|
CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE [26541]
|
Facility
|
IP
|
$15.94
|
|
|
Service Code
|
NDC 0904632946
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.24 |
| Max. Negotiated Rate |
$15.94 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.62
|
| Rate for Payer: Aetna of WY Medicare |
$10.20
|
| Rate for Payer: Altius Commercial |
$15.30
|
| Rate for Payer: Beech Street Commercial |
$15.62
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.46
|
| Rate for Payer: Cash Price |
$11.16
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.46
|
| Rate for Payer: Cigna of WY Commercial |
$15.62
|
| Rate for Payer: Entrust Commercial |
$15.14
|
| Rate for Payer: First Choice Health Commercial |
$15.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.72
|
| Rate for Payer: HealthUtah PPO |
$15.94
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.46
|
| Rate for Payer: Multiplan Medicare/VA |
$9.24
|
| Rate for Payer: One Health Plan of WY PPO |
$15.62
|
| Rate for Payer: PacificSource Commercial |
$14.35
|
| Rate for Payer: PHCS PPO |
$15.62
|
| Rate for Payer: Three Rivers PPO |
$11.96
|
| Rate for Payer: TriWest Veterans Administration |
$9.72
|
| Rate for Payer: United Healthcare Commercial |
$15.22
|
| Rate for Payer: United Healthcare Medicare |
$9.72
|
| Rate for Payer: WINHealth Partners Commercial |
$15.14
|
| Rate for Payer: Wise Provider Network Commercial |
$15.14
|
|
|
CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE [26541]
|
Facility
|
IP
|
$16.09
|
|
|
Service Code
|
NDC 4612219565
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.32 |
| Max. Negotiated Rate |
$16.09 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.77
|
| Rate for Payer: Aetna of WY Medicare |
$10.30
|
| Rate for Payer: Altius Commercial |
$15.45
|
| Rate for Payer: Beech Street Commercial |
$15.77
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.61
|
| Rate for Payer: Cash Price |
$11.26
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.61
|
| Rate for Payer: Cigna of WY Commercial |
$15.77
|
| Rate for Payer: Entrust Commercial |
$15.29
|
| Rate for Payer: First Choice Health Commercial |
$15.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.81
|
| Rate for Payer: HealthUtah PPO |
$16.09
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.61
|
| Rate for Payer: Multiplan Medicare/VA |
$9.32
|
| Rate for Payer: One Health Plan of WY PPO |
$15.77
|
| Rate for Payer: PacificSource Commercial |
$14.48
|
| Rate for Payer: PHCS PPO |
$15.77
|
| Rate for Payer: Three Rivers PPO |
$12.07
|
| Rate for Payer: TriWest Veterans Administration |
$9.81
|
| Rate for Payer: United Healthcare Commercial |
$15.37
|
| Rate for Payer: United Healthcare Medicare |
$9.81
|
| Rate for Payer: WINHealth Partners Commercial |
$15.29
|
| Rate for Payer: Wise Provider Network Commercial |
$15.29
|
|
|
CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE [26541]
|
Facility
|
OP
|
$15.94
|
|
|
Service Code
|
NDC 0904632946
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.63 |
| Max. Negotiated Rate |
$15.94 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.62
|
| Rate for Payer: Aetna of WY Medicare |
$10.52
|
| Rate for Payer: Altius Commercial |
$15.30
|
| Rate for Payer: Beech Street Commercial |
$15.62
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.46
|
| Rate for Payer: Cash Price |
$11.16
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.46
|
| Rate for Payer: Cigna of WY Commercial |
$15.62
|
| Rate for Payer: Entrust Commercial |
$15.14
|
| Rate for Payer: First Choice Health Commercial |
$15.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.09
|
| Rate for Payer: HealthUtah PPO |
$15.94
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.46
|
| Rate for Payer: Multiplan Medicare/VA |
$8.63
|
| Rate for Payer: One Health Plan of WY PPO |
$15.62
|
| Rate for Payer: PacificSource Commercial |
$14.35
|
| Rate for Payer: PHCS PPO |
$15.62
|
| Rate for Payer: Three Rivers PPO |
$11.96
|
| Rate for Payer: TriWest Veterans Administration |
$9.09
|
| Rate for Payer: United Healthcare Commercial |
$15.22
|
| Rate for Payer: United Healthcare Medicare |
$9.09
|
| Rate for Payer: WINHealth Partners Commercial |
$15.62
|
| Rate for Payer: Wise Provider Network Commercial |
$15.14
|
|
|
CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE LIQUID GEL DROPS [20408]
|
Facility
|
IP
|
$17.31
|
|
|
Service Code
|
NDC 0023920515
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.03 |
| Max. Negotiated Rate |
$17.31 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.96
|
| Rate for Payer: Aetna of WY Medicare |
$11.08
|
| Rate for Payer: Altius Commercial |
$16.62
|
| Rate for Payer: Beech Street Commercial |
$16.96
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.79
|
| Rate for Payer: Cash Price |
$12.12
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.79
|
| Rate for Payer: Cigna of WY Commercial |
$16.96
|
| Rate for Payer: Entrust Commercial |
$16.44
|
| Rate for Payer: First Choice Health Commercial |
$16.44
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.44
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.56
|
| Rate for Payer: HealthUtah PPO |
$17.31
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.79
|
| Rate for Payer: Multiplan Medicare/VA |
$10.03
|
| Rate for Payer: One Health Plan of WY PPO |
$16.96
|
| Rate for Payer: PacificSource Commercial |
$15.58
|
| Rate for Payer: PHCS PPO |
$16.96
|
| Rate for Payer: Three Rivers PPO |
$12.98
|
| Rate for Payer: TriWest Veterans Administration |
$10.56
|
| Rate for Payer: United Healthcare Commercial |
$16.53
|
| Rate for Payer: United Healthcare Medicare |
$10.56
|
| Rate for Payer: WINHealth Partners Commercial |
$16.44
|
| Rate for Payer: Wise Provider Network Commercial |
$16.44
|
|
|
CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE LIQUID GEL DROPS [20408]
|
Facility
|
OP
|
$17.31
|
|
|
Service Code
|
NDC 0023920515
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.37 |
| Max. Negotiated Rate |
$17.31 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.96
|
| Rate for Payer: Aetna of WY Medicare |
$11.42
|
| Rate for Payer: Altius Commercial |
$16.62
|
| Rate for Payer: Beech Street Commercial |
$16.96
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.79
|
| Rate for Payer: Cash Price |
$12.12
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.79
|
| Rate for Payer: Cigna of WY Commercial |
$16.96
|
| Rate for Payer: Entrust Commercial |
$16.44
|
| Rate for Payer: First Choice Health Commercial |
$16.44
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.44
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.87
|
| Rate for Payer: HealthUtah PPO |
$17.31
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.79
|
| Rate for Payer: Multiplan Medicare/VA |
$9.37
|
| Rate for Payer: One Health Plan of WY PPO |
$16.96
|
| Rate for Payer: PacificSource Commercial |
$15.58
|
| Rate for Payer: PHCS PPO |
$16.96
|
| Rate for Payer: Three Rivers PPO |
$12.98
|
| Rate for Payer: TriWest Veterans Administration |
$9.87
|
| Rate for Payer: United Healthcare Commercial |
$16.53
|
| Rate for Payer: United Healthcare Medicare |
$9.87
|
| Rate for Payer: WINHealth Partners Commercial |
$16.96
|
| Rate for Payer: Wise Provider Network Commercial |
$16.44
|
|
|
CARDIOPULMONARY RESUSCITATION
|
Professional
|
Both
|
$876.00
|
|
|
Service Code
|
HCPCS 92950
|
| Min. Negotiated Rate |
$147.67 |
| Max. Negotiated Rate |
$876.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$858.48
|
| Rate for Payer: Aetna of WY Medicare |
$173.73
|
| Rate for Payer: Beech Street Commercial |
$832.20
|
| Rate for Payer: Cash Price |
$613.20
|
| Rate for Payer: Cash Price |
$613.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$849.72
|
| Rate for Payer: Cigna of WY Commercial |
$858.48
|
| Rate for Payer: First Choice Health Commercial |
$788.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$832.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$173.73
|
| Rate for Payer: HealthUtah PPO |
$876.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$849.72
|
| Rate for Payer: Multiplan Medicare/VA |
$147.67
|
| Rate for Payer: One Health Plan of WY PPO |
$858.48
|
| Rate for Payer: PacificSource Commercial |
$788.40
|
| Rate for Payer: PHCS PPO |
$832.20
|
| Rate for Payer: Three Rivers PPO |
$657.00
|
| Rate for Payer: TriWest Veterans Administration |
$173.73
|
| Rate for Payer: United Healthcare Commercial |
$832.20
|
| Rate for Payer: WINHealth Partners Commercial |
$832.20
|
|
|
CARDIOVERSION ELECTIVE ARRHYTHMIA EXTERNAL
|
Professional
|
Both
|
$876.00
|
|
|
Service Code
|
HCPCS 92960
|
| Min. Negotiated Rate |
$87.41 |
| Max. Negotiated Rate |
$876.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$858.48
|
| Rate for Payer: Aetna of WY Medicare |
$102.84
|
| Rate for Payer: Beech Street Commercial |
$832.20
|
| Rate for Payer: Cash Price |
$613.20
|
| Rate for Payer: Cash Price |
$613.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$849.72
|
| Rate for Payer: Cigna of WY Commercial |
$858.48
|
| Rate for Payer: First Choice Health Commercial |
$788.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$832.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$102.84
|
| Rate for Payer: HealthUtah PPO |
$876.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$849.72
|
| Rate for Payer: Multiplan Medicare/VA |
$87.41
|
| Rate for Payer: One Health Plan of WY PPO |
$858.48
|
| Rate for Payer: PacificSource Commercial |
$788.40
|
| Rate for Payer: PHCS PPO |
$832.20
|
| Rate for Payer: Three Rivers PPO |
$657.00
|
| Rate for Payer: TriWest Veterans Administration |
$102.84
|
| Rate for Payer: United Healthcare Commercial |
$832.20
|
| Rate for Payer: WINHealth Partners Commercial |
$832.20
|
|
|
CARPECTOMY 1 BONE
|
Professional
|
Both
|
$6,138.00
|
|
|
Service Code
|
HCPCS 25210
|
| Min. Negotiated Rate |
$412.89 |
| Max. Negotiated Rate |
$6,138.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$6,015.24
|
| Rate for Payer: Aetna of WY Medicare |
$485.75
|
| Rate for Payer: Beech Street Commercial |
$5,831.10
|
| Rate for Payer: Cash Price |
$4,296.60
|
| Rate for Payer: Cash Price |
$4,296.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$5,953.86
|
| Rate for Payer: Cigna of WY Commercial |
$6,015.24
|
| Rate for Payer: First Choice Health Commercial |
$5,524.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5,831.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$485.75
|
| Rate for Payer: HealthUtah PPO |
$6,138.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5,953.86
|
| Rate for Payer: Multiplan Medicare/VA |
$412.89
|
| Rate for Payer: One Health Plan of WY PPO |
$6,015.24
|
| Rate for Payer: PacificSource Commercial |
$5,524.20
|
| Rate for Payer: PHCS PPO |
$5,831.10
|
| Rate for Payer: Three Rivers PPO |
$4,603.50
|
| Rate for Payer: TriWest Veterans Administration |
$485.75
|
| Rate for Payer: United Healthcare Commercial |
$5,831.10
|
| Rate for Payer: WINHealth Partners Commercial |
$5,217.30
|
|
|
CARPECTOMY 1 BONE
|
Professional
|
Both
|
$6,138.00
|
|
|
Service Code
|
HCPCS 25210 80
|
| Min. Negotiated Rate |
$412.89 |
| Max. Negotiated Rate |
$6,138.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$6,015.24
|
| Rate for Payer: Beech Street Commercial |
$5,831.10
|
| Rate for Payer: Cash Price |
$4,296.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$5,953.86
|
| Rate for Payer: Cigna of WY Commercial |
$6,015.24
|
| Rate for Payer: First Choice Health Commercial |
$5,524.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5,831.10
|
| Rate for Payer: HealthUtah PPO |
$6,138.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5,953.86
|
| Rate for Payer: One Health Plan of WY PPO |
$6,015.24
|
| Rate for Payer: PacificSource Commercial |
$5,524.20
|
| Rate for Payer: PHCS PPO |
$5,831.10
|
| Rate for Payer: Three Rivers PPO |
$4,603.50
|
| Rate for Payer: United Healthcare Commercial |
$5,831.10
|
| Rate for Payer: WINHealth Partners Commercial |
$5,217.30
|
|
|
CARPECTOMY 1 BONE
|
Professional
|
Both
|
$6,138.00
|
|
|
Service Code
|
HCPCS 25210 AS
|
| Min. Negotiated Rate |
$412.89 |
| Max. Negotiated Rate |
$6,138.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$6,015.24
|
| Rate for Payer: Beech Street Commercial |
$5,831.10
|
| Rate for Payer: Cash Price |
$4,296.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$5,953.86
|
| Rate for Payer: Cigna of WY Commercial |
$6,015.24
|
| Rate for Payer: First Choice Health Commercial |
$5,524.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5,831.10
|
| Rate for Payer: HealthUtah PPO |
$6,138.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5,953.86
|
| Rate for Payer: One Health Plan of WY PPO |
$6,015.24
|
| Rate for Payer: PacificSource Commercial |
$5,524.20
|
| Rate for Payer: PHCS PPO |
$5,831.10
|
| Rate for Payer: Three Rivers PPO |
$4,603.50
|
| Rate for Payer: United Healthcare Commercial |
$5,831.10
|
| Rate for Payer: WINHealth Partners Commercial |
$5,217.30
|
|
|
CARPECTOMY ALL BONES PROXIMAL ROW
|
Professional
|
Both
|
$8,219.00
|
|
|
Service Code
|
HCPCS 25215 AS
|
| Min. Negotiated Rate |
$515.69 |
| Max. Negotiated Rate |
$8,219.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$8,054.62
|
| Rate for Payer: Beech Street Commercial |
$7,808.05
|
| Rate for Payer: Cash Price |
$5,753.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$7,972.43
|
| Rate for Payer: Cigna of WY Commercial |
$8,054.62
|
| Rate for Payer: First Choice Health Commercial |
$7,397.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$7,808.05
|
| Rate for Payer: HealthUtah PPO |
$8,219.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$7,972.43
|
| Rate for Payer: One Health Plan of WY PPO |
$8,054.62
|
| Rate for Payer: PacificSource Commercial |
$7,397.10
|
| Rate for Payer: PHCS PPO |
$7,808.05
|
| Rate for Payer: Three Rivers PPO |
$6,164.25
|
| Rate for Payer: United Healthcare Commercial |
$7,808.05
|
| Rate for Payer: WINHealth Partners Commercial |
$6,986.15
|
|
|
CARPECTOMY ALL BONES PROXIMAL ROW
|
Professional
|
Both
|
$8,219.00
|
|
|
Service Code
|
HCPCS 25215
|
| Min. Negotiated Rate |
$515.69 |
| Max. Negotiated Rate |
$8,219.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$8,054.62
|
| Rate for Payer: Aetna of WY Medicare |
$606.69
|
| Rate for Payer: Beech Street Commercial |
$7,808.05
|
| Rate for Payer: Cash Price |
$5,753.30
|
| Rate for Payer: Cash Price |
$5,753.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$7,972.43
|
| Rate for Payer: Cigna of WY Commercial |
$8,054.62
|
| Rate for Payer: First Choice Health Commercial |
$7,397.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$7,808.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$606.69
|
| Rate for Payer: HealthUtah PPO |
$8,219.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$7,972.43
|
| Rate for Payer: Multiplan Medicare/VA |
$515.69
|
| Rate for Payer: One Health Plan of WY PPO |
$8,054.62
|
| Rate for Payer: PacificSource Commercial |
$7,397.10
|
| Rate for Payer: PHCS PPO |
$7,808.05
|
| Rate for Payer: Three Rivers PPO |
$6,164.25
|
| Rate for Payer: TriWest Veterans Administration |
$606.69
|
| Rate for Payer: United Healthcare Commercial |
$7,808.05
|
| Rate for Payer: WINHealth Partners Commercial |
$6,986.15
|
|
|
CART ASTRAL BUNDLE TOP PLATE
|
Facility
|
IP
|
$1,802.50
|
|
| Hospital Charge Code |
2100168
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,044.55 |
| Max. Negotiated Rate |
$1,802.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,766.45
|
| Rate for Payer: Aetna of WY Medicare |
$1,153.60
|
| Rate for Payer: Altius Commercial |
$1,730.40
|
| Rate for Payer: Beech Street Commercial |
$1,766.45
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,748.42
|
| Rate for Payer: Cash Price |
$1,261.75
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,748.42
|
| Rate for Payer: Cigna of WY Commercial |
$1,766.45
|
| Rate for Payer: Entrust Commercial |
$1,712.38
|
| Rate for Payer: First Choice Health Commercial |
$1,712.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,712.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,099.52
|
| Rate for Payer: HealthUtah PPO |
$1,802.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,748.42
|
| Rate for Payer: Multiplan Medicare/VA |
$1,044.55
|
| Rate for Payer: One Health Plan of WY PPO |
$1,766.45
|
| Rate for Payer: PacificSource Commercial |
$1,622.25
|
| Rate for Payer: PHCS PPO |
$1,766.45
|
| Rate for Payer: Three Rivers PPO |
$1,351.88
|
| Rate for Payer: TriWest Veterans Administration |
$1,099.52
|
| Rate for Payer: United Healthcare Commercial |
$1,721.39
|
| Rate for Payer: United Healthcare Medicare |
$1,099.52
|
| Rate for Payer: WINHealth Partners Commercial |
$1,712.38
|
| Rate for Payer: Wise Provider Network Commercial |
$1,712.38
|
|
|
CART ASTRAL BUNDLE TOP PLATE
|
Facility
|
OP
|
$1,802.50
|
|
| Hospital Charge Code |
2100168
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$976.05 |
| Max. Negotiated Rate |
$1,802.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,766.45
|
| Rate for Payer: Aetna of WY Medicare |
$1,189.65
|
| Rate for Payer: Altius Commercial |
$1,730.40
|
| Rate for Payer: Beech Street Commercial |
$1,766.45
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,748.42
|
| Rate for Payer: Cash Price |
$1,261.75
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,748.42
|
| Rate for Payer: Cigna of WY Commercial |
$1,766.45
|
| Rate for Payer: Entrust Commercial |
$1,712.38
|
| Rate for Payer: First Choice Health Commercial |
$1,712.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,712.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,027.42
|
| Rate for Payer: HealthUtah PPO |
$1,802.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,748.42
|
| Rate for Payer: Multiplan Medicare/VA |
$976.05
|
| Rate for Payer: One Health Plan of WY PPO |
$1,766.45
|
| Rate for Payer: PacificSource Commercial |
$1,622.25
|
| Rate for Payer: PHCS PPO |
$1,766.45
|
| Rate for Payer: Three Rivers PPO |
$1,351.88
|
| Rate for Payer: TriWest Veterans Administration |
$1,027.42
|
| Rate for Payer: United Healthcare Commercial |
$1,721.39
|
| Rate for Payer: United Healthcare Medicare |
$1,027.42
|
| Rate for Payer: WINHealth Partners Commercial |
$1,766.45
|
| Rate for Payer: Wise Provider Network Commercial |
$1,712.38
|
|
|
CARVEDILOL 12.5 MG TABLET [1841]
|
Facility
|
IP
|
$15.33
|
|
|
Service Code
|
NDC 0904630261
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.88 |
| Max. Negotiated Rate |
$15.33 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.02
|
| Rate for Payer: Aetna of WY Medicare |
$9.81
|
| Rate for Payer: Altius Commercial |
$14.72
|
| Rate for Payer: Beech Street Commercial |
$15.02
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.87
|
| Rate for Payer: Cash Price |
$10.73
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.87
|
| Rate for Payer: Cigna of WY Commercial |
$15.02
|
| Rate for Payer: Entrust Commercial |
$14.56
|
| Rate for Payer: First Choice Health Commercial |
$14.56
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.56
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.35
|
| Rate for Payer: HealthUtah PPO |
$15.33
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.87
|
| Rate for Payer: Multiplan Medicare/VA |
$8.88
|
| Rate for Payer: One Health Plan of WY PPO |
$15.02
|
| Rate for Payer: PacificSource Commercial |
$13.80
|
| Rate for Payer: PHCS PPO |
$15.02
|
| Rate for Payer: Three Rivers PPO |
$11.50
|
| Rate for Payer: TriWest Veterans Administration |
$9.35
|
| Rate for Payer: United Healthcare Commercial |
$14.64
|
| Rate for Payer: United Healthcare Medicare |
$9.35
|
| Rate for Payer: WINHealth Partners Commercial |
$14.56
|
| Rate for Payer: Wise Provider Network Commercial |
$14.56
|
|
|
CARVEDILOL 12.5 MG TABLET [1841]
|
Facility
|
OP
|
$15.33
|
|
|
Service Code
|
NDC 0904630261
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.30 |
| Max. Negotiated Rate |
$15.33 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.02
|
| Rate for Payer: Aetna of WY Medicare |
$10.12
|
| Rate for Payer: Altius Commercial |
$14.72
|
| Rate for Payer: Beech Street Commercial |
$15.02
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.87
|
| Rate for Payer: Cash Price |
$10.73
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.87
|
| Rate for Payer: Cigna of WY Commercial |
$15.02
|
| Rate for Payer: Entrust Commercial |
$14.56
|
| Rate for Payer: First Choice Health Commercial |
$14.56
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.56
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.74
|
| Rate for Payer: HealthUtah PPO |
$15.33
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.87
|
| Rate for Payer: Multiplan Medicare/VA |
$8.30
|
| Rate for Payer: One Health Plan of WY PPO |
$15.02
|
| Rate for Payer: PacificSource Commercial |
$13.80
|
| Rate for Payer: PHCS PPO |
$15.02
|
| Rate for Payer: Three Rivers PPO |
$11.50
|
| Rate for Payer: TriWest Veterans Administration |
$8.74
|
| Rate for Payer: United Healthcare Commercial |
$14.64
|
| Rate for Payer: United Healthcare Medicare |
$8.74
|
| Rate for Payer: WINHealth Partners Commercial |
$15.02
|
| Rate for Payer: Wise Provider Network Commercial |
$14.56
|
|
|
CARVEDILOL 3.125 MG TABLET [8251]
|
Facility
|
IP
|
$15.33
|
|
|
Service Code
|
NDC 0904630061
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.88 |
| Max. Negotiated Rate |
$15.33 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.02
|
| Rate for Payer: Aetna of WY Medicare |
$9.81
|
| Rate for Payer: Altius Commercial |
$14.72
|
| Rate for Payer: Beech Street Commercial |
$15.02
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.87
|
| Rate for Payer: Cash Price |
$10.73
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.87
|
| Rate for Payer: Cigna of WY Commercial |
$15.02
|
| Rate for Payer: Entrust Commercial |
$14.56
|
| Rate for Payer: First Choice Health Commercial |
$14.56
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.56
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.35
|
| Rate for Payer: HealthUtah PPO |
$15.33
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.87
|
| Rate for Payer: Multiplan Medicare/VA |
$8.88
|
| Rate for Payer: One Health Plan of WY PPO |
$15.02
|
| Rate for Payer: PacificSource Commercial |
$13.80
|
| Rate for Payer: PHCS PPO |
$15.02
|
| Rate for Payer: Three Rivers PPO |
$11.50
|
| Rate for Payer: TriWest Veterans Administration |
$9.35
|
| Rate for Payer: United Healthcare Commercial |
$14.64
|
| Rate for Payer: United Healthcare Medicare |
$9.35
|
| Rate for Payer: WINHealth Partners Commercial |
$14.56
|
| Rate for Payer: Wise Provider Network Commercial |
$14.56
|
|
|
CARVEDILOL 3.125 MG TABLET [8251]
|
Facility
|
OP
|
$15.33
|
|
|
Service Code
|
NDC 0904630061
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.30 |
| Max. Negotiated Rate |
$15.33 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.02
|
| Rate for Payer: Aetna of WY Medicare |
$10.12
|
| Rate for Payer: Altius Commercial |
$14.72
|
| Rate for Payer: Beech Street Commercial |
$15.02
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.87
|
| Rate for Payer: Cash Price |
$10.73
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.87
|
| Rate for Payer: Cigna of WY Commercial |
$15.02
|
| Rate for Payer: Entrust Commercial |
$14.56
|
| Rate for Payer: First Choice Health Commercial |
$14.56
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.56
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.74
|
| Rate for Payer: HealthUtah PPO |
$15.33
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.87
|
| Rate for Payer: Multiplan Medicare/VA |
$8.30
|
| Rate for Payer: One Health Plan of WY PPO |
$15.02
|
| Rate for Payer: PacificSource Commercial |
$13.80
|
| Rate for Payer: PHCS PPO |
$15.02
|
| Rate for Payer: Three Rivers PPO |
$11.50
|
| Rate for Payer: TriWest Veterans Administration |
$8.74
|
| Rate for Payer: United Healthcare Commercial |
$14.64
|
| Rate for Payer: United Healthcare Medicare |
$8.74
|
| Rate for Payer: WINHealth Partners Commercial |
$15.02
|
| Rate for Payer: Wise Provider Network Commercial |
$14.56
|
|
|
CA SCREEN;FLEXI SIGMOIDSCOPE
|
Professional
|
Both
|
$1,648.00
|
|
|
Service Code
|
HCPCS G0104
|
| Min. Negotiated Rate |
$46.16 |
| Max. Negotiated Rate |
$1,648.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,615.04
|
| Rate for Payer: Aetna of WY Medicare |
$54.31
|
| Rate for Payer: Beech Street Commercial |
$1,565.60
|
| Rate for Payer: Cash Price |
$1,153.60
|
| Rate for Payer: Cash Price |
$1,153.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,598.56
|
| Rate for Payer: Cigna of WY Commercial |
$1,615.04
|
| Rate for Payer: First Choice Health Commercial |
$1,483.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,565.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$54.31
|
| Rate for Payer: HealthUtah PPO |
$1,648.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,598.56
|
| Rate for Payer: Multiplan Medicare/VA |
$46.16
|
| Rate for Payer: One Health Plan of WY PPO |
$1,615.04
|
| Rate for Payer: PacificSource Commercial |
$1,483.20
|
| Rate for Payer: PHCS PPO |
$1,565.60
|
| Rate for Payer: Three Rivers PPO |
$1,236.00
|
| Rate for Payer: TriWest Veterans Administration |
$54.31
|
| Rate for Payer: United Healthcare Commercial |
$1,565.60
|
| Rate for Payer: WINHealth Partners Commercial |
$1,565.60
|
|
|
CA SCREEN;PELVIC/BREAST EXAM
|
Professional
|
Both
|
$90.00
|
|
|
Service Code
|
HCPCS G0101
|
| Min. Negotiated Rate |
$22.31 |
| Max. Negotiated Rate |
$90.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$88.20
|
| Rate for Payer: Aetna of WY Medicare |
$26.25
|
| Rate for Payer: Beech Street Commercial |
$85.50
|
| Rate for Payer: Cash Price |
$63.00
|
| Rate for Payer: Cash Price |
$63.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$87.30
|
| Rate for Payer: Cigna of WY Commercial |
$88.20
|
| Rate for Payer: First Choice Health Commercial |
$81.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$85.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$26.25
|
| Rate for Payer: HealthUtah PPO |
$90.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$87.30
|
| Rate for Payer: Multiplan Medicare/VA |
$22.31
|
| Rate for Payer: One Health Plan of WY PPO |
$88.20
|
| Rate for Payer: PacificSource Commercial |
$81.00
|
| Rate for Payer: PHCS PPO |
$85.50
|
| Rate for Payer: Three Rivers PPO |
$67.50
|
| Rate for Payer: TriWest Veterans Administration |
$26.25
|
| Rate for Payer: United Healthcare Commercial |
$85.50
|
| Rate for Payer: WINHealth Partners Commercial |
$85.50
|
|
|
CASE MANAGEMENT
|
Professional
|
Both
|
$71.00
|
|
|
Service Code
|
HCPCS T1016
|
| Min. Negotiated Rate |
$53.25 |
| Max. Negotiated Rate |
$71.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$69.58
|
| Rate for Payer: Beech Street Commercial |
$67.45
|
| Rate for Payer: Cash Price |
$49.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$68.87
|
| Rate for Payer: Cigna of WY Commercial |
$69.58
|
| Rate for Payer: First Choice Health Commercial |
$63.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$67.45
|
| Rate for Payer: HealthUtah PPO |
$71.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$68.87
|
| Rate for Payer: One Health Plan of WY PPO |
$69.58
|
| Rate for Payer: PacificSource Commercial |
$63.90
|
| Rate for Payer: PHCS PPO |
$67.45
|
| Rate for Payer: Three Rivers PPO |
$53.25
|
| Rate for Payer: United Healthcare Commercial |
$67.45
|
| Rate for Payer: WINHealth Partners Commercial |
$67.45
|
|
|
CASIRI AND IMDEV REPEAT
|
Professional
|
Both
|
$564.00
|
|
|
Service Code
|
HCPCS M0240
|
| Min. Negotiated Rate |
$423.00 |
| Max. Negotiated Rate |
$564.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$552.72
|
| Rate for Payer: Beech Street Commercial |
$535.80
|
| Rate for Payer: Cash Price |
$394.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$547.08
|
| Rate for Payer: Cigna of WY Commercial |
$552.72
|
| Rate for Payer: First Choice Health Commercial |
$507.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$535.80
|
| Rate for Payer: HealthUtah PPO |
$564.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$547.08
|
| Rate for Payer: One Health Plan of WY PPO |
$552.72
|
| Rate for Payer: PacificSource Commercial |
$507.60
|
| Rate for Payer: PHCS PPO |
$535.80
|
| Rate for Payer: Three Rivers PPO |
$423.00
|
| Rate for Payer: United Healthcare Commercial |
$535.80
|
| Rate for Payer: WINHealth Partners Commercial |
$535.80
|
|
|
CASIRIVI AND IMDEVI INJ
|
Professional
|
Both
|
$649.00
|
|
|
Service Code
|
HCPCS M0243
|
| Min. Negotiated Rate |
$486.75 |
| Max. Negotiated Rate |
$649.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$636.02
|
| Rate for Payer: Beech Street Commercial |
$616.55
|
| Rate for Payer: Cash Price |
$454.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$629.53
|
| Rate for Payer: Cigna of WY Commercial |
$636.02
|
| Rate for Payer: First Choice Health Commercial |
$584.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$616.55
|
| Rate for Payer: HealthUtah PPO |
$649.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$629.53
|
| Rate for Payer: One Health Plan of WY PPO |
$636.02
|
| Rate for Payer: PacificSource Commercial |
$584.10
|
| Rate for Payer: PHCS PPO |
$616.55
|
| Rate for Payer: Three Rivers PPO |
$486.75
|
| Rate for Payer: United Healthcare Commercial |
$616.55
|
| Rate for Payer: WINHealth Partners Commercial |
$616.55
|
|
|
CAST LINER DELTA DRY 2 IN
|
Facility
|
IP
|
$10.24
|
|
| Hospital Charge Code |
2250110
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$5.93 |
| Max. Negotiated Rate |
$10.24 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$10.04
|
| Rate for Payer: Aetna of WY Medicare |
$6.55
|
| Rate for Payer: Altius Commercial |
$9.83
|
| Rate for Payer: Beech Street Commercial |
$10.04
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$9.93
|
| Rate for Payer: Cash Price |
$7.17
|
| Rate for Payer: ChoiceCare Network Commercial |
$9.93
|
| Rate for Payer: Cigna of WY Commercial |
$10.04
|
| Rate for Payer: Entrust Commercial |
$9.73
|
| Rate for Payer: First Choice Health Commercial |
$9.73
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$9.73
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$6.25
|
| Rate for Payer: HealthUtah PPO |
$10.24
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$9.93
|
| Rate for Payer: Multiplan Medicare/VA |
$5.93
|
| Rate for Payer: One Health Plan of WY PPO |
$10.04
|
| Rate for Payer: PacificSource Commercial |
$9.22
|
| Rate for Payer: PHCS PPO |
$10.04
|
| Rate for Payer: Three Rivers PPO |
$7.68
|
| Rate for Payer: TriWest Veterans Administration |
$6.25
|
| Rate for Payer: United Healthcare Commercial |
$9.78
|
| Rate for Payer: United Healthcare Medicare |
$6.25
|
| Rate for Payer: WINHealth Partners Commercial |
$9.73
|
| Rate for Payer: Wise Provider Network Commercial |
$9.73
|
|
|
CAST LINER DELTA DRY 2 IN
|
Facility
|
OP
|
$10.24
|
|
| Hospital Charge Code |
2250110
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$5.54 |
| Max. Negotiated Rate |
$10.24 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$10.04
|
| Rate for Payer: Aetna of WY Medicare |
$6.76
|
| Rate for Payer: Altius Commercial |
$9.83
|
| Rate for Payer: Beech Street Commercial |
$10.04
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$9.93
|
| Rate for Payer: Cash Price |
$7.17
|
| Rate for Payer: ChoiceCare Network Commercial |
$9.93
|
| Rate for Payer: Cigna of WY Commercial |
$10.04
|
| Rate for Payer: Entrust Commercial |
$9.73
|
| Rate for Payer: First Choice Health Commercial |
$9.73
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$9.73
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$5.84
|
| Rate for Payer: HealthUtah PPO |
$10.24
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$9.93
|
| Rate for Payer: Multiplan Medicare/VA |
$5.54
|
| Rate for Payer: One Health Plan of WY PPO |
$10.04
|
| Rate for Payer: PacificSource Commercial |
$9.22
|
| Rate for Payer: PHCS PPO |
$10.04
|
| Rate for Payer: Three Rivers PPO |
$7.68
|
| Rate for Payer: TriWest Veterans Administration |
$5.84
|
| Rate for Payer: United Healthcare Commercial |
$9.78
|
| Rate for Payer: United Healthcare Medicare |
$5.84
|
| Rate for Payer: WINHealth Partners Commercial |
$10.04
|
| Rate for Payer: Wise Provider Network Commercial |
$9.73
|
|
