|
PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION [43636]
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 6438076621
|
|
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
|
|
|
PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION [43636]
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 4338609019
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.02
|
| Rate for Payer: Aetna of WY Medicare |
$0.01
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.02
|
| Rate for Payer: Altius Commercial |
$0.02
|
| Rate for Payer: Beech Street Commercial |
$0.02
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.02
|
| Rate for Payer: Cigna of WY Commercial |
$0.02
|
| Rate for Payer: Entrust Commercial |
$0.02
|
| Rate for Payer: First Choice Health Commercial |
$0.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.01
|
| Rate for Payer: HealthUtah PPO |
$0.02
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.02
|
| Rate for Payer: Multiplan Medicare/VA |
$0.01
|
| Rate for Payer: One Health Plan of WY PPO |
$0.02
|
| Rate for Payer: PacificSource Commercial |
$0.02
|
| Rate for Payer: PHCS PPO |
$0.02
|
| Rate for Payer: Three Rivers PPO |
$0.02
|
| Rate for Payer: TriWest Veterans Administration |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.02
|
| Rate for Payer: United Healthcare Medicare |
$0.01
|
| Rate for Payer: WINHealth Partners Commercial |
$0.02
|
| Rate for Payer: Wise Provider Network Commercial |
$0.02
|
|
|
PEG 400-HYPROMELLOSE-GLYCERIN 1 %-0.2 %-0.2 % EYE DROPS [25871]
|
Facility
|
IP
|
$0.45
|
|
|
Service Code
|
NDC 5789618105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.44
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.43
|
| Rate for Payer: Altius Commercial |
$0.43
|
| Rate for Payer: Beech Street Commercial |
$0.44
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.37
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.44
|
| Rate for Payer: Cigna of WY Commercial |
$0.44
|
| Rate for Payer: Entrust Commercial |
$0.43
|
| Rate for Payer: First Choice Health Commercial |
$0.43
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.43
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.30
|
| Rate for Payer: HealthUtah PPO |
$0.45
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.44
|
| Rate for Payer: Multiplan Medicare/VA |
$0.28
|
| Rate for Payer: One Health Plan of WY PPO |
$0.44
|
| Rate for Payer: PacificSource Commercial |
$0.41
|
| Rate for Payer: PHCS PPO |
$0.44
|
| Rate for Payer: Three Rivers PPO |
$0.34
|
| Rate for Payer: TriWest Veterans Administration |
$0.30
|
| Rate for Payer: United Healthcare Commercial |
$0.39
|
| Rate for Payer: United Healthcare Medicare |
$0.30
|
| Rate for Payer: WINHealth Partners Commercial |
$0.43
|
| Rate for Payer: Wise Provider Network Commercial |
$0.43
|
|
|
PEG 400-HYPROMELLOSE-GLYCERIN 1 %-0.2 %-0.2 % EYE DROPS [25871]
|
Facility
|
OP
|
$0.45
|
|
|
Service Code
|
NDC 5789618105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.44
|
| Rate for Payer: Aetna of WY Medicare |
$0.30
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.43
|
| Rate for Payer: Altius Commercial |
$0.43
|
| Rate for Payer: Beech Street Commercial |
$0.44
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.37
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.44
|
| Rate for Payer: Cigna of WY Commercial |
$0.44
|
| Rate for Payer: Entrust Commercial |
$0.43
|
| Rate for Payer: First Choice Health Commercial |
$0.43
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.43
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.26
|
| Rate for Payer: HealthUtah PPO |
$0.45
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.44
|
| Rate for Payer: Multiplan Medicare/VA |
$0.25
|
| Rate for Payer: One Health Plan of WY PPO |
$0.44
|
| Rate for Payer: PacificSource Commercial |
$0.41
|
| Rate for Payer: PHCS PPO |
$0.44
|
| Rate for Payer: Three Rivers PPO |
$0.34
|
| Rate for Payer: TriWest Veterans Administration |
$0.26
|
| Rate for Payer: United Healthcare Commercial |
$0.39
|
| Rate for Payer: United Healthcare Medicare |
$0.26
|
| Rate for Payer: WINHealth Partners Commercial |
$0.44
|
| Rate for Payer: Wise Provider Network Commercial |
$0.43
|
|
|
PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE DROPS [28340]
|
Facility
|
OP
|
$1.64
|
|
|
Service Code
|
NDC 0536121994
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.90 |
| Max. Negotiated Rate |
$1.64 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.61
|
| Rate for Payer: Aetna of WY Medicare |
$1.08
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.57
|
| Rate for Payer: Altius Commercial |
$1.57
|
| Rate for Payer: Beech Street Commercial |
$1.61
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.35
|
| Rate for Payer: Cash Price |
$1.15
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.59
|
| Rate for Payer: Cigna of WY Commercial |
$1.61
|
| Rate for Payer: Entrust Commercial |
$1.56
|
| Rate for Payer: First Choice Health Commercial |
$1.56
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.56
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.95
|
| Rate for Payer: HealthUtah PPO |
$1.64
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.59
|
| Rate for Payer: Multiplan Medicare/VA |
$0.90
|
| Rate for Payer: One Health Plan of WY PPO |
$1.61
|
| Rate for Payer: PacificSource Commercial |
$1.48
|
| Rate for Payer: PHCS PPO |
$1.61
|
| Rate for Payer: Three Rivers PPO |
$1.23
|
| Rate for Payer: TriWest Veterans Administration |
$0.95
|
| Rate for Payer: United Healthcare Commercial |
$1.43
|
| Rate for Payer: United Healthcare Medicare |
$0.95
|
| Rate for Payer: WINHealth Partners Commercial |
$1.61
|
| Rate for Payer: Wise Provider Network Commercial |
$1.56
|
|
|
PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE DROPS [28340]
|
Facility
|
IP
|
$1.64
|
|
|
Service Code
|
NDC 0536121994
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.03 |
| Max. Negotiated Rate |
$1.64 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.61
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.57
|
| Rate for Payer: Altius Commercial |
$1.57
|
| Rate for Payer: Beech Street Commercial |
$1.61
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.35
|
| Rate for Payer: Cash Price |
$1.15
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.59
|
| Rate for Payer: Cigna of WY Commercial |
$1.61
|
| Rate for Payer: Entrust Commercial |
$1.56
|
| Rate for Payer: First Choice Health Commercial |
$1.56
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.56
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.08
|
| Rate for Payer: HealthUtah PPO |
$1.64
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.59
|
| Rate for Payer: Multiplan Medicare/VA |
$1.03
|
| Rate for Payer: One Health Plan of WY PPO |
$1.61
|
| Rate for Payer: PacificSource Commercial |
$1.48
|
| Rate for Payer: PHCS PPO |
$1.61
|
| Rate for Payer: Three Rivers PPO |
$1.23
|
| Rate for Payer: TriWest Veterans Administration |
$1.08
|
| Rate for Payer: United Healthcare Commercial |
$1.43
|
| Rate for Payer: United Healthcare Medicare |
$1.08
|
| Rate for Payer: WINHealth Partners Commercial |
$1.56
|
| Rate for Payer: Wise Provider Network Commercial |
$1.56
|
|
|
PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR [139076]
|
Facility
|
OP
|
$16,059.98
|
|
|
Service Code
|
HCPCS J2506
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8,849.05 |
| Max. Negotiated Rate |
$16,059.98 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15,738.78
|
| Rate for Payer: Aetna of WY Medicare |
$10,599.59
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15,417.58
|
| Rate for Payer: Altius Commercial |
$15,417.58
|
| Rate for Payer: Beech Street Commercial |
$15,738.78
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13,185.24
|
| Rate for Payer: Cash Price |
$11,241.98
|
| Rate for Payer: ChoiceCare Network Commercial |
$15,578.18
|
| Rate for Payer: Cigna of WY Commercial |
$15,738.78
|
| Rate for Payer: Entrust Commercial |
$15,256.98
|
| Rate for Payer: First Choice Health Commercial |
$15,256.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15,256.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9,314.79
|
| Rate for Payer: HealthUtah PPO |
$16,059.98
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15,578.18
|
| Rate for Payer: Multiplan Medicare/VA |
$8,849.05
|
| Rate for Payer: One Health Plan of WY PPO |
$15,738.78
|
| Rate for Payer: PacificSource Commercial |
$14,453.98
|
| Rate for Payer: PHCS PPO |
$15,738.78
|
| Rate for Payer: Three Rivers PPO |
$12,044.98
|
| Rate for Payer: TriWest Veterans Administration |
$9,314.79
|
| Rate for Payer: United Healthcare Commercial |
$13,972.18
|
| Rate for Payer: United Healthcare Medicare |
$9,314.79
|
| Rate for Payer: WINHealth Partners Commercial |
$15,738.78
|
| Rate for Payer: Wise Provider Network Commercial |
$15,256.98
|
|
|
PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR [139076]
|
Facility
|
IP
|
$16,059.98
|
|
|
Service Code
|
HCPCS J2506
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10,069.61 |
| Max. Negotiated Rate |
$16,059.98 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15,738.78
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15,417.58
|
| Rate for Payer: Altius Commercial |
$15,417.58
|
| Rate for Payer: Beech Street Commercial |
$15,738.78
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13,185.24
|
| Rate for Payer: Cash Price |
$11,241.98
|
| Rate for Payer: ChoiceCare Network Commercial |
$15,578.18
|
| Rate for Payer: Cigna of WY Commercial |
$15,738.78
|
| Rate for Payer: Entrust Commercial |
$15,256.98
|
| Rate for Payer: First Choice Health Commercial |
$15,256.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15,256.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10,599.59
|
| Rate for Payer: HealthUtah PPO |
$16,059.98
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15,578.18
|
| Rate for Payer: Multiplan Medicare/VA |
$10,069.61
|
| Rate for Payer: One Health Plan of WY PPO |
$15,738.78
|
| Rate for Payer: PacificSource Commercial |
$14,453.98
|
| Rate for Payer: PHCS PPO |
$15,738.78
|
| Rate for Payer: Three Rivers PPO |
$12,044.98
|
| Rate for Payer: TriWest Veterans Administration |
$10,599.59
|
| Rate for Payer: United Healthcare Commercial |
$13,972.18
|
| Rate for Payer: United Healthcare Medicare |
$10,599.59
|
| Rate for Payer: WINHealth Partners Commercial |
$15,256.98
|
| Rate for Payer: Wise Provider Network Commercial |
$15,256.98
|
|
|
PEGFILGRASTIM-CBQV 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUT INJECTOR [185354]
|
Facility
|
OP
|
$10,437.50
|
|
|
Service Code
|
HCPCS Q5111
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,751.06 |
| Max. Negotiated Rate |
$10,437.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$10,228.75
|
| Rate for Payer: Aetna of WY Medicare |
$6,888.75
|
| Rate for Payer: Altius Auto/Workers Compensation |
$10,020.00
|
| Rate for Payer: Altius Commercial |
$10,020.00
|
| Rate for Payer: Beech Street Commercial |
$10,228.75
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$8,569.19
|
| Rate for Payer: Cash Price |
$7,306.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$10,124.38
|
| Rate for Payer: Cigna of WY Commercial |
$10,228.75
|
| Rate for Payer: Entrust Commercial |
$9,915.62
|
| Rate for Payer: First Choice Health Commercial |
$9,915.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$9,915.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$6,053.75
|
| Rate for Payer: HealthUtah PPO |
$10,437.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$10,124.38
|
| Rate for Payer: Multiplan Medicare/VA |
$5,751.06
|
| Rate for Payer: One Health Plan of WY PPO |
$10,228.75
|
| Rate for Payer: PacificSource Commercial |
$9,393.75
|
| Rate for Payer: PHCS PPO |
$10,228.75
|
| Rate for Payer: Three Rivers PPO |
$7,828.12
|
| Rate for Payer: TriWest Veterans Administration |
$6,053.75
|
| Rate for Payer: United Healthcare Commercial |
$9,080.62
|
| Rate for Payer: United Healthcare Medicare |
$6,053.75
|
| Rate for Payer: WINHealth Partners Commercial |
$10,228.75
|
| Rate for Payer: Wise Provider Network Commercial |
$9,915.62
|
|
|
PEGFILGRASTIM-CBQV 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUT INJECTOR [185354]
|
Facility
|
IP
|
$10,437.50
|
|
|
Service Code
|
HCPCS Q5111
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6,544.31 |
| Max. Negotiated Rate |
$10,437.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$10,228.75
|
| Rate for Payer: Altius Auto/Workers Compensation |
$10,020.00
|
| Rate for Payer: Altius Commercial |
$10,020.00
|
| Rate for Payer: Beech Street Commercial |
$10,228.75
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$8,569.19
|
| Rate for Payer: Cash Price |
$7,306.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$10,124.38
|
| Rate for Payer: Cigna of WY Commercial |
$10,228.75
|
| Rate for Payer: Entrust Commercial |
$9,915.62
|
| Rate for Payer: First Choice Health Commercial |
$9,915.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$9,915.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$6,888.75
|
| Rate for Payer: HealthUtah PPO |
$10,437.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$10,124.38
|
| Rate for Payer: Multiplan Medicare/VA |
$6,544.31
|
| Rate for Payer: One Health Plan of WY PPO |
$10,228.75
|
| Rate for Payer: PacificSource Commercial |
$9,393.75
|
| Rate for Payer: PHCS PPO |
$10,228.75
|
| Rate for Payer: Three Rivers PPO |
$7,828.12
|
| Rate for Payer: TriWest Veterans Administration |
$6,888.75
|
| Rate for Payer: United Healthcare Commercial |
$9,080.62
|
| Rate for Payer: United Healthcare Medicare |
$6,888.75
|
| Rate for Payer: WINHealth Partners Commercial |
$9,915.62
|
| Rate for Payer: Wise Provider Network Commercial |
$9,915.62
|
|
|
PEGFILGRASTIM-JMDB 6 MG/0.6 ML SUBCUTANEOUS SYRINGE [152826]
|
Facility
|
OP
|
$5,233.75
|
|
|
Service Code
|
HCPCS Q5108
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,883.80 |
| Max. Negotiated Rate |
$5,233.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5,129.08
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$10,243.45
|
| Rate for Payer: Aetna of WY Medicare |
$3,454.28
|
| Rate for Payer: Aetna of WY Medicare |
$6,898.65
|
| Rate for Payer: Altius Auto/Workers Compensation |
$10,034.40
|
| Rate for Payer: Altius Auto/Workers Compensation |
$5,024.40
|
| Rate for Payer: Altius Commercial |
$5,024.40
|
| Rate for Payer: Altius Commercial |
$10,034.40
|
| Rate for Payer: Beech Street Commercial |
$10,243.45
|
| Rate for Payer: Beech Street Commercial |
$5,129.08
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$4,296.91
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$8,581.50
|
| Rate for Payer: Cash Price |
$7,316.75
|
| Rate for Payer: Cash Price |
$3,663.62
|
| Rate for Payer: ChoiceCare Network Commercial |
$5,076.74
|
| Rate for Payer: ChoiceCare Network Commercial |
$10,138.92
|
| Rate for Payer: Cigna of WY Commercial |
$10,243.45
|
| Rate for Payer: Cigna of WY Commercial |
$5,129.08
|
| Rate for Payer: Entrust Commercial |
$4,972.06
|
| Rate for Payer: Entrust Commercial |
$9,929.88
|
| Rate for Payer: First Choice Health Commercial |
$9,929.88
|
| Rate for Payer: First Choice Health Commercial |
$4,972.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$9,929.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,972.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3,035.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$6,062.45
|
| Rate for Payer: HealthUtah PPO |
$10,452.50
|
| Rate for Payer: HealthUtah PPO |
$5,233.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$10,138.92
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5,076.74
|
| Rate for Payer: Multiplan Medicare/VA |
$2,883.80
|
| Rate for Payer: Multiplan Medicare/VA |
$5,759.33
|
| Rate for Payer: One Health Plan of WY PPO |
$10,243.45
|
| Rate for Payer: One Health Plan of WY PPO |
$5,129.08
|
| Rate for Payer: PacificSource Commercial |
$4,710.38
|
| Rate for Payer: PacificSource Commercial |
$9,407.25
|
| Rate for Payer: PHCS PPO |
$10,243.45
|
| Rate for Payer: PHCS PPO |
$5,129.08
|
| Rate for Payer: Three Rivers PPO |
$7,839.38
|
| Rate for Payer: Three Rivers PPO |
$3,925.31
|
| Rate for Payer: TriWest Veterans Administration |
$3,035.58
|
| Rate for Payer: TriWest Veterans Administration |
$6,062.45
|
| Rate for Payer: United Healthcare Commercial |
$9,093.68
|
| Rate for Payer: United Healthcare Commercial |
$4,553.36
|
| Rate for Payer: United Healthcare Medicare |
$3,035.58
|
| Rate for Payer: United Healthcare Medicare |
$6,062.45
|
| Rate for Payer: WINHealth Partners Commercial |
$10,243.45
|
| Rate for Payer: WINHealth Partners Commercial |
$5,129.08
|
| Rate for Payer: Wise Provider Network Commercial |
$9,929.88
|
| Rate for Payer: Wise Provider Network Commercial |
$4,972.06
|
|
|
PEGFILGRASTIM-JMDB 6 MG/0.6 ML SUBCUTANEOUS SYRINGE [152826]
|
Facility
|
IP
|
$5,233.75
|
|
|
Service Code
|
HCPCS Q5108
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,281.56 |
| Max. Negotiated Rate |
$5,233.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5,129.08
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$10,243.45
|
| Rate for Payer: Altius Auto/Workers Compensation |
$5,024.40
|
| Rate for Payer: Altius Auto/Workers Compensation |
$10,034.40
|
| Rate for Payer: Altius Commercial |
$10,034.40
|
| Rate for Payer: Altius Commercial |
$5,024.40
|
| Rate for Payer: Beech Street Commercial |
$5,129.08
|
| Rate for Payer: Beech Street Commercial |
$10,243.45
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$8,581.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$4,296.91
|
| Rate for Payer: Cash Price |
$3,663.62
|
| Rate for Payer: Cash Price |
$7,316.75
|
| Rate for Payer: ChoiceCare Network Commercial |
$10,138.92
|
| Rate for Payer: ChoiceCare Network Commercial |
$5,076.74
|
| Rate for Payer: Cigna of WY Commercial |
$5,129.08
|
| Rate for Payer: Cigna of WY Commercial |
$10,243.45
|
| Rate for Payer: Entrust Commercial |
$9,929.88
|
| Rate for Payer: Entrust Commercial |
$4,972.06
|
| Rate for Payer: First Choice Health Commercial |
$9,929.88
|
| Rate for Payer: First Choice Health Commercial |
$4,972.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$9,929.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,972.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3,454.28
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$6,898.65
|
| Rate for Payer: HealthUtah PPO |
$5,233.75
|
| Rate for Payer: HealthUtah PPO |
$10,452.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$10,138.92
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5,076.74
|
| Rate for Payer: Multiplan Medicare/VA |
$3,281.56
|
| Rate for Payer: Multiplan Medicare/VA |
$6,553.72
|
| Rate for Payer: One Health Plan of WY PPO |
$5,129.08
|
| Rate for Payer: One Health Plan of WY PPO |
$10,243.45
|
| Rate for Payer: PacificSource Commercial |
$4,710.38
|
| Rate for Payer: PacificSource Commercial |
$9,407.25
|
| Rate for Payer: PHCS PPO |
$10,243.45
|
| Rate for Payer: PHCS PPO |
$5,129.08
|
| Rate for Payer: Three Rivers PPO |
$7,839.38
|
| Rate for Payer: Three Rivers PPO |
$3,925.31
|
| Rate for Payer: TriWest Veterans Administration |
$3,454.28
|
| Rate for Payer: TriWest Veterans Administration |
$6,898.65
|
| Rate for Payer: United Healthcare Commercial |
$9,093.68
|
| Rate for Payer: United Healthcare Commercial |
$4,553.36
|
| Rate for Payer: United Healthcare Medicare |
$3,454.28
|
| Rate for Payer: United Healthcare Medicare |
$6,898.65
|
| Rate for Payer: WINHealth Partners Commercial |
$9,929.88
|
| Rate for Payer: WINHealth Partners Commercial |
$4,972.06
|
| Rate for Payer: Wise Provider Network Commercial |
$9,929.88
|
| Rate for Payer: Wise Provider Network Commercial |
$4,972.06
|
|
|
PEGLOTICASE 8 MG/ML INTRAVENOUS SOLUTION [91105]
|
Facility
|
OP
|
$40,972.80
|
|
|
Service Code
|
HCPCS J2507
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22,576.01 |
| Max. Negotiated Rate |
$40,972.80 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$40,153.34
|
| Rate for Payer: Aetna of WY Medicare |
$27,042.05
|
| Rate for Payer: Altius Auto/Workers Compensation |
$39,333.89
|
| Rate for Payer: Altius Commercial |
$39,333.89
|
| Rate for Payer: Beech Street Commercial |
$40,153.34
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$33,638.67
|
| Rate for Payer: Cash Price |
$28,680.96
|
| Rate for Payer: ChoiceCare Network Commercial |
$39,743.62
|
| Rate for Payer: Cigna of WY Commercial |
$40,153.34
|
| Rate for Payer: Entrust Commercial |
$38,924.16
|
| Rate for Payer: First Choice Health Commercial |
$38,924.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$38,924.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$23,764.22
|
| Rate for Payer: HealthUtah PPO |
$40,972.80
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$39,743.62
|
| Rate for Payer: Multiplan Medicare/VA |
$22,576.01
|
| Rate for Payer: One Health Plan of WY PPO |
$40,153.34
|
| Rate for Payer: PacificSource Commercial |
$36,875.52
|
| Rate for Payer: PHCS PPO |
$40,153.34
|
| Rate for Payer: Three Rivers PPO |
$30,729.60
|
| Rate for Payer: TriWest Veterans Administration |
$23,764.22
|
| Rate for Payer: United Healthcare Commercial |
$35,646.34
|
| Rate for Payer: United Healthcare Medicare |
$23,764.22
|
| Rate for Payer: WINHealth Partners Commercial |
$40,153.34
|
| Rate for Payer: Wise Provider Network Commercial |
$38,924.16
|
|
|
PEGLOTICASE 8 MG/ML INTRAVENOUS SOLUTION [91105]
|
Facility
|
IP
|
$40,972.80
|
|
|
Service Code
|
HCPCS J2507
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25,689.95 |
| Max. Negotiated Rate |
$40,972.80 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$40,153.34
|
| Rate for Payer: Altius Auto/Workers Compensation |
$39,333.89
|
| Rate for Payer: Altius Commercial |
$39,333.89
|
| Rate for Payer: Beech Street Commercial |
$40,153.34
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$33,638.67
|
| Rate for Payer: Cash Price |
$28,680.96
|
| Rate for Payer: ChoiceCare Network Commercial |
$39,743.62
|
| Rate for Payer: Cigna of WY Commercial |
$40,153.34
|
| Rate for Payer: Entrust Commercial |
$38,924.16
|
| Rate for Payer: First Choice Health Commercial |
$38,924.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$38,924.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$27,042.05
|
| Rate for Payer: HealthUtah PPO |
$40,972.80
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$39,743.62
|
| Rate for Payer: Multiplan Medicare/VA |
$25,689.95
|
| Rate for Payer: One Health Plan of WY PPO |
$40,153.34
|
| Rate for Payer: PacificSource Commercial |
$36,875.52
|
| Rate for Payer: PHCS PPO |
$40,153.34
|
| Rate for Payer: Three Rivers PPO |
$30,729.60
|
| Rate for Payer: TriWest Veterans Administration |
$27,042.05
|
| Rate for Payer: United Healthcare Commercial |
$35,646.34
|
| Rate for Payer: United Healthcare Medicare |
$27,042.05
|
| Rate for Payer: WINHealth Partners Commercial |
$38,924.16
|
| Rate for Payer: Wise Provider Network Commercial |
$38,924.16
|
|
|
PEG PULL FEEDING TUBE 20FR KIT
|
Facility
|
OP
|
$240.28
|
|
| Hospital Charge Code |
27800000S1
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$132.39 |
| Max. Negotiated Rate |
$240.28 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$235.47
|
| Rate for Payer: Aetna of WY Medicare |
$158.58
|
| Rate for Payer: Altius Auto/Workers Compensation |
$230.67
|
| Rate for Payer: Altius Commercial |
$230.67
|
| Rate for Payer: Beech Street Commercial |
$235.47
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$197.27
|
| Rate for Payer: Cash Price |
$168.19
|
| Rate for Payer: ChoiceCare Network Commercial |
$233.07
|
| Rate for Payer: Cigna of WY Commercial |
$235.47
|
| Rate for Payer: Entrust Commercial |
$228.27
|
| Rate for Payer: First Choice Health Commercial |
$228.27
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$228.27
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$139.36
|
| Rate for Payer: HealthUtah PPO |
$240.28
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$233.07
|
| Rate for Payer: Multiplan Medicare/VA |
$132.39
|
| Rate for Payer: One Health Plan of WY PPO |
$235.47
|
| Rate for Payer: PacificSource Commercial |
$216.25
|
| Rate for Payer: PHCS PPO |
$235.47
|
| Rate for Payer: Three Rivers PPO |
$180.21
|
| Rate for Payer: TriWest Veterans Administration |
$139.36
|
| Rate for Payer: United Healthcare Commercial |
$209.04
|
| Rate for Payer: United Healthcare Medicare |
$139.36
|
| Rate for Payer: WINHealth Partners Commercial |
$235.47
|
| Rate for Payer: Wise Provider Network Commercial |
$228.27
|
|
|
PEG PULL FEEDING TUBE 20FR KIT
|
Facility
|
IP
|
$240.28
|
|
| Hospital Charge Code |
27800000S1
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$150.66 |
| Max. Negotiated Rate |
$240.28 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$235.47
|
| Rate for Payer: Altius Auto/Workers Compensation |
$230.67
|
| Rate for Payer: Altius Commercial |
$230.67
|
| Rate for Payer: Beech Street Commercial |
$235.47
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$197.27
|
| Rate for Payer: Cash Price |
$168.19
|
| Rate for Payer: ChoiceCare Network Commercial |
$233.07
|
| Rate for Payer: Cigna of WY Commercial |
$235.47
|
| Rate for Payer: Entrust Commercial |
$228.27
|
| Rate for Payer: First Choice Health Commercial |
$228.27
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$228.27
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$158.58
|
| Rate for Payer: HealthUtah PPO |
$240.28
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$233.07
|
| Rate for Payer: Multiplan Medicare/VA |
$150.66
|
| Rate for Payer: One Health Plan of WY PPO |
$235.47
|
| Rate for Payer: PacificSource Commercial |
$216.25
|
| Rate for Payer: PHCS PPO |
$235.47
|
| Rate for Payer: Three Rivers PPO |
$180.21
|
| Rate for Payer: TriWest Veterans Administration |
$158.58
|
| Rate for Payer: United Healthcare Commercial |
$209.04
|
| Rate for Payer: United Healthcare Medicare |
$158.58
|
| Rate for Payer: WINHealth Partners Commercial |
$228.27
|
| Rate for Payer: Wise Provider Network Commercial |
$228.27
|
|
|
PELVIC BINDER T-POD RESPONDER
|
Facility
|
OP
|
$445.20
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$245.31 |
| Max. Negotiated Rate |
$445.20 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$436.30
|
| Rate for Payer: Aetna of WY Medicare |
$293.83
|
| Rate for Payer: Altius Auto/Workers Compensation |
$427.39
|
| Rate for Payer: Altius Commercial |
$427.39
|
| Rate for Payer: Beech Street Commercial |
$436.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$365.51
|
| Rate for Payer: Cash Price |
$311.64
|
| Rate for Payer: ChoiceCare Network Commercial |
$431.84
|
| Rate for Payer: Cigna of WY Commercial |
$436.30
|
| Rate for Payer: Entrust Commercial |
$422.94
|
| Rate for Payer: First Choice Health Commercial |
$422.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$422.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$258.22
|
| Rate for Payer: HealthUtah PPO |
$445.20
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$431.84
|
| Rate for Payer: Multiplan Medicare/VA |
$245.31
|
| Rate for Payer: One Health Plan of WY PPO |
$436.30
|
| Rate for Payer: PacificSource Commercial |
$400.68
|
| Rate for Payer: PHCS PPO |
$436.30
|
| Rate for Payer: Three Rivers PPO |
$333.90
|
| Rate for Payer: TriWest Veterans Administration |
$258.22
|
| Rate for Payer: United Healthcare Commercial |
$387.32
|
| Rate for Payer: United Healthcare Medicare |
$258.22
|
| Rate for Payer: WINHealth Partners Commercial |
$436.30
|
| Rate for Payer: Wise Provider Network Commercial |
$422.94
|
|
|
PELVIC BINDER T-POD RESPONDER
|
Facility
|
IP
|
$445.20
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$279.14 |
| Max. Negotiated Rate |
$445.20 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$436.30
|
| Rate for Payer: Altius Auto/Workers Compensation |
$427.39
|
| Rate for Payer: Altius Commercial |
$427.39
|
| Rate for Payer: Beech Street Commercial |
$436.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$365.51
|
| Rate for Payer: Cash Price |
$311.64
|
| Rate for Payer: ChoiceCare Network Commercial |
$431.84
|
| Rate for Payer: Cigna of WY Commercial |
$436.30
|
| Rate for Payer: Entrust Commercial |
$422.94
|
| Rate for Payer: First Choice Health Commercial |
$422.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$422.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$293.83
|
| Rate for Payer: HealthUtah PPO |
$445.20
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$431.84
|
| Rate for Payer: Multiplan Medicare/VA |
$279.14
|
| Rate for Payer: One Health Plan of WY PPO |
$436.30
|
| Rate for Payer: PacificSource Commercial |
$400.68
|
| Rate for Payer: PHCS PPO |
$436.30
|
| Rate for Payer: Three Rivers PPO |
$333.90
|
| Rate for Payer: TriWest Veterans Administration |
$293.83
|
| Rate for Payer: United Healthcare Commercial |
$387.32
|
| Rate for Payer: United Healthcare Medicare |
$293.83
|
| Rate for Payer: WINHealth Partners Commercial |
$422.94
|
| Rate for Payer: Wise Provider Network Commercial |
$422.94
|
|
|
PELVIC EXAMINATION W/ANESTHESIA OTHER THAN LOCAL
|
Professional
|
Both
|
$535.00
|
|
|
Service Code
|
HCPCS 57410
|
| Hospital Charge Code |
57410
|
| Min. Negotiated Rate |
$86.68 |
| Max. Negotiated Rate |
$535.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$524.30
|
| Rate for Payer: Aetna of WY Medicare |
$101.98
|
| Rate for Payer: Beech Street Commercial |
$508.25
|
| Rate for Payer: Cash Price |
$374.50
|
| Rate for Payer: Cash Price |
$374.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$518.95
|
| Rate for Payer: Cigna of WY Commercial |
$524.30
|
| Rate for Payer: First Choice Health Commercial |
$481.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$508.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$101.98
|
| Rate for Payer: HealthUtah PPO |
$535.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$518.95
|
| Rate for Payer: Multiplan Medicare/VA |
$86.68
|
| Rate for Payer: One Health Plan of WY PPO |
$524.30
|
| Rate for Payer: PacificSource Commercial |
$481.50
|
| Rate for Payer: PHCS PPO |
$508.25
|
| Rate for Payer: Three Rivers PPO |
$401.25
|
| Rate for Payer: TriWest Veterans Administration |
$101.98
|
| Rate for Payer: United Healthcare Commercial |
$465.45
|
| Rate for Payer: United Healthcare Medicare |
$101.98
|
| Rate for Payer: WINHealth Partners Commercial |
$454.75
|
|
|
PELVIC FIXATION OTHER THAN SACRUM
|
Professional
|
Both
|
$1,027.00
|
|
|
Service Code
|
HCPCS 22848
|
| Hospital Charge Code |
22848
|
| Min. Negotiated Rate |
$286.28 |
| Max. Negotiated Rate |
$1,027.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,006.46
|
| Rate for Payer: Aetna of WY Medicare |
$336.80
|
| Rate for Payer: Beech Street Commercial |
$975.65
|
| Rate for Payer: Cash Price |
$718.90
|
| Rate for Payer: Cash Price |
$718.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$996.19
|
| Rate for Payer: Cigna of WY Commercial |
$1,006.46
|
| Rate for Payer: First Choice Health Commercial |
$924.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$975.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$336.80
|
| Rate for Payer: HealthUtah PPO |
$1,027.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$996.19
|
| Rate for Payer: Multiplan Medicare/VA |
$286.28
|
| Rate for Payer: One Health Plan of WY PPO |
$1,006.46
|
| Rate for Payer: PacificSource Commercial |
$924.30
|
| Rate for Payer: PHCS PPO |
$975.65
|
| Rate for Payer: Three Rivers PPO |
$770.25
|
| Rate for Payer: TriWest Veterans Administration |
$336.80
|
| Rate for Payer: United Healthcare Commercial |
$893.49
|
| Rate for Payer: United Healthcare Medicare |
$336.80
|
| Rate for Payer: WINHealth Partners Commercial |
$872.95
|
|
|
PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION [139191]
|
Facility
|
IP
|
$1,460.52
|
|
|
Service Code
|
HCPCS J9271
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$915.75 |
| Max. Negotiated Rate |
$1,460.52 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,431.31
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,402.10
|
| Rate for Payer: Altius Commercial |
$1,402.10
|
| Rate for Payer: Beech Street Commercial |
$1,431.31
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,199.09
|
| Rate for Payer: Cash Price |
$1,022.36
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,416.70
|
| Rate for Payer: Cigna of WY Commercial |
$1,431.31
|
| Rate for Payer: Entrust Commercial |
$1,387.49
|
| Rate for Payer: First Choice Health Commercial |
$1,387.49
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,387.49
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$963.94
|
| Rate for Payer: HealthUtah PPO |
$1,460.52
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,416.70
|
| Rate for Payer: Multiplan Medicare/VA |
$915.75
|
| Rate for Payer: One Health Plan of WY PPO |
$1,431.31
|
| Rate for Payer: PacificSource Commercial |
$1,314.47
|
| Rate for Payer: PHCS PPO |
$1,431.31
|
| Rate for Payer: Three Rivers PPO |
$1,095.39
|
| Rate for Payer: TriWest Veterans Administration |
$963.94
|
| Rate for Payer: United Healthcare Commercial |
$1,270.65
|
| Rate for Payer: United Healthcare Medicare |
$963.94
|
| Rate for Payer: WINHealth Partners Commercial |
$1,387.49
|
| Rate for Payer: Wise Provider Network Commercial |
$1,387.49
|
|
|
PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION [139191]
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Facility
|
OP
|
$1,460.52
|
|
|
Service Code
|
HCPCS J9271
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$804.75 |
| Max. Negotiated Rate |
$1,460.52 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,431.31
|
| Rate for Payer: Aetna of WY Medicare |
$963.94
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,402.10
|
| Rate for Payer: Altius Commercial |
$1,402.10
|
| Rate for Payer: Beech Street Commercial |
$1,431.31
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,199.09
|
| Rate for Payer: Cash Price |
$1,022.36
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,416.70
|
| Rate for Payer: Cigna of WY Commercial |
$1,431.31
|
| Rate for Payer: Entrust Commercial |
$1,387.49
|
| Rate for Payer: First Choice Health Commercial |
$1,387.49
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,387.49
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$847.10
|
| Rate for Payer: HealthUtah PPO |
$1,460.52
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,416.70
|
| Rate for Payer: Multiplan Medicare/VA |
$804.75
|
| Rate for Payer: One Health Plan of WY PPO |
$1,431.31
|
| Rate for Payer: PacificSource Commercial |
$1,314.47
|
| Rate for Payer: PHCS PPO |
$1,431.31
|
| Rate for Payer: Three Rivers PPO |
$1,095.39
|
| Rate for Payer: TriWest Veterans Administration |
$847.10
|
| Rate for Payer: United Healthcare Commercial |
$1,270.65
|
| Rate for Payer: United Healthcare Medicare |
$847.10
|
| Rate for Payer: WINHealth Partners Commercial |
$1,431.31
|
| Rate for Payer: Wise Provider Network Commercial |
$1,387.49
|
|
|
PEMETREXED DISODIUM 1,000 MG INTRAVENOUS POWDER FOR SOLUTION [175931]
|
Facility
|
OP
|
$1,059.50
|
|
|
Service Code
|
HCPCS J9305
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$583.78 |
| Max. Negotiated Rate |
$1,059.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,038.31
|
| Rate for Payer: Aetna of WY Medicare |
$699.27
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,017.12
|
| Rate for Payer: Altius Commercial |
$1,017.12
|
| Rate for Payer: Beech Street Commercial |
$1,038.31
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$869.85
|
| Rate for Payer: Cash Price |
$741.65
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,027.72
|
| Rate for Payer: Cigna of WY Commercial |
$1,038.31
|
| Rate for Payer: Entrust Commercial |
$1,006.52
|
| Rate for Payer: First Choice Health Commercial |
$1,006.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,006.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$614.51
|
| Rate for Payer: HealthUtah PPO |
$1,059.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,027.72
|
| Rate for Payer: Multiplan Medicare/VA |
$583.78
|
| Rate for Payer: One Health Plan of WY PPO |
$1,038.31
|
| Rate for Payer: PacificSource Commercial |
$953.55
|
| Rate for Payer: PHCS PPO |
$1,038.31
|
| Rate for Payer: Three Rivers PPO |
$794.62
|
| Rate for Payer: TriWest Veterans Administration |
$614.51
|
| Rate for Payer: United Healthcare Commercial |
$921.76
|
| Rate for Payer: United Healthcare Medicare |
$614.51
|
| Rate for Payer: WINHealth Partners Commercial |
$1,038.31
|
| Rate for Payer: Wise Provider Network Commercial |
$1,006.52
|
|
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PEMETREXED DISODIUM 1,000 MG INTRAVENOUS POWDER FOR SOLUTION [175931]
|
Facility
|
IP
|
$1,059.50
|
|
|
Service Code
|
HCPCS J9305
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$664.31 |
| Max. Negotiated Rate |
$1,059.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,038.31
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,017.12
|
| Rate for Payer: Altius Commercial |
$1,017.12
|
| Rate for Payer: Beech Street Commercial |
$1,038.31
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$869.85
|
| Rate for Payer: Cash Price |
$741.65
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,027.72
|
| Rate for Payer: Cigna of WY Commercial |
$1,038.31
|
| Rate for Payer: Entrust Commercial |
$1,006.52
|
| Rate for Payer: First Choice Health Commercial |
$1,006.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,006.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$699.27
|
| Rate for Payer: HealthUtah PPO |
$1,059.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,027.72
|
| Rate for Payer: Multiplan Medicare/VA |
$664.31
|
| Rate for Payer: One Health Plan of WY PPO |
$1,038.31
|
| Rate for Payer: PacificSource Commercial |
$953.55
|
| Rate for Payer: PHCS PPO |
$1,038.31
|
| Rate for Payer: Three Rivers PPO |
$794.62
|
| Rate for Payer: TriWest Veterans Administration |
$699.27
|
| Rate for Payer: United Healthcare Commercial |
$921.76
|
| Rate for Payer: United Healthcare Medicare |
$699.27
|
| Rate for Payer: WINHealth Partners Commercial |
$1,006.52
|
| Rate for Payer: Wise Provider Network Commercial |
$1,006.52
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|
PENG BENZATHINE/PROCAINE INJ
|
Professional
|
Both
|
$20.00
|
|
|
Service Code
|
HCPCS J0558
|
| Hospital Charge Code |
J0558
|
| Min. Negotiated Rate |
$14.76 |
| Max. Negotiated Rate |
$20.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$19.60
|
| Rate for Payer: Aetna of WY Medicare |
$17.37
|
| Rate for Payer: Beech Street Commercial |
$19.00
|
| Rate for Payer: Cash Price |
$14.00
|
| Rate for Payer: Cash Price |
$14.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$19.40
|
| Rate for Payer: Cigna of WY Commercial |
$19.60
|
| Rate for Payer: First Choice Health Commercial |
$18.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$19.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$17.37
|
| Rate for Payer: HealthUtah PPO |
$20.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$19.40
|
| Rate for Payer: Multiplan Medicare/VA |
$14.76
|
| Rate for Payer: One Health Plan of WY PPO |
$19.60
|
| Rate for Payer: PacificSource Commercial |
$18.00
|
| Rate for Payer: PHCS PPO |
$19.00
|
| Rate for Payer: Three Rivers PPO |
$15.00
|
| Rate for Payer: TriWest Veterans Administration |
$17.37
|
| Rate for Payer: United Healthcare Commercial |
$17.40
|
| Rate for Payer: United Healthcare Medicare |
$17.37
|
| Rate for Payer: WINHealth Partners Commercial |
$19.00
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