|
PROCISE EZ VIEW WAND
|
Facility
|
IP
|
$1,146.01
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$718.55 |
| Max. Negotiated Rate |
$1,146.01 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,123.09
|
| 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 |
$756.37
|
| Rate for Payer: HealthUtah PPO |
$1,146.01
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,111.63
|
| Rate for Payer: Multiplan Medicare/VA |
$718.55
|
| 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 |
$756.37
|
| Rate for Payer: United Healthcare Commercial |
$997.03
|
| Rate for Payer: United Healthcare Medicare |
$756.37
|
| Rate for Payer: WINHealth Partners Commercial |
$1,088.71
|
| Rate for Payer: Wise Provider Network Commercial |
$1,088.71
|
|
|
PROCTOSGMDSC RIGID W/BX SINGLE/MULTIPLE
|
Professional
|
Both
|
$885.00
|
|
|
Service Code
|
HCPCS 45305
|
| Hospital Charge Code |
45305
|
| Min. Negotiated Rate |
$59.22 |
| Max. Negotiated Rate |
$885.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$867.30
|
| Rate for Payer: Aetna of WY Medicare |
$69.67
|
| Rate for Payer: Beech Street Commercial |
$840.75
|
| Rate for Payer: Cash Price |
$619.50
|
| Rate for Payer: Cash Price |
$619.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$858.45
|
| Rate for Payer: Cigna of WY Commercial |
$867.30
|
| Rate for Payer: First Choice Health Commercial |
$796.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$840.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$69.67
|
| Rate for Payer: HealthUtah PPO |
$885.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$858.45
|
| Rate for Payer: Multiplan Medicare/VA |
$59.22
|
| Rate for Payer: One Health Plan of WY PPO |
$867.30
|
| Rate for Payer: PacificSource Commercial |
$796.50
|
| Rate for Payer: PHCS PPO |
$840.75
|
| Rate for Payer: Three Rivers PPO |
$663.75
|
| Rate for Payer: TriWest Veterans Administration |
$69.67
|
| Rate for Payer: United Healthcare Commercial |
$769.95
|
| Rate for Payer: United Healthcare Medicare |
$69.67
|
| Rate for Payer: WINHealth Partners Commercial |
$752.25
|
|
|
PROF SVCS ALLG IMMNTX X W/PRV ALLGIC XTRCS 1 NJX
|
Professional
|
Both
|
$21.00
|
|
|
Service Code
|
HCPCS 95115
|
| Hospital Charge Code |
95115
|
| Min. Negotiated Rate |
$8.56 |
| Max. Negotiated Rate |
$21.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$20.58
|
| Rate for Payer: Aetna of WY Medicare |
$10.07
|
| Rate for Payer: Beech Street Commercial |
$19.95
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$20.37
|
| Rate for Payer: Cigna of WY Commercial |
$20.58
|
| Rate for Payer: First Choice Health Commercial |
$18.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$19.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.07
|
| Rate for Payer: HealthUtah PPO |
$21.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$20.37
|
| Rate for Payer: Multiplan Medicare/VA |
$8.56
|
| Rate for Payer: One Health Plan of WY PPO |
$20.58
|
| Rate for Payer: PacificSource Commercial |
$18.90
|
| Rate for Payer: PHCS PPO |
$19.95
|
| Rate for Payer: Three Rivers PPO |
$15.75
|
| Rate for Payer: TriWest Veterans Administration |
$10.07
|
| Rate for Payer: United Healthcare Commercial |
$18.27
|
| Rate for Payer: United Healthcare Medicare |
$10.07
|
| Rate for Payer: WINHealth Partners Commercial |
$19.95
|
|
|
PROF SVCS ALLG IMMNTX X W/PRV ALLGIC XTRCS NJXS
|
Professional
|
Both
|
$43.00
|
|
|
Service Code
|
HCPCS 95117
|
| Hospital Charge Code |
95117
|
| Min. Negotiated Rate |
$10.23 |
| Max. Negotiated Rate |
$43.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$42.14
|
| Rate for Payer: Aetna of WY Medicare |
$12.03
|
| Rate for Payer: Beech Street Commercial |
$40.85
|
| Rate for Payer: Cash Price |
$30.10
|
| Rate for Payer: Cash Price |
$30.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$41.71
|
| Rate for Payer: Cigna of WY Commercial |
$42.14
|
| Rate for Payer: First Choice Health Commercial |
$38.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$40.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$12.03
|
| Rate for Payer: HealthUtah PPO |
$43.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$41.71
|
| Rate for Payer: Multiplan Medicare/VA |
$10.23
|
| Rate for Payer: One Health Plan of WY PPO |
$42.14
|
| Rate for Payer: PacificSource Commercial |
$38.70
|
| Rate for Payer: PHCS PPO |
$40.85
|
| Rate for Payer: Three Rivers PPO |
$32.25
|
| Rate for Payer: TriWest Veterans Administration |
$12.03
|
| Rate for Payer: United Healthcare Commercial |
$37.41
|
| Rate for Payer: United Healthcare Medicare |
$12.03
|
| Rate for Payer: WINHealth Partners Commercial |
$40.85
|
|
|
PROGRAM EVAL IMPLANTABLE IN PERSN DUAL LD PACER
|
Professional
|
Both
|
$338.00
|
|
|
Service Code
|
HCPCS 93280
|
| Hospital Charge Code |
93280
|
| Min. Negotiated Rate |
$65.19 |
| Max. Negotiated Rate |
$338.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$331.24
|
| Rate for Payer: Aetna of WY Medicare |
$76.69
|
| Rate for Payer: Beech Street Commercial |
$321.10
|
| Rate for Payer: Cash Price |
$236.60
|
| Rate for Payer: Cash Price |
$236.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$327.86
|
| Rate for Payer: Cigna of WY Commercial |
$331.24
|
| Rate for Payer: First Choice Health Commercial |
$304.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$321.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$76.69
|
| Rate for Payer: HealthUtah PPO |
$338.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$327.86
|
| Rate for Payer: Multiplan Medicare/VA |
$65.19
|
| Rate for Payer: One Health Plan of WY PPO |
$331.24
|
| Rate for Payer: PacificSource Commercial |
$304.20
|
| Rate for Payer: PHCS PPO |
$321.10
|
| Rate for Payer: Three Rivers PPO |
$253.50
|
| Rate for Payer: TriWest Veterans Administration |
$76.69
|
| Rate for Payer: United Healthcare Commercial |
$294.06
|
| Rate for Payer: United Healthcare Medicare |
$76.69
|
| Rate for Payer: WINHealth Partners Commercial |
$321.10
|
|
|
PROLARYN PLUS 1.0CC
|
Facility
|
OP
|
$2,572.50
|
|
| Hospital Charge Code |
27800000S1
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,417.45 |
| Max. Negotiated Rate |
$2,572.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,521.05
|
| Rate for Payer: Aetna of WY Medicare |
$1,697.85
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2,469.60
|
| Rate for Payer: Altius Commercial |
$2,469.60
|
| Rate for Payer: Beech Street Commercial |
$2,521.05
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,112.02
|
| Rate for Payer: Cash Price |
$1,800.75
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,495.32
|
| Rate for Payer: Cigna of WY Commercial |
$2,521.05
|
| Rate for Payer: Entrust Commercial |
$2,443.88
|
| Rate for Payer: First Choice Health Commercial |
$2,443.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,443.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,492.05
|
| Rate for Payer: HealthUtah PPO |
$2,572.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,495.32
|
| Rate for Payer: Multiplan Medicare/VA |
$1,417.45
|
| Rate for Payer: One Health Plan of WY PPO |
$2,521.05
|
| Rate for Payer: PacificSource Commercial |
$2,315.25
|
| Rate for Payer: PHCS PPO |
$2,521.05
|
| Rate for Payer: Three Rivers PPO |
$1,929.38
|
| Rate for Payer: TriWest Veterans Administration |
$1,492.05
|
| Rate for Payer: United Healthcare Commercial |
$2,238.08
|
| Rate for Payer: United Healthcare Medicare |
$1,492.05
|
| Rate for Payer: WINHealth Partners Commercial |
$2,521.05
|
| Rate for Payer: Wise Provider Network Commercial |
$2,443.88
|
|
|
PROLARYN PLUS 1.0CC
|
Facility
|
IP
|
$2,572.50
|
|
| Hospital Charge Code |
27800000S1
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,612.96 |
| Max. Negotiated Rate |
$2,572.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,521.05
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2,469.60
|
| Rate for Payer: Altius Commercial |
$2,469.60
|
| Rate for Payer: Beech Street Commercial |
$2,521.05
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,112.02
|
| Rate for Payer: Cash Price |
$1,800.75
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,495.32
|
| Rate for Payer: Cigna of WY Commercial |
$2,521.05
|
| Rate for Payer: Entrust Commercial |
$2,443.88
|
| Rate for Payer: First Choice Health Commercial |
$2,443.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,443.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,697.85
|
| Rate for Payer: HealthUtah PPO |
$2,572.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,495.32
|
| Rate for Payer: Multiplan Medicare/VA |
$1,612.96
|
| Rate for Payer: One Health Plan of WY PPO |
$2,521.05
|
| Rate for Payer: PacificSource Commercial |
$2,315.25
|
| Rate for Payer: PHCS PPO |
$2,521.05
|
| Rate for Payer: Three Rivers PPO |
$1,929.38
|
| Rate for Payer: TriWest Veterans Administration |
$1,697.85
|
| Rate for Payer: United Healthcare Commercial |
$2,238.08
|
| Rate for Payer: United Healthcare Medicare |
$1,697.85
|
| Rate for Payer: WINHealth Partners Commercial |
$2,443.88
|
| Rate for Payer: Wise Provider Network Commercial |
$2,443.88
|
|
|
PROLNG E/M SVC BEFORE&/AFTER DIR PT CARE 1ST HR
|
Professional
|
Both
|
$410.00
|
|
|
Service Code
|
HCPCS 99358
|
| Hospital Charge Code |
99358
|
| Min. Negotiated Rate |
$307.50 |
| Max. Negotiated Rate |
$410.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$401.80
|
| Rate for Payer: Beech Street Commercial |
$389.50
|
| Rate for Payer: Cash Price |
$287.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$397.70
|
| Rate for Payer: Cigna of WY Commercial |
$401.80
|
| Rate for Payer: First Choice Health Commercial |
$369.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$389.50
|
| Rate for Payer: HealthUtah PPO |
$410.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$397.70
|
| Rate for Payer: One Health Plan of WY PPO |
$401.80
|
| Rate for Payer: PacificSource Commercial |
$369.00
|
| Rate for Payer: PHCS PPO |
$389.50
|
| Rate for Payer: Three Rivers PPO |
$307.50
|
| Rate for Payer: United Healthcare Commercial |
$356.70
|
| Rate for Payer: WINHealth Partners Commercial |
$389.50
|
|
|
PROLONGED INPATIENT/OBSERVATION EM SVC EA 15 MIN
|
Professional
|
Both
|
$158.00
|
|
|
Service Code
|
HCPCS 99418
|
| Hospital Charge Code |
99418
|
| Min. Negotiated Rate |
$118.50 |
| Max. Negotiated Rate |
$158.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$154.84
|
| Rate for Payer: Beech Street Commercial |
$150.10
|
| Rate for Payer: Cash Price |
$110.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$153.26
|
| Rate for Payer: Cigna of WY Commercial |
$154.84
|
| Rate for Payer: First Choice Health Commercial |
$142.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$150.10
|
| Rate for Payer: HealthUtah PPO |
$158.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$153.26
|
| Rate for Payer: One Health Plan of WY PPO |
$154.84
|
| Rate for Payer: PacificSource Commercial |
$142.20
|
| Rate for Payer: PHCS PPO |
$150.10
|
| Rate for Payer: Three Rivers PPO |
$118.50
|
| Rate for Payer: United Healthcare Commercial |
$137.46
|
| Rate for Payer: WINHealth Partners Commercial |
$150.10
|
|
|
PROLONGED OUTPATIENT E/M SERVICE EACH 15 MINUTES
|
Professional
|
Both
|
$102.00
|
|
|
Service Code
|
HCPCS 99417
|
| Hospital Charge Code |
99417
|
| Min. Negotiated Rate |
$76.50 |
| Max. Negotiated Rate |
$102.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$99.96
|
| Rate for Payer: Beech Street Commercial |
$96.90
|
| Rate for Payer: Cash Price |
$71.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$98.94
|
| Rate for Payer: Cigna of WY Commercial |
$99.96
|
| Rate for Payer: First Choice Health Commercial |
$91.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$96.90
|
| Rate for Payer: HealthUtah PPO |
$102.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$98.94
|
| Rate for Payer: One Health Plan of WY PPO |
$99.96
|
| Rate for Payer: PacificSource Commercial |
$91.80
|
| Rate for Payer: PHCS PPO |
$96.90
|
| Rate for Payer: Three Rivers PPO |
$76.50
|
| Rate for Payer: United Healthcare Commercial |
$88.74
|
| Rate for Payer: WINHealth Partners Commercial |
$96.90
|
|
|
PROLONGED SVC OUTPATIENT SETTING 1ST HOUR
|
Professional
|
Both
|
$398.00
|
|
|
Service Code
|
HCPCS 99354
|
| Hospital Charge Code |
99354
|
| Min. Negotiated Rate |
$298.50 |
| Max. Negotiated Rate |
$398.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$390.04
|
| Rate for Payer: Beech Street Commercial |
$378.10
|
| Rate for Payer: Cash Price |
$278.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$386.06
|
| Rate for Payer: Cigna of WY Commercial |
$390.04
|
| Rate for Payer: First Choice Health Commercial |
$358.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$378.10
|
| Rate for Payer: HealthUtah PPO |
$398.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$386.06
|
| Rate for Payer: One Health Plan of WY PPO |
$390.04
|
| Rate for Payer: PacificSource Commercial |
$358.20
|
| Rate for Payer: PHCS PPO |
$378.10
|
| Rate for Payer: Three Rivers PPO |
$298.50
|
| Rate for Payer: United Healthcare Commercial |
$346.26
|
| Rate for Payer: WINHealth Partners Commercial |
$378.10
|
|
|
PROLONGED SVC OUTPATIENT SETTING EA ADDL 30 MIN
|
Professional
|
Both
|
$555.00
|
|
|
Service Code
|
HCPCS 99355
|
| Hospital Charge Code |
99355
|
| Min. Negotiated Rate |
$416.25 |
| Max. Negotiated Rate |
$555.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$543.90
|
| Rate for Payer: Beech Street Commercial |
$527.25
|
| Rate for Payer: Cash Price |
$388.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$538.35
|
| Rate for Payer: Cigna of WY Commercial |
$543.90
|
| Rate for Payer: First Choice Health Commercial |
$499.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$527.25
|
| Rate for Payer: HealthUtah PPO |
$555.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$538.35
|
| Rate for Payer: One Health Plan of WY PPO |
$543.90
|
| Rate for Payer: PacificSource Commercial |
$499.50
|
| Rate for Payer: PHCS PPO |
$527.25
|
| Rate for Payer: Three Rivers PPO |
$416.25
|
| Rate for Payer: United Healthcare Commercial |
$482.85
|
| Rate for Payer: WINHealth Partners Commercial |
$527.25
|
|
|
PROLONG OUTPT/OFFICE VIS
|
Professional
|
Both
|
$102.00
|
|
|
Service Code
|
HCPCS G2212
|
| Hospital Charge Code |
G2212
|
| Min. Negotiated Rate |
$25.52 |
| Max. Negotiated Rate |
$102.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$99.96
|
| Rate for Payer: Aetna of WY Medicare |
$30.02
|
| Rate for Payer: Beech Street Commercial |
$96.90
|
| Rate for Payer: Cash Price |
$71.40
|
| Rate for Payer: Cash Price |
$71.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$98.94
|
| Rate for Payer: Cigna of WY Commercial |
$99.96
|
| Rate for Payer: First Choice Health Commercial |
$91.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$96.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$30.02
|
| Rate for Payer: HealthUtah PPO |
$102.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$98.94
|
| Rate for Payer: Multiplan Medicare/VA |
$25.52
|
| Rate for Payer: One Health Plan of WY PPO |
$99.96
|
| Rate for Payer: PacificSource Commercial |
$91.80
|
| Rate for Payer: PHCS PPO |
$96.90
|
| Rate for Payer: Three Rivers PPO |
$76.50
|
| Rate for Payer: TriWest Veterans Administration |
$30.02
|
| Rate for Payer: United Healthcare Commercial |
$88.74
|
| Rate for Payer: United Healthcare Medicare |
$30.02
|
| Rate for Payer: WINHealth Partners Commercial |
$96.90
|
|
|
PROMETHAZINE 25 MG RECTAL SUPPOSITORY [4253]
|
Facility
|
OP
|
$31.68
|
|
|
Service Code
|
NDC 0713052606
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.46 |
| Max. Negotiated Rate |
$31.68 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$31.05
|
| Rate for Payer: Aetna of WY Medicare |
$20.91
|
| Rate for Payer: Altius Auto/Workers Compensation |
$30.41
|
| Rate for Payer: Altius Commercial |
$30.41
|
| Rate for Payer: Beech Street Commercial |
$31.05
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$26.01
|
| Rate for Payer: Cash Price |
$22.18
|
| Rate for Payer: ChoiceCare Network Commercial |
$30.73
|
| Rate for Payer: Cigna of WY Commercial |
$31.05
|
| Rate for Payer: Entrust Commercial |
$30.10
|
| Rate for Payer: First Choice Health Commercial |
$30.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$30.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$18.37
|
| Rate for Payer: HealthUtah PPO |
$31.68
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$30.73
|
| Rate for Payer: Multiplan Medicare/VA |
$17.46
|
| Rate for Payer: One Health Plan of WY PPO |
$31.05
|
| Rate for Payer: PacificSource Commercial |
$28.51
|
| Rate for Payer: PHCS PPO |
$31.05
|
| Rate for Payer: Three Rivers PPO |
$23.76
|
| Rate for Payer: TriWest Veterans Administration |
$18.37
|
| Rate for Payer: United Healthcare Commercial |
$27.56
|
| Rate for Payer: United Healthcare Medicare |
$18.37
|
| Rate for Payer: WINHealth Partners Commercial |
$31.05
|
| Rate for Payer: Wise Provider Network Commercial |
$30.10
|
|
|
PROMETHAZINE 25 MG RECTAL SUPPOSITORY [4253]
|
Facility
|
IP
|
$31.68
|
|
|
Service Code
|
NDC 0713052612
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.86 |
| Max. Negotiated Rate |
$31.68 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$31.05
|
| Rate for Payer: Altius Auto/Workers Compensation |
$30.41
|
| Rate for Payer: Altius Commercial |
$30.41
|
| Rate for Payer: Beech Street Commercial |
$31.05
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$26.01
|
| Rate for Payer: Cash Price |
$22.18
|
| Rate for Payer: ChoiceCare Network Commercial |
$30.73
|
| Rate for Payer: Cigna of WY Commercial |
$31.05
|
| Rate for Payer: Entrust Commercial |
$30.10
|
| Rate for Payer: First Choice Health Commercial |
$30.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$30.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$20.91
|
| Rate for Payer: HealthUtah PPO |
$31.68
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$30.73
|
| Rate for Payer: Multiplan Medicare/VA |
$19.86
|
| Rate for Payer: One Health Plan of WY PPO |
$31.05
|
| Rate for Payer: PacificSource Commercial |
$28.51
|
| Rate for Payer: PHCS PPO |
$31.05
|
| Rate for Payer: Three Rivers PPO |
$23.76
|
| Rate for Payer: TriWest Veterans Administration |
$20.91
|
| Rate for Payer: United Healthcare Commercial |
$27.56
|
| Rate for Payer: United Healthcare Medicare |
$20.91
|
| Rate for Payer: WINHealth Partners Commercial |
$30.10
|
| Rate for Payer: Wise Provider Network Commercial |
$30.10
|
|
|
PROMETHAZINE 25 MG RECTAL SUPPOSITORY [4253]
|
Facility
|
OP
|
$31.68
|
|
|
Service Code
|
NDC 0713052612
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.46 |
| Max. Negotiated Rate |
$31.68 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$31.05
|
| Rate for Payer: Aetna of WY Medicare |
$20.91
|
| Rate for Payer: Altius Auto/Workers Compensation |
$30.41
|
| Rate for Payer: Altius Commercial |
$30.41
|
| Rate for Payer: Beech Street Commercial |
$31.05
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$26.01
|
| Rate for Payer: Cash Price |
$22.18
|
| Rate for Payer: ChoiceCare Network Commercial |
$30.73
|
| Rate for Payer: Cigna of WY Commercial |
$31.05
|
| Rate for Payer: Entrust Commercial |
$30.10
|
| Rate for Payer: First Choice Health Commercial |
$30.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$30.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$18.37
|
| Rate for Payer: HealthUtah PPO |
$31.68
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$30.73
|
| Rate for Payer: Multiplan Medicare/VA |
$17.46
|
| Rate for Payer: One Health Plan of WY PPO |
$31.05
|
| Rate for Payer: PacificSource Commercial |
$28.51
|
| Rate for Payer: PHCS PPO |
$31.05
|
| Rate for Payer: Three Rivers PPO |
$23.76
|
| Rate for Payer: TriWest Veterans Administration |
$18.37
|
| Rate for Payer: United Healthcare Commercial |
$27.56
|
| Rate for Payer: United Healthcare Medicare |
$18.37
|
| Rate for Payer: WINHealth Partners Commercial |
$31.05
|
| Rate for Payer: Wise Provider Network Commercial |
$30.10
|
|
|
PROMETHAZINE 25 MG RECTAL SUPPOSITORY [4253]
|
Facility
|
IP
|
$31.68
|
|
|
Service Code
|
NDC 0713052606
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.86 |
| Max. Negotiated Rate |
$31.68 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$31.05
|
| Rate for Payer: Altius Auto/Workers Compensation |
$30.41
|
| Rate for Payer: Altius Commercial |
$30.41
|
| Rate for Payer: Beech Street Commercial |
$31.05
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$26.01
|
| Rate for Payer: Cash Price |
$22.18
|
| Rate for Payer: ChoiceCare Network Commercial |
$30.73
|
| Rate for Payer: Cigna of WY Commercial |
$31.05
|
| Rate for Payer: Entrust Commercial |
$30.10
|
| Rate for Payer: First Choice Health Commercial |
$30.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$30.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$20.91
|
| Rate for Payer: HealthUtah PPO |
$31.68
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$30.73
|
| Rate for Payer: Multiplan Medicare/VA |
$19.86
|
| Rate for Payer: One Health Plan of WY PPO |
$31.05
|
| Rate for Payer: PacificSource Commercial |
$28.51
|
| Rate for Payer: PHCS PPO |
$31.05
|
| Rate for Payer: Three Rivers PPO |
$23.76
|
| Rate for Payer: TriWest Veterans Administration |
$20.91
|
| Rate for Payer: United Healthcare Commercial |
$27.56
|
| Rate for Payer: United Healthcare Medicare |
$20.91
|
| Rate for Payer: WINHealth Partners Commercial |
$30.10
|
| Rate for Payer: Wise Provider Network Commercial |
$30.10
|
|
|
PROMETHAZINE 25 MG TABLET [13336]
|
Facility
|
IP
|
$1.65
|
|
|
Service Code
|
NDC 6808415511
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.03 |
| Max. Negotiated Rate |
$1.65 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.62
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.58
|
| Rate for Payer: Altius Commercial |
$1.58
|
| Rate for Payer: Beech Street Commercial |
$1.62
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.35
|
| Rate for Payer: Cash Price |
$1.16
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.60
|
| Rate for Payer: Cigna of WY Commercial |
$1.62
|
| Rate for Payer: Entrust Commercial |
$1.57
|
| Rate for Payer: First Choice Health Commercial |
$1.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.09
|
| Rate for Payer: HealthUtah PPO |
$1.65
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.60
|
| Rate for Payer: Multiplan Medicare/VA |
$1.03
|
| Rate for Payer: One Health Plan of WY PPO |
$1.62
|
| Rate for Payer: PacificSource Commercial |
$1.48
|
| Rate for Payer: PHCS PPO |
$1.62
|
| Rate for Payer: Three Rivers PPO |
$1.24
|
| Rate for Payer: TriWest Veterans Administration |
$1.09
|
| Rate for Payer: United Healthcare Commercial |
$1.44
|
| Rate for Payer: United Healthcare Medicare |
$1.09
|
| Rate for Payer: WINHealth Partners Commercial |
$1.57
|
| Rate for Payer: Wise Provider Network Commercial |
$1.57
|
|
|
PROMETHAZINE 25 MG TABLET [13336]
|
Facility
|
IP
|
$0.46
|
|
|
Service Code
|
NDC 0904646161
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$0.46 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.45
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.44
|
| Rate for Payer: Altius Commercial |
$0.44
|
| Rate for Payer: Beech Street Commercial |
$0.45
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.38
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.45
|
| Rate for Payer: Cigna of WY Commercial |
$0.45
|
| Rate for Payer: Entrust Commercial |
$0.44
|
| Rate for Payer: First Choice Health Commercial |
$0.44
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.44
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.30
|
| Rate for Payer: HealthUtah PPO |
$0.46
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.45
|
| Rate for Payer: Multiplan Medicare/VA |
$0.29
|
| Rate for Payer: One Health Plan of WY PPO |
$0.45
|
| Rate for Payer: PacificSource Commercial |
$0.41
|
| Rate for Payer: PHCS PPO |
$0.45
|
| Rate for Payer: Three Rivers PPO |
$0.35
|
| Rate for Payer: TriWest Veterans Administration |
$0.30
|
| Rate for Payer: United Healthcare Commercial |
$0.40
|
| Rate for Payer: United Healthcare Medicare |
$0.30
|
| Rate for Payer: WINHealth Partners Commercial |
$0.44
|
| Rate for Payer: Wise Provider Network Commercial |
$0.44
|
|
|
PROMETHAZINE 25 MG TABLET [13336]
|
Facility
|
OP
|
$1.65
|
|
|
Service Code
|
NDC 6808415511
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.91 |
| Max. Negotiated Rate |
$1.65 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.62
|
| Rate for Payer: Aetna of WY Medicare |
$1.09
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.58
|
| Rate for Payer: Altius Commercial |
$1.58
|
| Rate for Payer: Beech Street Commercial |
$1.62
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.35
|
| Rate for Payer: Cash Price |
$1.16
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.60
|
| Rate for Payer: Cigna of WY Commercial |
$1.62
|
| Rate for Payer: Entrust Commercial |
$1.57
|
| Rate for Payer: First Choice Health Commercial |
$1.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.96
|
| Rate for Payer: HealthUtah PPO |
$1.65
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.60
|
| Rate for Payer: Multiplan Medicare/VA |
$0.91
|
| Rate for Payer: One Health Plan of WY PPO |
$1.62
|
| Rate for Payer: PacificSource Commercial |
$1.48
|
| Rate for Payer: PHCS PPO |
$1.62
|
| Rate for Payer: Three Rivers PPO |
$1.24
|
| Rate for Payer: TriWest Veterans Administration |
$0.96
|
| Rate for Payer: United Healthcare Commercial |
$1.44
|
| Rate for Payer: United Healthcare Medicare |
$0.96
|
| Rate for Payer: WINHealth Partners Commercial |
$1.62
|
| Rate for Payer: Wise Provider Network Commercial |
$1.57
|
|
|
PROMETHAZINE 25 MG TABLET [13336]
|
Facility
|
OP
|
$0.46
|
|
|
Service Code
|
NDC 0904646161
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$0.46 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.45
|
| Rate for Payer: Aetna of WY Medicare |
$0.30
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.44
|
| Rate for Payer: Altius Commercial |
$0.44
|
| Rate for Payer: Beech Street Commercial |
$0.45
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.38
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.45
|
| Rate for Payer: Cigna of WY Commercial |
$0.45
|
| Rate for Payer: Entrust Commercial |
$0.44
|
| Rate for Payer: First Choice Health Commercial |
$0.44
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.44
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.27
|
| Rate for Payer: HealthUtah PPO |
$0.46
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.45
|
| Rate for Payer: Multiplan Medicare/VA |
$0.25
|
| Rate for Payer: One Health Plan of WY PPO |
$0.45
|
| Rate for Payer: PacificSource Commercial |
$0.41
|
| Rate for Payer: PHCS PPO |
$0.45
|
| Rate for Payer: Three Rivers PPO |
$0.35
|
| Rate for Payer: TriWest Veterans Administration |
$0.27
|
| Rate for Payer: United Healthcare Commercial |
$0.40
|
| Rate for Payer: United Healthcare Medicare |
$0.27
|
| Rate for Payer: WINHealth Partners Commercial |
$0.45
|
| Rate for Payer: Wise Provider Network Commercial |
$0.44
|
|
|
PROMETHAZINE HCL INJECTION
|
Professional
|
Both
|
$34.00
|
|
|
Service Code
|
HCPCS J2550
|
| Hospital Charge Code |
J2550
|
| Min. Negotiated Rate |
$2.63 |
| Max. Negotiated Rate |
$34.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$33.32
|
| Rate for Payer: Aetna of WY Medicare |
$3.10
|
| Rate for Payer: Beech Street Commercial |
$32.30
|
| Rate for Payer: Cash Price |
$23.80
|
| Rate for Payer: Cash Price |
$23.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$32.98
|
| Rate for Payer: Cigna of WY Commercial |
$33.32
|
| Rate for Payer: First Choice Health Commercial |
$30.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$32.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3.10
|
| Rate for Payer: HealthUtah PPO |
$34.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$32.98
|
| Rate for Payer: Multiplan Medicare/VA |
$2.63
|
| Rate for Payer: One Health Plan of WY PPO |
$33.32
|
| Rate for Payer: PacificSource Commercial |
$30.60
|
| Rate for Payer: PHCS PPO |
$32.30
|
| Rate for Payer: Three Rivers PPO |
$25.50
|
| Rate for Payer: TriWest Veterans Administration |
$3.10
|
| Rate for Payer: United Healthcare Commercial |
$29.58
|
| Rate for Payer: United Healthcare Medicare |
$3.10
|
| Rate for Payer: WINHealth Partners Commercial |
$32.30
|
|
|
PROPOFOL 10 MG/ML INTRAVENOUS EMULSION [17487]
|
Facility
|
IP
|
$16.20
|
|
|
Service Code
|
NDC 6332326922
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.16 |
| Max. Negotiated Rate |
$16.20 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.88
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.55
|
| Rate for Payer: Altius Commercial |
$15.55
|
| Rate for Payer: Beech Street Commercial |
$15.88
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.30
|
| Rate for Payer: Cash Price |
$11.34
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.71
|
| Rate for Payer: Cigna of WY Commercial |
$15.88
|
| Rate for Payer: Entrust Commercial |
$15.39
|
| Rate for Payer: First Choice Health Commercial |
$15.39
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.39
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.69
|
| Rate for Payer: HealthUtah PPO |
$16.20
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.71
|
| Rate for Payer: Multiplan Medicare/VA |
$10.16
|
| Rate for Payer: One Health Plan of WY PPO |
$15.88
|
| Rate for Payer: PacificSource Commercial |
$14.58
|
| Rate for Payer: PHCS PPO |
$15.88
|
| Rate for Payer: Three Rivers PPO |
$12.15
|
| Rate for Payer: TriWest Veterans Administration |
$10.69
|
| Rate for Payer: United Healthcare Commercial |
$14.09
|
| Rate for Payer: United Healthcare Medicare |
$10.69
|
| Rate for Payer: WINHealth Partners Commercial |
$15.39
|
| Rate for Payer: Wise Provider Network Commercial |
$15.39
|
|
|
PROPOFOL 10 MG/ML INTRAVENOUS EMULSION [17487]
|
Facility
|
IP
|
$16.12
|
|
|
Service Code
|
NDC 4359854952
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.11 |
| Max. Negotiated Rate |
$16.12 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.80
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.48
|
| Rate for Payer: Altius Commercial |
$15.48
|
| Rate for Payer: Beech Street Commercial |
$15.80
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.23
|
| Rate for Payer: Cash Price |
$11.28
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.64
|
| Rate for Payer: Cigna of WY Commercial |
$15.80
|
| Rate for Payer: Entrust Commercial |
$15.31
|
| Rate for Payer: First Choice Health Commercial |
$15.31
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.31
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.64
|
| Rate for Payer: HealthUtah PPO |
$16.12
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.64
|
| Rate for Payer: Multiplan Medicare/VA |
$10.11
|
| Rate for Payer: One Health Plan of WY PPO |
$15.80
|
| Rate for Payer: PacificSource Commercial |
$14.51
|
| Rate for Payer: PHCS PPO |
$15.80
|
| Rate for Payer: Three Rivers PPO |
$12.09
|
| Rate for Payer: TriWest Veterans Administration |
$10.64
|
| Rate for Payer: United Healthcare Commercial |
$14.02
|
| Rate for Payer: United Healthcare Medicare |
$10.64
|
| Rate for Payer: WINHealth Partners Commercial |
$15.31
|
| Rate for Payer: Wise Provider Network Commercial |
$15.31
|
|
|
PROPOFOL 10 MG/ML INTRAVENOUS EMULSION [17487]
|
Facility
|
OP
|
$16.12
|
|
|
Service Code
|
NDC 4359854952
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.88 |
| Max. Negotiated Rate |
$16.12 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.80
|
| Rate for Payer: Aetna of WY Medicare |
$10.64
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.48
|
| Rate for Payer: Altius Commercial |
$15.48
|
| Rate for Payer: Beech Street Commercial |
$15.80
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.23
|
| Rate for Payer: Cash Price |
$11.28
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.64
|
| Rate for Payer: Cigna of WY Commercial |
$15.80
|
| Rate for Payer: Entrust Commercial |
$15.31
|
| Rate for Payer: First Choice Health Commercial |
$15.31
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.31
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.35
|
| Rate for Payer: HealthUtah PPO |
$16.12
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.64
|
| Rate for Payer: Multiplan Medicare/VA |
$8.88
|
| Rate for Payer: One Health Plan of WY PPO |
$15.80
|
| Rate for Payer: PacificSource Commercial |
$14.51
|
| Rate for Payer: PHCS PPO |
$15.80
|
| Rate for Payer: Three Rivers PPO |
$12.09
|
| Rate for Payer: TriWest Veterans Administration |
$9.35
|
| Rate for Payer: United Healthcare Commercial |
$14.02
|
| Rate for Payer: United Healthcare Medicare |
$9.35
|
| Rate for Payer: WINHealth Partners Commercial |
$15.80
|
| Rate for Payer: Wise Provider Network Commercial |
$15.31
|
|
