|
JUMPSTART FLEX EFIT
|
Facility
|
OP
|
$107.52
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$59.24 |
| Max. Negotiated Rate |
$107.52 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$105.37
|
| Rate for Payer: Aetna of WY Medicare |
$70.96
|
| Rate for Payer: Altius Auto/Workers Compensation |
$103.22
|
| Rate for Payer: Altius Commercial |
$103.22
|
| Rate for Payer: Beech Street Commercial |
$105.37
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$88.27
|
| Rate for Payer: Cash Price |
$75.26
|
| Rate for Payer: ChoiceCare Network Commercial |
$104.29
|
| Rate for Payer: Cigna of WY Commercial |
$105.37
|
| Rate for Payer: Entrust Commercial |
$102.14
|
| Rate for Payer: First Choice Health Commercial |
$102.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$102.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$62.36
|
| Rate for Payer: HealthUtah PPO |
$107.52
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$104.29
|
| Rate for Payer: Multiplan Medicare/VA |
$59.24
|
| Rate for Payer: One Health Plan of WY PPO |
$105.37
|
| Rate for Payer: PacificSource Commercial |
$96.77
|
| Rate for Payer: PHCS PPO |
$105.37
|
| Rate for Payer: Three Rivers PPO |
$80.64
|
| Rate for Payer: TriWest Veterans Administration |
$62.36
|
| Rate for Payer: United Healthcare Commercial |
$93.54
|
| Rate for Payer: United Healthcare Medicare |
$62.36
|
| Rate for Payer: WINHealth Partners Commercial |
$105.37
|
| Rate for Payer: Wise Provider Network Commercial |
$102.14
|
|
|
KANGAROO PUMP SET W/FLUSH BAG
|
Facility
|
IP
|
$16.56
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$10.38 |
| Max. Negotiated Rate |
$16.56 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.23
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.90
|
| Rate for Payer: Altius Commercial |
$15.90
|
| Rate for Payer: Beech Street Commercial |
$16.23
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.60
|
| Rate for Payer: Cash Price |
$11.59
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.06
|
| Rate for Payer: Cigna of WY Commercial |
$16.23
|
| Rate for Payer: Entrust Commercial |
$15.73
|
| Rate for Payer: First Choice Health Commercial |
$15.73
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.73
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.93
|
| Rate for Payer: HealthUtah PPO |
$16.56
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.06
|
| Rate for Payer: Multiplan Medicare/VA |
$10.38
|
| Rate for Payer: One Health Plan of WY PPO |
$16.23
|
| Rate for Payer: PacificSource Commercial |
$14.90
|
| Rate for Payer: PHCS PPO |
$16.23
|
| Rate for Payer: Three Rivers PPO |
$12.42
|
| Rate for Payer: TriWest Veterans Administration |
$10.93
|
| Rate for Payer: United Healthcare Commercial |
$14.41
|
| Rate for Payer: United Healthcare Medicare |
$10.93
|
| Rate for Payer: WINHealth Partners Commercial |
$15.73
|
| Rate for Payer: Wise Provider Network Commercial |
$15.73
|
|
|
KANGAROO PUMP SET W/FLUSH BAG
|
Facility
|
OP
|
$16.56
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$9.12 |
| Max. Negotiated Rate |
$16.56 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.23
|
| Rate for Payer: Aetna of WY Medicare |
$10.93
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.90
|
| Rate for Payer: Altius Commercial |
$15.90
|
| Rate for Payer: Beech Street Commercial |
$16.23
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.60
|
| Rate for Payer: Cash Price |
$11.59
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.06
|
| Rate for Payer: Cigna of WY Commercial |
$16.23
|
| Rate for Payer: Entrust Commercial |
$15.73
|
| Rate for Payer: First Choice Health Commercial |
$15.73
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.73
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.60
|
| Rate for Payer: HealthUtah PPO |
$16.56
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.06
|
| Rate for Payer: Multiplan Medicare/VA |
$9.12
|
| Rate for Payer: One Health Plan of WY PPO |
$16.23
|
| Rate for Payer: PacificSource Commercial |
$14.90
|
| Rate for Payer: PHCS PPO |
$16.23
|
| Rate for Payer: Three Rivers PPO |
$12.42
|
| Rate for Payer: TriWest Veterans Administration |
$9.60
|
| Rate for Payer: United Healthcare Commercial |
$14.41
|
| Rate for Payer: United Healthcare Medicare |
$9.60
|
| Rate for Payer: WINHealth Partners Commercial |
$16.23
|
| Rate for Payer: Wise Provider Network Commercial |
$15.73
|
|
|
KCI 500ML INFO CANNISTER
|
Facility
|
IP
|
$94.37
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$59.17 |
| Max. Negotiated Rate |
$94.37 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$92.48
|
| Rate for Payer: Altius Auto/Workers Compensation |
$90.60
|
| Rate for Payer: Altius Commercial |
$90.60
|
| Rate for Payer: Beech Street Commercial |
$92.48
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$77.48
|
| Rate for Payer: Cash Price |
$66.06
|
| Rate for Payer: ChoiceCare Network Commercial |
$91.54
|
| Rate for Payer: Cigna of WY Commercial |
$92.48
|
| Rate for Payer: Entrust Commercial |
$89.65
|
| Rate for Payer: First Choice Health Commercial |
$89.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$89.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$62.28
|
| Rate for Payer: HealthUtah PPO |
$94.37
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$91.54
|
| Rate for Payer: Multiplan Medicare/VA |
$59.17
|
| Rate for Payer: One Health Plan of WY PPO |
$92.48
|
| Rate for Payer: PacificSource Commercial |
$84.93
|
| Rate for Payer: PHCS PPO |
$92.48
|
| Rate for Payer: Three Rivers PPO |
$70.78
|
| Rate for Payer: TriWest Veterans Administration |
$62.28
|
| Rate for Payer: United Healthcare Commercial |
$82.10
|
| Rate for Payer: United Healthcare Medicare |
$62.28
|
| Rate for Payer: WINHealth Partners Commercial |
$89.65
|
| Rate for Payer: Wise Provider Network Commercial |
$89.65
|
|
|
KCI 500ML INFO CANNISTER
|
Facility
|
OP
|
$94.37
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$52.00 |
| Max. Negotiated Rate |
$94.37 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$92.48
|
| Rate for Payer: Aetna of WY Medicare |
$62.28
|
| Rate for Payer: Altius Auto/Workers Compensation |
$90.60
|
| Rate for Payer: Altius Commercial |
$90.60
|
| Rate for Payer: Beech Street Commercial |
$92.48
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$77.48
|
| Rate for Payer: Cash Price |
$66.06
|
| Rate for Payer: ChoiceCare Network Commercial |
$91.54
|
| Rate for Payer: Cigna of WY Commercial |
$92.48
|
| Rate for Payer: Entrust Commercial |
$89.65
|
| Rate for Payer: First Choice Health Commercial |
$89.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$89.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$54.73
|
| Rate for Payer: HealthUtah PPO |
$94.37
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$91.54
|
| Rate for Payer: Multiplan Medicare/VA |
$52.00
|
| Rate for Payer: One Health Plan of WY PPO |
$92.48
|
| Rate for Payer: PacificSource Commercial |
$84.93
|
| Rate for Payer: PHCS PPO |
$92.48
|
| Rate for Payer: Three Rivers PPO |
$70.78
|
| Rate for Payer: TriWest Veterans Administration |
$54.73
|
| Rate for Payer: United Healthcare Commercial |
$82.10
|
| Rate for Payer: United Healthcare Medicare |
$54.73
|
| Rate for Payer: WINHealth Partners Commercial |
$92.48
|
| Rate for Payer: Wise Provider Network Commercial |
$89.65
|
|
|
KCI ABTHERA ABDOMEN DRESSING
|
Facility
|
OP
|
$1,642.20
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$904.85 |
| Max. Negotiated Rate |
$1,642.20 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,609.36
|
| Rate for Payer: Aetna of WY Medicare |
$1,083.85
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,576.51
|
| Rate for Payer: Altius Commercial |
$1,576.51
|
| Rate for Payer: Beech Street Commercial |
$1,609.36
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,348.25
|
| Rate for Payer: Cash Price |
$1,149.54
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,592.93
|
| Rate for Payer: Cigna of WY Commercial |
$1,609.36
|
| Rate for Payer: Entrust Commercial |
$1,560.09
|
| Rate for Payer: First Choice Health Commercial |
$1,560.09
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,560.09
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$952.48
|
| Rate for Payer: HealthUtah PPO |
$1,642.20
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,592.93
|
| Rate for Payer: Multiplan Medicare/VA |
$904.85
|
| Rate for Payer: One Health Plan of WY PPO |
$1,609.36
|
| Rate for Payer: PacificSource Commercial |
$1,477.98
|
| Rate for Payer: PHCS PPO |
$1,609.36
|
| Rate for Payer: Three Rivers PPO |
$1,231.65
|
| Rate for Payer: TriWest Veterans Administration |
$952.48
|
| Rate for Payer: United Healthcare Commercial |
$1,428.71
|
| Rate for Payer: United Healthcare Medicare |
$952.48
|
| Rate for Payer: WINHealth Partners Commercial |
$1,609.36
|
| Rate for Payer: Wise Provider Network Commercial |
$1,560.09
|
|
|
KCI ABTHERA ABDOMEN DRESSING
|
Facility
|
IP
|
$1,642.20
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,029.66 |
| Max. Negotiated Rate |
$1,642.20 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,609.36
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,576.51
|
| Rate for Payer: Altius Commercial |
$1,576.51
|
| Rate for Payer: Beech Street Commercial |
$1,609.36
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,348.25
|
| Rate for Payer: Cash Price |
$1,149.54
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,592.93
|
| Rate for Payer: Cigna of WY Commercial |
$1,609.36
|
| Rate for Payer: Entrust Commercial |
$1,560.09
|
| Rate for Payer: First Choice Health Commercial |
$1,560.09
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,560.09
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,083.85
|
| Rate for Payer: HealthUtah PPO |
$1,642.20
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,592.93
|
| Rate for Payer: Multiplan Medicare/VA |
$1,029.66
|
| Rate for Payer: One Health Plan of WY PPO |
$1,609.36
|
| Rate for Payer: PacificSource Commercial |
$1,477.98
|
| Rate for Payer: PHCS PPO |
$1,609.36
|
| Rate for Payer: Three Rivers PPO |
$1,231.65
|
| Rate for Payer: TriWest Veterans Administration |
$1,083.85
|
| Rate for Payer: United Healthcare Commercial |
$1,428.71
|
| Rate for Payer: United Healthcare Medicare |
$1,083.85
|
| Rate for Payer: WINHealth Partners Commercial |
$1,560.09
|
| Rate for Payer: Wise Provider Network Commercial |
$1,560.09
|
|
|
KCI VAC GRANUFOAM LG
|
Facility
|
IP
|
$151.68
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$95.10 |
| Max. Negotiated Rate |
$151.68 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$148.65
|
| Rate for Payer: Altius Auto/Workers Compensation |
$145.61
|
| Rate for Payer: Altius Commercial |
$145.61
|
| Rate for Payer: Beech Street Commercial |
$148.65
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$124.53
|
| Rate for Payer: Cash Price |
$106.18
|
| Rate for Payer: ChoiceCare Network Commercial |
$147.13
|
| Rate for Payer: Cigna of WY Commercial |
$148.65
|
| Rate for Payer: Entrust Commercial |
$144.10
|
| Rate for Payer: First Choice Health Commercial |
$144.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$144.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$100.11
|
| Rate for Payer: HealthUtah PPO |
$151.68
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$147.13
|
| Rate for Payer: Multiplan Medicare/VA |
$95.10
|
| Rate for Payer: One Health Plan of WY PPO |
$148.65
|
| Rate for Payer: PacificSource Commercial |
$136.51
|
| Rate for Payer: PHCS PPO |
$148.65
|
| Rate for Payer: Three Rivers PPO |
$113.76
|
| Rate for Payer: TriWest Veterans Administration |
$100.11
|
| Rate for Payer: United Healthcare Commercial |
$131.96
|
| Rate for Payer: United Healthcare Medicare |
$100.11
|
| Rate for Payer: WINHealth Partners Commercial |
$144.10
|
| Rate for Payer: Wise Provider Network Commercial |
$144.10
|
|
|
KCI VAC GRANUFOAM LG
|
Facility
|
OP
|
$151.68
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$83.58 |
| Max. Negotiated Rate |
$151.68 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$148.65
|
| Rate for Payer: Aetna of WY Medicare |
$100.11
|
| Rate for Payer: Altius Auto/Workers Compensation |
$145.61
|
| Rate for Payer: Altius Commercial |
$145.61
|
| Rate for Payer: Beech Street Commercial |
$148.65
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$124.53
|
| Rate for Payer: Cash Price |
$106.18
|
| Rate for Payer: ChoiceCare Network Commercial |
$147.13
|
| Rate for Payer: Cigna of WY Commercial |
$148.65
|
| Rate for Payer: Entrust Commercial |
$144.10
|
| Rate for Payer: First Choice Health Commercial |
$144.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$144.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$87.97
|
| Rate for Payer: HealthUtah PPO |
$151.68
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$147.13
|
| Rate for Payer: Multiplan Medicare/VA |
$83.58
|
| Rate for Payer: One Health Plan of WY PPO |
$148.65
|
| Rate for Payer: PacificSource Commercial |
$136.51
|
| Rate for Payer: PHCS PPO |
$148.65
|
| Rate for Payer: Three Rivers PPO |
$113.76
|
| Rate for Payer: TriWest Veterans Administration |
$87.97
|
| Rate for Payer: United Healthcare Commercial |
$131.96
|
| Rate for Payer: United Healthcare Medicare |
$87.97
|
| Rate for Payer: WINHealth Partners Commercial |
$148.65
|
| Rate for Payer: Wise Provider Network Commercial |
$144.10
|
|
|
KCI VAC GRANUFOAM MED
|
Facility
|
OP
|
$125.75
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$69.29 |
| Max. Negotiated Rate |
$125.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$123.24
|
| Rate for Payer: Aetna of WY Medicare |
$83.00
|
| Rate for Payer: Altius Auto/Workers Compensation |
$120.72
|
| Rate for Payer: Altius Commercial |
$120.72
|
| Rate for Payer: Beech Street Commercial |
$123.24
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$103.24
|
| Rate for Payer: Cash Price |
$88.03
|
| Rate for Payer: ChoiceCare Network Commercial |
$121.98
|
| Rate for Payer: Cigna of WY Commercial |
$123.24
|
| Rate for Payer: Entrust Commercial |
$119.46
|
| Rate for Payer: First Choice Health Commercial |
$119.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$119.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$72.94
|
| Rate for Payer: HealthUtah PPO |
$125.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$121.98
|
| Rate for Payer: Multiplan Medicare/VA |
$69.29
|
| Rate for Payer: One Health Plan of WY PPO |
$123.24
|
| Rate for Payer: PacificSource Commercial |
$113.18
|
| Rate for Payer: PHCS PPO |
$123.24
|
| Rate for Payer: Three Rivers PPO |
$94.31
|
| Rate for Payer: TriWest Veterans Administration |
$72.94
|
| Rate for Payer: United Healthcare Commercial |
$109.40
|
| Rate for Payer: United Healthcare Medicare |
$72.94
|
| Rate for Payer: WINHealth Partners Commercial |
$123.24
|
| Rate for Payer: Wise Provider Network Commercial |
$119.46
|
|
|
KCI VAC GRANUFOAM MED
|
Facility
|
IP
|
$125.75
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$78.85 |
| Max. Negotiated Rate |
$125.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$123.24
|
| Rate for Payer: Altius Auto/Workers Compensation |
$120.72
|
| Rate for Payer: Altius Commercial |
$120.72
|
| Rate for Payer: Beech Street Commercial |
$123.24
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$103.24
|
| Rate for Payer: Cash Price |
$88.03
|
| Rate for Payer: ChoiceCare Network Commercial |
$121.98
|
| Rate for Payer: Cigna of WY Commercial |
$123.24
|
| Rate for Payer: Entrust Commercial |
$119.46
|
| Rate for Payer: First Choice Health Commercial |
$119.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$119.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$83.00
|
| Rate for Payer: HealthUtah PPO |
$125.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$121.98
|
| Rate for Payer: Multiplan Medicare/VA |
$78.85
|
| Rate for Payer: One Health Plan of WY PPO |
$123.24
|
| Rate for Payer: PacificSource Commercial |
$113.18
|
| Rate for Payer: PHCS PPO |
$123.24
|
| Rate for Payer: Three Rivers PPO |
$94.31
|
| Rate for Payer: TriWest Veterans Administration |
$83.00
|
| Rate for Payer: United Healthcare Commercial |
$109.40
|
| Rate for Payer: United Healthcare Medicare |
$83.00
|
| Rate for Payer: WINHealth Partners Commercial |
$119.46
|
| Rate for Payer: Wise Provider Network Commercial |
$119.46
|
|
|
KCI VAC GRANUFOAM SMALL
|
Facility
|
OP
|
$99.83
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$55.01 |
| Max. Negotiated Rate |
$99.83 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$97.83
|
| Rate for Payer: Aetna of WY Medicare |
$65.89
|
| Rate for Payer: Altius Auto/Workers Compensation |
$95.84
|
| Rate for Payer: Altius Commercial |
$95.84
|
| Rate for Payer: Beech Street Commercial |
$97.83
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$81.96
|
| Rate for Payer: Cash Price |
$69.88
|
| Rate for Payer: ChoiceCare Network Commercial |
$96.84
|
| Rate for Payer: Cigna of WY Commercial |
$97.83
|
| Rate for Payer: Entrust Commercial |
$94.84
|
| Rate for Payer: First Choice Health Commercial |
$94.84
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$94.84
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$57.90
|
| Rate for Payer: HealthUtah PPO |
$99.83
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$96.84
|
| Rate for Payer: Multiplan Medicare/VA |
$55.01
|
| Rate for Payer: One Health Plan of WY PPO |
$97.83
|
| Rate for Payer: PacificSource Commercial |
$89.85
|
| Rate for Payer: PHCS PPO |
$97.83
|
| Rate for Payer: Three Rivers PPO |
$74.87
|
| Rate for Payer: TriWest Veterans Administration |
$57.90
|
| Rate for Payer: United Healthcare Commercial |
$86.85
|
| Rate for Payer: United Healthcare Medicare |
$57.90
|
| Rate for Payer: WINHealth Partners Commercial |
$97.83
|
| Rate for Payer: Wise Provider Network Commercial |
$94.84
|
|
|
KCI VAC GRANUFOAM SMALL
|
Facility
|
IP
|
$99.83
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$62.59 |
| Max. Negotiated Rate |
$99.83 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$97.83
|
| Rate for Payer: Altius Auto/Workers Compensation |
$95.84
|
| Rate for Payer: Altius Commercial |
$95.84
|
| Rate for Payer: Beech Street Commercial |
$97.83
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$81.96
|
| Rate for Payer: Cash Price |
$69.88
|
| Rate for Payer: ChoiceCare Network Commercial |
$96.84
|
| Rate for Payer: Cigna of WY Commercial |
$97.83
|
| Rate for Payer: Entrust Commercial |
$94.84
|
| Rate for Payer: First Choice Health Commercial |
$94.84
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$94.84
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$65.89
|
| Rate for Payer: HealthUtah PPO |
$99.83
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$96.84
|
| Rate for Payer: Multiplan Medicare/VA |
$62.59
|
| Rate for Payer: One Health Plan of WY PPO |
$97.83
|
| Rate for Payer: PacificSource Commercial |
$89.85
|
| Rate for Payer: PHCS PPO |
$97.83
|
| Rate for Payer: Three Rivers PPO |
$74.87
|
| Rate for Payer: TriWest Veterans Administration |
$65.89
|
| Rate for Payer: United Healthcare Commercial |
$86.85
|
| Rate for Payer: United Healthcare Medicare |
$65.89
|
| Rate for Payer: WINHealth Partners Commercial |
$94.84
|
| Rate for Payer: Wise Provider Network Commercial |
$94.84
|
|
|
KCI WHITE FOAM SM DRESS
|
Facility
|
IP
|
$26.73
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$16.76 |
| Max. Negotiated Rate |
$26.73 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$26.20
|
| Rate for Payer: Altius Auto/Workers Compensation |
$25.66
|
| Rate for Payer: Altius Commercial |
$25.66
|
| Rate for Payer: Beech Street Commercial |
$26.20
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$21.95
|
| Rate for Payer: Cash Price |
$18.71
|
| Rate for Payer: ChoiceCare Network Commercial |
$25.93
|
| Rate for Payer: Cigna of WY Commercial |
$26.20
|
| Rate for Payer: Entrust Commercial |
$25.39
|
| Rate for Payer: First Choice Health Commercial |
$25.39
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$25.39
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$17.64
|
| Rate for Payer: HealthUtah PPO |
$26.73
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$25.93
|
| Rate for Payer: Multiplan Medicare/VA |
$16.76
|
| Rate for Payer: One Health Plan of WY PPO |
$26.20
|
| Rate for Payer: PacificSource Commercial |
$24.06
|
| Rate for Payer: PHCS PPO |
$26.20
|
| Rate for Payer: Three Rivers PPO |
$20.05
|
| Rate for Payer: TriWest Veterans Administration |
$17.64
|
| Rate for Payer: United Healthcare Commercial |
$23.26
|
| Rate for Payer: United Healthcare Medicare |
$17.64
|
| Rate for Payer: WINHealth Partners Commercial |
$25.39
|
| Rate for Payer: Wise Provider Network Commercial |
$25.39
|
|
|
KCI WHITE FOAM SM DRESS
|
Facility
|
OP
|
$26.73
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$14.73 |
| Max. Negotiated Rate |
$26.73 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$26.20
|
| Rate for Payer: Aetna of WY Medicare |
$17.64
|
| Rate for Payer: Altius Auto/Workers Compensation |
$25.66
|
| Rate for Payer: Altius Commercial |
$25.66
|
| Rate for Payer: Beech Street Commercial |
$26.20
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$21.95
|
| Rate for Payer: Cash Price |
$18.71
|
| Rate for Payer: ChoiceCare Network Commercial |
$25.93
|
| Rate for Payer: Cigna of WY Commercial |
$26.20
|
| Rate for Payer: Entrust Commercial |
$25.39
|
| Rate for Payer: First Choice Health Commercial |
$25.39
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$25.39
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$15.50
|
| Rate for Payer: HealthUtah PPO |
$26.73
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$25.93
|
| Rate for Payer: Multiplan Medicare/VA |
$14.73
|
| Rate for Payer: One Health Plan of WY PPO |
$26.20
|
| Rate for Payer: PacificSource Commercial |
$24.06
|
| Rate for Payer: PHCS PPO |
$26.20
|
| Rate for Payer: Three Rivers PPO |
$20.05
|
| Rate for Payer: TriWest Veterans Administration |
$15.50
|
| Rate for Payer: United Healthcare Commercial |
$23.26
|
| Rate for Payer: United Healthcare Medicare |
$15.50
|
| Rate for Payer: WINHealth Partners Commercial |
$26.20
|
| Rate for Payer: Wise Provider Network Commercial |
$25.39
|
|
|
KETAMINE 100 MG/ML INJECTION SOLUTION [20474]
|
Facility
|
OP
|
$21.65
|
|
|
Service Code
|
NDC 0409205115
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.93 |
| Max. Negotiated Rate |
$21.65 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$21.22
|
| Rate for Payer: Aetna of WY Medicare |
$14.29
|
| Rate for Payer: Altius Auto/Workers Compensation |
$20.78
|
| Rate for Payer: Altius Commercial |
$20.78
|
| Rate for Payer: Beech Street Commercial |
$21.22
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$17.77
|
| Rate for Payer: Cash Price |
$15.16
|
| Rate for Payer: ChoiceCare Network Commercial |
$21.00
|
| Rate for Payer: Cigna of WY Commercial |
$21.22
|
| Rate for Payer: Entrust Commercial |
$20.57
|
| Rate for Payer: First Choice Health Commercial |
$20.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$20.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$12.56
|
| Rate for Payer: HealthUtah PPO |
$21.65
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$21.00
|
| Rate for Payer: Multiplan Medicare/VA |
$11.93
|
| Rate for Payer: One Health Plan of WY PPO |
$21.22
|
| Rate for Payer: PacificSource Commercial |
$19.48
|
| Rate for Payer: PHCS PPO |
$21.22
|
| Rate for Payer: Three Rivers PPO |
$16.24
|
| Rate for Payer: TriWest Veterans Administration |
$12.56
|
| Rate for Payer: United Healthcare Commercial |
$18.84
|
| Rate for Payer: United Healthcare Medicare |
$12.56
|
| Rate for Payer: WINHealth Partners Commercial |
$21.22
|
| Rate for Payer: Wise Provider Network Commercial |
$20.57
|
|
|
KETAMINE 100 MG/ML INJECTION SOLUTION [20474]
|
Facility
|
IP
|
$21.65
|
|
|
Service Code
|
NDC 0409205105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.57 |
| Max. Negotiated Rate |
$21.65 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$21.22
|
| Rate for Payer: Altius Auto/Workers Compensation |
$20.78
|
| Rate for Payer: Altius Commercial |
$20.78
|
| Rate for Payer: Beech Street Commercial |
$21.22
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$17.77
|
| Rate for Payer: Cash Price |
$15.16
|
| Rate for Payer: ChoiceCare Network Commercial |
$21.00
|
| Rate for Payer: Cigna of WY Commercial |
$21.22
|
| Rate for Payer: Entrust Commercial |
$20.57
|
| Rate for Payer: First Choice Health Commercial |
$20.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$20.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$14.29
|
| Rate for Payer: HealthUtah PPO |
$21.65
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$21.00
|
| Rate for Payer: Multiplan Medicare/VA |
$13.57
|
| Rate for Payer: One Health Plan of WY PPO |
$21.22
|
| Rate for Payer: PacificSource Commercial |
$19.48
|
| Rate for Payer: PHCS PPO |
$21.22
|
| Rate for Payer: Three Rivers PPO |
$16.24
|
| Rate for Payer: TriWest Veterans Administration |
$14.29
|
| Rate for Payer: United Healthcare Commercial |
$18.84
|
| Rate for Payer: United Healthcare Medicare |
$14.29
|
| Rate for Payer: WINHealth Partners Commercial |
$20.57
|
| Rate for Payer: Wise Provider Network Commercial |
$20.57
|
|
|
KETAMINE 100 MG/ML INJECTION SOLUTION [20474]
|
Facility
|
OP
|
$21.65
|
|
|
Service Code
|
NDC 0409205105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.93 |
| Max. Negotiated Rate |
$21.65 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$21.22
|
| Rate for Payer: Aetna of WY Medicare |
$14.29
|
| Rate for Payer: Altius Auto/Workers Compensation |
$20.78
|
| Rate for Payer: Altius Commercial |
$20.78
|
| Rate for Payer: Beech Street Commercial |
$21.22
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$17.77
|
| Rate for Payer: Cash Price |
$15.16
|
| Rate for Payer: ChoiceCare Network Commercial |
$21.00
|
| Rate for Payer: Cigna of WY Commercial |
$21.22
|
| Rate for Payer: Entrust Commercial |
$20.57
|
| Rate for Payer: First Choice Health Commercial |
$20.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$20.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$12.56
|
| Rate for Payer: HealthUtah PPO |
$21.65
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$21.00
|
| Rate for Payer: Multiplan Medicare/VA |
$11.93
|
| Rate for Payer: One Health Plan of WY PPO |
$21.22
|
| Rate for Payer: PacificSource Commercial |
$19.48
|
| Rate for Payer: PHCS PPO |
$21.22
|
| Rate for Payer: Three Rivers PPO |
$16.24
|
| Rate for Payer: TriWest Veterans Administration |
$12.56
|
| Rate for Payer: United Healthcare Commercial |
$18.84
|
| Rate for Payer: United Healthcare Medicare |
$12.56
|
| Rate for Payer: WINHealth Partners Commercial |
$21.22
|
| Rate for Payer: Wise Provider Network Commercial |
$20.57
|
|
|
KETAMINE 100 MG/ML INJECTION SOLUTION [20474]
|
Facility
|
IP
|
$21.65
|
|
|
Service Code
|
NDC 0409205115
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.57 |
| Max. Negotiated Rate |
$21.65 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$21.22
|
| Rate for Payer: Altius Auto/Workers Compensation |
$20.78
|
| Rate for Payer: Altius Commercial |
$20.78
|
| Rate for Payer: Beech Street Commercial |
$21.22
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$17.77
|
| Rate for Payer: Cash Price |
$15.16
|
| Rate for Payer: ChoiceCare Network Commercial |
$21.00
|
| Rate for Payer: Cigna of WY Commercial |
$21.22
|
| Rate for Payer: Entrust Commercial |
$20.57
|
| Rate for Payer: First Choice Health Commercial |
$20.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$20.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$14.29
|
| Rate for Payer: HealthUtah PPO |
$21.65
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$21.00
|
| Rate for Payer: Multiplan Medicare/VA |
$13.57
|
| Rate for Payer: One Health Plan of WY PPO |
$21.22
|
| Rate for Payer: PacificSource Commercial |
$19.48
|
| Rate for Payer: PHCS PPO |
$21.22
|
| Rate for Payer: Three Rivers PPO |
$16.24
|
| Rate for Payer: TriWest Veterans Administration |
$14.29
|
| Rate for Payer: United Healthcare Commercial |
$18.84
|
| Rate for Payer: United Healthcare Medicare |
$14.29
|
| Rate for Payer: WINHealth Partners Commercial |
$20.57
|
| Rate for Payer: Wise Provider Network Commercial |
$20.57
|
|
|
KETAMINE 10 MG/ML INJECTION SOLUTION [14883]
|
Facility
|
OP
|
$18.86
|
|
|
Service Code
|
NDC 5515043810
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.39 |
| Max. Negotiated Rate |
$18.86 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18.48
|
| Rate for Payer: Aetna of WY Medicare |
$12.45
|
| Rate for Payer: Altius Auto/Workers Compensation |
$18.11
|
| Rate for Payer: Altius Commercial |
$18.11
|
| Rate for Payer: Beech Street Commercial |
$18.48
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.48
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$18.29
|
| Rate for Payer: Cigna of WY Commercial |
$18.48
|
| Rate for Payer: Entrust Commercial |
$17.92
|
| Rate for Payer: First Choice Health Commercial |
$17.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.94
|
| Rate for Payer: HealthUtah PPO |
$18.86
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$18.29
|
| Rate for Payer: Multiplan Medicare/VA |
$10.39
|
| Rate for Payer: One Health Plan of WY PPO |
$18.48
|
| Rate for Payer: PacificSource Commercial |
$16.97
|
| Rate for Payer: PHCS PPO |
$18.48
|
| Rate for Payer: Three Rivers PPO |
$14.14
|
| Rate for Payer: TriWest Veterans Administration |
$10.94
|
| Rate for Payer: United Healthcare Commercial |
$16.41
|
| Rate for Payer: United Healthcare Medicare |
$10.94
|
| Rate for Payer: WINHealth Partners Commercial |
$18.48
|
| Rate for Payer: Wise Provider Network Commercial |
$17.92
|
|
|
KETAMINE 10 MG/ML INJECTION SOLUTION [14883]
|
Facility
|
IP
|
$18.86
|
|
|
Service Code
|
NDC 5515043801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.83 |
| Max. Negotiated Rate |
$18.86 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18.48
|
| Rate for Payer: Altius Auto/Workers Compensation |
$18.11
|
| Rate for Payer: Altius Commercial |
$18.11
|
| Rate for Payer: Beech Street Commercial |
$18.48
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.48
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$18.29
|
| Rate for Payer: Cigna of WY Commercial |
$18.48
|
| Rate for Payer: Entrust Commercial |
$17.92
|
| Rate for Payer: First Choice Health Commercial |
$17.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$12.45
|
| Rate for Payer: HealthUtah PPO |
$18.86
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$18.29
|
| Rate for Payer: Multiplan Medicare/VA |
$11.83
|
| Rate for Payer: One Health Plan of WY PPO |
$18.48
|
| Rate for Payer: PacificSource Commercial |
$16.97
|
| Rate for Payer: PHCS PPO |
$18.48
|
| Rate for Payer: Three Rivers PPO |
$14.14
|
| Rate for Payer: TriWest Veterans Administration |
$12.45
|
| Rate for Payer: United Healthcare Commercial |
$16.41
|
| Rate for Payer: United Healthcare Medicare |
$12.45
|
| Rate for Payer: WINHealth Partners Commercial |
$17.92
|
| Rate for Payer: Wise Provider Network Commercial |
$17.92
|
|
|
KETAMINE 10 MG/ML INJECTION SOLUTION [14883]
|
Facility
|
IP
|
$18.86
|
|
|
Service Code
|
NDC 5515043810
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.83 |
| Max. Negotiated Rate |
$18.86 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18.48
|
| Rate for Payer: Altius Auto/Workers Compensation |
$18.11
|
| Rate for Payer: Altius Commercial |
$18.11
|
| Rate for Payer: Beech Street Commercial |
$18.48
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.48
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$18.29
|
| Rate for Payer: Cigna of WY Commercial |
$18.48
|
| Rate for Payer: Entrust Commercial |
$17.92
|
| Rate for Payer: First Choice Health Commercial |
$17.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$12.45
|
| Rate for Payer: HealthUtah PPO |
$18.86
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$18.29
|
| Rate for Payer: Multiplan Medicare/VA |
$11.83
|
| Rate for Payer: One Health Plan of WY PPO |
$18.48
|
| Rate for Payer: PacificSource Commercial |
$16.97
|
| Rate for Payer: PHCS PPO |
$18.48
|
| Rate for Payer: Three Rivers PPO |
$14.14
|
| Rate for Payer: TriWest Veterans Administration |
$12.45
|
| Rate for Payer: United Healthcare Commercial |
$16.41
|
| Rate for Payer: United Healthcare Medicare |
$12.45
|
| Rate for Payer: WINHealth Partners Commercial |
$17.92
|
| Rate for Payer: Wise Provider Network Commercial |
$17.92
|
|
|
KETAMINE 10 MG/ML INJECTION SOLUTION [14883]
|
Facility
|
OP
|
$18.86
|
|
|
Service Code
|
NDC 5515043801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.39 |
| Max. Negotiated Rate |
$18.86 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18.48
|
| Rate for Payer: Aetna of WY Medicare |
$12.45
|
| Rate for Payer: Altius Auto/Workers Compensation |
$18.11
|
| Rate for Payer: Altius Commercial |
$18.11
|
| Rate for Payer: Beech Street Commercial |
$18.48
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.48
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$18.29
|
| Rate for Payer: Cigna of WY Commercial |
$18.48
|
| Rate for Payer: Entrust Commercial |
$17.92
|
| Rate for Payer: First Choice Health Commercial |
$17.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.94
|
| Rate for Payer: HealthUtah PPO |
$18.86
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$18.29
|
| Rate for Payer: Multiplan Medicare/VA |
$10.39
|
| Rate for Payer: One Health Plan of WY PPO |
$18.48
|
| Rate for Payer: PacificSource Commercial |
$16.97
|
| Rate for Payer: PHCS PPO |
$18.48
|
| Rate for Payer: Three Rivers PPO |
$14.14
|
| Rate for Payer: TriWest Veterans Administration |
$10.94
|
| Rate for Payer: United Healthcare Commercial |
$16.41
|
| Rate for Payer: United Healthcare Medicare |
$10.94
|
| Rate for Payer: WINHealth Partners Commercial |
$18.48
|
| Rate for Payer: Wise Provider Network Commercial |
$17.92
|
|
|
KETAMINE 50 MG/ML INJECTION SOLUTION [16220]
|
Facility
|
IP
|
$17.56
|
|
|
Service Code
|
NDC 0143950801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.01 |
| Max. Negotiated Rate |
$17.56 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$17.21
|
| Rate for Payer: Altius Auto/Workers Compensation |
$16.86
|
| Rate for Payer: Altius Commercial |
$16.86
|
| Rate for Payer: Beech Street Commercial |
$17.21
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.42
|
| Rate for Payer: Cash Price |
$12.29
|
| Rate for Payer: ChoiceCare Network Commercial |
$17.03
|
| Rate for Payer: Cigna of WY Commercial |
$17.21
|
| Rate for Payer: Entrust Commercial |
$16.68
|
| Rate for Payer: First Choice Health Commercial |
$16.68
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.68
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.59
|
| Rate for Payer: HealthUtah PPO |
$17.56
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.03
|
| Rate for Payer: Multiplan Medicare/VA |
$11.01
|
| Rate for Payer: One Health Plan of WY PPO |
$17.21
|
| Rate for Payer: PacificSource Commercial |
$15.80
|
| Rate for Payer: PHCS PPO |
$17.21
|
| Rate for Payer: Three Rivers PPO |
$13.17
|
| Rate for Payer: TriWest Veterans Administration |
$11.59
|
| Rate for Payer: United Healthcare Commercial |
$15.28
|
| Rate for Payer: United Healthcare Medicare |
$11.59
|
| Rate for Payer: WINHealth Partners Commercial |
$16.68
|
| Rate for Payer: Wise Provider Network Commercial |
$16.68
|
|
|
KETAMINE 50 MG/ML INJECTION SOLUTION [16220]
|
Facility
|
OP
|
$17.56
|
|
|
Service Code
|
NDC 0143950801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.68 |
| Max. Negotiated Rate |
$17.56 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$17.21
|
| Rate for Payer: Aetna of WY Medicare |
$11.59
|
| Rate for Payer: Altius Auto/Workers Compensation |
$16.86
|
| Rate for Payer: Altius Commercial |
$16.86
|
| Rate for Payer: Beech Street Commercial |
$17.21
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.42
|
| Rate for Payer: Cash Price |
$12.29
|
| Rate for Payer: ChoiceCare Network Commercial |
$17.03
|
| Rate for Payer: Cigna of WY Commercial |
$17.21
|
| Rate for Payer: Entrust Commercial |
$16.68
|
| Rate for Payer: First Choice Health Commercial |
$16.68
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.68
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.18
|
| Rate for Payer: HealthUtah PPO |
$17.56
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.03
|
| Rate for Payer: Multiplan Medicare/VA |
$9.68
|
| Rate for Payer: One Health Plan of WY PPO |
$17.21
|
| Rate for Payer: PacificSource Commercial |
$15.80
|
| Rate for Payer: PHCS PPO |
$17.21
|
| Rate for Payer: Three Rivers PPO |
$13.17
|
| Rate for Payer: TriWest Veterans Administration |
$10.18
|
| Rate for Payer: United Healthcare Commercial |
$15.28
|
| Rate for Payer: United Healthcare Medicare |
$10.18
|
| Rate for Payer: WINHealth Partners Commercial |
$17.21
|
| Rate for Payer: Wise Provider Network Commercial |
$16.68
|
|
