MORGAN MEDI FLOW LENS MT2000
|
Facility
|
IP
|
$126.25
|
|
Hospital Charge Code |
27200000S1
|
Hospital Revenue Code
|
272
|
Min. Negotiated Rate |
$79.16 |
Max. Negotiated Rate |
$126.25 |
Rate for Payer: Aetna of WY Commercial/Medical Rental |
$123.72
|
Rate for Payer: Altius Auto/Workers Compensation |
$121.20
|
Rate for Payer: Altius Commercial |
$121.20
|
Rate for Payer: Beech Street Commercial |
$123.72
|
Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$103.65
|
Rate for Payer: Cash Price |
$88.37
|
Rate for Payer: ChoiceCare Network Commercial |
$122.46
|
Rate for Payer: Cigna of WY Commercial |
$123.72
|
Rate for Payer: Entrust Commercial |
$119.94
|
Rate for Payer: First Choice Health Commercial |
$119.94
|
Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$119.94
|
Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$83.32
|
Rate for Payer: HealthUtah PPO |
$126.25
|
Rate for Payer: Idaho Integrated Healthcare Commercial |
$122.46
|
Rate for Payer: Multiplan Medicare/VA |
$79.16
|
Rate for Payer: One Health Plan of WY PPO |
$123.72
|
Rate for Payer: PacificSource Commercial |
$113.62
|
Rate for Payer: PHCS PPO |
$123.72
|
Rate for Payer: Three Rivers PPO |
$94.69
|
Rate for Payer: TriWest Veterans Administration |
$83.32
|
Rate for Payer: United Healthcare Commercial |
$109.84
|
Rate for Payer: United Healthcare Medicare |
$83.32
|
Rate for Payer: WINHealth Partners Commercial |
$119.94
|
Rate for Payer: Wise Provider Network Commercial |
$119.94
|
|
MORPHINE 10 MG/ML INTRAVENOUS SOLUTION [10700]
|
Facility
|
IP
|
$24.55
|
|
Service Code
|
HCPCS J2270
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$15.39 |
Max. Negotiated Rate |
$24.55 |
Rate for Payer: Aetna of WY Commercial/Medical Rental |
$24.06
|
Rate for Payer: Altius Auto/Workers Compensation |
$23.57
|
Rate for Payer: Altius Commercial |
$23.57
|
Rate for Payer: Beech Street Commercial |
$24.06
|
Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$20.16
|
Rate for Payer: Cash Price |
$17.19
|
Rate for Payer: ChoiceCare Network Commercial |
$23.81
|
Rate for Payer: Cigna of WY Commercial |
$24.06
|
Rate for Payer: Entrust Commercial |
$23.32
|
Rate for Payer: First Choice Health Commercial |
$23.32
|
Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$23.32
|
Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$16.20
|
Rate for Payer: HealthUtah PPO |
$24.55
|
Rate for Payer: Idaho Integrated Healthcare Commercial |
$23.81
|
Rate for Payer: Multiplan Medicare/VA |
$15.39
|
Rate for Payer: One Health Plan of WY PPO |
$24.06
|
Rate for Payer: PacificSource Commercial |
$22.10
|
Rate for Payer: PHCS PPO |
$24.06
|
Rate for Payer: Three Rivers PPO |
$18.41
|
Rate for Payer: TriWest Veterans Administration |
$16.20
|
Rate for Payer: United Healthcare Commercial |
$21.36
|
Rate for Payer: United Healthcare Medicare |
$16.20
|
Rate for Payer: WINHealth Partners Commercial |
$23.32
|
Rate for Payer: Wise Provider Network Commercial |
$23.32
|
|
MORPHINE 10 MG/ML INTRAVENOUS SOLUTION [10700]
|
Facility
|
OP
|
$24.55
|
|
Service Code
|
HCPCS J2270
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$13.53 |
Max. Negotiated Rate |
$24.55 |
Rate for Payer: Aetna of WY Commercial/Medical Rental |
$24.06
|
Rate for Payer: Aetna of WY Medicare |
$16.20
|
Rate for Payer: Altius Auto/Workers Compensation |
$23.57
|
Rate for Payer: Altius Commercial |
$23.57
|
Rate for Payer: Beech Street Commercial |
$24.06
|
Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$20.16
|
Rate for Payer: Cash Price |
$17.19
|
Rate for Payer: ChoiceCare Network Commercial |
$23.81
|
Rate for Payer: Cigna of WY Commercial |
$24.06
|
Rate for Payer: Entrust Commercial |
$23.32
|
Rate for Payer: First Choice Health Commercial |
$23.32
|
Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$23.32
|
Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$14.24
|
Rate for Payer: HealthUtah PPO |
$24.55
|
Rate for Payer: Idaho Integrated Healthcare Commercial |
$23.81
|
Rate for Payer: Multiplan Medicare/VA |
$13.53
|
Rate for Payer: One Health Plan of WY PPO |
$24.06
|
Rate for Payer: PacificSource Commercial |
$22.10
|
Rate for Payer: PHCS PPO |
$24.06
|
Rate for Payer: Three Rivers PPO |
$18.41
|
Rate for Payer: TriWest Veterans Administration |
$14.24
|
Rate for Payer: United Healthcare Commercial |
$21.36
|
Rate for Payer: United Healthcare Medicare |
$14.24
|
Rate for Payer: WINHealth Partners Commercial |
$24.06
|
Rate for Payer: Wise Provider Network Commercial |
$23.32
|
|
MORPHINE 4 MG/ML INJECTION SOLUTION (WRAPPED) [4000721]
|
Facility
|
OP
|
$25.76
|
|
Service Code
|
HCPCS J2270
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$14.19 |
Max. Negotiated Rate |
$25.76 |
Rate for Payer: Aetna of WY Commercial/Medical Rental |
$25.24
|
Rate for Payer: Aetna of WY Commercial/Medical Rental |
$24.49
|
Rate for Payer: Aetna of WY Medicare |
$17.00
|
Rate for Payer: Aetna of WY Medicare |
$16.49
|
Rate for Payer: Altius Auto/Workers Compensation |
$23.99
|
Rate for Payer: Altius Auto/Workers Compensation |
$24.73
|
Rate for Payer: Altius Commercial |
$24.73
|
Rate for Payer: Altius Commercial |
$23.99
|
Rate for Payer: Beech Street Commercial |
$24.49
|
Rate for Payer: Beech Street Commercial |
$25.24
|
Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$21.15
|
Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$20.52
|
Rate for Payer: Cash Price |
$17.49
|
Rate for Payer: Cash Price |
$18.03
|
Rate for Payer: ChoiceCare Network Commercial |
$24.99
|
Rate for Payer: ChoiceCare Network Commercial |
$24.24
|
Rate for Payer: Cigna of WY Commercial |
$24.49
|
Rate for Payer: Cigna of WY Commercial |
$25.24
|
Rate for Payer: Entrust Commercial |
$24.47
|
Rate for Payer: Entrust Commercial |
$23.74
|
Rate for Payer: First Choice Health Commercial |
$23.74
|
Rate for Payer: First Choice Health Commercial |
$24.47
|
Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$23.74
|
Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$24.47
|
Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$14.94
|
Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$14.49
|
Rate for Payer: HealthUtah PPO |
$24.99
|
Rate for Payer: HealthUtah PPO |
$25.76
|
Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.24
|
Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.99
|
Rate for Payer: Multiplan Medicare/VA |
$14.19
|
Rate for Payer: Multiplan Medicare/VA |
$13.77
|
Rate for Payer: One Health Plan of WY PPO |
$24.49
|
Rate for Payer: One Health Plan of WY PPO |
$25.24
|
Rate for Payer: PacificSource Commercial |
$23.18
|
Rate for Payer: PacificSource Commercial |
$22.49
|
Rate for Payer: PHCS PPO |
$24.49
|
Rate for Payer: PHCS PPO |
$25.24
|
Rate for Payer: Three Rivers PPO |
$18.74
|
Rate for Payer: Three Rivers PPO |
$19.32
|
Rate for Payer: TriWest Veterans Administration |
$14.94
|
Rate for Payer: TriWest Veterans Administration |
$14.49
|
Rate for Payer: United Healthcare Commercial |
$21.74
|
Rate for Payer: United Healthcare Commercial |
$22.41
|
Rate for Payer: United Healthcare Medicare |
$14.94
|
Rate for Payer: United Healthcare Medicare |
$14.49
|
Rate for Payer: WINHealth Partners Commercial |
$24.49
|
Rate for Payer: WINHealth Partners Commercial |
$25.24
|
Rate for Payer: Wise Provider Network Commercial |
$23.74
|
Rate for Payer: Wise Provider Network Commercial |
$24.47
|
|
MORPHINE 4 MG/ML INJECTION SOLUTION (WRAPPED) [4000721]
|
Facility
|
IP
|
$25.76
|
|
Service Code
|
HCPCS J2270
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$16.15 |
Max. Negotiated Rate |
$25.76 |
Rate for Payer: Aetna of WY Commercial/Medical Rental |
$25.24
|
Rate for Payer: Aetna of WY Commercial/Medical Rental |
$24.49
|
Rate for Payer: Altius Auto/Workers Compensation |
$24.73
|
Rate for Payer: Altius Auto/Workers Compensation |
$23.99
|
Rate for Payer: Altius Commercial |
$23.99
|
Rate for Payer: Altius Commercial |
$24.73
|
Rate for Payer: Beech Street Commercial |
$25.24
|
Rate for Payer: Beech Street Commercial |
$24.49
|
Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$20.52
|
Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$21.15
|
Rate for Payer: Cash Price |
$18.03
|
Rate for Payer: Cash Price |
$17.49
|
Rate for Payer: ChoiceCare Network Commercial |
$24.24
|
Rate for Payer: ChoiceCare Network Commercial |
$24.99
|
Rate for Payer: Cigna of WY Commercial |
$25.24
|
Rate for Payer: Cigna of WY Commercial |
$24.49
|
Rate for Payer: Entrust Commercial |
$23.74
|
Rate for Payer: Entrust Commercial |
$24.47
|
Rate for Payer: First Choice Health Commercial |
$23.74
|
Rate for Payer: First Choice Health Commercial |
$24.47
|
Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$23.74
|
Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$24.47
|
Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$17.00
|
Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$16.49
|
Rate for Payer: HealthUtah PPO |
$25.76
|
Rate for Payer: HealthUtah PPO |
$24.99
|
Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.24
|
Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.99
|
Rate for Payer: Multiplan Medicare/VA |
$16.15
|
Rate for Payer: Multiplan Medicare/VA |
$15.67
|
Rate for Payer: One Health Plan of WY PPO |
$25.24
|
Rate for Payer: One Health Plan of WY PPO |
$24.49
|
Rate for Payer: PacificSource Commercial |
$23.18
|
Rate for Payer: PacificSource Commercial |
$22.49
|
Rate for Payer: PHCS PPO |
$24.49
|
Rate for Payer: PHCS PPO |
$25.24
|
Rate for Payer: Three Rivers PPO |
$18.74
|
Rate for Payer: Three Rivers PPO |
$19.32
|
Rate for Payer: TriWest Veterans Administration |
$17.00
|
Rate for Payer: TriWest Veterans Administration |
$16.49
|
Rate for Payer: United Healthcare Commercial |
$21.74
|
Rate for Payer: United Healthcare Commercial |
$22.41
|
Rate for Payer: United Healthcare Medicare |
$17.00
|
Rate for Payer: United Healthcare Medicare |
$16.49
|
Rate for Payer: WINHealth Partners Commercial |
$23.74
|
Rate for Payer: WINHealth Partners Commercial |
$24.47
|
Rate for Payer: Wise Provider Network Commercial |
$23.74
|
Rate for Payer: Wise Provider Network Commercial |
$24.47
|
|
MORPHINE 4 MG/ML INTRAVENOUS SYRINGE [132141]
|
Facility
|
OP
|
$32.82
|
|
Service Code
|
HCPCS J2270
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$18.08 |
Max. Negotiated Rate |
$32.82 |
Rate for Payer: Aetna of WY Commercial/Medical Rental |
$32.16
|
Rate for Payer: Aetna of WY Medicare |
$21.66
|
Rate for Payer: Altius Auto/Workers Compensation |
$31.51
|
Rate for Payer: Altius Commercial |
$31.51
|
Rate for Payer: Beech Street Commercial |
$32.16
|
Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$26.95
|
Rate for Payer: Cash Price |
$22.97
|
Rate for Payer: ChoiceCare Network Commercial |
$31.84
|
Rate for Payer: Cigna of WY Commercial |
$32.16
|
Rate for Payer: Entrust Commercial |
$31.18
|
Rate for Payer: First Choice Health Commercial |
$31.18
|
Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$31.18
|
Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$19.04
|
Rate for Payer: HealthUtah PPO |
$32.82
|
Rate for Payer: Idaho Integrated Healthcare Commercial |
$31.84
|
Rate for Payer: Multiplan Medicare/VA |
$18.08
|
Rate for Payer: One Health Plan of WY PPO |
$32.16
|
Rate for Payer: PacificSource Commercial |
$29.54
|
Rate for Payer: PHCS PPO |
$32.16
|
Rate for Payer: Three Rivers PPO |
$24.62
|
Rate for Payer: TriWest Veterans Administration |
$19.04
|
Rate for Payer: United Healthcare Commercial |
$28.55
|
Rate for Payer: United Healthcare Medicare |
$19.04
|
Rate for Payer: WINHealth Partners Commercial |
$32.16
|
Rate for Payer: Wise Provider Network Commercial |
$31.18
|
|
MORPHINE 4 MG/ML INTRAVENOUS SYRINGE [132141]
|
Facility
|
IP
|
$32.82
|
|
Service Code
|
HCPCS J2270
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$20.58 |
Max. Negotiated Rate |
$32.82 |
Rate for Payer: Aetna of WY Commercial/Medical Rental |
$32.16
|
Rate for Payer: Altius Auto/Workers Compensation |
$31.51
|
Rate for Payer: Altius Commercial |
$31.51
|
Rate for Payer: Beech Street Commercial |
$32.16
|
Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$26.95
|
Rate for Payer: Cash Price |
$22.97
|
Rate for Payer: ChoiceCare Network Commercial |
$31.84
|
Rate for Payer: Cigna of WY Commercial |
$32.16
|
Rate for Payer: Entrust Commercial |
$31.18
|
Rate for Payer: First Choice Health Commercial |
$31.18
|
Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$31.18
|
Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$21.66
|
Rate for Payer: HealthUtah PPO |
$32.82
|
Rate for Payer: Idaho Integrated Healthcare Commercial |
$31.84
|
Rate for Payer: Multiplan Medicare/VA |
$20.58
|
Rate for Payer: One Health Plan of WY PPO |
$32.16
|
Rate for Payer: PacificSource Commercial |
$29.54
|
Rate for Payer: PHCS PPO |
$32.16
|
Rate for Payer: Three Rivers PPO |
$24.62
|
Rate for Payer: TriWest Veterans Administration |
$21.66
|
Rate for Payer: United Healthcare Commercial |
$28.55
|
Rate for Payer: United Healthcare Medicare |
$21.66
|
Rate for Payer: WINHealth Partners Commercial |
$31.18
|
Rate for Payer: Wise Provider Network Commercial |
$31.18
|
|
MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION [3049]
|
Facility
|
OP
|
$2.40
|
|
Service Code
|
NDC 0406800315
|
Hospital Revenue Code
|
250
|
Min. Negotiated Rate |
$1.32 |
Max. Negotiated Rate |
$2.40 |
Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.35
|
Rate for Payer: Aetna of WY Medicare |
$1.58
|
Rate for Payer: Altius Auto/Workers Compensation |
$2.30
|
Rate for Payer: Altius Commercial |
$2.30
|
Rate for Payer: Beech Street Commercial |
$2.35
|
Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.97
|
Rate for Payer: Cash Price |
$1.68
|
Rate for Payer: ChoiceCare Network Commercial |
$2.33
|
Rate for Payer: Cigna of WY Commercial |
$2.35
|
Rate for Payer: Entrust Commercial |
$2.28
|
Rate for Payer: First Choice Health Commercial |
$2.28
|
Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.28
|
Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.39
|
Rate for Payer: HealthUtah PPO |
$2.40
|
Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.33
|
Rate for Payer: Multiplan Medicare/VA |
$1.32
|
Rate for Payer: One Health Plan of WY PPO |
$2.35
|
Rate for Payer: PacificSource Commercial |
$2.16
|
Rate for Payer: PHCS PPO |
$2.35
|
Rate for Payer: Three Rivers PPO |
$1.80
|
Rate for Payer: TriWest Veterans Administration |
$1.39
|
Rate for Payer: United Healthcare Commercial |
$2.09
|
Rate for Payer: United Healthcare Medicare |
$1.39
|
Rate for Payer: WINHealth Partners Commercial |
$2.35
|
Rate for Payer: Wise Provider Network Commercial |
$2.28
|
|
MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION [3049]
|
Facility
|
IP
|
$2.40
|
|
Service Code
|
NDC 0406800315
|
Hospital Revenue Code
|
250
|
Min. Negotiated Rate |
$1.50 |
Max. Negotiated Rate |
$2.40 |
Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.35
|
Rate for Payer: Altius Auto/Workers Compensation |
$2.30
|
Rate for Payer: Altius Commercial |
$2.30
|
Rate for Payer: Beech Street Commercial |
$2.35
|
Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.97
|
Rate for Payer: Cash Price |
$1.68
|
Rate for Payer: ChoiceCare Network Commercial |
$2.33
|
Rate for Payer: Cigna of WY Commercial |
$2.35
|
Rate for Payer: Entrust Commercial |
$2.28
|
Rate for Payer: First Choice Health Commercial |
$2.28
|
Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.28
|
Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.58
|
Rate for Payer: HealthUtah PPO |
$2.40
|
Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.33
|
Rate for Payer: Multiplan Medicare/VA |
$1.50
|
Rate for Payer: One Health Plan of WY PPO |
$2.35
|
Rate for Payer: PacificSource Commercial |
$2.16
|
Rate for Payer: PHCS PPO |
$2.35
|
Rate for Payer: Three Rivers PPO |
$1.80
|
Rate for Payer: TriWest Veterans Administration |
$1.58
|
Rate for Payer: United Healthcare Commercial |
$2.09
|
Rate for Payer: United Healthcare Medicare |
$1.58
|
Rate for Payer: WINHealth Partners Commercial |
$2.28
|
Rate for Payer: Wise Provider Network Commercial |
$2.28
|
|
MORPHINE ER 15 MG TABLET,EXTENDED RELEASE [16017]
|
Facility
|
OP
|
$1.87
|
|
Service Code
|
NDC 4285880101
|
Hospital Revenue Code
|
250
|
Min. Negotiated Rate |
$1.03 |
Max. Negotiated Rate |
$1.87 |
Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.83
|
Rate for Payer: Aetna of WY Medicare |
$1.23
|
Rate for Payer: Altius Auto/Workers Compensation |
$1.80
|
Rate for Payer: Altius Commercial |
$1.80
|
Rate for Payer: Beech Street Commercial |
$1.83
|
Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.54
|
Rate for Payer: Cash Price |
$1.31
|
Rate for Payer: ChoiceCare Network Commercial |
$1.81
|
Rate for Payer: Cigna of WY Commercial |
$1.83
|
Rate for Payer: Entrust Commercial |
$1.78
|
Rate for Payer: First Choice Health Commercial |
$1.78
|
Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.78
|
Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.08
|
Rate for Payer: HealthUtah PPO |
$1.87
|
Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.81
|
Rate for Payer: Multiplan Medicare/VA |
$1.03
|
Rate for Payer: One Health Plan of WY PPO |
$1.83
|
Rate for Payer: PacificSource Commercial |
$1.68
|
Rate for Payer: PHCS PPO |
$1.83
|
Rate for Payer: Three Rivers PPO |
$1.40
|
Rate for Payer: TriWest Veterans Administration |
$1.08
|
Rate for Payer: United Healthcare Commercial |
$1.63
|
Rate for Payer: United Healthcare Medicare |
$1.08
|
Rate for Payer: WINHealth Partners Commercial |
$1.83
|
Rate for Payer: Wise Provider Network Commercial |
$1.78
|
|
MORPHINE ER 15 MG TABLET,EXTENDED RELEASE [16017]
|
Facility
|
OP
|
$3.23
|
|
Service Code
|
NDC 6808415711
|
Hospital Revenue Code
|
250
|
Min. Negotiated Rate |
$1.78 |
Max. Negotiated Rate |
$3.23 |
Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3.17
|
Rate for Payer: Aetna of WY Medicare |
$2.13
|
Rate for Payer: Altius Auto/Workers Compensation |
$3.10
|
Rate for Payer: Altius Commercial |
$3.10
|
Rate for Payer: Beech Street Commercial |
$3.17
|
Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.65
|
Rate for Payer: Cash Price |
$2.26
|
Rate for Payer: ChoiceCare Network Commercial |
$3.13
|
Rate for Payer: Cigna of WY Commercial |
$3.17
|
Rate for Payer: Entrust Commercial |
$3.07
|
Rate for Payer: First Choice Health Commercial |
$3.07
|
Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3.07
|
Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.87
|
Rate for Payer: HealthUtah PPO |
$3.23
|
Rate for Payer: Idaho Integrated Healthcare Commercial |
$3.13
|
Rate for Payer: Multiplan Medicare/VA |
$1.78
|
Rate for Payer: One Health Plan of WY PPO |
$3.17
|
Rate for Payer: PacificSource Commercial |
$2.91
|
Rate for Payer: PHCS PPO |
$3.17
|
Rate for Payer: Three Rivers PPO |
$2.42
|
Rate for Payer: TriWest Veterans Administration |
$1.87
|
Rate for Payer: United Healthcare Commercial |
$2.81
|
Rate for Payer: United Healthcare Medicare |
$1.87
|
Rate for Payer: WINHealth Partners Commercial |
$3.17
|
Rate for Payer: Wise Provider Network Commercial |
$3.07
|
|
MORPHINE ER 15 MG TABLET,EXTENDED RELEASE [16017]
|
Facility
|
IP
|
$3.23
|
|
Service Code
|
NDC 6808415711
|
Hospital Revenue Code
|
250
|
Min. Negotiated Rate |
$2.03 |
Max. Negotiated Rate |
$3.23 |
Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3.17
|
Rate for Payer: Altius Auto/Workers Compensation |
$3.10
|
Rate for Payer: Altius Commercial |
$3.10
|
Rate for Payer: Beech Street Commercial |
$3.17
|
Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.65
|
Rate for Payer: Cash Price |
$2.26
|
Rate for Payer: ChoiceCare Network Commercial |
$3.13
|
Rate for Payer: Cigna of WY Commercial |
$3.17
|
Rate for Payer: Entrust Commercial |
$3.07
|
Rate for Payer: First Choice Health Commercial |
$3.07
|
Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3.07
|
Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2.13
|
Rate for Payer: HealthUtah PPO |
$3.23
|
Rate for Payer: Idaho Integrated Healthcare Commercial |
$3.13
|
Rate for Payer: Multiplan Medicare/VA |
$2.03
|
Rate for Payer: One Health Plan of WY PPO |
$3.17
|
Rate for Payer: PacificSource Commercial |
$2.91
|
Rate for Payer: PHCS PPO |
$3.17
|
Rate for Payer: Three Rivers PPO |
$2.42
|
Rate for Payer: TriWest Veterans Administration |
$2.13
|
Rate for Payer: United Healthcare Commercial |
$2.81
|
Rate for Payer: United Healthcare Medicare |
$2.13
|
Rate for Payer: WINHealth Partners Commercial |
$3.07
|
Rate for Payer: Wise Provider Network Commercial |
$3.07
|
|
MORPHINE ER 15 MG TABLET,EXTENDED RELEASE [16017]
|
Facility
|
IP
|
$2.68
|
|
Service Code
|
NDC 0406831501
|
Hospital Revenue Code
|
250
|
Min. Negotiated Rate |
$1.68 |
Max. Negotiated Rate |
$2.68 |
Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.63
|
Rate for Payer: Altius Auto/Workers Compensation |
$2.57
|
Rate for Payer: Altius Commercial |
$2.57
|
Rate for Payer: Beech Street Commercial |
$2.63
|
Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.20
|
Rate for Payer: Cash Price |
$1.88
|
Rate for Payer: ChoiceCare Network Commercial |
$2.60
|
Rate for Payer: Cigna of WY Commercial |
$2.63
|
Rate for Payer: Entrust Commercial |
$2.55
|
Rate for Payer: First Choice Health Commercial |
$2.55
|
Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.55
|
Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.77
|
Rate for Payer: HealthUtah PPO |
$2.68
|
Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.60
|
Rate for Payer: Multiplan Medicare/VA |
$1.68
|
Rate for Payer: One Health Plan of WY PPO |
$2.63
|
Rate for Payer: PacificSource Commercial |
$2.41
|
Rate for Payer: PHCS PPO |
$2.63
|
Rate for Payer: Three Rivers PPO |
$2.01
|
Rate for Payer: TriWest Veterans Administration |
$1.77
|
Rate for Payer: United Healthcare Commercial |
$2.33
|
Rate for Payer: United Healthcare Medicare |
$1.77
|
Rate for Payer: WINHealth Partners Commercial |
$2.55
|
Rate for Payer: Wise Provider Network Commercial |
$2.55
|
|
MORPHINE ER 15 MG TABLET,EXTENDED RELEASE [16017]
|
Facility
|
OP
|
$2.68
|
|
Service Code
|
NDC 0406831501
|
Hospital Revenue Code
|
250
|
Min. Negotiated Rate |
$1.48 |
Max. Negotiated Rate |
$2.68 |
Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.63
|
Rate for Payer: Aetna of WY Medicare |
$1.77
|
Rate for Payer: Altius Auto/Workers Compensation |
$2.57
|
Rate for Payer: Altius Commercial |
$2.57
|
Rate for Payer: Beech Street Commercial |
$2.63
|
Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.20
|
Rate for Payer: Cash Price |
$1.88
|
Rate for Payer: ChoiceCare Network Commercial |
$2.60
|
Rate for Payer: Cigna of WY Commercial |
$2.63
|
Rate for Payer: Entrust Commercial |
$2.55
|
Rate for Payer: First Choice Health Commercial |
$2.55
|
Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.55
|
Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.55
|
Rate for Payer: HealthUtah PPO |
$2.68
|
Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.60
|
Rate for Payer: Multiplan Medicare/VA |
$1.48
|
Rate for Payer: One Health Plan of WY PPO |
$2.63
|
Rate for Payer: PacificSource Commercial |
$2.41
|
Rate for Payer: PHCS PPO |
$2.63
|
Rate for Payer: Three Rivers PPO |
$2.01
|
Rate for Payer: TriWest Veterans Administration |
$1.55
|
Rate for Payer: United Healthcare Commercial |
$2.33
|
Rate for Payer: United Healthcare Medicare |
$1.55
|
Rate for Payer: WINHealth Partners Commercial |
$2.63
|
Rate for Payer: Wise Provider Network Commercial |
$2.55
|
|
MORPHINE ER 15 MG TABLET,EXTENDED RELEASE [16017]
|
Facility
|
IP
|
$1.87
|
|
Service Code
|
NDC 4285880101
|
Hospital Revenue Code
|
250
|
Min. Negotiated Rate |
$1.17 |
Max. Negotiated Rate |
$1.87 |
Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.83
|
Rate for Payer: Altius Auto/Workers Compensation |
$1.80
|
Rate for Payer: Altius Commercial |
$1.80
|
Rate for Payer: Beech Street Commercial |
$1.83
|
Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.54
|
Rate for Payer: Cash Price |
$1.31
|
Rate for Payer: ChoiceCare Network Commercial |
$1.81
|
Rate for Payer: Cigna of WY Commercial |
$1.83
|
Rate for Payer: Entrust Commercial |
$1.78
|
Rate for Payer: First Choice Health Commercial |
$1.78
|
Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.78
|
Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.23
|
Rate for Payer: HealthUtah PPO |
$1.87
|
Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.81
|
Rate for Payer: Multiplan Medicare/VA |
$1.17
|
Rate for Payer: One Health Plan of WY PPO |
$1.83
|
Rate for Payer: PacificSource Commercial |
$1.68
|
Rate for Payer: PHCS PPO |
$1.83
|
Rate for Payer: Three Rivers PPO |
$1.40
|
Rate for Payer: TriWest Veterans Administration |
$1.23
|
Rate for Payer: United Healthcare Commercial |
$1.63
|
Rate for Payer: United Healthcare Medicare |
$1.23
|
Rate for Payer: WINHealth Partners Commercial |
$1.78
|
Rate for Payer: Wise Provider Network Commercial |
$1.78
|
|
MORPHINE (PF) 1 MG/ML INJECTION SOLUTION [7885]
|
Facility
|
IP
|
$25.86
|
|
Service Code
|
HCPCS J2274
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$16.21 |
Max. Negotiated Rate |
$25.86 |
Rate for Payer: Aetna of WY Commercial/Medical Rental |
$25.34
|
Rate for Payer: Altius Auto/Workers Compensation |
$24.83
|
Rate for Payer: Altius Commercial |
$24.83
|
Rate for Payer: Beech Street Commercial |
$25.34
|
Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$21.23
|
Rate for Payer: Cash Price |
$18.10
|
Rate for Payer: ChoiceCare Network Commercial |
$25.08
|
Rate for Payer: Cigna of WY Commercial |
$25.34
|
Rate for Payer: Entrust Commercial |
$24.57
|
Rate for Payer: First Choice Health Commercial |
$24.57
|
Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$24.57
|
Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$17.07
|
Rate for Payer: HealthUtah PPO |
$25.86
|
Rate for Payer: Idaho Integrated Healthcare Commercial |
$25.08
|
Rate for Payer: Multiplan Medicare/VA |
$16.21
|
Rate for Payer: One Health Plan of WY PPO |
$25.34
|
Rate for Payer: PacificSource Commercial |
$23.27
|
Rate for Payer: PHCS PPO |
$25.34
|
Rate for Payer: Three Rivers PPO |
$19.40
|
Rate for Payer: TriWest Veterans Administration |
$17.07
|
Rate for Payer: United Healthcare Commercial |
$22.50
|
Rate for Payer: United Healthcare Medicare |
$17.07
|
Rate for Payer: WINHealth Partners Commercial |
$24.57
|
Rate for Payer: Wise Provider Network Commercial |
$24.57
|
|
MORPHINE (PF) 1 MG/ML INJECTION SOLUTION [7885]
|
Facility
|
OP
|
$25.86
|
|
Service Code
|
HCPCS J2274
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$14.25 |
Max. Negotiated Rate |
$25.86 |
Rate for Payer: Aetna of WY Commercial/Medical Rental |
$25.34
|
Rate for Payer: Aetna of WY Medicare |
$17.07
|
Rate for Payer: Altius Auto/Workers Compensation |
$24.83
|
Rate for Payer: Altius Commercial |
$24.83
|
Rate for Payer: Beech Street Commercial |
$25.34
|
Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$21.23
|
Rate for Payer: Cash Price |
$18.10
|
Rate for Payer: ChoiceCare Network Commercial |
$25.08
|
Rate for Payer: Cigna of WY Commercial |
$25.34
|
Rate for Payer: Entrust Commercial |
$24.57
|
Rate for Payer: First Choice Health Commercial |
$24.57
|
Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$24.57
|
Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$15.00
|
Rate for Payer: HealthUtah PPO |
$25.86
|
Rate for Payer: Idaho Integrated Healthcare Commercial |
$25.08
|
Rate for Payer: Multiplan Medicare/VA |
$14.25
|
Rate for Payer: One Health Plan of WY PPO |
$25.34
|
Rate for Payer: PacificSource Commercial |
$23.27
|
Rate for Payer: PHCS PPO |
$25.34
|
Rate for Payer: Three Rivers PPO |
$19.40
|
Rate for Payer: TriWest Veterans Administration |
$15.00
|
Rate for Payer: United Healthcare Commercial |
$22.50
|
Rate for Payer: United Healthcare Medicare |
$15.00
|
Rate for Payer: WINHealth Partners Commercial |
$25.34
|
Rate for Payer: Wise Provider Network Commercial |
$24.57
|
|
MORPHINE SULFATE INJECTION
|
Professional
|
Both
|
$36.00
|
|
Service Code
|
HCPCS J2270
|
Hospital Charge Code |
J2270
|
Min. Negotiated Rate |
$3.79 |
Max. Negotiated Rate |
$36.00 |
Rate for Payer: Aetna of WY Commercial/Medical Rental |
$35.28
|
Rate for Payer: Aetna of WY Medicare |
$4.46
|
Rate for Payer: Beech Street Commercial |
$34.20
|
Rate for Payer: Cash Price |
$25.20
|
Rate for Payer: Cash Price |
$25.20
|
Rate for Payer: ChoiceCare Network Commercial |
$34.92
|
Rate for Payer: Cigna of WY Commercial |
$35.28
|
Rate for Payer: First Choice Health Commercial |
$32.40
|
Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$34.20
|
Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$4.46
|
Rate for Payer: HealthUtah PPO |
$36.00
|
Rate for Payer: Idaho Integrated Healthcare Commercial |
$34.92
|
Rate for Payer: Multiplan Medicare/VA |
$3.79
|
Rate for Payer: One Health Plan of WY PPO |
$35.28
|
Rate for Payer: PacificSource Commercial |
$32.40
|
Rate for Payer: PHCS PPO |
$34.20
|
Rate for Payer: Three Rivers PPO |
$27.00
|
Rate for Payer: TriWest Veterans Administration |
$4.46
|
Rate for Payer: United Healthcare Commercial |
$31.32
|
Rate for Payer: United Healthcare Medicare |
$4.46
|
Rate for Payer: WINHealth Partners Commercial |
$34.20
|
|
MOTION FLUOR EVAL SWLNG FUNCJ C/V REC
|
Professional
|
Both
|
$315.00
|
|
Service Code
|
HCPCS 92611
|
Hospital Charge Code |
92611
|
Min. Negotiated Rate |
$76.31 |
Max. Negotiated Rate |
$315.00 |
Rate for Payer: Aetna of WY Commercial/Medical Rental |
$308.70
|
Rate for Payer: Aetna of WY Medicare |
$89.78
|
Rate for Payer: Beech Street Commercial |
$299.25
|
Rate for Payer: Cash Price |
$220.50
|
Rate for Payer: Cash Price |
$220.50
|
Rate for Payer: ChoiceCare Network Commercial |
$305.55
|
Rate for Payer: Cigna of WY Commercial |
$308.70
|
Rate for Payer: First Choice Health Commercial |
$283.50
|
Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$299.25
|
Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$89.78
|
Rate for Payer: HealthUtah PPO |
$315.00
|
Rate for Payer: Idaho Integrated Healthcare Commercial |
$305.55
|
Rate for Payer: Multiplan Medicare/VA |
$76.31
|
Rate for Payer: One Health Plan of WY PPO |
$308.70
|
Rate for Payer: PacificSource Commercial |
$283.50
|
Rate for Payer: PHCS PPO |
$299.25
|
Rate for Payer: Three Rivers PPO |
$236.25
|
Rate for Payer: TriWest Veterans Administration |
$89.78
|
Rate for Payer: United Healthcare Commercial |
$274.05
|
Rate for Payer: United Healthcare Medicare |
$89.78
|
Rate for Payer: WINHealth Partners Commercial |
$299.25
|
|
MOXIFLOXACIN 400 MG TABLET [5836]
|
Facility
|
OP
|
$29.25
|
|
Service Code
|
NDC 1366820130
|
Hospital Revenue Code
|
250
|
Min. Negotiated Rate |
$16.12 |
Max. Negotiated Rate |
$29.25 |
Rate for Payer: Aetna of WY Commercial/Medical Rental |
$28.66
|
Rate for Payer: Aetna of WY Medicare |
$19.30
|
Rate for Payer: Altius Auto/Workers Compensation |
$28.08
|
Rate for Payer: Altius Commercial |
$28.08
|
Rate for Payer: Beech Street Commercial |
$28.66
|
Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$24.01
|
Rate for Payer: Cash Price |
$20.47
|
Rate for Payer: ChoiceCare Network Commercial |
$28.37
|
Rate for Payer: Cigna of WY Commercial |
$28.66
|
Rate for Payer: Entrust Commercial |
$27.79
|
Rate for Payer: First Choice Health Commercial |
$27.79
|
Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$27.79
|
Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$16.96
|
Rate for Payer: HealthUtah PPO |
$29.25
|
Rate for Payer: Idaho Integrated Healthcare Commercial |
$28.37
|
Rate for Payer: Multiplan Medicare/VA |
$16.12
|
Rate for Payer: One Health Plan of WY PPO |
$28.66
|
Rate for Payer: PacificSource Commercial |
$26.32
|
Rate for Payer: PHCS PPO |
$28.66
|
Rate for Payer: Three Rivers PPO |
$21.94
|
Rate for Payer: TriWest Veterans Administration |
$16.96
|
Rate for Payer: United Healthcare Commercial |
$25.45
|
Rate for Payer: United Healthcare Medicare |
$16.96
|
Rate for Payer: WINHealth Partners Commercial |
$28.66
|
Rate for Payer: Wise Provider Network Commercial |
$27.79
|
|
MOXIFLOXACIN 400 MG TABLET [5836]
|
Facility
|
IP
|
$29.25
|
|
Service Code
|
NDC 1366820130
|
Hospital Revenue Code
|
250
|
Min. Negotiated Rate |
$18.34 |
Max. Negotiated Rate |
$29.25 |
Rate for Payer: Aetna of WY Commercial/Medical Rental |
$28.66
|
Rate for Payer: Altius Auto/Workers Compensation |
$28.08
|
Rate for Payer: Altius Commercial |
$28.08
|
Rate for Payer: Beech Street Commercial |
$28.66
|
Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$24.01
|
Rate for Payer: Cash Price |
$20.47
|
Rate for Payer: ChoiceCare Network Commercial |
$28.37
|
Rate for Payer: Cigna of WY Commercial |
$28.66
|
Rate for Payer: Entrust Commercial |
$27.79
|
Rate for Payer: First Choice Health Commercial |
$27.79
|
Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$27.79
|
Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$19.30
|
Rate for Payer: HealthUtah PPO |
$29.25
|
Rate for Payer: Idaho Integrated Healthcare Commercial |
$28.37
|
Rate for Payer: Multiplan Medicare/VA |
$18.34
|
Rate for Payer: One Health Plan of WY PPO |
$28.66
|
Rate for Payer: PacificSource Commercial |
$26.32
|
Rate for Payer: PHCS PPO |
$28.66
|
Rate for Payer: Three Rivers PPO |
$21.94
|
Rate for Payer: TriWest Veterans Administration |
$19.30
|
Rate for Payer: United Healthcare Commercial |
$25.45
|
Rate for Payer: United Healthcare Medicare |
$19.30
|
Rate for Payer: WINHealth Partners Commercial |
$27.79
|
Rate for Payer: Wise Provider Network Commercial |
$27.79
|
|
MOXIFLOXACIN 400 MG TABLET [5836]
|
Facility
|
OP
|
$34.50
|
|
Service Code
|
NDC 6808472211
|
Hospital Revenue Code
|
250
|
Min. Negotiated Rate |
$19.01 |
Max. Negotiated Rate |
$34.50 |
Rate for Payer: Aetna of WY Commercial/Medical Rental |
$33.81
|
Rate for Payer: Aetna of WY Medicare |
$22.77
|
Rate for Payer: Altius Auto/Workers Compensation |
$33.12
|
Rate for Payer: Altius Commercial |
$33.12
|
Rate for Payer: Beech Street Commercial |
$33.81
|
Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$28.32
|
Rate for Payer: Cash Price |
$24.15
|
Rate for Payer: ChoiceCare Network Commercial |
$33.46
|
Rate for Payer: Cigna of WY Commercial |
$33.81
|
Rate for Payer: Entrust Commercial |
$32.78
|
Rate for Payer: First Choice Health Commercial |
$32.78
|
Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$32.78
|
Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$20.01
|
Rate for Payer: HealthUtah PPO |
$34.50
|
Rate for Payer: Idaho Integrated Healthcare Commercial |
$33.46
|
Rate for Payer: Multiplan Medicare/VA |
$19.01
|
Rate for Payer: One Health Plan of WY PPO |
$33.81
|
Rate for Payer: PacificSource Commercial |
$31.05
|
Rate for Payer: PHCS PPO |
$33.81
|
Rate for Payer: Three Rivers PPO |
$25.88
|
Rate for Payer: TriWest Veterans Administration |
$20.01
|
Rate for Payer: United Healthcare Commercial |
$30.02
|
Rate for Payer: United Healthcare Medicare |
$20.01
|
Rate for Payer: WINHealth Partners Commercial |
$33.81
|
Rate for Payer: Wise Provider Network Commercial |
$32.78
|
|
MOXIFLOXACIN 400 MG TABLET [5836]
|
Facility
|
IP
|
$34.50
|
|
Service Code
|
NDC 6808472211
|
Hospital Revenue Code
|
250
|
Min. Negotiated Rate |
$21.63 |
Max. Negotiated Rate |
$34.50 |
Rate for Payer: Aetna of WY Commercial/Medical Rental |
$33.81
|
Rate for Payer: Altius Auto/Workers Compensation |
$33.12
|
Rate for Payer: Altius Commercial |
$33.12
|
Rate for Payer: Beech Street Commercial |
$33.81
|
Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$28.32
|
Rate for Payer: Cash Price |
$24.15
|
Rate for Payer: ChoiceCare Network Commercial |
$33.46
|
Rate for Payer: Cigna of WY Commercial |
$33.81
|
Rate for Payer: Entrust Commercial |
$32.78
|
Rate for Payer: First Choice Health Commercial |
$32.78
|
Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$32.78
|
Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$22.77
|
Rate for Payer: HealthUtah PPO |
$34.50
|
Rate for Payer: Idaho Integrated Healthcare Commercial |
$33.46
|
Rate for Payer: Multiplan Medicare/VA |
$21.63
|
Rate for Payer: One Health Plan of WY PPO |
$33.81
|
Rate for Payer: PacificSource Commercial |
$31.05
|
Rate for Payer: PHCS PPO |
$33.81
|
Rate for Payer: Three Rivers PPO |
$25.88
|
Rate for Payer: TriWest Veterans Administration |
$22.77
|
Rate for Payer: United Healthcare Commercial |
$30.02
|
Rate for Payer: United Healthcare Medicare |
$22.77
|
Rate for Payer: WINHealth Partners Commercial |
$32.78
|
Rate for Payer: Wise Provider Network Commercial |
$32.78
|
|
MPSV4 VACCINE GROUPS ACYW-135 SUBQ USE
|
Professional
|
Both
|
$186.00
|
|
Service Code
|
HCPCS 90733
|
Hospital Charge Code |
90733
|
Min. Negotiated Rate |
$139.50 |
Max. Negotiated Rate |
$186.00 |
Rate for Payer: Aetna of WY Commercial/Medical Rental |
$182.28
|
Rate for Payer: Beech Street Commercial |
$176.70
|
Rate for Payer: Cash Price |
$130.20
|
Rate for Payer: ChoiceCare Network Commercial |
$180.42
|
Rate for Payer: Cigna of WY Commercial |
$182.28
|
Rate for Payer: First Choice Health Commercial |
$167.40
|
Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$176.70
|
Rate for Payer: HealthUtah PPO |
$186.00
|
Rate for Payer: Idaho Integrated Healthcare Commercial |
$180.42
|
Rate for Payer: One Health Plan of WY PPO |
$182.28
|
Rate for Payer: PacificSource Commercial |
$167.40
|
Rate for Payer: PHCS PPO |
$176.70
|
Rate for Payer: Three Rivers PPO |
$139.50
|
Rate for Payer: United Healthcare Commercial |
$161.82
|
Rate for Payer: WINHealth Partners Commercial |
$186.00
|
|
MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET [86783]
|
Facility
|
OP
|
$0.17
|
|
Service Code
|
NDC 4098522368
|
Hospital Revenue Code
|
250
|
Min. Negotiated Rate |
$0.09 |
Max. Negotiated Rate |
$0.17 |
Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.17
|
Rate for Payer: Aetna of WY Medicare |
$0.11
|
Rate for Payer: Altius Auto/Workers Compensation |
$0.16
|
Rate for Payer: Altius Commercial |
$0.16
|
Rate for Payer: Beech Street Commercial |
$0.17
|
Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.14
|
Rate for Payer: Cash Price |
$0.12
|
Rate for Payer: ChoiceCare Network Commercial |
$0.16
|
Rate for Payer: Cigna of WY Commercial |
$0.17
|
Rate for Payer: Entrust Commercial |
$0.16
|
Rate for Payer: First Choice Health Commercial |
$0.16
|
Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.16
|
Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.10
|
Rate for Payer: HealthUtah PPO |
$0.17
|
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 |
$0.17
|
Rate for Payer: PacificSource Commercial |
$0.15
|
Rate for Payer: PHCS PPO |
$0.17
|
Rate for Payer: Three Rivers PPO |
$0.13
|
Rate for Payer: TriWest Veterans Administration |
$0.10
|
Rate for Payer: United Healthcare Commercial |
$0.15
|
Rate for Payer: United Healthcare Medicare |
$0.10
|
Rate for Payer: WINHealth Partners Commercial |
$0.17
|
Rate for Payer: Wise Provider Network Commercial |
$0.16
|
|