|
OFFICE/OUTPATIENT ESTABLISHED LOW MDM 20 MIN
|
Professional
|
Both
|
$163.00
|
|
|
Service Code
|
HCPCS 99213
|
| Hospital Charge Code |
99213
|
| Min. Negotiated Rate |
$53.82 |
| Max. Negotiated Rate |
$159.74 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$159.74
|
| Rate for Payer: Aetna of WY Medicare |
$63.32
|
| Rate for Payer: Beech Street Commercial |
$154.85
|
| Rate for Payer: Cash Price |
$114.10
|
| Rate for Payer: Cash Price |
$114.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$158.11
|
| Rate for Payer: Cigna of WY Commercial |
$159.74
|
| Rate for Payer: First Choice Health Commercial |
$146.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$154.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$63.32
|
| Rate for Payer: HealthUtah PPO |
$63.48
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$158.11
|
| Rate for Payer: Multiplan Medicare/VA |
$53.82
|
| Rate for Payer: One Health Plan of WY PPO |
$159.74
|
| Rate for Payer: PacificSource Commercial |
$146.70
|
| Rate for Payer: PHCS PPO |
$154.85
|
| Rate for Payer: Three Rivers PPO |
$122.25
|
| Rate for Payer: TriWest Veterans Administration |
$63.32
|
| Rate for Payer: United Healthcare Commercial |
$141.81
|
| Rate for Payer: United Healthcare Medicare |
$63.32
|
| Rate for Payer: WINHealth Partners Commercial |
$154.85
|
|
|
OFFICE/OUTPATIENT ESTABLISHED MOD MDM 30 MIN
|
Professional
|
Both
|
$240.00
|
|
|
Service Code
|
HCPCS 99214
|
| Hospital Charge Code |
99214
|
| Min. Negotiated Rate |
$99.74 |
| Max. Negotiated Rate |
$235.20 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$235.20
|
| Rate for Payer: Beech Street Commercial |
$228.00
|
| Rate for Payer: Cash Price |
$168.00
|
| Rate for Payer: Cash Price |
$168.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$232.80
|
| Rate for Payer: Cigna of WY Commercial |
$235.20
|
| Rate for Payer: First Choice Health Commercial |
$216.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$228.00
|
| Rate for Payer: HealthUtah PPO |
$99.74
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$232.80
|
| Rate for Payer: One Health Plan of WY PPO |
$235.20
|
| Rate for Payer: PacificSource Commercial |
$216.00
|
| Rate for Payer: PHCS PPO |
$228.00
|
| Rate for Payer: Three Rivers PPO |
$180.00
|
| Rate for Payer: United Healthcare Commercial |
$208.80
|
| Rate for Payer: WINHealth Partners Commercial |
$228.00
|
|
|
OFFICE/OUTPATIENT ESTABLISHED SF MDM 10 MIN
|
Professional
|
Both
|
$132.00
|
|
|
Service Code
|
HCPCS 99212
|
| Hospital Charge Code |
99212
|
| Min. Negotiated Rate |
$28.79 |
| Max. Negotiated Rate |
$129.36 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$129.36
|
| Rate for Payer: Aetna of WY Medicare |
$33.87
|
| Rate for Payer: Beech Street Commercial |
$125.40
|
| Rate for Payer: Cash Price |
$92.40
|
| Rate for Payer: Cash Price |
$92.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$128.04
|
| Rate for Payer: Cigna of WY Commercial |
$129.36
|
| Rate for Payer: First Choice Health Commercial |
$118.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$125.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$33.87
|
| Rate for Payer: HealthUtah PPO |
$45.64
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$128.04
|
| Rate for Payer: Multiplan Medicare/VA |
$28.79
|
| Rate for Payer: One Health Plan of WY PPO |
$129.36
|
| Rate for Payer: PacificSource Commercial |
$118.80
|
| Rate for Payer: PHCS PPO |
$125.40
|
| Rate for Payer: Three Rivers PPO |
$99.00
|
| Rate for Payer: TriWest Veterans Administration |
$33.87
|
| Rate for Payer: United Healthcare Commercial |
$114.84
|
| Rate for Payer: United Healthcare Medicare |
$33.87
|
| Rate for Payer: WINHealth Partners Commercial |
$125.40
|
|
|
OFFICE/OUTPATIENT EST PT MAY NOT REQ PHYS/QHP
|
Professional
|
Both
|
$82.00
|
|
|
Service Code
|
HCPCS 99211
|
| Hospital Charge Code |
99211
|
| Min. Negotiated Rate |
$7.17 |
| Max. Negotiated Rate |
$80.36 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$80.36
|
| Rate for Payer: Aetna of WY Medicare |
$8.43
|
| Rate for Payer: Beech Street Commercial |
$77.90
|
| Rate for Payer: Cash Price |
$57.40
|
| Rate for Payer: Cash Price |
$57.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$79.54
|
| Rate for Payer: Cigna of WY Commercial |
$80.36
|
| Rate for Payer: First Choice Health Commercial |
$73.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$77.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.43
|
| Rate for Payer: HealthUtah PPO |
$25.44
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$79.54
|
| Rate for Payer: Multiplan Medicare/VA |
$7.17
|
| Rate for Payer: One Health Plan of WY PPO |
$80.36
|
| Rate for Payer: PacificSource Commercial |
$73.80
|
| Rate for Payer: PHCS PPO |
$77.90
|
| Rate for Payer: Three Rivers PPO |
$61.50
|
| Rate for Payer: TriWest Veterans Administration |
$8.43
|
| Rate for Payer: United Healthcare Commercial |
$71.34
|
| Rate for Payer: United Healthcare Medicare |
$8.43
|
| Rate for Payer: WINHealth Partners Commercial |
$77.90
|
|
|
OFFICE OUTPATIENT NEW 10 MINUTES
|
Professional
|
Both
|
$118.00
|
|
|
Service Code
|
HCPCS 99201
|
| Hospital Charge Code |
99201
|
| Min. Negotiated Rate |
$42.93 |
| Max. Negotiated Rate |
$115.64 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$115.64
|
| Rate for Payer: Beech Street Commercial |
$112.10
|
| Rate for Payer: Cash Price |
$82.60
|
| Rate for Payer: Cash Price |
$82.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$114.46
|
| Rate for Payer: Cigna of WY Commercial |
$115.64
|
| Rate for Payer: First Choice Health Commercial |
$106.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$112.10
|
| Rate for Payer: HealthUtah PPO |
$42.93
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$114.46
|
| Rate for Payer: One Health Plan of WY PPO |
$115.64
|
| Rate for Payer: PacificSource Commercial |
$106.20
|
| Rate for Payer: PHCS PPO |
$112.10
|
| Rate for Payer: Three Rivers PPO |
$88.50
|
| Rate for Payer: United Healthcare Commercial |
$102.66
|
| Rate for Payer: WINHealth Partners Commercial |
$112.10
|
|
|
OFFICE/OUTPATIENT NEW HIGH MDM 60 MINUTES
|
Professional
|
Both
|
$546.00
|
|
|
Service Code
|
HCPCS 99205
|
| Hospital Charge Code |
99205
|
| Min. Negotiated Rate |
$147.90 |
| Max. Negotiated Rate |
$535.08 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$535.08
|
| Rate for Payer: Aetna of WY Medicare |
$174.00
|
| Rate for Payer: Beech Street Commercial |
$518.70
|
| Rate for Payer: Cash Price |
$382.20
|
| Rate for Payer: Cash Price |
$382.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$529.62
|
| Rate for Payer: Cigna of WY Commercial |
$535.08
|
| Rate for Payer: First Choice Health Commercial |
$491.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$518.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$174.00
|
| Rate for Payer: HealthUtah PPO |
$210.10
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$529.62
|
| Rate for Payer: Multiplan Medicare/VA |
$147.90
|
| Rate for Payer: One Health Plan of WY PPO |
$535.08
|
| Rate for Payer: PacificSource Commercial |
$491.40
|
| Rate for Payer: PHCS PPO |
$518.70
|
| Rate for Payer: Three Rivers PPO |
$409.50
|
| Rate for Payer: TriWest Veterans Administration |
$174.00
|
| Rate for Payer: United Healthcare Commercial |
$475.02
|
| Rate for Payer: United Healthcare Medicare |
$174.00
|
| Rate for Payer: WINHealth Partners Commercial |
$518.70
|
|
|
OFFICE/OUTPATIENT NEW LOW MDM 30 MINUTES
|
Professional
|
Both
|
$296.00
|
|
|
Service Code
|
HCPCS 99203
|
| Hospital Charge Code |
99203
|
| Min. Negotiated Rate |
$66.75 |
| Max. Negotiated Rate |
$290.08 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$290.08
|
| Rate for Payer: Aetna of WY Medicare |
$78.53
|
| Rate for Payer: Beech Street Commercial |
$281.20
|
| Rate for Payer: Cash Price |
$207.20
|
| Rate for Payer: Cash Price |
$207.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$287.12
|
| Rate for Payer: Cigna of WY Commercial |
$290.08
|
| Rate for Payer: First Choice Health Commercial |
$266.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$281.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$78.53
|
| Rate for Payer: HealthUtah PPO |
$115.84
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$287.12
|
| Rate for Payer: Multiplan Medicare/VA |
$66.75
|
| Rate for Payer: One Health Plan of WY PPO |
$290.08
|
| Rate for Payer: PacificSource Commercial |
$266.40
|
| Rate for Payer: PHCS PPO |
$281.20
|
| Rate for Payer: Three Rivers PPO |
$222.00
|
| Rate for Payer: TriWest Veterans Administration |
$78.53
|
| Rate for Payer: United Healthcare Commercial |
$257.52
|
| Rate for Payer: United Healthcare Medicare |
$78.53
|
| Rate for Payer: WINHealth Partners Commercial |
$281.20
|
|
|
OFFICE/OUTPATIENT NEW MODERATE MDM 45 MINUTES
|
Professional
|
Both
|
$404.00
|
|
|
Service Code
|
HCPCS 99204
|
| Hospital Charge Code |
99204
|
| Min. Negotiated Rate |
$108.75 |
| Max. Negotiated Rate |
$395.92 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$395.92
|
| Rate for Payer: Aetna of WY Medicare |
$127.94
|
| Rate for Payer: Beech Street Commercial |
$383.80
|
| Rate for Payer: Cash Price |
$282.80
|
| Rate for Payer: Cash Price |
$282.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$391.88
|
| Rate for Payer: Cigna of WY Commercial |
$395.92
|
| Rate for Payer: First Choice Health Commercial |
$363.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$383.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$127.94
|
| Rate for Payer: HealthUtah PPO |
$164.99
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$391.88
|
| Rate for Payer: Multiplan Medicare/VA |
$108.75
|
| Rate for Payer: One Health Plan of WY PPO |
$395.92
|
| Rate for Payer: PacificSource Commercial |
$363.60
|
| Rate for Payer: PHCS PPO |
$383.80
|
| Rate for Payer: Three Rivers PPO |
$303.00
|
| Rate for Payer: TriWest Veterans Administration |
$127.94
|
| Rate for Payer: United Healthcare Commercial |
$351.48
|
| Rate for Payer: United Healthcare Medicare |
$127.94
|
| Rate for Payer: WINHealth Partners Commercial |
$383.80
|
|
|
OFFICE/OUTPATIENT NEW SF MDM 15 MINUTES
|
Professional
|
Both
|
$199.00
|
|
|
Service Code
|
HCPCS 99202
|
| Hospital Charge Code |
99202
|
| Min. Negotiated Rate |
$38.67 |
| Max. Negotiated Rate |
$195.02 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$195.02
|
| Rate for Payer: Aetna of WY Medicare |
$45.49
|
| Rate for Payer: Beech Street Commercial |
$189.05
|
| Rate for Payer: Cash Price |
$139.30
|
| Rate for Payer: Cash Price |
$139.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$193.03
|
| Rate for Payer: Cigna of WY Commercial |
$195.02
|
| Rate for Payer: First Choice Health Commercial |
$179.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$189.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$45.49
|
| Rate for Payer: HealthUtah PPO |
$77.55
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$193.03
|
| Rate for Payer: Multiplan Medicare/VA |
$38.67
|
| Rate for Payer: One Health Plan of WY PPO |
$195.02
|
| Rate for Payer: PacificSource Commercial |
$179.10
|
| Rate for Payer: PHCS PPO |
$189.05
|
| Rate for Payer: Three Rivers PPO |
$149.25
|
| Rate for Payer: TriWest Veterans Administration |
$45.49
|
| Rate for Payer: United Healthcare Commercial |
$173.13
|
| Rate for Payer: United Healthcare Medicare |
$45.49
|
| Rate for Payer: WINHealth Partners Commercial |
$189.05
|
|
|
OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION [34710]
|
Facility
|
OP
|
$93.98
|
|
|
Service Code
|
HCPCS J2359
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$51.78 |
| Max. Negotiated Rate |
$93.98 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$92.10
|
| Rate for Payer: Aetna of WY Medicare |
$62.03
|
| Rate for Payer: Altius Auto/Workers Compensation |
$90.22
|
| Rate for Payer: Altius Commercial |
$90.22
|
| Rate for Payer: Beech Street Commercial |
$92.10
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$77.16
|
| Rate for Payer: Cash Price |
$65.79
|
| Rate for Payer: ChoiceCare Network Commercial |
$91.16
|
| Rate for Payer: Cigna of WY Commercial |
$92.10
|
| Rate for Payer: Entrust Commercial |
$89.28
|
| Rate for Payer: First Choice Health Commercial |
$89.28
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$89.28
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$54.51
|
| Rate for Payer: HealthUtah PPO |
$93.98
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$91.16
|
| Rate for Payer: Multiplan Medicare/VA |
$51.78
|
| Rate for Payer: One Health Plan of WY PPO |
$92.10
|
| Rate for Payer: PacificSource Commercial |
$84.58
|
| Rate for Payer: PHCS PPO |
$92.10
|
| Rate for Payer: Three Rivers PPO |
$70.48
|
| Rate for Payer: TriWest Veterans Administration |
$54.51
|
| Rate for Payer: United Healthcare Commercial |
$81.76
|
| Rate for Payer: United Healthcare Medicare |
$54.51
|
| Rate for Payer: WINHealth Partners Commercial |
$92.10
|
| Rate for Payer: Wise Provider Network Commercial |
$89.28
|
|
|
OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION [34710]
|
Facility
|
IP
|
$93.98
|
|
|
Service Code
|
HCPCS J2359
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$58.93 |
| Max. Negotiated Rate |
$93.98 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$92.10
|
| Rate for Payer: Altius Auto/Workers Compensation |
$90.22
|
| Rate for Payer: Altius Commercial |
$90.22
|
| Rate for Payer: Beech Street Commercial |
$92.10
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$77.16
|
| Rate for Payer: Cash Price |
$65.79
|
| Rate for Payer: ChoiceCare Network Commercial |
$91.16
|
| Rate for Payer: Cigna of WY Commercial |
$92.10
|
| Rate for Payer: Entrust Commercial |
$89.28
|
| Rate for Payer: First Choice Health Commercial |
$89.28
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$89.28
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$62.03
|
| Rate for Payer: HealthUtah PPO |
$93.98
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$91.16
|
| Rate for Payer: Multiplan Medicare/VA |
$58.93
|
| Rate for Payer: One Health Plan of WY PPO |
$92.10
|
| Rate for Payer: PacificSource Commercial |
$84.58
|
| Rate for Payer: PHCS PPO |
$92.10
|
| Rate for Payer: Three Rivers PPO |
$70.48
|
| Rate for Payer: TriWest Veterans Administration |
$62.03
|
| Rate for Payer: United Healthcare Commercial |
$81.76
|
| Rate for Payer: United Healthcare Medicare |
$62.03
|
| Rate for Payer: WINHealth Partners Commercial |
$89.28
|
| Rate for Payer: Wise Provider Network Commercial |
$89.28
|
|
|
OLANZAPINE 2.5 MG TABLET [7609]
|
Facility
|
IP
|
$1.76
|
|
|
Service Code
|
NDC 6808452501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.10 |
| Max. Negotiated Rate |
$1.76 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.72
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.69
|
| Rate for Payer: Altius Commercial |
$1.69
|
| Rate for Payer: Beech Street Commercial |
$1.72
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.44
|
| Rate for Payer: Cash Price |
$1.23
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.71
|
| Rate for Payer: Cigna of WY Commercial |
$1.72
|
| Rate for Payer: Entrust Commercial |
$1.67
|
| Rate for Payer: First Choice Health Commercial |
$1.67
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.67
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.16
|
| Rate for Payer: HealthUtah PPO |
$1.76
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.71
|
| Rate for Payer: Multiplan Medicare/VA |
$1.10
|
| Rate for Payer: One Health Plan of WY PPO |
$1.72
|
| Rate for Payer: PacificSource Commercial |
$1.58
|
| Rate for Payer: PHCS PPO |
$1.72
|
| Rate for Payer: Three Rivers PPO |
$1.32
|
| Rate for Payer: TriWest Veterans Administration |
$1.16
|
| Rate for Payer: United Healthcare Commercial |
$1.53
|
| Rate for Payer: United Healthcare Medicare |
$1.16
|
| Rate for Payer: WINHealth Partners Commercial |
$1.67
|
| Rate for Payer: Wise Provider Network Commercial |
$1.67
|
|
|
OLANZAPINE 2.5 MG TABLET [7609]
|
Facility
|
OP
|
$1.76
|
|
|
Service Code
|
NDC 6808452501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.97 |
| Max. Negotiated Rate |
$1.76 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.72
|
| Rate for Payer: Aetna of WY Medicare |
$1.16
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.69
|
| Rate for Payer: Altius Commercial |
$1.69
|
| Rate for Payer: Beech Street Commercial |
$1.72
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.44
|
| Rate for Payer: Cash Price |
$1.23
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.71
|
| Rate for Payer: Cigna of WY Commercial |
$1.72
|
| Rate for Payer: Entrust Commercial |
$1.67
|
| Rate for Payer: First Choice Health Commercial |
$1.67
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.67
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.02
|
| Rate for Payer: HealthUtah PPO |
$1.76
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.71
|
| Rate for Payer: Multiplan Medicare/VA |
$0.97
|
| Rate for Payer: One Health Plan of WY PPO |
$1.72
|
| Rate for Payer: PacificSource Commercial |
$1.58
|
| Rate for Payer: PHCS PPO |
$1.72
|
| Rate for Payer: Three Rivers PPO |
$1.32
|
| Rate for Payer: TriWest Veterans Administration |
$1.02
|
| Rate for Payer: United Healthcare Commercial |
$1.53
|
| Rate for Payer: United Healthcare Medicare |
$1.02
|
| Rate for Payer: WINHealth Partners Commercial |
$1.72
|
| Rate for Payer: Wise Provider Network Commercial |
$1.67
|
|
|
OLANZAPINE 2.5 MG TABLET [7609]
|
Facility
|
IP
|
$1.76
|
|
|
Service Code
|
NDC 6808452511
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.10 |
| Max. Negotiated Rate |
$1.76 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.72
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.69
|
| Rate for Payer: Altius Commercial |
$1.69
|
| Rate for Payer: Beech Street Commercial |
$1.72
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.44
|
| Rate for Payer: Cash Price |
$1.23
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.71
|
| Rate for Payer: Cigna of WY Commercial |
$1.72
|
| Rate for Payer: Entrust Commercial |
$1.67
|
| Rate for Payer: First Choice Health Commercial |
$1.67
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.67
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.16
|
| Rate for Payer: HealthUtah PPO |
$1.76
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.71
|
| Rate for Payer: Multiplan Medicare/VA |
$1.10
|
| Rate for Payer: One Health Plan of WY PPO |
$1.72
|
| Rate for Payer: PacificSource Commercial |
$1.58
|
| Rate for Payer: PHCS PPO |
$1.72
|
| Rate for Payer: Three Rivers PPO |
$1.32
|
| Rate for Payer: TriWest Veterans Administration |
$1.16
|
| Rate for Payer: United Healthcare Commercial |
$1.53
|
| Rate for Payer: United Healthcare Medicare |
$1.16
|
| Rate for Payer: WINHealth Partners Commercial |
$1.67
|
| Rate for Payer: Wise Provider Network Commercial |
$1.67
|
|
|
OLANZAPINE 2.5 MG TABLET [7609]
|
Facility
|
OP
|
$1.76
|
|
|
Service Code
|
NDC 6808452511
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.97 |
| Max. Negotiated Rate |
$1.76 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.72
|
| Rate for Payer: Aetna of WY Medicare |
$1.16
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.69
|
| Rate for Payer: Altius Commercial |
$1.69
|
| Rate for Payer: Beech Street Commercial |
$1.72
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.44
|
| Rate for Payer: Cash Price |
$1.23
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.71
|
| Rate for Payer: Cigna of WY Commercial |
$1.72
|
| Rate for Payer: Entrust Commercial |
$1.67
|
| Rate for Payer: First Choice Health Commercial |
$1.67
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.67
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.02
|
| Rate for Payer: HealthUtah PPO |
$1.76
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.71
|
| Rate for Payer: Multiplan Medicare/VA |
$0.97
|
| Rate for Payer: One Health Plan of WY PPO |
$1.72
|
| Rate for Payer: PacificSource Commercial |
$1.58
|
| Rate for Payer: PHCS PPO |
$1.72
|
| Rate for Payer: Three Rivers PPO |
$1.32
|
| Rate for Payer: TriWest Veterans Administration |
$1.02
|
| Rate for Payer: United Healthcare Commercial |
$1.53
|
| Rate for Payer: United Healthcare Medicare |
$1.02
|
| Rate for Payer: WINHealth Partners Commercial |
$1.72
|
| Rate for Payer: Wise Provider Network Commercial |
$1.67
|
|
|
OLANZAPINE 5 MG TABLET [5412]
|
Facility
|
OP
|
$1.99
|
|
|
Service Code
|
NDC 6808472311
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.10 |
| Max. Negotiated Rate |
$1.99 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.95
|
| Rate for Payer: Aetna of WY Medicare |
$1.31
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.91
|
| Rate for Payer: Altius Commercial |
$1.91
|
| Rate for Payer: Beech Street Commercial |
$1.95
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.63
|
| Rate for Payer: Cash Price |
$1.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.93
|
| Rate for Payer: Cigna of WY Commercial |
$1.95
|
| Rate for Payer: Entrust Commercial |
$1.89
|
| Rate for Payer: First Choice Health Commercial |
$1.89
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.89
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.15
|
| Rate for Payer: HealthUtah PPO |
$1.99
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.93
|
| Rate for Payer: Multiplan Medicare/VA |
$1.10
|
| Rate for Payer: One Health Plan of WY PPO |
$1.95
|
| Rate for Payer: PacificSource Commercial |
$1.79
|
| Rate for Payer: PHCS PPO |
$1.95
|
| Rate for Payer: Three Rivers PPO |
$1.49
|
| Rate for Payer: TriWest Veterans Administration |
$1.15
|
| Rate for Payer: United Healthcare Commercial |
$1.73
|
| Rate for Payer: United Healthcare Medicare |
$1.15
|
| Rate for Payer: WINHealth Partners Commercial |
$1.95
|
| Rate for Payer: Wise Provider Network Commercial |
$1.89
|
|
|
OLANZAPINE 5 MG TABLET [5412]
|
Facility
|
OP
|
$1.99
|
|
|
Service Code
|
NDC 6808472301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.10 |
| Max. Negotiated Rate |
$1.99 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.95
|
| Rate for Payer: Aetna of WY Medicare |
$1.31
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.91
|
| Rate for Payer: Altius Commercial |
$1.91
|
| Rate for Payer: Beech Street Commercial |
$1.95
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.63
|
| Rate for Payer: Cash Price |
$1.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.93
|
| Rate for Payer: Cigna of WY Commercial |
$1.95
|
| Rate for Payer: Entrust Commercial |
$1.89
|
| Rate for Payer: First Choice Health Commercial |
$1.89
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.89
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.15
|
| Rate for Payer: HealthUtah PPO |
$1.99
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.93
|
| Rate for Payer: Multiplan Medicare/VA |
$1.10
|
| Rate for Payer: One Health Plan of WY PPO |
$1.95
|
| Rate for Payer: PacificSource Commercial |
$1.79
|
| Rate for Payer: PHCS PPO |
$1.95
|
| Rate for Payer: Three Rivers PPO |
$1.49
|
| Rate for Payer: TriWest Veterans Administration |
$1.15
|
| Rate for Payer: United Healthcare Commercial |
$1.73
|
| Rate for Payer: United Healthcare Medicare |
$1.15
|
| Rate for Payer: WINHealth Partners Commercial |
$1.95
|
| Rate for Payer: Wise Provider Network Commercial |
$1.89
|
|
|
OLANZAPINE 5 MG TABLET [5412]
|
Facility
|
IP
|
$1.99
|
|
|
Service Code
|
NDC 6808472301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.25 |
| Max. Negotiated Rate |
$1.99 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.95
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.91
|
| Rate for Payer: Altius Commercial |
$1.91
|
| Rate for Payer: Beech Street Commercial |
$1.95
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.63
|
| Rate for Payer: Cash Price |
$1.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.93
|
| Rate for Payer: Cigna of WY Commercial |
$1.95
|
| Rate for Payer: Entrust Commercial |
$1.89
|
| Rate for Payer: First Choice Health Commercial |
$1.89
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.89
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.31
|
| Rate for Payer: HealthUtah PPO |
$1.99
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.93
|
| Rate for Payer: Multiplan Medicare/VA |
$1.25
|
| Rate for Payer: One Health Plan of WY PPO |
$1.95
|
| Rate for Payer: PacificSource Commercial |
$1.79
|
| Rate for Payer: PHCS PPO |
$1.95
|
| Rate for Payer: Three Rivers PPO |
$1.49
|
| Rate for Payer: TriWest Veterans Administration |
$1.31
|
| Rate for Payer: United Healthcare Commercial |
$1.73
|
| Rate for Payer: United Healthcare Medicare |
$1.31
|
| Rate for Payer: WINHealth Partners Commercial |
$1.89
|
| Rate for Payer: Wise Provider Network Commercial |
$1.89
|
|
|
OLANZAPINE 5 MG TABLET [5412]
|
Facility
|
OP
|
$1.43
|
|
|
Service Code
|
NDC 6050531118
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$1.43 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.40
|
| Rate for Payer: Aetna of WY Medicare |
$0.94
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.37
|
| Rate for Payer: Altius Commercial |
$1.37
|
| Rate for Payer: Beech Street Commercial |
$1.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.17
|
| Rate for Payer: Cash Price |
$1.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.39
|
| Rate for Payer: Cigna of WY Commercial |
$1.40
|
| Rate for Payer: Entrust Commercial |
$1.36
|
| Rate for Payer: First Choice Health Commercial |
$1.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.83
|
| Rate for Payer: HealthUtah PPO |
$1.43
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.39
|
| Rate for Payer: Multiplan Medicare/VA |
$0.79
|
| Rate for Payer: One Health Plan of WY PPO |
$1.40
|
| Rate for Payer: PacificSource Commercial |
$1.29
|
| Rate for Payer: PHCS PPO |
$1.40
|
| Rate for Payer: Three Rivers PPO |
$1.07
|
| Rate for Payer: TriWest Veterans Administration |
$0.83
|
| Rate for Payer: United Healthcare Commercial |
$1.24
|
| Rate for Payer: United Healthcare Medicare |
$0.83
|
| Rate for Payer: WINHealth Partners Commercial |
$1.40
|
| Rate for Payer: Wise Provider Network Commercial |
$1.36
|
|
|
OLANZAPINE 5 MG TABLET [5412]
|
Facility
|
IP
|
$1.43
|
|
|
Service Code
|
NDC 6050531118
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.90 |
| Max. Negotiated Rate |
$1.43 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.40
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.37
|
| Rate for Payer: Altius Commercial |
$1.37
|
| Rate for Payer: Beech Street Commercial |
$1.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.17
|
| Rate for Payer: Cash Price |
$1.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.39
|
| Rate for Payer: Cigna of WY Commercial |
$1.40
|
| Rate for Payer: Entrust Commercial |
$1.36
|
| Rate for Payer: First Choice Health Commercial |
$1.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.94
|
| Rate for Payer: HealthUtah PPO |
$1.43
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.39
|
| Rate for Payer: Multiplan Medicare/VA |
$0.90
|
| Rate for Payer: One Health Plan of WY PPO |
$1.40
|
| Rate for Payer: PacificSource Commercial |
$1.29
|
| Rate for Payer: PHCS PPO |
$1.40
|
| Rate for Payer: Three Rivers PPO |
$1.07
|
| Rate for Payer: TriWest Veterans Administration |
$0.94
|
| Rate for Payer: United Healthcare Commercial |
$1.24
|
| Rate for Payer: United Healthcare Medicare |
$0.94
|
| Rate for Payer: WINHealth Partners Commercial |
$1.36
|
| Rate for Payer: Wise Provider Network Commercial |
$1.36
|
|
|
OLANZAPINE 5 MG TABLET [5412]
|
Facility
|
IP
|
$1.99
|
|
|
Service Code
|
NDC 6808472311
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.25 |
| Max. Negotiated Rate |
$1.99 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.95
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.91
|
| Rate for Payer: Altius Commercial |
$1.91
|
| Rate for Payer: Beech Street Commercial |
$1.95
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.63
|
| Rate for Payer: Cash Price |
$1.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.93
|
| Rate for Payer: Cigna of WY Commercial |
$1.95
|
| Rate for Payer: Entrust Commercial |
$1.89
|
| Rate for Payer: First Choice Health Commercial |
$1.89
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.89
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.31
|
| Rate for Payer: HealthUtah PPO |
$1.99
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.93
|
| Rate for Payer: Multiplan Medicare/VA |
$1.25
|
| Rate for Payer: One Health Plan of WY PPO |
$1.95
|
| Rate for Payer: PacificSource Commercial |
$1.79
|
| Rate for Payer: PHCS PPO |
$1.95
|
| Rate for Payer: Three Rivers PPO |
$1.49
|
| Rate for Payer: TriWest Veterans Administration |
$1.31
|
| Rate for Payer: United Healthcare Commercial |
$1.73
|
| Rate for Payer: United Healthcare Medicare |
$1.31
|
| Rate for Payer: WINHealth Partners Commercial |
$1.89
|
| Rate for Payer: Wise Provider Network Commercial |
$1.89
|
|
|
OLANZAPINE 5 MG TABLET [5412]
|
Facility
|
IP
|
$0.92
|
|
|
Service Code
|
NDC 6050531110
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$0.92 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.90
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.88
|
| Rate for Payer: Altius Commercial |
$0.88
|
| Rate for Payer: Beech Street Commercial |
$0.90
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.76
|
| Rate for Payer: Cash Price |
$0.65
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.89
|
| Rate for Payer: Cigna of WY Commercial |
$0.90
|
| Rate for Payer: Entrust Commercial |
$0.87
|
| Rate for Payer: First Choice Health Commercial |
$0.87
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.87
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.61
|
| Rate for Payer: HealthUtah PPO |
$0.92
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.89
|
| Rate for Payer: Multiplan Medicare/VA |
$0.58
|
| Rate for Payer: One Health Plan of WY PPO |
$0.90
|
| Rate for Payer: PacificSource Commercial |
$0.83
|
| Rate for Payer: PHCS PPO |
$0.90
|
| Rate for Payer: Three Rivers PPO |
$0.69
|
| Rate for Payer: TriWest Veterans Administration |
$0.61
|
| Rate for Payer: United Healthcare Commercial |
$0.80
|
| Rate for Payer: United Healthcare Medicare |
$0.61
|
| Rate for Payer: WINHealth Partners Commercial |
$0.87
|
| Rate for Payer: Wise Provider Network Commercial |
$0.87
|
|
|
OLANZAPINE 5 MG TABLET [5412]
|
Facility
|
OP
|
$0.92
|
|
|
Service Code
|
NDC 6050531110
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$0.92 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.90
|
| Rate for Payer: Aetna of WY Medicare |
$0.61
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.88
|
| Rate for Payer: Altius Commercial |
$0.88
|
| Rate for Payer: Beech Street Commercial |
$0.90
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.76
|
| Rate for Payer: Cash Price |
$0.65
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.89
|
| Rate for Payer: Cigna of WY Commercial |
$0.90
|
| Rate for Payer: Entrust Commercial |
$0.87
|
| Rate for Payer: First Choice Health Commercial |
$0.87
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.87
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.53
|
| Rate for Payer: HealthUtah PPO |
$0.92
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.89
|
| Rate for Payer: Multiplan Medicare/VA |
$0.51
|
| Rate for Payer: One Health Plan of WY PPO |
$0.90
|
| Rate for Payer: PacificSource Commercial |
$0.83
|
| Rate for Payer: PHCS PPO |
$0.90
|
| Rate for Payer: Three Rivers PPO |
$0.69
|
| Rate for Payer: TriWest Veterans Administration |
$0.53
|
| Rate for Payer: United Healthcare Commercial |
$0.80
|
| Rate for Payer: United Healthcare Medicare |
$0.53
|
| Rate for Payer: WINHealth Partners Commercial |
$0.90
|
| Rate for Payer: Wise Provider Network Commercial |
$0.87
|
|
|
OLYMPUS ENDOCUFF LG GREEN
|
Facility
|
OP
|
$86.62
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$47.73 |
| Max. Negotiated Rate |
$86.62 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$84.89
|
| Rate for Payer: Aetna of WY Medicare |
$57.17
|
| Rate for Payer: Altius Auto/Workers Compensation |
$83.16
|
| Rate for Payer: Altius Commercial |
$83.16
|
| Rate for Payer: Beech Street Commercial |
$84.89
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$71.12
|
| Rate for Payer: Cash Price |
$60.64
|
| Rate for Payer: ChoiceCare Network Commercial |
$84.02
|
| Rate for Payer: Cigna of WY Commercial |
$84.89
|
| Rate for Payer: Entrust Commercial |
$82.29
|
| Rate for Payer: First Choice Health Commercial |
$82.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$82.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$50.24
|
| Rate for Payer: HealthUtah PPO |
$86.62
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$84.02
|
| Rate for Payer: Multiplan Medicare/VA |
$47.73
|
| Rate for Payer: One Health Plan of WY PPO |
$84.89
|
| Rate for Payer: PacificSource Commercial |
$77.96
|
| Rate for Payer: PHCS PPO |
$84.89
|
| Rate for Payer: Three Rivers PPO |
$64.96
|
| Rate for Payer: TriWest Veterans Administration |
$50.24
|
| Rate for Payer: United Healthcare Commercial |
$75.36
|
| Rate for Payer: United Healthcare Medicare |
$50.24
|
| Rate for Payer: WINHealth Partners Commercial |
$84.89
|
| Rate for Payer: Wise Provider Network Commercial |
$82.29
|
|
|
OLYMPUS ENDOCUFF LG GREEN
|
Facility
|
IP
|
$86.62
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$54.31 |
| Max. Negotiated Rate |
$86.62 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$84.89
|
| Rate for Payer: Altius Auto/Workers Compensation |
$83.16
|
| Rate for Payer: Altius Commercial |
$83.16
|
| Rate for Payer: Beech Street Commercial |
$84.89
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$71.12
|
| Rate for Payer: Cash Price |
$60.64
|
| Rate for Payer: ChoiceCare Network Commercial |
$84.02
|
| Rate for Payer: Cigna of WY Commercial |
$84.89
|
| Rate for Payer: Entrust Commercial |
$82.29
|
| Rate for Payer: First Choice Health Commercial |
$82.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$82.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$57.17
|
| Rate for Payer: HealthUtah PPO |
$86.62
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$84.02
|
| Rate for Payer: Multiplan Medicare/VA |
$54.31
|
| Rate for Payer: One Health Plan of WY PPO |
$84.89
|
| Rate for Payer: PacificSource Commercial |
$77.96
|
| Rate for Payer: PHCS PPO |
$84.89
|
| Rate for Payer: Three Rivers PPO |
$64.96
|
| Rate for Payer: TriWest Veterans Administration |
$57.17
|
| Rate for Payer: United Healthcare Commercial |
$75.36
|
| Rate for Payer: United Healthcare Medicare |
$57.17
|
| Rate for Payer: WINHealth Partners Commercial |
$82.29
|
| Rate for Payer: Wise Provider Network Commercial |
$82.29
|
|
