|
ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER [17856]
|
Facility
|
OP
|
$18.80
|
|
|
Service Code
|
NDC 0054074287
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.36 |
| Max. Negotiated Rate |
$18.80 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18.42
|
| Rate for Payer: Aetna of WY Medicare |
$12.41
|
| Rate for Payer: Altius Auto/Workers Compensation |
$18.05
|
| Rate for Payer: Altius Commercial |
$18.05
|
| Rate for Payer: Beech Street Commercial |
$18.42
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.43
|
| Rate for Payer: Cash Price |
$13.16
|
| Rate for Payer: ChoiceCare Network Commercial |
$18.24
|
| Rate for Payer: Cigna of WY Commercial |
$18.42
|
| Rate for Payer: Entrust Commercial |
$17.86
|
| Rate for Payer: First Choice Health Commercial |
$17.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.90
|
| Rate for Payer: HealthUtah PPO |
$18.80
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$18.24
|
| Rate for Payer: Multiplan Medicare/VA |
$10.36
|
| Rate for Payer: One Health Plan of WY PPO |
$18.42
|
| Rate for Payer: PacificSource Commercial |
$16.92
|
| Rate for Payer: PHCS PPO |
$18.42
|
| Rate for Payer: Three Rivers PPO |
$14.10
|
| Rate for Payer: TriWest Veterans Administration |
$10.90
|
| Rate for Payer: United Healthcare Commercial |
$16.36
|
| Rate for Payer: United Healthcare Medicare |
$10.90
|
| Rate for Payer: WINHealth Partners Commercial |
$18.42
|
| Rate for Payer: Wise Provider Network Commercial |
$17.86
|
|
|
ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER [17856]
|
Facility
|
IP
|
$18.80
|
|
|
Service Code
|
NDC 0781729685
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.79 |
| Max. Negotiated Rate |
$18.80 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18.42
|
| Rate for Payer: Altius Auto/Workers Compensation |
$18.05
|
| Rate for Payer: Altius Commercial |
$18.05
|
| Rate for Payer: Beech Street Commercial |
$18.42
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.43
|
| Rate for Payer: Cash Price |
$13.16
|
| Rate for Payer: ChoiceCare Network Commercial |
$18.24
|
| Rate for Payer: Cigna of WY Commercial |
$18.42
|
| Rate for Payer: Entrust Commercial |
$17.86
|
| Rate for Payer: First Choice Health Commercial |
$17.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$12.41
|
| Rate for Payer: HealthUtah PPO |
$18.80
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$18.24
|
| Rate for Payer: Multiplan Medicare/VA |
$11.79
|
| Rate for Payer: One Health Plan of WY PPO |
$18.42
|
| Rate for Payer: PacificSource Commercial |
$16.92
|
| Rate for Payer: PHCS PPO |
$18.42
|
| Rate for Payer: Three Rivers PPO |
$14.10
|
| Rate for Payer: TriWest Veterans Administration |
$12.41
|
| Rate for Payer: United Healthcare Commercial |
$16.36
|
| Rate for Payer: United Healthcare Medicare |
$12.41
|
| Rate for Payer: WINHealth Partners Commercial |
$17.86
|
| Rate for Payer: Wise Provider Network Commercial |
$17.86
|
|
|
ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER [17856]
|
Facility
|
IP
|
$18.80
|
|
|
Service Code
|
NDC 0054074287
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.79 |
| Max. Negotiated Rate |
$18.80 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18.42
|
| Rate for Payer: Altius Auto/Workers Compensation |
$18.05
|
| Rate for Payer: Altius Commercial |
$18.05
|
| Rate for Payer: Beech Street Commercial |
$18.42
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.43
|
| Rate for Payer: Cash Price |
$13.16
|
| Rate for Payer: ChoiceCare Network Commercial |
$18.24
|
| Rate for Payer: Cigna of WY Commercial |
$18.42
|
| Rate for Payer: Entrust Commercial |
$17.86
|
| Rate for Payer: First Choice Health Commercial |
$17.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$12.41
|
| Rate for Payer: HealthUtah PPO |
$18.80
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$18.24
|
| Rate for Payer: Multiplan Medicare/VA |
$11.79
|
| Rate for Payer: One Health Plan of WY PPO |
$18.42
|
| Rate for Payer: PacificSource Commercial |
$16.92
|
| Rate for Payer: PHCS PPO |
$18.42
|
| Rate for Payer: Three Rivers PPO |
$14.10
|
| Rate for Payer: TriWest Veterans Administration |
$12.41
|
| Rate for Payer: United Healthcare Commercial |
$16.36
|
| Rate for Payer: United Healthcare Medicare |
$12.41
|
| Rate for Payer: WINHealth Partners Commercial |
$17.86
|
| Rate for Payer: Wise Provider Network Commercial |
$17.86
|
|
|
ALCOHOL/SUBSTANCE SCREEN & INTERVEN 15-30 MIN
|
Professional
|
Both
|
$42.00
|
|
|
Service Code
|
HCPCS 99408
|
| Hospital Charge Code |
99408
|
| Min. Negotiated Rate |
$31.50 |
| Max. Negotiated Rate |
$42.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$41.16
|
| Rate for Payer: Beech Street Commercial |
$39.90
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$40.74
|
| Rate for Payer: Cigna of WY Commercial |
$41.16
|
| Rate for Payer: First Choice Health Commercial |
$37.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$39.90
|
| Rate for Payer: HealthUtah PPO |
$42.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$40.74
|
| Rate for Payer: One Health Plan of WY PPO |
$41.16
|
| Rate for Payer: PacificSource Commercial |
$37.80
|
| Rate for Payer: PHCS PPO |
$39.90
|
| Rate for Payer: Three Rivers PPO |
$31.50
|
| Rate for Payer: United Healthcare Commercial |
$36.54
|
| Rate for Payer: WINHealth Partners Commercial |
$39.90
|
|
|
ALCOHOL SWABS [16312]
|
Facility
|
OP
|
$0.07
|
|
|
Service Code
|
NDC 5751544000
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.07
|
| Rate for Payer: Aetna of WY Medicare |
$0.05
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.07
|
| Rate for Payer: Altius Commercial |
$0.07
|
| Rate for Payer: Beech Street Commercial |
$0.07
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.07
|
| Rate for Payer: Cigna of WY Commercial |
$0.07
|
| Rate for Payer: Entrust Commercial |
$0.07
|
| Rate for Payer: First Choice Health Commercial |
$0.07
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.07
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.04
|
| Rate for Payer: HealthUtah PPO |
$0.07
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.07
|
| Rate for Payer: Multiplan Medicare/VA |
$0.04
|
| Rate for Payer: One Health Plan of WY PPO |
$0.07
|
| Rate for Payer: PacificSource Commercial |
$0.06
|
| Rate for Payer: PHCS PPO |
$0.07
|
| Rate for Payer: Three Rivers PPO |
$0.05
|
| Rate for Payer: TriWest Veterans Administration |
$0.04
|
| Rate for Payer: United Healthcare Commercial |
$0.06
|
| Rate for Payer: United Healthcare Medicare |
$0.04
|
| Rate for Payer: WINHealth Partners Commercial |
$0.07
|
| Rate for Payer: Wise Provider Network Commercial |
$0.07
|
|
|
ALCOHOL SWABS [16312]
|
Facility
|
IP
|
$0.07
|
|
|
Service Code
|
NDC 5751544000
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.07
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.07
|
| Rate for Payer: Altius Commercial |
$0.07
|
| Rate for Payer: Beech Street Commercial |
$0.07
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.07
|
| Rate for Payer: Cigna of WY Commercial |
$0.07
|
| Rate for Payer: Entrust Commercial |
$0.07
|
| Rate for Payer: First Choice Health Commercial |
$0.07
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.07
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.05
|
| Rate for Payer: HealthUtah PPO |
$0.07
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.07
|
| Rate for Payer: Multiplan Medicare/VA |
$0.04
|
| Rate for Payer: One Health Plan of WY PPO |
$0.07
|
| Rate for Payer: PacificSource Commercial |
$0.06
|
| Rate for Payer: PHCS PPO |
$0.07
|
| Rate for Payer: Three Rivers PPO |
$0.05
|
| Rate for Payer: TriWest Veterans Administration |
$0.05
|
| Rate for Payer: United Healthcare Commercial |
$0.06
|
| Rate for Payer: United Healthcare Medicare |
$0.05
|
| Rate for Payer: WINHealth Partners Commercial |
$0.07
|
| Rate for Payer: Wise Provider Network Commercial |
$0.07
|
|
|
ALENDRONATE 35 MG TABLET [9417]
|
Facility
|
OP
|
$3.50
|
|
|
Service Code
|
NDC 6909722316
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.93 |
| Max. Negotiated Rate |
$3.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3.43
|
| Rate for Payer: Aetna of WY Medicare |
$2.31
|
| Rate for Payer: Altius Auto/Workers Compensation |
$3.36
|
| Rate for Payer: Altius Commercial |
$3.36
|
| Rate for Payer: Beech Street Commercial |
$3.43
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.87
|
| Rate for Payer: Cash Price |
$2.45
|
| Rate for Payer: ChoiceCare Network Commercial |
$3.40
|
| Rate for Payer: Cigna of WY Commercial |
$3.43
|
| Rate for Payer: Entrust Commercial |
$3.32
|
| Rate for Payer: First Choice Health Commercial |
$3.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2.03
|
| Rate for Payer: HealthUtah PPO |
$3.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3.40
|
| Rate for Payer: Multiplan Medicare/VA |
$1.93
|
| Rate for Payer: One Health Plan of WY PPO |
$3.43
|
| Rate for Payer: PacificSource Commercial |
$3.15
|
| Rate for Payer: PHCS PPO |
$3.43
|
| Rate for Payer: Three Rivers PPO |
$2.62
|
| Rate for Payer: TriWest Veterans Administration |
$2.03
|
| Rate for Payer: United Healthcare Commercial |
$3.04
|
| Rate for Payer: United Healthcare Medicare |
$2.03
|
| Rate for Payer: WINHealth Partners Commercial |
$3.43
|
| Rate for Payer: Wise Provider Network Commercial |
$3.32
|
|
|
ALENDRONATE 35 MG TABLET [9417]
|
Facility
|
IP
|
$3.50
|
|
|
Service Code
|
NDC 6909722316
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.19 |
| Max. Negotiated Rate |
$3.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3.43
|
| Rate for Payer: Altius Auto/Workers Compensation |
$3.36
|
| Rate for Payer: Altius Commercial |
$3.36
|
| Rate for Payer: Beech Street Commercial |
$3.43
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.87
|
| Rate for Payer: Cash Price |
$2.45
|
| Rate for Payer: ChoiceCare Network Commercial |
$3.40
|
| Rate for Payer: Cigna of WY Commercial |
$3.43
|
| Rate for Payer: Entrust Commercial |
$3.32
|
| Rate for Payer: First Choice Health Commercial |
$3.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2.31
|
| Rate for Payer: HealthUtah PPO |
$3.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3.40
|
| Rate for Payer: Multiplan Medicare/VA |
$2.19
|
| Rate for Payer: One Health Plan of WY PPO |
$3.43
|
| Rate for Payer: PacificSource Commercial |
$3.15
|
| Rate for Payer: PHCS PPO |
$3.43
|
| Rate for Payer: Three Rivers PPO |
$2.62
|
| Rate for Payer: TriWest Veterans Administration |
$2.31
|
| Rate for Payer: United Healthcare Commercial |
$3.04
|
| Rate for Payer: United Healthcare Medicare |
$2.31
|
| Rate for Payer: WINHealth Partners Commercial |
$3.32
|
| Rate for Payer: Wise Provider Network Commercial |
$3.32
|
|
|
ALENDRONATE 70 MG TABLET [4785]
|
Facility
|
IP
|
$2.50
|
|
|
Service Code
|
NDC 6498034214
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.57 |
| Max. Negotiated Rate |
$2.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.45
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.40
|
| Rate for Payer: Altius Commercial |
$2.40
|
| Rate for Payer: Beech Street Commercial |
$2.45
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.05
|
| Rate for Payer: Cash Price |
$1.75
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.42
|
| Rate for Payer: Cigna of WY Commercial |
$2.45
|
| Rate for Payer: Entrust Commercial |
$2.38
|
| Rate for Payer: First Choice Health Commercial |
$2.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.65
|
| Rate for Payer: HealthUtah PPO |
$2.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.42
|
| Rate for Payer: Multiplan Medicare/VA |
$1.57
|
| Rate for Payer: One Health Plan of WY PPO |
$2.45
|
| Rate for Payer: PacificSource Commercial |
$2.25
|
| Rate for Payer: PHCS PPO |
$2.45
|
| Rate for Payer: Three Rivers PPO |
$1.88
|
| Rate for Payer: TriWest Veterans Administration |
$1.65
|
| Rate for Payer: United Healthcare Commercial |
$2.18
|
| Rate for Payer: United Healthcare Medicare |
$1.65
|
| Rate for Payer: WINHealth Partners Commercial |
$2.38
|
| Rate for Payer: Wise Provider Network Commercial |
$2.38
|
|
|
ALENDRONATE 70 MG TABLET [4785]
|
Facility
|
OP
|
$2.50
|
|
|
Service Code
|
NDC 6498034214
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.38 |
| Max. Negotiated Rate |
$2.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.45
|
| Rate for Payer: Aetna of WY Medicare |
$1.65
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.40
|
| Rate for Payer: Altius Commercial |
$2.40
|
| Rate for Payer: Beech Street Commercial |
$2.45
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.05
|
| Rate for Payer: Cash Price |
$1.75
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.42
|
| Rate for Payer: Cigna of WY Commercial |
$2.45
|
| Rate for Payer: Entrust Commercial |
$2.38
|
| Rate for Payer: First Choice Health Commercial |
$2.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.45
|
| Rate for Payer: HealthUtah PPO |
$2.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.42
|
| Rate for Payer: Multiplan Medicare/VA |
$1.38
|
| Rate for Payer: One Health Plan of WY PPO |
$2.45
|
| Rate for Payer: PacificSource Commercial |
$2.25
|
| Rate for Payer: PHCS PPO |
$2.45
|
| Rate for Payer: Three Rivers PPO |
$1.88
|
| Rate for Payer: TriWest Veterans Administration |
$1.45
|
| Rate for Payer: United Healthcare Commercial |
$2.18
|
| Rate for Payer: United Healthcare Medicare |
$1.45
|
| Rate for Payer: WINHealth Partners Commercial |
$2.45
|
| Rate for Payer: Wise Provider Network Commercial |
$2.38
|
|
|
ALEXIS O RETRACTOR XLARGE
|
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
|
|
|
ALEXIS O RETRACTOR XLARGE
|
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
|
|
|
ALLERGAN I BALLOON
|
Facility
|
IP
|
$472.50
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$296.26 |
| Max. Negotiated Rate |
$472.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$463.05
|
| Rate for Payer: Altius Auto/Workers Compensation |
$453.60
|
| Rate for Payer: Altius Commercial |
$453.60
|
| Rate for Payer: Beech Street Commercial |
$463.05
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$387.92
|
| Rate for Payer: Cash Price |
$330.75
|
| Rate for Payer: ChoiceCare Network Commercial |
$458.32
|
| Rate for Payer: Cigna of WY Commercial |
$463.05
|
| Rate for Payer: Entrust Commercial |
$448.88
|
| Rate for Payer: First Choice Health Commercial |
$448.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$448.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$311.85
|
| Rate for Payer: HealthUtah PPO |
$472.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$458.32
|
| Rate for Payer: Multiplan Medicare/VA |
$296.26
|
| Rate for Payer: One Health Plan of WY PPO |
$463.05
|
| Rate for Payer: PacificSource Commercial |
$425.25
|
| Rate for Payer: PHCS PPO |
$463.05
|
| Rate for Payer: Three Rivers PPO |
$354.38
|
| Rate for Payer: TriWest Veterans Administration |
$311.85
|
| Rate for Payer: United Healthcare Commercial |
$411.08
|
| Rate for Payer: United Healthcare Medicare |
$311.85
|
| Rate for Payer: WINHealth Partners Commercial |
$448.88
|
| Rate for Payer: Wise Provider Network Commercial |
$448.88
|
|
|
ALLERGAN I BALLOON
|
Facility
|
OP
|
$472.50
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$260.35 |
| Max. Negotiated Rate |
$472.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$463.05
|
| Rate for Payer: Aetna of WY Medicare |
$311.85
|
| Rate for Payer: Altius Auto/Workers Compensation |
$453.60
|
| Rate for Payer: Altius Commercial |
$453.60
|
| Rate for Payer: Beech Street Commercial |
$463.05
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$387.92
|
| Rate for Payer: Cash Price |
$330.75
|
| Rate for Payer: ChoiceCare Network Commercial |
$458.32
|
| Rate for Payer: Cigna of WY Commercial |
$463.05
|
| Rate for Payer: Entrust Commercial |
$448.88
|
| Rate for Payer: First Choice Health Commercial |
$448.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$448.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$274.05
|
| Rate for Payer: HealthUtah PPO |
$472.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$458.32
|
| Rate for Payer: Multiplan Medicare/VA |
$260.35
|
| Rate for Payer: One Health Plan of WY PPO |
$463.05
|
| Rate for Payer: PacificSource Commercial |
$425.25
|
| Rate for Payer: PHCS PPO |
$463.05
|
| Rate for Payer: Three Rivers PPO |
$354.38
|
| Rate for Payer: TriWest Veterans Administration |
$274.05
|
| Rate for Payer: United Healthcare Commercial |
$411.08
|
| Rate for Payer: United Healthcare Medicare |
$274.05
|
| Rate for Payer: WINHealth Partners Commercial |
$463.05
|
| Rate for Payer: Wise Provider Network Commercial |
$448.88
|
|
|
ALLERGEN SPEC IGE CRUDE ALLERGEN EXTRACT EACH
|
Professional
|
Both
|
$56.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
86003
|
| Min. Negotiated Rate |
$4.44 |
| Max. Negotiated Rate |
$56.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$54.88
|
| Rate for Payer: Aetna of WY Medicare |
$5.22
|
| Rate for Payer: Beech Street Commercial |
$53.20
|
| Rate for Payer: Cash Price |
$39.20
|
| Rate for Payer: Cash Price |
$39.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$54.32
|
| Rate for Payer: Cigna of WY Commercial |
$54.88
|
| Rate for Payer: First Choice Health Commercial |
$50.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$53.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$5.22
|
| Rate for Payer: HealthUtah PPO |
$56.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$54.32
|
| Rate for Payer: Multiplan Medicare/VA |
$4.44
|
| Rate for Payer: One Health Plan of WY PPO |
$54.88
|
| Rate for Payer: PacificSource Commercial |
$50.40
|
| Rate for Payer: PHCS PPO |
$53.20
|
| Rate for Payer: Three Rivers PPO |
$42.00
|
| Rate for Payer: TriWest Veterans Administration |
$5.22
|
| Rate for Payer: United Healthcare Commercial |
$48.72
|
| Rate for Payer: United Healthcare Medicare |
$5.22
|
| Rate for Payer: WINHealth Partners Commercial |
$53.20
|
|
|
ALLOGRAFT FOR SPINE SURGERY ONLY MORSELIZED
|
Professional
|
Both
|
$1,303.00
|
|
|
Service Code
|
HCPCS 20930 AS
|
| Hospital Charge Code |
20930
|
| Min. Negotiated Rate |
$977.25 |
| Max. Negotiated Rate |
$1,303.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,276.94
|
| Rate for Payer: Beech Street Commercial |
$1,237.85
|
| Rate for Payer: Cash Price |
$912.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,263.91
|
| Rate for Payer: Cigna of WY Commercial |
$1,276.94
|
| Rate for Payer: First Choice Health Commercial |
$1,172.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,237.85
|
| Rate for Payer: HealthUtah PPO |
$1,303.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,263.91
|
| Rate for Payer: One Health Plan of WY PPO |
$1,276.94
|
| Rate for Payer: PacificSource Commercial |
$1,172.70
|
| Rate for Payer: PHCS PPO |
$1,237.85
|
| Rate for Payer: Three Rivers PPO |
$977.25
|
| Rate for Payer: United Healthcare Commercial |
$1,133.61
|
| Rate for Payer: WINHealth Partners Commercial |
$1,107.55
|
|
|
ALLOGRAFT FOR SPINE SURGERY ONLY MORSELIZED
|
Professional
|
Both
|
$1,303.00
|
|
|
Service Code
|
HCPCS 20930 80
|
| Hospital Charge Code |
20930
|
| Min. Negotiated Rate |
$977.25 |
| Max. Negotiated Rate |
$1,303.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,276.94
|
| Rate for Payer: Beech Street Commercial |
$1,237.85
|
| Rate for Payer: Cash Price |
$912.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,263.91
|
| Rate for Payer: Cigna of WY Commercial |
$1,276.94
|
| Rate for Payer: First Choice Health Commercial |
$1,172.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,237.85
|
| Rate for Payer: HealthUtah PPO |
$1,303.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,263.91
|
| Rate for Payer: One Health Plan of WY PPO |
$1,276.94
|
| Rate for Payer: PacificSource Commercial |
$1,172.70
|
| Rate for Payer: PHCS PPO |
$1,237.85
|
| Rate for Payer: Three Rivers PPO |
$977.25
|
| Rate for Payer: United Healthcare Commercial |
$1,133.61
|
| Rate for Payer: WINHealth Partners Commercial |
$1,107.55
|
|
|
ALLOGRAFT FOR SPINE SURGERY ONLY MORSELIZED
|
Professional
|
Both
|
$1,303.00
|
|
|
Service Code
|
HCPCS 20930
|
| Hospital Charge Code |
20930
|
| Min. Negotiated Rate |
$977.25 |
| Max. Negotiated Rate |
$1,303.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,276.94
|
| Rate for Payer: Beech Street Commercial |
$1,237.85
|
| Rate for Payer: Cash Price |
$912.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,263.91
|
| Rate for Payer: Cigna of WY Commercial |
$1,276.94
|
| Rate for Payer: First Choice Health Commercial |
$1,172.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,237.85
|
| Rate for Payer: HealthUtah PPO |
$1,303.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,263.91
|
| Rate for Payer: One Health Plan of WY PPO |
$1,276.94
|
| Rate for Payer: PacificSource Commercial |
$1,172.70
|
| Rate for Payer: PHCS PPO |
$1,237.85
|
| Rate for Payer: Three Rivers PPO |
$977.25
|
| Rate for Payer: United Healthcare Commercial |
$1,133.61
|
| Rate for Payer: WINHealth Partners Commercial |
$1,107.55
|
|
|
ALLOGRAFT FOR SPINE SURGERY ONLY STRUCTURAL
|
Professional
|
Both
|
$367.00
|
|
|
Service Code
|
HCPCS 20931 80
|
| Hospital Charge Code |
20931
|
| Min. Negotiated Rate |
$87.56 |
| Max. Negotiated Rate |
$367.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$359.66
|
| Rate for Payer: Aetna of WY Medicare |
$103.01
|
| Rate for Payer: Beech Street Commercial |
$348.65
|
| Rate for Payer: Cash Price |
$256.90
|
| Rate for Payer: Cash Price |
$256.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$355.99
|
| Rate for Payer: Cigna of WY Commercial |
$359.66
|
| Rate for Payer: First Choice Health Commercial |
$330.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$348.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$103.01
|
| Rate for Payer: HealthUtah PPO |
$367.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$355.99
|
| Rate for Payer: Multiplan Medicare/VA |
$87.56
|
| Rate for Payer: One Health Plan of WY PPO |
$359.66
|
| Rate for Payer: PacificSource Commercial |
$330.30
|
| Rate for Payer: PHCS PPO |
$348.65
|
| Rate for Payer: Three Rivers PPO |
$275.25
|
| Rate for Payer: TriWest Veterans Administration |
$103.01
|
| Rate for Payer: United Healthcare Commercial |
$319.29
|
| Rate for Payer: United Healthcare Medicare |
$103.01
|
| Rate for Payer: WINHealth Partners Commercial |
$311.95
|
|
|
ALLOGRAFT FOR SPINE SURGERY ONLY STRUCTURAL
|
Professional
|
Both
|
$367.00
|
|
|
Service Code
|
HCPCS 20931 AS
|
| Hospital Charge Code |
20931
|
| Min. Negotiated Rate |
$87.56 |
| Max. Negotiated Rate |
$367.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$359.66
|
| Rate for Payer: Aetna of WY Medicare |
$103.01
|
| Rate for Payer: Beech Street Commercial |
$348.65
|
| Rate for Payer: Cash Price |
$256.90
|
| Rate for Payer: Cash Price |
$256.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$355.99
|
| Rate for Payer: Cigna of WY Commercial |
$359.66
|
| Rate for Payer: First Choice Health Commercial |
$330.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$348.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$103.01
|
| Rate for Payer: HealthUtah PPO |
$367.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$355.99
|
| Rate for Payer: Multiplan Medicare/VA |
$87.56
|
| Rate for Payer: One Health Plan of WY PPO |
$359.66
|
| Rate for Payer: PacificSource Commercial |
$330.30
|
| Rate for Payer: PHCS PPO |
$348.65
|
| Rate for Payer: Three Rivers PPO |
$275.25
|
| Rate for Payer: TriWest Veterans Administration |
$103.01
|
| Rate for Payer: United Healthcare Commercial |
$319.29
|
| Rate for Payer: United Healthcare Medicare |
$103.01
|
| Rate for Payer: WINHealth Partners Commercial |
$311.95
|
|
|
ALLOPURINOL 100 MG TABLET [7409]
|
Facility
|
IP
|
$1.66
|
|
|
Service Code
|
NDC 6068767711
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.04 |
| Max. Negotiated Rate |
$1.66 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.63
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.59
|
| Rate for Payer: Altius Commercial |
$1.59
|
| Rate for Payer: Beech Street Commercial |
$1.63
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.36
|
| Rate for Payer: Cash Price |
$1.16
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.61
|
| Rate for Payer: Cigna of WY Commercial |
$1.63
|
| Rate for Payer: Entrust Commercial |
$1.58
|
| Rate for Payer: First Choice Health Commercial |
$1.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.10
|
| Rate for Payer: HealthUtah PPO |
$1.66
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.61
|
| Rate for Payer: Multiplan Medicare/VA |
$1.04
|
| Rate for Payer: One Health Plan of WY PPO |
$1.63
|
| Rate for Payer: PacificSource Commercial |
$1.49
|
| Rate for Payer: PHCS PPO |
$1.63
|
| Rate for Payer: Three Rivers PPO |
$1.24
|
| Rate for Payer: TriWest Veterans Administration |
$1.10
|
| Rate for Payer: United Healthcare Commercial |
$1.44
|
| Rate for Payer: United Healthcare Medicare |
$1.10
|
| Rate for Payer: WINHealth Partners Commercial |
$1.58
|
| Rate for Payer: Wise Provider Network Commercial |
$1.58
|
|
|
ALLOPURINOL 100 MG TABLET [7409]
|
Facility
|
IP
|
$1.66
|
|
|
Service Code
|
NDC 6258498801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.04 |
| Max. Negotiated Rate |
$1.66 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.63
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.59
|
| Rate for Payer: Altius Commercial |
$1.59
|
| Rate for Payer: Beech Street Commercial |
$1.63
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.36
|
| Rate for Payer: Cash Price |
$1.16
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.61
|
| Rate for Payer: Cigna of WY Commercial |
$1.63
|
| Rate for Payer: Entrust Commercial |
$1.58
|
| Rate for Payer: First Choice Health Commercial |
$1.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.10
|
| Rate for Payer: HealthUtah PPO |
$1.66
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.61
|
| Rate for Payer: Multiplan Medicare/VA |
$1.04
|
| Rate for Payer: One Health Plan of WY PPO |
$1.63
|
| Rate for Payer: PacificSource Commercial |
$1.49
|
| Rate for Payer: PHCS PPO |
$1.63
|
| Rate for Payer: Three Rivers PPO |
$1.24
|
| Rate for Payer: TriWest Veterans Administration |
$1.10
|
| Rate for Payer: United Healthcare Commercial |
$1.44
|
| Rate for Payer: United Healthcare Medicare |
$1.10
|
| Rate for Payer: WINHealth Partners Commercial |
$1.58
|
| Rate for Payer: Wise Provider Network Commercial |
$1.58
|
|
|
ALLOPURINOL 100 MG TABLET [7409]
|
Facility
|
OP
|
$1.66
|
|
|
Service Code
|
NDC 6068767711
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.91 |
| Max. Negotiated Rate |
$1.66 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.63
|
| Rate for Payer: Aetna of WY Medicare |
$1.10
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.59
|
| Rate for Payer: Altius Commercial |
$1.59
|
| Rate for Payer: Beech Street Commercial |
$1.63
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.36
|
| Rate for Payer: Cash Price |
$1.16
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.61
|
| Rate for Payer: Cigna of WY Commercial |
$1.63
|
| Rate for Payer: Entrust Commercial |
$1.58
|
| Rate for Payer: First Choice Health Commercial |
$1.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.96
|
| Rate for Payer: HealthUtah PPO |
$1.66
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.61
|
| Rate for Payer: Multiplan Medicare/VA |
$0.91
|
| Rate for Payer: One Health Plan of WY PPO |
$1.63
|
| Rate for Payer: PacificSource Commercial |
$1.49
|
| Rate for Payer: PHCS PPO |
$1.63
|
| Rate for Payer: Three Rivers PPO |
$1.24
|
| Rate for Payer: TriWest Veterans Administration |
$0.96
|
| Rate for Payer: United Healthcare Commercial |
$1.44
|
| Rate for Payer: United Healthcare Medicare |
$0.96
|
| Rate for Payer: WINHealth Partners Commercial |
$1.63
|
| Rate for Payer: Wise Provider Network Commercial |
$1.58
|
|
|
ALLOPURINOL 100 MG TABLET [7409]
|
Facility
|
OP
|
$1.66
|
|
|
Service Code
|
NDC 6258498801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.91 |
| Max. Negotiated Rate |
$1.66 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.63
|
| Rate for Payer: Aetna of WY Medicare |
$1.10
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.59
|
| Rate for Payer: Altius Commercial |
$1.59
|
| Rate for Payer: Beech Street Commercial |
$1.63
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.36
|
| Rate for Payer: Cash Price |
$1.16
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.61
|
| Rate for Payer: Cigna of WY Commercial |
$1.63
|
| Rate for Payer: Entrust Commercial |
$1.58
|
| Rate for Payer: First Choice Health Commercial |
$1.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.96
|
| Rate for Payer: HealthUtah PPO |
$1.66
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.61
|
| Rate for Payer: Multiplan Medicare/VA |
$0.91
|
| Rate for Payer: One Health Plan of WY PPO |
$1.63
|
| Rate for Payer: PacificSource Commercial |
$1.49
|
| Rate for Payer: PHCS PPO |
$1.63
|
| Rate for Payer: Three Rivers PPO |
$1.24
|
| Rate for Payer: TriWest Veterans Administration |
$0.96
|
| Rate for Payer: United Healthcare Commercial |
$1.44
|
| Rate for Payer: United Healthcare Medicare |
$0.96
|
| Rate for Payer: WINHealth Partners Commercial |
$1.63
|
| Rate for Payer: Wise Provider Network Commercial |
$1.58
|
|
|
ALLOPURINOL 300 MG TABLET [16060]
|
Facility
|
IP
|
$2.28
|
|
|
Service Code
|
NDC 0378018101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$2.28 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.23
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.19
|
| Rate for Payer: Altius Commercial |
$2.19
|
| Rate for Payer: Beech Street Commercial |
$2.23
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.87
|
| Rate for Payer: Cash Price |
$1.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.21
|
| Rate for Payer: Cigna of WY Commercial |
$2.23
|
| Rate for Payer: Entrust Commercial |
$2.17
|
| Rate for Payer: First Choice Health Commercial |
$2.17
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.17
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.50
|
| Rate for Payer: HealthUtah PPO |
$2.28
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.21
|
| Rate for Payer: Multiplan Medicare/VA |
$1.43
|
| Rate for Payer: One Health Plan of WY PPO |
$2.23
|
| Rate for Payer: PacificSource Commercial |
$2.05
|
| Rate for Payer: PHCS PPO |
$2.23
|
| Rate for Payer: Three Rivers PPO |
$1.71
|
| Rate for Payer: TriWest Veterans Administration |
$1.50
|
| Rate for Payer: United Healthcare Commercial |
$1.98
|
| Rate for Payer: United Healthcare Medicare |
$1.50
|
| Rate for Payer: WINHealth Partners Commercial |
$2.17
|
| Rate for Payer: Wise Provider Network Commercial |
$2.17
|
|
