|
ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY [1510]
|
Facility
|
IP
|
$16.42
|
|
|
Service Code
|
NDC 4580273030
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.52 |
| Max. Negotiated Rate |
$16.42 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.09
|
| Rate for Payer: Aetna of WY Medicare |
$10.51
|
| Rate for Payer: Altius Commercial |
$15.76
|
| Rate for Payer: Beech Street Commercial |
$16.09
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.93
|
| Rate for Payer: Cash Price |
$11.49
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.93
|
| Rate for Payer: Cigna of WY Commercial |
$16.09
|
| Rate for Payer: Entrust Commercial |
$15.60
|
| Rate for Payer: First Choice Health Commercial |
$15.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.02
|
| Rate for Payer: HealthUtah PPO |
$16.42
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.93
|
| Rate for Payer: Multiplan Medicare/VA |
$9.52
|
| Rate for Payer: One Health Plan of WY PPO |
$16.09
|
| Rate for Payer: PacificSource Commercial |
$14.78
|
| Rate for Payer: PHCS PPO |
$16.09
|
| Rate for Payer: Three Rivers PPO |
$12.32
|
| Rate for Payer: TriWest Veterans Administration |
$10.02
|
| Rate for Payer: United Healthcare Commercial |
$15.68
|
| Rate for Payer: United Healthcare Medicare |
$10.02
|
| Rate for Payer: WINHealth Partners Commercial |
$15.60
|
| Rate for Payer: Wise Provider Network Commercial |
$15.60
|
|
|
ACETAMINOPHEN ER 650 MG TABLET,EXTENDED RELEASE [8567]
|
Facility
|
IP
|
$15.22
|
|
|
Service Code
|
NDC 5166033301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.82 |
| Max. Negotiated Rate |
$15.22 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.92
|
| Rate for Payer: Aetna of WY Medicare |
$9.74
|
| Rate for Payer: Altius Commercial |
$14.61
|
| Rate for Payer: Beech Street Commercial |
$14.92
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.76
|
| Rate for Payer: Cash Price |
$10.66
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.76
|
| Rate for Payer: Cigna of WY Commercial |
$14.92
|
| Rate for Payer: Entrust Commercial |
$14.46
|
| Rate for Payer: First Choice Health Commercial |
$14.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.28
|
| Rate for Payer: HealthUtah PPO |
$15.22
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.76
|
| Rate for Payer: Multiplan Medicare/VA |
$8.82
|
| Rate for Payer: One Health Plan of WY PPO |
$14.92
|
| Rate for Payer: PacificSource Commercial |
$13.70
|
| Rate for Payer: PHCS PPO |
$14.92
|
| Rate for Payer: Three Rivers PPO |
$11.42
|
| Rate for Payer: TriWest Veterans Administration |
$9.28
|
| Rate for Payer: United Healthcare Commercial |
$14.54
|
| Rate for Payer: United Healthcare Medicare |
$9.28
|
| Rate for Payer: WINHealth Partners Commercial |
$14.46
|
| Rate for Payer: Wise Provider Network Commercial |
$14.46
|
|
|
ACETAMINOPHEN ER 650 MG TABLET,EXTENDED RELEASE [8567]
|
Facility
|
OP
|
$15.22
|
|
|
Service Code
|
NDC 5166033301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.24 |
| Max. Negotiated Rate |
$15.22 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.92
|
| Rate for Payer: Aetna of WY Medicare |
$10.05
|
| Rate for Payer: Altius Commercial |
$14.61
|
| Rate for Payer: Beech Street Commercial |
$14.92
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.76
|
| Rate for Payer: Cash Price |
$10.66
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.76
|
| Rate for Payer: Cigna of WY Commercial |
$14.92
|
| Rate for Payer: Entrust Commercial |
$14.46
|
| Rate for Payer: First Choice Health Commercial |
$14.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.68
|
| Rate for Payer: HealthUtah PPO |
$15.22
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.76
|
| Rate for Payer: Multiplan Medicare/VA |
$8.24
|
| Rate for Payer: One Health Plan of WY PPO |
$14.92
|
| Rate for Payer: PacificSource Commercial |
$13.70
|
| Rate for Payer: PHCS PPO |
$14.92
|
| Rate for Payer: Three Rivers PPO |
$11.42
|
| Rate for Payer: TriWest Veterans Administration |
$8.68
|
| Rate for Payer: United Healthcare Commercial |
$14.54
|
| Rate for Payer: United Healthcare Medicare |
$8.68
|
| Rate for Payer: WINHealth Partners Commercial |
$14.92
|
| Rate for Payer: Wise Provider Network Commercial |
$14.46
|
|
|
ACETAZOLAMIDE 250 MG TABLET [5981]
|
Facility
|
IP
|
$16.40
|
|
|
Service Code
|
NDC 7075672111
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.50 |
| Max. Negotiated Rate |
$16.40 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.07
|
| Rate for Payer: Aetna of WY Medicare |
$10.50
|
| Rate for Payer: Altius Commercial |
$15.74
|
| Rate for Payer: Beech Street Commercial |
$16.07
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.91
|
| Rate for Payer: Cash Price |
$11.48
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.91
|
| Rate for Payer: Cigna of WY Commercial |
$16.07
|
| Rate for Payer: Entrust Commercial |
$15.58
|
| Rate for Payer: First Choice Health Commercial |
$15.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.00
|
| Rate for Payer: HealthUtah PPO |
$16.40
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.91
|
| Rate for Payer: Multiplan Medicare/VA |
$9.50
|
| Rate for Payer: One Health Plan of WY PPO |
$16.07
|
| Rate for Payer: PacificSource Commercial |
$14.76
|
| Rate for Payer: PHCS PPO |
$16.07
|
| Rate for Payer: Three Rivers PPO |
$12.30
|
| Rate for Payer: TriWest Veterans Administration |
$10.00
|
| Rate for Payer: United Healthcare Commercial |
$15.66
|
| Rate for Payer: United Healthcare Medicare |
$10.00
|
| Rate for Payer: WINHealth Partners Commercial |
$15.58
|
| Rate for Payer: Wise Provider Network Commercial |
$15.58
|
|
|
ACETAZOLAMIDE 250 MG TABLET [5981]
|
Facility
|
OP
|
$16.40
|
|
|
Service Code
|
NDC 7075672111
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.88 |
| Max. Negotiated Rate |
$16.40 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.07
|
| Rate for Payer: Aetna of WY Medicare |
$10.82
|
| Rate for Payer: Altius Commercial |
$15.74
|
| Rate for Payer: Beech Street Commercial |
$16.07
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.91
|
| Rate for Payer: Cash Price |
$11.48
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.91
|
| Rate for Payer: Cigna of WY Commercial |
$16.07
|
| Rate for Payer: Entrust Commercial |
$15.58
|
| Rate for Payer: First Choice Health Commercial |
$15.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.35
|
| Rate for Payer: HealthUtah PPO |
$16.40
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.91
|
| Rate for Payer: Multiplan Medicare/VA |
$8.88
|
| Rate for Payer: One Health Plan of WY PPO |
$16.07
|
| Rate for Payer: PacificSource Commercial |
$14.76
|
| Rate for Payer: PHCS PPO |
$16.07
|
| Rate for Payer: Three Rivers PPO |
$12.30
|
| Rate for Payer: TriWest Veterans Administration |
$9.35
|
| Rate for Payer: United Healthcare Commercial |
$15.66
|
| Rate for Payer: United Healthcare Medicare |
$9.35
|
| Rate for Payer: WINHealth Partners Commercial |
$16.07
|
| Rate for Payer: Wise Provider Network Commercial |
$15.58
|
|
|
ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION [35100]
|
Facility
|
IP
|
$28.75
|
|
|
Service Code
|
HCPCS J0132
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.66 |
| Max. Negotiated Rate |
$28.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$28.18
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$36.14
|
| Rate for Payer: Aetna of WY Medicare |
$18.40
|
| Rate for Payer: Aetna of WY Medicare |
$23.60
|
| Rate for Payer: Altius Commercial |
$35.40
|
| Rate for Payer: Altius Commercial |
$27.60
|
| Rate for Payer: Beech Street Commercial |
$28.18
|
| Rate for Payer: Beech Street Commercial |
$36.14
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$35.77
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$27.89
|
| Rate for Payer: Cash Price |
$25.81
|
| Rate for Payer: Cash Price |
$20.12
|
| Rate for Payer: ChoiceCare Network Commercial |
$27.89
|
| Rate for Payer: ChoiceCare Network Commercial |
$35.77
|
| Rate for Payer: Cigna of WY Commercial |
$36.14
|
| Rate for Payer: Cigna of WY Commercial |
$28.18
|
| Rate for Payer: Entrust Commercial |
$27.31
|
| Rate for Payer: Entrust Commercial |
$35.04
|
| Rate for Payer: First Choice Health Commercial |
$35.04
|
| Rate for Payer: First Choice Health Commercial |
$27.31
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$35.04
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$27.31
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$22.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$17.54
|
| Rate for Payer: HealthUtah PPO |
$36.88
|
| Rate for Payer: HealthUtah PPO |
$28.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$27.89
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$35.77
|
| Rate for Payer: Multiplan Medicare/VA |
$21.37
|
| Rate for Payer: Multiplan Medicare/VA |
$16.66
|
| Rate for Payer: One Health Plan of WY PPO |
$28.18
|
| Rate for Payer: One Health Plan of WY PPO |
$36.14
|
| Rate for Payer: PacificSource Commercial |
$25.88
|
| Rate for Payer: PacificSource Commercial |
$33.19
|
| Rate for Payer: PHCS PPO |
$28.18
|
| Rate for Payer: PHCS PPO |
$36.14
|
| Rate for Payer: Three Rivers PPO |
$27.66
|
| Rate for Payer: Three Rivers PPO |
$21.56
|
| Rate for Payer: TriWest Veterans Administration |
$22.50
|
| Rate for Payer: TriWest Veterans Administration |
$17.54
|
| Rate for Payer: United Healthcare Commercial |
$27.46
|
| Rate for Payer: United Healthcare Commercial |
$35.22
|
| Rate for Payer: United Healthcare Medicare |
$17.54
|
| Rate for Payer: United Healthcare Medicare |
$22.50
|
| Rate for Payer: WINHealth Partners Commercial |
$27.31
|
| Rate for Payer: WINHealth Partners Commercial |
$35.04
|
| Rate for Payer: Wise Provider Network Commercial |
$35.04
|
| Rate for Payer: Wise Provider Network Commercial |
$27.31
|
|
|
ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION [35100]
|
Facility
|
OP
|
$36.88
|
|
|
Service Code
|
HCPCS J0132
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.97 |
| Max. Negotiated Rate |
$36.88 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$36.14
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$28.18
|
| Rate for Payer: Aetna of WY Medicare |
$18.98
|
| Rate for Payer: Aetna of WY Medicare |
$24.34
|
| Rate for Payer: Altius Commercial |
$27.60
|
| Rate for Payer: Altius Commercial |
$35.40
|
| Rate for Payer: Beech Street Commercial |
$28.18
|
| Rate for Payer: Beech Street Commercial |
$36.14
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$27.89
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$35.77
|
| Rate for Payer: Cash Price |
$20.12
|
| Rate for Payer: Cash Price |
$25.81
|
| Rate for Payer: ChoiceCare Network Commercial |
$27.89
|
| Rate for Payer: ChoiceCare Network Commercial |
$35.77
|
| Rate for Payer: Cigna of WY Commercial |
$36.14
|
| Rate for Payer: Cigna of WY Commercial |
$28.18
|
| Rate for Payer: Entrust Commercial |
$27.31
|
| Rate for Payer: Entrust Commercial |
$35.04
|
| Rate for Payer: First Choice Health Commercial |
$27.31
|
| Rate for Payer: First Choice Health Commercial |
$35.04
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$35.04
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$27.31
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$16.39
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$21.02
|
| Rate for Payer: HealthUtah PPO |
$36.88
|
| Rate for Payer: HealthUtah PPO |
$28.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$35.77
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$27.89
|
| Rate for Payer: Multiplan Medicare/VA |
$15.57
|
| Rate for Payer: Multiplan Medicare/VA |
$19.97
|
| Rate for Payer: One Health Plan of WY PPO |
$28.18
|
| Rate for Payer: One Health Plan of WY PPO |
$36.14
|
| Rate for Payer: PacificSource Commercial |
$33.19
|
| Rate for Payer: PacificSource Commercial |
$25.88
|
| Rate for Payer: PHCS PPO |
$28.18
|
| Rate for Payer: PHCS PPO |
$36.14
|
| Rate for Payer: Three Rivers PPO |
$21.56
|
| Rate for Payer: Three Rivers PPO |
$27.66
|
| Rate for Payer: TriWest Veterans Administration |
$21.02
|
| Rate for Payer: TriWest Veterans Administration |
$16.39
|
| Rate for Payer: United Healthcare Commercial |
$27.46
|
| Rate for Payer: United Healthcare Commercial |
$35.22
|
| Rate for Payer: United Healthcare Medicare |
$21.02
|
| Rate for Payer: United Healthcare Medicare |
$16.39
|
| Rate for Payer: WINHealth Partners Commercial |
$28.18
|
| Rate for Payer: WINHealth Partners Commercial |
$36.14
|
| Rate for Payer: Wise Provider Network Commercial |
$27.31
|
| Rate for Payer: Wise Provider Network Commercial |
$35.04
|
|
|
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION [1047]
|
Facility
|
OP
|
$18.04
|
|
|
Service Code
|
HCPCS J7608
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.77 |
| Max. Negotiated Rate |
$18.04 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$17.68
|
| Rate for Payer: Aetna of WY Medicare |
$11.91
|
| Rate for Payer: Altius Commercial |
$17.32
|
| Rate for Payer: Beech Street Commercial |
$17.68
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$17.50
|
| Rate for Payer: Cash Price |
$12.63
|
| Rate for Payer: ChoiceCare Network Commercial |
$17.50
|
| Rate for Payer: Cigna of WY Commercial |
$17.68
|
| Rate for Payer: Entrust Commercial |
$17.14
|
| Rate for Payer: First Choice Health Commercial |
$17.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.28
|
| Rate for Payer: HealthUtah PPO |
$18.04
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.50
|
| Rate for Payer: Multiplan Medicare/VA |
$9.77
|
| Rate for Payer: One Health Plan of WY PPO |
$17.68
|
| Rate for Payer: PacificSource Commercial |
$16.24
|
| Rate for Payer: PHCS PPO |
$17.68
|
| Rate for Payer: Three Rivers PPO |
$13.53
|
| Rate for Payer: TriWest Veterans Administration |
$10.28
|
| Rate for Payer: United Healthcare Commercial |
$17.23
|
| Rate for Payer: United Healthcare Medicare |
$10.28
|
| Rate for Payer: WINHealth Partners Commercial |
$17.68
|
| Rate for Payer: Wise Provider Network Commercial |
$17.14
|
|
|
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION [1047]
|
Facility
|
IP
|
$18.04
|
|
|
Service Code
|
HCPCS J7608
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.45 |
| Max. Negotiated Rate |
$18.04 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$17.68
|
| Rate for Payer: Aetna of WY Medicare |
$11.55
|
| Rate for Payer: Altius Commercial |
$17.32
|
| Rate for Payer: Beech Street Commercial |
$17.68
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$17.50
|
| Rate for Payer: Cash Price |
$12.63
|
| Rate for Payer: ChoiceCare Network Commercial |
$17.50
|
| Rate for Payer: Cigna of WY Commercial |
$17.68
|
| Rate for Payer: Entrust Commercial |
$17.14
|
| Rate for Payer: First Choice Health Commercial |
$17.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.00
|
| Rate for Payer: HealthUtah PPO |
$18.04
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.50
|
| Rate for Payer: Multiplan Medicare/VA |
$10.45
|
| Rate for Payer: One Health Plan of WY PPO |
$17.68
|
| Rate for Payer: PacificSource Commercial |
$16.24
|
| Rate for Payer: PHCS PPO |
$17.68
|
| Rate for Payer: Three Rivers PPO |
$13.53
|
| Rate for Payer: TriWest Veterans Administration |
$11.00
|
| Rate for Payer: United Healthcare Commercial |
$17.23
|
| Rate for Payer: United Healthcare Medicare |
$11.00
|
| Rate for Payer: WINHealth Partners Commercial |
$17.14
|
| Rate for Payer: Wise Provider Network Commercial |
$17.14
|
|
|
ACHILLES SPEED BRIDGE
|
Facility
|
OP
|
$6,090.00
|
|
| Hospital Charge Code |
3000990
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,297.74 |
| Max. Negotiated Rate |
$6,090.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5,968.20
|
| Rate for Payer: Aetna of WY Medicare |
$4,019.40
|
| Rate for Payer: Altius Commercial |
$5,846.40
|
| Rate for Payer: Beech Street Commercial |
$5,968.20
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$5,907.30
|
| Rate for Payer: Cash Price |
$4,263.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$5,907.30
|
| Rate for Payer: Cigna of WY Commercial |
$5,968.20
|
| Rate for Payer: Entrust Commercial |
$5,785.50
|
| Rate for Payer: First Choice Health Commercial |
$5,785.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5,785.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3,471.30
|
| Rate for Payer: HealthUtah PPO |
$6,090.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5,907.30
|
| Rate for Payer: Multiplan Medicare/VA |
$3,297.74
|
| Rate for Payer: One Health Plan of WY PPO |
$5,968.20
|
| Rate for Payer: PacificSource Commercial |
$5,481.00
|
| Rate for Payer: PHCS PPO |
$5,968.20
|
| Rate for Payer: Three Rivers PPO |
$4,567.50
|
| Rate for Payer: TriWest Veterans Administration |
$3,471.30
|
| Rate for Payer: United Healthcare Commercial |
$5,815.95
|
| Rate for Payer: United Healthcare Medicare |
$3,471.30
|
| Rate for Payer: WINHealth Partners Commercial |
$5,968.20
|
| Rate for Payer: Wise Provider Network Commercial |
$5,785.50
|
|
|
ACHILLES SPEED BRIDGE
|
Facility
|
IP
|
$6,090.00
|
|
| Hospital Charge Code |
3000990
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,529.16 |
| Max. Negotiated Rate |
$6,090.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5,968.20
|
| Rate for Payer: Aetna of WY Medicare |
$3,897.60
|
| Rate for Payer: Altius Commercial |
$5,846.40
|
| Rate for Payer: Beech Street Commercial |
$5,968.20
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$5,907.30
|
| Rate for Payer: Cash Price |
$4,263.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$5,907.30
|
| Rate for Payer: Cigna of WY Commercial |
$5,968.20
|
| Rate for Payer: Entrust Commercial |
$5,785.50
|
| Rate for Payer: First Choice Health Commercial |
$5,785.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5,785.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3,714.90
|
| Rate for Payer: HealthUtah PPO |
$6,090.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5,907.30
|
| Rate for Payer: Multiplan Medicare/VA |
$3,529.16
|
| Rate for Payer: One Health Plan of WY PPO |
$5,968.20
|
| Rate for Payer: PacificSource Commercial |
$5,481.00
|
| Rate for Payer: PHCS PPO |
$5,968.20
|
| Rate for Payer: Three Rivers PPO |
$4,567.50
|
| Rate for Payer: TriWest Veterans Administration |
$3,714.90
|
| Rate for Payer: United Healthcare Commercial |
$5,815.95
|
| Rate for Payer: United Healthcare Medicare |
$3,714.90
|
| Rate for Payer: WINHealth Partners Commercial |
$5,785.50
|
| Rate for Payer: Wise Provider Network Commercial |
$5,785.50
|
|
|
ACL BAYPN W/EYE .094X18"
|
Facility
|
IP
|
$1,004.50
|
|
| Hospital Charge Code |
3002031
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$582.11 |
| Max. Negotiated Rate |
$1,004.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$984.41
|
| Rate for Payer: Aetna of WY Medicare |
$642.88
|
| Rate for Payer: Altius Commercial |
$964.32
|
| Rate for Payer: Beech Street Commercial |
$984.41
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$974.36
|
| Rate for Payer: Cash Price |
$703.15
|
| Rate for Payer: ChoiceCare Network Commercial |
$974.36
|
| Rate for Payer: Cigna of WY Commercial |
$984.41
|
| Rate for Payer: Entrust Commercial |
$954.28
|
| Rate for Payer: First Choice Health Commercial |
$954.28
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$954.28
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$612.74
|
| Rate for Payer: HealthUtah PPO |
$1,004.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$974.36
|
| Rate for Payer: Multiplan Medicare/VA |
$582.11
|
| Rate for Payer: One Health Plan of WY PPO |
$984.41
|
| Rate for Payer: PacificSource Commercial |
$904.05
|
| Rate for Payer: PHCS PPO |
$984.41
|
| Rate for Payer: Three Rivers PPO |
$753.38
|
| Rate for Payer: TriWest Veterans Administration |
$612.74
|
| Rate for Payer: United Healthcare Commercial |
$959.30
|
| Rate for Payer: United Healthcare Medicare |
$612.74
|
| Rate for Payer: WINHealth Partners Commercial |
$954.28
|
| Rate for Payer: Wise Provider Network Commercial |
$954.28
|
|
|
ACL BAYPN W/EYE .094X18"
|
Facility
|
OP
|
$1,004.50
|
|
| Hospital Charge Code |
3002031
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$543.94 |
| Max. Negotiated Rate |
$1,004.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$984.41
|
| Rate for Payer: Aetna of WY Medicare |
$662.97
|
| Rate for Payer: Altius Commercial |
$964.32
|
| Rate for Payer: Beech Street Commercial |
$984.41
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$974.36
|
| Rate for Payer: Cash Price |
$703.15
|
| Rate for Payer: ChoiceCare Network Commercial |
$974.36
|
| Rate for Payer: Cigna of WY Commercial |
$984.41
|
| Rate for Payer: Entrust Commercial |
$954.28
|
| Rate for Payer: First Choice Health Commercial |
$954.28
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$954.28
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$572.56
|
| Rate for Payer: HealthUtah PPO |
$1,004.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$974.36
|
| Rate for Payer: Multiplan Medicare/VA |
$543.94
|
| Rate for Payer: One Health Plan of WY PPO |
$984.41
|
| Rate for Payer: PacificSource Commercial |
$904.05
|
| Rate for Payer: PHCS PPO |
$984.41
|
| Rate for Payer: Three Rivers PPO |
$753.38
|
| Rate for Payer: TriWest Veterans Administration |
$572.56
|
| Rate for Payer: United Healthcare Commercial |
$959.30
|
| Rate for Payer: United Healthcare Medicare |
$572.56
|
| Rate for Payer: WINHealth Partners Commercial |
$984.41
|
| Rate for Payer: Wise Provider Network Commercial |
$954.28
|
|
|
ACL DISPOSABLE PROCEDURE KIT
|
Facility
|
IP
|
$542.50
|
|
| Hospital Charge Code |
3003048
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$314.38 |
| Max. Negotiated Rate |
$542.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$531.65
|
| Rate for Payer: Aetna of WY Medicare |
$347.20
|
| Rate for Payer: Altius Commercial |
$520.80
|
| Rate for Payer: Beech Street Commercial |
$531.65
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$526.22
|
| Rate for Payer: Cash Price |
$379.75
|
| Rate for Payer: ChoiceCare Network Commercial |
$526.22
|
| Rate for Payer: Cigna of WY Commercial |
$531.65
|
| Rate for Payer: Entrust Commercial |
$515.38
|
| Rate for Payer: First Choice Health Commercial |
$515.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$515.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$330.92
|
| Rate for Payer: HealthUtah PPO |
$542.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$526.22
|
| Rate for Payer: Multiplan Medicare/VA |
$314.38
|
| Rate for Payer: One Health Plan of WY PPO |
$531.65
|
| Rate for Payer: PacificSource Commercial |
$488.25
|
| Rate for Payer: PHCS PPO |
$531.65
|
| Rate for Payer: Three Rivers PPO |
$406.88
|
| Rate for Payer: TriWest Veterans Administration |
$330.92
|
| Rate for Payer: United Healthcare Commercial |
$518.09
|
| Rate for Payer: United Healthcare Medicare |
$330.92
|
| Rate for Payer: WINHealth Partners Commercial |
$515.38
|
| Rate for Payer: Wise Provider Network Commercial |
$515.38
|
|
|
ACL DISPOSABLE PROCEDURE KIT
|
Facility
|
OP
|
$542.50
|
|
| Hospital Charge Code |
3003048
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$293.76 |
| Max. Negotiated Rate |
$542.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$531.65
|
| Rate for Payer: Aetna of WY Medicare |
$358.05
|
| Rate for Payer: Altius Commercial |
$520.80
|
| Rate for Payer: Beech Street Commercial |
$531.65
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$526.22
|
| Rate for Payer: Cash Price |
$379.75
|
| Rate for Payer: ChoiceCare Network Commercial |
$526.22
|
| Rate for Payer: Cigna of WY Commercial |
$531.65
|
| Rate for Payer: Entrust Commercial |
$515.38
|
| Rate for Payer: First Choice Health Commercial |
$515.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$515.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$309.22
|
| Rate for Payer: HealthUtah PPO |
$542.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$526.22
|
| Rate for Payer: Multiplan Medicare/VA |
$293.76
|
| Rate for Payer: One Health Plan of WY PPO |
$531.65
|
| Rate for Payer: PacificSource Commercial |
$488.25
|
| Rate for Payer: PHCS PPO |
$531.65
|
| Rate for Payer: Three Rivers PPO |
$406.88
|
| Rate for Payer: TriWest Veterans Administration |
$309.22
|
| Rate for Payer: United Healthcare Commercial |
$518.09
|
| Rate for Payer: United Healthcare Medicare |
$309.22
|
| Rate for Payer: WINHealth Partners Commercial |
$531.65
|
| Rate for Payer: Wise Provider Network Commercial |
$515.38
|
|
|
ACNE SURGERY
|
Professional
|
Both
|
$228.00
|
|
|
Service Code
|
HCPCS 10040
|
| Min. Negotiated Rate |
$42.42 |
| Max. Negotiated Rate |
$228.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$223.44
|
| Rate for Payer: Aetna of WY Medicare |
$49.90
|
| Rate for Payer: Beech Street Commercial |
$216.60
|
| Rate for Payer: Cash Price |
$159.60
|
| Rate for Payer: Cash Price |
$159.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$221.16
|
| Rate for Payer: Cigna of WY Commercial |
$223.44
|
| Rate for Payer: First Choice Health Commercial |
$205.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$216.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$49.90
|
| Rate for Payer: HealthUtah PPO |
$228.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$221.16
|
| Rate for Payer: Multiplan Medicare/VA |
$42.42
|
| Rate for Payer: One Health Plan of WY PPO |
$223.44
|
| Rate for Payer: PacificSource Commercial |
$205.20
|
| Rate for Payer: PHCS PPO |
$216.60
|
| Rate for Payer: Three Rivers PPO |
$171.00
|
| Rate for Payer: TriWest Veterans Administration |
$49.90
|
| Rate for Payer: United Healthcare Commercial |
$216.60
|
| Rate for Payer: WINHealth Partners Commercial |
$193.80
|
|
|
ACTICOAT DRESSING 6" X 6"
|
Facility
|
OP
|
$66.25
|
|
| Hospital Charge Code |
2000068
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$35.87 |
| Max. Negotiated Rate |
$66.25 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$64.92
|
| Rate for Payer: Aetna of WY Medicare |
$43.72
|
| Rate for Payer: Altius Commercial |
$63.60
|
| Rate for Payer: Beech Street Commercial |
$64.92
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$64.26
|
| Rate for Payer: Cash Price |
$46.37
|
| Rate for Payer: ChoiceCare Network Commercial |
$64.26
|
| Rate for Payer: Cigna of WY Commercial |
$64.92
|
| Rate for Payer: Entrust Commercial |
$62.94
|
| Rate for Payer: First Choice Health Commercial |
$62.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$62.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$37.76
|
| Rate for Payer: HealthUtah PPO |
$66.25
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$64.26
|
| Rate for Payer: Multiplan Medicare/VA |
$35.87
|
| Rate for Payer: One Health Plan of WY PPO |
$64.92
|
| Rate for Payer: PacificSource Commercial |
$59.62
|
| Rate for Payer: PHCS PPO |
$64.92
|
| Rate for Payer: Three Rivers PPO |
$49.69
|
| Rate for Payer: TriWest Veterans Administration |
$37.76
|
| Rate for Payer: United Healthcare Commercial |
$63.27
|
| Rate for Payer: United Healthcare Medicare |
$37.76
|
| Rate for Payer: WINHealth Partners Commercial |
$64.92
|
| Rate for Payer: Wise Provider Network Commercial |
$62.94
|
|
|
ACTICOAT DRESSING 6" X 6"
|
Facility
|
IP
|
$66.25
|
|
| Hospital Charge Code |
2000068
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$38.39 |
| Max. Negotiated Rate |
$66.25 |
| Rate for Payer: United Healthcare Commercial |
$63.27
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$64.92
|
| Rate for Payer: Aetna of WY Medicare |
$42.40
|
| Rate for Payer: Altius Commercial |
$63.60
|
| Rate for Payer: Beech Street Commercial |
$64.92
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$64.26
|
| Rate for Payer: Cash Price |
$46.37
|
| Rate for Payer: ChoiceCare Network Commercial |
$64.26
|
| Rate for Payer: Cigna of WY Commercial |
$64.92
|
| Rate for Payer: Entrust Commercial |
$62.94
|
| Rate for Payer: First Choice Health Commercial |
$62.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$62.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$40.41
|
| Rate for Payer: HealthUtah PPO |
$66.25
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$64.26
|
| Rate for Payer: Multiplan Medicare/VA |
$38.39
|
| Rate for Payer: One Health Plan of WY PPO |
$64.92
|
| Rate for Payer: PacificSource Commercial |
$59.62
|
| Rate for Payer: PHCS PPO |
$64.92
|
| Rate for Payer: Three Rivers PPO |
$49.69
|
| Rate for Payer: TriWest Veterans Administration |
$40.41
|
| Rate for Payer: United Healthcare Medicare |
$40.41
|
| Rate for Payer: WINHealth Partners Commercial |
$62.94
|
| Rate for Payer: Wise Provider Network Commercial |
$62.94
|
|
|
ACTIVATED CHARCOAL 25 G/120 ML SUSPENSION (WRAPPED) [4000700]
|
Facility
|
OP
|
$15.73
|
|
|
Service Code
|
NDC 6668920204
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.52 |
| Max. Negotiated Rate |
$15.73 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.42
|
| Rate for Payer: Aetna of WY Medicare |
$10.38
|
| Rate for Payer: Altius Commercial |
$15.10
|
| Rate for Payer: Beech Street Commercial |
$15.42
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.26
|
| Rate for Payer: Cash Price |
$11.01
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.26
|
| Rate for Payer: Cigna of WY Commercial |
$15.42
|
| Rate for Payer: Entrust Commercial |
$14.94
|
| Rate for Payer: First Choice Health Commercial |
$14.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.97
|
| Rate for Payer: HealthUtah PPO |
$15.73
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.26
|
| Rate for Payer: Multiplan Medicare/VA |
$8.52
|
| Rate for Payer: One Health Plan of WY PPO |
$15.42
|
| Rate for Payer: PacificSource Commercial |
$14.16
|
| Rate for Payer: PHCS PPO |
$15.42
|
| Rate for Payer: Three Rivers PPO |
$11.80
|
| Rate for Payer: TriWest Veterans Administration |
$8.97
|
| Rate for Payer: United Healthcare Commercial |
$15.02
|
| Rate for Payer: United Healthcare Medicare |
$8.97
|
| Rate for Payer: WINHealth Partners Commercial |
$15.42
|
| Rate for Payer: Wise Provider Network Commercial |
$14.94
|
|
|
ACTIVATED CHARCOAL 25 G/120 ML SUSPENSION (WRAPPED) [4000700]
|
Facility
|
IP
|
$15.73
|
|
|
Service Code
|
NDC 6668920204
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.12 |
| Max. Negotiated Rate |
$15.73 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.42
|
| Rate for Payer: Aetna of WY Medicare |
$10.07
|
| Rate for Payer: Altius Commercial |
$15.10
|
| Rate for Payer: Beech Street Commercial |
$15.42
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.26
|
| Rate for Payer: Cash Price |
$11.01
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.26
|
| Rate for Payer: Cigna of WY Commercial |
$15.42
|
| Rate for Payer: Entrust Commercial |
$14.94
|
| Rate for Payer: First Choice Health Commercial |
$14.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.60
|
| Rate for Payer: HealthUtah PPO |
$15.73
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.26
|
| Rate for Payer: Multiplan Medicare/VA |
$9.12
|
| Rate for Payer: One Health Plan of WY PPO |
$15.42
|
| Rate for Payer: PacificSource Commercial |
$14.16
|
| Rate for Payer: PHCS PPO |
$15.42
|
| Rate for Payer: Three Rivers PPO |
$11.80
|
| Rate for Payer: TriWest Veterans Administration |
$9.60
|
| Rate for Payer: United Healthcare Commercial |
$15.02
|
| Rate for Payer: United Healthcare Medicare |
$9.60
|
| Rate for Payer: WINHealth Partners Commercial |
$14.94
|
| Rate for Payer: Wise Provider Network Commercial |
$14.94
|
|
|
ACTIVATED CHARCOAL 25 G/120 ML SUSPENSION (WRAPPED) [4000700]
|
Facility
|
IP
|
$15.45
|
|
|
Service Code
|
NDC 0574052174
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.95 |
| Max. Negotiated Rate |
$15.45 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.14
|
| Rate for Payer: Aetna of WY Medicare |
$9.89
|
| Rate for Payer: Altius Commercial |
$14.83
|
| Rate for Payer: Beech Street Commercial |
$15.14
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.99
|
| Rate for Payer: Cash Price |
$10.81
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.99
|
| Rate for Payer: Cigna of WY Commercial |
$15.14
|
| Rate for Payer: Entrust Commercial |
$14.68
|
| Rate for Payer: First Choice Health Commercial |
$14.68
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.68
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.42
|
| Rate for Payer: HealthUtah PPO |
$15.45
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.99
|
| Rate for Payer: Multiplan Medicare/VA |
$8.95
|
| Rate for Payer: One Health Plan of WY PPO |
$15.14
|
| Rate for Payer: PacificSource Commercial |
$13.90
|
| Rate for Payer: PHCS PPO |
$15.14
|
| Rate for Payer: Three Rivers PPO |
$11.59
|
| Rate for Payer: TriWest Veterans Administration |
$9.42
|
| Rate for Payer: United Healthcare Commercial |
$14.75
|
| Rate for Payer: United Healthcare Medicare |
$9.42
|
| Rate for Payer: WINHealth Partners Commercial |
$14.68
|
| Rate for Payer: Wise Provider Network Commercial |
$14.68
|
|
|
ACTIVATED CHARCOAL 25 G/120 ML SUSPENSION (WRAPPED) [4000700]
|
Facility
|
OP
|
$15.45
|
|
|
Service Code
|
NDC 0574052174
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.37 |
| Max. Negotiated Rate |
$15.45 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.14
|
| Rate for Payer: Aetna of WY Medicare |
$10.20
|
| Rate for Payer: Altius Commercial |
$14.83
|
| Rate for Payer: Beech Street Commercial |
$15.14
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.99
|
| Rate for Payer: Cash Price |
$10.81
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.99
|
| Rate for Payer: Cigna of WY Commercial |
$15.14
|
| Rate for Payer: Entrust Commercial |
$14.68
|
| Rate for Payer: First Choice Health Commercial |
$14.68
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.68
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.81
|
| Rate for Payer: HealthUtah PPO |
$15.45
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.99
|
| Rate for Payer: Multiplan Medicare/VA |
$8.37
|
| Rate for Payer: One Health Plan of WY PPO |
$15.14
|
| Rate for Payer: PacificSource Commercial |
$13.90
|
| Rate for Payer: PHCS PPO |
$15.14
|
| Rate for Payer: Three Rivers PPO |
$11.59
|
| Rate for Payer: TriWest Veterans Administration |
$8.81
|
| Rate for Payer: United Healthcare Commercial |
$14.75
|
| Rate for Payer: United Healthcare Medicare |
$8.81
|
| Rate for Payer: WINHealth Partners Commercial |
$15.14
|
| Rate for Payer: Wise Provider Network Commercial |
$14.68
|
|
|
ACTIVATED CHARCOAL-SORBITOL 25 GRAM/120 ML SUSPENSION (WRAPPED) [4000701]
|
Facility
|
IP
|
$15.45
|
|
|
Service Code
|
NDC 0574052074
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.95 |
| Max. Negotiated Rate |
$15.45 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.14
|
| Rate for Payer: Aetna of WY Medicare |
$9.89
|
| Rate for Payer: Altius Commercial |
$14.83
|
| Rate for Payer: Beech Street Commercial |
$15.14
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.99
|
| Rate for Payer: Cash Price |
$10.81
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.99
|
| Rate for Payer: Cigna of WY Commercial |
$15.14
|
| Rate for Payer: Entrust Commercial |
$14.68
|
| Rate for Payer: First Choice Health Commercial |
$14.68
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.68
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.42
|
| Rate for Payer: HealthUtah PPO |
$15.45
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.99
|
| Rate for Payer: Multiplan Medicare/VA |
$8.95
|
| Rate for Payer: One Health Plan of WY PPO |
$15.14
|
| Rate for Payer: PacificSource Commercial |
$13.90
|
| Rate for Payer: PHCS PPO |
$15.14
|
| Rate for Payer: Three Rivers PPO |
$11.59
|
| Rate for Payer: TriWest Veterans Administration |
$9.42
|
| Rate for Payer: United Healthcare Commercial |
$14.75
|
| Rate for Payer: United Healthcare Medicare |
$9.42
|
| Rate for Payer: WINHealth Partners Commercial |
$14.68
|
| Rate for Payer: Wise Provider Network Commercial |
$14.68
|
|
|
ACTIVATED CHARCOAL-SORBITOL 25 GRAM/120 ML SUSPENSION (WRAPPED) [4000701]
|
Facility
|
OP
|
$15.45
|
|
|
Service Code
|
NDC 0574052074
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.37 |
| Max. Negotiated Rate |
$15.45 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.14
|
| Rate for Payer: Aetna of WY Medicare |
$10.20
|
| Rate for Payer: Altius Commercial |
$14.83
|
| Rate for Payer: Beech Street Commercial |
$15.14
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.99
|
| Rate for Payer: Cash Price |
$10.81
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.99
|
| Rate for Payer: Cigna of WY Commercial |
$15.14
|
| Rate for Payer: Entrust Commercial |
$14.68
|
| Rate for Payer: First Choice Health Commercial |
$14.68
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.68
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.81
|
| Rate for Payer: HealthUtah PPO |
$15.45
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.99
|
| Rate for Payer: Multiplan Medicare/VA |
$8.37
|
| Rate for Payer: One Health Plan of WY PPO |
$15.14
|
| Rate for Payer: PacificSource Commercial |
$13.90
|
| Rate for Payer: PHCS PPO |
$15.14
|
| Rate for Payer: Three Rivers PPO |
$11.59
|
| Rate for Payer: TriWest Veterans Administration |
$8.81
|
| Rate for Payer: United Healthcare Commercial |
$14.75
|
| Rate for Payer: United Healthcare Medicare |
$8.81
|
| Rate for Payer: WINHealth Partners Commercial |
$15.14
|
| Rate for Payer: Wise Provider Network Commercial |
$14.68
|
|
|
ACTIVE CORD DISP 12BX
|
Facility
|
IP
|
$50.40
|
|
| Hospital Charge Code |
2650032
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$29.21 |
| Max. Negotiated Rate |
$50.40 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$49.39
|
| Rate for Payer: Aetna of WY Medicare |
$32.26
|
| Rate for Payer: Altius Commercial |
$48.38
|
| Rate for Payer: Beech Street Commercial |
$49.39
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$48.89
|
| Rate for Payer: Cash Price |
$35.28
|
| Rate for Payer: ChoiceCare Network Commercial |
$48.89
|
| Rate for Payer: Cigna of WY Commercial |
$49.39
|
| Rate for Payer: Entrust Commercial |
$47.88
|
| Rate for Payer: First Choice Health Commercial |
$47.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$47.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$30.74
|
| Rate for Payer: HealthUtah PPO |
$50.40
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$48.89
|
| Rate for Payer: Multiplan Medicare/VA |
$29.21
|
| Rate for Payer: One Health Plan of WY PPO |
$49.39
|
| Rate for Payer: PacificSource Commercial |
$45.36
|
| Rate for Payer: PHCS PPO |
$49.39
|
| Rate for Payer: Three Rivers PPO |
$37.80
|
| Rate for Payer: TriWest Veterans Administration |
$30.74
|
| Rate for Payer: United Healthcare Commercial |
$48.13
|
| Rate for Payer: United Healthcare Medicare |
$30.74
|
| Rate for Payer: WINHealth Partners Commercial |
$47.88
|
| Rate for Payer: Wise Provider Network Commercial |
$47.88
|
|
