|
THORASEAL CHEST DRAIN
|
Facility
|
OP
|
$103.27
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$56.90 |
| Max. Negotiated Rate |
$103.27 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$101.20
|
| Rate for Payer: Aetna of WY Medicare |
$68.16
|
| Rate for Payer: Altius Auto/Workers Compensation |
$99.14
|
| Rate for Payer: Altius Commercial |
$99.14
|
| Rate for Payer: Beech Street Commercial |
$101.20
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$84.78
|
| Rate for Payer: Cash Price |
$72.29
|
| Rate for Payer: ChoiceCare Network Commercial |
$100.17
|
| Rate for Payer: Cigna of WY Commercial |
$101.20
|
| Rate for Payer: Entrust Commercial |
$98.11
|
| Rate for Payer: First Choice Health Commercial |
$98.11
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$98.11
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$59.90
|
| Rate for Payer: HealthUtah PPO |
$103.27
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$100.17
|
| Rate for Payer: Multiplan Medicare/VA |
$56.90
|
| Rate for Payer: One Health Plan of WY PPO |
$101.20
|
| Rate for Payer: PacificSource Commercial |
$92.94
|
| Rate for Payer: PHCS PPO |
$101.20
|
| Rate for Payer: Three Rivers PPO |
$77.45
|
| Rate for Payer: TriWest Veterans Administration |
$59.90
|
| Rate for Payer: United Healthcare Commercial |
$89.84
|
| Rate for Payer: United Healthcare Medicare |
$59.90
|
| Rate for Payer: WINHealth Partners Commercial |
$101.20
|
| Rate for Payer: Wise Provider Network Commercial |
$98.11
|
|
|
THOR RIB BELT CUSTOM FABRICA
|
Professional
|
Both
|
$28.00
|
|
|
Service Code
|
HCPCS L0220
|
| Hospital Charge Code |
L0220
|
| Min. Negotiated Rate |
$21.00 |
| Max. Negotiated Rate |
$134.74 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$27.44
|
| Rate for Payer: Aetna of WY Medicare |
$134.74
|
| Rate for Payer: Beech Street Commercial |
$26.60
|
| Rate for Payer: Cash Price |
$19.60
|
| Rate for Payer: Cash Price |
$19.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$27.16
|
| Rate for Payer: Cigna of WY Commercial |
$27.44
|
| Rate for Payer: First Choice Health Commercial |
$25.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$26.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$134.74
|
| Rate for Payer: HealthUtah PPO |
$28.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$27.16
|
| Rate for Payer: Multiplan Medicare/VA |
$114.53
|
| Rate for Payer: One Health Plan of WY PPO |
$27.44
|
| Rate for Payer: PacificSource Commercial |
$25.20
|
| Rate for Payer: PHCS PPO |
$26.60
|
| Rate for Payer: Three Rivers PPO |
$21.00
|
| Rate for Payer: TriWest Veterans Administration |
$134.74
|
| Rate for Payer: United Healthcare Commercial |
$24.36
|
| Rate for Payer: United Healthcare Medicare |
$134.74
|
| Rate for Payer: WINHealth Partners Commercial |
$26.60
|
|
|
THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION [46169]
|
Facility
|
IP
|
$150.50
|
|
|
Service Code
|
NDC 0338032201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$94.36 |
| Max. Negotiated Rate |
$150.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$147.49
|
| Rate for Payer: Altius Auto/Workers Compensation |
$144.48
|
| Rate for Payer: Altius Commercial |
$144.48
|
| Rate for Payer: Beech Street Commercial |
$147.49
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$123.56
|
| Rate for Payer: Cash Price |
$105.35
|
| Rate for Payer: ChoiceCare Network Commercial |
$145.98
|
| Rate for Payer: Cigna of WY Commercial |
$147.49
|
| Rate for Payer: Entrust Commercial |
$142.98
|
| Rate for Payer: First Choice Health Commercial |
$142.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$142.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$99.33
|
| Rate for Payer: HealthUtah PPO |
$150.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$145.98
|
| Rate for Payer: Multiplan Medicare/VA |
$94.36
|
| Rate for Payer: One Health Plan of WY PPO |
$147.49
|
| Rate for Payer: PacificSource Commercial |
$135.45
|
| Rate for Payer: PHCS PPO |
$147.49
|
| Rate for Payer: Three Rivers PPO |
$112.88
|
| Rate for Payer: TriWest Veterans Administration |
$99.33
|
| Rate for Payer: United Healthcare Commercial |
$130.94
|
| Rate for Payer: United Healthcare Medicare |
$99.33
|
| Rate for Payer: WINHealth Partners Commercial |
$142.98
|
| Rate for Payer: Wise Provider Network Commercial |
$142.98
|
|
|
THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION [46169]
|
Facility
|
OP
|
$150.50
|
|
|
Service Code
|
NDC 0338032201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$82.93 |
| Max. Negotiated Rate |
$150.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$147.49
|
| Rate for Payer: Aetna of WY Medicare |
$99.33
|
| Rate for Payer: Altius Auto/Workers Compensation |
$144.48
|
| Rate for Payer: Altius Commercial |
$144.48
|
| Rate for Payer: Beech Street Commercial |
$147.49
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$123.56
|
| Rate for Payer: Cash Price |
$105.35
|
| Rate for Payer: ChoiceCare Network Commercial |
$145.98
|
| Rate for Payer: Cigna of WY Commercial |
$147.49
|
| Rate for Payer: Entrust Commercial |
$142.98
|
| Rate for Payer: First Choice Health Commercial |
$142.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$142.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$87.29
|
| Rate for Payer: HealthUtah PPO |
$150.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$145.98
|
| Rate for Payer: Multiplan Medicare/VA |
$82.93
|
| Rate for Payer: One Health Plan of WY PPO |
$147.49
|
| Rate for Payer: PacificSource Commercial |
$135.45
|
| Rate for Payer: PHCS PPO |
$147.49
|
| Rate for Payer: Three Rivers PPO |
$112.88
|
| Rate for Payer: TriWest Veterans Administration |
$87.29
|
| Rate for Payer: United Healthcare Commercial |
$130.94
|
| Rate for Payer: United Healthcare Medicare |
$87.29
|
| Rate for Payer: WINHealth Partners Commercial |
$147.49
|
| Rate for Payer: Wise Provider Network Commercial |
$142.98
|
|
|
THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION [46169]
|
Facility
|
IP
|
$150.50
|
|
|
Service Code
|
NDC 0338032401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$94.36 |
| Max. Negotiated Rate |
$150.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$147.49
|
| Rate for Payer: Altius Auto/Workers Compensation |
$144.48
|
| Rate for Payer: Altius Commercial |
$144.48
|
| Rate for Payer: Beech Street Commercial |
$147.49
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$123.56
|
| Rate for Payer: Cash Price |
$105.35
|
| Rate for Payer: ChoiceCare Network Commercial |
$145.98
|
| Rate for Payer: Cigna of WY Commercial |
$147.49
|
| Rate for Payer: Entrust Commercial |
$142.98
|
| Rate for Payer: First Choice Health Commercial |
$142.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$142.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$99.33
|
| Rate for Payer: HealthUtah PPO |
$150.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$145.98
|
| Rate for Payer: Multiplan Medicare/VA |
$94.36
|
| Rate for Payer: One Health Plan of WY PPO |
$147.49
|
| Rate for Payer: PacificSource Commercial |
$135.45
|
| Rate for Payer: PHCS PPO |
$147.49
|
| Rate for Payer: Three Rivers PPO |
$112.88
|
| Rate for Payer: TriWest Veterans Administration |
$99.33
|
| Rate for Payer: United Healthcare Commercial |
$130.94
|
| Rate for Payer: United Healthcare Medicare |
$99.33
|
| Rate for Payer: WINHealth Partners Commercial |
$142.98
|
| Rate for Payer: Wise Provider Network Commercial |
$142.98
|
|
|
THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION [46169]
|
Facility
|
OP
|
$150.50
|
|
|
Service Code
|
NDC 0338032401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$82.93 |
| Max. Negotiated Rate |
$150.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$147.49
|
| Rate for Payer: Aetna of WY Medicare |
$99.33
|
| Rate for Payer: Altius Auto/Workers Compensation |
$144.48
|
| Rate for Payer: Altius Commercial |
$144.48
|
| Rate for Payer: Beech Street Commercial |
$147.49
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$123.56
|
| Rate for Payer: Cash Price |
$105.35
|
| Rate for Payer: ChoiceCare Network Commercial |
$145.98
|
| Rate for Payer: Cigna of WY Commercial |
$147.49
|
| Rate for Payer: Entrust Commercial |
$142.98
|
| Rate for Payer: First Choice Health Commercial |
$142.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$142.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$87.29
|
| Rate for Payer: HealthUtah PPO |
$150.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$145.98
|
| Rate for Payer: Multiplan Medicare/VA |
$82.93
|
| Rate for Payer: One Health Plan of WY PPO |
$147.49
|
| Rate for Payer: PacificSource Commercial |
$135.45
|
| Rate for Payer: PHCS PPO |
$147.49
|
| Rate for Payer: Three Rivers PPO |
$112.88
|
| Rate for Payer: TriWest Veterans Administration |
$87.29
|
| Rate for Payer: United Healthcare Commercial |
$130.94
|
| Rate for Payer: United Healthcare Medicare |
$87.29
|
| Rate for Payer: WINHealth Partners Commercial |
$147.49
|
| Rate for Payer: Wise Provider Network Commercial |
$142.98
|
|
|
THUNDERBEAT POWERSEAL SEALER DIVIDER
|
Facility
|
OP
|
$1,662.50
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$916.04 |
| Max. Negotiated Rate |
$1,662.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,629.25
|
| Rate for Payer: Aetna of WY Medicare |
$1,097.25
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,596.00
|
| Rate for Payer: Altius Commercial |
$1,596.00
|
| Rate for Payer: Beech Street Commercial |
$1,629.25
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,364.91
|
| Rate for Payer: Cash Price |
$1,163.75
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,612.62
|
| Rate for Payer: Cigna of WY Commercial |
$1,629.25
|
| Rate for Payer: Entrust Commercial |
$1,579.38
|
| Rate for Payer: First Choice Health Commercial |
$1,579.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,579.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$964.25
|
| Rate for Payer: HealthUtah PPO |
$1,662.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,612.62
|
| Rate for Payer: Multiplan Medicare/VA |
$916.04
|
| Rate for Payer: One Health Plan of WY PPO |
$1,629.25
|
| Rate for Payer: PacificSource Commercial |
$1,496.25
|
| Rate for Payer: PHCS PPO |
$1,629.25
|
| Rate for Payer: Three Rivers PPO |
$1,246.88
|
| Rate for Payer: TriWest Veterans Administration |
$964.25
|
| Rate for Payer: United Healthcare Commercial |
$1,446.38
|
| Rate for Payer: United Healthcare Medicare |
$964.25
|
| Rate for Payer: WINHealth Partners Commercial |
$1,629.25
|
| Rate for Payer: Wise Provider Network Commercial |
$1,579.38
|
|
|
THUNDERBEAT POWERSEAL SEALER DIVIDER
|
Facility
|
IP
|
$1,662.50
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,042.39 |
| Max. Negotiated Rate |
$1,662.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,629.25
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,596.00
|
| Rate for Payer: Altius Commercial |
$1,596.00
|
| Rate for Payer: Beech Street Commercial |
$1,629.25
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,364.91
|
| Rate for Payer: Cash Price |
$1,163.75
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,612.62
|
| Rate for Payer: Cigna of WY Commercial |
$1,629.25
|
| Rate for Payer: Entrust Commercial |
$1,579.38
|
| Rate for Payer: First Choice Health Commercial |
$1,579.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,579.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,097.25
|
| Rate for Payer: HealthUtah PPO |
$1,662.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,612.62
|
| Rate for Payer: Multiplan Medicare/VA |
$1,042.39
|
| Rate for Payer: One Health Plan of WY PPO |
$1,629.25
|
| Rate for Payer: PacificSource Commercial |
$1,496.25
|
| Rate for Payer: PHCS PPO |
$1,629.25
|
| Rate for Payer: Three Rivers PPO |
$1,246.88
|
| Rate for Payer: TriWest Veterans Administration |
$1,097.25
|
| Rate for Payer: United Healthcare Commercial |
$1,446.38
|
| Rate for Payer: United Healthcare Medicare |
$1,097.25
|
| Rate for Payer: WINHealth Partners Commercial |
$1,579.38
|
| Rate for Payer: Wise Provider Network Commercial |
$1,579.38
|
|
|
THYROIDECTOMY RMVL REMAINING TISS FLWG PRTL RMVL
|
Professional
|
Both
|
$5,612.00
|
|
|
Service Code
|
HCPCS 60260 80
|
| Hospital Charge Code |
60260
|
| Min. Negotiated Rate |
$884.64 |
| Max. Negotiated Rate |
$5,612.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5,499.76
|
| Rate for Payer: Aetna of WY Medicare |
$1,040.75
|
| Rate for Payer: Beech Street Commercial |
$5,331.40
|
| Rate for Payer: Cash Price |
$3,928.40
|
| Rate for Payer: Cash Price |
$3,928.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$5,443.64
|
| Rate for Payer: Cigna of WY Commercial |
$5,499.76
|
| Rate for Payer: First Choice Health Commercial |
$5,050.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5,331.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,040.75
|
| Rate for Payer: HealthUtah PPO |
$5,612.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5,443.64
|
| Rate for Payer: Multiplan Medicare/VA |
$884.64
|
| Rate for Payer: One Health Plan of WY PPO |
$5,499.76
|
| Rate for Payer: PacificSource Commercial |
$5,050.80
|
| Rate for Payer: PHCS PPO |
$5,331.40
|
| Rate for Payer: Three Rivers PPO |
$4,209.00
|
| Rate for Payer: TriWest Veterans Administration |
$1,040.75
|
| Rate for Payer: United Healthcare Commercial |
$4,882.44
|
| Rate for Payer: United Healthcare Medicare |
$1,040.75
|
| Rate for Payer: WINHealth Partners Commercial |
$4,770.20
|
|
|
THYROIDECTOMY RMVL REMAINING TISS FLWG PRTL RMVL
|
Professional
|
Both
|
$5,612.00
|
|
|
Service Code
|
HCPCS 60260 AS
|
| Hospital Charge Code |
60260
|
| Min. Negotiated Rate |
$884.64 |
| Max. Negotiated Rate |
$5,612.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5,499.76
|
| Rate for Payer: Aetna of WY Medicare |
$1,040.75
|
| Rate for Payer: Beech Street Commercial |
$5,331.40
|
| Rate for Payer: Cash Price |
$3,928.40
|
| Rate for Payer: Cash Price |
$3,928.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$5,443.64
|
| Rate for Payer: Cigna of WY Commercial |
$5,499.76
|
| Rate for Payer: First Choice Health Commercial |
$5,050.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5,331.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,040.75
|
| Rate for Payer: HealthUtah PPO |
$5,612.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5,443.64
|
| Rate for Payer: Multiplan Medicare/VA |
$884.64
|
| Rate for Payer: One Health Plan of WY PPO |
$5,499.76
|
| Rate for Payer: PacificSource Commercial |
$5,050.80
|
| Rate for Payer: PHCS PPO |
$5,331.40
|
| Rate for Payer: Three Rivers PPO |
$4,209.00
|
| Rate for Payer: TriWest Veterans Administration |
$1,040.75
|
| Rate for Payer: United Healthcare Commercial |
$4,882.44
|
| Rate for Payer: United Healthcare Medicare |
$1,040.75
|
| Rate for Payer: WINHealth Partners Commercial |
$4,770.20
|
|
|
THYROIDECTOMY SUBSTERNAL CERVICAL APPROACH
|
Professional
|
Both
|
$3,539.00
|
|
|
Service Code
|
HCPCS 60271
|
| Hospital Charge Code |
60271
|
| Min. Negotiated Rate |
$856.95 |
| Max. Negotiated Rate |
$3,539.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,468.22
|
| Rate for Payer: Aetna of WY Medicare |
$1,008.18
|
| Rate for Payer: Beech Street Commercial |
$3,362.05
|
| Rate for Payer: Cash Price |
$2,477.30
|
| Rate for Payer: Cash Price |
$2,477.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,432.83
|
| Rate for Payer: Cigna of WY Commercial |
$3,468.22
|
| Rate for Payer: First Choice Health Commercial |
$3,185.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,362.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,008.18
|
| Rate for Payer: HealthUtah PPO |
$3,539.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,432.83
|
| Rate for Payer: Multiplan Medicare/VA |
$856.95
|
| Rate for Payer: One Health Plan of WY PPO |
$3,468.22
|
| Rate for Payer: PacificSource Commercial |
$3,185.10
|
| Rate for Payer: PHCS PPO |
$3,362.05
|
| Rate for Payer: Three Rivers PPO |
$2,654.25
|
| Rate for Payer: TriWest Veterans Administration |
$1,008.18
|
| Rate for Payer: United Healthcare Commercial |
$3,078.93
|
| Rate for Payer: United Healthcare Medicare |
$1,008.18
|
| Rate for Payer: WINHealth Partners Commercial |
$3,008.15
|
|
|
THYROIDECTOMY TOTAL/COMPLETE
|
Professional
|
Both
|
$4,733.00
|
|
|
Service Code
|
HCPCS 60240 AS
|
| Hospital Charge Code |
60240
|
| Min. Negotiated Rate |
$745.75 |
| Max. Negotiated Rate |
$4,733.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4,638.34
|
| Rate for Payer: Aetna of WY Medicare |
$877.35
|
| Rate for Payer: Beech Street Commercial |
$4,496.35
|
| Rate for Payer: Cash Price |
$3,313.10
|
| Rate for Payer: Cash Price |
$3,313.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$4,591.01
|
| Rate for Payer: Cigna of WY Commercial |
$4,638.34
|
| Rate for Payer: First Choice Health Commercial |
$4,259.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,496.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$877.35
|
| Rate for Payer: HealthUtah PPO |
$4,733.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4,591.01
|
| Rate for Payer: Multiplan Medicare/VA |
$745.75
|
| Rate for Payer: One Health Plan of WY PPO |
$4,638.34
|
| Rate for Payer: PacificSource Commercial |
$4,259.70
|
| Rate for Payer: PHCS PPO |
$4,496.35
|
| Rate for Payer: Three Rivers PPO |
$3,549.75
|
| Rate for Payer: TriWest Veterans Administration |
$877.35
|
| Rate for Payer: United Healthcare Commercial |
$4,117.71
|
| Rate for Payer: United Healthcare Medicare |
$877.35
|
| Rate for Payer: WINHealth Partners Commercial |
$4,023.05
|
|
|
THYROIDECTOMY TOTAL/COMPLETE
|
Professional
|
Both
|
$4,733.00
|
|
|
Service Code
|
HCPCS 60240 80
|
| Hospital Charge Code |
60240
|
| Min. Negotiated Rate |
$745.75 |
| Max. Negotiated Rate |
$4,733.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4,638.34
|
| Rate for Payer: Aetna of WY Medicare |
$877.35
|
| Rate for Payer: Beech Street Commercial |
$4,496.35
|
| Rate for Payer: Cash Price |
$3,313.10
|
| Rate for Payer: Cash Price |
$3,313.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$4,591.01
|
| Rate for Payer: Cigna of WY Commercial |
$4,638.34
|
| Rate for Payer: First Choice Health Commercial |
$4,259.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,496.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$877.35
|
| Rate for Payer: HealthUtah PPO |
$4,733.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4,591.01
|
| Rate for Payer: Multiplan Medicare/VA |
$745.75
|
| Rate for Payer: One Health Plan of WY PPO |
$4,638.34
|
| Rate for Payer: PacificSource Commercial |
$4,259.70
|
| Rate for Payer: PHCS PPO |
$4,496.35
|
| Rate for Payer: Three Rivers PPO |
$3,549.75
|
| Rate for Payer: TriWest Veterans Administration |
$877.35
|
| Rate for Payer: United Healthcare Commercial |
$4,117.71
|
| Rate for Payer: United Healthcare Medicare |
$877.35
|
| Rate for Payer: WINHealth Partners Commercial |
$4,023.05
|
|
|
THYROIDECTOMY TOTAL/COMPLETE
|
Professional
|
Both
|
$4,733.00
|
|
|
Service Code
|
HCPCS 60240
|
| Hospital Charge Code |
60240
|
| Min. Negotiated Rate |
$745.75 |
| Max. Negotiated Rate |
$4,733.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4,638.34
|
| Rate for Payer: Aetna of WY Medicare |
$877.35
|
| Rate for Payer: Beech Street Commercial |
$4,496.35
|
| Rate for Payer: Cash Price |
$3,313.10
|
| Rate for Payer: Cash Price |
$3,313.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$4,591.01
|
| Rate for Payer: Cigna of WY Commercial |
$4,638.34
|
| Rate for Payer: First Choice Health Commercial |
$4,259.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,496.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$877.35
|
| Rate for Payer: HealthUtah PPO |
$4,733.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4,591.01
|
| Rate for Payer: Multiplan Medicare/VA |
$745.75
|
| Rate for Payer: One Health Plan of WY PPO |
$4,638.34
|
| Rate for Payer: PacificSource Commercial |
$4,259.70
|
| Rate for Payer: PHCS PPO |
$4,496.35
|
| Rate for Payer: Three Rivers PPO |
$3,549.75
|
| Rate for Payer: TriWest Veterans Administration |
$877.35
|
| Rate for Payer: United Healthcare Commercial |
$4,117.71
|
| Rate for Payer: United Healthcare Medicare |
$877.35
|
| Rate for Payer: WINHealth Partners Commercial |
$4,023.05
|
|
|
THYROID (PORK) 30 MG TABLET [88044]
|
Facility
|
OP
|
$2.75
|
|
|
Service Code
|
NDC 4219232901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.52 |
| Max. Negotiated Rate |
$2.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.70
|
| Rate for Payer: Aetna of WY Medicare |
$1.82
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.64
|
| Rate for Payer: Altius Commercial |
$2.64
|
| Rate for Payer: Beech Street Commercial |
$2.70
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.26
|
| Rate for Payer: Cash Price |
$1.93
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.67
|
| Rate for Payer: Cigna of WY Commercial |
$2.70
|
| Rate for Payer: Entrust Commercial |
$2.61
|
| Rate for Payer: First Choice Health Commercial |
$2.61
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.61
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.60
|
| Rate for Payer: HealthUtah PPO |
$2.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.67
|
| Rate for Payer: Multiplan Medicare/VA |
$1.52
|
| Rate for Payer: One Health Plan of WY PPO |
$2.70
|
| Rate for Payer: PacificSource Commercial |
$2.48
|
| Rate for Payer: PHCS PPO |
$2.70
|
| Rate for Payer: Three Rivers PPO |
$2.06
|
| Rate for Payer: TriWest Veterans Administration |
$1.60
|
| Rate for Payer: United Healthcare Commercial |
$2.39
|
| Rate for Payer: United Healthcare Medicare |
$1.60
|
| Rate for Payer: WINHealth Partners Commercial |
$2.70
|
| Rate for Payer: Wise Provider Network Commercial |
$2.61
|
|
|
THYROID (PORK) 30 MG TABLET [88044]
|
Facility
|
IP
|
$2.75
|
|
|
Service Code
|
NDC 4219232901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.72 |
| Max. Negotiated Rate |
$2.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.70
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.64
|
| Rate for Payer: Altius Commercial |
$2.64
|
| Rate for Payer: Beech Street Commercial |
$2.70
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.26
|
| Rate for Payer: Cash Price |
$1.93
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.67
|
| Rate for Payer: Cigna of WY Commercial |
$2.70
|
| Rate for Payer: Entrust Commercial |
$2.61
|
| Rate for Payer: First Choice Health Commercial |
$2.61
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.61
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.82
|
| Rate for Payer: HealthUtah PPO |
$2.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.67
|
| Rate for Payer: Multiplan Medicare/VA |
$1.72
|
| Rate for Payer: One Health Plan of WY PPO |
$2.70
|
| Rate for Payer: PacificSource Commercial |
$2.48
|
| Rate for Payer: PHCS PPO |
$2.70
|
| Rate for Payer: Three Rivers PPO |
$2.06
|
| Rate for Payer: TriWest Veterans Administration |
$1.82
|
| Rate for Payer: United Healthcare Commercial |
$2.39
|
| Rate for Payer: United Healthcare Medicare |
$1.82
|
| Rate for Payer: WINHealth Partners Commercial |
$2.61
|
| Rate for Payer: Wise Provider Network Commercial |
$2.61
|
|
|
THYROID (PORK) 60 MG TABLET [88045]
|
Facility
|
IP
|
$2.69
|
|
|
Service Code
|
NDC 7583431201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.69 |
| Max. Negotiated Rate |
$2.69 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.64
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.58
|
| Rate for Payer: Altius Commercial |
$2.58
|
| Rate for Payer: Beech Street Commercial |
$2.64
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.21
|
| Rate for Payer: Cash Price |
$1.88
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.61
|
| Rate for Payer: Cigna of WY Commercial |
$2.64
|
| Rate for Payer: Entrust Commercial |
$2.56
|
| Rate for Payer: First Choice Health Commercial |
$2.56
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.56
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.78
|
| Rate for Payer: HealthUtah PPO |
$2.69
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.61
|
| Rate for Payer: Multiplan Medicare/VA |
$1.69
|
| Rate for Payer: One Health Plan of WY PPO |
$2.64
|
| Rate for Payer: PacificSource Commercial |
$2.42
|
| Rate for Payer: PHCS PPO |
$2.64
|
| Rate for Payer: Three Rivers PPO |
$2.02
|
| Rate for Payer: TriWest Veterans Administration |
$1.78
|
| Rate for Payer: United Healthcare Commercial |
$2.34
|
| Rate for Payer: United Healthcare Medicare |
$1.78
|
| Rate for Payer: WINHealth Partners Commercial |
$2.56
|
| Rate for Payer: Wise Provider Network Commercial |
$2.56
|
|
|
THYROID (PORK) 60 MG TABLET [88045]
|
Facility
|
OP
|
$2.69
|
|
|
Service Code
|
NDC 7583431201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.48 |
| Max. Negotiated Rate |
$2.69 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.64
|
| Rate for Payer: Aetna of WY Medicare |
$1.78
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.58
|
| Rate for Payer: Altius Commercial |
$2.58
|
| Rate for Payer: Beech Street Commercial |
$2.64
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.21
|
| Rate for Payer: Cash Price |
$1.88
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.61
|
| Rate for Payer: Cigna of WY Commercial |
$2.64
|
| Rate for Payer: Entrust Commercial |
$2.56
|
| Rate for Payer: First Choice Health Commercial |
$2.56
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.56
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.56
|
| Rate for Payer: HealthUtah PPO |
$2.69
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.61
|
| Rate for Payer: Multiplan Medicare/VA |
$1.48
|
| Rate for Payer: One Health Plan of WY PPO |
$2.64
|
| Rate for Payer: PacificSource Commercial |
$2.42
|
| Rate for Payer: PHCS PPO |
$2.64
|
| Rate for Payer: Three Rivers PPO |
$2.02
|
| Rate for Payer: TriWest Veterans Administration |
$1.56
|
| Rate for Payer: United Healthcare Commercial |
$2.34
|
| Rate for Payer: United Healthcare Medicare |
$1.56
|
| Rate for Payer: WINHealth Partners Commercial |
$2.64
|
| Rate for Payer: Wise Provider Network Commercial |
$2.56
|
|
|
THYROID (PORK) 60 MG TABLET [88045]
|
Facility
|
IP
|
$3.06
|
|
|
Service Code
|
NDC 4219233001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.92 |
| Max. Negotiated Rate |
$3.06 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3.00
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.94
|
| Rate for Payer: Altius Commercial |
$2.94
|
| Rate for Payer: Beech Street Commercial |
$3.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.51
|
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.97
|
| Rate for Payer: Cigna of WY Commercial |
$3.00
|
| Rate for Payer: Entrust Commercial |
$2.91
|
| Rate for Payer: First Choice Health Commercial |
$2.91
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.91
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2.02
|
| Rate for Payer: HealthUtah PPO |
$3.06
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.97
|
| Rate for Payer: Multiplan Medicare/VA |
$1.92
|
| Rate for Payer: One Health Plan of WY PPO |
$3.00
|
| Rate for Payer: PacificSource Commercial |
$2.75
|
| Rate for Payer: PHCS PPO |
$3.00
|
| Rate for Payer: Three Rivers PPO |
$2.30
|
| Rate for Payer: TriWest Veterans Administration |
$2.02
|
| Rate for Payer: United Healthcare Commercial |
$2.66
|
| Rate for Payer: United Healthcare Medicare |
$2.02
|
| Rate for Payer: WINHealth Partners Commercial |
$2.91
|
| Rate for Payer: Wise Provider Network Commercial |
$2.91
|
|
|
THYROID (PORK) 60 MG TABLET [88045]
|
Facility
|
OP
|
$3.06
|
|
|
Service Code
|
NDC 4219233001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.69 |
| Max. Negotiated Rate |
$3.06 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3.00
|
| Rate for Payer: Aetna of WY Medicare |
$2.02
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.94
|
| Rate for Payer: Altius Commercial |
$2.94
|
| Rate for Payer: Beech Street Commercial |
$3.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.51
|
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.97
|
| Rate for Payer: Cigna of WY Commercial |
$3.00
|
| Rate for Payer: Entrust Commercial |
$2.91
|
| Rate for Payer: First Choice Health Commercial |
$2.91
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.91
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.77
|
| Rate for Payer: HealthUtah PPO |
$3.06
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.97
|
| Rate for Payer: Multiplan Medicare/VA |
$1.69
|
| Rate for Payer: One Health Plan of WY PPO |
$3.00
|
| Rate for Payer: PacificSource Commercial |
$2.75
|
| Rate for Payer: PHCS PPO |
$3.00
|
| Rate for Payer: Three Rivers PPO |
$2.30
|
| Rate for Payer: TriWest Veterans Administration |
$1.77
|
| Rate for Payer: United Healthcare Commercial |
$2.66
|
| Rate for Payer: United Healthcare Medicare |
$1.77
|
| Rate for Payer: WINHealth Partners Commercial |
$3.00
|
| Rate for Payer: Wise Provider Network Commercial |
$2.91
|
|
|
THYROTROPIN ALFA 0.9 MG INTRAMUSCULAR SOLUTION [161995]
|
Facility
|
IP
|
$1,944.02
|
|
|
Service Code
|
HCPCS J3240
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,218.90 |
| Max. Negotiated Rate |
$1,944.02 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,905.14
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,866.26
|
| Rate for Payer: Altius Commercial |
$1,866.26
|
| Rate for Payer: Beech Street Commercial |
$1,905.14
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,596.04
|
| Rate for Payer: Cash Price |
$1,360.81
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,885.70
|
| Rate for Payer: Cigna of WY Commercial |
$1,905.14
|
| Rate for Payer: Entrust Commercial |
$1,846.82
|
| Rate for Payer: First Choice Health Commercial |
$1,846.82
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,846.82
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,283.05
|
| Rate for Payer: HealthUtah PPO |
$1,944.02
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,885.70
|
| Rate for Payer: Multiplan Medicare/VA |
$1,218.90
|
| Rate for Payer: One Health Plan of WY PPO |
$1,905.14
|
| Rate for Payer: PacificSource Commercial |
$1,749.62
|
| Rate for Payer: PHCS PPO |
$1,905.14
|
| Rate for Payer: Three Rivers PPO |
$1,458.02
|
| Rate for Payer: TriWest Veterans Administration |
$1,283.05
|
| Rate for Payer: United Healthcare Commercial |
$1,691.30
|
| Rate for Payer: United Healthcare Medicare |
$1,283.05
|
| Rate for Payer: WINHealth Partners Commercial |
$1,846.82
|
| Rate for Payer: Wise Provider Network Commercial |
$1,846.82
|
|
|
THYROTROPIN ALFA 0.9 MG INTRAMUSCULAR SOLUTION [161995]
|
Facility
|
OP
|
$1,944.02
|
|
|
Service Code
|
HCPCS J3240
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,071.16 |
| Max. Negotiated Rate |
$1,944.02 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,905.14
|
| Rate for Payer: Aetna of WY Medicare |
$1,283.05
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,866.26
|
| Rate for Payer: Altius Commercial |
$1,866.26
|
| Rate for Payer: Beech Street Commercial |
$1,905.14
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,596.04
|
| Rate for Payer: Cash Price |
$1,360.81
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,885.70
|
| Rate for Payer: Cigna of WY Commercial |
$1,905.14
|
| Rate for Payer: Entrust Commercial |
$1,846.82
|
| Rate for Payer: First Choice Health Commercial |
$1,846.82
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,846.82
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,127.53
|
| Rate for Payer: HealthUtah PPO |
$1,944.02
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,885.70
|
| Rate for Payer: Multiplan Medicare/VA |
$1,071.16
|
| Rate for Payer: One Health Plan of WY PPO |
$1,905.14
|
| Rate for Payer: PacificSource Commercial |
$1,749.62
|
| Rate for Payer: PHCS PPO |
$1,905.14
|
| Rate for Payer: Three Rivers PPO |
$1,458.02
|
| Rate for Payer: TriWest Veterans Administration |
$1,127.53
|
| Rate for Payer: United Healthcare Commercial |
$1,691.30
|
| Rate for Payer: United Healthcare Medicare |
$1,127.53
|
| Rate for Payer: WINHealth Partners Commercial |
$1,905.14
|
| Rate for Payer: Wise Provider Network Commercial |
$1,846.82
|
|
|
TIBIAL ACL KIT DISP AR-1898S
|
Facility
|
IP
|
$434.00
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$272.12 |
| Max. Negotiated Rate |
$434.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$425.32
|
| Rate for Payer: Altius Auto/Workers Compensation |
$416.64
|
| Rate for Payer: Altius Commercial |
$416.64
|
| Rate for Payer: Beech Street Commercial |
$425.32
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$356.31
|
| Rate for Payer: Cash Price |
$303.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$420.98
|
| Rate for Payer: Cigna of WY Commercial |
$425.32
|
| Rate for Payer: Entrust Commercial |
$412.30
|
| Rate for Payer: First Choice Health Commercial |
$412.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$412.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$286.44
|
| Rate for Payer: HealthUtah PPO |
$434.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$420.98
|
| Rate for Payer: Multiplan Medicare/VA |
$272.12
|
| Rate for Payer: One Health Plan of WY PPO |
$425.32
|
| Rate for Payer: PacificSource Commercial |
$390.60
|
| Rate for Payer: PHCS PPO |
$425.32
|
| Rate for Payer: Three Rivers PPO |
$325.50
|
| Rate for Payer: TriWest Veterans Administration |
$286.44
|
| Rate for Payer: United Healthcare Commercial |
$377.58
|
| Rate for Payer: United Healthcare Medicare |
$286.44
|
| Rate for Payer: WINHealth Partners Commercial |
$412.30
|
| Rate for Payer: Wise Provider Network Commercial |
$412.30
|
|
|
TIBIAL ACL KIT DISP AR-1898S
|
Facility
|
OP
|
$434.00
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$239.13 |
| Max. Negotiated Rate |
$434.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$425.32
|
| Rate for Payer: Aetna of WY Medicare |
$286.44
|
| Rate for Payer: Altius Auto/Workers Compensation |
$416.64
|
| Rate for Payer: Altius Commercial |
$416.64
|
| Rate for Payer: Beech Street Commercial |
$425.32
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$356.31
|
| Rate for Payer: Cash Price |
$303.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$420.98
|
| Rate for Payer: Cigna of WY Commercial |
$425.32
|
| Rate for Payer: Entrust Commercial |
$412.30
|
| Rate for Payer: First Choice Health Commercial |
$412.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$412.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$251.72
|
| Rate for Payer: HealthUtah PPO |
$434.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$420.98
|
| Rate for Payer: Multiplan Medicare/VA |
$239.13
|
| Rate for Payer: One Health Plan of WY PPO |
$425.32
|
| Rate for Payer: PacificSource Commercial |
$390.60
|
| Rate for Payer: PHCS PPO |
$425.32
|
| Rate for Payer: Three Rivers PPO |
$325.50
|
| Rate for Payer: TriWest Veterans Administration |
$251.72
|
| Rate for Payer: United Healthcare Commercial |
$377.58
|
| Rate for Payer: United Healthcare Medicare |
$251.72
|
| Rate for Payer: WINHealth Partners Commercial |
$425.32
|
| Rate for Payer: Wise Provider Network Commercial |
$412.30
|
|
|
TICAGRELOR 90 MG TABLET [93051]
|
Facility
|
IP
|
$25.17
|
|
|
Service Code
|
NDC 0186077739
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.78 |
| Max. Negotiated Rate |
$25.17 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$24.67
|
| Rate for Payer: Altius Auto/Workers Compensation |
$24.16
|
| Rate for Payer: Altius Commercial |
$24.16
|
| Rate for Payer: Beech Street Commercial |
$24.67
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$20.66
|
| Rate for Payer: Cash Price |
$17.62
|
| Rate for Payer: ChoiceCare Network Commercial |
$24.41
|
| Rate for Payer: Cigna of WY Commercial |
$24.67
|
| Rate for Payer: Entrust Commercial |
$23.91
|
| Rate for Payer: First Choice Health Commercial |
$23.91
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$23.91
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$16.61
|
| Rate for Payer: HealthUtah PPO |
$25.17
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.41
|
| Rate for Payer: Multiplan Medicare/VA |
$15.78
|
| Rate for Payer: One Health Plan of WY PPO |
$24.67
|
| Rate for Payer: PacificSource Commercial |
$22.65
|
| Rate for Payer: PHCS PPO |
$24.67
|
| Rate for Payer: Three Rivers PPO |
$18.88
|
| Rate for Payer: TriWest Veterans Administration |
$16.61
|
| Rate for Payer: United Healthcare Commercial |
$21.90
|
| Rate for Payer: United Healthcare Medicare |
$16.61
|
| Rate for Payer: WINHealth Partners Commercial |
$23.91
|
| Rate for Payer: Wise Provider Network Commercial |
$23.91
|
|
