|
CEM MIXING BOWL PALABOWL
|
Facility
|
IP
|
$157.50
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$98.75 |
| Max. Negotiated Rate |
$157.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$154.35
|
| Rate for Payer: Altius Auto/Workers Compensation |
$151.20
|
| Rate for Payer: Altius Commercial |
$151.20
|
| Rate for Payer: Beech Street Commercial |
$154.35
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$129.31
|
| Rate for Payer: Cash Price |
$110.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$152.78
|
| Rate for Payer: Cigna of WY Commercial |
$154.35
|
| Rate for Payer: Entrust Commercial |
$149.62
|
| Rate for Payer: First Choice Health Commercial |
$149.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$149.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$103.95
|
| Rate for Payer: HealthUtah PPO |
$157.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$152.78
|
| Rate for Payer: Multiplan Medicare/VA |
$98.75
|
| Rate for Payer: One Health Plan of WY PPO |
$154.35
|
| Rate for Payer: PacificSource Commercial |
$141.75
|
| Rate for Payer: PHCS PPO |
$154.35
|
| Rate for Payer: Three Rivers PPO |
$118.12
|
| Rate for Payer: TriWest Veterans Administration |
$103.95
|
| Rate for Payer: United Healthcare Commercial |
$137.02
|
| Rate for Payer: United Healthcare Medicare |
$103.95
|
| Rate for Payer: WINHealth Partners Commercial |
$149.62
|
| Rate for Payer: Wise Provider Network Commercial |
$149.62
|
|
|
CEM MIXING BOWL PALABOWL
|
Facility
|
OP
|
$157.50
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$86.78 |
| Max. Negotiated Rate |
$157.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$154.35
|
| Rate for Payer: Aetna of WY Medicare |
$103.95
|
| Rate for Payer: Altius Auto/Workers Compensation |
$151.20
|
| Rate for Payer: Altius Commercial |
$151.20
|
| Rate for Payer: Beech Street Commercial |
$154.35
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$129.31
|
| Rate for Payer: Cash Price |
$110.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$152.78
|
| Rate for Payer: Cigna of WY Commercial |
$154.35
|
| Rate for Payer: Entrust Commercial |
$149.62
|
| Rate for Payer: First Choice Health Commercial |
$149.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$149.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$91.35
|
| Rate for Payer: HealthUtah PPO |
$157.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$152.78
|
| Rate for Payer: Multiplan Medicare/VA |
$86.78
|
| Rate for Payer: One Health Plan of WY PPO |
$154.35
|
| Rate for Payer: PacificSource Commercial |
$141.75
|
| Rate for Payer: PHCS PPO |
$154.35
|
| Rate for Payer: Three Rivers PPO |
$118.12
|
| Rate for Payer: TriWest Veterans Administration |
$91.35
|
| Rate for Payer: United Healthcare Commercial |
$137.02
|
| Rate for Payer: United Healthcare Medicare |
$91.35
|
| Rate for Payer: WINHealth Partners Commercial |
$154.35
|
| Rate for Payer: Wise Provider Network Commercial |
$149.62
|
|
|
CENTRAL 1 LUMEN CATH CORDIS
|
Facility
|
OP
|
$333.20
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$183.59 |
| Max. Negotiated Rate |
$333.20 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$326.54
|
| Rate for Payer: Aetna of WY Medicare |
$219.91
|
| Rate for Payer: Altius Auto/Workers Compensation |
$319.87
|
| Rate for Payer: Altius Commercial |
$319.87
|
| Rate for Payer: Beech Street Commercial |
$326.54
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$273.56
|
| Rate for Payer: Cash Price |
$233.24
|
| Rate for Payer: ChoiceCare Network Commercial |
$323.20
|
| Rate for Payer: Cigna of WY Commercial |
$326.54
|
| Rate for Payer: Entrust Commercial |
$316.54
|
| Rate for Payer: First Choice Health Commercial |
$316.54
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$316.54
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$193.26
|
| Rate for Payer: HealthUtah PPO |
$333.20
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$323.20
|
| Rate for Payer: Multiplan Medicare/VA |
$183.59
|
| Rate for Payer: One Health Plan of WY PPO |
$326.54
|
| Rate for Payer: PacificSource Commercial |
$299.88
|
| Rate for Payer: PHCS PPO |
$326.54
|
| Rate for Payer: Three Rivers PPO |
$249.90
|
| Rate for Payer: TriWest Veterans Administration |
$193.26
|
| Rate for Payer: United Healthcare Commercial |
$289.88
|
| Rate for Payer: United Healthcare Medicare |
$193.26
|
| Rate for Payer: WINHealth Partners Commercial |
$326.54
|
| Rate for Payer: Wise Provider Network Commercial |
$316.54
|
|
|
CENTRAL 1 LUMEN CATH CORDIS
|
Facility
|
IP
|
$333.20
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$208.92 |
| Max. Negotiated Rate |
$333.20 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$326.54
|
| Rate for Payer: Altius Auto/Workers Compensation |
$319.87
|
| Rate for Payer: Altius Commercial |
$319.87
|
| Rate for Payer: Beech Street Commercial |
$326.54
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$273.56
|
| Rate for Payer: Cash Price |
$233.24
|
| Rate for Payer: ChoiceCare Network Commercial |
$323.20
|
| Rate for Payer: Cigna of WY Commercial |
$326.54
|
| Rate for Payer: Entrust Commercial |
$316.54
|
| Rate for Payer: First Choice Health Commercial |
$316.54
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$316.54
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$219.91
|
| Rate for Payer: HealthUtah PPO |
$333.20
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$323.20
|
| Rate for Payer: Multiplan Medicare/VA |
$208.92
|
| Rate for Payer: One Health Plan of WY PPO |
$326.54
|
| Rate for Payer: PacificSource Commercial |
$299.88
|
| Rate for Payer: PHCS PPO |
$326.54
|
| Rate for Payer: Three Rivers PPO |
$249.90
|
| Rate for Payer: TriWest Veterans Administration |
$219.91
|
| Rate for Payer: United Healthcare Commercial |
$289.88
|
| Rate for Payer: United Healthcare Medicare |
$219.91
|
| Rate for Payer: WINHealth Partners Commercial |
$316.54
|
| Rate for Payer: Wise Provider Network Commercial |
$316.54
|
|
|
CENTRAL 3 LUMEN CATH PEDIATRIC
|
Facility
|
IP
|
$464.10
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$290.99 |
| Max. Negotiated Rate |
$464.10 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$454.82
|
| Rate for Payer: Altius Auto/Workers Compensation |
$445.54
|
| Rate for Payer: Altius Commercial |
$445.54
|
| Rate for Payer: Beech Street Commercial |
$454.82
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$381.03
|
| Rate for Payer: Cash Price |
$324.87
|
| Rate for Payer: ChoiceCare Network Commercial |
$450.18
|
| Rate for Payer: Cigna of WY Commercial |
$454.82
|
| Rate for Payer: Entrust Commercial |
$440.90
|
| Rate for Payer: First Choice Health Commercial |
$440.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$440.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$306.31
|
| Rate for Payer: HealthUtah PPO |
$464.10
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$450.18
|
| Rate for Payer: Multiplan Medicare/VA |
$290.99
|
| Rate for Payer: One Health Plan of WY PPO |
$454.82
|
| Rate for Payer: PacificSource Commercial |
$417.69
|
| Rate for Payer: PHCS PPO |
$454.82
|
| Rate for Payer: Three Rivers PPO |
$348.08
|
| Rate for Payer: TriWest Veterans Administration |
$306.31
|
| Rate for Payer: United Healthcare Commercial |
$403.77
|
| Rate for Payer: United Healthcare Medicare |
$306.31
|
| Rate for Payer: WINHealth Partners Commercial |
$440.90
|
| Rate for Payer: Wise Provider Network Commercial |
$440.90
|
|
|
CENTRAL 3 LUMEN CATH PEDIATRIC
|
Facility
|
OP
|
$464.10
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$255.72 |
| Max. Negotiated Rate |
$464.10 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$454.82
|
| Rate for Payer: Aetna of WY Medicare |
$306.31
|
| Rate for Payer: Altius Auto/Workers Compensation |
$445.54
|
| Rate for Payer: Altius Commercial |
$445.54
|
| Rate for Payer: Beech Street Commercial |
$454.82
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$381.03
|
| Rate for Payer: Cash Price |
$324.87
|
| Rate for Payer: ChoiceCare Network Commercial |
$450.18
|
| Rate for Payer: Cigna of WY Commercial |
$454.82
|
| Rate for Payer: Entrust Commercial |
$440.90
|
| Rate for Payer: First Choice Health Commercial |
$440.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$440.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$269.18
|
| Rate for Payer: HealthUtah PPO |
$464.10
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$450.18
|
| Rate for Payer: Multiplan Medicare/VA |
$255.72
|
| Rate for Payer: One Health Plan of WY PPO |
$454.82
|
| Rate for Payer: PacificSource Commercial |
$417.69
|
| Rate for Payer: PHCS PPO |
$454.82
|
| Rate for Payer: Three Rivers PPO |
$348.08
|
| Rate for Payer: TriWest Veterans Administration |
$269.18
|
| Rate for Payer: United Healthcare Commercial |
$403.77
|
| Rate for Payer: United Healthcare Medicare |
$269.18
|
| Rate for Payer: WINHealth Partners Commercial |
$454.82
|
| Rate for Payer: Wise Provider Network Commercial |
$440.90
|
|
|
CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION [12451]
|
Facility
|
OP
|
$0.92
|
|
|
Service Code
|
NDC 0093417773
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$0.92 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.90
|
| Rate for Payer: Aetna of WY Medicare |
$0.61
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.88
|
| Rate for Payer: Altius Commercial |
$0.88
|
| Rate for Payer: Beech Street Commercial |
$0.90
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.76
|
| Rate for Payer: Cash Price |
$0.64
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.89
|
| Rate for Payer: Cigna of WY Commercial |
$0.90
|
| Rate for Payer: Entrust Commercial |
$0.87
|
| Rate for Payer: First Choice Health Commercial |
$0.87
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.87
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.53
|
| Rate for Payer: HealthUtah PPO |
$0.92
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.89
|
| Rate for Payer: Multiplan Medicare/VA |
$0.51
|
| Rate for Payer: One Health Plan of WY PPO |
$0.90
|
| Rate for Payer: PacificSource Commercial |
$0.83
|
| Rate for Payer: PHCS PPO |
$0.90
|
| Rate for Payer: Three Rivers PPO |
$0.69
|
| Rate for Payer: TriWest Veterans Administration |
$0.53
|
| Rate for Payer: United Healthcare Commercial |
$0.80
|
| Rate for Payer: United Healthcare Medicare |
$0.53
|
| Rate for Payer: WINHealth Partners Commercial |
$0.90
|
| Rate for Payer: Wise Provider Network Commercial |
$0.87
|
|
|
CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION [12451]
|
Facility
|
IP
|
$0.92
|
|
|
Service Code
|
NDC 0093417773
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$0.92 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.90
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.88
|
| Rate for Payer: Altius Commercial |
$0.88
|
| Rate for Payer: Beech Street Commercial |
$0.90
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.76
|
| Rate for Payer: Cash Price |
$0.64
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.89
|
| Rate for Payer: Cigna of WY Commercial |
$0.90
|
| Rate for Payer: Entrust Commercial |
$0.87
|
| Rate for Payer: First Choice Health Commercial |
$0.87
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.87
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.61
|
| Rate for Payer: HealthUtah PPO |
$0.92
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.89
|
| Rate for Payer: Multiplan Medicare/VA |
$0.58
|
| Rate for Payer: One Health Plan of WY PPO |
$0.90
|
| Rate for Payer: PacificSource Commercial |
$0.83
|
| Rate for Payer: PHCS PPO |
$0.90
|
| Rate for Payer: Three Rivers PPO |
$0.69
|
| Rate for Payer: TriWest Veterans Administration |
$0.61
|
| Rate for Payer: United Healthcare Commercial |
$0.80
|
| Rate for Payer: United Healthcare Medicare |
$0.61
|
| Rate for Payer: WINHealth Partners Commercial |
$0.87
|
| Rate for Payer: Wise Provider Network Commercial |
$0.87
|
|
|
CEPHALEXIN 250 MG CAPSULE [3879]
|
Facility
|
IP
|
$1.60
|
|
|
Service Code
|
NDC 5026815115
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$1.60 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.57
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.54
|
| Rate for Payer: Altius Commercial |
$1.54
|
| Rate for Payer: Beech Street Commercial |
$1.57
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.31
|
| Rate for Payer: Cash Price |
$1.12
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.55
|
| Rate for Payer: Cigna of WY Commercial |
$1.57
|
| Rate for Payer: Entrust Commercial |
$1.52
|
| Rate for Payer: First Choice Health Commercial |
$1.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.06
|
| Rate for Payer: HealthUtah PPO |
$1.60
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.55
|
| Rate for Payer: Multiplan Medicare/VA |
$1.00
|
| Rate for Payer: One Health Plan of WY PPO |
$1.57
|
| Rate for Payer: PacificSource Commercial |
$1.44
|
| Rate for Payer: PHCS PPO |
$1.57
|
| Rate for Payer: Three Rivers PPO |
$1.20
|
| Rate for Payer: TriWest Veterans Administration |
$1.06
|
| Rate for Payer: United Healthcare Commercial |
$1.39
|
| Rate for Payer: United Healthcare Medicare |
$1.06
|
| Rate for Payer: WINHealth Partners Commercial |
$1.52
|
| Rate for Payer: Wise Provider Network Commercial |
$1.52
|
|
|
CEPHALEXIN 250 MG CAPSULE [3879]
|
Facility
|
OP
|
$1.29
|
|
|
Service Code
|
NDC 6068715201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.71 |
| Max. Negotiated Rate |
$1.29 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.26
|
| Rate for Payer: Aetna of WY Medicare |
$0.85
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.24
|
| Rate for Payer: Altius Commercial |
$1.24
|
| Rate for Payer: Beech Street Commercial |
$1.26
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.06
|
| Rate for Payer: Cash Price |
$0.91
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.25
|
| Rate for Payer: Cigna of WY Commercial |
$1.26
|
| Rate for Payer: Entrust Commercial |
$1.23
|
| Rate for Payer: First Choice Health Commercial |
$1.23
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.23
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.75
|
| Rate for Payer: HealthUtah PPO |
$1.29
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.25
|
| Rate for Payer: Multiplan Medicare/VA |
$0.71
|
| Rate for Payer: One Health Plan of WY PPO |
$1.26
|
| Rate for Payer: PacificSource Commercial |
$1.16
|
| Rate for Payer: PHCS PPO |
$1.26
|
| Rate for Payer: Three Rivers PPO |
$0.97
|
| Rate for Payer: TriWest Veterans Administration |
$0.75
|
| Rate for Payer: United Healthcare Commercial |
$1.12
|
| Rate for Payer: United Healthcare Medicare |
$0.75
|
| Rate for Payer: WINHealth Partners Commercial |
$1.26
|
| Rate for Payer: Wise Provider Network Commercial |
$1.23
|
|
|
CEPHALEXIN 250 MG CAPSULE [3879]
|
Facility
|
OP
|
$1.60
|
|
|
Service Code
|
NDC 5026815115
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$1.60 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.57
|
| Rate for Payer: Aetna of WY Medicare |
$1.06
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.54
|
| Rate for Payer: Altius Commercial |
$1.54
|
| Rate for Payer: Beech Street Commercial |
$1.57
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.31
|
| Rate for Payer: Cash Price |
$1.12
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.55
|
| Rate for Payer: Cigna of WY Commercial |
$1.57
|
| Rate for Payer: Entrust Commercial |
$1.52
|
| Rate for Payer: First Choice Health Commercial |
$1.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.93
|
| Rate for Payer: HealthUtah PPO |
$1.60
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.55
|
| Rate for Payer: Multiplan Medicare/VA |
$0.88
|
| Rate for Payer: One Health Plan of WY PPO |
$1.57
|
| Rate for Payer: PacificSource Commercial |
$1.44
|
| Rate for Payer: PHCS PPO |
$1.57
|
| Rate for Payer: Three Rivers PPO |
$1.20
|
| Rate for Payer: TriWest Veterans Administration |
$0.93
|
| Rate for Payer: United Healthcare Commercial |
$1.39
|
| Rate for Payer: United Healthcare Medicare |
$0.93
|
| Rate for Payer: WINHealth Partners Commercial |
$1.57
|
| Rate for Payer: Wise Provider Network Commercial |
$1.52
|
|
|
CEPHALEXIN 250 MG CAPSULE [3879]
|
Facility
|
IP
|
$1.29
|
|
|
Service Code
|
NDC 6068715201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.81 |
| Max. Negotiated Rate |
$1.29 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.26
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.24
|
| Rate for Payer: Altius Commercial |
$1.24
|
| Rate for Payer: Beech Street Commercial |
$1.26
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.06
|
| Rate for Payer: Cash Price |
$0.91
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.25
|
| Rate for Payer: Cigna of WY Commercial |
$1.26
|
| Rate for Payer: Entrust Commercial |
$1.23
|
| Rate for Payer: First Choice Health Commercial |
$1.23
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.23
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.85
|
| Rate for Payer: HealthUtah PPO |
$1.29
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.25
|
| Rate for Payer: Multiplan Medicare/VA |
$0.81
|
| Rate for Payer: One Health Plan of WY PPO |
$1.26
|
| Rate for Payer: PacificSource Commercial |
$1.16
|
| Rate for Payer: PHCS PPO |
$1.26
|
| Rate for Payer: Three Rivers PPO |
$0.97
|
| Rate for Payer: TriWest Veterans Administration |
$0.85
|
| Rate for Payer: United Healthcare Commercial |
$1.12
|
| Rate for Payer: United Healthcare Medicare |
$0.85
|
| Rate for Payer: WINHealth Partners Commercial |
$1.23
|
| Rate for Payer: Wise Provider Network Commercial |
$1.23
|
|
|
CEPHALEXIN 250 MG CAPSULE [3879]
|
Facility
|
IP
|
$1.60
|
|
|
Service Code
|
NDC 5026815111
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$1.60 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.57
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.54
|
| Rate for Payer: Altius Commercial |
$1.54
|
| Rate for Payer: Beech Street Commercial |
$1.57
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.31
|
| Rate for Payer: Cash Price |
$1.12
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.55
|
| Rate for Payer: Cigna of WY Commercial |
$1.57
|
| Rate for Payer: Entrust Commercial |
$1.52
|
| Rate for Payer: First Choice Health Commercial |
$1.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.06
|
| Rate for Payer: HealthUtah PPO |
$1.60
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.55
|
| Rate for Payer: Multiplan Medicare/VA |
$1.00
|
| Rate for Payer: One Health Plan of WY PPO |
$1.57
|
| Rate for Payer: PacificSource Commercial |
$1.44
|
| Rate for Payer: PHCS PPO |
$1.57
|
| Rate for Payer: Three Rivers PPO |
$1.20
|
| Rate for Payer: TriWest Veterans Administration |
$1.06
|
| Rate for Payer: United Healthcare Commercial |
$1.39
|
| Rate for Payer: United Healthcare Medicare |
$1.06
|
| Rate for Payer: WINHealth Partners Commercial |
$1.52
|
| Rate for Payer: Wise Provider Network Commercial |
$1.52
|
|
|
CEPHALEXIN 250 MG CAPSULE [3879]
|
Facility
|
OP
|
$1.60
|
|
|
Service Code
|
NDC 5026815111
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$1.60 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.57
|
| Rate for Payer: Aetna of WY Medicare |
$1.06
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.54
|
| Rate for Payer: Altius Commercial |
$1.54
|
| Rate for Payer: Beech Street Commercial |
$1.57
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.31
|
| Rate for Payer: Cash Price |
$1.12
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.55
|
| Rate for Payer: Cigna of WY Commercial |
$1.57
|
| Rate for Payer: Entrust Commercial |
$1.52
|
| Rate for Payer: First Choice Health Commercial |
$1.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.93
|
| Rate for Payer: HealthUtah PPO |
$1.60
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.55
|
| Rate for Payer: Multiplan Medicare/VA |
$0.88
|
| Rate for Payer: One Health Plan of WY PPO |
$1.57
|
| Rate for Payer: PacificSource Commercial |
$1.44
|
| Rate for Payer: PHCS PPO |
$1.57
|
| Rate for Payer: Three Rivers PPO |
$1.20
|
| Rate for Payer: TriWest Veterans Administration |
$0.93
|
| Rate for Payer: United Healthcare Commercial |
$1.39
|
| Rate for Payer: United Healthcare Medicare |
$0.93
|
| Rate for Payer: WINHealth Partners Commercial |
$1.57
|
| Rate for Payer: Wise Provider Network Commercial |
$1.52
|
|
|
CEPHALEXIN 250 MG CAPSULE [3879]
|
Facility
|
IP
|
$1.29
|
|
|
Service Code
|
NDC 6068715211
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.81 |
| Max. Negotiated Rate |
$1.29 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.26
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.24
|
| Rate for Payer: Altius Commercial |
$1.24
|
| Rate for Payer: Beech Street Commercial |
$1.26
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.06
|
| Rate for Payer: Cash Price |
$0.91
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.25
|
| Rate for Payer: Cigna of WY Commercial |
$1.26
|
| Rate for Payer: Entrust Commercial |
$1.23
|
| Rate for Payer: First Choice Health Commercial |
$1.23
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.23
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.85
|
| Rate for Payer: HealthUtah PPO |
$1.29
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.25
|
| Rate for Payer: Multiplan Medicare/VA |
$0.81
|
| Rate for Payer: One Health Plan of WY PPO |
$1.26
|
| Rate for Payer: PacificSource Commercial |
$1.16
|
| Rate for Payer: PHCS PPO |
$1.26
|
| Rate for Payer: Three Rivers PPO |
$0.97
|
| Rate for Payer: TriWest Veterans Administration |
$0.85
|
| Rate for Payer: United Healthcare Commercial |
$1.12
|
| Rate for Payer: United Healthcare Medicare |
$0.85
|
| Rate for Payer: WINHealth Partners Commercial |
$1.23
|
| Rate for Payer: Wise Provider Network Commercial |
$1.23
|
|
|
CEPHALEXIN 250 MG CAPSULE [3879]
|
Facility
|
OP
|
$1.29
|
|
|
Service Code
|
NDC 6068715211
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.71 |
| Max. Negotiated Rate |
$1.29 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.26
|
| Rate for Payer: Aetna of WY Medicare |
$0.85
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.24
|
| Rate for Payer: Altius Commercial |
$1.24
|
| Rate for Payer: Beech Street Commercial |
$1.26
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.06
|
| Rate for Payer: Cash Price |
$0.91
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.25
|
| Rate for Payer: Cigna of WY Commercial |
$1.26
|
| Rate for Payer: Entrust Commercial |
$1.23
|
| Rate for Payer: First Choice Health Commercial |
$1.23
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.23
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.75
|
| Rate for Payer: HealthUtah PPO |
$1.29
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.25
|
| Rate for Payer: Multiplan Medicare/VA |
$0.71
|
| Rate for Payer: One Health Plan of WY PPO |
$1.26
|
| Rate for Payer: PacificSource Commercial |
$1.16
|
| Rate for Payer: PHCS PPO |
$1.26
|
| Rate for Payer: Three Rivers PPO |
$0.97
|
| Rate for Payer: TriWest Veterans Administration |
$0.75
|
| Rate for Payer: United Healthcare Commercial |
$1.12
|
| Rate for Payer: United Healthcare Medicare |
$0.75
|
| Rate for Payer: WINHealth Partners Commercial |
$1.26
|
| Rate for Payer: Wise Provider Network Commercial |
$1.23
|
|
|
CEPHALEXIN 500 MG CAPSULE [12107]
|
Facility
|
IP
|
$1.45
|
|
|
Service Code
|
NDC 6068716301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.91 |
| Max. Negotiated Rate |
$1.45 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.42
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.39
|
| Rate for Payer: Altius Commercial |
$1.39
|
| Rate for Payer: Beech Street Commercial |
$1.42
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.19
|
| Rate for Payer: Cash Price |
$1.02
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.41
|
| Rate for Payer: Cigna of WY Commercial |
$1.42
|
| Rate for Payer: Entrust Commercial |
$1.38
|
| Rate for Payer: First Choice Health Commercial |
$1.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.96
|
| Rate for Payer: HealthUtah PPO |
$1.45
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.41
|
| Rate for Payer: Multiplan Medicare/VA |
$0.91
|
| Rate for Payer: One Health Plan of WY PPO |
$1.42
|
| Rate for Payer: PacificSource Commercial |
$1.30
|
| Rate for Payer: PHCS PPO |
$1.42
|
| Rate for Payer: Three Rivers PPO |
$1.09
|
| Rate for Payer: TriWest Veterans Administration |
$0.96
|
| Rate for Payer: United Healthcare Commercial |
$1.26
|
| Rate for Payer: United Healthcare Medicare |
$0.96
|
| Rate for Payer: WINHealth Partners Commercial |
$1.38
|
| Rate for Payer: Wise Provider Network Commercial |
$1.38
|
|
|
CEPHALEXIN 500 MG CAPSULE [12107]
|
Facility
|
IP
|
$1.14
|
|
|
Service Code
|
NDC 5026815211
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.71 |
| Max. Negotiated Rate |
$1.14 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.12
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.09
|
| Rate for Payer: Altius Commercial |
$1.09
|
| Rate for Payer: Beech Street Commercial |
$1.12
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.94
|
| Rate for Payer: Cash Price |
$0.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.11
|
| Rate for Payer: Cigna of WY Commercial |
$1.12
|
| Rate for Payer: Entrust Commercial |
$1.08
|
| Rate for Payer: First Choice Health Commercial |
$1.08
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.08
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.75
|
| Rate for Payer: HealthUtah PPO |
$1.14
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.11
|
| Rate for Payer: Multiplan Medicare/VA |
$0.71
|
| Rate for Payer: One Health Plan of WY PPO |
$1.12
|
| Rate for Payer: PacificSource Commercial |
$1.03
|
| Rate for Payer: PHCS PPO |
$1.12
|
| Rate for Payer: Three Rivers PPO |
$0.86
|
| Rate for Payer: TriWest Veterans Administration |
$0.75
|
| Rate for Payer: United Healthcare Commercial |
$0.99
|
| Rate for Payer: United Healthcare Medicare |
$0.75
|
| Rate for Payer: WINHealth Partners Commercial |
$1.08
|
| Rate for Payer: Wise Provider Network Commercial |
$1.08
|
|
|
CEPHALEXIN 500 MG CAPSULE [12107]
|
Facility
|
OP
|
$1.45
|
|
|
Service Code
|
NDC 6068716311
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$1.45 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.42
|
| Rate for Payer: Aetna of WY Medicare |
$0.96
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.39
|
| Rate for Payer: Altius Commercial |
$1.39
|
| Rate for Payer: Beech Street Commercial |
$1.42
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.19
|
| Rate for Payer: Cash Price |
$1.02
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.41
|
| Rate for Payer: Cigna of WY Commercial |
$1.42
|
| Rate for Payer: Entrust Commercial |
$1.38
|
| Rate for Payer: First Choice Health Commercial |
$1.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.84
|
| Rate for Payer: HealthUtah PPO |
$1.45
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.41
|
| Rate for Payer: Multiplan Medicare/VA |
$0.80
|
| Rate for Payer: One Health Plan of WY PPO |
$1.42
|
| Rate for Payer: PacificSource Commercial |
$1.30
|
| Rate for Payer: PHCS PPO |
$1.42
|
| Rate for Payer: Three Rivers PPO |
$1.09
|
| Rate for Payer: TriWest Veterans Administration |
$0.84
|
| Rate for Payer: United Healthcare Commercial |
$1.26
|
| Rate for Payer: United Healthcare Medicare |
$0.84
|
| Rate for Payer: WINHealth Partners Commercial |
$1.42
|
| Rate for Payer: Wise Provider Network Commercial |
$1.38
|
|
|
CEPHALEXIN 500 MG CAPSULE [12107]
|
Facility
|
OP
|
$1.14
|
|
|
Service Code
|
NDC 5026815211
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$1.14 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.12
|
| Rate for Payer: Aetna of WY Medicare |
$0.75
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.09
|
| Rate for Payer: Altius Commercial |
$1.09
|
| Rate for Payer: Beech Street Commercial |
$1.12
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.94
|
| Rate for Payer: Cash Price |
$0.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.11
|
| Rate for Payer: Cigna of WY Commercial |
$1.12
|
| Rate for Payer: Entrust Commercial |
$1.08
|
| Rate for Payer: First Choice Health Commercial |
$1.08
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.08
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.66
|
| Rate for Payer: HealthUtah PPO |
$1.14
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.11
|
| Rate for Payer: Multiplan Medicare/VA |
$0.63
|
| Rate for Payer: One Health Plan of WY PPO |
$1.12
|
| Rate for Payer: PacificSource Commercial |
$1.03
|
| Rate for Payer: PHCS PPO |
$1.12
|
| Rate for Payer: Three Rivers PPO |
$0.86
|
| Rate for Payer: TriWest Veterans Administration |
$0.66
|
| Rate for Payer: United Healthcare Commercial |
$0.99
|
| Rate for Payer: United Healthcare Medicare |
$0.66
|
| Rate for Payer: WINHealth Partners Commercial |
$1.12
|
| Rate for Payer: Wise Provider Network Commercial |
$1.08
|
|
|
CEPHALEXIN 500 MG CAPSULE [12107]
|
Facility
|
OP
|
$1.45
|
|
|
Service Code
|
NDC 6068716301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$1.45 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.42
|
| Rate for Payer: Aetna of WY Medicare |
$0.96
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.39
|
| Rate for Payer: Altius Commercial |
$1.39
|
| Rate for Payer: Beech Street Commercial |
$1.42
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.19
|
| Rate for Payer: Cash Price |
$1.02
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.41
|
| Rate for Payer: Cigna of WY Commercial |
$1.42
|
| Rate for Payer: Entrust Commercial |
$1.38
|
| Rate for Payer: First Choice Health Commercial |
$1.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.84
|
| Rate for Payer: HealthUtah PPO |
$1.45
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.41
|
| Rate for Payer: Multiplan Medicare/VA |
$0.80
|
| Rate for Payer: One Health Plan of WY PPO |
$1.42
|
| Rate for Payer: PacificSource Commercial |
$1.30
|
| Rate for Payer: PHCS PPO |
$1.42
|
| Rate for Payer: Three Rivers PPO |
$1.09
|
| Rate for Payer: TriWest Veterans Administration |
$0.84
|
| Rate for Payer: United Healthcare Commercial |
$1.26
|
| Rate for Payer: United Healthcare Medicare |
$0.84
|
| Rate for Payer: WINHealth Partners Commercial |
$1.42
|
| Rate for Payer: Wise Provider Network Commercial |
$1.38
|
|
|
CEPHALEXIN 500 MG CAPSULE [12107]
|
Facility
|
IP
|
$1.45
|
|
|
Service Code
|
NDC 6068716311
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.91 |
| Max. Negotiated Rate |
$1.45 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.42
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.39
|
| Rate for Payer: Altius Commercial |
$1.39
|
| Rate for Payer: Beech Street Commercial |
$1.42
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.19
|
| Rate for Payer: Cash Price |
$1.02
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.41
|
| Rate for Payer: Cigna of WY Commercial |
$1.42
|
| Rate for Payer: Entrust Commercial |
$1.38
|
| Rate for Payer: First Choice Health Commercial |
$1.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.96
|
| Rate for Payer: HealthUtah PPO |
$1.45
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.41
|
| Rate for Payer: Multiplan Medicare/VA |
$0.91
|
| Rate for Payer: One Health Plan of WY PPO |
$1.42
|
| Rate for Payer: PacificSource Commercial |
$1.30
|
| Rate for Payer: PHCS PPO |
$1.42
|
| Rate for Payer: Three Rivers PPO |
$1.09
|
| Rate for Payer: TriWest Veterans Administration |
$0.96
|
| Rate for Payer: United Healthcare Commercial |
$1.26
|
| Rate for Payer: United Healthcare Medicare |
$0.96
|
| Rate for Payer: WINHealth Partners Commercial |
$1.38
|
| Rate for Payer: Wise Provider Network Commercial |
$1.38
|
|
|
CERCLAGE CERVIX PREGNANCY ABDOMINAL
|
Professional
|
Both
|
$584.00
|
|
|
Service Code
|
HCPCS 59325
|
| Hospital Charge Code |
59325
|
| Min. Negotiated Rate |
$192.22 |
| Max. Negotiated Rate |
$584.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$572.32
|
| Rate for Payer: Aetna of WY Medicare |
$226.14
|
| Rate for Payer: Beech Street Commercial |
$554.80
|
| Rate for Payer: Cash Price |
$408.80
|
| Rate for Payer: Cash Price |
$408.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$566.48
|
| Rate for Payer: Cigna of WY Commercial |
$572.32
|
| Rate for Payer: First Choice Health Commercial |
$525.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$554.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$226.14
|
| Rate for Payer: HealthUtah PPO |
$584.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$566.48
|
| Rate for Payer: Multiplan Medicare/VA |
$192.22
|
| Rate for Payer: One Health Plan of WY PPO |
$572.32
|
| Rate for Payer: PacificSource Commercial |
$525.60
|
| Rate for Payer: PHCS PPO |
$554.80
|
| Rate for Payer: Three Rivers PPO |
$438.00
|
| Rate for Payer: TriWest Veterans Administration |
$226.14
|
| Rate for Payer: United Healthcare Commercial |
$508.08
|
| Rate for Payer: United Healthcare Medicare |
$226.14
|
| Rate for Payer: WINHealth Partners Commercial |
$496.40
|
|
|
CERCLAGE CERVIX PREGNANCY VAGINAL
|
Professional
|
Both
|
$365.00
|
|
|
Service Code
|
HCPCS 59320
|
| Hospital Charge Code |
59320
|
| Min. Negotiated Rate |
$121.46 |
| Max. Negotiated Rate |
$365.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$357.70
|
| Rate for Payer: Aetna of WY Medicare |
$142.90
|
| Rate for Payer: Beech Street Commercial |
$346.75
|
| Rate for Payer: Cash Price |
$255.50
|
| Rate for Payer: Cash Price |
$255.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$354.05
|
| Rate for Payer: Cigna of WY Commercial |
$357.70
|
| Rate for Payer: First Choice Health Commercial |
$328.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$346.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$142.90
|
| Rate for Payer: HealthUtah PPO |
$365.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$354.05
|
| Rate for Payer: Multiplan Medicare/VA |
$121.46
|
| Rate for Payer: One Health Plan of WY PPO |
$357.70
|
| Rate for Payer: PacificSource Commercial |
$328.50
|
| Rate for Payer: PHCS PPO |
$346.75
|
| Rate for Payer: Three Rivers PPO |
$273.75
|
| Rate for Payer: TriWest Veterans Administration |
$142.90
|
| Rate for Payer: United Healthcare Commercial |
$317.55
|
| Rate for Payer: United Healthcare Medicare |
$142.90
|
| Rate for Payer: WINHealth Partners Commercial |
$310.25
|
|
|
CERTOLIZUMAB PEGOL 400 MG/2 ML (200 MG/ML X2) SUBCUTANEOUS SYRINGE KIT [86986]
|
Facility
|
IP
|
$9,014.15
|
|
|
Service Code
|
HCPCS J0717
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,651.87 |
| Max. Negotiated Rate |
$9,014.15 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$8,833.87
|
| Rate for Payer: Altius Auto/Workers Compensation |
$8,653.58
|
| Rate for Payer: Altius Commercial |
$8,653.58
|
| Rate for Payer: Beech Street Commercial |
$8,833.87
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$7,400.62
|
| Rate for Payer: Cash Price |
$6,309.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$8,743.73
|
| Rate for Payer: Cigna of WY Commercial |
$8,833.87
|
| Rate for Payer: Entrust Commercial |
$8,563.44
|
| Rate for Payer: First Choice Health Commercial |
$8,563.44
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$8,563.44
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$5,949.34
|
| Rate for Payer: HealthUtah PPO |
$9,014.15
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$8,743.73
|
| Rate for Payer: Multiplan Medicare/VA |
$5,651.87
|
| Rate for Payer: One Health Plan of WY PPO |
$8,833.87
|
| Rate for Payer: PacificSource Commercial |
$8,112.74
|
| Rate for Payer: PHCS PPO |
$8,833.87
|
| Rate for Payer: Three Rivers PPO |
$6,760.61
|
| Rate for Payer: TriWest Veterans Administration |
$5,949.34
|
| Rate for Payer: United Healthcare Commercial |
$7,842.31
|
| Rate for Payer: United Healthcare Medicare |
$5,949.34
|
| Rate for Payer: WINHealth Partners Commercial |
$8,563.44
|
| Rate for Payer: Wise Provider Network Commercial |
$8,563.44
|
|
