|
PREGABALIN 75 MG CAPSULE [39103]
|
Facility
|
OP
|
$5.39
|
|
|
Service Code
|
NDC 6068749501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.97 |
| Max. Negotiated Rate |
$5.39 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5.28
|
| Rate for Payer: Aetna of WY Medicare |
$3.56
|
| Rate for Payer: Altius Auto/Workers Compensation |
$5.17
|
| Rate for Payer: Altius Commercial |
$5.17
|
| Rate for Payer: Beech Street Commercial |
$5.28
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$4.43
|
| Rate for Payer: Cash Price |
$3.77
|
| Rate for Payer: ChoiceCare Network Commercial |
$5.23
|
| Rate for Payer: Cigna of WY Commercial |
$5.28
|
| Rate for Payer: Entrust Commercial |
$5.12
|
| Rate for Payer: First Choice Health Commercial |
$5.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3.13
|
| Rate for Payer: HealthUtah PPO |
$5.39
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5.23
|
| Rate for Payer: Multiplan Medicare/VA |
$2.97
|
| Rate for Payer: One Health Plan of WY PPO |
$5.28
|
| Rate for Payer: PacificSource Commercial |
$4.85
|
| Rate for Payer: PHCS PPO |
$5.28
|
| Rate for Payer: Three Rivers PPO |
$4.04
|
| Rate for Payer: TriWest Veterans Administration |
$3.13
|
| Rate for Payer: United Healthcare Commercial |
$4.69
|
| Rate for Payer: United Healthcare Medicare |
$3.13
|
| Rate for Payer: WINHealth Partners Commercial |
$5.28
|
| Rate for Payer: Wise Provider Network Commercial |
$5.12
|
|
|
PREGABALIN 75 MG CAPSULE [39103]
|
Facility
|
IP
|
$5.39
|
|
|
Service Code
|
NDC 6068749511
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.38 |
| Max. Negotiated Rate |
$5.39 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5.28
|
| Rate for Payer: Altius Auto/Workers Compensation |
$5.17
|
| Rate for Payer: Altius Commercial |
$5.17
|
| Rate for Payer: Beech Street Commercial |
$5.28
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$4.43
|
| Rate for Payer: Cash Price |
$3.77
|
| Rate for Payer: ChoiceCare Network Commercial |
$5.23
|
| Rate for Payer: Cigna of WY Commercial |
$5.28
|
| Rate for Payer: Entrust Commercial |
$5.12
|
| Rate for Payer: First Choice Health Commercial |
$5.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3.56
|
| Rate for Payer: HealthUtah PPO |
$5.39
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5.23
|
| Rate for Payer: Multiplan Medicare/VA |
$3.38
|
| Rate for Payer: One Health Plan of WY PPO |
$5.28
|
| Rate for Payer: PacificSource Commercial |
$4.85
|
| Rate for Payer: PHCS PPO |
$5.28
|
| Rate for Payer: Three Rivers PPO |
$4.04
|
| Rate for Payer: TriWest Veterans Administration |
$3.56
|
| Rate for Payer: United Healthcare Commercial |
$4.69
|
| Rate for Payer: United Healthcare Medicare |
$3.56
|
| Rate for Payer: WINHealth Partners Commercial |
$5.12
|
| Rate for Payer: Wise Provider Network Commercial |
$5.12
|
|
|
PREGABALIN 75 MG CAPSULE [39103]
|
Facility
|
OP
|
$5.39
|
|
|
Service Code
|
NDC 6068749511
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.97 |
| Max. Negotiated Rate |
$5.39 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5.28
|
| Rate for Payer: Aetna of WY Medicare |
$3.56
|
| Rate for Payer: Altius Auto/Workers Compensation |
$5.17
|
| Rate for Payer: Altius Commercial |
$5.17
|
| Rate for Payer: Beech Street Commercial |
$5.28
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$4.43
|
| Rate for Payer: Cash Price |
$3.77
|
| Rate for Payer: ChoiceCare Network Commercial |
$5.23
|
| Rate for Payer: Cigna of WY Commercial |
$5.28
|
| Rate for Payer: Entrust Commercial |
$5.12
|
| Rate for Payer: First Choice Health Commercial |
$5.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3.13
|
| Rate for Payer: HealthUtah PPO |
$5.39
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5.23
|
| Rate for Payer: Multiplan Medicare/VA |
$2.97
|
| Rate for Payer: One Health Plan of WY PPO |
$5.28
|
| Rate for Payer: PacificSource Commercial |
$4.85
|
| Rate for Payer: PHCS PPO |
$5.28
|
| Rate for Payer: Three Rivers PPO |
$4.04
|
| Rate for Payer: TriWest Veterans Administration |
$3.13
|
| Rate for Payer: United Healthcare Commercial |
$4.69
|
| Rate for Payer: United Healthcare Medicare |
$3.13
|
| Rate for Payer: WINHealth Partners Commercial |
$5.28
|
| Rate for Payer: Wise Provider Network Commercial |
$5.12
|
|
|
PREGABALIN 75 MG CAPSULE [39103]
|
Facility
|
IP
|
$5.39
|
|
|
Service Code
|
NDC 6068749501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.38 |
| Max. Negotiated Rate |
$5.39 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5.28
|
| Rate for Payer: Altius Auto/Workers Compensation |
$5.17
|
| Rate for Payer: Altius Commercial |
$5.17
|
| Rate for Payer: Beech Street Commercial |
$5.28
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$4.43
|
| Rate for Payer: Cash Price |
$3.77
|
| Rate for Payer: ChoiceCare Network Commercial |
$5.23
|
| Rate for Payer: Cigna of WY Commercial |
$5.28
|
| Rate for Payer: Entrust Commercial |
$5.12
|
| Rate for Payer: First Choice Health Commercial |
$5.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3.56
|
| Rate for Payer: HealthUtah PPO |
$5.39
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5.23
|
| Rate for Payer: Multiplan Medicare/VA |
$3.38
|
| Rate for Payer: One Health Plan of WY PPO |
$5.28
|
| Rate for Payer: PacificSource Commercial |
$4.85
|
| Rate for Payer: PHCS PPO |
$5.28
|
| Rate for Payer: Three Rivers PPO |
$4.04
|
| Rate for Payer: TriWest Veterans Administration |
$3.56
|
| Rate for Payer: United Healthcare Commercial |
$4.69
|
| Rate for Payer: United Healthcare Medicare |
$3.56
|
| Rate for Payer: WINHealth Partners Commercial |
$5.12
|
| Rate for Payer: Wise Provider Network Commercial |
$5.12
|
|
|
PRENATAL VITAMINS (WRAPPER) [408000155]
|
Facility
|
OP
|
$0.13
|
|
|
Service Code
|
NDC 0904531360
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.13
|
| Rate for Payer: Aetna of WY Medicare |
$0.09
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.12
|
| Rate for Payer: Altius Commercial |
$0.12
|
| Rate for Payer: Beech Street Commercial |
$0.13
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.11
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.13
|
| Rate for Payer: Cigna of WY Commercial |
$0.13
|
| Rate for Payer: Entrust Commercial |
$0.12
|
| Rate for Payer: First Choice Health Commercial |
$0.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.08
|
| Rate for Payer: HealthUtah PPO |
$0.13
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.13
|
| Rate for Payer: Multiplan Medicare/VA |
$0.07
|
| Rate for Payer: One Health Plan of WY PPO |
$0.13
|
| Rate for Payer: PacificSource Commercial |
$0.12
|
| Rate for Payer: PHCS PPO |
$0.13
|
| Rate for Payer: Three Rivers PPO |
$0.10
|
| Rate for Payer: TriWest Veterans Administration |
$0.08
|
| Rate for Payer: United Healthcare Commercial |
$0.11
|
| Rate for Payer: United Healthcare Medicare |
$0.08
|
| Rate for Payer: WINHealth Partners Commercial |
$0.13
|
| Rate for Payer: Wise Provider Network Commercial |
$0.12
|
|
|
PRENATAL VITAMINS (WRAPPER) [408000155]
|
Facility
|
IP
|
$0.13
|
|
|
Service Code
|
NDC 0904531360
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.13
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.12
|
| Rate for Payer: Altius Commercial |
$0.12
|
| Rate for Payer: Beech Street Commercial |
$0.13
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.11
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.13
|
| Rate for Payer: Cigna of WY Commercial |
$0.13
|
| Rate for Payer: Entrust Commercial |
$0.12
|
| Rate for Payer: First Choice Health Commercial |
$0.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.09
|
| Rate for Payer: HealthUtah PPO |
$0.13
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.13
|
| Rate for Payer: Multiplan Medicare/VA |
$0.08
|
| Rate for Payer: One Health Plan of WY PPO |
$0.13
|
| Rate for Payer: PacificSource Commercial |
$0.12
|
| Rate for Payer: PHCS PPO |
$0.13
|
| Rate for Payer: Three Rivers PPO |
$0.10
|
| Rate for Payer: TriWest Veterans Administration |
$0.09
|
| Rate for Payer: United Healthcare Commercial |
$0.11
|
| Rate for Payer: United Healthcare Medicare |
$0.09
|
| Rate for Payer: WINHealth Partners Commercial |
$0.12
|
| Rate for Payer: Wise Provider Network Commercial |
$0.12
|
|
|
PREP SITE F/S/N/H/F/G/M/D GT 1ST 100 SQ CM/1PCT
|
Professional
|
Both
|
$1,330.00
|
|
|
Service Code
|
HCPCS 15004
|
| Hospital Charge Code |
15004
|
| Min. Negotiated Rate |
$210.09 |
| Max. Negotiated Rate |
$1,330.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,303.40
|
| Rate for Payer: Aetna of WY Medicare |
$247.16
|
| Rate for Payer: Beech Street Commercial |
$1,263.50
|
| Rate for Payer: Cash Price |
$931.00
|
| Rate for Payer: Cash Price |
$931.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,290.10
|
| Rate for Payer: Cigna of WY Commercial |
$1,303.40
|
| Rate for Payer: First Choice Health Commercial |
$1,197.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,263.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$247.16
|
| Rate for Payer: HealthUtah PPO |
$1,330.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,290.10
|
| Rate for Payer: Multiplan Medicare/VA |
$210.09
|
| Rate for Payer: One Health Plan of WY PPO |
$1,303.40
|
| Rate for Payer: PacificSource Commercial |
$1,197.00
|
| Rate for Payer: PHCS PPO |
$1,263.50
|
| Rate for Payer: Three Rivers PPO |
$997.50
|
| Rate for Payer: TriWest Veterans Administration |
$247.16
|
| Rate for Payer: United Healthcare Commercial |
$1,157.10
|
| Rate for Payer: United Healthcare Medicare |
$247.16
|
| Rate for Payer: WINHealth Partners Commercial |
$1,130.50
|
|
|
PREP SITE TRUNK/ARM/LEG 1ST 100 SQ CM/1PCT
|
Professional
|
Both
|
$1,121.00
|
|
|
Service Code
|
HCPCS 15002
|
| Hospital Charge Code |
15002
|
| Min. Negotiated Rate |
$176.95 |
| Max. Negotiated Rate |
$1,121.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,098.58
|
| Rate for Payer: Aetna of WY Medicare |
$208.18
|
| Rate for Payer: Beech Street Commercial |
$1,064.95
|
| Rate for Payer: Cash Price |
$784.70
|
| Rate for Payer: Cash Price |
$784.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,087.37
|
| Rate for Payer: Cigna of WY Commercial |
$1,098.58
|
| Rate for Payer: First Choice Health Commercial |
$1,008.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,064.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$208.18
|
| Rate for Payer: HealthUtah PPO |
$1,121.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,087.37
|
| Rate for Payer: Multiplan Medicare/VA |
$176.95
|
| Rate for Payer: One Health Plan of WY PPO |
$1,098.58
|
| Rate for Payer: PacificSource Commercial |
$1,008.90
|
| Rate for Payer: PHCS PPO |
$1,064.95
|
| Rate for Payer: Three Rivers PPO |
$840.75
|
| Rate for Payer: TriWest Veterans Administration |
$208.18
|
| Rate for Payer: United Healthcare Commercial |
$975.27
|
| Rate for Payer: United Healthcare Medicare |
$208.18
|
| Rate for Payer: WINHealth Partners Commercial |
$952.85
|
|
|
PRESSURIZED/NONPRESSURIZED INHALATION TREATMENT
|
Professional
|
Both
|
$84.00
|
|
|
Service Code
|
HCPCS 94640
|
| Hospital Charge Code |
94640
|
| Min. Negotiated Rate |
$6.60 |
| Max. Negotiated Rate |
$84.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$82.32
|
| Rate for Payer: Aetna of WY Medicare |
$7.77
|
| Rate for Payer: Beech Street Commercial |
$79.80
|
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$81.48
|
| Rate for Payer: Cigna of WY Commercial |
$82.32
|
| Rate for Payer: First Choice Health Commercial |
$75.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$79.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$7.77
|
| Rate for Payer: HealthUtah PPO |
$84.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$81.48
|
| Rate for Payer: Multiplan Medicare/VA |
$6.60
|
| Rate for Payer: One Health Plan of WY PPO |
$82.32
|
| Rate for Payer: PacificSource Commercial |
$75.60
|
| Rate for Payer: PHCS PPO |
$79.80
|
| Rate for Payer: Three Rivers PPO |
$63.00
|
| Rate for Payer: TriWest Veterans Administration |
$7.77
|
| Rate for Payer: United Healthcare Commercial |
$73.08
|
| Rate for Payer: United Healthcare Medicare |
$7.77
|
| Rate for Payer: WINHealth Partners Commercial |
$79.80
|
|
|
PREV MED CNSL&/RSK FCTR RDCTJ INDV APPROX 15 MIN
|
Professional
|
Both
|
$154.00
|
|
|
Service Code
|
HCPCS 99401
|
| Hospital Charge Code |
99401
|
| Min. Negotiated Rate |
$115.50 |
| Max. Negotiated Rate |
$154.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$150.92
|
| Rate for Payer: Beech Street Commercial |
$146.30
|
| Rate for Payer: Cash Price |
$107.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$149.38
|
| Rate for Payer: Cigna of WY Commercial |
$150.92
|
| Rate for Payer: First Choice Health Commercial |
$138.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$146.30
|
| Rate for Payer: HealthUtah PPO |
$154.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$149.38
|
| Rate for Payer: One Health Plan of WY PPO |
$150.92
|
| Rate for Payer: PacificSource Commercial |
$138.60
|
| Rate for Payer: PHCS PPO |
$146.30
|
| Rate for Payer: Three Rivers PPO |
$115.50
|
| Rate for Payer: United Healthcare Commercial |
$133.98
|
| Rate for Payer: WINHealth Partners Commercial |
$146.30
|
|
|
PREV MED CNSL&/RSK FCTR RDCTJ INDV APPROX 30 MIN
|
Professional
|
Both
|
$135.00
|
|
|
Service Code
|
HCPCS 99402
|
| Hospital Charge Code |
99402
|
| Min. Negotiated Rate |
$101.25 |
| Max. Negotiated Rate |
$135.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$132.30
|
| Rate for Payer: Beech Street Commercial |
$128.25
|
| Rate for Payer: Cash Price |
$94.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$130.95
|
| Rate for Payer: Cigna of WY Commercial |
$132.30
|
| Rate for Payer: First Choice Health Commercial |
$121.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$128.25
|
| Rate for Payer: HealthUtah PPO |
$135.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$130.95
|
| Rate for Payer: One Health Plan of WY PPO |
$132.30
|
| Rate for Payer: PacificSource Commercial |
$121.50
|
| Rate for Payer: PHCS PPO |
$128.25
|
| Rate for Payer: Three Rivers PPO |
$101.25
|
| Rate for Payer: United Healthcare Commercial |
$117.45
|
| Rate for Payer: WINHealth Partners Commercial |
$128.25
|
|
|
PREV MED CNSL&/RSK FCTR RDCTJ INDV APPROX 60 MIN
|
Professional
|
Both
|
$528.00
|
|
|
Service Code
|
HCPCS 99404
|
| Hospital Charge Code |
99404
|
| Min. Negotiated Rate |
$396.00 |
| Max. Negotiated Rate |
$528.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$517.44
|
| Rate for Payer: Beech Street Commercial |
$501.60
|
| Rate for Payer: Cash Price |
$369.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$512.16
|
| Rate for Payer: Cigna of WY Commercial |
$517.44
|
| Rate for Payer: First Choice Health Commercial |
$475.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$501.60
|
| Rate for Payer: HealthUtah PPO |
$528.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$512.16
|
| Rate for Payer: One Health Plan of WY PPO |
$517.44
|
| Rate for Payer: PacificSource Commercial |
$475.20
|
| Rate for Payer: PHCS PPO |
$501.60
|
| Rate for Payer: Three Rivers PPO |
$396.00
|
| Rate for Payer: United Healthcare Commercial |
$459.36
|
| Rate for Payer: WINHealth Partners Commercial |
$501.60
|
|
|
PR MEDROXYPROGESTERONE ACETATE
|
Professional
|
Both
|
$1.00
|
|
|
Service Code
|
HCPCS J1050
|
| Hospital Charge Code |
J1050
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$1.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.98
|
| Rate for Payer: Beech Street Commercial |
$0.95
|
| Rate for Payer: Cash Price |
$0.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.97
|
| Rate for Payer: Cigna of WY Commercial |
$0.98
|
| Rate for Payer: First Choice Health Commercial |
$0.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.95
|
| Rate for Payer: HealthUtah PPO |
$1.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.97
|
| Rate for Payer: One Health Plan of WY PPO |
$0.98
|
| Rate for Payer: PacificSource Commercial |
$0.90
|
| Rate for Payer: PHCS PPO |
$0.95
|
| Rate for Payer: Three Rivers PPO |
$0.75
|
| Rate for Payer: United Healthcare Commercial |
$0.87
|
| Rate for Payer: WINHealth Partners Commercial |
$0.95
|
|
|
PROBE COVER 5.5 X 36
|
Facility
|
OP
|
$12.12
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$6.68 |
| Max. Negotiated Rate |
$12.12 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$11.88
|
| Rate for Payer: Aetna of WY Medicare |
$8.00
|
| Rate for Payer: Altius Auto/Workers Compensation |
$11.64
|
| Rate for Payer: Altius Commercial |
$11.64
|
| Rate for Payer: Beech Street Commercial |
$11.88
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$9.95
|
| Rate for Payer: Cash Price |
$8.48
|
| Rate for Payer: ChoiceCare Network Commercial |
$11.76
|
| Rate for Payer: Cigna of WY Commercial |
$11.88
|
| Rate for Payer: Entrust Commercial |
$11.51
|
| Rate for Payer: First Choice Health Commercial |
$11.51
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$11.51
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$7.03
|
| Rate for Payer: HealthUtah PPO |
$12.12
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$11.76
|
| Rate for Payer: Multiplan Medicare/VA |
$6.68
|
| Rate for Payer: One Health Plan of WY PPO |
$11.88
|
| Rate for Payer: PacificSource Commercial |
$10.91
|
| Rate for Payer: PHCS PPO |
$11.88
|
| Rate for Payer: Three Rivers PPO |
$9.09
|
| Rate for Payer: TriWest Veterans Administration |
$7.03
|
| Rate for Payer: United Healthcare Commercial |
$10.54
|
| Rate for Payer: United Healthcare Medicare |
$7.03
|
| Rate for Payer: WINHealth Partners Commercial |
$11.88
|
| Rate for Payer: Wise Provider Network Commercial |
$11.51
|
|
|
PROBE COVER 5.5 X 36
|
Facility
|
IP
|
$12.12
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$7.60 |
| Max. Negotiated Rate |
$12.12 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$11.88
|
| Rate for Payer: Altius Auto/Workers Compensation |
$11.64
|
| Rate for Payer: Altius Commercial |
$11.64
|
| Rate for Payer: Beech Street Commercial |
$11.88
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$9.95
|
| Rate for Payer: Cash Price |
$8.48
|
| Rate for Payer: ChoiceCare Network Commercial |
$11.76
|
| Rate for Payer: Cigna of WY Commercial |
$11.88
|
| Rate for Payer: Entrust Commercial |
$11.51
|
| Rate for Payer: First Choice Health Commercial |
$11.51
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$11.51
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.00
|
| Rate for Payer: HealthUtah PPO |
$12.12
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$11.76
|
| Rate for Payer: Multiplan Medicare/VA |
$7.60
|
| Rate for Payer: One Health Plan of WY PPO |
$11.88
|
| Rate for Payer: PacificSource Commercial |
$10.91
|
| Rate for Payer: PHCS PPO |
$11.88
|
| Rate for Payer: Three Rivers PPO |
$9.09
|
| Rate for Payer: TriWest Veterans Administration |
$8.00
|
| Rate for Payer: United Healthcare Commercial |
$10.54
|
| Rate for Payer: United Healthcare Medicare |
$8.00
|
| Rate for Payer: WINHealth Partners Commercial |
$11.51
|
| Rate for Payer: Wise Provider Network Commercial |
$11.51
|
|
|
PROBE COVER KIT INTRAOPERATIVE
|
Facility
|
OP
|
$37.17
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$20.48 |
| Max. Negotiated Rate |
$37.17 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$36.43
|
| Rate for Payer: Aetna of WY Medicare |
$24.53
|
| Rate for Payer: Altius Auto/Workers Compensation |
$35.68
|
| Rate for Payer: Altius Commercial |
$35.68
|
| Rate for Payer: Beech Street Commercial |
$36.43
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$30.52
|
| Rate for Payer: Cash Price |
$26.02
|
| Rate for Payer: ChoiceCare Network Commercial |
$36.05
|
| Rate for Payer: Cigna of WY Commercial |
$36.43
|
| Rate for Payer: Entrust Commercial |
$35.31
|
| Rate for Payer: First Choice Health Commercial |
$35.31
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$35.31
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$21.56
|
| Rate for Payer: HealthUtah PPO |
$37.17
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$36.05
|
| Rate for Payer: Multiplan Medicare/VA |
$20.48
|
| Rate for Payer: One Health Plan of WY PPO |
$36.43
|
| Rate for Payer: PacificSource Commercial |
$33.45
|
| Rate for Payer: PHCS PPO |
$36.43
|
| Rate for Payer: Three Rivers PPO |
$27.88
|
| Rate for Payer: TriWest Veterans Administration |
$21.56
|
| Rate for Payer: United Healthcare Commercial |
$32.34
|
| Rate for Payer: United Healthcare Medicare |
$21.56
|
| Rate for Payer: WINHealth Partners Commercial |
$36.43
|
| Rate for Payer: Wise Provider Network Commercial |
$35.31
|
|
|
PROBE COVER KIT INTRAOPERATIVE
|
Facility
|
IP
|
$37.17
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$23.31 |
| Max. Negotiated Rate |
$37.17 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$36.43
|
| Rate for Payer: Altius Auto/Workers Compensation |
$35.68
|
| Rate for Payer: Altius Commercial |
$35.68
|
| Rate for Payer: Beech Street Commercial |
$36.43
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$30.52
|
| Rate for Payer: Cash Price |
$26.02
|
| Rate for Payer: ChoiceCare Network Commercial |
$36.05
|
| Rate for Payer: Cigna of WY Commercial |
$36.43
|
| Rate for Payer: Entrust Commercial |
$35.31
|
| Rate for Payer: First Choice Health Commercial |
$35.31
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$35.31
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$24.53
|
| Rate for Payer: HealthUtah PPO |
$37.17
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$36.05
|
| Rate for Payer: Multiplan Medicare/VA |
$23.31
|
| Rate for Payer: One Health Plan of WY PPO |
$36.43
|
| Rate for Payer: PacificSource Commercial |
$33.45
|
| Rate for Payer: PHCS PPO |
$36.43
|
| Rate for Payer: Three Rivers PPO |
$27.88
|
| Rate for Payer: TriWest Veterans Administration |
$24.53
|
| Rate for Payer: United Healthcare Commercial |
$32.34
|
| Rate for Payer: United Healthcare Medicare |
$24.53
|
| Rate for Payer: WINHealth Partners Commercial |
$35.31
|
| Rate for Payer: Wise Provider Network Commercial |
$35.31
|
|
|
PROBE COVER WITH GEL 4X48
|
Facility
|
IP
|
$30.46
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$19.10 |
| Max. Negotiated Rate |
$30.46 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$29.85
|
| Rate for Payer: Altius Auto/Workers Compensation |
$29.24
|
| Rate for Payer: Altius Commercial |
$29.24
|
| Rate for Payer: Beech Street Commercial |
$29.85
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$25.01
|
| Rate for Payer: Cash Price |
$21.32
|
| Rate for Payer: ChoiceCare Network Commercial |
$29.55
|
| Rate for Payer: Cigna of WY Commercial |
$29.85
|
| Rate for Payer: Entrust Commercial |
$28.94
|
| Rate for Payer: First Choice Health Commercial |
$28.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$28.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$20.10
|
| Rate for Payer: HealthUtah PPO |
$30.46
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$29.55
|
| Rate for Payer: Multiplan Medicare/VA |
$19.10
|
| Rate for Payer: One Health Plan of WY PPO |
$29.85
|
| Rate for Payer: PacificSource Commercial |
$27.41
|
| Rate for Payer: PHCS PPO |
$29.85
|
| Rate for Payer: Three Rivers PPO |
$22.84
|
| Rate for Payer: TriWest Veterans Administration |
$20.10
|
| Rate for Payer: United Healthcare Commercial |
$26.50
|
| Rate for Payer: United Healthcare Medicare |
$20.10
|
| Rate for Payer: WINHealth Partners Commercial |
$28.94
|
| Rate for Payer: Wise Provider Network Commercial |
$28.94
|
|
|
PROBE COVER WITH GEL 4X48
|
Facility
|
OP
|
$30.46
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$16.78 |
| Max. Negotiated Rate |
$30.46 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$29.85
|
| Rate for Payer: Aetna of WY Medicare |
$20.10
|
| Rate for Payer: Altius Auto/Workers Compensation |
$29.24
|
| Rate for Payer: Altius Commercial |
$29.24
|
| Rate for Payer: Beech Street Commercial |
$29.85
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$25.01
|
| Rate for Payer: Cash Price |
$21.32
|
| Rate for Payer: ChoiceCare Network Commercial |
$29.55
|
| Rate for Payer: Cigna of WY Commercial |
$29.85
|
| Rate for Payer: Entrust Commercial |
$28.94
|
| Rate for Payer: First Choice Health Commercial |
$28.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$28.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$17.67
|
| Rate for Payer: HealthUtah PPO |
$30.46
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$29.55
|
| Rate for Payer: Multiplan Medicare/VA |
$16.78
|
| Rate for Payer: One Health Plan of WY PPO |
$29.85
|
| Rate for Payer: PacificSource Commercial |
$27.41
|
| Rate for Payer: PHCS PPO |
$29.85
|
| Rate for Payer: Three Rivers PPO |
$22.84
|
| Rate for Payer: TriWest Veterans Administration |
$17.67
|
| Rate for Payer: United Healthcare Commercial |
$26.50
|
| Rate for Payer: United Healthcare Medicare |
$17.67
|
| Rate for Payer: WINHealth Partners Commercial |
$29.85
|
| Rate for Payer: Wise Provider Network Commercial |
$28.94
|
|
|
PROBENECID 500 MG TABLET [20552]
|
Facility
|
OP
|
$2.38
|
|
|
Service Code
|
NDC 0591534701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.31 |
| Max. Negotiated Rate |
$2.38 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.33
|
| Rate for Payer: Aetna of WY Medicare |
$1.57
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.28
|
| Rate for Payer: Altius Commercial |
$2.28
|
| Rate for Payer: Beech Street Commercial |
$2.33
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.95
|
| Rate for Payer: Cash Price |
$1.66
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.31
|
| Rate for Payer: Cigna of WY Commercial |
$2.33
|
| Rate for Payer: Entrust Commercial |
$2.26
|
| Rate for Payer: First Choice Health Commercial |
$2.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.38
|
| Rate for Payer: HealthUtah PPO |
$2.38
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.31
|
| Rate for Payer: Multiplan Medicare/VA |
$1.31
|
| Rate for Payer: One Health Plan of WY PPO |
$2.33
|
| Rate for Payer: PacificSource Commercial |
$2.14
|
| Rate for Payer: PHCS PPO |
$2.33
|
| Rate for Payer: Three Rivers PPO |
$1.78
|
| Rate for Payer: TriWest Veterans Administration |
$1.38
|
| Rate for Payer: United Healthcare Commercial |
$2.07
|
| Rate for Payer: United Healthcare Medicare |
$1.38
|
| Rate for Payer: WINHealth Partners Commercial |
$2.33
|
| Rate for Payer: Wise Provider Network Commercial |
$2.26
|
|
|
PROBENECID 500 MG TABLET [20552]
|
Facility
|
IP
|
$2.38
|
|
|
Service Code
|
NDC 0591534701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$2.38 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.33
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.28
|
| Rate for Payer: Altius Commercial |
$2.28
|
| Rate for Payer: Beech Street Commercial |
$2.33
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.95
|
| Rate for Payer: Cash Price |
$1.66
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.31
|
| Rate for Payer: Cigna of WY Commercial |
$2.33
|
| Rate for Payer: Entrust Commercial |
$2.26
|
| Rate for Payer: First Choice Health Commercial |
$2.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.57
|
| Rate for Payer: HealthUtah PPO |
$2.38
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.31
|
| Rate for Payer: Multiplan Medicare/VA |
$1.49
|
| Rate for Payer: One Health Plan of WY PPO |
$2.33
|
| Rate for Payer: PacificSource Commercial |
$2.14
|
| Rate for Payer: PHCS PPO |
$2.33
|
| Rate for Payer: Three Rivers PPO |
$1.78
|
| Rate for Payer: TriWest Veterans Administration |
$1.57
|
| Rate for Payer: United Healthcare Commercial |
$2.07
|
| Rate for Payer: United Healthcare Medicare |
$1.57
|
| Rate for Payer: WINHealth Partners Commercial |
$2.26
|
| Rate for Payer: Wise Provider Network Commercial |
$2.26
|
|
|
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION [94700]
|
Facility
|
OP
|
$26.91
|
|
|
Service Code
|
HCPCS J0780
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.83 |
| Max. Negotiated Rate |
$26.91 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$26.37
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$24.66
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$24.44
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$28.03
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$24.70
|
| Rate for Payer: Aetna of WY Medicare |
$17.76
|
| Rate for Payer: Aetna of WY Medicare |
$18.88
|
| Rate for Payer: Aetna of WY Medicare |
$16.63
|
| Rate for Payer: Aetna of WY Medicare |
$16.61
|
| Rate for Payer: Aetna of WY Medicare |
$16.46
|
| Rate for Payer: Altius Auto/Workers Compensation |
$25.83
|
| Rate for Payer: Altius Auto/Workers Compensation |
$24.15
|
| Rate for Payer: Altius Auto/Workers Compensation |
$23.94
|
| Rate for Payer: Altius Auto/Workers Compensation |
$24.19
|
| Rate for Payer: Altius Auto/Workers Compensation |
$27.46
|
| Rate for Payer: Altius Commercial |
$27.46
|
| Rate for Payer: Altius Commercial |
$24.15
|
| Rate for Payer: Altius Commercial |
$24.19
|
| Rate for Payer: Altius Commercial |
$23.94
|
| Rate for Payer: Altius Commercial |
$25.83
|
| Rate for Payer: Beech Street Commercial |
$26.37
|
| Rate for Payer: Beech Street Commercial |
$24.44
|
| Rate for Payer: Beech Street Commercial |
$24.70
|
| Rate for Payer: Beech Street Commercial |
$24.66
|
| Rate for Payer: Beech Street Commercial |
$28.03
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$22.09
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$20.66
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$20.48
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$20.69
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$23.48
|
| Rate for Payer: Cash Price |
$20.02
|
| Rate for Payer: Cash Price |
$17.61
|
| Rate for Payer: Cash Price |
$17.46
|
| Rate for Payer: Cash Price |
$17.64
|
| Rate for Payer: Cash Price |
$18.83
|
| Rate for Payer: ChoiceCare Network Commercial |
$27.74
|
| Rate for Payer: ChoiceCare Network Commercial |
$26.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$24.41
|
| Rate for Payer: ChoiceCare Network Commercial |
$24.44
|
| Rate for Payer: ChoiceCare Network Commercial |
$24.19
|
| Rate for Payer: Cigna of WY Commercial |
$24.44
|
| Rate for Payer: Cigna of WY Commercial |
$24.66
|
| Rate for Payer: Cigna of WY Commercial |
$24.70
|
| Rate for Payer: Cigna of WY Commercial |
$26.37
|
| Rate for Payer: Cigna of WY Commercial |
$28.03
|
| Rate for Payer: Entrust Commercial |
$23.69
|
| Rate for Payer: Entrust Commercial |
$23.90
|
| Rate for Payer: Entrust Commercial |
$23.94
|
| Rate for Payer: Entrust Commercial |
$27.17
|
| Rate for Payer: Entrust Commercial |
$25.56
|
| Rate for Payer: First Choice Health Commercial |
$23.69
|
| Rate for Payer: First Choice Health Commercial |
$25.56
|
| Rate for Payer: First Choice Health Commercial |
$27.17
|
| Rate for Payer: First Choice Health Commercial |
$23.94
|
| Rate for Payer: First Choice Health Commercial |
$23.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$23.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$23.69
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$27.17
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$25.56
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$23.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$16.59
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$14.47
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$14.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$15.61
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$14.59
|
| Rate for Payer: HealthUtah PPO |
$24.94
|
| Rate for Payer: HealthUtah PPO |
$25.20
|
| Rate for Payer: HealthUtah PPO |
$25.16
|
| Rate for Payer: HealthUtah PPO |
$28.60
|
| Rate for Payer: HealthUtah PPO |
$26.91
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$26.10
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$27.74
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.41
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.19
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.44
|
| Rate for Payer: Multiplan Medicare/VA |
$15.76
|
| Rate for Payer: Multiplan Medicare/VA |
$13.74
|
| Rate for Payer: Multiplan Medicare/VA |
$13.89
|
| Rate for Payer: Multiplan Medicare/VA |
$14.83
|
| Rate for Payer: Multiplan Medicare/VA |
$13.86
|
| Rate for Payer: One Health Plan of WY PPO |
$24.66
|
| Rate for Payer: One Health Plan of WY PPO |
$24.44
|
| Rate for Payer: One Health Plan of WY PPO |
$24.70
|
| Rate for Payer: One Health Plan of WY PPO |
$26.37
|
| Rate for Payer: One Health Plan of WY PPO |
$28.03
|
| Rate for Payer: PacificSource Commercial |
$22.68
|
| Rate for Payer: PacificSource Commercial |
$22.45
|
| Rate for Payer: PacificSource Commercial |
$24.22
|
| Rate for Payer: PacificSource Commercial |
$25.74
|
| Rate for Payer: PacificSource Commercial |
$22.64
|
| Rate for Payer: PHCS PPO |
$28.03
|
| Rate for Payer: PHCS PPO |
$24.66
|
| Rate for Payer: PHCS PPO |
$24.70
|
| Rate for Payer: PHCS PPO |
$26.37
|
| Rate for Payer: PHCS PPO |
$24.44
|
| Rate for Payer: Three Rivers PPO |
$18.87
|
| Rate for Payer: Three Rivers PPO |
$18.90
|
| Rate for Payer: Three Rivers PPO |
$18.70
|
| Rate for Payer: Three Rivers PPO |
$21.45
|
| Rate for Payer: Three Rivers PPO |
$20.18
|
| Rate for Payer: TriWest Veterans Administration |
$14.59
|
| Rate for Payer: TriWest Veterans Administration |
$15.61
|
| Rate for Payer: TriWest Veterans Administration |
$16.59
|
| Rate for Payer: TriWest Veterans Administration |
$14.62
|
| Rate for Payer: TriWest Veterans Administration |
$14.47
|
| Rate for Payer: United Healthcare Commercial |
$23.41
|
| Rate for Payer: United Healthcare Commercial |
$21.89
|
| Rate for Payer: United Healthcare Commercial |
$21.70
|
| Rate for Payer: United Healthcare Commercial |
$21.92
|
| Rate for Payer: United Healthcare Commercial |
$24.88
|
| Rate for Payer: United Healthcare Medicare |
$14.62
|
| Rate for Payer: United Healthcare Medicare |
$15.61
|
| Rate for Payer: United Healthcare Medicare |
$14.47
|
| Rate for Payer: United Healthcare Medicare |
$14.59
|
| Rate for Payer: United Healthcare Medicare |
$16.59
|
| Rate for Payer: WINHealth Partners Commercial |
$24.44
|
| Rate for Payer: WINHealth Partners Commercial |
$26.37
|
| Rate for Payer: WINHealth Partners Commercial |
$28.03
|
| Rate for Payer: WINHealth Partners Commercial |
$24.70
|
| Rate for Payer: WINHealth Partners Commercial |
$24.66
|
| Rate for Payer: Wise Provider Network Commercial |
$23.94
|
| Rate for Payer: Wise Provider Network Commercial |
$27.17
|
| Rate for Payer: Wise Provider Network Commercial |
$23.90
|
| Rate for Payer: Wise Provider Network Commercial |
$23.69
|
| Rate for Payer: Wise Provider Network Commercial |
$25.56
|
|
|
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION [94700]
|
Facility
|
IP
|
$28.60
|
|
|
Service Code
|
HCPCS J0780
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.93 |
| Max. Negotiated Rate |
$28.60 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$28.03
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$24.70
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$26.37
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$24.44
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$24.66
|
| Rate for Payer: Altius Auto/Workers Compensation |
$27.46
|
| Rate for Payer: Altius Auto/Workers Compensation |
$24.19
|
| Rate for Payer: Altius Auto/Workers Compensation |
$24.15
|
| Rate for Payer: Altius Auto/Workers Compensation |
$23.94
|
| Rate for Payer: Altius Auto/Workers Compensation |
$25.83
|
| Rate for Payer: Altius Commercial |
$24.15
|
| Rate for Payer: Altius Commercial |
$24.19
|
| Rate for Payer: Altius Commercial |
$27.46
|
| Rate for Payer: Altius Commercial |
$23.94
|
| Rate for Payer: Altius Commercial |
$25.83
|
| Rate for Payer: Beech Street Commercial |
$24.66
|
| Rate for Payer: Beech Street Commercial |
$24.44
|
| Rate for Payer: Beech Street Commercial |
$26.37
|
| Rate for Payer: Beech Street Commercial |
$28.03
|
| Rate for Payer: Beech Street Commercial |
$24.70
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$20.48
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$20.66
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$20.69
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$22.09
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$23.48
|
| Rate for Payer: Cash Price |
$20.02
|
| Rate for Payer: Cash Price |
$17.61
|
| Rate for Payer: Cash Price |
$17.46
|
| Rate for Payer: Cash Price |
$17.64
|
| Rate for Payer: Cash Price |
$18.83
|
| Rate for Payer: ChoiceCare Network Commercial |
$27.74
|
| Rate for Payer: ChoiceCare Network Commercial |
$24.19
|
| Rate for Payer: ChoiceCare Network Commercial |
$24.44
|
| Rate for Payer: ChoiceCare Network Commercial |
$24.41
|
| Rate for Payer: ChoiceCare Network Commercial |
$26.10
|
| Rate for Payer: Cigna of WY Commercial |
$28.03
|
| Rate for Payer: Cigna of WY Commercial |
$24.66
|
| Rate for Payer: Cigna of WY Commercial |
$26.37
|
| Rate for Payer: Cigna of WY Commercial |
$24.70
|
| Rate for Payer: Cigna of WY Commercial |
$24.44
|
| Rate for Payer: Entrust Commercial |
$23.69
|
| Rate for Payer: Entrust Commercial |
$27.17
|
| Rate for Payer: Entrust Commercial |
$23.94
|
| Rate for Payer: Entrust Commercial |
$23.90
|
| Rate for Payer: Entrust Commercial |
$25.56
|
| Rate for Payer: First Choice Health Commercial |
$23.90
|
| Rate for Payer: First Choice Health Commercial |
$23.69
|
| Rate for Payer: First Choice Health Commercial |
$27.17
|
| Rate for Payer: First Choice Health Commercial |
$25.56
|
| Rate for Payer: First Choice Health Commercial |
$23.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$27.17
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$25.56
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$23.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$23.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$23.69
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$16.61
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$16.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$18.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$17.76
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$16.63
|
| Rate for Payer: HealthUtah PPO |
$26.91
|
| Rate for Payer: HealthUtah PPO |
$24.94
|
| Rate for Payer: HealthUtah PPO |
$25.16
|
| Rate for Payer: HealthUtah PPO |
$28.60
|
| Rate for Payer: HealthUtah PPO |
$25.20
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.41
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$27.74
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$26.10
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.19
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.44
|
| Rate for Payer: Multiplan Medicare/VA |
$15.80
|
| Rate for Payer: Multiplan Medicare/VA |
$15.78
|
| Rate for Payer: Multiplan Medicare/VA |
$15.64
|
| Rate for Payer: Multiplan Medicare/VA |
$16.87
|
| Rate for Payer: Multiplan Medicare/VA |
$17.93
|
| Rate for Payer: One Health Plan of WY PPO |
$24.44
|
| Rate for Payer: One Health Plan of WY PPO |
$24.66
|
| Rate for Payer: One Health Plan of WY PPO |
$24.70
|
| Rate for Payer: One Health Plan of WY PPO |
$26.37
|
| Rate for Payer: One Health Plan of WY PPO |
$28.03
|
| Rate for Payer: PacificSource Commercial |
$22.45
|
| Rate for Payer: PacificSource Commercial |
$22.68
|
| Rate for Payer: PacificSource Commercial |
$22.64
|
| Rate for Payer: PacificSource Commercial |
$24.22
|
| Rate for Payer: PacificSource Commercial |
$25.74
|
| Rate for Payer: PHCS PPO |
$26.37
|
| Rate for Payer: PHCS PPO |
$28.03
|
| Rate for Payer: PHCS PPO |
$24.70
|
| Rate for Payer: PHCS PPO |
$24.44
|
| Rate for Payer: PHCS PPO |
$24.66
|
| Rate for Payer: Three Rivers PPO |
$18.87
|
| Rate for Payer: Three Rivers PPO |
$21.45
|
| Rate for Payer: Three Rivers PPO |
$20.18
|
| Rate for Payer: Three Rivers PPO |
$18.90
|
| Rate for Payer: Three Rivers PPO |
$18.70
|
| Rate for Payer: TriWest Veterans Administration |
$18.88
|
| Rate for Payer: TriWest Veterans Administration |
$16.63
|
| Rate for Payer: TriWest Veterans Administration |
$16.46
|
| Rate for Payer: TriWest Veterans Administration |
$16.61
|
| Rate for Payer: TriWest Veterans Administration |
$17.76
|
| Rate for Payer: United Healthcare Commercial |
$23.41
|
| Rate for Payer: United Healthcare Commercial |
$24.88
|
| Rate for Payer: United Healthcare Commercial |
$21.70
|
| Rate for Payer: United Healthcare Commercial |
$21.89
|
| Rate for Payer: United Healthcare Commercial |
$21.92
|
| Rate for Payer: United Healthcare Medicare |
$16.63
|
| Rate for Payer: United Healthcare Medicare |
$17.76
|
| Rate for Payer: United Healthcare Medicare |
$16.61
|
| Rate for Payer: United Healthcare Medicare |
$16.46
|
| Rate for Payer: United Healthcare Medicare |
$18.88
|
| Rate for Payer: WINHealth Partners Commercial |
$23.90
|
| Rate for Payer: WINHealth Partners Commercial |
$25.56
|
| Rate for Payer: WINHealth Partners Commercial |
$27.17
|
| Rate for Payer: WINHealth Partners Commercial |
$23.94
|
| Rate for Payer: WINHealth Partners Commercial |
$23.69
|
| Rate for Payer: Wise Provider Network Commercial |
$23.90
|
| Rate for Payer: Wise Provider Network Commercial |
$27.17
|
| Rate for Payer: Wise Provider Network Commercial |
$25.56
|
| Rate for Payer: Wise Provider Network Commercial |
$23.69
|
| Rate for Payer: Wise Provider Network Commercial |
$23.94
|
|
|
PROCHLORPERAZINE INJECTION
|
Professional
|
Both
|
$23.00
|
|
|
Service Code
|
HCPCS J0780
|
| Hospital Charge Code |
J0780
|
| Min. Negotiated Rate |
$3.35 |
| Max. Negotiated Rate |
$23.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$22.54
|
| Rate for Payer: Aetna of WY Medicare |
$3.94
|
| Rate for Payer: Beech Street Commercial |
$21.85
|
| Rate for Payer: Cash Price |
$16.10
|
| Rate for Payer: Cash Price |
$16.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$22.31
|
| Rate for Payer: Cigna of WY Commercial |
$22.54
|
| Rate for Payer: First Choice Health Commercial |
$20.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$21.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3.94
|
| Rate for Payer: HealthUtah PPO |
$23.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$22.31
|
| Rate for Payer: Multiplan Medicare/VA |
$3.35
|
| Rate for Payer: One Health Plan of WY PPO |
$22.54
|
| Rate for Payer: PacificSource Commercial |
$20.70
|
| Rate for Payer: PHCS PPO |
$21.85
|
| Rate for Payer: Three Rivers PPO |
$17.25
|
| Rate for Payer: TriWest Veterans Administration |
$3.94
|
| Rate for Payer: United Healthcare Commercial |
$20.01
|
| Rate for Payer: United Healthcare Medicare |
$3.94
|
| Rate for Payer: WINHealth Partners Commercial |
$21.85
|
|
|
PROCISE EZ VIEW WAND
|
Facility
|
OP
|
$1,146.01
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$631.45 |
| Max. Negotiated Rate |
$1,146.01 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,123.09
|
| Rate for Payer: Aetna of WY Medicare |
$756.37
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,100.17
|
| Rate for Payer: Altius Commercial |
$1,100.17
|
| Rate for Payer: Beech Street Commercial |
$1,123.09
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$940.87
|
| Rate for Payer: Cash Price |
$802.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,111.63
|
| Rate for Payer: Cigna of WY Commercial |
$1,123.09
|
| Rate for Payer: Entrust Commercial |
$1,088.71
|
| Rate for Payer: First Choice Health Commercial |
$1,088.71
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,088.71
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$664.69
|
| Rate for Payer: HealthUtah PPO |
$1,146.01
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,111.63
|
| Rate for Payer: Multiplan Medicare/VA |
$631.45
|
| Rate for Payer: One Health Plan of WY PPO |
$1,123.09
|
| Rate for Payer: PacificSource Commercial |
$1,031.41
|
| Rate for Payer: PHCS PPO |
$1,123.09
|
| Rate for Payer: Three Rivers PPO |
$859.51
|
| Rate for Payer: TriWest Veterans Administration |
$664.69
|
| Rate for Payer: United Healthcare Commercial |
$997.03
|
| Rate for Payer: United Healthcare Medicare |
$664.69
|
| Rate for Payer: WINHealth Partners Commercial |
$1,123.09
|
| Rate for Payer: Wise Provider Network Commercial |
$1,088.71
|
|
