|
CIPROFLOXACIN 0.3 % EYE DROPS [11373]
|
Facility
|
OP
|
$15.75
|
|
|
Service Code
|
NDC 6131465625
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.68 |
| Max. Negotiated Rate |
$15.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.44
|
| Rate for Payer: Aetna of WY Medicare |
$10.40
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.12
|
| Rate for Payer: Altius Commercial |
$15.12
|
| Rate for Payer: Beech Street Commercial |
$15.44
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.93
|
| Rate for Payer: Cash Price |
$11.02
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.28
|
| Rate for Payer: Cigna of WY Commercial |
$15.44
|
| Rate for Payer: Entrust Commercial |
$14.96
|
| Rate for Payer: First Choice Health Commercial |
$14.96
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.96
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.14
|
| Rate for Payer: HealthUtah PPO |
$15.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.28
|
| Rate for Payer: Multiplan Medicare/VA |
$8.68
|
| Rate for Payer: One Health Plan of WY PPO |
$15.44
|
| Rate for Payer: PacificSource Commercial |
$14.18
|
| Rate for Payer: PHCS PPO |
$15.44
|
| Rate for Payer: Three Rivers PPO |
$11.81
|
| Rate for Payer: TriWest Veterans Administration |
$9.14
|
| Rate for Payer: United Healthcare Commercial |
$13.70
|
| Rate for Payer: United Healthcare Medicare |
$9.14
|
| Rate for Payer: WINHealth Partners Commercial |
$15.44
|
| Rate for Payer: Wise Provider Network Commercial |
$14.96
|
|
|
CIPROFLOXACIN 0.3 % EYE DROPS [11373]
|
Facility
|
IP
|
$15.75
|
|
|
Service Code
|
NDC 6131465625
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.88 |
| Max. Negotiated Rate |
$15.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.44
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.12
|
| Rate for Payer: Altius Commercial |
$15.12
|
| Rate for Payer: Beech Street Commercial |
$15.44
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.93
|
| Rate for Payer: Cash Price |
$11.02
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.28
|
| Rate for Payer: Cigna of WY Commercial |
$15.44
|
| Rate for Payer: Entrust Commercial |
$14.96
|
| Rate for Payer: First Choice Health Commercial |
$14.96
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.96
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.40
|
| Rate for Payer: HealthUtah PPO |
$15.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.28
|
| Rate for Payer: Multiplan Medicare/VA |
$9.88
|
| Rate for Payer: One Health Plan of WY PPO |
$15.44
|
| Rate for Payer: PacificSource Commercial |
$14.18
|
| Rate for Payer: PHCS PPO |
$15.44
|
| Rate for Payer: Three Rivers PPO |
$11.81
|
| Rate for Payer: TriWest Veterans Administration |
$10.40
|
| Rate for Payer: United Healthcare Commercial |
$13.70
|
| Rate for Payer: United Healthcare Medicare |
$10.40
|
| Rate for Payer: WINHealth Partners Commercial |
$14.96
|
| Rate for Payer: Wise Provider Network Commercial |
$14.96
|
|
|
CIPROFLOXACIN 0.3 % EYE DROPS [11373]
|
Facility
|
IP
|
$10.50
|
|
|
Service Code
|
NDC 6131465605
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.58 |
| Max. Negotiated Rate |
$10.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$10.29
|
| Rate for Payer: Altius Auto/Workers Compensation |
$10.08
|
| Rate for Payer: Altius Commercial |
$10.08
|
| Rate for Payer: Beech Street Commercial |
$10.29
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$8.62
|
| Rate for Payer: Cash Price |
$7.35
|
| Rate for Payer: ChoiceCare Network Commercial |
$10.18
|
| Rate for Payer: Cigna of WY Commercial |
$10.29
|
| Rate for Payer: Entrust Commercial |
$9.98
|
| Rate for Payer: First Choice Health Commercial |
$9.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$9.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$6.93
|
| Rate for Payer: HealthUtah PPO |
$10.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$10.18
|
| Rate for Payer: Multiplan Medicare/VA |
$6.58
|
| Rate for Payer: One Health Plan of WY PPO |
$10.29
|
| Rate for Payer: PacificSource Commercial |
$9.45
|
| Rate for Payer: PHCS PPO |
$10.29
|
| Rate for Payer: Three Rivers PPO |
$7.88
|
| Rate for Payer: TriWest Veterans Administration |
$6.93
|
| Rate for Payer: United Healthcare Commercial |
$9.14
|
| Rate for Payer: United Healthcare Medicare |
$6.93
|
| Rate for Payer: WINHealth Partners Commercial |
$9.98
|
| Rate for Payer: Wise Provider Network Commercial |
$9.98
|
|
|
CIPROFLOXACIN 0.3 % EYE DROPS [11373]
|
Facility
|
OP
|
$10.50
|
|
|
Service Code
|
NDC 6131465605
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.79 |
| Max. Negotiated Rate |
$10.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$10.29
|
| Rate for Payer: Aetna of WY Medicare |
$6.93
|
| Rate for Payer: Altius Auto/Workers Compensation |
$10.08
|
| Rate for Payer: Altius Commercial |
$10.08
|
| Rate for Payer: Beech Street Commercial |
$10.29
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$8.62
|
| Rate for Payer: Cash Price |
$7.35
|
| Rate for Payer: ChoiceCare Network Commercial |
$10.18
|
| Rate for Payer: Cigna of WY Commercial |
$10.29
|
| Rate for Payer: Entrust Commercial |
$9.98
|
| Rate for Payer: First Choice Health Commercial |
$9.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$9.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$6.09
|
| Rate for Payer: HealthUtah PPO |
$10.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$10.18
|
| Rate for Payer: Multiplan Medicare/VA |
$5.79
|
| Rate for Payer: One Health Plan of WY PPO |
$10.29
|
| Rate for Payer: PacificSource Commercial |
$9.45
|
| Rate for Payer: PHCS PPO |
$10.29
|
| Rate for Payer: Three Rivers PPO |
$7.88
|
| Rate for Payer: TriWest Veterans Administration |
$6.09
|
| Rate for Payer: United Healthcare Commercial |
$9.14
|
| Rate for Payer: United Healthcare Medicare |
$6.09
|
| Rate for Payer: WINHealth Partners Commercial |
$10.29
|
| Rate for Payer: Wise Provider Network Commercial |
$9.98
|
|
|
CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [5086]
|
Facility
|
IP
|
$15.08
|
|
|
Service Code
|
HCPCS J0744
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.46 |
| Max. Negotiated Rate |
$15.08 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.78
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.75
|
| Rate for Payer: Altius Auto/Workers Compensation |
$14.48
|
| Rate for Payer: Altius Auto/Workers Compensation |
$14.45
|
| Rate for Payer: Altius Commercial |
$14.45
|
| Rate for Payer: Altius Commercial |
$14.48
|
| Rate for Payer: Beech Street Commercial |
$14.78
|
| Rate for Payer: Beech Street Commercial |
$14.75
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.36
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.38
|
| Rate for Payer: Cash Price |
$10.56
|
| Rate for Payer: Cash Price |
$10.53
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.63
|
| Rate for Payer: Cigna of WY Commercial |
$14.78
|
| Rate for Payer: Cigna of WY Commercial |
$14.75
|
| Rate for Payer: Entrust Commercial |
$14.30
|
| Rate for Payer: Entrust Commercial |
$14.33
|
| Rate for Payer: First Choice Health Commercial |
$14.30
|
| Rate for Payer: First Choice Health Commercial |
$14.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.93
|
| Rate for Payer: HealthUtah PPO |
$15.08
|
| Rate for Payer: HealthUtah PPO |
$15.05
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.60
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.63
|
| Rate for Payer: Multiplan Medicare/VA |
$9.46
|
| Rate for Payer: Multiplan Medicare/VA |
$9.44
|
| Rate for Payer: One Health Plan of WY PPO |
$14.78
|
| Rate for Payer: One Health Plan of WY PPO |
$14.75
|
| Rate for Payer: PacificSource Commercial |
$13.57
|
| Rate for Payer: PacificSource Commercial |
$13.54
|
| Rate for Payer: PHCS PPO |
$14.75
|
| Rate for Payer: PHCS PPO |
$14.78
|
| Rate for Payer: Three Rivers PPO |
$11.29
|
| Rate for Payer: Three Rivers PPO |
$11.31
|
| Rate for Payer: TriWest Veterans Administration |
$9.95
|
| Rate for Payer: TriWest Veterans Administration |
$9.93
|
| Rate for Payer: United Healthcare Commercial |
$13.09
|
| Rate for Payer: United Healthcare Commercial |
$13.12
|
| Rate for Payer: United Healthcare Medicare |
$9.95
|
| Rate for Payer: United Healthcare Medicare |
$9.93
|
| Rate for Payer: WINHealth Partners Commercial |
$14.30
|
| Rate for Payer: WINHealth Partners Commercial |
$14.33
|
| Rate for Payer: Wise Provider Network Commercial |
$14.30
|
| Rate for Payer: Wise Provider Network Commercial |
$14.33
|
|
|
CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [5086]
|
Facility
|
OP
|
$15.08
|
|
|
Service Code
|
HCPCS J0744
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.31 |
| Max. Negotiated Rate |
$15.08 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.78
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.75
|
| Rate for Payer: Aetna of WY Medicare |
$9.95
|
| Rate for Payer: Aetna of WY Medicare |
$9.93
|
| Rate for Payer: Altius Auto/Workers Compensation |
$14.45
|
| Rate for Payer: Altius Auto/Workers Compensation |
$14.48
|
| Rate for Payer: Altius Commercial |
$14.48
|
| Rate for Payer: Altius Commercial |
$14.45
|
| Rate for Payer: Beech Street Commercial |
$14.75
|
| Rate for Payer: Beech Street Commercial |
$14.78
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.38
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.36
|
| Rate for Payer: Cash Price |
$10.53
|
| Rate for Payer: Cash Price |
$10.56
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.63
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.60
|
| Rate for Payer: Cigna of WY Commercial |
$14.75
|
| Rate for Payer: Cigna of WY Commercial |
$14.78
|
| Rate for Payer: Entrust Commercial |
$14.33
|
| Rate for Payer: Entrust Commercial |
$14.30
|
| Rate for Payer: First Choice Health Commercial |
$14.30
|
| Rate for Payer: First Choice Health Commercial |
$14.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.73
|
| Rate for Payer: HealthUtah PPO |
$15.05
|
| Rate for Payer: HealthUtah PPO |
$15.08
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.60
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.63
|
| Rate for Payer: Multiplan Medicare/VA |
$8.31
|
| Rate for Payer: Multiplan Medicare/VA |
$8.29
|
| Rate for Payer: One Health Plan of WY PPO |
$14.75
|
| Rate for Payer: One Health Plan of WY PPO |
$14.78
|
| Rate for Payer: PacificSource Commercial |
$13.57
|
| Rate for Payer: PacificSource Commercial |
$13.54
|
| Rate for Payer: PHCS PPO |
$14.75
|
| Rate for Payer: PHCS PPO |
$14.78
|
| Rate for Payer: Three Rivers PPO |
$11.29
|
| Rate for Payer: Three Rivers PPO |
$11.31
|
| Rate for Payer: TriWest Veterans Administration |
$8.75
|
| Rate for Payer: TriWest Veterans Administration |
$8.73
|
| Rate for Payer: United Healthcare Commercial |
$13.09
|
| Rate for Payer: United Healthcare Commercial |
$13.12
|
| Rate for Payer: United Healthcare Medicare |
$8.75
|
| Rate for Payer: United Healthcare Medicare |
$8.73
|
| Rate for Payer: WINHealth Partners Commercial |
$14.75
|
| Rate for Payer: WINHealth Partners Commercial |
$14.78
|
| Rate for Payer: Wise Provider Network Commercial |
$14.30
|
| Rate for Payer: Wise Provider Network Commercial |
$14.33
|
|
|
CIPROFLOXACIN 500 MG TABLET [7555]
|
Facility
|
IP
|
$1.16
|
|
|
Service Code
|
NDC 0904708361
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.73 |
| Max. Negotiated Rate |
$1.16 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.14
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.11
|
| Rate for Payer: Altius Commercial |
$1.11
|
| Rate for Payer: Beech Street Commercial |
$1.14
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.95
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.13
|
| Rate for Payer: Cigna of WY Commercial |
$1.14
|
| Rate for Payer: Entrust Commercial |
$1.10
|
| Rate for Payer: First Choice Health Commercial |
$1.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.77
|
| Rate for Payer: HealthUtah PPO |
$1.16
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.13
|
| Rate for Payer: Multiplan Medicare/VA |
$0.73
|
| Rate for Payer: One Health Plan of WY PPO |
$1.14
|
| Rate for Payer: PacificSource Commercial |
$1.04
|
| Rate for Payer: PHCS PPO |
$1.14
|
| Rate for Payer: Three Rivers PPO |
$0.87
|
| Rate for Payer: TriWest Veterans Administration |
$0.77
|
| Rate for Payer: United Healthcare Commercial |
$1.01
|
| Rate for Payer: United Healthcare Medicare |
$0.77
|
| Rate for Payer: WINHealth Partners Commercial |
$1.10
|
| Rate for Payer: Wise Provider Network Commercial |
$1.10
|
|
|
CIPROFLOXACIN 500 MG TABLET [7555]
|
Facility
|
IP
|
$0.84
|
|
|
Service Code
|
NDC 0143992801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$0.84 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.82
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.81
|
| Rate for Payer: Altius Commercial |
$0.81
|
| Rate for Payer: Beech Street Commercial |
$0.82
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.69
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.81
|
| Rate for Payer: Cigna of WY Commercial |
$0.82
|
| Rate for Payer: Entrust Commercial |
$0.80
|
| Rate for Payer: First Choice Health Commercial |
$0.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.55
|
| Rate for Payer: HealthUtah PPO |
$0.84
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.81
|
| Rate for Payer: Multiplan Medicare/VA |
$0.53
|
| Rate for Payer: One Health Plan of WY PPO |
$0.82
|
| Rate for Payer: PacificSource Commercial |
$0.76
|
| Rate for Payer: PHCS PPO |
$0.82
|
| Rate for Payer: Three Rivers PPO |
$0.63
|
| Rate for Payer: TriWest Veterans Administration |
$0.55
|
| Rate for Payer: United Healthcare Commercial |
$0.73
|
| Rate for Payer: United Healthcare Medicare |
$0.55
|
| Rate for Payer: WINHealth Partners Commercial |
$0.80
|
| Rate for Payer: Wise Provider Network Commercial |
$0.80
|
|
|
CIPROFLOXACIN 500 MG TABLET [7555]
|
Facility
|
OP
|
$0.84
|
|
|
Service Code
|
NDC 0143992801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$0.84 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.82
|
| Rate for Payer: Aetna of WY Medicare |
$0.55
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.81
|
| Rate for Payer: Altius Commercial |
$0.81
|
| Rate for Payer: Beech Street Commercial |
$0.82
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.69
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.81
|
| Rate for Payer: Cigna of WY Commercial |
$0.82
|
| Rate for Payer: Entrust Commercial |
$0.80
|
| Rate for Payer: First Choice Health Commercial |
$0.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.49
|
| Rate for Payer: HealthUtah PPO |
$0.84
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.81
|
| Rate for Payer: Multiplan Medicare/VA |
$0.46
|
| Rate for Payer: One Health Plan of WY PPO |
$0.82
|
| Rate for Payer: PacificSource Commercial |
$0.76
|
| Rate for Payer: PHCS PPO |
$0.82
|
| Rate for Payer: Three Rivers PPO |
$0.63
|
| Rate for Payer: TriWest Veterans Administration |
$0.49
|
| Rate for Payer: United Healthcare Commercial |
$0.73
|
| Rate for Payer: United Healthcare Medicare |
$0.49
|
| Rate for Payer: WINHealth Partners Commercial |
$0.82
|
| Rate for Payer: Wise Provider Network Commercial |
$0.80
|
|
|
CIPROFLOXACIN 500 MG TABLET [7555]
|
Facility
|
OP
|
$1.16
|
|
|
Service Code
|
NDC 0904708361
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$1.16 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.14
|
| Rate for Payer: Aetna of WY Medicare |
$0.77
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.11
|
| Rate for Payer: Altius Commercial |
$1.11
|
| Rate for Payer: Beech Street Commercial |
$1.14
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.95
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.13
|
| Rate for Payer: Cigna of WY Commercial |
$1.14
|
| Rate for Payer: Entrust Commercial |
$1.10
|
| Rate for Payer: First Choice Health Commercial |
$1.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.67
|
| Rate for Payer: HealthUtah PPO |
$1.16
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.13
|
| Rate for Payer: Multiplan Medicare/VA |
$0.64
|
| Rate for Payer: One Health Plan of WY PPO |
$1.14
|
| Rate for Payer: PacificSource Commercial |
$1.04
|
| Rate for Payer: PHCS PPO |
$1.14
|
| Rate for Payer: Three Rivers PPO |
$0.87
|
| Rate for Payer: TriWest Veterans Administration |
$0.67
|
| Rate for Payer: United Healthcare Commercial |
$1.01
|
| Rate for Payer: United Healthcare Medicare |
$0.67
|
| Rate for Payer: WINHealth Partners Commercial |
$1.14
|
| Rate for Payer: Wise Provider Network Commercial |
$1.10
|
|
|
CIRCUIT JACKSON REES 1L ANES
|
Facility
|
IP
|
$48.91
|
|
| Hospital Charge Code |
27000000S1
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$30.67 |
| Max. Negotiated Rate |
$48.91 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$47.93
|
| Rate for Payer: Altius Auto/Workers Compensation |
$46.95
|
| Rate for Payer: Altius Commercial |
$46.95
|
| Rate for Payer: Beech Street Commercial |
$47.93
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$40.16
|
| Rate for Payer: Cash Price |
$34.24
|
| Rate for Payer: ChoiceCare Network Commercial |
$47.44
|
| Rate for Payer: Cigna of WY Commercial |
$47.93
|
| Rate for Payer: Entrust Commercial |
$46.46
|
| Rate for Payer: First Choice Health Commercial |
$46.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$46.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$32.28
|
| Rate for Payer: HealthUtah PPO |
$48.91
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$47.44
|
| Rate for Payer: Multiplan Medicare/VA |
$30.67
|
| Rate for Payer: One Health Plan of WY PPO |
$47.93
|
| Rate for Payer: PacificSource Commercial |
$44.02
|
| Rate for Payer: PHCS PPO |
$47.93
|
| Rate for Payer: Three Rivers PPO |
$36.68
|
| Rate for Payer: TriWest Veterans Administration |
$32.28
|
| Rate for Payer: United Healthcare Commercial |
$42.55
|
| Rate for Payer: United Healthcare Medicare |
$32.28
|
| Rate for Payer: WINHealth Partners Commercial |
$46.46
|
| Rate for Payer: Wise Provider Network Commercial |
$46.46
|
|
|
CIRCUIT JACKSON REES 1L ANES
|
Facility
|
OP
|
$48.91
|
|
| Hospital Charge Code |
27000000S1
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$26.95 |
| Max. Negotiated Rate |
$48.91 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$47.93
|
| Rate for Payer: Aetna of WY Medicare |
$32.28
|
| Rate for Payer: Altius Auto/Workers Compensation |
$46.95
|
| Rate for Payer: Altius Commercial |
$46.95
|
| Rate for Payer: Beech Street Commercial |
$47.93
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$40.16
|
| Rate for Payer: Cash Price |
$34.24
|
| Rate for Payer: ChoiceCare Network Commercial |
$47.44
|
| Rate for Payer: Cigna of WY Commercial |
$47.93
|
| Rate for Payer: Entrust Commercial |
$46.46
|
| Rate for Payer: First Choice Health Commercial |
$46.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$46.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$28.37
|
| Rate for Payer: HealthUtah PPO |
$48.91
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$47.44
|
| Rate for Payer: Multiplan Medicare/VA |
$26.95
|
| Rate for Payer: One Health Plan of WY PPO |
$47.93
|
| Rate for Payer: PacificSource Commercial |
$44.02
|
| Rate for Payer: PHCS PPO |
$47.93
|
| Rate for Payer: Three Rivers PPO |
$36.68
|
| Rate for Payer: TriWest Veterans Administration |
$28.37
|
| Rate for Payer: United Healthcare Commercial |
$42.55
|
| Rate for Payer: United Healthcare Medicare |
$28.37
|
| Rate for Payer: WINHealth Partners Commercial |
$47.93
|
| Rate for Payer: Wise Provider Network Commercial |
$46.46
|
|
|
CIRCUIT NEO PANDA W/MASK
|
Facility
|
OP
|
$41.51
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$22.87 |
| Max. Negotiated Rate |
$41.51 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$40.68
|
| Rate for Payer: Aetna of WY Medicare |
$27.40
|
| Rate for Payer: Altius Auto/Workers Compensation |
$39.85
|
| Rate for Payer: Altius Commercial |
$39.85
|
| Rate for Payer: Beech Street Commercial |
$40.68
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$34.08
|
| Rate for Payer: Cash Price |
$29.05
|
| Rate for Payer: ChoiceCare Network Commercial |
$40.26
|
| Rate for Payer: Cigna of WY Commercial |
$40.68
|
| Rate for Payer: Entrust Commercial |
$39.43
|
| Rate for Payer: First Choice Health Commercial |
$39.43
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$39.43
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$24.08
|
| Rate for Payer: HealthUtah PPO |
$41.51
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$40.26
|
| Rate for Payer: Multiplan Medicare/VA |
$22.87
|
| Rate for Payer: One Health Plan of WY PPO |
$40.68
|
| Rate for Payer: PacificSource Commercial |
$37.36
|
| Rate for Payer: PHCS PPO |
$40.68
|
| Rate for Payer: Three Rivers PPO |
$31.13
|
| Rate for Payer: TriWest Veterans Administration |
$24.08
|
| Rate for Payer: United Healthcare Commercial |
$36.11
|
| Rate for Payer: United Healthcare Medicare |
$24.08
|
| Rate for Payer: WINHealth Partners Commercial |
$40.68
|
| Rate for Payer: Wise Provider Network Commercial |
$39.43
|
|
|
CIRCUIT NEO PANDA W/MASK
|
Facility
|
IP
|
$41.51
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$26.03 |
| Max. Negotiated Rate |
$41.51 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$40.68
|
| Rate for Payer: Altius Auto/Workers Compensation |
$39.85
|
| Rate for Payer: Altius Commercial |
$39.85
|
| Rate for Payer: Beech Street Commercial |
$40.68
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$34.08
|
| Rate for Payer: Cash Price |
$29.05
|
| Rate for Payer: ChoiceCare Network Commercial |
$40.26
|
| Rate for Payer: Cigna of WY Commercial |
$40.68
|
| Rate for Payer: Entrust Commercial |
$39.43
|
| Rate for Payer: First Choice Health Commercial |
$39.43
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$39.43
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$27.40
|
| Rate for Payer: HealthUtah PPO |
$41.51
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$40.26
|
| Rate for Payer: Multiplan Medicare/VA |
$26.03
|
| Rate for Payer: One Health Plan of WY PPO |
$40.68
|
| Rate for Payer: PacificSource Commercial |
$37.36
|
| Rate for Payer: PHCS PPO |
$40.68
|
| Rate for Payer: Three Rivers PPO |
$31.13
|
| Rate for Payer: TriWest Veterans Administration |
$27.40
|
| Rate for Payer: United Healthcare Commercial |
$36.11
|
| Rate for Payer: United Healthcare Medicare |
$27.40
|
| Rate for Payer: WINHealth Partners Commercial |
$39.43
|
| Rate for Payer: Wise Provider Network Commercial |
$39.43
|
|
|
CIRCUMCISION AGE >28 DAYS
|
Professional
|
Both
|
$990.00
|
|
|
Service Code
|
HCPCS 54161
|
| Hospital Charge Code |
54161
|
| Min. Negotiated Rate |
$161.87 |
| Max. Negotiated Rate |
$990.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$970.20
|
| Rate for Payer: Aetna of WY Medicare |
$190.43
|
| Rate for Payer: Beech Street Commercial |
$940.50
|
| Rate for Payer: Cash Price |
$693.00
|
| Rate for Payer: Cash Price |
$693.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$960.30
|
| Rate for Payer: Cigna of WY Commercial |
$970.20
|
| Rate for Payer: First Choice Health Commercial |
$891.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$940.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$190.43
|
| Rate for Payer: HealthUtah PPO |
$990.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$960.30
|
| Rate for Payer: Multiplan Medicare/VA |
$161.87
|
| Rate for Payer: One Health Plan of WY PPO |
$970.20
|
| Rate for Payer: PacificSource Commercial |
$891.00
|
| Rate for Payer: PHCS PPO |
$940.50
|
| Rate for Payer: Three Rivers PPO |
$742.50
|
| Rate for Payer: TriWest Veterans Administration |
$190.43
|
| Rate for Payer: United Healthcare Commercial |
$861.30
|
| Rate for Payer: United Healthcare Medicare |
$190.43
|
| Rate for Payer: WINHealth Partners Commercial |
$841.50
|
|
|
CIRCUMCISION NEONATE
|
Professional
|
Both
|
$769.00
|
|
|
Service Code
|
HCPCS 54160
|
| Hospital Charge Code |
54160
|
| Min. Negotiated Rate |
$119.10 |
| Max. Negotiated Rate |
$769.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$753.62
|
| Rate for Payer: Aetna of WY Medicare |
$140.12
|
| Rate for Payer: Beech Street Commercial |
$730.55
|
| Rate for Payer: Cash Price |
$538.30
|
| Rate for Payer: Cash Price |
$538.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$745.93
|
| Rate for Payer: Cigna of WY Commercial |
$753.62
|
| Rate for Payer: First Choice Health Commercial |
$692.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$730.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$140.12
|
| Rate for Payer: HealthUtah PPO |
$769.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$745.93
|
| Rate for Payer: Multiplan Medicare/VA |
$119.10
|
| Rate for Payer: One Health Plan of WY PPO |
$753.62
|
| Rate for Payer: PacificSource Commercial |
$692.10
|
| Rate for Payer: PHCS PPO |
$730.55
|
| Rate for Payer: Three Rivers PPO |
$576.75
|
| Rate for Payer: TriWest Veterans Administration |
$140.12
|
| Rate for Payer: United Healthcare Commercial |
$669.03
|
| Rate for Payer: United Healthcare Medicare |
$140.12
|
| Rate for Payer: WINHealth Partners Commercial |
$653.65
|
|
|
CIRCUMCISION W/CLAMP/OTH DEV W/BLOCK
|
Professional
|
Both
|
$514.00
|
|
|
Service Code
|
HCPCS 54150
|
| Hospital Charge Code |
54150
|
| Min. Negotiated Rate |
$385.50 |
| Max. Negotiated Rate |
$514.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$503.72
|
| Rate for Payer: Beech Street Commercial |
$488.30
|
| Rate for Payer: Cash Price |
$359.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$498.58
|
| Rate for Payer: Cigna of WY Commercial |
$503.72
|
| Rate for Payer: First Choice Health Commercial |
$462.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$488.30
|
| Rate for Payer: HealthUtah PPO |
$514.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$498.58
|
| Rate for Payer: One Health Plan of WY PPO |
$503.72
|
| Rate for Payer: PacificSource Commercial |
$462.60
|
| Rate for Payer: PHCS PPO |
$488.30
|
| Rate for Payer: Three Rivers PPO |
$385.50
|
| Rate for Payer: United Healthcare Commercial |
$447.18
|
| Rate for Payer: WINHealth Partners Commercial |
$436.90
|
|
|
CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION [12719]
|
Facility
|
OP
|
$19.00
|
|
|
Service Code
|
NDC 7128871411
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.47 |
| Max. Negotiated Rate |
$19.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18.62
|
| Rate for Payer: Aetna of WY Medicare |
$12.54
|
| Rate for Payer: Altius Auto/Workers Compensation |
$18.24
|
| Rate for Payer: Altius Commercial |
$18.24
|
| Rate for Payer: Beech Street Commercial |
$18.62
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.60
|
| Rate for Payer: Cash Price |
$13.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$18.43
|
| Rate for Payer: Cigna of WY Commercial |
$18.62
|
| Rate for Payer: Entrust Commercial |
$18.05
|
| Rate for Payer: First Choice Health Commercial |
$18.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$18.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.02
|
| Rate for Payer: HealthUtah PPO |
$19.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$18.43
|
| Rate for Payer: Multiplan Medicare/VA |
$10.47
|
| Rate for Payer: One Health Plan of WY PPO |
$18.62
|
| Rate for Payer: PacificSource Commercial |
$17.10
|
| Rate for Payer: PHCS PPO |
$18.62
|
| Rate for Payer: Three Rivers PPO |
$14.25
|
| Rate for Payer: TriWest Veterans Administration |
$11.02
|
| Rate for Payer: United Healthcare Commercial |
$16.53
|
| Rate for Payer: United Healthcare Medicare |
$11.02
|
| Rate for Payer: WINHealth Partners Commercial |
$18.62
|
| Rate for Payer: Wise Provider Network Commercial |
$18.05
|
|
|
CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION [12719]
|
Facility
|
OP
|
$19.00
|
|
|
Service Code
|
NDC 7128871410
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.47 |
| Max. Negotiated Rate |
$19.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18.62
|
| Rate for Payer: Aetna of WY Medicare |
$12.54
|
| Rate for Payer: Altius Auto/Workers Compensation |
$18.24
|
| Rate for Payer: Altius Commercial |
$18.24
|
| Rate for Payer: Beech Street Commercial |
$18.62
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.60
|
| Rate for Payer: Cash Price |
$13.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$18.43
|
| Rate for Payer: Cigna of WY Commercial |
$18.62
|
| Rate for Payer: Entrust Commercial |
$18.05
|
| Rate for Payer: First Choice Health Commercial |
$18.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$18.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.02
|
| Rate for Payer: HealthUtah PPO |
$19.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$18.43
|
| Rate for Payer: Multiplan Medicare/VA |
$10.47
|
| Rate for Payer: One Health Plan of WY PPO |
$18.62
|
| Rate for Payer: PacificSource Commercial |
$17.10
|
| Rate for Payer: PHCS PPO |
$18.62
|
| Rate for Payer: Three Rivers PPO |
$14.25
|
| Rate for Payer: TriWest Veterans Administration |
$11.02
|
| Rate for Payer: United Healthcare Commercial |
$16.53
|
| Rate for Payer: United Healthcare Medicare |
$11.02
|
| Rate for Payer: WINHealth Partners Commercial |
$18.62
|
| Rate for Payer: Wise Provider Network Commercial |
$18.05
|
|
|
CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION [12719]
|
Facility
|
IP
|
$19.00
|
|
|
Service Code
|
NDC 7128871410
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.91 |
| Max. Negotiated Rate |
$19.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18.62
|
| Rate for Payer: Altius Auto/Workers Compensation |
$18.24
|
| Rate for Payer: Altius Commercial |
$18.24
|
| Rate for Payer: Beech Street Commercial |
$18.62
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.60
|
| Rate for Payer: Cash Price |
$13.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$18.43
|
| Rate for Payer: Cigna of WY Commercial |
$18.62
|
| Rate for Payer: Entrust Commercial |
$18.05
|
| Rate for Payer: First Choice Health Commercial |
$18.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$18.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$12.54
|
| Rate for Payer: HealthUtah PPO |
$19.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$18.43
|
| Rate for Payer: Multiplan Medicare/VA |
$11.91
|
| Rate for Payer: One Health Plan of WY PPO |
$18.62
|
| Rate for Payer: PacificSource Commercial |
$17.10
|
| Rate for Payer: PHCS PPO |
$18.62
|
| Rate for Payer: Three Rivers PPO |
$14.25
|
| Rate for Payer: TriWest Veterans Administration |
$12.54
|
| Rate for Payer: United Healthcare Commercial |
$16.53
|
| Rate for Payer: United Healthcare Medicare |
$12.54
|
| Rate for Payer: WINHealth Partners Commercial |
$18.05
|
| Rate for Payer: Wise Provider Network Commercial |
$18.05
|
|
|
CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION [12719]
|
Facility
|
IP
|
$19.00
|
|
|
Service Code
|
NDC 7128871411
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.91 |
| Max. Negotiated Rate |
$19.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18.62
|
| Rate for Payer: Altius Auto/Workers Compensation |
$18.24
|
| Rate for Payer: Altius Commercial |
$18.24
|
| Rate for Payer: Beech Street Commercial |
$18.62
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.60
|
| Rate for Payer: Cash Price |
$13.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$18.43
|
| Rate for Payer: Cigna of WY Commercial |
$18.62
|
| Rate for Payer: Entrust Commercial |
$18.05
|
| Rate for Payer: First Choice Health Commercial |
$18.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$18.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$12.54
|
| Rate for Payer: HealthUtah PPO |
$19.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$18.43
|
| Rate for Payer: Multiplan Medicare/VA |
$11.91
|
| Rate for Payer: One Health Plan of WY PPO |
$18.62
|
| Rate for Payer: PacificSource Commercial |
$17.10
|
| Rate for Payer: PHCS PPO |
$18.62
|
| Rate for Payer: Three Rivers PPO |
$14.25
|
| Rate for Payer: TriWest Veterans Administration |
$12.54
|
| Rate for Payer: United Healthcare Commercial |
$16.53
|
| Rate for Payer: United Healthcare Medicare |
$12.54
|
| Rate for Payer: WINHealth Partners Commercial |
$18.05
|
| Rate for Payer: Wise Provider Network Commercial |
$18.05
|
|
|
CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION [11330]
|
Facility
|
OP
|
$17.24
|
|
|
Service Code
|
HCPCS J9060
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.50 |
| Max. Negotiated Rate |
$17.24 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.90
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.32
|
| Rate for Payer: Aetna of WY Medicare |
$11.38
|
| Rate for Payer: Aetna of WY Medicare |
$10.99
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.98
|
| Rate for Payer: Altius Auto/Workers Compensation |
$16.55
|
| Rate for Payer: Altius Commercial |
$16.55
|
| Rate for Payer: Altius Commercial |
$15.98
|
| Rate for Payer: Beech Street Commercial |
$16.32
|
| Rate for Payer: Beech Street Commercial |
$16.90
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.15
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.67
|
| Rate for Payer: Cash Price |
$11.65
|
| Rate for Payer: Cash Price |
$12.07
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.72
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.15
|
| Rate for Payer: Cigna of WY Commercial |
$16.32
|
| Rate for Payer: Cigna of WY Commercial |
$16.90
|
| Rate for Payer: Entrust Commercial |
$16.38
|
| Rate for Payer: Entrust Commercial |
$15.82
|
| Rate for Payer: First Choice Health Commercial |
$15.82
|
| Rate for Payer: First Choice Health Commercial |
$16.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.82
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.66
|
| Rate for Payer: HealthUtah PPO |
$16.65
|
| Rate for Payer: HealthUtah PPO |
$17.24
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.15
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.72
|
| Rate for Payer: Multiplan Medicare/VA |
$9.50
|
| Rate for Payer: Multiplan Medicare/VA |
$9.17
|
| Rate for Payer: One Health Plan of WY PPO |
$16.32
|
| Rate for Payer: One Health Plan of WY PPO |
$16.90
|
| Rate for Payer: PacificSource Commercial |
$15.52
|
| Rate for Payer: PacificSource Commercial |
$14.98
|
| Rate for Payer: PHCS PPO |
$16.32
|
| Rate for Payer: PHCS PPO |
$16.90
|
| Rate for Payer: Three Rivers PPO |
$12.49
|
| Rate for Payer: Three Rivers PPO |
$12.93
|
| Rate for Payer: TriWest Veterans Administration |
$10.00
|
| Rate for Payer: TriWest Veterans Administration |
$9.66
|
| Rate for Payer: United Healthcare Commercial |
$14.49
|
| Rate for Payer: United Healthcare Commercial |
$15.00
|
| Rate for Payer: United Healthcare Medicare |
$10.00
|
| Rate for Payer: United Healthcare Medicare |
$9.66
|
| Rate for Payer: WINHealth Partners Commercial |
$16.32
|
| Rate for Payer: WINHealth Partners Commercial |
$16.90
|
| Rate for Payer: Wise Provider Network Commercial |
$15.82
|
| Rate for Payer: Wise Provider Network Commercial |
$16.38
|
|
|
CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION [11330]
|
Facility
|
IP
|
$17.24
|
|
|
Service Code
|
HCPCS J9060
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.81 |
| Max. Negotiated Rate |
$17.24 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.90
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.32
|
| Rate for Payer: Altius Auto/Workers Compensation |
$16.55
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.98
|
| Rate for Payer: Altius Commercial |
$15.98
|
| Rate for Payer: Altius Commercial |
$16.55
|
| Rate for Payer: Beech Street Commercial |
$16.90
|
| Rate for Payer: Beech Street Commercial |
$16.32
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.67
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.15
|
| Rate for Payer: Cash Price |
$12.07
|
| Rate for Payer: Cash Price |
$11.65
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.15
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.72
|
| Rate for Payer: Cigna of WY Commercial |
$16.90
|
| Rate for Payer: Cigna of WY Commercial |
$16.32
|
| Rate for Payer: Entrust Commercial |
$15.82
|
| Rate for Payer: Entrust Commercial |
$16.38
|
| Rate for Payer: First Choice Health Commercial |
$15.82
|
| Rate for Payer: First Choice Health Commercial |
$16.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.82
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.99
|
| Rate for Payer: HealthUtah PPO |
$17.24
|
| Rate for Payer: HealthUtah PPO |
$16.65
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.15
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.72
|
| Rate for Payer: Multiplan Medicare/VA |
$10.81
|
| Rate for Payer: Multiplan Medicare/VA |
$10.44
|
| Rate for Payer: One Health Plan of WY PPO |
$16.90
|
| Rate for Payer: One Health Plan of WY PPO |
$16.32
|
| Rate for Payer: PacificSource Commercial |
$15.52
|
| Rate for Payer: PacificSource Commercial |
$14.98
|
| Rate for Payer: PHCS PPO |
$16.32
|
| Rate for Payer: PHCS PPO |
$16.90
|
| Rate for Payer: Three Rivers PPO |
$12.49
|
| Rate for Payer: Three Rivers PPO |
$12.93
|
| Rate for Payer: TriWest Veterans Administration |
$11.38
|
| Rate for Payer: TriWest Veterans Administration |
$10.99
|
| Rate for Payer: United Healthcare Commercial |
$14.49
|
| Rate for Payer: United Healthcare Commercial |
$15.00
|
| Rate for Payer: United Healthcare Medicare |
$11.38
|
| Rate for Payer: United Healthcare Medicare |
$10.99
|
| Rate for Payer: WINHealth Partners Commercial |
$15.82
|
| Rate for Payer: WINHealth Partners Commercial |
$16.38
|
| Rate for Payer: Wise Provider Network Commercial |
$15.82
|
| Rate for Payer: Wise Provider Network Commercial |
$16.38
|
|
|
CLARIFIX CRYOTHERAPY DEVICE
|
Facility
|
OP
|
$5,465.18
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,011.31 |
| Max. Negotiated Rate |
$5,465.18 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5,355.88
|
| Rate for Payer: Aetna of WY Medicare |
$3,607.02
|
| Rate for Payer: Altius Auto/Workers Compensation |
$5,246.57
|
| Rate for Payer: Altius Commercial |
$5,246.57
|
| Rate for Payer: Beech Street Commercial |
$5,355.88
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$4,486.91
|
| Rate for Payer: Cash Price |
$3,825.63
|
| Rate for Payer: ChoiceCare Network Commercial |
$5,301.22
|
| Rate for Payer: Cigna of WY Commercial |
$5,355.88
|
| Rate for Payer: Entrust Commercial |
$5,191.92
|
| Rate for Payer: First Choice Health Commercial |
$5,191.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5,191.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3,169.80
|
| Rate for Payer: HealthUtah PPO |
$5,465.18
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5,301.22
|
| Rate for Payer: Multiplan Medicare/VA |
$3,011.31
|
| Rate for Payer: One Health Plan of WY PPO |
$5,355.88
|
| Rate for Payer: PacificSource Commercial |
$4,918.66
|
| Rate for Payer: PHCS PPO |
$5,355.88
|
| Rate for Payer: Three Rivers PPO |
$4,098.88
|
| Rate for Payer: TriWest Veterans Administration |
$3,169.80
|
| Rate for Payer: United Healthcare Commercial |
$4,754.71
|
| Rate for Payer: United Healthcare Medicare |
$3,169.80
|
| Rate for Payer: WINHealth Partners Commercial |
$5,355.88
|
| Rate for Payer: Wise Provider Network Commercial |
$5,191.92
|
|
|
CLARIFIX CRYOTHERAPY DEVICE
|
Facility
|
IP
|
$5,465.18
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,426.67 |
| Max. Negotiated Rate |
$5,465.18 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5,355.88
|
| Rate for Payer: Altius Auto/Workers Compensation |
$5,246.57
|
| Rate for Payer: Altius Commercial |
$5,246.57
|
| Rate for Payer: Beech Street Commercial |
$5,355.88
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$4,486.91
|
| Rate for Payer: Cash Price |
$3,825.63
|
| Rate for Payer: ChoiceCare Network Commercial |
$5,301.22
|
| Rate for Payer: Cigna of WY Commercial |
$5,355.88
|
| Rate for Payer: Entrust Commercial |
$5,191.92
|
| Rate for Payer: First Choice Health Commercial |
$5,191.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5,191.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3,607.02
|
| Rate for Payer: HealthUtah PPO |
$5,465.18
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5,301.22
|
| Rate for Payer: Multiplan Medicare/VA |
$3,426.67
|
| Rate for Payer: One Health Plan of WY PPO |
$5,355.88
|
| Rate for Payer: PacificSource Commercial |
$4,918.66
|
| Rate for Payer: PHCS PPO |
$5,355.88
|
| Rate for Payer: Three Rivers PPO |
$4,098.88
|
| Rate for Payer: TriWest Veterans Administration |
$3,607.02
|
| Rate for Payer: United Healthcare Commercial |
$4,754.71
|
| Rate for Payer: United Healthcare Medicare |
$3,607.02
|
| Rate for Payer: WINHealth Partners Commercial |
$5,191.92
|
| Rate for Payer: Wise Provider Network Commercial |
$5,191.92
|
|
