|
CV STRS TST XERS&/OR RX CONT ECG W/SI&R
|
Professional
|
Both
|
$508.00
|
|
|
Service Code
|
HCPCS 93015
|
| Hospital Charge Code |
93015
|
| Min. Negotiated Rate |
$59.83 |
| Max. Negotiated Rate |
$508.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$497.84
|
| Rate for Payer: Aetna of WY Medicare |
$70.39
|
| Rate for Payer: Beech Street Commercial |
$482.60
|
| Rate for Payer: Cash Price |
$355.60
|
| Rate for Payer: Cash Price |
$355.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$492.76
|
| Rate for Payer: Cigna of WY Commercial |
$497.84
|
| Rate for Payer: First Choice Health Commercial |
$457.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$482.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$70.39
|
| Rate for Payer: HealthUtah PPO |
$508.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$492.76
|
| Rate for Payer: Multiplan Medicare/VA |
$59.83
|
| Rate for Payer: One Health Plan of WY PPO |
$497.84
|
| Rate for Payer: PacificSource Commercial |
$457.20
|
| Rate for Payer: PHCS PPO |
$482.60
|
| Rate for Payer: Three Rivers PPO |
$381.00
|
| Rate for Payer: TriWest Veterans Administration |
$70.39
|
| Rate for Payer: United Healthcare Commercial |
$441.96
|
| Rate for Payer: United Healthcare Medicare |
$70.39
|
| Rate for Payer: WINHealth Partners Commercial |
$482.60
|
|
|
CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION [12255]
|
Facility
|
OP
|
$39.19
|
|
|
Service Code
|
HCPCS J3420
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.59 |
| Max. Negotiated Rate |
$39.19 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$38.41
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$24.74
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$38.68
|
| Rate for Payer: Aetna of WY Medicare |
$25.87
|
| Rate for Payer: Aetna of WY Medicare |
$26.05
|
| Rate for Payer: Aetna of WY Medicare |
$16.66
|
| Rate for Payer: Altius Auto/Workers Compensation |
$37.62
|
| Rate for Payer: Altius Auto/Workers Compensation |
$24.23
|
| Rate for Payer: Altius Auto/Workers Compensation |
$37.89
|
| Rate for Payer: Altius Commercial |
$37.62
|
| Rate for Payer: Altius Commercial |
$37.89
|
| Rate for Payer: Altius Commercial |
$24.23
|
| Rate for Payer: Beech Street Commercial |
$38.41
|
| Rate for Payer: Beech Street Commercial |
$38.68
|
| Rate for Payer: Beech Street Commercial |
$24.74
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$32.17
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$20.72
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$32.40
|
| Rate for Payer: Cash Price |
$27.43
|
| Rate for Payer: Cash Price |
$17.67
|
| Rate for Payer: Cash Price |
$27.63
|
| Rate for Payer: ChoiceCare Network Commercial |
$38.01
|
| Rate for Payer: ChoiceCare Network Commercial |
$38.29
|
| Rate for Payer: ChoiceCare Network Commercial |
$24.48
|
| Rate for Payer: Cigna of WY Commercial |
$38.68
|
| Rate for Payer: Cigna of WY Commercial |
$24.74
|
| Rate for Payer: Cigna of WY Commercial |
$38.41
|
| Rate for Payer: Entrust Commercial |
$37.50
|
| Rate for Payer: Entrust Commercial |
$37.23
|
| Rate for Payer: Entrust Commercial |
$23.98
|
| Rate for Payer: First Choice Health Commercial |
$37.23
|
| Rate for Payer: First Choice Health Commercial |
$23.98
|
| Rate for Payer: First Choice Health Commercial |
$37.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$23.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$37.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$37.23
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$22.73
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$14.64
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$22.89
|
| Rate for Payer: HealthUtah PPO |
$25.24
|
| Rate for Payer: HealthUtah PPO |
$39.47
|
| Rate for Payer: HealthUtah PPO |
$39.19
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$38.29
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.48
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$38.01
|
| Rate for Payer: Multiplan Medicare/VA |
$13.91
|
| Rate for Payer: Multiplan Medicare/VA |
$21.59
|
| Rate for Payer: Multiplan Medicare/VA |
$21.75
|
| Rate for Payer: One Health Plan of WY PPO |
$24.74
|
| Rate for Payer: One Health Plan of WY PPO |
$38.68
|
| Rate for Payer: One Health Plan of WY PPO |
$38.41
|
| Rate for Payer: PacificSource Commercial |
$35.52
|
| Rate for Payer: PacificSource Commercial |
$35.27
|
| Rate for Payer: PacificSource Commercial |
$22.72
|
| Rate for Payer: PHCS PPO |
$38.41
|
| Rate for Payer: PHCS PPO |
$24.74
|
| Rate for Payer: PHCS PPO |
$38.68
|
| Rate for Payer: Three Rivers PPO |
$29.39
|
| Rate for Payer: Three Rivers PPO |
$18.93
|
| Rate for Payer: Three Rivers PPO |
$29.60
|
| Rate for Payer: TriWest Veterans Administration |
$22.89
|
| Rate for Payer: TriWest Veterans Administration |
$22.73
|
| Rate for Payer: TriWest Veterans Administration |
$14.64
|
| Rate for Payer: United Healthcare Commercial |
$21.96
|
| Rate for Payer: United Healthcare Commercial |
$34.10
|
| Rate for Payer: United Healthcare Commercial |
$34.34
|
| Rate for Payer: United Healthcare Medicare |
$22.89
|
| Rate for Payer: United Healthcare Medicare |
$14.64
|
| Rate for Payer: United Healthcare Medicare |
$22.73
|
| Rate for Payer: WINHealth Partners Commercial |
$38.68
|
| Rate for Payer: WINHealth Partners Commercial |
$24.74
|
| Rate for Payer: WINHealth Partners Commercial |
$38.41
|
| Rate for Payer: Wise Provider Network Commercial |
$23.98
|
| Rate for Payer: Wise Provider Network Commercial |
$37.50
|
| Rate for Payer: Wise Provider Network Commercial |
$37.23
|
|
|
CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION [12255]
|
Facility
|
IP
|
$25.24
|
|
|
Service Code
|
HCPCS J3420
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.83 |
| Max. Negotiated Rate |
$25.24 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$24.74
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$38.41
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$38.68
|
| Rate for Payer: Altius Auto/Workers Compensation |
$24.23
|
| Rate for Payer: Altius Auto/Workers Compensation |
$37.62
|
| Rate for Payer: Altius Auto/Workers Compensation |
$37.89
|
| Rate for Payer: Altius Commercial |
$37.62
|
| Rate for Payer: Altius Commercial |
$24.23
|
| Rate for Payer: Altius Commercial |
$37.89
|
| Rate for Payer: Beech Street Commercial |
$38.68
|
| Rate for Payer: Beech Street Commercial |
$38.41
|
| Rate for Payer: Beech Street Commercial |
$24.74
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$20.72
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$32.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$32.17
|
| Rate for Payer: Cash Price |
$27.43
|
| Rate for Payer: Cash Price |
$17.67
|
| Rate for Payer: Cash Price |
$27.63
|
| Rate for Payer: ChoiceCare Network Commercial |
$24.48
|
| Rate for Payer: ChoiceCare Network Commercial |
$38.29
|
| Rate for Payer: ChoiceCare Network Commercial |
$38.01
|
| Rate for Payer: Cigna of WY Commercial |
$38.41
|
| Rate for Payer: Cigna of WY Commercial |
$38.68
|
| Rate for Payer: Cigna of WY Commercial |
$24.74
|
| Rate for Payer: Entrust Commercial |
$37.50
|
| Rate for Payer: Entrust Commercial |
$23.98
|
| Rate for Payer: Entrust Commercial |
$37.23
|
| Rate for Payer: First Choice Health Commercial |
$37.23
|
| Rate for Payer: First Choice Health Commercial |
$37.50
|
| Rate for Payer: First Choice Health Commercial |
$23.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$23.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$37.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$37.23
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$16.66
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$25.87
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$26.05
|
| Rate for Payer: HealthUtah PPO |
$25.24
|
| Rate for Payer: HealthUtah PPO |
$39.19
|
| Rate for Payer: HealthUtah PPO |
$39.47
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$38.29
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$38.01
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.48
|
| Rate for Payer: Multiplan Medicare/VA |
$24.75
|
| Rate for Payer: Multiplan Medicare/VA |
$15.83
|
| Rate for Payer: Multiplan Medicare/VA |
$24.57
|
| Rate for Payer: One Health Plan of WY PPO |
$24.74
|
| Rate for Payer: One Health Plan of WY PPO |
$38.41
|
| Rate for Payer: One Health Plan of WY PPO |
$38.68
|
| Rate for Payer: PacificSource Commercial |
$35.52
|
| Rate for Payer: PacificSource Commercial |
$22.72
|
| Rate for Payer: PacificSource Commercial |
$35.27
|
| Rate for Payer: PHCS PPO |
$38.41
|
| Rate for Payer: PHCS PPO |
$24.74
|
| Rate for Payer: PHCS PPO |
$38.68
|
| Rate for Payer: Three Rivers PPO |
$29.39
|
| Rate for Payer: Three Rivers PPO |
$18.93
|
| Rate for Payer: Three Rivers PPO |
$29.60
|
| Rate for Payer: TriWest Veterans Administration |
$25.87
|
| Rate for Payer: TriWest Veterans Administration |
$16.66
|
| Rate for Payer: TriWest Veterans Administration |
$26.05
|
| Rate for Payer: United Healthcare Commercial |
$21.96
|
| Rate for Payer: United Healthcare Commercial |
$34.34
|
| Rate for Payer: United Healthcare Commercial |
$34.10
|
| Rate for Payer: United Healthcare Medicare |
$16.66
|
| Rate for Payer: United Healthcare Medicare |
$26.05
|
| Rate for Payer: United Healthcare Medicare |
$25.87
|
| Rate for Payer: WINHealth Partners Commercial |
$37.23
|
| Rate for Payer: WINHealth Partners Commercial |
$23.98
|
| Rate for Payer: WINHealth Partners Commercial |
$37.50
|
| Rate for Payer: Wise Provider Network Commercial |
$37.50
|
| Rate for Payer: Wise Provider Network Commercial |
$23.98
|
| Rate for Payer: Wise Provider Network Commercial |
$37.23
|
|
|
CYANOCOBALAMIN (VIT B-12) 1,000 MCG TABLET [6084]
|
Facility
|
OP
|
$0.83
|
|
|
Service Code
|
NDC 5026885515
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$0.83 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.81
|
| Rate for Payer: Aetna of WY Medicare |
$0.55
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.80
|
| Rate for Payer: Altius Commercial |
$0.80
|
| Rate for Payer: Beech Street Commercial |
$0.81
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.68
|
| Rate for Payer: Cash Price |
$0.58
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.81
|
| Rate for Payer: Cigna of WY Commercial |
$0.81
|
| Rate for Payer: Entrust Commercial |
$0.79
|
| Rate for Payer: First Choice Health Commercial |
$0.79
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.79
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.48
|
| Rate for Payer: HealthUtah PPO |
$0.83
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.81
|
| Rate for Payer: Multiplan Medicare/VA |
$0.46
|
| Rate for Payer: One Health Plan of WY PPO |
$0.81
|
| Rate for Payer: PacificSource Commercial |
$0.75
|
| Rate for Payer: PHCS PPO |
$0.81
|
| Rate for Payer: Three Rivers PPO |
$0.62
|
| Rate for Payer: TriWest Veterans Administration |
$0.48
|
| Rate for Payer: United Healthcare Commercial |
$0.72
|
| Rate for Payer: United Healthcare Medicare |
$0.48
|
| Rate for Payer: WINHealth Partners Commercial |
$0.81
|
| Rate for Payer: Wise Provider Network Commercial |
$0.79
|
|
|
CYANOCOBALAMIN (VIT B-12) 1,000 MCG TABLET [6084]
|
Facility
|
IP
|
$0.83
|
|
|
Service Code
|
NDC 5026885511
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.52 |
| Max. Negotiated Rate |
$0.83 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.81
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.80
|
| Rate for Payer: Altius Commercial |
$0.80
|
| Rate for Payer: Beech Street Commercial |
$0.81
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.68
|
| Rate for Payer: Cash Price |
$0.58
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.81
|
| Rate for Payer: Cigna of WY Commercial |
$0.81
|
| Rate for Payer: Entrust Commercial |
$0.79
|
| Rate for Payer: First Choice Health Commercial |
$0.79
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.79
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.55
|
| Rate for Payer: HealthUtah PPO |
$0.83
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.81
|
| Rate for Payer: Multiplan Medicare/VA |
$0.52
|
| Rate for Payer: One Health Plan of WY PPO |
$0.81
|
| Rate for Payer: PacificSource Commercial |
$0.75
|
| Rate for Payer: PHCS PPO |
$0.81
|
| Rate for Payer: Three Rivers PPO |
$0.62
|
| Rate for Payer: TriWest Veterans Administration |
$0.55
|
| Rate for Payer: United Healthcare Commercial |
$0.72
|
| Rate for Payer: United Healthcare Medicare |
$0.55
|
| Rate for Payer: WINHealth Partners Commercial |
$0.79
|
| Rate for Payer: Wise Provider Network Commercial |
$0.79
|
|
|
CYANOCOBALAMIN (VIT B-12) 1,000 MCG TABLET [6084]
|
Facility
|
IP
|
$0.83
|
|
|
Service Code
|
NDC 5026885515
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.52 |
| Max. Negotiated Rate |
$0.83 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.81
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.80
|
| Rate for Payer: Altius Commercial |
$0.80
|
| Rate for Payer: Beech Street Commercial |
$0.81
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.68
|
| Rate for Payer: Cash Price |
$0.58
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.81
|
| Rate for Payer: Cigna of WY Commercial |
$0.81
|
| Rate for Payer: Entrust Commercial |
$0.79
|
| Rate for Payer: First Choice Health Commercial |
$0.79
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.79
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.55
|
| Rate for Payer: HealthUtah PPO |
$0.83
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.81
|
| Rate for Payer: Multiplan Medicare/VA |
$0.52
|
| Rate for Payer: One Health Plan of WY PPO |
$0.81
|
| Rate for Payer: PacificSource Commercial |
$0.75
|
| Rate for Payer: PHCS PPO |
$0.81
|
| Rate for Payer: Three Rivers PPO |
$0.62
|
| Rate for Payer: TriWest Veterans Administration |
$0.55
|
| Rate for Payer: United Healthcare Commercial |
$0.72
|
| Rate for Payer: United Healthcare Medicare |
$0.55
|
| Rate for Payer: WINHealth Partners Commercial |
$0.79
|
| Rate for Payer: Wise Provider Network Commercial |
$0.79
|
|
|
CYANOCOBALAMIN (VIT B-12) 1,000 MCG TABLET [6084]
|
Facility
|
OP
|
$0.83
|
|
|
Service Code
|
NDC 5026885511
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$0.83 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.81
|
| Rate for Payer: Aetna of WY Medicare |
$0.55
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.80
|
| Rate for Payer: Altius Commercial |
$0.80
|
| Rate for Payer: Beech Street Commercial |
$0.81
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.68
|
| Rate for Payer: Cash Price |
$0.58
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.81
|
| Rate for Payer: Cigna of WY Commercial |
$0.81
|
| Rate for Payer: Entrust Commercial |
$0.79
|
| Rate for Payer: First Choice Health Commercial |
$0.79
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.79
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.48
|
| Rate for Payer: HealthUtah PPO |
$0.83
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.81
|
| Rate for Payer: Multiplan Medicare/VA |
$0.46
|
| Rate for Payer: One Health Plan of WY PPO |
$0.81
|
| Rate for Payer: PacificSource Commercial |
$0.75
|
| Rate for Payer: PHCS PPO |
$0.81
|
| Rate for Payer: Three Rivers PPO |
$0.62
|
| Rate for Payer: TriWest Veterans Administration |
$0.48
|
| Rate for Payer: United Healthcare Commercial |
$0.72
|
| Rate for Payer: United Healthcare Medicare |
$0.48
|
| Rate for Payer: WINHealth Partners Commercial |
$0.81
|
| Rate for Payer: Wise Provider Network Commercial |
$0.79
|
|
|
CYCLOBENZAPRINE 10 MG TABLET [286]
|
Facility
|
OP
|
$0.71
|
|
|
Service Code
|
NDC 6068755811
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$0.71 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.70
|
| Rate for Payer: Aetna of WY Medicare |
$0.47
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.68
|
| Rate for Payer: Altius Commercial |
$0.68
|
| Rate for Payer: Beech Street Commercial |
$0.70
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.58
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.69
|
| Rate for Payer: Cigna of WY Commercial |
$0.70
|
| Rate for Payer: Entrust Commercial |
$0.67
|
| Rate for Payer: First Choice Health Commercial |
$0.67
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.67
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.41
|
| Rate for Payer: HealthUtah PPO |
$0.71
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.69
|
| Rate for Payer: Multiplan Medicare/VA |
$0.39
|
| Rate for Payer: One Health Plan of WY PPO |
$0.70
|
| Rate for Payer: PacificSource Commercial |
$0.64
|
| Rate for Payer: PHCS PPO |
$0.70
|
| Rate for Payer: Three Rivers PPO |
$0.53
|
| Rate for Payer: TriWest Veterans Administration |
$0.41
|
| Rate for Payer: United Healthcare Commercial |
$0.62
|
| Rate for Payer: United Healthcare Medicare |
$0.41
|
| Rate for Payer: WINHealth Partners Commercial |
$0.70
|
| Rate for Payer: Wise Provider Network Commercial |
$0.67
|
|
|
CYCLOBENZAPRINE 10 MG TABLET [286]
|
Facility
|
IP
|
$0.71
|
|
|
Service Code
|
NDC 6068755811
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$0.71 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.70
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.68
|
| Rate for Payer: Altius Commercial |
$0.68
|
| Rate for Payer: Beech Street Commercial |
$0.70
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.58
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.69
|
| Rate for Payer: Cigna of WY Commercial |
$0.70
|
| Rate for Payer: Entrust Commercial |
$0.67
|
| Rate for Payer: First Choice Health Commercial |
$0.67
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.67
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.47
|
| Rate for Payer: HealthUtah PPO |
$0.71
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.69
|
| Rate for Payer: Multiplan Medicare/VA |
$0.45
|
| Rate for Payer: One Health Plan of WY PPO |
$0.70
|
| Rate for Payer: PacificSource Commercial |
$0.64
|
| Rate for Payer: PHCS PPO |
$0.70
|
| Rate for Payer: Three Rivers PPO |
$0.53
|
| Rate for Payer: TriWest Veterans Administration |
$0.47
|
| Rate for Payer: United Healthcare Commercial |
$0.62
|
| Rate for Payer: United Healthcare Medicare |
$0.47
|
| Rate for Payer: WINHealth Partners Commercial |
$0.67
|
| Rate for Payer: Wise Provider Network Commercial |
$0.67
|
|
|
CYCLOBENZAPRINE 10 MG TABLET [286]
|
Facility
|
IP
|
$0.71
|
|
|
Service Code
|
NDC 6068755801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$0.71 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.70
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.68
|
| Rate for Payer: Altius Commercial |
$0.68
|
| Rate for Payer: Beech Street Commercial |
$0.70
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.58
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.69
|
| Rate for Payer: Cigna of WY Commercial |
$0.70
|
| Rate for Payer: Entrust Commercial |
$0.67
|
| Rate for Payer: First Choice Health Commercial |
$0.67
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.67
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.47
|
| Rate for Payer: HealthUtah PPO |
$0.71
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.69
|
| Rate for Payer: Multiplan Medicare/VA |
$0.45
|
| Rate for Payer: One Health Plan of WY PPO |
$0.70
|
| Rate for Payer: PacificSource Commercial |
$0.64
|
| Rate for Payer: PHCS PPO |
$0.70
|
| Rate for Payer: Three Rivers PPO |
$0.53
|
| Rate for Payer: TriWest Veterans Administration |
$0.47
|
| Rate for Payer: United Healthcare Commercial |
$0.62
|
| Rate for Payer: United Healthcare Medicare |
$0.47
|
| Rate for Payer: WINHealth Partners Commercial |
$0.67
|
| Rate for Payer: Wise Provider Network Commercial |
$0.67
|
|
|
CYCLOBENZAPRINE 10 MG TABLET [286]
|
Facility
|
OP
|
$0.71
|
|
|
Service Code
|
NDC 6068755801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$0.71 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.70
|
| Rate for Payer: Aetna of WY Medicare |
$0.47
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.68
|
| Rate for Payer: Altius Commercial |
$0.68
|
| Rate for Payer: Beech Street Commercial |
$0.70
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.58
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.69
|
| Rate for Payer: Cigna of WY Commercial |
$0.70
|
| Rate for Payer: Entrust Commercial |
$0.67
|
| Rate for Payer: First Choice Health Commercial |
$0.67
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.67
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.41
|
| Rate for Payer: HealthUtah PPO |
$0.71
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.69
|
| Rate for Payer: Multiplan Medicare/VA |
$0.39
|
| Rate for Payer: One Health Plan of WY PPO |
$0.70
|
| Rate for Payer: PacificSource Commercial |
$0.64
|
| Rate for Payer: PHCS PPO |
$0.70
|
| Rate for Payer: Three Rivers PPO |
$0.53
|
| Rate for Payer: TriWest Veterans Administration |
$0.41
|
| Rate for Payer: United Healthcare Commercial |
$0.62
|
| Rate for Payer: United Healthcare Medicare |
$0.41
|
| Rate for Payer: WINHealth Partners Commercial |
$0.70
|
| Rate for Payer: Wise Provider Network Commercial |
$0.67
|
|
|
CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION [19355]
|
Facility
|
IP
|
$344.63
|
|
|
Service Code
|
HCPCS J9075
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$216.08 |
| Max. Negotiated Rate |
$344.63 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$337.74
|
| Rate for Payer: Altius Auto/Workers Compensation |
$330.84
|
| Rate for Payer: Altius Commercial |
$330.84
|
| Rate for Payer: Beech Street Commercial |
$337.74
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$282.94
|
| Rate for Payer: Cash Price |
$241.24
|
| Rate for Payer: ChoiceCare Network Commercial |
$334.29
|
| Rate for Payer: Cigna of WY Commercial |
$337.74
|
| Rate for Payer: Entrust Commercial |
$327.40
|
| Rate for Payer: First Choice Health Commercial |
$327.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$327.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$227.46
|
| Rate for Payer: HealthUtah PPO |
$344.63
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$334.29
|
| Rate for Payer: Multiplan Medicare/VA |
$216.08
|
| Rate for Payer: One Health Plan of WY PPO |
$337.74
|
| Rate for Payer: PacificSource Commercial |
$310.17
|
| Rate for Payer: PHCS PPO |
$337.74
|
| Rate for Payer: Three Rivers PPO |
$258.47
|
| Rate for Payer: TriWest Veterans Administration |
$227.46
|
| Rate for Payer: United Healthcare Commercial |
$299.83
|
| Rate for Payer: United Healthcare Medicare |
$227.46
|
| Rate for Payer: WINHealth Partners Commercial |
$327.40
|
| Rate for Payer: Wise Provider Network Commercial |
$327.40
|
|
|
CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION [19355]
|
Facility
|
OP
|
$344.63
|
|
|
Service Code
|
HCPCS J9075
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$189.89 |
| Max. Negotiated Rate |
$344.63 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$337.74
|
| Rate for Payer: Aetna of WY Medicare |
$227.46
|
| Rate for Payer: Altius Auto/Workers Compensation |
$330.84
|
| Rate for Payer: Altius Commercial |
$330.84
|
| Rate for Payer: Beech Street Commercial |
$337.74
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$282.94
|
| Rate for Payer: Cash Price |
$241.24
|
| Rate for Payer: ChoiceCare Network Commercial |
$334.29
|
| Rate for Payer: Cigna of WY Commercial |
$337.74
|
| Rate for Payer: Entrust Commercial |
$327.40
|
| Rate for Payer: First Choice Health Commercial |
$327.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$327.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$199.89
|
| Rate for Payer: HealthUtah PPO |
$344.63
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$334.29
|
| Rate for Payer: Multiplan Medicare/VA |
$189.89
|
| Rate for Payer: One Health Plan of WY PPO |
$337.74
|
| Rate for Payer: PacificSource Commercial |
$310.17
|
| Rate for Payer: PHCS PPO |
$337.74
|
| Rate for Payer: Three Rivers PPO |
$258.47
|
| Rate for Payer: TriWest Veterans Administration |
$199.89
|
| Rate for Payer: United Healthcare Commercial |
$299.83
|
| Rate for Payer: United Healthcare Medicare |
$199.89
|
| Rate for Payer: WINHealth Partners Commercial |
$337.74
|
| Rate for Payer: Wise Provider Network Commercial |
$327.40
|
|
|
CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE [27717]
|
Facility
|
IP
|
$32.28
|
|
|
Service Code
|
NDC 0023916360
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.24 |
| Max. Negotiated Rate |
$32.28 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$31.63
|
| Rate for Payer: Altius Auto/Workers Compensation |
$30.99
|
| Rate for Payer: Altius Commercial |
$30.99
|
| Rate for Payer: Beech Street Commercial |
$31.63
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$26.50
|
| Rate for Payer: Cash Price |
$22.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$31.31
|
| Rate for Payer: Cigna of WY Commercial |
$31.63
|
| Rate for Payer: Entrust Commercial |
$30.67
|
| Rate for Payer: First Choice Health Commercial |
$30.67
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$30.67
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$21.30
|
| Rate for Payer: HealthUtah PPO |
$32.28
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$31.31
|
| Rate for Payer: Multiplan Medicare/VA |
$20.24
|
| Rate for Payer: One Health Plan of WY PPO |
$31.63
|
| Rate for Payer: PacificSource Commercial |
$29.05
|
| Rate for Payer: PHCS PPO |
$31.63
|
| Rate for Payer: Three Rivers PPO |
$24.21
|
| Rate for Payer: TriWest Veterans Administration |
$21.30
|
| Rate for Payer: United Healthcare Commercial |
$28.08
|
| Rate for Payer: United Healthcare Medicare |
$21.30
|
| Rate for Payer: WINHealth Partners Commercial |
$30.67
|
| Rate for Payer: Wise Provider Network Commercial |
$30.67
|
|
|
CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE [27717]
|
Facility
|
IP
|
$15.75
|
|
|
Service Code
|
NDC 6050562022
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.88 |
| Max. Negotiated Rate |
$15.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.44
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.12
|
| Rate for Payer: Altius Commercial |
$15.12
|
| Rate for Payer: Beech Street Commercial |
$15.44
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.93
|
| Rate for Payer: Cash Price |
$11.02
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.28
|
| Rate for Payer: Cigna of WY Commercial |
$15.44
|
| Rate for Payer: Entrust Commercial |
$14.96
|
| Rate for Payer: First Choice Health Commercial |
$14.96
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.96
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.40
|
| Rate for Payer: HealthUtah PPO |
$15.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.28
|
| Rate for Payer: Multiplan Medicare/VA |
$9.88
|
| Rate for Payer: One Health Plan of WY PPO |
$15.44
|
| Rate for Payer: PacificSource Commercial |
$14.18
|
| Rate for Payer: PHCS PPO |
$15.44
|
| Rate for Payer: Three Rivers PPO |
$11.81
|
| Rate for Payer: TriWest Veterans Administration |
$10.40
|
| Rate for Payer: United Healthcare Commercial |
$13.70
|
| Rate for Payer: United Healthcare Medicare |
$10.40
|
| Rate for Payer: WINHealth Partners Commercial |
$14.96
|
| Rate for Payer: Wise Provider Network Commercial |
$14.96
|
|
|
CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE [27717]
|
Facility
|
OP
|
$15.75
|
|
|
Service Code
|
NDC 6050562022
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.68 |
| Max. Negotiated Rate |
$15.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.44
|
| Rate for Payer: Aetna of WY Medicare |
$10.40
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.12
|
| Rate for Payer: Altius Commercial |
$15.12
|
| Rate for Payer: Beech Street Commercial |
$15.44
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.93
|
| Rate for Payer: Cash Price |
$11.02
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.28
|
| Rate for Payer: Cigna of WY Commercial |
$15.44
|
| Rate for Payer: Entrust Commercial |
$14.96
|
| Rate for Payer: First Choice Health Commercial |
$14.96
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.96
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.14
|
| Rate for Payer: HealthUtah PPO |
$15.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.28
|
| Rate for Payer: Multiplan Medicare/VA |
$8.68
|
| Rate for Payer: One Health Plan of WY PPO |
$15.44
|
| Rate for Payer: PacificSource Commercial |
$14.18
|
| Rate for Payer: PHCS PPO |
$15.44
|
| Rate for Payer: Three Rivers PPO |
$11.81
|
| Rate for Payer: TriWest Veterans Administration |
$9.14
|
| Rate for Payer: United Healthcare Commercial |
$13.70
|
| Rate for Payer: United Healthcare Medicare |
$9.14
|
| Rate for Payer: WINHealth Partners Commercial |
$15.44
|
| Rate for Payer: Wise Provider Network Commercial |
$14.96
|
|
|
CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE [27717]
|
Facility
|
OP
|
$32.28
|
|
|
Service Code
|
NDC 0023916360
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.79 |
| Max. Negotiated Rate |
$32.28 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$31.63
|
| Rate for Payer: Aetna of WY Medicare |
$21.30
|
| Rate for Payer: Altius Auto/Workers Compensation |
$30.99
|
| Rate for Payer: Altius Commercial |
$30.99
|
| Rate for Payer: Beech Street Commercial |
$31.63
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$26.50
|
| Rate for Payer: Cash Price |
$22.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$31.31
|
| Rate for Payer: Cigna of WY Commercial |
$31.63
|
| Rate for Payer: Entrust Commercial |
$30.67
|
| Rate for Payer: First Choice Health Commercial |
$30.67
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$30.67
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$18.72
|
| Rate for Payer: HealthUtah PPO |
$32.28
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$31.31
|
| Rate for Payer: Multiplan Medicare/VA |
$17.79
|
| Rate for Payer: One Health Plan of WY PPO |
$31.63
|
| Rate for Payer: PacificSource Commercial |
$29.05
|
| Rate for Payer: PHCS PPO |
$31.63
|
| Rate for Payer: Three Rivers PPO |
$24.21
|
| Rate for Payer: TriWest Veterans Administration |
$18.72
|
| Rate for Payer: United Healthcare Commercial |
$28.08
|
| Rate for Payer: United Healthcare Medicare |
$18.72
|
| Rate for Payer: WINHealth Partners Commercial |
$31.63
|
| Rate for Payer: Wise Provider Network Commercial |
$30.67
|
|
|
CYGNUS, PER SQ CM
|
Professional
|
Both
|
$431.00
|
|
|
Service Code
|
HCPCS Q4170
|
| Hospital Charge Code |
Q4170
|
| Min. Negotiated Rate |
$48.22 |
| Max. Negotiated Rate |
$431.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$422.38
|
| Rate for Payer: Aetna of WY Medicare |
$56.73
|
| Rate for Payer: Beech Street Commercial |
$409.45
|
| Rate for Payer: Cash Price |
$301.70
|
| Rate for Payer: Cash Price |
$301.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$418.07
|
| Rate for Payer: Cigna of WY Commercial |
$422.38
|
| Rate for Payer: First Choice Health Commercial |
$387.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$409.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$56.73
|
| Rate for Payer: HealthUtah PPO |
$431.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$418.07
|
| Rate for Payer: Multiplan Medicare/VA |
$48.22
|
| Rate for Payer: One Health Plan of WY PPO |
$422.38
|
| Rate for Payer: PacificSource Commercial |
$387.90
|
| Rate for Payer: PHCS PPO |
$409.45
|
| Rate for Payer: Three Rivers PPO |
$323.25
|
| Rate for Payer: TriWest Veterans Administration |
$56.73
|
| Rate for Payer: United Healthcare Commercial |
$374.97
|
| Rate for Payer: United Healthcare Medicare |
$56.73
|
| Rate for Payer: WINHealth Partners Commercial |
$409.45
|
|
|
CYSTORRHAPHY SUTR BLDR WND INJ/RPT SIMPLE
|
Professional
|
Both
|
$3,856.00
|
|
|
Service Code
|
HCPCS 51860 80
|
| Hospital Charge Code |
51860
|
| Min. Negotiated Rate |
$607.84 |
| Max. Negotiated Rate |
$3,856.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,778.88
|
| Rate for Payer: Aetna of WY Medicare |
$715.10
|
| Rate for Payer: Beech Street Commercial |
$3,663.20
|
| Rate for Payer: Cash Price |
$2,699.20
|
| Rate for Payer: Cash Price |
$2,699.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,740.32
|
| Rate for Payer: Cigna of WY Commercial |
$3,778.88
|
| Rate for Payer: First Choice Health Commercial |
$3,470.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,663.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$715.10
|
| Rate for Payer: HealthUtah PPO |
$3,856.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,740.32
|
| Rate for Payer: Multiplan Medicare/VA |
$607.84
|
| Rate for Payer: One Health Plan of WY PPO |
$3,778.88
|
| Rate for Payer: PacificSource Commercial |
$3,470.40
|
| Rate for Payer: PHCS PPO |
$3,663.20
|
| Rate for Payer: Three Rivers PPO |
$2,892.00
|
| Rate for Payer: TriWest Veterans Administration |
$715.10
|
| Rate for Payer: United Healthcare Commercial |
$3,354.72
|
| Rate for Payer: United Healthcare Medicare |
$715.10
|
| Rate for Payer: WINHealth Partners Commercial |
$3,277.60
|
|
|
CYSTORRHAPHY SUTR BLDR WND INJ/RPT SIMPLE
|
Professional
|
Both
|
$3,856.00
|
|
|
Service Code
|
HCPCS 51860 AS
|
| Hospital Charge Code |
51860
|
| Min. Negotiated Rate |
$607.84 |
| Max. Negotiated Rate |
$3,856.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,778.88
|
| Rate for Payer: Aetna of WY Medicare |
$715.10
|
| Rate for Payer: Beech Street Commercial |
$3,663.20
|
| Rate for Payer: Cash Price |
$2,699.20
|
| Rate for Payer: Cash Price |
$2,699.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,740.32
|
| Rate for Payer: Cigna of WY Commercial |
$3,778.88
|
| Rate for Payer: First Choice Health Commercial |
$3,470.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,663.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$715.10
|
| Rate for Payer: HealthUtah PPO |
$3,856.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,740.32
|
| Rate for Payer: Multiplan Medicare/VA |
$607.84
|
| Rate for Payer: One Health Plan of WY PPO |
$3,778.88
|
| Rate for Payer: PacificSource Commercial |
$3,470.40
|
| Rate for Payer: PHCS PPO |
$3,663.20
|
| Rate for Payer: Three Rivers PPO |
$2,892.00
|
| Rate for Payer: TriWest Veterans Administration |
$715.10
|
| Rate for Payer: United Healthcare Commercial |
$3,354.72
|
| Rate for Payer: United Healthcare Medicare |
$715.10
|
| Rate for Payer: WINHealth Partners Commercial |
$3,277.60
|
|
|
CYSTORRHAPHY SUTR BLDR WND INJ/RPT SIMPLE
|
Professional
|
Both
|
$3,856.00
|
|
|
Service Code
|
HCPCS 51860
|
| Hospital Charge Code |
51860
|
| Min. Negotiated Rate |
$607.84 |
| Max. Negotiated Rate |
$3,856.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,778.88
|
| Rate for Payer: Aetna of WY Medicare |
$715.10
|
| Rate for Payer: Beech Street Commercial |
$3,663.20
|
| Rate for Payer: Cash Price |
$2,699.20
|
| Rate for Payer: Cash Price |
$2,699.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,740.32
|
| Rate for Payer: Cigna of WY Commercial |
$3,778.88
|
| Rate for Payer: First Choice Health Commercial |
$3,470.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,663.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$715.10
|
| Rate for Payer: HealthUtah PPO |
$3,856.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,740.32
|
| Rate for Payer: Multiplan Medicare/VA |
$607.84
|
| Rate for Payer: One Health Plan of WY PPO |
$3,778.88
|
| Rate for Payer: PacificSource Commercial |
$3,470.40
|
| Rate for Payer: PHCS PPO |
$3,663.20
|
| Rate for Payer: Three Rivers PPO |
$2,892.00
|
| Rate for Payer: TriWest Veterans Administration |
$715.10
|
| Rate for Payer: United Healthcare Commercial |
$3,354.72
|
| Rate for Payer: United Healthcare Medicare |
$715.10
|
| Rate for Payer: WINHealth Partners Commercial |
$3,277.60
|
|
|
CYSTOURETHROSCOPY
|
Professional
|
Both
|
$834.00
|
|
|
Service Code
|
HCPCS 52000
|
| Hospital Charge Code |
52000
|
| Min. Negotiated Rate |
$64.86 |
| Max. Negotiated Rate |
$834.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$817.32
|
| Rate for Payer: Aetna of WY Medicare |
$76.31
|
| Rate for Payer: Beech Street Commercial |
$792.30
|
| Rate for Payer: Cash Price |
$583.80
|
| Rate for Payer: Cash Price |
$583.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$808.98
|
| Rate for Payer: Cigna of WY Commercial |
$817.32
|
| Rate for Payer: First Choice Health Commercial |
$750.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$792.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$76.31
|
| Rate for Payer: HealthUtah PPO |
$834.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$808.98
|
| Rate for Payer: Multiplan Medicare/VA |
$64.86
|
| Rate for Payer: One Health Plan of WY PPO |
$817.32
|
| Rate for Payer: PacificSource Commercial |
$750.60
|
| Rate for Payer: PHCS PPO |
$792.30
|
| Rate for Payer: Three Rivers PPO |
$625.50
|
| Rate for Payer: TriWest Veterans Administration |
$76.31
|
| Rate for Payer: United Healthcare Commercial |
$725.58
|
| Rate for Payer: United Healthcare Medicare |
$76.31
|
| Rate for Payer: WINHealth Partners Commercial |
$708.90
|
|
|
CYSTO W/SIMPLE REMOVAL STONE & STENT
|
Professional
|
Both
|
$2,043.00
|
|
|
Service Code
|
HCPCS 52310
|
| Hospital Charge Code |
52310
|
| Min. Negotiated Rate |
$122.14 |
| Max. Negotiated Rate |
$2,043.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,002.14
|
| Rate for Payer: Aetna of WY Medicare |
$143.70
|
| Rate for Payer: Beech Street Commercial |
$1,940.85
|
| Rate for Payer: Cash Price |
$1,430.10
|
| Rate for Payer: Cash Price |
$1,430.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,981.71
|
| Rate for Payer: Cigna of WY Commercial |
$2,002.14
|
| Rate for Payer: First Choice Health Commercial |
$1,838.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,940.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$143.70
|
| Rate for Payer: HealthUtah PPO |
$2,043.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,981.71
|
| Rate for Payer: Multiplan Medicare/VA |
$122.14
|
| Rate for Payer: One Health Plan of WY PPO |
$2,002.14
|
| Rate for Payer: PacificSource Commercial |
$1,838.70
|
| Rate for Payer: PHCS PPO |
$1,940.85
|
| Rate for Payer: Three Rivers PPO |
$1,532.25
|
| Rate for Payer: TriWest Veterans Administration |
$143.70
|
| Rate for Payer: United Healthcare Commercial |
$1,777.41
|
| Rate for Payer: United Healthcare Medicare |
$143.70
|
| Rate for Payer: WINHealth Partners Commercial |
$1,736.55
|
|
|
CYTAL, PER SQUARE CENTIMETER
|
Professional
|
Both
|
$227.00
|
|
|
Service Code
|
HCPCS Q4166
|
| Hospital Charge Code |
Q4166
|
| Min. Negotiated Rate |
$16.32 |
| Max. Negotiated Rate |
$227.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$222.46
|
| Rate for Payer: Aetna of WY Medicare |
$19.20
|
| Rate for Payer: Beech Street Commercial |
$215.65
|
| Rate for Payer: Cash Price |
$158.90
|
| Rate for Payer: Cash Price |
$158.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$220.19
|
| Rate for Payer: Cigna of WY Commercial |
$222.46
|
| Rate for Payer: First Choice Health Commercial |
$204.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$215.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$19.20
|
| Rate for Payer: HealthUtah PPO |
$227.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$220.19
|
| Rate for Payer: Multiplan Medicare/VA |
$16.32
|
| Rate for Payer: One Health Plan of WY PPO |
$222.46
|
| Rate for Payer: PacificSource Commercial |
$204.30
|
| Rate for Payer: PHCS PPO |
$215.65
|
| Rate for Payer: Three Rivers PPO |
$170.25
|
| Rate for Payer: TriWest Veterans Administration |
$19.20
|
| Rate for Payer: United Healthcare Commercial |
$197.49
|
| Rate for Payer: United Healthcare Medicare |
$19.20
|
| Rate for Payer: WINHealth Partners Commercial |
$215.65
|
|
|
CYTARABINE (PF) 100 MG/5 ML (20 MG/ML) INJECTION SOLUTION [87075]
|
Facility
|
IP
|
$20.08
|
|
|
Service Code
|
HCPCS J9100
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.59 |
| Max. Negotiated Rate |
$20.08 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$19.68
|
| Rate for Payer: Altius Auto/Workers Compensation |
$19.28
|
| Rate for Payer: Altius Commercial |
$19.28
|
| Rate for Payer: Beech Street Commercial |
$19.68
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.49
|
| Rate for Payer: Cash Price |
$14.05
|
| Rate for Payer: ChoiceCare Network Commercial |
$19.48
|
| Rate for Payer: Cigna of WY Commercial |
$19.68
|
| Rate for Payer: Entrust Commercial |
$19.08
|
| Rate for Payer: First Choice Health Commercial |
$19.08
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$19.08
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$13.25
|
| Rate for Payer: HealthUtah PPO |
$20.08
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$19.48
|
| Rate for Payer: Multiplan Medicare/VA |
$12.59
|
| Rate for Payer: One Health Plan of WY PPO |
$19.68
|
| Rate for Payer: PacificSource Commercial |
$18.07
|
| Rate for Payer: PHCS PPO |
$19.68
|
| Rate for Payer: Three Rivers PPO |
$15.06
|
| Rate for Payer: TriWest Veterans Administration |
$13.25
|
| Rate for Payer: United Healthcare Commercial |
$17.47
|
| Rate for Payer: United Healthcare Medicare |
$13.25
|
| Rate for Payer: WINHealth Partners Commercial |
$19.08
|
| Rate for Payer: Wise Provider Network Commercial |
$19.08
|
|
