|
TERUMO PINNACLE SHEATH TIF TIP 5FR X 10CM
|
Facility
|
IP
|
$49.00
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$30.72 |
| Max. Negotiated Rate |
$49.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$48.02
|
| Rate for Payer: Altius Auto/Workers Compensation |
$47.04
|
| Rate for Payer: Altius Commercial |
$47.04
|
| Rate for Payer: Beech Street Commercial |
$48.02
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$40.23
|
| Rate for Payer: Cash Price |
$34.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$47.53
|
| Rate for Payer: Cigna of WY Commercial |
$48.02
|
| Rate for Payer: Entrust Commercial |
$46.55
|
| Rate for Payer: First Choice Health Commercial |
$46.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$46.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$32.34
|
| Rate for Payer: HealthUtah PPO |
$49.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$47.53
|
| Rate for Payer: Multiplan Medicare/VA |
$30.72
|
| Rate for Payer: One Health Plan of WY PPO |
$48.02
|
| Rate for Payer: PacificSource Commercial |
$44.10
|
| Rate for Payer: PHCS PPO |
$48.02
|
| Rate for Payer: Three Rivers PPO |
$36.75
|
| Rate for Payer: TriWest Veterans Administration |
$32.34
|
| Rate for Payer: United Healthcare Commercial |
$42.63
|
| Rate for Payer: United Healthcare Medicare |
$32.34
|
| Rate for Payer: WINHealth Partners Commercial |
$46.55
|
| Rate for Payer: Wise Provider Network Commercial |
$46.55
|
|
|
TERUMO PINNACLE SHEATH TIF TIP 6FR X 10CM
|
Facility
|
OP
|
$49.00
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$27.00 |
| Max. Negotiated Rate |
$49.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$48.02
|
| Rate for Payer: Aetna of WY Medicare |
$32.34
|
| Rate for Payer: Altius Auto/Workers Compensation |
$47.04
|
| Rate for Payer: Altius Commercial |
$47.04
|
| Rate for Payer: Beech Street Commercial |
$48.02
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$40.23
|
| Rate for Payer: Cash Price |
$34.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$47.53
|
| Rate for Payer: Cigna of WY Commercial |
$48.02
|
| Rate for Payer: Entrust Commercial |
$46.55
|
| Rate for Payer: First Choice Health Commercial |
$46.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$46.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$28.42
|
| Rate for Payer: HealthUtah PPO |
$49.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$47.53
|
| Rate for Payer: Multiplan Medicare/VA |
$27.00
|
| Rate for Payer: One Health Plan of WY PPO |
$48.02
|
| Rate for Payer: PacificSource Commercial |
$44.10
|
| Rate for Payer: PHCS PPO |
$48.02
|
| Rate for Payer: Three Rivers PPO |
$36.75
|
| Rate for Payer: TriWest Veterans Administration |
$28.42
|
| Rate for Payer: United Healthcare Commercial |
$42.63
|
| Rate for Payer: United Healthcare Medicare |
$28.42
|
| Rate for Payer: WINHealth Partners Commercial |
$48.02
|
| Rate for Payer: Wise Provider Network Commercial |
$46.55
|
|
|
TERUMO PINNACLE SHEATH TIF TIP 6FR X 10CM
|
Facility
|
IP
|
$49.00
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$30.72 |
| Max. Negotiated Rate |
$49.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$48.02
|
| Rate for Payer: Altius Auto/Workers Compensation |
$47.04
|
| Rate for Payer: Altius Commercial |
$47.04
|
| Rate for Payer: Beech Street Commercial |
$48.02
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$40.23
|
| Rate for Payer: Cash Price |
$34.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$47.53
|
| Rate for Payer: Cigna of WY Commercial |
$48.02
|
| Rate for Payer: Entrust Commercial |
$46.55
|
| Rate for Payer: First Choice Health Commercial |
$46.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$46.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$32.34
|
| Rate for Payer: HealthUtah PPO |
$49.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$47.53
|
| Rate for Payer: Multiplan Medicare/VA |
$30.72
|
| Rate for Payer: One Health Plan of WY PPO |
$48.02
|
| Rate for Payer: PacificSource Commercial |
$44.10
|
| Rate for Payer: PHCS PPO |
$48.02
|
| Rate for Payer: Three Rivers PPO |
$36.75
|
| Rate for Payer: TriWest Veterans Administration |
$32.34
|
| Rate for Payer: United Healthcare Commercial |
$42.63
|
| Rate for Payer: United Healthcare Medicare |
$32.34
|
| Rate for Payer: WINHealth Partners Commercial |
$46.55
|
| Rate for Payer: Wise Provider Network Commercial |
$46.55
|
|
|
TERUMO PINNACLE SHEATH TIF TIP 7FR X 10CM
|
Facility
|
IP
|
$49.00
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$30.72 |
| Max. Negotiated Rate |
$49.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$48.02
|
| Rate for Payer: Altius Auto/Workers Compensation |
$47.04
|
| Rate for Payer: Altius Commercial |
$47.04
|
| Rate for Payer: Beech Street Commercial |
$48.02
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$40.23
|
| Rate for Payer: Cash Price |
$34.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$47.53
|
| Rate for Payer: Cigna of WY Commercial |
$48.02
|
| Rate for Payer: Entrust Commercial |
$46.55
|
| Rate for Payer: First Choice Health Commercial |
$46.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$46.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$32.34
|
| Rate for Payer: HealthUtah PPO |
$49.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$47.53
|
| Rate for Payer: Multiplan Medicare/VA |
$30.72
|
| Rate for Payer: One Health Plan of WY PPO |
$48.02
|
| Rate for Payer: PacificSource Commercial |
$44.10
|
| Rate for Payer: PHCS PPO |
$48.02
|
| Rate for Payer: Three Rivers PPO |
$36.75
|
| Rate for Payer: TriWest Veterans Administration |
$32.34
|
| Rate for Payer: United Healthcare Commercial |
$42.63
|
| Rate for Payer: United Healthcare Medicare |
$32.34
|
| Rate for Payer: WINHealth Partners Commercial |
$46.55
|
| Rate for Payer: Wise Provider Network Commercial |
$46.55
|
|
|
TERUMO PINNACLE SHEATH TIF TIP 7FR X 10CM
|
Facility
|
OP
|
$49.00
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$27.00 |
| Max. Negotiated Rate |
$49.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$48.02
|
| Rate for Payer: Aetna of WY Medicare |
$32.34
|
| Rate for Payer: Altius Auto/Workers Compensation |
$47.04
|
| Rate for Payer: Altius Commercial |
$47.04
|
| Rate for Payer: Beech Street Commercial |
$48.02
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$40.23
|
| Rate for Payer: Cash Price |
$34.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$47.53
|
| Rate for Payer: Cigna of WY Commercial |
$48.02
|
| Rate for Payer: Entrust Commercial |
$46.55
|
| Rate for Payer: First Choice Health Commercial |
$46.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$46.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$28.42
|
| Rate for Payer: HealthUtah PPO |
$49.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$47.53
|
| Rate for Payer: Multiplan Medicare/VA |
$27.00
|
| Rate for Payer: One Health Plan of WY PPO |
$48.02
|
| Rate for Payer: PacificSource Commercial |
$44.10
|
| Rate for Payer: PHCS PPO |
$48.02
|
| Rate for Payer: Three Rivers PPO |
$36.75
|
| Rate for Payer: TriWest Veterans Administration |
$28.42
|
| Rate for Payer: United Healthcare Commercial |
$42.63
|
| Rate for Payer: United Healthcare Medicare |
$28.42
|
| Rate for Payer: WINHealth Partners Commercial |
$48.02
|
| Rate for Payer: Wise Provider Network Commercial |
$46.55
|
|
|
TERUMO STANDARD TR BAND & INFLATOR
|
Facility
|
OP
|
$161.00
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$88.71 |
| Max. Negotiated Rate |
$161.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$157.78
|
| Rate for Payer: Aetna of WY Medicare |
$106.26
|
| Rate for Payer: Altius Auto/Workers Compensation |
$154.56
|
| Rate for Payer: Altius Commercial |
$154.56
|
| Rate for Payer: Beech Street Commercial |
$157.78
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$132.18
|
| Rate for Payer: Cash Price |
$112.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$156.17
|
| Rate for Payer: Cigna of WY Commercial |
$157.78
|
| Rate for Payer: Entrust Commercial |
$152.95
|
| Rate for Payer: First Choice Health Commercial |
$152.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$152.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$93.38
|
| Rate for Payer: HealthUtah PPO |
$161.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$156.17
|
| Rate for Payer: Multiplan Medicare/VA |
$88.71
|
| Rate for Payer: One Health Plan of WY PPO |
$157.78
|
| Rate for Payer: PacificSource Commercial |
$144.90
|
| Rate for Payer: PHCS PPO |
$157.78
|
| Rate for Payer: Three Rivers PPO |
$120.75
|
| Rate for Payer: TriWest Veterans Administration |
$93.38
|
| Rate for Payer: United Healthcare Commercial |
$140.07
|
| Rate for Payer: United Healthcare Medicare |
$93.38
|
| Rate for Payer: WINHealth Partners Commercial |
$157.78
|
| Rate for Payer: Wise Provider Network Commercial |
$152.95
|
|
|
TERUMO STANDARD TR BAND & INFLATOR
|
Facility
|
IP
|
$161.00
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$100.95 |
| Max. Negotiated Rate |
$161.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$157.78
|
| Rate for Payer: Altius Auto/Workers Compensation |
$154.56
|
| Rate for Payer: Altius Commercial |
$154.56
|
| Rate for Payer: Beech Street Commercial |
$157.78
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$132.18
|
| Rate for Payer: Cash Price |
$112.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$156.17
|
| Rate for Payer: Cigna of WY Commercial |
$157.78
|
| Rate for Payer: Entrust Commercial |
$152.95
|
| Rate for Payer: First Choice Health Commercial |
$152.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$152.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$106.26
|
| Rate for Payer: HealthUtah PPO |
$161.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$156.17
|
| Rate for Payer: Multiplan Medicare/VA |
$100.95
|
| Rate for Payer: One Health Plan of WY PPO |
$157.78
|
| Rate for Payer: PacificSource Commercial |
$144.90
|
| Rate for Payer: PHCS PPO |
$157.78
|
| Rate for Payer: Three Rivers PPO |
$120.75
|
| Rate for Payer: TriWest Veterans Administration |
$106.26
|
| Rate for Payer: United Healthcare Commercial |
$140.07
|
| Rate for Payer: United Healthcare Medicare |
$106.26
|
| Rate for Payer: WINHealth Partners Commercial |
$152.95
|
| Rate for Payer: Wise Provider Network Commercial |
$152.95
|
|
|
TERUMO TORQUE DEVICE
|
Facility
|
IP
|
$23.20
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$14.55 |
| Max. Negotiated Rate |
$23.20 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$22.74
|
| Rate for Payer: Altius Auto/Workers Compensation |
$22.27
|
| Rate for Payer: Altius Commercial |
$22.27
|
| Rate for Payer: Beech Street Commercial |
$22.74
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$19.05
|
| Rate for Payer: Cash Price |
$16.24
|
| Rate for Payer: ChoiceCare Network Commercial |
$22.50
|
| Rate for Payer: Cigna of WY Commercial |
$22.74
|
| Rate for Payer: Entrust Commercial |
$22.04
|
| Rate for Payer: First Choice Health Commercial |
$22.04
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$22.04
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$15.31
|
| Rate for Payer: HealthUtah PPO |
$23.20
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$22.50
|
| Rate for Payer: Multiplan Medicare/VA |
$14.55
|
| Rate for Payer: One Health Plan of WY PPO |
$22.74
|
| Rate for Payer: PacificSource Commercial |
$20.88
|
| Rate for Payer: PHCS PPO |
$22.74
|
| Rate for Payer: Three Rivers PPO |
$17.40
|
| Rate for Payer: TriWest Veterans Administration |
$15.31
|
| Rate for Payer: United Healthcare Commercial |
$20.18
|
| Rate for Payer: United Healthcare Medicare |
$15.31
|
| Rate for Payer: WINHealth Partners Commercial |
$22.04
|
| Rate for Payer: Wise Provider Network Commercial |
$22.04
|
|
|
TERUMO TORQUE DEVICE
|
Facility
|
OP
|
$23.20
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$12.78 |
| Max. Negotiated Rate |
$23.20 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$22.74
|
| Rate for Payer: Aetna of WY Medicare |
$15.31
|
| Rate for Payer: Altius Auto/Workers Compensation |
$22.27
|
| Rate for Payer: Altius Commercial |
$22.27
|
| Rate for Payer: Beech Street Commercial |
$22.74
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$19.05
|
| Rate for Payer: Cash Price |
$16.24
|
| Rate for Payer: ChoiceCare Network Commercial |
$22.50
|
| Rate for Payer: Cigna of WY Commercial |
$22.74
|
| Rate for Payer: Entrust Commercial |
$22.04
|
| Rate for Payer: First Choice Health Commercial |
$22.04
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$22.04
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$13.46
|
| Rate for Payer: HealthUtah PPO |
$23.20
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$22.50
|
| Rate for Payer: Multiplan Medicare/VA |
$12.78
|
| Rate for Payer: One Health Plan of WY PPO |
$22.74
|
| Rate for Payer: PacificSource Commercial |
$20.88
|
| Rate for Payer: PHCS PPO |
$22.74
|
| Rate for Payer: Three Rivers PPO |
$17.40
|
| Rate for Payer: TriWest Veterans Administration |
$13.46
|
| Rate for Payer: United Healthcare Commercial |
$20.18
|
| Rate for Payer: United Healthcare Medicare |
$13.46
|
| Rate for Payer: WINHealth Partners Commercial |
$22.74
|
| Rate for Payer: Wise Provider Network Commercial |
$22.04
|
|
|
TESTOSTERONE CYPIONAT 200 MG
|
Professional
|
Both
|
$50.00
|
|
|
Service Code
|
HCPCS J1080
|
| Hospital Charge Code |
J1080
|
| Min. Negotiated Rate |
$37.50 |
| Max. Negotiated Rate |
$50.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$49.00
|
| Rate for Payer: Beech Street Commercial |
$47.50
|
| Rate for Payer: Cash Price |
$35.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$48.50
|
| Rate for Payer: Cigna of WY Commercial |
$49.00
|
| Rate for Payer: First Choice Health Commercial |
$45.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$47.50
|
| Rate for Payer: HealthUtah PPO |
$50.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$48.50
|
| Rate for Payer: One Health Plan of WY PPO |
$49.00
|
| Rate for Payer: PacificSource Commercial |
$45.00
|
| Rate for Payer: PHCS PPO |
$47.50
|
| Rate for Payer: Three Rivers PPO |
$37.50
|
| Rate for Payer: United Healthcare Commercial |
$43.50
|
| Rate for Payer: WINHealth Partners Commercial |
$47.50
|
|
|
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL [17354]
|
Facility
|
IP
|
$58.98
|
|
|
Service Code
|
HCPCS J1071
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.98 |
| Max. Negotiated Rate |
$58.98 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$57.80
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$54.14
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$54.39
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$44.62
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$49.74
|
| Rate for Payer: Altius Auto/Workers Compensation |
$56.62
|
| Rate for Payer: Altius Auto/Workers Compensation |
$53.03
|
| Rate for Payer: Altius Auto/Workers Compensation |
$48.72
|
| Rate for Payer: Altius Auto/Workers Compensation |
$43.71
|
| Rate for Payer: Altius Auto/Workers Compensation |
$53.28
|
| Rate for Payer: Altius Commercial |
$48.72
|
| Rate for Payer: Altius Commercial |
$53.03
|
| Rate for Payer: Altius Commercial |
$56.62
|
| Rate for Payer: Altius Commercial |
$43.71
|
| Rate for Payer: Altius Commercial |
$53.28
|
| Rate for Payer: Beech Street Commercial |
$49.74
|
| Rate for Payer: Beech Street Commercial |
$44.62
|
| Rate for Payer: Beech Street Commercial |
$54.39
|
| Rate for Payer: Beech Street Commercial |
$57.80
|
| Rate for Payer: Beech Street Commercial |
$54.14
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$37.38
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$41.67
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$45.35
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$45.57
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$48.42
|
| Rate for Payer: Cash Price |
$41.29
|
| Rate for Payer: Cash Price |
$35.52
|
| Rate for Payer: Cash Price |
$31.87
|
| Rate for Payer: Cash Price |
$38.67
|
| Rate for Payer: Cash Price |
$38.85
|
| Rate for Payer: ChoiceCare Network Commercial |
$57.21
|
| Rate for Payer: ChoiceCare Network Commercial |
$44.16
|
| Rate for Payer: ChoiceCare Network Commercial |
$53.58
|
| Rate for Payer: ChoiceCare Network Commercial |
$49.23
|
| Rate for Payer: ChoiceCare Network Commercial |
$53.84
|
| Rate for Payer: Cigna of WY Commercial |
$57.80
|
| Rate for Payer: Cigna of WY Commercial |
$49.74
|
| Rate for Payer: Cigna of WY Commercial |
$54.39
|
| Rate for Payer: Cigna of WY Commercial |
$54.14
|
| Rate for Payer: Cigna of WY Commercial |
$44.62
|
| Rate for Payer: Entrust Commercial |
$43.25
|
| Rate for Payer: Entrust Commercial |
$56.03
|
| Rate for Payer: Entrust Commercial |
$52.48
|
| Rate for Payer: Entrust Commercial |
$48.21
|
| Rate for Payer: Entrust Commercial |
$52.72
|
| Rate for Payer: First Choice Health Commercial |
$48.21
|
| Rate for Payer: First Choice Health Commercial |
$43.25
|
| Rate for Payer: First Choice Health Commercial |
$56.03
|
| Rate for Payer: First Choice Health Commercial |
$52.72
|
| Rate for Payer: First Choice Health Commercial |
$52.48
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$56.03
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$52.72
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$48.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$52.48
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$43.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$33.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$30.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$38.93
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$36.63
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$36.46
|
| Rate for Payer: HealthUtah PPO |
$55.50
|
| Rate for Payer: HealthUtah PPO |
$45.53
|
| Rate for Payer: HealthUtah PPO |
$50.75
|
| Rate for Payer: HealthUtah PPO |
$58.98
|
| Rate for Payer: HealthUtah PPO |
$55.24
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$49.23
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$57.21
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$53.84
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$44.16
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$53.58
|
| Rate for Payer: Multiplan Medicare/VA |
$34.64
|
| Rate for Payer: Multiplan Medicare/VA |
$31.82
|
| Rate for Payer: Multiplan Medicare/VA |
$28.55
|
| Rate for Payer: Multiplan Medicare/VA |
$34.80
|
| Rate for Payer: Multiplan Medicare/VA |
$36.98
|
| Rate for Payer: One Health Plan of WY PPO |
$44.62
|
| Rate for Payer: One Health Plan of WY PPO |
$49.74
|
| Rate for Payer: One Health Plan of WY PPO |
$54.14
|
| Rate for Payer: One Health Plan of WY PPO |
$54.39
|
| Rate for Payer: One Health Plan of WY PPO |
$57.80
|
| Rate for Payer: PacificSource Commercial |
$40.98
|
| Rate for Payer: PacificSource Commercial |
$49.72
|
| Rate for Payer: PacificSource Commercial |
$45.68
|
| Rate for Payer: PacificSource Commercial |
$49.95
|
| Rate for Payer: PacificSource Commercial |
$53.08
|
| Rate for Payer: PHCS PPO |
$54.39
|
| Rate for Payer: PHCS PPO |
$57.80
|
| Rate for Payer: PHCS PPO |
$54.14
|
| Rate for Payer: PHCS PPO |
$44.62
|
| Rate for Payer: PHCS PPO |
$49.74
|
| Rate for Payer: Three Rivers PPO |
$38.06
|
| Rate for Payer: Three Rivers PPO |
$44.24
|
| Rate for Payer: Three Rivers PPO |
$41.62
|
| Rate for Payer: Three Rivers PPO |
$41.43
|
| Rate for Payer: Three Rivers PPO |
$34.15
|
| Rate for Payer: TriWest Veterans Administration |
$38.93
|
| Rate for Payer: TriWest Veterans Administration |
$36.46
|
| Rate for Payer: TriWest Veterans Administration |
$30.05
|
| Rate for Payer: TriWest Veterans Administration |
$33.50
|
| Rate for Payer: TriWest Veterans Administration |
$36.63
|
| Rate for Payer: United Healthcare Commercial |
$48.28
|
| Rate for Payer: United Healthcare Commercial |
$51.31
|
| Rate for Payer: United Healthcare Commercial |
$39.61
|
| Rate for Payer: United Healthcare Commercial |
$44.15
|
| Rate for Payer: United Healthcare Commercial |
$48.06
|
| Rate for Payer: United Healthcare Medicare |
$36.46
|
| Rate for Payer: United Healthcare Medicare |
$36.63
|
| Rate for Payer: United Healthcare Medicare |
$33.50
|
| Rate for Payer: United Healthcare Medicare |
$30.05
|
| Rate for Payer: United Healthcare Medicare |
$38.93
|
| Rate for Payer: WINHealth Partners Commercial |
$48.21
|
| Rate for Payer: WINHealth Partners Commercial |
$52.72
|
| Rate for Payer: WINHealth Partners Commercial |
$56.03
|
| Rate for Payer: WINHealth Partners Commercial |
$52.48
|
| Rate for Payer: WINHealth Partners Commercial |
$43.25
|
| Rate for Payer: Wise Provider Network Commercial |
$48.21
|
| Rate for Payer: Wise Provider Network Commercial |
$56.03
|
| Rate for Payer: Wise Provider Network Commercial |
$52.72
|
| Rate for Payer: Wise Provider Network Commercial |
$43.25
|
| Rate for Payer: Wise Provider Network Commercial |
$52.48
|
|
|
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL [17354]
|
Facility
|
OP
|
$55.50
|
|
|
Service Code
|
HCPCS J1071
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.58 |
| Max. Negotiated Rate |
$55.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$54.39
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$49.74
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$44.62
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$57.80
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$54.14
|
| Rate for Payer: Aetna of WY Medicare |
$36.63
|
| Rate for Payer: Aetna of WY Medicare |
$38.93
|
| Rate for Payer: Aetna of WY Medicare |
$36.46
|
| Rate for Payer: Aetna of WY Medicare |
$33.50
|
| Rate for Payer: Aetna of WY Medicare |
$30.05
|
| Rate for Payer: Altius Auto/Workers Compensation |
$53.28
|
| Rate for Payer: Altius Auto/Workers Compensation |
$48.72
|
| Rate for Payer: Altius Auto/Workers Compensation |
$43.71
|
| Rate for Payer: Altius Auto/Workers Compensation |
$53.03
|
| Rate for Payer: Altius Auto/Workers Compensation |
$56.62
|
| Rate for Payer: Altius Commercial |
$56.62
|
| Rate for Payer: Altius Commercial |
$48.72
|
| Rate for Payer: Altius Commercial |
$53.03
|
| Rate for Payer: Altius Commercial |
$43.71
|
| Rate for Payer: Altius Commercial |
$53.28
|
| Rate for Payer: Beech Street Commercial |
$54.39
|
| Rate for Payer: Beech Street Commercial |
$44.62
|
| Rate for Payer: Beech Street Commercial |
$54.14
|
| Rate for Payer: Beech Street Commercial |
$49.74
|
| Rate for Payer: Beech Street Commercial |
$57.80
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$45.57
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$41.67
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$37.38
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$45.35
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$48.42
|
| Rate for Payer: Cash Price |
$41.29
|
| Rate for Payer: Cash Price |
$35.52
|
| Rate for Payer: Cash Price |
$31.87
|
| Rate for Payer: Cash Price |
$38.67
|
| Rate for Payer: Cash Price |
$38.85
|
| Rate for Payer: ChoiceCare Network Commercial |
$57.21
|
| Rate for Payer: ChoiceCare Network Commercial |
$53.84
|
| Rate for Payer: ChoiceCare Network Commercial |
$49.23
|
| Rate for Payer: ChoiceCare Network Commercial |
$53.58
|
| Rate for Payer: ChoiceCare Network Commercial |
$44.16
|
| Rate for Payer: Cigna of WY Commercial |
$44.62
|
| Rate for Payer: Cigna of WY Commercial |
$49.74
|
| Rate for Payer: Cigna of WY Commercial |
$54.14
|
| Rate for Payer: Cigna of WY Commercial |
$54.39
|
| Rate for Payer: Cigna of WY Commercial |
$57.80
|
| Rate for Payer: Entrust Commercial |
$43.25
|
| Rate for Payer: Entrust Commercial |
$48.21
|
| Rate for Payer: Entrust Commercial |
$52.48
|
| Rate for Payer: Entrust Commercial |
$56.03
|
| Rate for Payer: Entrust Commercial |
$52.72
|
| Rate for Payer: First Choice Health Commercial |
$43.25
|
| Rate for Payer: First Choice Health Commercial |
$52.72
|
| Rate for Payer: First Choice Health Commercial |
$56.03
|
| Rate for Payer: First Choice Health Commercial |
$52.48
|
| Rate for Payer: First Choice Health Commercial |
$48.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$52.48
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$43.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$56.03
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$52.72
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$48.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$34.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$26.41
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$32.04
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$32.19
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$29.44
|
| Rate for Payer: HealthUtah PPO |
$45.53
|
| Rate for Payer: HealthUtah PPO |
$55.24
|
| Rate for Payer: HealthUtah PPO |
$50.75
|
| Rate for Payer: HealthUtah PPO |
$58.98
|
| Rate for Payer: HealthUtah PPO |
$55.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$53.84
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$57.21
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$49.23
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$44.16
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$53.58
|
| Rate for Payer: Multiplan Medicare/VA |
$32.50
|
| Rate for Payer: Multiplan Medicare/VA |
$25.09
|
| Rate for Payer: Multiplan Medicare/VA |
$30.44
|
| Rate for Payer: Multiplan Medicare/VA |
$30.58
|
| Rate for Payer: Multiplan Medicare/VA |
$27.96
|
| Rate for Payer: One Health Plan of WY PPO |
$49.74
|
| Rate for Payer: One Health Plan of WY PPO |
$44.62
|
| Rate for Payer: One Health Plan of WY PPO |
$54.14
|
| Rate for Payer: One Health Plan of WY PPO |
$54.39
|
| Rate for Payer: One Health Plan of WY PPO |
$57.80
|
| Rate for Payer: PacificSource Commercial |
$49.72
|
| Rate for Payer: PacificSource Commercial |
$40.98
|
| Rate for Payer: PacificSource Commercial |
$49.95
|
| Rate for Payer: PacificSource Commercial |
$53.08
|
| Rate for Payer: PacificSource Commercial |
$45.68
|
| Rate for Payer: PHCS PPO |
$57.80
|
| Rate for Payer: PHCS PPO |
$49.74
|
| Rate for Payer: PHCS PPO |
$54.14
|
| Rate for Payer: PHCS PPO |
$54.39
|
| Rate for Payer: PHCS PPO |
$44.62
|
| Rate for Payer: Three Rivers PPO |
$38.06
|
| Rate for Payer: Three Rivers PPO |
$41.43
|
| Rate for Payer: Three Rivers PPO |
$34.15
|
| Rate for Payer: Three Rivers PPO |
$44.24
|
| Rate for Payer: Three Rivers PPO |
$41.62
|
| Rate for Payer: TriWest Veterans Administration |
$29.44
|
| Rate for Payer: TriWest Veterans Administration |
$32.19
|
| Rate for Payer: TriWest Veterans Administration |
$34.21
|
| Rate for Payer: TriWest Veterans Administration |
$32.04
|
| Rate for Payer: TriWest Veterans Administration |
$26.41
|
| Rate for Payer: United Healthcare Commercial |
$48.28
|
| Rate for Payer: United Healthcare Commercial |
$44.15
|
| Rate for Payer: United Healthcare Commercial |
$39.61
|
| Rate for Payer: United Healthcare Commercial |
$48.06
|
| Rate for Payer: United Healthcare Commercial |
$51.31
|
| Rate for Payer: United Healthcare Medicare |
$32.04
|
| Rate for Payer: United Healthcare Medicare |
$32.19
|
| Rate for Payer: United Healthcare Medicare |
$26.41
|
| Rate for Payer: United Healthcare Medicare |
$29.44
|
| Rate for Payer: United Healthcare Medicare |
$34.21
|
| Rate for Payer: WINHealth Partners Commercial |
$44.62
|
| Rate for Payer: WINHealth Partners Commercial |
$54.39
|
| Rate for Payer: WINHealth Partners Commercial |
$57.80
|
| Rate for Payer: WINHealth Partners Commercial |
$54.14
|
| Rate for Payer: WINHealth Partners Commercial |
$49.74
|
| Rate for Payer: Wise Provider Network Commercial |
$52.48
|
| Rate for Payer: Wise Provider Network Commercial |
$56.03
|
| Rate for Payer: Wise Provider Network Commercial |
$48.21
|
| Rate for Payer: Wise Provider Network Commercial |
$43.25
|
| Rate for Payer: Wise Provider Network Commercial |
$52.72
|
|
|
TETANUS-DIPHTHERIA TOXOIDS-TD 2 LF UNIT-2 LF UNIT/0.5 ML IM SUSPENSION [31261]
|
Facility
|
OP
|
$97.95
|
|
|
Service Code
|
HCPCS 90714
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$53.97 |
| Max. Negotiated Rate |
$97.95 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$95.99
|
| Rate for Payer: Aetna of WY Medicare |
$64.65
|
| Rate for Payer: Altius Auto/Workers Compensation |
$94.03
|
| Rate for Payer: Altius Commercial |
$94.03
|
| Rate for Payer: Beech Street Commercial |
$95.99
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$80.42
|
| Rate for Payer: Cash Price |
$68.56
|
| Rate for Payer: ChoiceCare Network Commercial |
$95.01
|
| Rate for Payer: Cigna of WY Commercial |
$95.99
|
| Rate for Payer: Entrust Commercial |
$93.05
|
| Rate for Payer: First Choice Health Commercial |
$93.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$93.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$56.81
|
| Rate for Payer: HealthUtah PPO |
$97.95
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$95.01
|
| Rate for Payer: Multiplan Medicare/VA |
$53.97
|
| Rate for Payer: One Health Plan of WY PPO |
$95.99
|
| Rate for Payer: PacificSource Commercial |
$88.16
|
| Rate for Payer: PHCS PPO |
$95.99
|
| Rate for Payer: Three Rivers PPO |
$73.46
|
| Rate for Payer: TriWest Veterans Administration |
$56.81
|
| Rate for Payer: United Healthcare Commercial |
$85.22
|
| Rate for Payer: United Healthcare Medicare |
$56.81
|
| Rate for Payer: WINHealth Partners Commercial |
$95.99
|
| Rate for Payer: Wise Provider Network Commercial |
$93.05
|
|
|
TETANUS-DIPHTHERIA TOXOIDS-TD 2 LF UNIT-2 LF UNIT/0.5 ML IM SUSPENSION [31261]
|
Facility
|
IP
|
$97.95
|
|
|
Service Code
|
HCPCS 90714
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$61.41 |
| Max. Negotiated Rate |
$97.95 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$95.99
|
| Rate for Payer: Altius Auto/Workers Compensation |
$94.03
|
| Rate for Payer: Altius Commercial |
$94.03
|
| Rate for Payer: Beech Street Commercial |
$95.99
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$80.42
|
| Rate for Payer: Cash Price |
$68.56
|
| Rate for Payer: ChoiceCare Network Commercial |
$95.01
|
| Rate for Payer: Cigna of WY Commercial |
$95.99
|
| Rate for Payer: Entrust Commercial |
$93.05
|
| Rate for Payer: First Choice Health Commercial |
$93.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$93.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$64.65
|
| Rate for Payer: HealthUtah PPO |
$97.95
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$95.01
|
| Rate for Payer: Multiplan Medicare/VA |
$61.41
|
| Rate for Payer: One Health Plan of WY PPO |
$95.99
|
| Rate for Payer: PacificSource Commercial |
$88.16
|
| Rate for Payer: PHCS PPO |
$95.99
|
| Rate for Payer: Three Rivers PPO |
$73.46
|
| Rate for Payer: TriWest Veterans Administration |
$64.65
|
| Rate for Payer: United Healthcare Commercial |
$85.22
|
| Rate for Payer: United Healthcare Medicare |
$64.65
|
| Rate for Payer: WINHealth Partners Commercial |
$93.05
|
| Rate for Payer: Wise Provider Network Commercial |
$93.05
|
|
|
TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE [53314]
|
Facility
|
IP
|
$664.17
|
|
|
Service Code
|
HCPCS J1670
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$416.43 |
| Max. Negotiated Rate |
$664.17 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$650.89
|
| Rate for Payer: Altius Auto/Workers Compensation |
$637.60
|
| Rate for Payer: Altius Commercial |
$637.60
|
| Rate for Payer: Beech Street Commercial |
$650.89
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$545.28
|
| Rate for Payer: Cash Price |
$464.92
|
| Rate for Payer: ChoiceCare Network Commercial |
$644.24
|
| Rate for Payer: Cigna of WY Commercial |
$650.89
|
| Rate for Payer: Entrust Commercial |
$630.96
|
| Rate for Payer: First Choice Health Commercial |
$630.96
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$630.96
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$438.35
|
| Rate for Payer: HealthUtah PPO |
$664.17
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$644.24
|
| Rate for Payer: Multiplan Medicare/VA |
$416.43
|
| Rate for Payer: One Health Plan of WY PPO |
$650.89
|
| Rate for Payer: PacificSource Commercial |
$597.75
|
| Rate for Payer: PHCS PPO |
$650.89
|
| Rate for Payer: Three Rivers PPO |
$498.13
|
| Rate for Payer: TriWest Veterans Administration |
$438.35
|
| Rate for Payer: United Healthcare Commercial |
$577.83
|
| Rate for Payer: United Healthcare Medicare |
$438.35
|
| Rate for Payer: WINHealth Partners Commercial |
$630.96
|
| Rate for Payer: Wise Provider Network Commercial |
$630.96
|
|
|
TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE [53314]
|
Facility
|
OP
|
$664.17
|
|
|
Service Code
|
HCPCS J1670
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$365.96 |
| Max. Negotiated Rate |
$664.17 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$650.89
|
| Rate for Payer: Aetna of WY Medicare |
$438.35
|
| Rate for Payer: Altius Auto/Workers Compensation |
$637.60
|
| Rate for Payer: Altius Commercial |
$637.60
|
| Rate for Payer: Beech Street Commercial |
$650.89
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$545.28
|
| Rate for Payer: Cash Price |
$464.92
|
| Rate for Payer: ChoiceCare Network Commercial |
$644.24
|
| Rate for Payer: Cigna of WY Commercial |
$650.89
|
| Rate for Payer: Entrust Commercial |
$630.96
|
| Rate for Payer: First Choice Health Commercial |
$630.96
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$630.96
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$385.22
|
| Rate for Payer: HealthUtah PPO |
$664.17
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$644.24
|
| Rate for Payer: Multiplan Medicare/VA |
$365.96
|
| Rate for Payer: One Health Plan of WY PPO |
$650.89
|
| Rate for Payer: PacificSource Commercial |
$597.75
|
| Rate for Payer: PHCS PPO |
$650.89
|
| Rate for Payer: Three Rivers PPO |
$498.13
|
| Rate for Payer: TriWest Veterans Administration |
$385.22
|
| Rate for Payer: United Healthcare Commercial |
$577.83
|
| Rate for Payer: United Healthcare Medicare |
$385.22
|
| Rate for Payer: WINHealth Partners Commercial |
$650.89
|
| Rate for Payer: Wise Provider Network Commercial |
$630.96
|
|
|
TETANUS IMMUNIZATION, IM
|
Professional
|
Both
|
$70.00
|
|
|
Service Code
|
HCPCS 90703
|
| Hospital Charge Code |
90703
|
| Min. Negotiated Rate |
$52.50 |
| Max. Negotiated Rate |
$70.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$68.60
|
| Rate for Payer: Beech Street Commercial |
$66.50
|
| Rate for Payer: Cash Price |
$49.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$67.90
|
| Rate for Payer: Cigna of WY Commercial |
$68.60
|
| Rate for Payer: First Choice Health Commercial |
$63.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$66.50
|
| Rate for Payer: HealthUtah PPO |
$70.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$67.90
|
| Rate for Payer: One Health Plan of WY PPO |
$68.60
|
| Rate for Payer: PacificSource Commercial |
$63.00
|
| Rate for Payer: PHCS PPO |
$66.50
|
| Rate for Payer: Three Rivers PPO |
$52.50
|
| Rate for Payer: United Healthcare Commercial |
$60.90
|
| Rate for Payer: WINHealth Partners Commercial |
$70.00
|
|
|
TETRACAINE HCL (PF) 0.5 % EYE DROPS [91533]
|
Facility
|
IP
|
$13.01
|
|
|
Service Code
|
NDC 0065074114
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.16 |
| Max. Negotiated Rate |
$13.01 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$12.75
|
| Rate for Payer: Altius Auto/Workers Compensation |
$12.49
|
| Rate for Payer: Altius Commercial |
$12.49
|
| Rate for Payer: Beech Street Commercial |
$12.75
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$10.68
|
| Rate for Payer: Cash Price |
$9.11
|
| Rate for Payer: ChoiceCare Network Commercial |
$12.62
|
| Rate for Payer: Cigna of WY Commercial |
$12.75
|
| Rate for Payer: Entrust Commercial |
$12.36
|
| Rate for Payer: First Choice Health Commercial |
$12.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$12.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.59
|
| Rate for Payer: HealthUtah PPO |
$13.01
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$12.62
|
| Rate for Payer: Multiplan Medicare/VA |
$8.16
|
| Rate for Payer: One Health Plan of WY PPO |
$12.75
|
| Rate for Payer: PacificSource Commercial |
$11.71
|
| Rate for Payer: PHCS PPO |
$12.75
|
| Rate for Payer: Three Rivers PPO |
$9.76
|
| Rate for Payer: TriWest Veterans Administration |
$8.59
|
| Rate for Payer: United Healthcare Commercial |
$11.32
|
| Rate for Payer: United Healthcare Medicare |
$8.59
|
| Rate for Payer: WINHealth Partners Commercial |
$12.36
|
| Rate for Payer: Wise Provider Network Commercial |
$12.36
|
|
|
TETRACAINE HCL (PF) 0.5 % EYE DROPS [91533]
|
Facility
|
OP
|
$13.01
|
|
|
Service Code
|
NDC 0065074114
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.17 |
| Max. Negotiated Rate |
$13.01 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$12.75
|
| Rate for Payer: Aetna of WY Medicare |
$8.59
|
| Rate for Payer: Altius Auto/Workers Compensation |
$12.49
|
| Rate for Payer: Altius Commercial |
$12.49
|
| Rate for Payer: Beech Street Commercial |
$12.75
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$10.68
|
| Rate for Payer: Cash Price |
$9.11
|
| Rate for Payer: ChoiceCare Network Commercial |
$12.62
|
| Rate for Payer: Cigna of WY Commercial |
$12.75
|
| Rate for Payer: Entrust Commercial |
$12.36
|
| Rate for Payer: First Choice Health Commercial |
$12.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$12.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$7.55
|
| Rate for Payer: HealthUtah PPO |
$13.01
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$12.62
|
| Rate for Payer: Multiplan Medicare/VA |
$7.17
|
| Rate for Payer: One Health Plan of WY PPO |
$12.75
|
| Rate for Payer: PacificSource Commercial |
$11.71
|
| Rate for Payer: PHCS PPO |
$12.75
|
| Rate for Payer: Three Rivers PPO |
$9.76
|
| Rate for Payer: TriWest Veterans Administration |
$7.55
|
| Rate for Payer: United Healthcare Commercial |
$11.32
|
| Rate for Payer: United Healthcare Medicare |
$7.55
|
| Rate for Payer: WINHealth Partners Commercial |
$12.75
|
| Rate for Payer: Wise Provider Network Commercial |
$12.36
|
|
|
TETRACAINE HCL (PF) 1 % (10 MG/ML) INJECTION SOLUTION [12460]
|
Facility
|
IP
|
$100.00
|
|
|
Service Code
|
NDC 5428812701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$62.70 |
| Max. Negotiated Rate |
$100.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$98.00
|
| Rate for Payer: Altius Auto/Workers Compensation |
$96.00
|
| Rate for Payer: Altius Commercial |
$96.00
|
| Rate for Payer: Beech Street Commercial |
$98.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$82.10
|
| Rate for Payer: Cash Price |
$70.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$97.00
|
| Rate for Payer: Cigna of WY Commercial |
$98.00
|
| Rate for Payer: Entrust Commercial |
$95.00
|
| Rate for Payer: First Choice Health Commercial |
$95.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$95.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$66.00
|
| Rate for Payer: HealthUtah PPO |
$100.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$97.00
|
| Rate for Payer: Multiplan Medicare/VA |
$62.70
|
| Rate for Payer: One Health Plan of WY PPO |
$98.00
|
| Rate for Payer: PacificSource Commercial |
$90.00
|
| Rate for Payer: PHCS PPO |
$98.00
|
| Rate for Payer: Three Rivers PPO |
$75.00
|
| Rate for Payer: TriWest Veterans Administration |
$66.00
|
| Rate for Payer: United Healthcare Commercial |
$87.00
|
| Rate for Payer: United Healthcare Medicare |
$66.00
|
| Rate for Payer: WINHealth Partners Commercial |
$95.00
|
| Rate for Payer: Wise Provider Network Commercial |
$95.00
|
|
|
TETRACAINE HCL (PF) 1 % (10 MG/ML) INJECTION SOLUTION [12460]
|
Facility
|
OP
|
$100.00
|
|
|
Service Code
|
NDC 5428812701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$55.10 |
| Max. Negotiated Rate |
$100.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$98.00
|
| Rate for Payer: Aetna of WY Medicare |
$66.00
|
| Rate for Payer: Altius Auto/Workers Compensation |
$96.00
|
| Rate for Payer: Altius Commercial |
$96.00
|
| Rate for Payer: Beech Street Commercial |
$98.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$82.10
|
| Rate for Payer: Cash Price |
$70.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$97.00
|
| Rate for Payer: Cigna of WY Commercial |
$98.00
|
| Rate for Payer: Entrust Commercial |
$95.00
|
| Rate for Payer: First Choice Health Commercial |
$95.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$95.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$58.00
|
| Rate for Payer: HealthUtah PPO |
$100.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$97.00
|
| Rate for Payer: Multiplan Medicare/VA |
$55.10
|
| Rate for Payer: One Health Plan of WY PPO |
$98.00
|
| Rate for Payer: PacificSource Commercial |
$90.00
|
| Rate for Payer: PHCS PPO |
$98.00
|
| Rate for Payer: Three Rivers PPO |
$75.00
|
| Rate for Payer: TriWest Veterans Administration |
$58.00
|
| Rate for Payer: United Healthcare Commercial |
$87.00
|
| Rate for Payer: United Healthcare Medicare |
$58.00
|
| Rate for Payer: WINHealth Partners Commercial |
$98.00
|
| Rate for Payer: Wise Provider Network Commercial |
$95.00
|
|
|
TETRACAINE HCL (PF) 1 % (10 MG/ML) INJECTION SOLUTION [12460]
|
Facility
|
IP
|
$100.00
|
|
|
Service Code
|
NDC 5428812710
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$62.70 |
| Max. Negotiated Rate |
$100.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$98.00
|
| Rate for Payer: Altius Auto/Workers Compensation |
$96.00
|
| Rate for Payer: Altius Commercial |
$96.00
|
| Rate for Payer: Beech Street Commercial |
$98.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$82.10
|
| Rate for Payer: Cash Price |
$70.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$97.00
|
| Rate for Payer: Cigna of WY Commercial |
$98.00
|
| Rate for Payer: Entrust Commercial |
$95.00
|
| Rate for Payer: First Choice Health Commercial |
$95.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$95.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$66.00
|
| Rate for Payer: HealthUtah PPO |
$100.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$97.00
|
| Rate for Payer: Multiplan Medicare/VA |
$62.70
|
| Rate for Payer: One Health Plan of WY PPO |
$98.00
|
| Rate for Payer: PacificSource Commercial |
$90.00
|
| Rate for Payer: PHCS PPO |
$98.00
|
| Rate for Payer: Three Rivers PPO |
$75.00
|
| Rate for Payer: TriWest Veterans Administration |
$66.00
|
| Rate for Payer: United Healthcare Commercial |
$87.00
|
| Rate for Payer: United Healthcare Medicare |
$66.00
|
| Rate for Payer: WINHealth Partners Commercial |
$95.00
|
| Rate for Payer: Wise Provider Network Commercial |
$95.00
|
|
|
TETRACAINE HCL (PF) 1 % (10 MG/ML) INJECTION SOLUTION [12460]
|
Facility
|
OP
|
$100.00
|
|
|
Service Code
|
NDC 5428812710
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$55.10 |
| Max. Negotiated Rate |
$100.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$98.00
|
| Rate for Payer: Aetna of WY Medicare |
$66.00
|
| Rate for Payer: Altius Auto/Workers Compensation |
$96.00
|
| Rate for Payer: Altius Commercial |
$96.00
|
| Rate for Payer: Beech Street Commercial |
$98.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$82.10
|
| Rate for Payer: Cash Price |
$70.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$97.00
|
| Rate for Payer: Cigna of WY Commercial |
$98.00
|
| Rate for Payer: Entrust Commercial |
$95.00
|
| Rate for Payer: First Choice Health Commercial |
$95.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$95.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$58.00
|
| Rate for Payer: HealthUtah PPO |
$100.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$97.00
|
| Rate for Payer: Multiplan Medicare/VA |
$55.10
|
| Rate for Payer: One Health Plan of WY PPO |
$98.00
|
| Rate for Payer: PacificSource Commercial |
$90.00
|
| Rate for Payer: PHCS PPO |
$98.00
|
| Rate for Payer: Three Rivers PPO |
$75.00
|
| Rate for Payer: TriWest Veterans Administration |
$58.00
|
| Rate for Payer: United Healthcare Commercial |
$87.00
|
| Rate for Payer: United Healthcare Medicare |
$58.00
|
| Rate for Payer: WINHealth Partners Commercial |
$98.00
|
| Rate for Payer: Wise Provider Network Commercial |
$95.00
|
|
|
THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN
|
Professional
|
Both
|
$296.00
|
|
|
Service Code
|
HCPCS 97530
|
| Hospital Charge Code |
97530
|
| Min. Negotiated Rate |
$30.54 |
| Max. Negotiated Rate |
$296.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$290.08
|
| Rate for Payer: Aetna of WY Medicare |
$35.93
|
| Rate for Payer: Beech Street Commercial |
$281.20
|
| Rate for Payer: Cash Price |
$207.20
|
| Rate for Payer: Cash Price |
$207.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$287.12
|
| Rate for Payer: Cigna of WY Commercial |
$290.08
|
| Rate for Payer: First Choice Health Commercial |
$266.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$281.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$35.93
|
| Rate for Payer: HealthUtah PPO |
$296.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$287.12
|
| Rate for Payer: Multiplan Medicare/VA |
$30.54
|
| Rate for Payer: One Health Plan of WY PPO |
$290.08
|
| Rate for Payer: PacificSource Commercial |
$266.40
|
| Rate for Payer: PHCS PPO |
$281.20
|
| Rate for Payer: Three Rivers PPO |
$222.00
|
| Rate for Payer: TriWest Veterans Administration |
$35.93
|
| Rate for Payer: United Healthcare Commercial |
$257.52
|
| Rate for Payer: United Healthcare Medicare |
$35.93
|
| Rate for Payer: WINHealth Partners Commercial |
$281.20
|
|
|
THERAPEUTIC INJECTION IV PUSH EACH NEW DRUG
|
Professional
|
Both
|
$205.00
|
|
|
Service Code
|
HCPCS 96375
|
| Hospital Charge Code |
96375
|
| Min. Negotiated Rate |
$12.73 |
| Max. Negotiated Rate |
$205.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$200.90
|
| Rate for Payer: Aetna of WY Medicare |
$14.98
|
| Rate for Payer: Beech Street Commercial |
$194.75
|
| Rate for Payer: Cash Price |
$143.50
|
| Rate for Payer: Cash Price |
$143.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$198.85
|
| Rate for Payer: Cigna of WY Commercial |
$200.90
|
| Rate for Payer: First Choice Health Commercial |
$184.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$194.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$14.98
|
| Rate for Payer: HealthUtah PPO |
$205.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$198.85
|
| Rate for Payer: Multiplan Medicare/VA |
$12.73
|
| Rate for Payer: One Health Plan of WY PPO |
$200.90
|
| Rate for Payer: PacificSource Commercial |
$184.50
|
| Rate for Payer: PHCS PPO |
$194.75
|
| Rate for Payer: Three Rivers PPO |
$153.75
|
| Rate for Payer: TriWest Veterans Administration |
$14.98
|
| Rate for Payer: United Healthcare Commercial |
$178.35
|
| Rate for Payer: United Healthcare Medicare |
$14.98
|
| Rate for Payer: WINHealth Partners Commercial |
$194.75
|
|
