|
MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE [139170]
|
Facility
|
OP
|
$487.75
|
|
|
Service Code
|
NDC 5816097602
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$268.75 |
| Max. Negotiated Rate |
$487.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$478.00
|
| Rate for Payer: Aetna of WY Medicare |
$321.92
|
| Rate for Payer: Altius Auto/Workers Compensation |
$468.24
|
| Rate for Payer: Altius Commercial |
$468.24
|
| Rate for Payer: Beech Street Commercial |
$478.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$400.44
|
| Rate for Payer: Cash Price |
$341.43
|
| Rate for Payer: ChoiceCare Network Commercial |
$473.12
|
| Rate for Payer: Cigna of WY Commercial |
$478.00
|
| Rate for Payer: Entrust Commercial |
$463.36
|
| Rate for Payer: First Choice Health Commercial |
$463.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$463.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$282.90
|
| Rate for Payer: HealthUtah PPO |
$487.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$473.12
|
| Rate for Payer: Multiplan Medicare/VA |
$268.75
|
| Rate for Payer: One Health Plan of WY PPO |
$478.00
|
| Rate for Payer: PacificSource Commercial |
$438.98
|
| Rate for Payer: PHCS PPO |
$478.00
|
| Rate for Payer: Three Rivers PPO |
$365.81
|
| Rate for Payer: TriWest Veterans Administration |
$282.90
|
| Rate for Payer: United Healthcare Commercial |
$424.34
|
| Rate for Payer: United Healthcare Medicare |
$282.90
|
| Rate for Payer: WINHealth Partners Commercial |
$478.00
|
| Rate for Payer: Wise Provider Network Commercial |
$463.36
|
|
|
MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE [139170]
|
Facility
|
IP
|
$487.75
|
|
|
Service Code
|
NDC 5816097620
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$305.82 |
| Max. Negotiated Rate |
$487.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$478.00
|
| Rate for Payer: Altius Auto/Workers Compensation |
$468.24
|
| Rate for Payer: Altius Commercial |
$468.24
|
| Rate for Payer: Beech Street Commercial |
$478.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$400.44
|
| Rate for Payer: Cash Price |
$341.43
|
| Rate for Payer: ChoiceCare Network Commercial |
$473.12
|
| Rate for Payer: Cigna of WY Commercial |
$478.00
|
| Rate for Payer: Entrust Commercial |
$463.36
|
| Rate for Payer: First Choice Health Commercial |
$463.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$463.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$321.92
|
| Rate for Payer: HealthUtah PPO |
$487.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$473.12
|
| Rate for Payer: Multiplan Medicare/VA |
$305.82
|
| Rate for Payer: One Health Plan of WY PPO |
$478.00
|
| Rate for Payer: PacificSource Commercial |
$438.98
|
| Rate for Payer: PHCS PPO |
$478.00
|
| Rate for Payer: Three Rivers PPO |
$365.81
|
| Rate for Payer: TriWest Veterans Administration |
$321.92
|
| Rate for Payer: United Healthcare Commercial |
$424.34
|
| Rate for Payer: United Healthcare Medicare |
$321.92
|
| Rate for Payer: WINHealth Partners Commercial |
$463.36
|
| Rate for Payer: Wise Provider Network Commercial |
$463.36
|
|
|
MENINGOCOCCAL VAC A,C,Y,W-135,CONJ TET (PF) 10 MCG/0.5 ML IM SOLUTION [158846]
|
Facility
|
IP
|
$342.44
|
|
|
Service Code
|
NDC 4928159058
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$214.71 |
| Max. Negotiated Rate |
$342.44 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$335.59
|
| Rate for Payer: Altius Auto/Workers Compensation |
$328.74
|
| Rate for Payer: Altius Commercial |
$328.74
|
| Rate for Payer: Beech Street Commercial |
$335.59
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$281.14
|
| Rate for Payer: Cash Price |
$239.71
|
| Rate for Payer: ChoiceCare Network Commercial |
$332.17
|
| Rate for Payer: Cigna of WY Commercial |
$335.59
|
| Rate for Payer: Entrust Commercial |
$325.32
|
| Rate for Payer: First Choice Health Commercial |
$325.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$325.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$226.01
|
| Rate for Payer: HealthUtah PPO |
$342.44
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$332.17
|
| Rate for Payer: Multiplan Medicare/VA |
$214.71
|
| Rate for Payer: One Health Plan of WY PPO |
$335.59
|
| Rate for Payer: PacificSource Commercial |
$308.20
|
| Rate for Payer: PHCS PPO |
$335.59
|
| Rate for Payer: Three Rivers PPO |
$256.83
|
| Rate for Payer: TriWest Veterans Administration |
$226.01
|
| Rate for Payer: United Healthcare Commercial |
$297.92
|
| Rate for Payer: United Healthcare Medicare |
$226.01
|
| Rate for Payer: WINHealth Partners Commercial |
$325.32
|
| Rate for Payer: Wise Provider Network Commercial |
$325.32
|
|
|
MENINGOCOCCAL VAC A,C,Y,W-135,CONJ TET (PF) 10 MCG/0.5 ML IM SOLUTION [158846]
|
Facility
|
OP
|
$342.44
|
|
|
Service Code
|
NDC 4928159058
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$188.68 |
| Max. Negotiated Rate |
$342.44 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$335.59
|
| Rate for Payer: Aetna of WY Medicare |
$226.01
|
| Rate for Payer: Altius Auto/Workers Compensation |
$328.74
|
| Rate for Payer: Altius Commercial |
$328.74
|
| Rate for Payer: Beech Street Commercial |
$335.59
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$281.14
|
| Rate for Payer: Cash Price |
$239.71
|
| Rate for Payer: ChoiceCare Network Commercial |
$332.17
|
| Rate for Payer: Cigna of WY Commercial |
$335.59
|
| Rate for Payer: Entrust Commercial |
$325.32
|
| Rate for Payer: First Choice Health Commercial |
$325.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$325.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$198.62
|
| Rate for Payer: HealthUtah PPO |
$342.44
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$332.17
|
| Rate for Payer: Multiplan Medicare/VA |
$188.68
|
| Rate for Payer: One Health Plan of WY PPO |
$335.59
|
| Rate for Payer: PacificSource Commercial |
$308.20
|
| Rate for Payer: PHCS PPO |
$335.59
|
| Rate for Payer: Three Rivers PPO |
$256.83
|
| Rate for Payer: TriWest Veterans Administration |
$198.62
|
| Rate for Payer: United Healthcare Commercial |
$297.92
|
| Rate for Payer: United Healthcare Medicare |
$198.62
|
| Rate for Payer: WINHealth Partners Commercial |
$335.59
|
| Rate for Payer: Wise Provider Network Commercial |
$325.32
|
|
|
MENINGOCOCCAL VAC A,C,Y,W-135,CONJ TET (PF) 10 MCG/0.5 ML IM SOLUTION [158846]
|
Facility
|
OP
|
$342.44
|
|
|
Service Code
|
NDC 4928159005
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$188.68 |
| Max. Negotiated Rate |
$342.44 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$335.59
|
| Rate for Payer: Aetna of WY Medicare |
$226.01
|
| Rate for Payer: Altius Auto/Workers Compensation |
$328.74
|
| Rate for Payer: Altius Commercial |
$328.74
|
| Rate for Payer: Beech Street Commercial |
$335.59
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$281.14
|
| Rate for Payer: Cash Price |
$239.71
|
| Rate for Payer: ChoiceCare Network Commercial |
$332.17
|
| Rate for Payer: Cigna of WY Commercial |
$335.59
|
| Rate for Payer: Entrust Commercial |
$325.32
|
| Rate for Payer: First Choice Health Commercial |
$325.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$325.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$198.62
|
| Rate for Payer: HealthUtah PPO |
$342.44
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$332.17
|
| Rate for Payer: Multiplan Medicare/VA |
$188.68
|
| Rate for Payer: One Health Plan of WY PPO |
$335.59
|
| Rate for Payer: PacificSource Commercial |
$308.20
|
| Rate for Payer: PHCS PPO |
$335.59
|
| Rate for Payer: Three Rivers PPO |
$256.83
|
| Rate for Payer: TriWest Veterans Administration |
$198.62
|
| Rate for Payer: United Healthcare Commercial |
$297.92
|
| Rate for Payer: United Healthcare Medicare |
$198.62
|
| Rate for Payer: WINHealth Partners Commercial |
$335.59
|
| Rate for Payer: Wise Provider Network Commercial |
$325.32
|
|
|
MENINGOCOCCAL VAC A,C,Y,W-135,CONJ TET (PF) 10 MCG/0.5 ML IM SOLUTION [158846]
|
Facility
|
IP
|
$342.44
|
|
|
Service Code
|
NDC 4928159005
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$214.71 |
| Max. Negotiated Rate |
$342.44 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$335.59
|
| Rate for Payer: Altius Auto/Workers Compensation |
$328.74
|
| Rate for Payer: Altius Commercial |
$328.74
|
| Rate for Payer: Beech Street Commercial |
$335.59
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$281.14
|
| Rate for Payer: Cash Price |
$239.71
|
| Rate for Payer: ChoiceCare Network Commercial |
$332.17
|
| Rate for Payer: Cigna of WY Commercial |
$335.59
|
| Rate for Payer: Entrust Commercial |
$325.32
|
| Rate for Payer: First Choice Health Commercial |
$325.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$325.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$226.01
|
| Rate for Payer: HealthUtah PPO |
$342.44
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$332.17
|
| Rate for Payer: Multiplan Medicare/VA |
$214.71
|
| Rate for Payer: One Health Plan of WY PPO |
$335.59
|
| Rate for Payer: PacificSource Commercial |
$308.20
|
| Rate for Payer: PHCS PPO |
$335.59
|
| Rate for Payer: Three Rivers PPO |
$256.83
|
| Rate for Payer: TriWest Veterans Administration |
$226.01
|
| Rate for Payer: United Healthcare Commercial |
$297.92
|
| Rate for Payer: United Healthcare Medicare |
$226.01
|
| Rate for Payer: WINHealth Partners Commercial |
$325.32
|
| Rate for Payer: Wise Provider Network Commercial |
$325.32
|
|
|
MENINGOC VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML IM KIT (2 VIALS) [89078]
|
Facility
|
OP
|
$249.00
|
|
|
Service Code
|
NDC 5816095509
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$137.20 |
| Max. Negotiated Rate |
$249.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$244.02
|
| Rate for Payer: Aetna of WY Medicare |
$164.34
|
| Rate for Payer: Altius Auto/Workers Compensation |
$239.04
|
| Rate for Payer: Altius Commercial |
$239.04
|
| Rate for Payer: Beech Street Commercial |
$244.02
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$204.43
|
| Rate for Payer: Cash Price |
$174.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$241.53
|
| Rate for Payer: Cigna of WY Commercial |
$244.02
|
| Rate for Payer: Entrust Commercial |
$236.55
|
| Rate for Payer: First Choice Health Commercial |
$236.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$236.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$144.42
|
| Rate for Payer: HealthUtah PPO |
$249.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$241.53
|
| Rate for Payer: Multiplan Medicare/VA |
$137.20
|
| Rate for Payer: One Health Plan of WY PPO |
$244.02
|
| Rate for Payer: PacificSource Commercial |
$224.10
|
| Rate for Payer: PHCS PPO |
$244.02
|
| Rate for Payer: Three Rivers PPO |
$186.75
|
| Rate for Payer: TriWest Veterans Administration |
$144.42
|
| Rate for Payer: United Healthcare Commercial |
$216.63
|
| Rate for Payer: United Healthcare Medicare |
$144.42
|
| Rate for Payer: WINHealth Partners Commercial |
$244.02
|
| Rate for Payer: Wise Provider Network Commercial |
$236.55
|
|
|
MENINGOC VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML IM KIT (2 VIALS) [89078]
|
Facility
|
IP
|
$249.00
|
|
|
Service Code
|
NDC 5816095509
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$156.12 |
| Max. Negotiated Rate |
$249.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$244.02
|
| Rate for Payer: Altius Auto/Workers Compensation |
$239.04
|
| Rate for Payer: Altius Commercial |
$239.04
|
| Rate for Payer: Beech Street Commercial |
$244.02
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$204.43
|
| Rate for Payer: Cash Price |
$174.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$241.53
|
| Rate for Payer: Cigna of WY Commercial |
$244.02
|
| Rate for Payer: Entrust Commercial |
$236.55
|
| Rate for Payer: First Choice Health Commercial |
$236.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$236.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$164.34
|
| Rate for Payer: HealthUtah PPO |
$249.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$241.53
|
| Rate for Payer: Multiplan Medicare/VA |
$156.12
|
| Rate for Payer: One Health Plan of WY PPO |
$244.02
|
| Rate for Payer: PacificSource Commercial |
$224.10
|
| Rate for Payer: PHCS PPO |
$244.02
|
| Rate for Payer: Three Rivers PPO |
$186.75
|
| Rate for Payer: TriWest Veterans Administration |
$164.34
|
| Rate for Payer: United Healthcare Commercial |
$216.63
|
| Rate for Payer: United Healthcare Medicare |
$164.34
|
| Rate for Payer: WINHealth Partners Commercial |
$236.55
|
| Rate for Payer: Wise Provider Network Commercial |
$236.55
|
|
|
MENTHOL 0.1 % LOTION [165097]
|
Facility
|
OP
|
$0.16
|
|
|
Service Code
|
NDC 7214002657
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.16
|
| Rate for Payer: Aetna of WY Medicare |
$0.11
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.15
|
| Rate for Payer: Altius Commercial |
$0.15
|
| Rate for Payer: Beech Street Commercial |
$0.16
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.13
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.16
|
| Rate for Payer: Cigna of WY Commercial |
$0.16
|
| Rate for Payer: Entrust Commercial |
$0.15
|
| Rate for Payer: First Choice Health Commercial |
$0.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.09
|
| Rate for Payer: HealthUtah PPO |
$0.16
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.16
|
| Rate for Payer: Multiplan Medicare/VA |
$0.09
|
| Rate for Payer: One Health Plan of WY PPO |
$0.16
|
| Rate for Payer: PacificSource Commercial |
$0.14
|
| Rate for Payer: PHCS PPO |
$0.16
|
| Rate for Payer: Three Rivers PPO |
$0.12
|
| Rate for Payer: TriWest Veterans Administration |
$0.09
|
| Rate for Payer: United Healthcare Commercial |
$0.14
|
| Rate for Payer: United Healthcare Medicare |
$0.09
|
| Rate for Payer: WINHealth Partners Commercial |
$0.16
|
| Rate for Payer: Wise Provider Network Commercial |
$0.15
|
|
|
MENTHOL 0.1 % LOTION [165097]
|
Facility
|
IP
|
$0.16
|
|
|
Service Code
|
NDC 7214002657
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.16
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.15
|
| Rate for Payer: Altius Commercial |
$0.15
|
| Rate for Payer: Beech Street Commercial |
$0.16
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.13
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.16
|
| Rate for Payer: Cigna of WY Commercial |
$0.16
|
| Rate for Payer: Entrust Commercial |
$0.15
|
| Rate for Payer: First Choice Health Commercial |
$0.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.11
|
| Rate for Payer: HealthUtah PPO |
$0.16
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.16
|
| Rate for Payer: Multiplan Medicare/VA |
$0.10
|
| Rate for Payer: One Health Plan of WY PPO |
$0.16
|
| Rate for Payer: PacificSource Commercial |
$0.14
|
| Rate for Payer: PHCS PPO |
$0.16
|
| Rate for Payer: Three Rivers PPO |
$0.12
|
| Rate for Payer: TriWest Veterans Administration |
$0.11
|
| Rate for Payer: United Healthcare Commercial |
$0.14
|
| Rate for Payer: United Healthcare Medicare |
$0.11
|
| Rate for Payer: WINHealth Partners Commercial |
$0.15
|
| Rate for Payer: Wise Provider Network Commercial |
$0.15
|
|
|
MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT [88457]
|
Facility
|
IP
|
$0.12
|
|
|
Service Code
|
NDC 7139967431
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.12
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.12
|
| Rate for Payer: Altius Commercial |
$0.12
|
| Rate for Payer: Beech Street Commercial |
$0.12
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.10
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.12
|
| Rate for Payer: Cigna of WY Commercial |
$0.12
|
| Rate for Payer: Entrust Commercial |
$0.11
|
| Rate for Payer: First Choice Health Commercial |
$0.11
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.11
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.08
|
| Rate for Payer: HealthUtah PPO |
$0.12
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.12
|
| Rate for Payer: Multiplan Medicare/VA |
$0.08
|
| Rate for Payer: One Health Plan of WY PPO |
$0.12
|
| Rate for Payer: PacificSource Commercial |
$0.11
|
| Rate for Payer: PHCS PPO |
$0.12
|
| Rate for Payer: Three Rivers PPO |
$0.09
|
| Rate for Payer: TriWest Veterans Administration |
$0.08
|
| Rate for Payer: United Healthcare Commercial |
$0.10
|
| Rate for Payer: United Healthcare Medicare |
$0.08
|
| Rate for Payer: WINHealth Partners Commercial |
$0.11
|
| Rate for Payer: Wise Provider Network Commercial |
$0.11
|
|
|
MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT [88457]
|
Facility
|
OP
|
$0.12
|
|
|
Service Code
|
NDC 7139967431
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.12
|
| Rate for Payer: Aetna of WY Medicare |
$0.08
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.12
|
| Rate for Payer: Altius Commercial |
$0.12
|
| Rate for Payer: Beech Street Commercial |
$0.12
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.10
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.12
|
| Rate for Payer: Cigna of WY Commercial |
$0.12
|
| Rate for Payer: Entrust Commercial |
$0.11
|
| Rate for Payer: First Choice Health Commercial |
$0.11
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.11
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.07
|
| Rate for Payer: HealthUtah PPO |
$0.12
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.12
|
| Rate for Payer: Multiplan Medicare/VA |
$0.07
|
| Rate for Payer: One Health Plan of WY PPO |
$0.12
|
| Rate for Payer: PacificSource Commercial |
$0.11
|
| Rate for Payer: PHCS PPO |
$0.12
|
| Rate for Payer: Three Rivers PPO |
$0.09
|
| Rate for Payer: TriWest Veterans Administration |
$0.07
|
| Rate for Payer: United Healthcare Commercial |
$0.10
|
| Rate for Payer: United Healthcare Medicare |
$0.07
|
| Rate for Payer: WINHealth Partners Commercial |
$0.12
|
| Rate for Payer: Wise Provider Network Commercial |
$0.11
|
|
|
MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT [88457]
|
Facility
|
OP
|
$0.12
|
|
|
Service Code
|
NDC 1013570104
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.12
|
| Rate for Payer: Aetna of WY Medicare |
$0.08
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.12
|
| Rate for Payer: Altius Commercial |
$0.12
|
| Rate for Payer: Beech Street Commercial |
$0.12
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.10
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.12
|
| Rate for Payer: Cigna of WY Commercial |
$0.12
|
| Rate for Payer: Entrust Commercial |
$0.11
|
| Rate for Payer: First Choice Health Commercial |
$0.11
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.11
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.07
|
| Rate for Payer: HealthUtah PPO |
$0.12
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.12
|
| Rate for Payer: Multiplan Medicare/VA |
$0.07
|
| Rate for Payer: One Health Plan of WY PPO |
$0.12
|
| Rate for Payer: PacificSource Commercial |
$0.11
|
| Rate for Payer: PHCS PPO |
$0.12
|
| Rate for Payer: Three Rivers PPO |
$0.09
|
| Rate for Payer: TriWest Veterans Administration |
$0.07
|
| Rate for Payer: United Healthcare Commercial |
$0.10
|
| Rate for Payer: United Healthcare Medicare |
$0.07
|
| Rate for Payer: WINHealth Partners Commercial |
$0.12
|
| Rate for Payer: Wise Provider Network Commercial |
$0.11
|
|
|
MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT [88457]
|
Facility
|
IP
|
$0.12
|
|
|
Service Code
|
NDC 1013570104
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.12
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.12
|
| Rate for Payer: Altius Commercial |
$0.12
|
| Rate for Payer: Beech Street Commercial |
$0.12
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.10
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.12
|
| Rate for Payer: Cigna of WY Commercial |
$0.12
|
| Rate for Payer: Entrust Commercial |
$0.11
|
| Rate for Payer: First Choice Health Commercial |
$0.11
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.11
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.08
|
| Rate for Payer: HealthUtah PPO |
$0.12
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.12
|
| Rate for Payer: Multiplan Medicare/VA |
$0.08
|
| Rate for Payer: One Health Plan of WY PPO |
$0.12
|
| Rate for Payer: PacificSource Commercial |
$0.11
|
| Rate for Payer: PHCS PPO |
$0.12
|
| Rate for Payer: Three Rivers PPO |
$0.09
|
| Rate for Payer: TriWest Veterans Administration |
$0.08
|
| Rate for Payer: United Healthcare Commercial |
$0.10
|
| Rate for Payer: United Healthcare Medicare |
$0.08
|
| Rate for Payer: WINHealth Partners Commercial |
$0.11
|
| Rate for Payer: Wise Provider Network Commercial |
$0.11
|
|
|
MENTHOL 0.5 %-CAMPHOR 0.75 %-ALLANTOIN 0.5 % NASAL GEL [161310]
|
Facility
|
OP
|
$3.22
|
|
|
Service Code
|
NDC 1116960451
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.77 |
| Max. Negotiated Rate |
$3.22 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3.16
|
| Rate for Payer: Aetna of WY Medicare |
$2.13
|
| Rate for Payer: Altius Auto/Workers Compensation |
$3.09
|
| Rate for Payer: Altius Commercial |
$3.09
|
| Rate for Payer: Beech Street Commercial |
$3.16
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.64
|
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$3.12
|
| Rate for Payer: Cigna of WY Commercial |
$3.16
|
| Rate for Payer: Entrust Commercial |
$3.06
|
| Rate for Payer: First Choice Health Commercial |
$3.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.87
|
| Rate for Payer: HealthUtah PPO |
$3.22
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3.12
|
| Rate for Payer: Multiplan Medicare/VA |
$1.77
|
| Rate for Payer: One Health Plan of WY PPO |
$3.16
|
| Rate for Payer: PacificSource Commercial |
$2.90
|
| Rate for Payer: PHCS PPO |
$3.16
|
| Rate for Payer: Three Rivers PPO |
$2.42
|
| Rate for Payer: TriWest Veterans Administration |
$1.87
|
| Rate for Payer: United Healthcare Commercial |
$2.80
|
| Rate for Payer: United Healthcare Medicare |
$1.87
|
| Rate for Payer: WINHealth Partners Commercial |
$3.16
|
| Rate for Payer: Wise Provider Network Commercial |
$3.06
|
|
|
MENTHOL 0.5 %-CAMPHOR 0.75 %-ALLANTOIN 0.5 % NASAL GEL [161310]
|
Facility
|
IP
|
$3.22
|
|
|
Service Code
|
NDC 1116960451
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.02 |
| Max. Negotiated Rate |
$3.22 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3.16
|
| Rate for Payer: Altius Auto/Workers Compensation |
$3.09
|
| Rate for Payer: Altius Commercial |
$3.09
|
| Rate for Payer: Beech Street Commercial |
$3.16
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.64
|
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$3.12
|
| Rate for Payer: Cigna of WY Commercial |
$3.16
|
| Rate for Payer: Entrust Commercial |
$3.06
|
| Rate for Payer: First Choice Health Commercial |
$3.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2.13
|
| Rate for Payer: HealthUtah PPO |
$3.22
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3.12
|
| Rate for Payer: Multiplan Medicare/VA |
$2.02
|
| Rate for Payer: One Health Plan of WY PPO |
$3.16
|
| Rate for Payer: PacificSource Commercial |
$2.90
|
| Rate for Payer: PHCS PPO |
$3.16
|
| Rate for Payer: Three Rivers PPO |
$2.42
|
| Rate for Payer: TriWest Veterans Administration |
$2.13
|
| Rate for Payer: United Healthcare Commercial |
$2.80
|
| Rate for Payer: United Healthcare Medicare |
$2.13
|
| Rate for Payer: WINHealth Partners Commercial |
$3.06
|
| Rate for Payer: Wise Provider Network Commercial |
$3.06
|
|
|
MEPERIDINE HYDROCHL /100 MG
|
Professional
|
Both
|
$63.00
|
|
|
Service Code
|
HCPCS J2175
|
| Hospital Charge Code |
J2175
|
| Min. Negotiated Rate |
$5.86 |
| Max. Negotiated Rate |
$63.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$61.74
|
| Rate for Payer: Aetna of WY Medicare |
$6.90
|
| Rate for Payer: Beech Street Commercial |
$59.85
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$61.11
|
| Rate for Payer: Cigna of WY Commercial |
$61.74
|
| Rate for Payer: First Choice Health Commercial |
$56.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$59.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$6.90
|
| Rate for Payer: HealthUtah PPO |
$63.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$61.11
|
| Rate for Payer: Multiplan Medicare/VA |
$5.86
|
| Rate for Payer: One Health Plan of WY PPO |
$61.74
|
| Rate for Payer: PacificSource Commercial |
$56.70
|
| Rate for Payer: PHCS PPO |
$59.85
|
| Rate for Payer: Three Rivers PPO |
$47.25
|
| Rate for Payer: TriWest Veterans Administration |
$6.90
|
| Rate for Payer: United Healthcare Commercial |
$54.81
|
| Rate for Payer: United Healthcare Medicare |
$6.90
|
| Rate for Payer: WINHealth Partners Commercial |
$59.85
|
|
|
MEPERIDINE (PF) 25 MG/ML INJECTION SYRINGE [39490]
|
Facility
|
OP
|
$36.14
|
|
|
Service Code
|
NDC 0409117630
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.91 |
| Max. Negotiated Rate |
$36.14 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$35.42
|
| Rate for Payer: Aetna of WY Medicare |
$23.85
|
| Rate for Payer: Altius Auto/Workers Compensation |
$34.69
|
| Rate for Payer: Altius Commercial |
$34.69
|
| Rate for Payer: Beech Street Commercial |
$35.42
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$29.67
|
| Rate for Payer: Cash Price |
$25.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$35.06
|
| Rate for Payer: Cigna of WY Commercial |
$35.42
|
| Rate for Payer: Entrust Commercial |
$34.33
|
| Rate for Payer: First Choice Health Commercial |
$34.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$34.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$20.96
|
| Rate for Payer: HealthUtah PPO |
$36.14
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$35.06
|
| Rate for Payer: Multiplan Medicare/VA |
$19.91
|
| Rate for Payer: One Health Plan of WY PPO |
$35.42
|
| Rate for Payer: PacificSource Commercial |
$32.53
|
| Rate for Payer: PHCS PPO |
$35.42
|
| Rate for Payer: Three Rivers PPO |
$27.10
|
| Rate for Payer: TriWest Veterans Administration |
$20.96
|
| Rate for Payer: United Healthcare Commercial |
$31.44
|
| Rate for Payer: United Healthcare Medicare |
$20.96
|
| Rate for Payer: WINHealth Partners Commercial |
$35.42
|
| Rate for Payer: Wise Provider Network Commercial |
$34.33
|
|
|
MEPERIDINE (PF) 25 MG/ML INJECTION SYRINGE [39490]
|
Facility
|
IP
|
$36.14
|
|
|
Service Code
|
NDC 0409117630
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.66 |
| Max. Negotiated Rate |
$36.14 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$35.42
|
| Rate for Payer: Altius Auto/Workers Compensation |
$34.69
|
| Rate for Payer: Altius Commercial |
$34.69
|
| Rate for Payer: Beech Street Commercial |
$35.42
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$29.67
|
| Rate for Payer: Cash Price |
$25.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$35.06
|
| Rate for Payer: Cigna of WY Commercial |
$35.42
|
| Rate for Payer: Entrust Commercial |
$34.33
|
| Rate for Payer: First Choice Health Commercial |
$34.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$34.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$23.85
|
| Rate for Payer: HealthUtah PPO |
$36.14
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$35.06
|
| Rate for Payer: Multiplan Medicare/VA |
$22.66
|
| Rate for Payer: One Health Plan of WY PPO |
$35.42
|
| Rate for Payer: PacificSource Commercial |
$32.53
|
| Rate for Payer: PHCS PPO |
$35.42
|
| Rate for Payer: Three Rivers PPO |
$27.10
|
| Rate for Payer: TriWest Veterans Administration |
$23.85
|
| Rate for Payer: United Healthcare Commercial |
$31.44
|
| Rate for Payer: United Healthcare Medicare |
$23.85
|
| Rate for Payer: WINHealth Partners Commercial |
$34.33
|
| Rate for Payer: Wise Provider Network Commercial |
$34.33
|
|
|
MEPERIDINE (PF) 25 MG/ML INJECTION SYRINGE [39490]
|
Facility
|
IP
|
$36.14
|
|
|
Service Code
|
NDC 0409117603
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.66 |
| Max. Negotiated Rate |
$36.14 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$35.42
|
| Rate for Payer: Altius Auto/Workers Compensation |
$34.69
|
| Rate for Payer: Altius Commercial |
$34.69
|
| Rate for Payer: Beech Street Commercial |
$35.42
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$29.67
|
| Rate for Payer: Cash Price |
$25.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$35.06
|
| Rate for Payer: Cigna of WY Commercial |
$35.42
|
| Rate for Payer: Entrust Commercial |
$34.33
|
| Rate for Payer: First Choice Health Commercial |
$34.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$34.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$23.85
|
| Rate for Payer: HealthUtah PPO |
$36.14
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$35.06
|
| Rate for Payer: Multiplan Medicare/VA |
$22.66
|
| Rate for Payer: One Health Plan of WY PPO |
$35.42
|
| Rate for Payer: PacificSource Commercial |
$32.53
|
| Rate for Payer: PHCS PPO |
$35.42
|
| Rate for Payer: Three Rivers PPO |
$27.10
|
| Rate for Payer: TriWest Veterans Administration |
$23.85
|
| Rate for Payer: United Healthcare Commercial |
$31.44
|
| Rate for Payer: United Healthcare Medicare |
$23.85
|
| Rate for Payer: WINHealth Partners Commercial |
$34.33
|
| Rate for Payer: Wise Provider Network Commercial |
$34.33
|
|
|
MEPERIDINE (PF) 25 MG/ML INJECTION SYRINGE [39490]
|
Facility
|
OP
|
$36.14
|
|
|
Service Code
|
NDC 0409117603
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.91 |
| Max. Negotiated Rate |
$36.14 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$35.42
|
| Rate for Payer: Aetna of WY Medicare |
$23.85
|
| Rate for Payer: Altius Auto/Workers Compensation |
$34.69
|
| Rate for Payer: Altius Commercial |
$34.69
|
| Rate for Payer: Beech Street Commercial |
$35.42
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$29.67
|
| Rate for Payer: Cash Price |
$25.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$35.06
|
| Rate for Payer: Cigna of WY Commercial |
$35.42
|
| Rate for Payer: Entrust Commercial |
$34.33
|
| Rate for Payer: First Choice Health Commercial |
$34.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$34.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$20.96
|
| Rate for Payer: HealthUtah PPO |
$36.14
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$35.06
|
| Rate for Payer: Multiplan Medicare/VA |
$19.91
|
| Rate for Payer: One Health Plan of WY PPO |
$35.42
|
| Rate for Payer: PacificSource Commercial |
$32.53
|
| Rate for Payer: PHCS PPO |
$35.42
|
| Rate for Payer: Three Rivers PPO |
$27.10
|
| Rate for Payer: TriWest Veterans Administration |
$20.96
|
| Rate for Payer: United Healthcare Commercial |
$31.44
|
| Rate for Payer: United Healthcare Medicare |
$20.96
|
| Rate for Payer: WINHealth Partners Commercial |
$35.42
|
| Rate for Payer: Wise Provider Network Commercial |
$34.33
|
|
|
MEPILEX BORDER HEEL 8.7"X9.1"
|
Facility
|
OP
|
$34.80
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$19.17 |
| Max. Negotiated Rate |
$34.80 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$34.10
|
| Rate for Payer: Aetna of WY Medicare |
$22.97
|
| Rate for Payer: Altius Auto/Workers Compensation |
$33.41
|
| Rate for Payer: Altius Commercial |
$33.41
|
| Rate for Payer: Beech Street Commercial |
$34.10
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$28.57
|
| Rate for Payer: Cash Price |
$24.36
|
| Rate for Payer: ChoiceCare Network Commercial |
$33.76
|
| Rate for Payer: Cigna of WY Commercial |
$34.10
|
| Rate for Payer: Entrust Commercial |
$33.06
|
| Rate for Payer: First Choice Health Commercial |
$33.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$33.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$20.18
|
| Rate for Payer: HealthUtah PPO |
$34.80
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$33.76
|
| Rate for Payer: Multiplan Medicare/VA |
$19.17
|
| Rate for Payer: One Health Plan of WY PPO |
$34.10
|
| Rate for Payer: PacificSource Commercial |
$31.32
|
| Rate for Payer: PHCS PPO |
$34.10
|
| Rate for Payer: Three Rivers PPO |
$26.10
|
| Rate for Payer: TriWest Veterans Administration |
$20.18
|
| Rate for Payer: United Healthcare Commercial |
$30.28
|
| Rate for Payer: United Healthcare Medicare |
$20.18
|
| Rate for Payer: WINHealth Partners Commercial |
$34.10
|
| Rate for Payer: Wise Provider Network Commercial |
$33.06
|
|
|
MEPILEX BORDER HEEL 8.7"X9.1"
|
Facility
|
IP
|
$34.80
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$21.82 |
| Max. Negotiated Rate |
$34.80 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$34.10
|
| Rate for Payer: Altius Auto/Workers Compensation |
$33.41
|
| Rate for Payer: Altius Commercial |
$33.41
|
| Rate for Payer: Beech Street Commercial |
$34.10
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$28.57
|
| Rate for Payer: Cash Price |
$24.36
|
| Rate for Payer: ChoiceCare Network Commercial |
$33.76
|
| Rate for Payer: Cigna of WY Commercial |
$34.10
|
| Rate for Payer: Entrust Commercial |
$33.06
|
| Rate for Payer: First Choice Health Commercial |
$33.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$33.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$22.97
|
| Rate for Payer: HealthUtah PPO |
$34.80
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$33.76
|
| Rate for Payer: Multiplan Medicare/VA |
$21.82
|
| Rate for Payer: One Health Plan of WY PPO |
$34.10
|
| Rate for Payer: PacificSource Commercial |
$31.32
|
| Rate for Payer: PHCS PPO |
$34.10
|
| Rate for Payer: Three Rivers PPO |
$26.10
|
| Rate for Payer: TriWest Veterans Administration |
$22.97
|
| Rate for Payer: United Healthcare Commercial |
$30.28
|
| Rate for Payer: United Healthcare Medicare |
$22.97
|
| Rate for Payer: WINHealth Partners Commercial |
$33.06
|
| Rate for Payer: Wise Provider Network Commercial |
$33.06
|
|
|
MEPILEX BORDER SACRUM 6.3X7.9"
|
Facility
|
OP
|
$20.69
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$11.40 |
| Max. Negotiated Rate |
$20.69 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$20.28
|
| Rate for Payer: Aetna of WY Medicare |
$13.66
|
| Rate for Payer: Altius Auto/Workers Compensation |
$19.86
|
| Rate for Payer: Altius Commercial |
$19.86
|
| Rate for Payer: Beech Street Commercial |
$20.28
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.99
|
| Rate for Payer: Cash Price |
$14.48
|
| Rate for Payer: ChoiceCare Network Commercial |
$20.07
|
| Rate for Payer: Cigna of WY Commercial |
$20.28
|
| Rate for Payer: Entrust Commercial |
$19.66
|
| Rate for Payer: First Choice Health Commercial |
$19.66
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$19.66
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$12.00
|
| Rate for Payer: HealthUtah PPO |
$20.69
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$20.07
|
| Rate for Payer: Multiplan Medicare/VA |
$11.40
|
| Rate for Payer: One Health Plan of WY PPO |
$20.28
|
| Rate for Payer: PacificSource Commercial |
$18.62
|
| Rate for Payer: PHCS PPO |
$20.28
|
| Rate for Payer: Three Rivers PPO |
$15.52
|
| Rate for Payer: TriWest Veterans Administration |
$12.00
|
| Rate for Payer: United Healthcare Commercial |
$18.00
|
| Rate for Payer: United Healthcare Medicare |
$12.00
|
| Rate for Payer: WINHealth Partners Commercial |
$20.28
|
| Rate for Payer: Wise Provider Network Commercial |
$19.66
|
|
|
MEPILEX BORDER SACRUM 6.3X7.9"
|
Facility
|
IP
|
$20.69
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$12.97 |
| Max. Negotiated Rate |
$20.69 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$20.28
|
| Rate for Payer: Altius Auto/Workers Compensation |
$19.86
|
| Rate for Payer: Altius Commercial |
$19.86
|
| Rate for Payer: Beech Street Commercial |
$20.28
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.99
|
| Rate for Payer: Cash Price |
$14.48
|
| Rate for Payer: ChoiceCare Network Commercial |
$20.07
|
| Rate for Payer: Cigna of WY Commercial |
$20.28
|
| Rate for Payer: Entrust Commercial |
$19.66
|
| Rate for Payer: First Choice Health Commercial |
$19.66
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$19.66
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$13.66
|
| Rate for Payer: HealthUtah PPO |
$20.69
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$20.07
|
| Rate for Payer: Multiplan Medicare/VA |
$12.97
|
| Rate for Payer: One Health Plan of WY PPO |
$20.28
|
| Rate for Payer: PacificSource Commercial |
$18.62
|
| Rate for Payer: PHCS PPO |
$20.28
|
| Rate for Payer: Three Rivers PPO |
$15.52
|
| Rate for Payer: TriWest Veterans Administration |
$13.66
|
| Rate for Payer: United Healthcare Commercial |
$18.00
|
| Rate for Payer: United Healthcare Medicare |
$13.66
|
| Rate for Payer: WINHealth Partners Commercial |
$19.66
|
| Rate for Payer: Wise Provider Network Commercial |
$19.66
|
|
