|
PSYLLIUM HUSK 0.52 GRAM CAPSULE [27780]
|
Facility
|
OP
|
$0.22
|
|
|
Service Code
|
NDC 4612210006
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.22
|
| Rate for Payer: Aetna of WY Medicare |
$0.15
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.21
|
| Rate for Payer: Altius Commercial |
$0.21
|
| Rate for Payer: Beech Street Commercial |
$0.22
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.18
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.21
|
| Rate for Payer: Cigna of WY Commercial |
$0.22
|
| Rate for Payer: Entrust Commercial |
$0.21
|
| Rate for Payer: First Choice Health Commercial |
$0.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.13
|
| Rate for Payer: HealthUtah PPO |
$0.22
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.21
|
| Rate for Payer: Multiplan Medicare/VA |
$0.12
|
| Rate for Payer: One Health Plan of WY PPO |
$0.22
|
| Rate for Payer: PacificSource Commercial |
$0.20
|
| Rate for Payer: PHCS PPO |
$0.22
|
| Rate for Payer: Three Rivers PPO |
$0.17
|
| Rate for Payer: TriWest Veterans Administration |
$0.13
|
| Rate for Payer: United Healthcare Commercial |
$0.19
|
| Rate for Payer: United Healthcare Medicare |
$0.13
|
| Rate for Payer: WINHealth Partners Commercial |
$0.22
|
| Rate for Payer: Wise Provider Network Commercial |
$0.21
|
|
|
PSYLLIUM HUSK 0.52 GRAM CAPSULE [27780]
|
Facility
|
OP
|
$0.29
|
|
|
Service Code
|
NDC 1191708151
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.28
|
| Rate for Payer: Aetna of WY Medicare |
$0.19
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.28
|
| Rate for Payer: Altius Commercial |
$0.28
|
| Rate for Payer: Beech Street Commercial |
$0.28
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.24
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.28
|
| Rate for Payer: Cigna of WY Commercial |
$0.28
|
| Rate for Payer: Entrust Commercial |
$0.28
|
| Rate for Payer: First Choice Health Commercial |
$0.28
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.28
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.17
|
| Rate for Payer: HealthUtah PPO |
$0.29
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.28
|
| Rate for Payer: Multiplan Medicare/VA |
$0.16
|
| Rate for Payer: One Health Plan of WY PPO |
$0.28
|
| Rate for Payer: PacificSource Commercial |
$0.26
|
| Rate for Payer: PHCS PPO |
$0.28
|
| Rate for Payer: Three Rivers PPO |
$0.22
|
| Rate for Payer: TriWest Veterans Administration |
$0.17
|
| Rate for Payer: United Healthcare Commercial |
$0.25
|
| Rate for Payer: United Healthcare Medicare |
$0.17
|
| Rate for Payer: WINHealth Partners Commercial |
$0.28
|
| Rate for Payer: Wise Provider Network Commercial |
$0.28
|
|
|
PSYLLIUM HUSK 0.52 GRAM CAPSULE [27780]
|
Facility
|
IP
|
$0.29
|
|
|
Service Code
|
NDC 1191708151
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.28
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.28
|
| Rate for Payer: Altius Commercial |
$0.28
|
| Rate for Payer: Beech Street Commercial |
$0.28
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.24
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.28
|
| Rate for Payer: Cigna of WY Commercial |
$0.28
|
| Rate for Payer: Entrust Commercial |
$0.28
|
| Rate for Payer: First Choice Health Commercial |
$0.28
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.28
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.19
|
| Rate for Payer: HealthUtah PPO |
$0.29
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.28
|
| Rate for Payer: Multiplan Medicare/VA |
$0.18
|
| Rate for Payer: One Health Plan of WY PPO |
$0.28
|
| Rate for Payer: PacificSource Commercial |
$0.26
|
| Rate for Payer: PHCS PPO |
$0.28
|
| Rate for Payer: Three Rivers PPO |
$0.22
|
| Rate for Payer: TriWest Veterans Administration |
$0.19
|
| Rate for Payer: United Healthcare Commercial |
$0.25
|
| Rate for Payer: United Healthcare Medicare |
$0.19
|
| Rate for Payer: WINHealth Partners Commercial |
$0.28
|
| Rate for Payer: Wise Provider Network Commercial |
$0.28
|
|
|
PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET [87776]
|
Facility
|
IP
|
$1.77
|
|
|
Service Code
|
NDC 3700002404
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.11 |
| Max. Negotiated Rate |
$1.77 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.73
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.70
|
| Rate for Payer: Altius Commercial |
$1.70
|
| Rate for Payer: Beech Street Commercial |
$1.73
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.45
|
| Rate for Payer: Cash Price |
$1.24
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.72
|
| Rate for Payer: Cigna of WY Commercial |
$1.73
|
| Rate for Payer: Entrust Commercial |
$1.68
|
| Rate for Payer: First Choice Health Commercial |
$1.68
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.68
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.17
|
| Rate for Payer: HealthUtah PPO |
$1.77
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.72
|
| Rate for Payer: Multiplan Medicare/VA |
$1.11
|
| Rate for Payer: One Health Plan of WY PPO |
$1.73
|
| Rate for Payer: PacificSource Commercial |
$1.59
|
| Rate for Payer: PHCS PPO |
$1.73
|
| Rate for Payer: Three Rivers PPO |
$1.33
|
| Rate for Payer: TriWest Veterans Administration |
$1.17
|
| Rate for Payer: United Healthcare Commercial |
$1.54
|
| Rate for Payer: United Healthcare Medicare |
$1.17
|
| Rate for Payer: WINHealth Partners Commercial |
$1.68
|
| Rate for Payer: Wise Provider Network Commercial |
$1.68
|
|
|
PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET [87776]
|
Facility
|
OP
|
$1.77
|
|
|
Service Code
|
NDC 3700002404
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.98 |
| Max. Negotiated Rate |
$1.77 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.73
|
| Rate for Payer: Aetna of WY Medicare |
$1.17
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.70
|
| Rate for Payer: Altius Commercial |
$1.70
|
| Rate for Payer: Beech Street Commercial |
$1.73
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.45
|
| Rate for Payer: Cash Price |
$1.24
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.72
|
| Rate for Payer: Cigna of WY Commercial |
$1.73
|
| Rate for Payer: Entrust Commercial |
$1.68
|
| Rate for Payer: First Choice Health Commercial |
$1.68
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.68
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.03
|
| Rate for Payer: HealthUtah PPO |
$1.77
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.72
|
| Rate for Payer: Multiplan Medicare/VA |
$0.98
|
| Rate for Payer: One Health Plan of WY PPO |
$1.73
|
| Rate for Payer: PacificSource Commercial |
$1.59
|
| Rate for Payer: PHCS PPO |
$1.73
|
| Rate for Payer: Three Rivers PPO |
$1.33
|
| Rate for Payer: TriWest Veterans Administration |
$1.03
|
| Rate for Payer: United Healthcare Commercial |
$1.54
|
| Rate for Payer: United Healthcare Medicare |
$1.03
|
| Rate for Payer: WINHealth Partners Commercial |
$1.73
|
| Rate for Payer: Wise Provider Network Commercial |
$1.68
|
|
|
PSYLLIUM SEED (SUGAR) ORAL POWDER [31256]
|
Facility
|
OP
|
$0.09
|
|
|
Service Code
|
NDC 8770140272
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.09
|
| Rate for Payer: Aetna of WY Medicare |
$0.06
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.09
|
| Rate for Payer: Altius Commercial |
$0.09
|
| Rate for Payer: Beech Street Commercial |
$0.09
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.07
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.09
|
| Rate for Payer: Cigna of WY Commercial |
$0.09
|
| Rate for Payer: Entrust Commercial |
$0.09
|
| Rate for Payer: First Choice Health Commercial |
$0.09
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.09
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.05
|
| Rate for Payer: HealthUtah PPO |
$0.09
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.09
|
| Rate for Payer: Multiplan Medicare/VA |
$0.05
|
| Rate for Payer: One Health Plan of WY PPO |
$0.09
|
| Rate for Payer: PacificSource Commercial |
$0.08
|
| Rate for Payer: PHCS PPO |
$0.09
|
| Rate for Payer: Three Rivers PPO |
$0.07
|
| Rate for Payer: TriWest Veterans Administration |
$0.05
|
| Rate for Payer: United Healthcare Commercial |
$0.08
|
| Rate for Payer: United Healthcare Medicare |
$0.05
|
| Rate for Payer: WINHealth Partners Commercial |
$0.09
|
| Rate for Payer: Wise Provider Network Commercial |
$0.09
|
|
|
PSYLLIUM SEED (SUGAR) ORAL POWDER [31256]
|
Facility
|
IP
|
$0.09
|
|
|
Service Code
|
NDC 8770140272
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.09
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.09
|
| Rate for Payer: Altius Commercial |
$0.09
|
| Rate for Payer: Beech Street Commercial |
$0.09
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.07
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.09
|
| Rate for Payer: Cigna of WY Commercial |
$0.09
|
| Rate for Payer: Entrust Commercial |
$0.09
|
| Rate for Payer: First Choice Health Commercial |
$0.09
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.09
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.06
|
| Rate for Payer: HealthUtah PPO |
$0.09
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.09
|
| Rate for Payer: Multiplan Medicare/VA |
$0.06
|
| Rate for Payer: One Health Plan of WY PPO |
$0.09
|
| Rate for Payer: PacificSource Commercial |
$0.08
|
| Rate for Payer: PHCS PPO |
$0.09
|
| Rate for Payer: Three Rivers PPO |
$0.07
|
| Rate for Payer: TriWest Veterans Administration |
$0.06
|
| Rate for Payer: United Healthcare Commercial |
$0.08
|
| Rate for Payer: United Healthcare Medicare |
$0.06
|
| Rate for Payer: WINHealth Partners Commercial |
$0.09
|
| Rate for Payer: Wise Provider Network Commercial |
$0.09
|
|
|
PULMONARY STRESS TESTING
|
Professional
|
Both
|
$164.00
|
|
|
Service Code
|
HCPCS 94618
|
| Hospital Charge Code |
94618
|
| Min. Negotiated Rate |
$28.17 |
| Max. Negotiated Rate |
$164.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$160.72
|
| Rate for Payer: Aetna of WY Medicare |
$33.14
|
| Rate for Payer: Beech Street Commercial |
$155.80
|
| Rate for Payer: Cash Price |
$114.80
|
| Rate for Payer: Cash Price |
$114.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$159.08
|
| Rate for Payer: Cigna of WY Commercial |
$160.72
|
| Rate for Payer: First Choice Health Commercial |
$147.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$155.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$33.14
|
| Rate for Payer: HealthUtah PPO |
$164.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$159.08
|
| Rate for Payer: Multiplan Medicare/VA |
$28.17
|
| Rate for Payer: One Health Plan of WY PPO |
$160.72
|
| Rate for Payer: PacificSource Commercial |
$147.60
|
| Rate for Payer: PHCS PPO |
$155.80
|
| Rate for Payer: Three Rivers PPO |
$123.00
|
| Rate for Payer: TriWest Veterans Administration |
$33.14
|
| Rate for Payer: United Healthcare Commercial |
$142.68
|
| Rate for Payer: United Healthcare Medicare |
$33.14
|
| Rate for Payer: WINHealth Partners Commercial |
$155.80
|
|
|
PUNCH BIOPSY SKIN EA SEP/ADDITIONAL LESION
|
Professional
|
Both
|
$135.00
|
|
|
Service Code
|
HCPCS 11105
|
| Hospital Charge Code |
11105
|
| Min. Negotiated Rate |
$20.71 |
| Max. Negotiated Rate |
$135.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$132.30
|
| Rate for Payer: Aetna of WY Medicare |
$24.37
|
| Rate for Payer: Beech Street Commercial |
$128.25
|
| Rate for Payer: Cash Price |
$94.50
|
| 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: Government Employees Health Association (GEHA) Medicare |
$24.37
|
| Rate for Payer: HealthUtah PPO |
$135.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$130.95
|
| Rate for Payer: Multiplan Medicare/VA |
$20.71
|
| 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: TriWest Veterans Administration |
$24.37
|
| Rate for Payer: United Healthcare Commercial |
$117.45
|
| Rate for Payer: United Healthcare Medicare |
$24.37
|
| Rate for Payer: WINHealth Partners Commercial |
$114.75
|
|
|
PUNCH BIOPSY SKIN SINGLE LESION
|
Professional
|
Both
|
$245.00
|
|
|
Service Code
|
HCPCS 11104
|
| Hospital Charge Code |
11104
|
| Min. Negotiated Rate |
$37.96 |
| Max. Negotiated Rate |
$245.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$240.10
|
| Rate for Payer: Aetna of WY Medicare |
$44.66
|
| Rate for Payer: Beech Street Commercial |
$232.75
|
| Rate for Payer: Cash Price |
$171.50
|
| Rate for Payer: Cash Price |
$171.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$237.65
|
| Rate for Payer: Cigna of WY Commercial |
$240.10
|
| Rate for Payer: First Choice Health Commercial |
$220.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$232.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$44.66
|
| Rate for Payer: HealthUtah PPO |
$245.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$237.65
|
| Rate for Payer: Multiplan Medicare/VA |
$37.96
|
| Rate for Payer: One Health Plan of WY PPO |
$240.10
|
| Rate for Payer: PacificSource Commercial |
$220.50
|
| Rate for Payer: PHCS PPO |
$232.75
|
| Rate for Payer: Three Rivers PPO |
$183.75
|
| Rate for Payer: TriWest Veterans Administration |
$44.66
|
| Rate for Payer: United Healthcare Commercial |
$213.15
|
| Rate for Payer: United Healthcare Medicare |
$44.66
|
| Rate for Payer: WINHealth Partners Commercial |
$208.25
|
|
|
PUNCTURE ASPIRATION ABSCESS HEMATOMA BULLA/CYST
|
Professional
|
Both
|
$474.00
|
|
|
Service Code
|
HCPCS 10160
|
| Hospital Charge Code |
10160
|
| Min. Negotiated Rate |
$79.83 |
| Max. Negotiated Rate |
$474.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$464.52
|
| Rate for Payer: Aetna of WY Medicare |
$93.92
|
| Rate for Payer: Beech Street Commercial |
$450.30
|
| Rate for Payer: Cash Price |
$331.80
|
| Rate for Payer: Cash Price |
$331.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$459.78
|
| Rate for Payer: Cigna of WY Commercial |
$464.52
|
| Rate for Payer: First Choice Health Commercial |
$426.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$450.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$93.92
|
| Rate for Payer: HealthUtah PPO |
$474.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$459.78
|
| Rate for Payer: Multiplan Medicare/VA |
$79.83
|
| Rate for Payer: One Health Plan of WY PPO |
$464.52
|
| Rate for Payer: PacificSource Commercial |
$426.60
|
| Rate for Payer: PHCS PPO |
$450.30
|
| Rate for Payer: Three Rivers PPO |
$355.50
|
| Rate for Payer: TriWest Veterans Administration |
$93.92
|
| Rate for Payer: United Healthcare Commercial |
$412.38
|
| Rate for Payer: United Healthcare Medicare |
$93.92
|
| Rate for Payer: WINHealth Partners Commercial |
$402.90
|
|
|
PUNCTURE ASPIRATION CYST OF BREAST
|
Professional
|
Both
|
$223.00
|
|
|
Service Code
|
HCPCS 19000
|
| Hospital Charge Code |
19000
|
| Min. Negotiated Rate |
$33.99 |
| Max. Negotiated Rate |
$223.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$218.54
|
| Rate for Payer: Aetna of WY Medicare |
$39.99
|
| Rate for Payer: Beech Street Commercial |
$211.85
|
| Rate for Payer: Cash Price |
$156.10
|
| Rate for Payer: Cash Price |
$156.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$216.31
|
| Rate for Payer: Cigna of WY Commercial |
$218.54
|
| Rate for Payer: First Choice Health Commercial |
$200.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$211.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$39.99
|
| Rate for Payer: HealthUtah PPO |
$223.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$216.31
|
| Rate for Payer: Multiplan Medicare/VA |
$33.99
|
| Rate for Payer: One Health Plan of WY PPO |
$218.54
|
| Rate for Payer: PacificSource Commercial |
$200.70
|
| Rate for Payer: PHCS PPO |
$211.85
|
| Rate for Payer: Three Rivers PPO |
$167.25
|
| Rate for Payer: TriWest Veterans Administration |
$39.99
|
| Rate for Payer: United Healthcare Commercial |
$194.01
|
| Rate for Payer: United Healthcare Medicare |
$39.99
|
| Rate for Payer: WINHealth Partners Commercial |
$189.55
|
|
|
PURE TONE AUDIOMETRY AIR ONLY
|
Professional
|
Both
|
$104.00
|
|
|
Service Code
|
HCPCS 92552
|
| Hospital Charge Code |
92552
|
| Min. Negotiated Rate |
$31.65 |
| Max. Negotiated Rate |
$104.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$101.92
|
| Rate for Payer: Aetna of WY Medicare |
$37.24
|
| Rate for Payer: Beech Street Commercial |
$98.80
|
| Rate for Payer: Cash Price |
$72.80
|
| Rate for Payer: Cash Price |
$72.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$100.88
|
| Rate for Payer: Cigna of WY Commercial |
$101.92
|
| Rate for Payer: First Choice Health Commercial |
$93.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$98.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$37.24
|
| Rate for Payer: HealthUtah PPO |
$104.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$100.88
|
| Rate for Payer: Multiplan Medicare/VA |
$31.65
|
| Rate for Payer: One Health Plan of WY PPO |
$101.92
|
| Rate for Payer: PacificSource Commercial |
$93.60
|
| Rate for Payer: PHCS PPO |
$98.80
|
| Rate for Payer: Three Rivers PPO |
$78.00
|
| Rate for Payer: TriWest Veterans Administration |
$37.24
|
| Rate for Payer: United Healthcare Commercial |
$90.48
|
| Rate for Payer: United Healthcare Medicare |
$37.24
|
| Rate for Payer: WINHealth Partners Commercial |
$98.80
|
|
|
PUREWICK FEMALE EXTERNAL CATHETER
|
Facility
|
IP
|
$27.45
|
|
| Hospital Charge Code |
27000000S1
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$17.21 |
| Max. Negotiated Rate |
$27.45 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$26.90
|
| Rate for Payer: Altius Auto/Workers Compensation |
$26.35
|
| Rate for Payer: Altius Commercial |
$26.35
|
| Rate for Payer: Beech Street Commercial |
$26.90
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$22.54
|
| Rate for Payer: Cash Price |
$19.22
|
| Rate for Payer: ChoiceCare Network Commercial |
$26.63
|
| Rate for Payer: Cigna of WY Commercial |
$26.90
|
| Rate for Payer: Entrust Commercial |
$26.08
|
| Rate for Payer: First Choice Health Commercial |
$26.08
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$26.08
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$18.12
|
| Rate for Payer: HealthUtah PPO |
$27.45
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$26.63
|
| Rate for Payer: Multiplan Medicare/VA |
$17.21
|
| Rate for Payer: One Health Plan of WY PPO |
$26.90
|
| Rate for Payer: PacificSource Commercial |
$24.70
|
| Rate for Payer: PHCS PPO |
$26.90
|
| Rate for Payer: Three Rivers PPO |
$20.59
|
| Rate for Payer: TriWest Veterans Administration |
$18.12
|
| Rate for Payer: United Healthcare Commercial |
$23.88
|
| Rate for Payer: United Healthcare Medicare |
$18.12
|
| Rate for Payer: WINHealth Partners Commercial |
$26.08
|
| Rate for Payer: Wise Provider Network Commercial |
$26.08
|
|
|
PUREWICK FEMALE EXTERNAL CATHETER
|
Facility
|
OP
|
$27.45
|
|
| Hospital Charge Code |
27000000S1
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$15.12 |
| Max. Negotiated Rate |
$27.45 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$26.90
|
| Rate for Payer: Aetna of WY Medicare |
$18.12
|
| Rate for Payer: Altius Auto/Workers Compensation |
$26.35
|
| Rate for Payer: Altius Commercial |
$26.35
|
| Rate for Payer: Beech Street Commercial |
$26.90
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$22.54
|
| Rate for Payer: Cash Price |
$19.22
|
| Rate for Payer: ChoiceCare Network Commercial |
$26.63
|
| Rate for Payer: Cigna of WY Commercial |
$26.90
|
| Rate for Payer: Entrust Commercial |
$26.08
|
| Rate for Payer: First Choice Health Commercial |
$26.08
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$26.08
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$15.92
|
| Rate for Payer: HealthUtah PPO |
$27.45
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$26.63
|
| Rate for Payer: Multiplan Medicare/VA |
$15.12
|
| Rate for Payer: One Health Plan of WY PPO |
$26.90
|
| Rate for Payer: PacificSource Commercial |
$24.70
|
| Rate for Payer: PHCS PPO |
$26.90
|
| Rate for Payer: Three Rivers PPO |
$20.59
|
| Rate for Payer: TriWest Veterans Administration |
$15.92
|
| Rate for Payer: United Healthcare Commercial |
$23.88
|
| Rate for Payer: United Healthcare Medicare |
$15.92
|
| Rate for Payer: WINHealth Partners Commercial |
$26.90
|
| Rate for Payer: Wise Provider Network Commercial |
$26.08
|
|
|
PUREWICK MALE EXTERNAL CATHETER
|
Facility
|
OP
|
$51.36
|
|
| Hospital Charge Code |
27000000S1
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$28.30 |
| Max. Negotiated Rate |
$51.36 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$50.33
|
| Rate for Payer: Aetna of WY Medicare |
$33.90
|
| Rate for Payer: Altius Auto/Workers Compensation |
$49.31
|
| Rate for Payer: Altius Commercial |
$49.31
|
| Rate for Payer: Beech Street Commercial |
$50.33
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$42.17
|
| Rate for Payer: Cash Price |
$35.95
|
| Rate for Payer: ChoiceCare Network Commercial |
$49.82
|
| Rate for Payer: Cigna of WY Commercial |
$50.33
|
| Rate for Payer: Entrust Commercial |
$48.79
|
| Rate for Payer: First Choice Health Commercial |
$48.79
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$48.79
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$29.79
|
| Rate for Payer: HealthUtah PPO |
$51.36
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$49.82
|
| Rate for Payer: Multiplan Medicare/VA |
$28.30
|
| Rate for Payer: One Health Plan of WY PPO |
$50.33
|
| Rate for Payer: PacificSource Commercial |
$46.22
|
| Rate for Payer: PHCS PPO |
$50.33
|
| Rate for Payer: Three Rivers PPO |
$38.52
|
| Rate for Payer: TriWest Veterans Administration |
$29.79
|
| Rate for Payer: United Healthcare Commercial |
$44.68
|
| Rate for Payer: United Healthcare Medicare |
$29.79
|
| Rate for Payer: WINHealth Partners Commercial |
$50.33
|
| Rate for Payer: Wise Provider Network Commercial |
$48.79
|
|
|
PUREWICK MALE EXTERNAL CATHETER
|
Facility
|
IP
|
$51.36
|
|
| Hospital Charge Code |
27000000S1
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$32.20 |
| Max. Negotiated Rate |
$51.36 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$50.33
|
| Rate for Payer: Altius Auto/Workers Compensation |
$49.31
|
| Rate for Payer: Altius Commercial |
$49.31
|
| Rate for Payer: Beech Street Commercial |
$50.33
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$42.17
|
| Rate for Payer: Cash Price |
$35.95
|
| Rate for Payer: ChoiceCare Network Commercial |
$49.82
|
| Rate for Payer: Cigna of WY Commercial |
$50.33
|
| Rate for Payer: Entrust Commercial |
$48.79
|
| Rate for Payer: First Choice Health Commercial |
$48.79
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$48.79
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$33.90
|
| Rate for Payer: HealthUtah PPO |
$51.36
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$49.82
|
| Rate for Payer: Multiplan Medicare/VA |
$32.20
|
| Rate for Payer: One Health Plan of WY PPO |
$50.33
|
| Rate for Payer: PacificSource Commercial |
$46.22
|
| Rate for Payer: PHCS PPO |
$50.33
|
| Rate for Payer: Three Rivers PPO |
$38.52
|
| Rate for Payer: TriWest Veterans Administration |
$33.90
|
| Rate for Payer: United Healthcare Commercial |
$44.68
|
| Rate for Payer: United Healthcare Medicare |
$33.90
|
| Rate for Payer: WINHealth Partners Commercial |
$48.79
|
| Rate for Payer: Wise Provider Network Commercial |
$48.79
|
|
|
PVB THORACIC SINGLE INJECTION SITE W/IMG GID
|
Professional
|
Both
|
$464.00
|
|
|
Service Code
|
HCPCS 64461
|
| Hospital Charge Code |
64461
|
| Min. Negotiated Rate |
$63.13 |
| Max. Negotiated Rate |
$464.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$454.72
|
| Rate for Payer: Aetna of WY Medicare |
$74.27
|
| Rate for Payer: Beech Street Commercial |
$440.80
|
| Rate for Payer: Cash Price |
$324.80
|
| Rate for Payer: Cash Price |
$324.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$450.08
|
| Rate for Payer: Cigna of WY Commercial |
$454.72
|
| Rate for Payer: First Choice Health Commercial |
$417.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$440.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$74.27
|
| Rate for Payer: HealthUtah PPO |
$464.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$450.08
|
| Rate for Payer: Multiplan Medicare/VA |
$63.13
|
| Rate for Payer: One Health Plan of WY PPO |
$454.72
|
| Rate for Payer: PacificSource Commercial |
$417.60
|
| Rate for Payer: PHCS PPO |
$440.80
|
| Rate for Payer: Three Rivers PPO |
$348.00
|
| Rate for Payer: TriWest Veterans Administration |
$74.27
|
| Rate for Payer: United Healthcare Commercial |
$403.68
|
| Rate for Payer: United Healthcare Medicare |
$74.27
|
| Rate for Payer: WINHealth Partners Commercial |
$394.40
|
|
|
PVB THORACIC SINGLE INJECTION SITE W/IMG GID
|
Professional
|
Both
|
$929.00
|
|
|
Service Code
|
HCPCS 64461 50
|
| Hospital Charge Code |
64461
|
| Min. Negotiated Rate |
$63.13 |
| Max. Negotiated Rate |
$929.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$910.42
|
| Rate for Payer: Aetna of WY Medicare |
$74.27
|
| Rate for Payer: Beech Street Commercial |
$882.55
|
| Rate for Payer: Cash Price |
$650.30
|
| Rate for Payer: Cash Price |
$650.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$901.13
|
| Rate for Payer: Cigna of WY Commercial |
$910.42
|
| Rate for Payer: First Choice Health Commercial |
$836.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$882.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$74.27
|
| Rate for Payer: HealthUtah PPO |
$929.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$901.13
|
| Rate for Payer: Multiplan Medicare/VA |
$63.13
|
| Rate for Payer: One Health Plan of WY PPO |
$910.42
|
| Rate for Payer: PacificSource Commercial |
$836.10
|
| Rate for Payer: PHCS PPO |
$882.55
|
| Rate for Payer: Three Rivers PPO |
$696.75
|
| Rate for Payer: TriWest Veterans Administration |
$74.27
|
| Rate for Payer: United Healthcare Commercial |
$808.23
|
| Rate for Payer: United Healthcare Medicare |
$74.27
|
| Rate for Payer: WINHealth Partners Commercial |
$789.65
|
|
|
PYRIDOXINE HCL 100 MG
|
Professional
|
Both
|
$19.00
|
|
|
Service Code
|
HCPCS J3415
|
| Hospital Charge Code |
J3415
|
| Min. Negotiated Rate |
$12.75 |
| Max. Negotiated Rate |
$19.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18.62
|
| Rate for Payer: Aetna of WY Medicare |
$15.00
|
| Rate for Payer: Beech Street Commercial |
$18.05
|
| Rate for Payer: Cash Price |
$13.30
|
| Rate for Payer: Cash Price |
$13.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$18.43
|
| Rate for Payer: Cigna of WY Commercial |
$18.62
|
| Rate for Payer: First Choice Health Commercial |
$17.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$18.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$15.00
|
| Rate for Payer: HealthUtah PPO |
$19.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$18.43
|
| Rate for Payer: Multiplan Medicare/VA |
$12.75
|
| Rate for Payer: One Health Plan of WY PPO |
$18.62
|
| Rate for Payer: PacificSource Commercial |
$17.10
|
| Rate for Payer: PHCS PPO |
$18.05
|
| Rate for Payer: Three Rivers PPO |
$14.25
|
| Rate for Payer: TriWest Veterans Administration |
$15.00
|
| Rate for Payer: United Healthcare Commercial |
$16.53
|
| Rate for Payer: United Healthcare Medicare |
$15.00
|
| Rate for Payer: WINHealth Partners Commercial |
$18.05
|
|
|
QC FILTER KIT -4000 FIRST PAC
|
Facility
|
IP
|
$651.35
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$408.40 |
| Max. Negotiated Rate |
$651.35 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$638.32
|
| Rate for Payer: Altius Auto/Workers Compensation |
$625.30
|
| Rate for Payer: Altius Commercial |
$625.30
|
| Rate for Payer: Beech Street Commercial |
$638.32
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$534.76
|
| Rate for Payer: Cash Price |
$455.94
|
| Rate for Payer: ChoiceCare Network Commercial |
$631.81
|
| Rate for Payer: Cigna of WY Commercial |
$638.32
|
| Rate for Payer: Entrust Commercial |
$618.78
|
| Rate for Payer: First Choice Health Commercial |
$618.78
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$618.78
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$429.89
|
| Rate for Payer: HealthUtah PPO |
$651.35
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$631.81
|
| Rate for Payer: Multiplan Medicare/VA |
$408.40
|
| Rate for Payer: One Health Plan of WY PPO |
$638.32
|
| Rate for Payer: PacificSource Commercial |
$586.22
|
| Rate for Payer: PHCS PPO |
$638.32
|
| Rate for Payer: Three Rivers PPO |
$488.51
|
| Rate for Payer: TriWest Veterans Administration |
$429.89
|
| Rate for Payer: United Healthcare Commercial |
$566.67
|
| Rate for Payer: United Healthcare Medicare |
$429.89
|
| Rate for Payer: WINHealth Partners Commercial |
$618.78
|
| Rate for Payer: Wise Provider Network Commercial |
$618.78
|
|
|
QC FILTER KIT -4000 FIRST PAC
|
Facility
|
OP
|
$651.35
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$358.89 |
| Max. Negotiated Rate |
$651.35 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$638.32
|
| Rate for Payer: Aetna of WY Medicare |
$429.89
|
| Rate for Payer: Altius Auto/Workers Compensation |
$625.30
|
| Rate for Payer: Altius Commercial |
$625.30
|
| Rate for Payer: Beech Street Commercial |
$638.32
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$534.76
|
| Rate for Payer: Cash Price |
$455.94
|
| Rate for Payer: ChoiceCare Network Commercial |
$631.81
|
| Rate for Payer: Cigna of WY Commercial |
$638.32
|
| Rate for Payer: Entrust Commercial |
$618.78
|
| Rate for Payer: First Choice Health Commercial |
$618.78
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$618.78
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$377.78
|
| Rate for Payer: HealthUtah PPO |
$651.35
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$631.81
|
| Rate for Payer: Multiplan Medicare/VA |
$358.89
|
| Rate for Payer: One Health Plan of WY PPO |
$638.32
|
| Rate for Payer: PacificSource Commercial |
$586.22
|
| Rate for Payer: PHCS PPO |
$638.32
|
| Rate for Payer: Three Rivers PPO |
$488.51
|
| Rate for Payer: TriWest Veterans Administration |
$377.78
|
| Rate for Payer: United Healthcare Commercial |
$566.67
|
| Rate for Payer: United Healthcare Medicare |
$377.78
|
| Rate for Payer: WINHealth Partners Commercial |
$638.32
|
| Rate for Payer: Wise Provider Network Commercial |
$618.78
|
|
|
QUADRICEPSPLASTY
|
Professional
|
Both
|
$3,828.00
|
|
|
Service Code
|
HCPCS 27430
|
| Hospital Charge Code |
27430
|
| Min. Negotiated Rate |
$613.63 |
| Max. Negotiated Rate |
$3,828.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,751.44
|
| Rate for Payer: Aetna of WY Medicare |
$721.92
|
| Rate for Payer: Beech Street Commercial |
$3,636.60
|
| Rate for Payer: Cash Price |
$2,679.60
|
| Rate for Payer: Cash Price |
$2,679.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,713.16
|
| Rate for Payer: Cigna of WY Commercial |
$3,751.44
|
| Rate for Payer: First Choice Health Commercial |
$3,445.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,636.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$721.92
|
| Rate for Payer: HealthUtah PPO |
$3,828.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,713.16
|
| Rate for Payer: Multiplan Medicare/VA |
$613.63
|
| Rate for Payer: One Health Plan of WY PPO |
$3,751.44
|
| Rate for Payer: PacificSource Commercial |
$3,445.20
|
| Rate for Payer: PHCS PPO |
$3,636.60
|
| Rate for Payer: Three Rivers PPO |
$2,871.00
|
| Rate for Payer: TriWest Veterans Administration |
$721.92
|
| Rate for Payer: United Healthcare Commercial |
$3,330.36
|
| Rate for Payer: United Healthcare Medicare |
$721.92
|
| Rate for Payer: WINHealth Partners Commercial |
$3,253.80
|
|
|
QUANTITATION DRUG NOT ELSEWHERE SPECIFIED
|
Professional
|
Both
|
$179.00
|
|
|
Service Code
|
HCPCS 80299
|
| Hospital Charge Code |
80299
|
| Min. Negotiated Rate |
$15.84 |
| Max. Negotiated Rate |
$179.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$175.42
|
| Rate for Payer: Aetna of WY Medicare |
$18.64
|
| Rate for Payer: Beech Street Commercial |
$170.05
|
| Rate for Payer: Cash Price |
$125.30
|
| Rate for Payer: Cash Price |
$125.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$173.63
|
| Rate for Payer: Cigna of WY Commercial |
$175.42
|
| Rate for Payer: First Choice Health Commercial |
$161.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$170.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$18.64
|
| Rate for Payer: HealthUtah PPO |
$179.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$173.63
|
| Rate for Payer: Multiplan Medicare/VA |
$15.84
|
| Rate for Payer: One Health Plan of WY PPO |
$175.42
|
| Rate for Payer: PacificSource Commercial |
$161.10
|
| Rate for Payer: PHCS PPO |
$170.05
|
| Rate for Payer: Three Rivers PPO |
$134.25
|
| Rate for Payer: TriWest Veterans Administration |
$18.64
|
| Rate for Payer: United Healthcare Commercial |
$155.73
|
| Rate for Payer: United Healthcare Medicare |
$18.64
|
| Rate for Payer: WINHealth Partners Commercial |
$170.05
|
|
|
QUETIAPINE 100 MG TABLET [7820]
|
Facility
|
OP
|
$2.12
|
|
|
Service Code
|
NDC 6068734911
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.17 |
| Max. Negotiated Rate |
$2.12 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.08
|
| Rate for Payer: Aetna of WY Medicare |
$1.40
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.04
|
| Rate for Payer: Altius Commercial |
$2.04
|
| Rate for Payer: Beech Street Commercial |
$2.08
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.74
|
| Rate for Payer: Cash Price |
$1.48
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.06
|
| Rate for Payer: Cigna of WY Commercial |
$2.08
|
| Rate for Payer: Entrust Commercial |
$2.01
|
| Rate for Payer: First Choice Health Commercial |
$2.01
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.01
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.23
|
| Rate for Payer: HealthUtah PPO |
$2.12
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.06
|
| Rate for Payer: Multiplan Medicare/VA |
$1.17
|
| Rate for Payer: One Health Plan of WY PPO |
$2.08
|
| Rate for Payer: PacificSource Commercial |
$1.91
|
| Rate for Payer: PHCS PPO |
$2.08
|
| Rate for Payer: Three Rivers PPO |
$1.59
|
| Rate for Payer: TriWest Veterans Administration |
$1.23
|
| Rate for Payer: United Healthcare Commercial |
$1.84
|
| Rate for Payer: United Healthcare Medicare |
$1.23
|
| Rate for Payer: WINHealth Partners Commercial |
$2.08
|
| Rate for Payer: Wise Provider Network Commercial |
$2.01
|
|
