
|
Rate for Payer: Multiplan Medicare/VA |
$710.15
|
Rate for Payer: One Health Plan of WY PPO |
$4,269.86
|
Rate for Payer: PacificSource Commercial |
$3,921.30
|
Rate for Payer: PHCS PPO |
$4,139.15
|
Rate for Payer: Three Rivers PPO |
$3,267.75
|
Rate for Payer: TriWest Veterans Administration |
$835.47
|
Rate for Payer: United Healthcare Commercial |
$3,790.59
|
Rate for Payer: United Healthcare Medicare |
$835.47
|
Rate for Payer: WINHealth Partners Commercial |
$3,703.45
|
|
ADJNT TIS TRNSFR/REARGMT ANY AREA 30.1-60 SQ CM
|
Professional
|
Both
|
$4,357.00
|
|
Service Code
|
HCPCS 14301 AS
|
Hospital Charge Code |
14301
|
Min. Negotiated Rate |
$710.15 |
Max. Negotiated Rate |
$4,357.00 |
Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4,269.86
|
Rate for Payer: Aetna of WY Medicare |
$835.47
|
Rate for Payer: Beech Street Commercial |
$4,139.15
|
Rate for Payer: Cash Price |
$3,049.90
|
Rate for Payer: Cash Price |
$3,049.90
|
Rate for Payer: ChoiceCare Network Commercial |
$4,226.29
|
Rate for Payer: Cigna of WY Commercial |
$4,269.86
|
Rate for Payer: First Choice Health Commercial |
$3,921.30
|
Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,139.15
|
Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$835.47
|
Rate for Payer: HealthUtah PPO |
$4,357.00
|
Rate for Payer: Idaho Integrated Healthcare Commercial |
$4,226.29
|
Rate for Payer: Multiplan Medicare/VA |
$710.15
|
Rate for Payer: One Health Plan of WY PPO |
$4,269.86
|
Rate for Payer: PacificSource Commercial |
$3,921.30
|
Rate for Payer: PHCS PPO |
$4,139.15
|
Rate for Payer: Three Rivers PPO |
$3,267.75
|
Rate for Payer: TriWest Veterans Administration |
$835.47
|
Rate for Payer: United Healthcare Commercial |
$3,790.59
|
Rate for Payer: United Healthcare Medicare |
$835.47
|
Rate for Payer: WINHealth Partners Commercial |
$3,703.45
|
|
ADJT/REARRGMT SCALP/ARM/LEG 10.1-30.0 SQ CM
|
Professional
|
Both
|
$3,542.00
|
|
Service Code
|
HCPCS 14021
|
Hospital Charge Code |
14021
|
Min. Negotiated Rate |
$582.12 |
Max. Negotiated Rate |
$3,542.00 |
Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,471.16
|
Rate for Payer: Aetna of WY Medicare |
$684.85
|
Rate for Payer: Beech Street Commercial |
$3,364.90
|
Rate for Payer: Cash Price |
$2,479.40
|
Rate for Payer: Cash Price |
$2,479.40
|
Rate for Payer: ChoiceCare Network Commercial |
$3,435.74
|
Rate for Payer: Cigna of WY Commercial |
$3,471.16
|
Rate for Payer: First Choice Health Commercial |
$3,187.80
|
Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,364.90
|
Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$684.85
|
Rate for Payer: HealthUtah PPO |
$3,542.00
|
Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,435.74
|
Rate for Payer: Multiplan Medicare/VA |
$582.12
|
Rate for Payer: One Health Plan of WY PPO |
$3,471.16
|
Rate for Payer: PacificSource Commercial |
$3,187.80
|
Rate for Payer: PHCS PPO |
$3,364.90
|
Rate for Payer: Three Rivers PPO |
$2,656.50
|
Rate for Payer: TriWest Veterans Administration |
$684.85
|
Rate for Payer: United Healthcare Commercial |
$3,081.54
|
Rate for Payer: United Healthcare Medicare |
$684.85
|
Rate for Payer: WINHealth Partners Commercial |
$3,010.70
|
|
ADJT TIS TRNSFR/REARGMT SCALP/ARM/LEG 10 SQ CM/<
|
Professional
|
Both
|
$2,802.00
|
|
Service Code
|
HCPCS 14020
|
Hospital Charge Code |
14020
|
Min. Negotiated Rate |
$467.19 |
Max. Negotiated Rate |
$2,802.00 |
Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,745.96
|
Rate for Payer: Aetna of WY Medicare |
$549.64
|
Rate for Payer: Beech Street Commercial |
$2,661.90
|
Rate for Payer: Cash Price |
$1,961.40
|
Rate for Payer: Cash Price |
$1,961.40
|
Rate for Payer: ChoiceCare Network Commercial |
$2,717.94
|
Rate for Payer: Cigna of WY Commercial |
$2,745.96
|
Rate for Payer: First Choice Health Commercial |
$2,521.80
|
Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,661.90
|
Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$549.64
|
Rate for Payer: HealthUtah PPO |
$2,802.00
|
Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,717.94
|
Rate for Payer: Multiplan Medicare/VA |
$467.19
|
Rate for Payer: One Health Plan of WY PPO |
$2,745.96
|
Rate for Payer: PacificSource Commercial |
$2,521.80
|
Rate for Payer: PHCS PPO |
$2,661.90
|
Rate for Payer: Three Rivers PPO |
$2,101.50
|
Rate for Payer: TriWest Veterans Administration |
$549.64
|
Rate for Payer: United Healthcare Commercial |
$2,437.74
|
Rate for Payer: United Healthcare Medicare |
$549.64
|
Rate for Payer: WINHealth Partners Commercial |
$2,381.70
|
|
ADJT TIS TRNS/REARGMT F/C/C/M/N/A/G/H/F 10SQCM/<
|
Professional
|
Both
|
$3,113.00
|
|
Service Code
|
HCPCS 14040
|
Hospital Charge Code |
14040
|
Min. Negotiated Rate |
$513.17 |
Max. Negotiated Rate |
$3,113.00 |
Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,050.74
|
Rate for Payer: Aetna of WY Medicare |
$603.73
|
Rate for Payer: Beech Street Commercial |
$2,957.35
|
Rate for Payer: Cash Price |
$2,179.10
|
Rate for Payer: Cash Price |
$2,179.10
|
Rate for Payer: ChoiceCare Network Commercial |
$3,019.61
|
Rate for Payer: Cigna of WY Commercial |
$3,050.74
|
Rate for Payer: First Choice Health Commercial |
$2,801.70
|
Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,957.35
|
Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$603.73
|
Rate for Payer: HealthUtah PPO |
$3,113.00
|
Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,019.61
|
Rate for Payer: Multiplan Medicare/VA |
$513.17
|
Rate for Payer: One Health Plan of WY PPO |
$3,050.74
|
Rate for Payer: PacificSource Commercial |
$2,801.70
|
Rate for Payer: PHCS PPO |
$2,957.35
|
Rate for Payer: Three Rivers PPO |
$2,334.75
|
Rate for Payer: TriWest Veterans Administration |
$603.73
|
Rate for Payer: United Healthcare Commercial |
$2,708.31
|
Rate for Payer: United Healthcare Medicare |
$603.73
|
Rate for Payer: WINHealth Partners Commercial |
$2,646.05
|
|
ADJUSTMENT GASTRIC BAND
|
Professional
|
Both
|
$194.00
|
|
Service Code
|
HCPCS S2083
|
Hospital Charge Code |
S2083
|
Min. Negotiated Rate |
$145.50 |
Max. Negotiated Rate |
$194.00 |
Rate for Payer: Aetna of WY Commercial/Medical Rental |
$190.12
|
Rate for Payer: Beech Street Commercial |
$184.30
|
Rate for Payer: Cash Price |
$135.80
|
Rate for Payer: ChoiceCare Network Commercial |
$188.18
|
Rate for Payer: Cigna of WY Commercial |
$190.12
|
Rate for Payer: First Choice Health Commercial |
$174.60
|
Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$184.30
|
Rate for Payer: HealthUtah PPO |
$194.00
|
Rate for Payer: Idaho Integrated Healthcare Commercial |
$188.18
|
Rate for Payer: One Health Plan of WY PPO |
$190.12
|
Rate for Payer: PacificSource Commercial |
$174.60
|
Rate for Payer: PHCS PPO |
$184.30
|
Rate for Payer: Three Rivers PPO |
$145.50
|
Rate for Payer: United Healthcare Commercial |
$168.78
|
Rate for Payer: WINHealth Partners Commercial |
$184.30
|
|
ADJUVANT AS01E (PF), COMPONENT (VIAL 1 OF 2) INTRAMUSCULAR SUSPENSION [182047]
|
Facility
|
IP
|
$382.50
|
|
Service Code
|
NDC 5816074403
|
Hospital Revenue Code
|
250
|
Min. Negotiated Rate |
$239.83 |
Max. Negotiated Rate |
$382.50 |
Rate for Payer: Aetna of WY Commercial/Medical Rental |
$374.85
|
Rate for Payer: Altius Auto/Workers Compensation |
$367.20
|
Rate for Payer: Altius Commercial |
$367.20
|
Rate for Payer: Beech Street Commercial |
$374.85
|
Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$314.03
|
Rate for Payer: Cash Price |
$267.75
|
Rate for Payer: ChoiceCare Network Commercial |
$371.02
|
Rate for Payer: Cigna of WY Commercial |
$374.85
|
Rate for Payer: Entrust Commercial |
$363.38
|
Rate for Payer: First Choice Health Commercial |
$363.38
|
Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$363.38
|
Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$252.45
|
Rate for Payer: HealthUtah PPO |
$382.50
|
Rate for Payer: Idaho Integrated Healthcare Commercial |
$371.02
|
Rate for Payer: Multiplan Medicare/VA |
$239.83
|
Rate for Payer: One Health Plan of WY PPO |
$374.85
|
Rate for Payer: PacificSource Commercial |
$344.25
|
Rate for Payer: PHCS PPO |
$374.85
|
Rate for Payer: Three Rivers PPO |
$286.88
|
Rate for Payer: TriWest Veterans Administration |
$252.45
|
Rate for Payer: United Healthcare Commercial |
$332.78
|
Rate for Payer: United Healthcare Medicare |
$252.45
|
Rate for Payer: WINHealth Partners Commercial |
$363.38
|
Rate for Payer: Wise Provider Network Commercial |
$363.38
|
|
ADJUVANT AS01E (PF), COMPONENT (VIAL 1 OF 2) INTRAMUSCULAR SUSPENSION [182047]
|
Facility
|
OP
|
$382.50
|
|
Service Code
|
NDC 5816074403
|
Hospital Revenue Code
|
250
|
Min. Negotiated Rate |
$210.76 |
Max. Negotiated Rate |
$382.50 |
Rate for Payer: Aetna of WY Commercial/Medical Rental |
$374.85
|
Rate for Payer: Aetna of WY Medicare |
$252.45
|
Rate for Payer: Altius Auto/Workers Compensation |
$367.20
|
Rate for Payer: Altius Commercial |
$367.20
|
Rate for Payer: Beech Street Commercial |
$374.85
|
Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$314.03
|
Rate for Payer: Cash Price |
$267.75
|
Rate for Payer: ChoiceCare Network Commercial |
$371.02
|
Rate for Payer: Cigna of WY Commercial |
$374.85
|
Rate for Payer: Entrust Commercial |
$363.38
|
Rate for Payer: First Choice Health Commercial |
$363.38
|
Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$363.38
|
Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$221.85
|
Rate for Payer: HealthUtah PPO |
$382.50
|
Rate for Payer: Idaho Integrated Healthcare Commercial |
$371.02
|
Rate for Payer: Multiplan Medicare/VA |
$210.76
|
Rate for Payer: One Health Plan of WY PPO |
$374.85
|
Rate for Payer: PacificSource Commercial |
$344.25
|
Rate for Payer: PHCS PPO |
$374.85
|
Rate for Payer: Three Rivers PPO |
$286.88
|
Rate for Payer: TriWest Veterans Administration |
$221.85
|
Rate for Payer: United Healthcare Commercial |
$332.78
|
Rate for Payer: United Healthcare Medicare |
$221.85
|
Rate for Payer: WINHealth Partners Commercial |
$374.85
|
Rate for Payer: Wise Provider Network Commercial |
$363.38
|
|