|
CARDIOVERSION ELECTIVE ARRHYTHMIA EXTERNAL
|
Professional
|
Both
|
$1,025.00
|
|
|
Service Code
|
HCPCS 92960
|
| Hospital Charge Code |
92960
|
| Min. Negotiated Rate |
$87.41 |
| Max. Negotiated Rate |
$1,025.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,004.50
|
| Rate for Payer: Aetna of WY Medicare |
$102.84
|
| Rate for Payer: Beech Street Commercial |
$973.75
|
| Rate for Payer: Cash Price |
$717.50
|
| Rate for Payer: Cash Price |
$717.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$994.25
|
| Rate for Payer: Cigna of WY Commercial |
$1,004.50
|
| Rate for Payer: First Choice Health Commercial |
$922.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$973.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$102.84
|
| Rate for Payer: HealthUtah PPO |
$1,025.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$994.25
|
| Rate for Payer: Multiplan Medicare/VA |
$87.41
|
| Rate for Payer: One Health Plan of WY PPO |
$1,004.50
|
| Rate for Payer: PacificSource Commercial |
$922.50
|
| Rate for Payer: PHCS PPO |
$973.75
|
| Rate for Payer: Three Rivers PPO |
$768.75
|
| Rate for Payer: TriWest Veterans Administration |
$102.84
|
| Rate for Payer: United Healthcare Commercial |
$891.75
|
| Rate for Payer: United Healthcare Medicare |
$102.84
|
| Rate for Payer: WINHealth Partners Commercial |
$973.75
|
|
|
CARPECTOMY 1 BONE
|
Professional
|
Both
|
$1,734.00
|
|
|
Service Code
|
HCPCS 25210
|
| Hospital Charge Code |
25210
|
| Min. Negotiated Rate |
$412.89 |
| Max. Negotiated Rate |
$1,734.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,699.32
|
| Rate for Payer: Aetna of WY Medicare |
$485.75
|
| Rate for Payer: Beech Street Commercial |
$1,647.30
|
| Rate for Payer: Cash Price |
$1,213.80
|
| Rate for Payer: Cash Price |
$1,213.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,681.98
|
| Rate for Payer: Cigna of WY Commercial |
$1,699.32
|
| Rate for Payer: First Choice Health Commercial |
$1,560.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,647.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$485.75
|
| Rate for Payer: HealthUtah PPO |
$1,734.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,681.98
|
| Rate for Payer: Multiplan Medicare/VA |
$412.89
|
| Rate for Payer: One Health Plan of WY PPO |
$1,699.32
|
| Rate for Payer: PacificSource Commercial |
$1,560.60
|
| Rate for Payer: PHCS PPO |
$1,647.30
|
| Rate for Payer: Three Rivers PPO |
$1,300.50
|
| Rate for Payer: TriWest Veterans Administration |
$485.75
|
| Rate for Payer: United Healthcare Commercial |
$1,508.58
|
| Rate for Payer: United Healthcare Medicare |
$485.75
|
| Rate for Payer: WINHealth Partners Commercial |
$1,473.90
|
|
|
CARPECTOMY 1 BONE
|
Professional
|
Both
|
$1,734.00
|
|
|
Service Code
|
HCPCS 25210 80
|
| Hospital Charge Code |
25210
|
| Min. Negotiated Rate |
$412.89 |
| Max. Negotiated Rate |
$1,734.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,699.32
|
| Rate for Payer: Aetna of WY Medicare |
$485.75
|
| Rate for Payer: Beech Street Commercial |
$1,647.30
|
| Rate for Payer: Cash Price |
$1,213.80
|
| Rate for Payer: Cash Price |
$1,213.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,681.98
|
| Rate for Payer: Cigna of WY Commercial |
$1,699.32
|
| Rate for Payer: First Choice Health Commercial |
$1,560.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,647.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$485.75
|
| Rate for Payer: HealthUtah PPO |
$1,734.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,681.98
|
| Rate for Payer: Multiplan Medicare/VA |
$412.89
|
| Rate for Payer: One Health Plan of WY PPO |
$1,699.32
|
| Rate for Payer: PacificSource Commercial |
$1,560.60
|
| Rate for Payer: PHCS PPO |
$1,647.30
|
| Rate for Payer: Three Rivers PPO |
$1,300.50
|
| Rate for Payer: TriWest Veterans Administration |
$485.75
|
| Rate for Payer: United Healthcare Commercial |
$1,508.58
|
| Rate for Payer: United Healthcare Medicare |
$485.75
|
| Rate for Payer: WINHealth Partners Commercial |
$1,473.90
|
|
|
CARPECTOMY 1 BONE
|
Professional
|
Both
|
$1,734.00
|
|
|
Service Code
|
HCPCS 25210 AS
|
| Hospital Charge Code |
25210
|
| Min. Negotiated Rate |
$412.89 |
| Max. Negotiated Rate |
$1,734.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,699.32
|
| Rate for Payer: Aetna of WY Medicare |
$485.75
|
| Rate for Payer: Beech Street Commercial |
$1,647.30
|
| Rate for Payer: Cash Price |
$1,213.80
|
| Rate for Payer: Cash Price |
$1,213.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,681.98
|
| Rate for Payer: Cigna of WY Commercial |
$1,699.32
|
| Rate for Payer: First Choice Health Commercial |
$1,560.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,647.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$485.75
|
| Rate for Payer: HealthUtah PPO |
$1,734.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,681.98
|
| Rate for Payer: Multiplan Medicare/VA |
$412.89
|
| Rate for Payer: One Health Plan of WY PPO |
$1,699.32
|
| Rate for Payer: PacificSource Commercial |
$1,560.60
|
| Rate for Payer: PHCS PPO |
$1,647.30
|
| Rate for Payer: Three Rivers PPO |
$1,300.50
|
| Rate for Payer: TriWest Veterans Administration |
$485.75
|
| Rate for Payer: United Healthcare Commercial |
$1,508.58
|
| Rate for Payer: United Healthcare Medicare |
$485.75
|
| Rate for Payer: WINHealth Partners Commercial |
$1,473.90
|
|
|
CARPECTOMY ALL BONES PROXIMAL ROW
|
Professional
|
Both
|
$2,166.00
|
|
|
Service Code
|
HCPCS 25215
|
| Hospital Charge Code |
25215
|
| Min. Negotiated Rate |
$515.69 |
| Max. Negotiated Rate |
$2,166.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,122.68
|
| Rate for Payer: Aetna of WY Medicare |
$606.69
|
| Rate for Payer: Beech Street Commercial |
$2,057.70
|
| Rate for Payer: Cash Price |
$1,516.20
|
| Rate for Payer: Cash Price |
$1,516.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,101.02
|
| Rate for Payer: Cigna of WY Commercial |
$2,122.68
|
| Rate for Payer: First Choice Health Commercial |
$1,949.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,057.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$606.69
|
| Rate for Payer: HealthUtah PPO |
$2,166.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,101.02
|
| Rate for Payer: Multiplan Medicare/VA |
$515.69
|
| Rate for Payer: One Health Plan of WY PPO |
$2,122.68
|
| Rate for Payer: PacificSource Commercial |
$1,949.40
|
| Rate for Payer: PHCS PPO |
$2,057.70
|
| Rate for Payer: Three Rivers PPO |
$1,624.50
|
| Rate for Payer: TriWest Veterans Administration |
$606.69
|
| Rate for Payer: United Healthcare Commercial |
$1,884.42
|
| Rate for Payer: United Healthcare Medicare |
$606.69
|
| Rate for Payer: WINHealth Partners Commercial |
$1,841.10
|
|
|
CARPECTOMY ALL BONES PROXIMAL ROW
|
Professional
|
Both
|
$2,166.00
|
|
|
Service Code
|
HCPCS 25215 AS
|
| Hospital Charge Code |
25215
|
| Min. Negotiated Rate |
$515.69 |
| Max. Negotiated Rate |
$2,166.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,122.68
|
| Rate for Payer: Aetna of WY Medicare |
$606.69
|
| Rate for Payer: Beech Street Commercial |
$2,057.70
|
| Rate for Payer: Cash Price |
$1,516.20
|
| Rate for Payer: Cash Price |
$1,516.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,101.02
|
| Rate for Payer: Cigna of WY Commercial |
$2,122.68
|
| Rate for Payer: First Choice Health Commercial |
$1,949.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,057.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$606.69
|
| Rate for Payer: HealthUtah PPO |
$2,166.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,101.02
|
| Rate for Payer: Multiplan Medicare/VA |
$515.69
|
| Rate for Payer: One Health Plan of WY PPO |
$2,122.68
|
| Rate for Payer: PacificSource Commercial |
$1,949.40
|
| Rate for Payer: PHCS PPO |
$2,057.70
|
| Rate for Payer: Three Rivers PPO |
$1,624.50
|
| Rate for Payer: TriWest Veterans Administration |
$606.69
|
| Rate for Payer: United Healthcare Commercial |
$1,884.42
|
| Rate for Payer: United Healthcare Medicare |
$606.69
|
| Rate for Payer: WINHealth Partners Commercial |
$1,841.10
|
|
|
CARVEDILOL 12.5 MG TABLET [1841]
|
Facility
|
OP
|
$0.33
|
|
|
Service Code
|
NDC 0904630261
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.33 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.32
|
| Rate for Payer: Aetna of WY Medicare |
$0.22
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.32
|
| Rate for Payer: Altius Commercial |
$0.32
|
| Rate for Payer: Beech Street Commercial |
$0.32
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.27
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.32
|
| Rate for Payer: Cigna of WY Commercial |
$0.32
|
| Rate for Payer: Entrust Commercial |
$0.31
|
| Rate for Payer: First Choice Health Commercial |
$0.31
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.31
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.19
|
| Rate for Payer: HealthUtah PPO |
$0.33
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.32
|
| Rate for Payer: Multiplan Medicare/VA |
$0.18
|
| Rate for Payer: One Health Plan of WY PPO |
$0.32
|
| Rate for Payer: PacificSource Commercial |
$0.30
|
| Rate for Payer: PHCS PPO |
$0.32
|
| Rate for Payer: Three Rivers PPO |
$0.25
|
| Rate for Payer: TriWest Veterans Administration |
$0.19
|
| Rate for Payer: United Healthcare Commercial |
$0.29
|
| Rate for Payer: United Healthcare Medicare |
$0.19
|
| Rate for Payer: WINHealth Partners Commercial |
$0.32
|
| Rate for Payer: Wise Provider Network Commercial |
$0.31
|
|
|
CARVEDILOL 12.5 MG TABLET [1841]
|
Facility
|
IP
|
$0.20
|
|
|
Service Code
|
NDC 6800115100
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.20
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.19
|
| Rate for Payer: Altius Commercial |
$0.19
|
| Rate for Payer: Beech Street Commercial |
$0.20
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.16
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.19
|
| Rate for Payer: Cigna of WY Commercial |
$0.20
|
| Rate for Payer: Entrust Commercial |
$0.19
|
| Rate for Payer: First Choice Health Commercial |
$0.19
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.19
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.13
|
| Rate for Payer: HealthUtah PPO |
$0.20
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.19
|
| Rate for Payer: Multiplan Medicare/VA |
$0.13
|
| Rate for Payer: One Health Plan of WY PPO |
$0.20
|
| Rate for Payer: PacificSource Commercial |
$0.18
|
| Rate for Payer: PHCS PPO |
$0.20
|
| Rate for Payer: Three Rivers PPO |
$0.15
|
| Rate for Payer: TriWest Veterans Administration |
$0.13
|
| Rate for Payer: United Healthcare Commercial |
$0.17
|
| Rate for Payer: United Healthcare Medicare |
$0.13
|
| Rate for Payer: WINHealth Partners Commercial |
$0.19
|
| Rate for Payer: Wise Provider Network Commercial |
$0.19
|
|
|
CARVEDILOL 12.5 MG TABLET [1841]
|
Facility
|
IP
|
$0.33
|
|
|
Service Code
|
NDC 0904630261
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.33 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.32
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.32
|
| Rate for Payer: Altius Commercial |
$0.32
|
| Rate for Payer: Beech Street Commercial |
$0.32
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.27
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.32
|
| Rate for Payer: Cigna of WY Commercial |
$0.32
|
| Rate for Payer: Entrust Commercial |
$0.31
|
| Rate for Payer: First Choice Health Commercial |
$0.31
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.31
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.22
|
| Rate for Payer: HealthUtah PPO |
$0.33
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.32
|
| Rate for Payer: Multiplan Medicare/VA |
$0.21
|
| Rate for Payer: One Health Plan of WY PPO |
$0.32
|
| Rate for Payer: PacificSource Commercial |
$0.30
|
| Rate for Payer: PHCS PPO |
$0.32
|
| Rate for Payer: Three Rivers PPO |
$0.25
|
| Rate for Payer: TriWest Veterans Administration |
$0.22
|
| Rate for Payer: United Healthcare Commercial |
$0.29
|
| Rate for Payer: United Healthcare Medicare |
$0.22
|
| Rate for Payer: WINHealth Partners Commercial |
$0.31
|
| Rate for Payer: Wise Provider Network Commercial |
$0.31
|
|
|
CARVEDILOL 12.5 MG TABLET [1841]
|
Facility
|
OP
|
$0.39
|
|
|
Service Code
|
NDC 0904730761
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.39 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.38
|
| Rate for Payer: Aetna of WY Medicare |
$0.26
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.37
|
| Rate for Payer: Altius Commercial |
$0.37
|
| Rate for Payer: Beech Street Commercial |
$0.38
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.32
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.38
|
| Rate for Payer: Cigna of WY Commercial |
$0.38
|
| Rate for Payer: Entrust Commercial |
$0.37
|
| Rate for Payer: First Choice Health Commercial |
$0.37
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.37
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.23
|
| Rate for Payer: HealthUtah PPO |
$0.39
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.38
|
| Rate for Payer: Multiplan Medicare/VA |
$0.21
|
| Rate for Payer: One Health Plan of WY PPO |
$0.38
|
| Rate for Payer: PacificSource Commercial |
$0.35
|
| Rate for Payer: PHCS PPO |
$0.38
|
| Rate for Payer: Three Rivers PPO |
$0.29
|
| Rate for Payer: TriWest Veterans Administration |
$0.23
|
| Rate for Payer: United Healthcare Commercial |
$0.34
|
| Rate for Payer: United Healthcare Medicare |
$0.23
|
| Rate for Payer: WINHealth Partners Commercial |
$0.38
|
| Rate for Payer: Wise Provider Network Commercial |
$0.37
|
|
|
CARVEDILOL 12.5 MG TABLET [1841]
|
Facility
|
IP
|
$0.39
|
|
|
Service Code
|
NDC 0904730761
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.39 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.38
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.37
|
| Rate for Payer: Altius Commercial |
$0.37
|
| Rate for Payer: Beech Street Commercial |
$0.38
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.32
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.38
|
| Rate for Payer: Cigna of WY Commercial |
$0.38
|
| Rate for Payer: Entrust Commercial |
$0.37
|
| Rate for Payer: First Choice Health Commercial |
$0.37
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.37
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.26
|
| Rate for Payer: HealthUtah PPO |
$0.39
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.38
|
| Rate for Payer: Multiplan Medicare/VA |
$0.24
|
| Rate for Payer: One Health Plan of WY PPO |
$0.38
|
| Rate for Payer: PacificSource Commercial |
$0.35
|
| Rate for Payer: PHCS PPO |
$0.38
|
| Rate for Payer: Three Rivers PPO |
$0.29
|
| Rate for Payer: TriWest Veterans Administration |
$0.26
|
| Rate for Payer: United Healthcare Commercial |
$0.34
|
| Rate for Payer: United Healthcare Medicare |
$0.26
|
| Rate for Payer: WINHealth Partners Commercial |
$0.37
|
| Rate for Payer: Wise Provider Network Commercial |
$0.37
|
|
|
CARVEDILOL 12.5 MG TABLET [1841]
|
Facility
|
OP
|
$0.20
|
|
|
Service Code
|
NDC 6800115100
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.20
|
| Rate for Payer: Aetna of WY Medicare |
$0.13
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.19
|
| Rate for Payer: Altius Commercial |
$0.19
|
| Rate for Payer: Beech Street Commercial |
$0.20
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.16
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.19
|
| Rate for Payer: Cigna of WY Commercial |
$0.20
|
| Rate for Payer: Entrust Commercial |
$0.19
|
| Rate for Payer: First Choice Health Commercial |
$0.19
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.19
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.12
|
| Rate for Payer: HealthUtah PPO |
$0.20
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.19
|
| Rate for Payer: Multiplan Medicare/VA |
$0.11
|
| Rate for Payer: One Health Plan of WY PPO |
$0.20
|
| Rate for Payer: PacificSource Commercial |
$0.18
|
| Rate for Payer: PHCS PPO |
$0.20
|
| Rate for Payer: Three Rivers PPO |
$0.15
|
| Rate for Payer: TriWest Veterans Administration |
$0.12
|
| Rate for Payer: United Healthcare Commercial |
$0.17
|
| Rate for Payer: United Healthcare Medicare |
$0.12
|
| Rate for Payer: WINHealth Partners Commercial |
$0.20
|
| Rate for Payer: Wise Provider Network Commercial |
$0.19
|
|
|
CARVEDILOL 3.125 MG TABLET [8251]
|
Facility
|
IP
|
$0.20
|
|
|
Service Code
|
NDC 6800115300
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.20
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.19
|
| Rate for Payer: Altius Commercial |
$0.19
|
| Rate for Payer: Beech Street Commercial |
$0.20
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.16
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.19
|
| Rate for Payer: Cigna of WY Commercial |
$0.20
|
| Rate for Payer: Entrust Commercial |
$0.19
|
| Rate for Payer: First Choice Health Commercial |
$0.19
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.19
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.13
|
| Rate for Payer: HealthUtah PPO |
$0.20
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.19
|
| Rate for Payer: Multiplan Medicare/VA |
$0.13
|
| Rate for Payer: One Health Plan of WY PPO |
$0.20
|
| Rate for Payer: PacificSource Commercial |
$0.18
|
| Rate for Payer: PHCS PPO |
$0.20
|
| Rate for Payer: Three Rivers PPO |
$0.15
|
| Rate for Payer: TriWest Veterans Administration |
$0.13
|
| Rate for Payer: United Healthcare Commercial |
$0.17
|
| Rate for Payer: United Healthcare Medicare |
$0.13
|
| Rate for Payer: WINHealth Partners Commercial |
$0.19
|
| Rate for Payer: Wise Provider Network Commercial |
$0.19
|
|
|
CARVEDILOL 3.125 MG TABLET [8251]
|
Facility
|
OP
|
$0.20
|
|
|
Service Code
|
NDC 6800115300
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.20
|
| Rate for Payer: Aetna of WY Medicare |
$0.13
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.19
|
| Rate for Payer: Altius Commercial |
$0.19
|
| Rate for Payer: Beech Street Commercial |
$0.20
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.16
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.19
|
| Rate for Payer: Cigna of WY Commercial |
$0.20
|
| Rate for Payer: Entrust Commercial |
$0.19
|
| Rate for Payer: First Choice Health Commercial |
$0.19
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.19
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.12
|
| Rate for Payer: HealthUtah PPO |
$0.20
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.19
|
| Rate for Payer: Multiplan Medicare/VA |
$0.11
|
| Rate for Payer: One Health Plan of WY PPO |
$0.20
|
| Rate for Payer: PacificSource Commercial |
$0.18
|
| Rate for Payer: PHCS PPO |
$0.20
|
| Rate for Payer: Three Rivers PPO |
$0.15
|
| Rate for Payer: TriWest Veterans Administration |
$0.12
|
| Rate for Payer: United Healthcare Commercial |
$0.17
|
| Rate for Payer: United Healthcare Medicare |
$0.12
|
| Rate for Payer: WINHealth Partners Commercial |
$0.20
|
| Rate for Payer: Wise Provider Network Commercial |
$0.19
|
|
|
CARVEDILOL 3.125 MG TABLET [8251]
|
Facility
|
OP
|
$0.33
|
|
|
Service Code
|
NDC 0904630061
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.33 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.32
|
| Rate for Payer: Aetna of WY Medicare |
$0.22
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.32
|
| Rate for Payer: Altius Commercial |
$0.32
|
| Rate for Payer: Beech Street Commercial |
$0.32
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.27
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.32
|
| Rate for Payer: Cigna of WY Commercial |
$0.32
|
| Rate for Payer: Entrust Commercial |
$0.31
|
| Rate for Payer: First Choice Health Commercial |
$0.31
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.31
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.19
|
| Rate for Payer: HealthUtah PPO |
$0.33
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.32
|
| Rate for Payer: Multiplan Medicare/VA |
$0.18
|
| Rate for Payer: One Health Plan of WY PPO |
$0.32
|
| Rate for Payer: PacificSource Commercial |
$0.30
|
| Rate for Payer: PHCS PPO |
$0.32
|
| Rate for Payer: Three Rivers PPO |
$0.25
|
| Rate for Payer: TriWest Veterans Administration |
$0.19
|
| Rate for Payer: United Healthcare Commercial |
$0.29
|
| Rate for Payer: United Healthcare Medicare |
$0.19
|
| Rate for Payer: WINHealth Partners Commercial |
$0.32
|
| Rate for Payer: Wise Provider Network Commercial |
$0.31
|
|
|
CARVEDILOL 3.125 MG TABLET [8251]
|
Facility
|
IP
|
$0.36
|
|
|
Service Code
|
NDC 0904730561
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.35
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.35
|
| Rate for Payer: Altius Commercial |
$0.35
|
| Rate for Payer: Beech Street Commercial |
$0.35
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.30
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.35
|
| Rate for Payer: Cigna of WY Commercial |
$0.35
|
| Rate for Payer: Entrust Commercial |
$0.34
|
| Rate for Payer: First Choice Health Commercial |
$0.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.24
|
| Rate for Payer: HealthUtah PPO |
$0.36
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.35
|
| Rate for Payer: Multiplan Medicare/VA |
$0.23
|
| Rate for Payer: One Health Plan of WY PPO |
$0.35
|
| Rate for Payer: PacificSource Commercial |
$0.32
|
| Rate for Payer: PHCS PPO |
$0.35
|
| Rate for Payer: Three Rivers PPO |
$0.27
|
| Rate for Payer: TriWest Veterans Administration |
$0.24
|
| Rate for Payer: United Healthcare Commercial |
$0.31
|
| Rate for Payer: United Healthcare Medicare |
$0.24
|
| Rate for Payer: WINHealth Partners Commercial |
$0.34
|
| Rate for Payer: Wise Provider Network Commercial |
$0.34
|
|
|
CARVEDILOL 3.125 MG TABLET [8251]
|
Facility
|
IP
|
$0.33
|
|
|
Service Code
|
NDC 0904630061
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.33 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.32
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.32
|
| Rate for Payer: Altius Commercial |
$0.32
|
| Rate for Payer: Beech Street Commercial |
$0.32
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.27
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.32
|
| Rate for Payer: Cigna of WY Commercial |
$0.32
|
| Rate for Payer: Entrust Commercial |
$0.31
|
| Rate for Payer: First Choice Health Commercial |
$0.31
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.31
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.22
|
| Rate for Payer: HealthUtah PPO |
$0.33
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.32
|
| Rate for Payer: Multiplan Medicare/VA |
$0.21
|
| Rate for Payer: One Health Plan of WY PPO |
$0.32
|
| Rate for Payer: PacificSource Commercial |
$0.30
|
| Rate for Payer: PHCS PPO |
$0.32
|
| Rate for Payer: Three Rivers PPO |
$0.25
|
| Rate for Payer: TriWest Veterans Administration |
$0.22
|
| Rate for Payer: United Healthcare Commercial |
$0.29
|
| Rate for Payer: United Healthcare Medicare |
$0.22
|
| Rate for Payer: WINHealth Partners Commercial |
$0.31
|
| Rate for Payer: Wise Provider Network Commercial |
$0.31
|
|
|
CARVEDILOL 3.125 MG TABLET [8251]
|
Facility
|
OP
|
$0.36
|
|
|
Service Code
|
NDC 0904730561
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.35
|
| Rate for Payer: Aetna of WY Medicare |
$0.24
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.35
|
| Rate for Payer: Altius Commercial |
$0.35
|
| Rate for Payer: Beech Street Commercial |
$0.35
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.30
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.35
|
| Rate for Payer: Cigna of WY Commercial |
$0.35
|
| Rate for Payer: Entrust Commercial |
$0.34
|
| Rate for Payer: First Choice Health Commercial |
$0.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.21
|
| Rate for Payer: HealthUtah PPO |
$0.36
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.35
|
| Rate for Payer: Multiplan Medicare/VA |
$0.20
|
| Rate for Payer: One Health Plan of WY PPO |
$0.35
|
| Rate for Payer: PacificSource Commercial |
$0.32
|
| Rate for Payer: PHCS PPO |
$0.35
|
| Rate for Payer: Three Rivers PPO |
$0.27
|
| Rate for Payer: TriWest Veterans Administration |
$0.21
|
| Rate for Payer: United Healthcare Commercial |
$0.31
|
| Rate for Payer: United Healthcare Medicare |
$0.21
|
| Rate for Payer: WINHealth Partners Commercial |
$0.35
|
| Rate for Payer: Wise Provider Network Commercial |
$0.34
|
|
|
CA SCREEN;FLEXI SIGMOIDSCOPE
|
Professional
|
Both
|
$1,928.00
|
|
|
Service Code
|
HCPCS G0104
|
| Hospital Charge Code |
G0104
|
| Min. Negotiated Rate |
$46.16 |
| Max. Negotiated Rate |
$1,928.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,889.44
|
| Rate for Payer: Aetna of WY Medicare |
$54.31
|
| Rate for Payer: Beech Street Commercial |
$1,831.60
|
| Rate for Payer: Cash Price |
$1,349.60
|
| Rate for Payer: Cash Price |
$1,349.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,870.16
|
| Rate for Payer: Cigna of WY Commercial |
$1,889.44
|
| Rate for Payer: First Choice Health Commercial |
$1,735.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,831.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$54.31
|
| Rate for Payer: HealthUtah PPO |
$1,928.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,870.16
|
| Rate for Payer: Multiplan Medicare/VA |
$46.16
|
| Rate for Payer: One Health Plan of WY PPO |
$1,889.44
|
| Rate for Payer: PacificSource Commercial |
$1,735.20
|
| Rate for Payer: PHCS PPO |
$1,831.60
|
| Rate for Payer: Three Rivers PPO |
$1,446.00
|
| Rate for Payer: TriWest Veterans Administration |
$54.31
|
| Rate for Payer: United Healthcare Commercial |
$1,677.36
|
| Rate for Payer: United Healthcare Medicare |
$54.31
|
| Rate for Payer: WINHealth Partners Commercial |
$1,831.60
|
|
|
CA SCREEN;PELVIC/BREAST EXAM
|
Professional
|
Both
|
$105.00
|
|
|
Service Code
|
HCPCS G0101
|
| Hospital Charge Code |
G0101
|
| Min. Negotiated Rate |
$22.31 |
| Max. Negotiated Rate |
$105.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$102.90
|
| Rate for Payer: Aetna of WY Medicare |
$26.25
|
| Rate for Payer: Beech Street Commercial |
$99.75
|
| Rate for Payer: Cash Price |
$73.50
|
| Rate for Payer: Cash Price |
$73.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$101.85
|
| Rate for Payer: Cigna of WY Commercial |
$102.90
|
| Rate for Payer: First Choice Health Commercial |
$94.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$99.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$26.25
|
| Rate for Payer: HealthUtah PPO |
$105.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$101.85
|
| Rate for Payer: Multiplan Medicare/VA |
$22.31
|
| Rate for Payer: One Health Plan of WY PPO |
$102.90
|
| Rate for Payer: PacificSource Commercial |
$94.50
|
| Rate for Payer: PHCS PPO |
$99.75
|
| Rate for Payer: Three Rivers PPO |
$78.75
|
| Rate for Payer: TriWest Veterans Administration |
$26.25
|
| Rate for Payer: United Healthcare Commercial |
$91.35
|
| Rate for Payer: United Healthcare Medicare |
$26.25
|
| Rate for Payer: WINHealth Partners Commercial |
$99.75
|
|
|
CASE MANAGEMENT
|
Professional
|
Both
|
$83.00
|
|
|
Service Code
|
HCPCS T1016
|
| Hospital Charge Code |
T1016
|
| Min. Negotiated Rate |
$62.25 |
| Max. Negotiated Rate |
$83.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$81.34
|
| Rate for Payer: Beech Street Commercial |
$78.85
|
| Rate for Payer: Cash Price |
$58.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$80.51
|
| Rate for Payer: Cigna of WY Commercial |
$81.34
|
| Rate for Payer: First Choice Health Commercial |
$74.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$78.85
|
| Rate for Payer: HealthUtah PPO |
$83.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$80.51
|
| Rate for Payer: One Health Plan of WY PPO |
$81.34
|
| Rate for Payer: PacificSource Commercial |
$74.70
|
| Rate for Payer: PHCS PPO |
$78.85
|
| Rate for Payer: Three Rivers PPO |
$62.25
|
| Rate for Payer: United Healthcare Commercial |
$72.21
|
| Rate for Payer: WINHealth Partners Commercial |
$78.85
|
|
|
CASIRI AND IMDEV REPEAT
|
Professional
|
Both
|
$660.00
|
|
|
Service Code
|
HCPCS M0240
|
| Hospital Charge Code |
M0240
|
| Min. Negotiated Rate |
$495.00 |
| Max. Negotiated Rate |
$660.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$646.80
|
| Rate for Payer: Beech Street Commercial |
$627.00
|
| Rate for Payer: Cash Price |
$462.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$640.20
|
| Rate for Payer: Cigna of WY Commercial |
$646.80
|
| Rate for Payer: First Choice Health Commercial |
$594.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$627.00
|
| Rate for Payer: HealthUtah PPO |
$660.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$640.20
|
| Rate for Payer: One Health Plan of WY PPO |
$646.80
|
| Rate for Payer: PacificSource Commercial |
$594.00
|
| Rate for Payer: PHCS PPO |
$627.00
|
| Rate for Payer: Three Rivers PPO |
$495.00
|
| Rate for Payer: United Healthcare Commercial |
$574.20
|
| Rate for Payer: WINHealth Partners Commercial |
$627.00
|
|
|
CASIRIVI AND IMDEVI INJ
|
Professional
|
Both
|
$759.00
|
|
|
Service Code
|
HCPCS M0243
|
| Hospital Charge Code |
M0243
|
| Min. Negotiated Rate |
$569.25 |
| Max. Negotiated Rate |
$759.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$743.82
|
| Rate for Payer: Beech Street Commercial |
$721.05
|
| Rate for Payer: Cash Price |
$531.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$736.23
|
| Rate for Payer: Cigna of WY Commercial |
$743.82
|
| Rate for Payer: First Choice Health Commercial |
$683.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$721.05
|
| Rate for Payer: HealthUtah PPO |
$759.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$736.23
|
| Rate for Payer: One Health Plan of WY PPO |
$743.82
|
| Rate for Payer: PacificSource Commercial |
$683.10
|
| Rate for Payer: PHCS PPO |
$721.05
|
| Rate for Payer: Three Rivers PPO |
$569.25
|
| Rate for Payer: United Healthcare Commercial |
$660.33
|
| Rate for Payer: WINHealth Partners Commercial |
$721.05
|
|
|
CASTOR OIL 100 % ORAL [43747]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 2438551530
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.08
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.08
|
| Rate for Payer: Altius Commercial |
$0.08
|
| Rate for Payer: Beech Street Commercial |
$0.08
|
| 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 |
$0.08
|
| Rate for Payer: Cigna of WY Commercial |
$0.08
|
| Rate for Payer: Entrust Commercial |
$0.08
|
| Rate for Payer: First Choice Health Commercial |
$0.08
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.08
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.05
|
| Rate for Payer: HealthUtah PPO |
$0.08
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.08
|
| Rate for Payer: Multiplan Medicare/VA |
$0.05
|
| Rate for Payer: One Health Plan of WY PPO |
$0.08
|
| Rate for Payer: PacificSource Commercial |
$0.07
|
| Rate for Payer: PHCS PPO |
$0.08
|
| Rate for Payer: Three Rivers PPO |
$0.06
|
| Rate for Payer: TriWest Veterans Administration |
$0.05
|
| Rate for Payer: United Healthcare Commercial |
$0.07
|
| Rate for Payer: United Healthcare Medicare |
$0.05
|
| Rate for Payer: WINHealth Partners Commercial |
$0.08
|
| Rate for Payer: Wise Provider Network Commercial |
$0.08
|
|
|
CASTOR OIL 100 % ORAL [43747]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 8770140068
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.08
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.08
|
| Rate for Payer: Altius Commercial |
$0.08
|
| Rate for Payer: Beech Street Commercial |
$0.08
|
| 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 |
$0.08
|
| Rate for Payer: Cigna of WY Commercial |
$0.08
|
| Rate for Payer: Entrust Commercial |
$0.08
|
| Rate for Payer: First Choice Health Commercial |
$0.08
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.08
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.05
|
| Rate for Payer: HealthUtah PPO |
$0.08
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.08
|
| Rate for Payer: Multiplan Medicare/VA |
$0.05
|
| Rate for Payer: One Health Plan of WY PPO |
$0.08
|
| Rate for Payer: PacificSource Commercial |
$0.07
|
| Rate for Payer: PHCS PPO |
$0.08
|
| Rate for Payer: Three Rivers PPO |
$0.06
|
| Rate for Payer: TriWest Veterans Administration |
$0.05
|
| Rate for Payer: United Healthcare Commercial |
$0.07
|
| Rate for Payer: United Healthcare Medicare |
$0.05
|
| Rate for Payer: WINHealth Partners Commercial |
$0.08
|
| Rate for Payer: Wise Provider Network Commercial |
$0.08
|
|
