|
MIDODRINE 10 MG TABLET [24215]
|
Facility
|
IP
|
$5.64
|
|
|
Service Code
|
NDC 6068740925
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.54 |
| Max. Negotiated Rate |
$5.64 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5.53
|
| Rate for Payer: Altius Auto/Workers Compensation |
$5.41
|
| Rate for Payer: Altius Commercial |
$5.41
|
| Rate for Payer: Beech Street Commercial |
$5.53
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$4.63
|
| Rate for Payer: Cash Price |
$3.95
|
| Rate for Payer: ChoiceCare Network Commercial |
$5.47
|
| Rate for Payer: Cigna of WY Commercial |
$5.53
|
| Rate for Payer: Entrust Commercial |
$5.36
|
| Rate for Payer: First Choice Health Commercial |
$5.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3.72
|
| Rate for Payer: HealthUtah PPO |
$5.64
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5.47
|
| Rate for Payer: Multiplan Medicare/VA |
$3.54
|
| Rate for Payer: One Health Plan of WY PPO |
$5.53
|
| Rate for Payer: PacificSource Commercial |
$5.08
|
| Rate for Payer: PHCS PPO |
$5.53
|
| Rate for Payer: Three Rivers PPO |
$4.23
|
| Rate for Payer: TriWest Veterans Administration |
$3.72
|
| Rate for Payer: United Healthcare Commercial |
$4.91
|
| Rate for Payer: United Healthcare Medicare |
$3.72
|
| Rate for Payer: WINHealth Partners Commercial |
$5.36
|
| Rate for Payer: Wise Provider Network Commercial |
$5.36
|
|
|
MIFEPRISTONE 200 MG TABLET [12041]
|
Facility
|
IP
|
$86.00
|
|
|
Service Code
|
NDC 6487500101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$53.92 |
| Max. Negotiated Rate |
$86.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$84.28
|
| Rate for Payer: Altius Auto/Workers Compensation |
$82.56
|
| Rate for Payer: Altius Commercial |
$82.56
|
| Rate for Payer: Beech Street Commercial |
$84.28
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$70.61
|
| Rate for Payer: Cash Price |
$60.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$83.42
|
| Rate for Payer: Cigna of WY Commercial |
$84.28
|
| Rate for Payer: Entrust Commercial |
$81.70
|
| Rate for Payer: First Choice Health Commercial |
$81.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$81.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$56.76
|
| Rate for Payer: HealthUtah PPO |
$86.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$83.42
|
| Rate for Payer: Multiplan Medicare/VA |
$53.92
|
| Rate for Payer: One Health Plan of WY PPO |
$84.28
|
| Rate for Payer: PacificSource Commercial |
$77.40
|
| Rate for Payer: PHCS PPO |
$84.28
|
| Rate for Payer: Three Rivers PPO |
$64.50
|
| Rate for Payer: TriWest Veterans Administration |
$56.76
|
| Rate for Payer: United Healthcare Commercial |
$74.82
|
| Rate for Payer: United Healthcare Medicare |
$56.76
|
| Rate for Payer: WINHealth Partners Commercial |
$81.70
|
| Rate for Payer: Wise Provider Network Commercial |
$81.70
|
|
|
MIFEPRISTONE 200 MG TABLET [12041]
|
Facility
|
OP
|
$86.00
|
|
|
Service Code
|
NDC 6487500101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$47.39 |
| Max. Negotiated Rate |
$86.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$84.28
|
| Rate for Payer: Aetna of WY Medicare |
$56.76
|
| Rate for Payer: Altius Auto/Workers Compensation |
$82.56
|
| Rate for Payer: Altius Commercial |
$82.56
|
| Rate for Payer: Beech Street Commercial |
$84.28
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$70.61
|
| Rate for Payer: Cash Price |
$60.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$83.42
|
| Rate for Payer: Cigna of WY Commercial |
$84.28
|
| Rate for Payer: Entrust Commercial |
$81.70
|
| Rate for Payer: First Choice Health Commercial |
$81.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$81.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$49.88
|
| Rate for Payer: HealthUtah PPO |
$86.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$83.42
|
| Rate for Payer: Multiplan Medicare/VA |
$47.39
|
| Rate for Payer: One Health Plan of WY PPO |
$84.28
|
| Rate for Payer: PacificSource Commercial |
$77.40
|
| Rate for Payer: PHCS PPO |
$84.28
|
| Rate for Payer: Three Rivers PPO |
$64.50
|
| Rate for Payer: TriWest Veterans Administration |
$49.88
|
| Rate for Payer: United Healthcare Commercial |
$74.82
|
| Rate for Payer: United Healthcare Medicare |
$49.88
|
| Rate for Payer: WINHealth Partners Commercial |
$84.28
|
| Rate for Payer: Wise Provider Network Commercial |
$81.70
|
|
|
MINDRAY DRYLINE AIRWAY ADAPT
|
Facility
|
OP
|
$10.22
|
|
| Hospital Charge Code |
27000000S1
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$5.63 |
| Max. Negotiated Rate |
$10.22 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$10.02
|
| Rate for Payer: Aetna of WY Medicare |
$6.75
|
| Rate for Payer: Altius Auto/Workers Compensation |
$9.81
|
| Rate for Payer: Altius Commercial |
$9.81
|
| Rate for Payer: Beech Street Commercial |
$10.02
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$8.39
|
| Rate for Payer: Cash Price |
$7.15
|
| Rate for Payer: ChoiceCare Network Commercial |
$9.91
|
| Rate for Payer: Cigna of WY Commercial |
$10.02
|
| Rate for Payer: Entrust Commercial |
$9.71
|
| Rate for Payer: First Choice Health Commercial |
$9.71
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$9.71
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$5.93
|
| Rate for Payer: HealthUtah PPO |
$10.22
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$9.91
|
| Rate for Payer: Multiplan Medicare/VA |
$5.63
|
| Rate for Payer: One Health Plan of WY PPO |
$10.02
|
| Rate for Payer: PacificSource Commercial |
$9.20
|
| Rate for Payer: PHCS PPO |
$10.02
|
| Rate for Payer: Three Rivers PPO |
$7.66
|
| Rate for Payer: TriWest Veterans Administration |
$5.93
|
| Rate for Payer: United Healthcare Commercial |
$8.89
|
| Rate for Payer: United Healthcare Medicare |
$5.93
|
| Rate for Payer: WINHealth Partners Commercial |
$10.02
|
| Rate for Payer: Wise Provider Network Commercial |
$9.71
|
|
|
MINDRAY DRYLINE AIRWAY ADAPT
|
Facility
|
IP
|
$10.22
|
|
| Hospital Charge Code |
27000000S1
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$6.41 |
| Max. Negotiated Rate |
$10.22 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$10.02
|
| Rate for Payer: Altius Auto/Workers Compensation |
$9.81
|
| Rate for Payer: Altius Commercial |
$9.81
|
| Rate for Payer: Beech Street Commercial |
$10.02
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$8.39
|
| Rate for Payer: Cash Price |
$7.15
|
| Rate for Payer: ChoiceCare Network Commercial |
$9.91
|
| Rate for Payer: Cigna of WY Commercial |
$10.02
|
| Rate for Payer: Entrust Commercial |
$9.71
|
| Rate for Payer: First Choice Health Commercial |
$9.71
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$9.71
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$6.75
|
| Rate for Payer: HealthUtah PPO |
$10.22
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$9.91
|
| Rate for Payer: Multiplan Medicare/VA |
$6.41
|
| Rate for Payer: One Health Plan of WY PPO |
$10.02
|
| Rate for Payer: PacificSource Commercial |
$9.20
|
| Rate for Payer: PHCS PPO |
$10.02
|
| Rate for Payer: Three Rivers PPO |
$7.66
|
| Rate for Payer: TriWest Veterans Administration |
$6.75
|
| Rate for Payer: United Healthcare Commercial |
$8.89
|
| Rate for Payer: United Healthcare Medicare |
$6.75
|
| Rate for Payer: WINHealth Partners Commercial |
$9.71
|
| Rate for Payer: Wise Provider Network Commercial |
$9.71
|
|
|
MINDRAY DRYLINE SAMPLING LINE
|
Facility
|
IP
|
$20.52
|
|
| Hospital Charge Code |
27000000S1
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$12.87 |
| Max. Negotiated Rate |
$20.52 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$20.11
|
| Rate for Payer: Altius Auto/Workers Compensation |
$19.70
|
| Rate for Payer: Altius Commercial |
$19.70
|
| Rate for Payer: Beech Street Commercial |
$20.11
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.85
|
| Rate for Payer: Cash Price |
$14.36
|
| Rate for Payer: ChoiceCare Network Commercial |
$19.90
|
| Rate for Payer: Cigna of WY Commercial |
$20.11
|
| Rate for Payer: Entrust Commercial |
$19.49
|
| Rate for Payer: First Choice Health Commercial |
$19.49
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$19.49
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$13.54
|
| Rate for Payer: HealthUtah PPO |
$20.52
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$19.90
|
| Rate for Payer: Multiplan Medicare/VA |
$12.87
|
| Rate for Payer: One Health Plan of WY PPO |
$20.11
|
| Rate for Payer: PacificSource Commercial |
$18.47
|
| Rate for Payer: PHCS PPO |
$20.11
|
| Rate for Payer: Three Rivers PPO |
$15.39
|
| Rate for Payer: TriWest Veterans Administration |
$13.54
|
| Rate for Payer: United Healthcare Commercial |
$17.85
|
| Rate for Payer: United Healthcare Medicare |
$13.54
|
| Rate for Payer: WINHealth Partners Commercial |
$19.49
|
| Rate for Payer: Wise Provider Network Commercial |
$19.49
|
|
|
MINDRAY DRYLINE SAMPLING LINE
|
Facility
|
OP
|
$20.52
|
|
| Hospital Charge Code |
27000000S1
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$11.31 |
| Max. Negotiated Rate |
$20.52 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$20.11
|
| Rate for Payer: Aetna of WY Medicare |
$13.54
|
| Rate for Payer: Altius Auto/Workers Compensation |
$19.70
|
| Rate for Payer: Altius Commercial |
$19.70
|
| Rate for Payer: Beech Street Commercial |
$20.11
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.85
|
| Rate for Payer: Cash Price |
$14.36
|
| Rate for Payer: ChoiceCare Network Commercial |
$19.90
|
| Rate for Payer: Cigna of WY Commercial |
$20.11
|
| Rate for Payer: Entrust Commercial |
$19.49
|
| Rate for Payer: First Choice Health Commercial |
$19.49
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$19.49
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.90
|
| Rate for Payer: HealthUtah PPO |
$20.52
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$19.90
|
| Rate for Payer: Multiplan Medicare/VA |
$11.31
|
| Rate for Payer: One Health Plan of WY PPO |
$20.11
|
| Rate for Payer: PacificSource Commercial |
$18.47
|
| Rate for Payer: PHCS PPO |
$20.11
|
| Rate for Payer: Three Rivers PPO |
$15.39
|
| Rate for Payer: TriWest Veterans Administration |
$11.90
|
| Rate for Payer: United Healthcare Commercial |
$17.85
|
| Rate for Payer: United Healthcare Medicare |
$11.90
|
| Rate for Payer: WINHealth Partners Commercial |
$20.11
|
| Rate for Payer: Wise Provider Network Commercial |
$19.49
|
|
|
MINERAL OIL ENEMA [10111]
|
Facility
|
IP
|
$0.06
|
|
|
Service Code
|
NDC 0132030140
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.06
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.06
|
| Rate for Payer: Altius Commercial |
$0.06
|
| Rate for Payer: Beech Street Commercial |
$0.06
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.06
|
| Rate for Payer: Cigna of WY Commercial |
$0.06
|
| Rate for Payer: Entrust Commercial |
$0.06
|
| Rate for Payer: First Choice Health Commercial |
$0.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.04
|
| Rate for Payer: HealthUtah PPO |
$0.06
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.06
|
| Rate for Payer: Multiplan Medicare/VA |
$0.04
|
| Rate for Payer: One Health Plan of WY PPO |
$0.06
|
| Rate for Payer: PacificSource Commercial |
$0.05
|
| Rate for Payer: PHCS PPO |
$0.06
|
| Rate for Payer: Three Rivers PPO |
$0.05
|
| Rate for Payer: TriWest Veterans Administration |
$0.04
|
| Rate for Payer: United Healthcare Commercial |
$0.05
|
| Rate for Payer: United Healthcare Medicare |
$0.04
|
| Rate for Payer: WINHealth Partners Commercial |
$0.06
|
| Rate for Payer: Wise Provider Network Commercial |
$0.06
|
|
|
MINERAL OIL ENEMA [10111]
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 0132030140
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.06
|
| Rate for Payer: Aetna of WY Medicare |
$0.04
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.06
|
| Rate for Payer: Altius Commercial |
$0.06
|
| Rate for Payer: Beech Street Commercial |
$0.06
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.06
|
| Rate for Payer: Cigna of WY Commercial |
$0.06
|
| Rate for Payer: Entrust Commercial |
$0.06
|
| Rate for Payer: First Choice Health Commercial |
$0.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.03
|
| Rate for Payer: HealthUtah PPO |
$0.06
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.06
|
| Rate for Payer: Multiplan Medicare/VA |
$0.03
|
| Rate for Payer: One Health Plan of WY PPO |
$0.06
|
| Rate for Payer: PacificSource Commercial |
$0.05
|
| Rate for Payer: PHCS PPO |
$0.06
|
| Rate for Payer: Three Rivers PPO |
$0.05
|
| Rate for Payer: TriWest Veterans Administration |
$0.03
|
| Rate for Payer: United Healthcare Commercial |
$0.05
|
| Rate for Payer: United Healthcare Medicare |
$0.03
|
| Rate for Payer: WINHealth Partners Commercial |
$0.06
|
| Rate for Payer: Wise Provider Network Commercial |
$0.06
|
|
|
MINERAL OIL, LIGHT STERILE [157680]
|
Facility
|
IP
|
$9.11
|
|
|
Service Code
|
NDC 6332325410
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.71 |
| Max. Negotiated Rate |
$9.11 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$8.93
|
| Rate for Payer: Altius Auto/Workers Compensation |
$8.75
|
| Rate for Payer: Altius Commercial |
$8.75
|
| Rate for Payer: Beech Street Commercial |
$8.93
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$7.48
|
| Rate for Payer: Cash Price |
$6.38
|
| Rate for Payer: ChoiceCare Network Commercial |
$8.84
|
| Rate for Payer: Cigna of WY Commercial |
$8.93
|
| Rate for Payer: Entrust Commercial |
$8.65
|
| Rate for Payer: First Choice Health Commercial |
$8.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$8.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$6.01
|
| Rate for Payer: HealthUtah PPO |
$9.11
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$8.84
|
| Rate for Payer: Multiplan Medicare/VA |
$5.71
|
| Rate for Payer: One Health Plan of WY PPO |
$8.93
|
| Rate for Payer: PacificSource Commercial |
$8.20
|
| Rate for Payer: PHCS PPO |
$8.93
|
| Rate for Payer: Three Rivers PPO |
$6.83
|
| Rate for Payer: TriWest Veterans Administration |
$6.01
|
| Rate for Payer: United Healthcare Commercial |
$7.93
|
| Rate for Payer: United Healthcare Medicare |
$6.01
|
| Rate for Payer: WINHealth Partners Commercial |
$8.65
|
| Rate for Payer: Wise Provider Network Commercial |
$8.65
|
|
|
MINERAL OIL, LIGHT STERILE [157680]
|
Facility
|
OP
|
$9.11
|
|
|
Service Code
|
NDC 6332325410
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.02 |
| Max. Negotiated Rate |
$9.11 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$8.93
|
| Rate for Payer: Aetna of WY Medicare |
$6.01
|
| Rate for Payer: Altius Auto/Workers Compensation |
$8.75
|
| Rate for Payer: Altius Commercial |
$8.75
|
| Rate for Payer: Beech Street Commercial |
$8.93
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$7.48
|
| Rate for Payer: Cash Price |
$6.38
|
| Rate for Payer: ChoiceCare Network Commercial |
$8.84
|
| Rate for Payer: Cigna of WY Commercial |
$8.93
|
| Rate for Payer: Entrust Commercial |
$8.65
|
| Rate for Payer: First Choice Health Commercial |
$8.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$8.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$5.28
|
| Rate for Payer: HealthUtah PPO |
$9.11
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$8.84
|
| Rate for Payer: Multiplan Medicare/VA |
$5.02
|
| Rate for Payer: One Health Plan of WY PPO |
$8.93
|
| Rate for Payer: PacificSource Commercial |
$8.20
|
| Rate for Payer: PHCS PPO |
$8.93
|
| Rate for Payer: Three Rivers PPO |
$6.83
|
| Rate for Payer: TriWest Veterans Administration |
$5.28
|
| Rate for Payer: United Healthcare Commercial |
$7.93
|
| Rate for Payer: United Healthcare Medicare |
$5.28
|
| Rate for Payer: WINHealth Partners Commercial |
$8.93
|
| Rate for Payer: Wise Provider Network Commercial |
$8.65
|
|
|
MINOCYCLINE 100 MG CAPSULE [4398]
|
Facility
|
IP
|
$2.23
|
|
|
Service Code
|
NDC 6586221150
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$2.23 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.19
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.14
|
| Rate for Payer: Altius Commercial |
$2.14
|
| Rate for Payer: Beech Street Commercial |
$2.19
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.83
|
| Rate for Payer: Cash Price |
$1.56
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.16
|
| Rate for Payer: Cigna of WY Commercial |
$2.19
|
| Rate for Payer: Entrust Commercial |
$2.12
|
| Rate for Payer: First Choice Health Commercial |
$2.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.47
|
| Rate for Payer: HealthUtah PPO |
$2.23
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.16
|
| Rate for Payer: Multiplan Medicare/VA |
$1.40
|
| Rate for Payer: One Health Plan of WY PPO |
$2.19
|
| Rate for Payer: PacificSource Commercial |
$2.01
|
| Rate for Payer: PHCS PPO |
$2.19
|
| Rate for Payer: Three Rivers PPO |
$1.67
|
| Rate for Payer: TriWest Veterans Administration |
$1.47
|
| Rate for Payer: United Healthcare Commercial |
$1.94
|
| Rate for Payer: United Healthcare Medicare |
$1.47
|
| Rate for Payer: WINHealth Partners Commercial |
$2.12
|
| Rate for Payer: Wise Provider Network Commercial |
$2.12
|
|
|
MINOCYCLINE 100 MG CAPSULE [4398]
|
Facility
|
OP
|
$2.23
|
|
|
Service Code
|
NDC 6586221150
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.23 |
| Max. Negotiated Rate |
$2.23 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.19
|
| Rate for Payer: Aetna of WY Medicare |
$1.47
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.14
|
| Rate for Payer: Altius Commercial |
$2.14
|
| Rate for Payer: Beech Street Commercial |
$2.19
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.83
|
| Rate for Payer: Cash Price |
$1.56
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.16
|
| Rate for Payer: Cigna of WY Commercial |
$2.19
|
| Rate for Payer: Entrust Commercial |
$2.12
|
| Rate for Payer: First Choice Health Commercial |
$2.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.29
|
| Rate for Payer: HealthUtah PPO |
$2.23
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.16
|
| Rate for Payer: Multiplan Medicare/VA |
$1.23
|
| Rate for Payer: One Health Plan of WY PPO |
$2.19
|
| Rate for Payer: PacificSource Commercial |
$2.01
|
| Rate for Payer: PHCS PPO |
$2.19
|
| Rate for Payer: Three Rivers PPO |
$1.67
|
| Rate for Payer: TriWest Veterans Administration |
$1.29
|
| Rate for Payer: United Healthcare Commercial |
$1.94
|
| Rate for Payer: United Healthcare Medicare |
$1.29
|
| Rate for Payer: WINHealth Partners Commercial |
$2.19
|
| Rate for Payer: Wise Provider Network Commercial |
$2.12
|
|
|
MIRENA, 52 MG
|
Professional
|
Both
|
$2,135.00
|
|
|
Service Code
|
HCPCS J7298
|
| Hospital Charge Code |
J7298
|
| Min. Negotiated Rate |
$1,601.25 |
| Max. Negotiated Rate |
$2,135.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,092.30
|
| Rate for Payer: Beech Street Commercial |
$2,028.25
|
| Rate for Payer: Cash Price |
$1,494.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,070.95
|
| Rate for Payer: Cigna of WY Commercial |
$2,092.30
|
| Rate for Payer: First Choice Health Commercial |
$1,921.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,028.25
|
| Rate for Payer: HealthUtah PPO |
$2,135.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,070.95
|
| Rate for Payer: One Health Plan of WY PPO |
$2,092.30
|
| Rate for Payer: PacificSource Commercial |
$1,921.50
|
| Rate for Payer: PHCS PPO |
$2,028.25
|
| Rate for Payer: Three Rivers PPO |
$1,601.25
|
| Rate for Payer: United Healthcare Commercial |
$1,857.45
|
| Rate for Payer: WINHealth Partners Commercial |
$2,028.25
|
|
|
MIRTAZAPINE 15 MG TABLET [16737]
|
Facility
|
OP
|
$0.96
|
|
|
Service Code
|
NDC 6808411911
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$0.96 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.94
|
| Rate for Payer: Aetna of WY Medicare |
$0.63
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.92
|
| Rate for Payer: Altius Commercial |
$0.92
|
| Rate for Payer: Beech Street Commercial |
$0.94
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.79
|
| Rate for Payer: Cash Price |
$0.67
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.93
|
| Rate for Payer: Cigna of WY Commercial |
$0.94
|
| Rate for Payer: Entrust Commercial |
$0.91
|
| Rate for Payer: First Choice Health Commercial |
$0.91
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.91
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.56
|
| Rate for Payer: HealthUtah PPO |
$0.96
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.93
|
| Rate for Payer: Multiplan Medicare/VA |
$0.53
|
| Rate for Payer: One Health Plan of WY PPO |
$0.94
|
| Rate for Payer: PacificSource Commercial |
$0.86
|
| Rate for Payer: PHCS PPO |
$0.94
|
| Rate for Payer: Three Rivers PPO |
$0.72
|
| Rate for Payer: TriWest Veterans Administration |
$0.56
|
| Rate for Payer: United Healthcare Commercial |
$0.84
|
| Rate for Payer: United Healthcare Medicare |
$0.56
|
| Rate for Payer: WINHealth Partners Commercial |
$0.94
|
| Rate for Payer: Wise Provider Network Commercial |
$0.91
|
|
|
MIRTAZAPINE 15 MG TABLET [16737]
|
Facility
|
OP
|
$0.96
|
|
|
Service Code
|
NDC 6808411901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$0.96 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.94
|
| Rate for Payer: Aetna of WY Medicare |
$0.63
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.92
|
| Rate for Payer: Altius Commercial |
$0.92
|
| Rate for Payer: Beech Street Commercial |
$0.94
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.79
|
| Rate for Payer: Cash Price |
$0.67
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.93
|
| Rate for Payer: Cigna of WY Commercial |
$0.94
|
| Rate for Payer: Entrust Commercial |
$0.91
|
| Rate for Payer: First Choice Health Commercial |
$0.91
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.91
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.56
|
| Rate for Payer: HealthUtah PPO |
$0.96
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.93
|
| Rate for Payer: Multiplan Medicare/VA |
$0.53
|
| Rate for Payer: One Health Plan of WY PPO |
$0.94
|
| Rate for Payer: PacificSource Commercial |
$0.86
|
| Rate for Payer: PHCS PPO |
$0.94
|
| Rate for Payer: Three Rivers PPO |
$0.72
|
| Rate for Payer: TriWest Veterans Administration |
$0.56
|
| Rate for Payer: United Healthcare Commercial |
$0.84
|
| Rate for Payer: United Healthcare Medicare |
$0.56
|
| Rate for Payer: WINHealth Partners Commercial |
$0.94
|
| Rate for Payer: Wise Provider Network Commercial |
$0.91
|
|
|
MIRTAZAPINE 15 MG TABLET [16737]
|
Facility
|
IP
|
$0.96
|
|
|
Service Code
|
NDC 6808411911
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$0.96 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.94
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.92
|
| Rate for Payer: Altius Commercial |
$0.92
|
| Rate for Payer: Beech Street Commercial |
$0.94
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.79
|
| Rate for Payer: Cash Price |
$0.67
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.93
|
| Rate for Payer: Cigna of WY Commercial |
$0.94
|
| Rate for Payer: Entrust Commercial |
$0.91
|
| Rate for Payer: First Choice Health Commercial |
$0.91
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.91
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.63
|
| Rate for Payer: HealthUtah PPO |
$0.96
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.93
|
| Rate for Payer: Multiplan Medicare/VA |
$0.60
|
| Rate for Payer: One Health Plan of WY PPO |
$0.94
|
| Rate for Payer: PacificSource Commercial |
$0.86
|
| Rate for Payer: PHCS PPO |
$0.94
|
| Rate for Payer: Three Rivers PPO |
$0.72
|
| Rate for Payer: TriWest Veterans Administration |
$0.63
|
| Rate for Payer: United Healthcare Commercial |
$0.84
|
| Rate for Payer: United Healthcare Medicare |
$0.63
|
| Rate for Payer: WINHealth Partners Commercial |
$0.91
|
| Rate for Payer: Wise Provider Network Commercial |
$0.91
|
|
|
MIRTAZAPINE 15 MG TABLET [16737]
|
Facility
|
IP
|
$0.96
|
|
|
Service Code
|
NDC 6808411901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$0.96 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.94
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.92
|
| Rate for Payer: Altius Commercial |
$0.92
|
| Rate for Payer: Beech Street Commercial |
$0.94
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.79
|
| Rate for Payer: Cash Price |
$0.67
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.93
|
| Rate for Payer: Cigna of WY Commercial |
$0.94
|
| Rate for Payer: Entrust Commercial |
$0.91
|
| Rate for Payer: First Choice Health Commercial |
$0.91
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.91
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.63
|
| Rate for Payer: HealthUtah PPO |
$0.96
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.93
|
| Rate for Payer: Multiplan Medicare/VA |
$0.60
|
| Rate for Payer: One Health Plan of WY PPO |
$0.94
|
| Rate for Payer: PacificSource Commercial |
$0.86
|
| Rate for Payer: PHCS PPO |
$0.94
|
| Rate for Payer: Three Rivers PPO |
$0.72
|
| Rate for Payer: TriWest Veterans Administration |
$0.63
|
| Rate for Payer: United Healthcare Commercial |
$0.84
|
| Rate for Payer: United Healthcare Medicare |
$0.63
|
| Rate for Payer: WINHealth Partners Commercial |
$0.91
|
| Rate for Payer: Wise Provider Network Commercial |
$0.91
|
|
|
MISOPROSTOL 100 MCG TABLET [14480]
|
Facility
|
IP
|
$2.65
|
|
|
Service Code
|
NDC 7095444310
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.66 |
| Max. Negotiated Rate |
$2.65 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.60
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.54
|
| Rate for Payer: Altius Commercial |
$2.54
|
| Rate for Payer: Beech Street Commercial |
$2.60
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.18
|
| Rate for Payer: Cash Price |
$1.85
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.57
|
| Rate for Payer: Cigna of WY Commercial |
$2.60
|
| Rate for Payer: Entrust Commercial |
$2.52
|
| Rate for Payer: First Choice Health Commercial |
$2.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.75
|
| Rate for Payer: HealthUtah PPO |
$2.65
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.57
|
| Rate for Payer: Multiplan Medicare/VA |
$1.66
|
| Rate for Payer: One Health Plan of WY PPO |
$2.60
|
| Rate for Payer: PacificSource Commercial |
$2.38
|
| Rate for Payer: PHCS PPO |
$2.60
|
| Rate for Payer: Three Rivers PPO |
$1.99
|
| Rate for Payer: TriWest Veterans Administration |
$1.75
|
| Rate for Payer: United Healthcare Commercial |
$2.31
|
| Rate for Payer: United Healthcare Medicare |
$1.75
|
| Rate for Payer: WINHealth Partners Commercial |
$2.52
|
| Rate for Payer: Wise Provider Network Commercial |
$2.52
|
|
|
MISOPROSTOL 100 MCG TABLET [14480]
|
Facility
|
OP
|
$2.65
|
|
|
Service Code
|
NDC 7095444310
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.46 |
| Max. Negotiated Rate |
$2.65 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.60
|
| Rate for Payer: Aetna of WY Medicare |
$1.75
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.54
|
| Rate for Payer: Altius Commercial |
$2.54
|
| Rate for Payer: Beech Street Commercial |
$2.60
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.18
|
| Rate for Payer: Cash Price |
$1.85
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.57
|
| Rate for Payer: Cigna of WY Commercial |
$2.60
|
| Rate for Payer: Entrust Commercial |
$2.52
|
| Rate for Payer: First Choice Health Commercial |
$2.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.54
|
| Rate for Payer: HealthUtah PPO |
$2.65
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.57
|
| Rate for Payer: Multiplan Medicare/VA |
$1.46
|
| Rate for Payer: One Health Plan of WY PPO |
$2.60
|
| Rate for Payer: PacificSource Commercial |
$2.38
|
| Rate for Payer: PHCS PPO |
$2.60
|
| Rate for Payer: Three Rivers PPO |
$1.99
|
| Rate for Payer: TriWest Veterans Administration |
$1.54
|
| Rate for Payer: United Healthcare Commercial |
$2.31
|
| Rate for Payer: United Healthcare Medicare |
$1.54
|
| Rate for Payer: WINHealth Partners Commercial |
$2.60
|
| Rate for Payer: Wise Provider Network Commercial |
$2.52
|
|
|
MISOPROSTOL 200 MCG TABLET [13174]
|
Facility
|
OP
|
$3.86
|
|
|
Service Code
|
NDC 7095444410
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.13 |
| Max. Negotiated Rate |
$3.86 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3.78
|
| Rate for Payer: Aetna of WY Medicare |
$2.55
|
| Rate for Payer: Altius Auto/Workers Compensation |
$3.71
|
| Rate for Payer: Altius Commercial |
$3.71
|
| Rate for Payer: Beech Street Commercial |
$3.78
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3.17
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$3.74
|
| Rate for Payer: Cigna of WY Commercial |
$3.78
|
| Rate for Payer: Entrust Commercial |
$3.67
|
| Rate for Payer: First Choice Health Commercial |
$3.67
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3.67
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2.24
|
| Rate for Payer: HealthUtah PPO |
$3.86
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3.74
|
| Rate for Payer: Multiplan Medicare/VA |
$2.13
|
| Rate for Payer: One Health Plan of WY PPO |
$3.78
|
| Rate for Payer: PacificSource Commercial |
$3.47
|
| Rate for Payer: PHCS PPO |
$3.78
|
| Rate for Payer: Three Rivers PPO |
$2.90
|
| Rate for Payer: TriWest Veterans Administration |
$2.24
|
| Rate for Payer: United Healthcare Commercial |
$3.36
|
| Rate for Payer: United Healthcare Medicare |
$2.24
|
| Rate for Payer: WINHealth Partners Commercial |
$3.78
|
| Rate for Payer: Wise Provider Network Commercial |
$3.67
|
|
|
MISOPROSTOL 200 MCG TABLET [13174]
|
Facility
|
IP
|
$3.86
|
|
|
Service Code
|
NDC 7095444410
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.42 |
| Max. Negotiated Rate |
$3.86 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3.78
|
| Rate for Payer: Altius Auto/Workers Compensation |
$3.71
|
| Rate for Payer: Altius Commercial |
$3.71
|
| Rate for Payer: Beech Street Commercial |
$3.78
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3.17
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$3.74
|
| Rate for Payer: Cigna of WY Commercial |
$3.78
|
| Rate for Payer: Entrust Commercial |
$3.67
|
| Rate for Payer: First Choice Health Commercial |
$3.67
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3.67
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2.55
|
| Rate for Payer: HealthUtah PPO |
$3.86
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3.74
|
| Rate for Payer: Multiplan Medicare/VA |
$2.42
|
| Rate for Payer: One Health Plan of WY PPO |
$3.78
|
| Rate for Payer: PacificSource Commercial |
$3.47
|
| Rate for Payer: PHCS PPO |
$3.78
|
| Rate for Payer: Three Rivers PPO |
$2.90
|
| Rate for Payer: TriWest Veterans Administration |
$2.55
|
| Rate for Payer: United Healthcare Commercial |
$3.36
|
| Rate for Payer: United Healthcare Medicare |
$2.55
|
| Rate for Payer: WINHealth Partners Commercial |
$3.67
|
| Rate for Payer: Wise Provider Network Commercial |
$3.67
|
|
|
MISOPROSTOL 25 MCG SPLIT TABS [400661]
|
Facility
|
OP
|
$0.36
|
|
|
Service Code
|
NDC 9999400661
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.35
|
| Rate for Payer: Aetna of WY Medicare |
$0.24
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.35
|
| Rate for Payer: Altius Commercial |
$0.35
|
| Rate for Payer: Beech Street Commercial |
$0.35
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.30
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.35
|
| Rate for Payer: Cigna of WY Commercial |
$0.35
|
| Rate for Payer: Entrust Commercial |
$0.34
|
| Rate for Payer: First Choice Health Commercial |
$0.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.21
|
| Rate for Payer: HealthUtah PPO |
$0.36
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.35
|
| Rate for Payer: Multiplan Medicare/VA |
$0.20
|
| Rate for Payer: One Health Plan of WY PPO |
$0.35
|
| Rate for Payer: PacificSource Commercial |
$0.32
|
| Rate for Payer: PHCS PPO |
$0.35
|
| Rate for Payer: Three Rivers PPO |
$0.27
|
| Rate for Payer: TriWest Veterans Administration |
$0.21
|
| Rate for Payer: United Healthcare Commercial |
$0.31
|
| Rate for Payer: United Healthcare Medicare |
$0.21
|
| Rate for Payer: WINHealth Partners Commercial |
$0.35
|
| Rate for Payer: Wise Provider Network Commercial |
$0.34
|
|
|
MISOPROSTOL 25 MCG SPLIT TABS [400661]
|
Facility
|
IP
|
$0.36
|
|
|
Service Code
|
NDC 9999400661
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.35
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.35
|
| Rate for Payer: Altius Commercial |
$0.35
|
| Rate for Payer: Beech Street Commercial |
$0.35
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.30
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.35
|
| Rate for Payer: Cigna of WY Commercial |
$0.35
|
| Rate for Payer: Entrust Commercial |
$0.34
|
| Rate for Payer: First Choice Health Commercial |
$0.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.24
|
| Rate for Payer: HealthUtah PPO |
$0.36
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.35
|
| Rate for Payer: Multiplan Medicare/VA |
$0.23
|
| Rate for Payer: One Health Plan of WY PPO |
$0.35
|
| Rate for Payer: PacificSource Commercial |
$0.32
|
| Rate for Payer: PHCS PPO |
$0.35
|
| Rate for Payer: Three Rivers PPO |
$0.27
|
| Rate for Payer: TriWest Veterans Administration |
$0.24
|
| Rate for Payer: United Healthcare Commercial |
$0.31
|
| Rate for Payer: United Healthcare Medicare |
$0.24
|
| Rate for Payer: WINHealth Partners Commercial |
$0.34
|
| Rate for Payer: Wise Provider Network Commercial |
$0.34
|
|
|
MNPJ W/ANES SHOULDER JT APPL FIXATION APPARATUS
|
Professional
|
Both
|
$1,007.00
|
|
|
Service Code
|
HCPCS 23700 AS
|
| Hospital Charge Code |
23700
|
| Min. Negotiated Rate |
$162.25 |
| Max. Negotiated Rate |
$1,007.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$986.86
|
| Rate for Payer: Aetna of WY Medicare |
$190.88
|
| Rate for Payer: Beech Street Commercial |
$956.65
|
| Rate for Payer: Cash Price |
$704.90
|
| Rate for Payer: Cash Price |
$704.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$976.79
|
| Rate for Payer: Cigna of WY Commercial |
$986.86
|
| Rate for Payer: First Choice Health Commercial |
$906.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$956.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$190.88
|
| Rate for Payer: HealthUtah PPO |
$1,007.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$976.79
|
| Rate for Payer: Multiplan Medicare/VA |
$162.25
|
| Rate for Payer: One Health Plan of WY PPO |
$986.86
|
| Rate for Payer: PacificSource Commercial |
$906.30
|
| Rate for Payer: PHCS PPO |
$956.65
|
| Rate for Payer: Three Rivers PPO |
$755.25
|
| Rate for Payer: TriWest Veterans Administration |
$190.88
|
| Rate for Payer: United Healthcare Commercial |
$876.09
|
| Rate for Payer: United Healthcare Medicare |
$190.88
|
| Rate for Payer: WINHealth Partners Commercial |
$855.95
|
|
