|
CYTARABINE (PF) 100 MG/5 ML (20 MG/ML) INJECTION SOLUTION [87075]
|
Facility
|
OP
|
$20.08
|
|
|
Service Code
|
HCPCS J9100
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.06 |
| Max. Negotiated Rate |
$20.08 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$19.68
|
| Rate for Payer: Aetna of WY Medicare |
$13.25
|
| 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 |
$11.65
|
| Rate for Payer: HealthUtah PPO |
$20.08
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$19.48
|
| Rate for Payer: Multiplan Medicare/VA |
$11.06
|
| 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 |
$11.65
|
| Rate for Payer: United Healthcare Commercial |
$17.47
|
| Rate for Payer: United Healthcare Medicare |
$11.65
|
| Rate for Payer: WINHealth Partners Commercial |
$19.68
|
| Rate for Payer: Wise Provider Network Commercial |
$19.08
|
|
|
CYTP CONCENTRATION SMEARS & INTERPRETATION
|
Professional
|
Both
|
$115.00
|
|
|
Service Code
|
HCPCS 88108
|
| Hospital Charge Code |
88108
|
| Min. Negotiated Rate |
$86.25 |
| Max. Negotiated Rate |
$115.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$112.70
|
| Rate for Payer: Beech Street Commercial |
$109.25
|
| Rate for Payer: Cash Price |
$80.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$111.55
|
| Rate for Payer: Cigna of WY Commercial |
$112.70
|
| Rate for Payer: First Choice Health Commercial |
$103.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$109.25
|
| Rate for Payer: HealthUtah PPO |
$115.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$111.55
|
| Rate for Payer: One Health Plan of WY PPO |
$112.70
|
| Rate for Payer: PacificSource Commercial |
$103.50
|
| Rate for Payer: PHCS PPO |
$109.25
|
| Rate for Payer: Three Rivers PPO |
$86.25
|
| Rate for Payer: United Healthcare Commercial |
$100.05
|
| Rate for Payer: WINHealth Partners Commercial |
$109.25
|
|
|
CYTP C/V AUTO THIN LYR PREPJ SCR SYS PHYS
|
Professional
|
Both
|
$60.00
|
|
|
Service Code
|
HCPCS 88174
|
| Hospital Charge Code |
88174
|
| Min. Negotiated Rate |
$21.56 |
| Max. Negotiated Rate |
$60.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$58.80
|
| Rate for Payer: Aetna of WY Medicare |
$25.37
|
| Rate for Payer: Beech Street Commercial |
$57.00
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$58.20
|
| Rate for Payer: Cigna of WY Commercial |
$58.80
|
| Rate for Payer: First Choice Health Commercial |
$54.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$57.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$25.37
|
| Rate for Payer: HealthUtah PPO |
$60.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$58.20
|
| Rate for Payer: Multiplan Medicare/VA |
$21.56
|
| Rate for Payer: One Health Plan of WY PPO |
$58.80
|
| Rate for Payer: PacificSource Commercial |
$54.00
|
| Rate for Payer: PHCS PPO |
$57.00
|
| Rate for Payer: Three Rivers PPO |
$45.00
|
| Rate for Payer: TriWest Veterans Administration |
$25.37
|
| Rate for Payer: United Healthcare Commercial |
$52.20
|
| Rate for Payer: United Healthcare Medicare |
$25.37
|
| Rate for Payer: WINHealth Partners Commercial |
$57.00
|
|
|
CYTP SLIDES CERV/VAG MNL SCRN PHYSICIAN SUPV
|
Professional
|
Both
|
$60.00
|
|
|
Service Code
|
HCPCS 88164
|
| Hospital Charge Code |
88164
|
| Min. Negotiated Rate |
$15.10 |
| Max. Negotiated Rate |
$60.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$58.80
|
| Rate for Payer: Aetna of WY Medicare |
$17.76
|
| Rate for Payer: Beech Street Commercial |
$57.00
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$58.20
|
| Rate for Payer: Cigna of WY Commercial |
$58.80
|
| Rate for Payer: First Choice Health Commercial |
$54.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$57.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$17.76
|
| Rate for Payer: HealthUtah PPO |
$60.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$58.20
|
| Rate for Payer: Multiplan Medicare/VA |
$15.10
|
| Rate for Payer: One Health Plan of WY PPO |
$58.80
|
| Rate for Payer: PacificSource Commercial |
$54.00
|
| Rate for Payer: PHCS PPO |
$57.00
|
| Rate for Payer: Three Rivers PPO |
$45.00
|
| Rate for Payer: TriWest Veterans Administration |
$17.76
|
| Rate for Payer: United Healthcare Commercial |
$52.20
|
| Rate for Payer: United Healthcare Medicare |
$17.76
|
| Rate for Payer: WINHealth Partners Commercial |
$57.00
|
|
|
DALBAVANCIN 500 MG INTRAVENOUS SOLUTION [136369]
|
Facility
|
IP
|
$1,794.13
|
|
|
Service Code
|
HCPCS J0875
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,124.92 |
| Max. Negotiated Rate |
$1,794.13 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,758.25
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,722.36
|
| Rate for Payer: Altius Commercial |
$1,722.36
|
| Rate for Payer: Beech Street Commercial |
$1,758.25
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,472.98
|
| Rate for Payer: Cash Price |
$1,255.89
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,740.31
|
| Rate for Payer: Cigna of WY Commercial |
$1,758.25
|
| Rate for Payer: Entrust Commercial |
$1,704.42
|
| Rate for Payer: First Choice Health Commercial |
$1,704.42
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,704.42
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,184.13
|
| Rate for Payer: HealthUtah PPO |
$1,794.13
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,740.31
|
| Rate for Payer: Multiplan Medicare/VA |
$1,124.92
|
| Rate for Payer: One Health Plan of WY PPO |
$1,758.25
|
| Rate for Payer: PacificSource Commercial |
$1,614.72
|
| Rate for Payer: PHCS PPO |
$1,758.25
|
| Rate for Payer: Three Rivers PPO |
$1,345.60
|
| Rate for Payer: TriWest Veterans Administration |
$1,184.13
|
| Rate for Payer: United Healthcare Commercial |
$1,560.89
|
| Rate for Payer: United Healthcare Medicare |
$1,184.13
|
| Rate for Payer: WINHealth Partners Commercial |
$1,704.42
|
| Rate for Payer: Wise Provider Network Commercial |
$1,704.42
|
|
|
DALBAVANCIN 500 MG INTRAVENOUS SOLUTION [136369]
|
Facility
|
OP
|
$1,794.13
|
|
|
Service Code
|
HCPCS J0875
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$988.57 |
| Max. Negotiated Rate |
$1,794.13 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,758.25
|
| Rate for Payer: Aetna of WY Medicare |
$1,184.13
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,722.36
|
| Rate for Payer: Altius Commercial |
$1,722.36
|
| Rate for Payer: Beech Street Commercial |
$1,758.25
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,472.98
|
| Rate for Payer: Cash Price |
$1,255.89
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,740.31
|
| Rate for Payer: Cigna of WY Commercial |
$1,758.25
|
| Rate for Payer: Entrust Commercial |
$1,704.42
|
| Rate for Payer: First Choice Health Commercial |
$1,704.42
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,704.42
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,040.60
|
| Rate for Payer: HealthUtah PPO |
$1,794.13
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,740.31
|
| Rate for Payer: Multiplan Medicare/VA |
$988.57
|
| Rate for Payer: One Health Plan of WY PPO |
$1,758.25
|
| Rate for Payer: PacificSource Commercial |
$1,614.72
|
| Rate for Payer: PHCS PPO |
$1,758.25
|
| Rate for Payer: Three Rivers PPO |
$1,345.60
|
| Rate for Payer: TriWest Veterans Administration |
$1,040.60
|
| Rate for Payer: United Healthcare Commercial |
$1,560.89
|
| Rate for Payer: United Healthcare Medicare |
$1,040.60
|
| Rate for Payer: WINHealth Partners Commercial |
$1,758.25
|
| Rate for Payer: Wise Provider Network Commercial |
$1,704.42
|
|
|
DANTROLENE 20 MG INTRAVENOUS SOLUTION [3097]
|
Facility
|
OP
|
$137.50
|
|
|
Service Code
|
NDC 2750500367
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$75.76 |
| Max. Negotiated Rate |
$137.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$134.75
|
| Rate for Payer: Aetna of WY Medicare |
$90.75
|
| Rate for Payer: Altius Auto/Workers Compensation |
$132.00
|
| Rate for Payer: Altius Commercial |
$132.00
|
| Rate for Payer: Beech Street Commercial |
$134.75
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$112.89
|
| Rate for Payer: Cash Price |
$96.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$133.38
|
| Rate for Payer: Cigna of WY Commercial |
$134.75
|
| Rate for Payer: Entrust Commercial |
$130.62
|
| Rate for Payer: First Choice Health Commercial |
$130.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$130.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$79.75
|
| Rate for Payer: HealthUtah PPO |
$137.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$133.38
|
| Rate for Payer: Multiplan Medicare/VA |
$75.76
|
| Rate for Payer: One Health Plan of WY PPO |
$134.75
|
| Rate for Payer: PacificSource Commercial |
$123.75
|
| Rate for Payer: PHCS PPO |
$134.75
|
| Rate for Payer: Three Rivers PPO |
$103.12
|
| Rate for Payer: TriWest Veterans Administration |
$79.75
|
| Rate for Payer: United Healthcare Commercial |
$119.62
|
| Rate for Payer: United Healthcare Medicare |
$79.75
|
| Rate for Payer: WINHealth Partners Commercial |
$134.75
|
| Rate for Payer: Wise Provider Network Commercial |
$130.62
|
|
|
DANTROLENE 20 MG INTRAVENOUS SOLUTION [3097]
|
Facility
|
OP
|
$137.50
|
|
|
Service Code
|
NDC 7867000367
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$75.76 |
| Max. Negotiated Rate |
$137.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$134.75
|
| Rate for Payer: Aetna of WY Medicare |
$90.75
|
| Rate for Payer: Altius Auto/Workers Compensation |
$132.00
|
| Rate for Payer: Altius Commercial |
$132.00
|
| Rate for Payer: Beech Street Commercial |
$134.75
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$112.89
|
| Rate for Payer: Cash Price |
$96.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$133.38
|
| Rate for Payer: Cigna of WY Commercial |
$134.75
|
| Rate for Payer: Entrust Commercial |
$130.62
|
| Rate for Payer: First Choice Health Commercial |
$130.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$130.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$79.75
|
| Rate for Payer: HealthUtah PPO |
$137.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$133.38
|
| Rate for Payer: Multiplan Medicare/VA |
$75.76
|
| Rate for Payer: One Health Plan of WY PPO |
$134.75
|
| Rate for Payer: PacificSource Commercial |
$123.75
|
| Rate for Payer: PHCS PPO |
$134.75
|
| Rate for Payer: Three Rivers PPO |
$103.12
|
| Rate for Payer: TriWest Veterans Administration |
$79.75
|
| Rate for Payer: United Healthcare Commercial |
$119.62
|
| Rate for Payer: United Healthcare Medicare |
$79.75
|
| Rate for Payer: WINHealth Partners Commercial |
$134.75
|
| Rate for Payer: Wise Provider Network Commercial |
$130.62
|
|
|
DANTROLENE 20 MG INTRAVENOUS SOLUTION [3097]
|
Facility
|
IP
|
$137.50
|
|
|
Service Code
|
NDC 7867000367
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$86.21 |
| Max. Negotiated Rate |
$137.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$134.75
|
| Rate for Payer: Altius Auto/Workers Compensation |
$132.00
|
| Rate for Payer: Altius Commercial |
$132.00
|
| Rate for Payer: Beech Street Commercial |
$134.75
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$112.89
|
| Rate for Payer: Cash Price |
$96.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$133.38
|
| Rate for Payer: Cigna of WY Commercial |
$134.75
|
| Rate for Payer: Entrust Commercial |
$130.62
|
| Rate for Payer: First Choice Health Commercial |
$130.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$130.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$90.75
|
| Rate for Payer: HealthUtah PPO |
$137.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$133.38
|
| Rate for Payer: Multiplan Medicare/VA |
$86.21
|
| Rate for Payer: One Health Plan of WY PPO |
$134.75
|
| Rate for Payer: PacificSource Commercial |
$123.75
|
| Rate for Payer: PHCS PPO |
$134.75
|
| Rate for Payer: Three Rivers PPO |
$103.12
|
| Rate for Payer: TriWest Veterans Administration |
$90.75
|
| Rate for Payer: United Healthcare Commercial |
$119.62
|
| Rate for Payer: United Healthcare Medicare |
$90.75
|
| Rate for Payer: WINHealth Partners Commercial |
$130.62
|
| Rate for Payer: Wise Provider Network Commercial |
$130.62
|
|
|
DANTROLENE 20 MG INTRAVENOUS SOLUTION [3097]
|
Facility
|
IP
|
$137.50
|
|
|
Service Code
|
NDC 2750500367
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$86.21 |
| Max. Negotiated Rate |
$137.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$134.75
|
| Rate for Payer: Altius Auto/Workers Compensation |
$132.00
|
| Rate for Payer: Altius Commercial |
$132.00
|
| Rate for Payer: Beech Street Commercial |
$134.75
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$112.89
|
| Rate for Payer: Cash Price |
$96.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$133.38
|
| Rate for Payer: Cigna of WY Commercial |
$134.75
|
| Rate for Payer: Entrust Commercial |
$130.62
|
| Rate for Payer: First Choice Health Commercial |
$130.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$130.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$90.75
|
| Rate for Payer: HealthUtah PPO |
$137.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$133.38
|
| Rate for Payer: Multiplan Medicare/VA |
$86.21
|
| Rate for Payer: One Health Plan of WY PPO |
$134.75
|
| Rate for Payer: PacificSource Commercial |
$123.75
|
| Rate for Payer: PHCS PPO |
$134.75
|
| Rate for Payer: Three Rivers PPO |
$103.12
|
| Rate for Payer: TriWest Veterans Administration |
$90.75
|
| Rate for Payer: United Healthcare Commercial |
$119.62
|
| Rate for Payer: United Healthcare Medicare |
$90.75
|
| Rate for Payer: WINHealth Partners Commercial |
$130.62
|
| Rate for Payer: Wise Provider Network Commercial |
$130.62
|
|
|
DAPAGLIFLOZIN PROPANEDIOL 10 MG TABLET [131704]
|
Facility
|
IP
|
$34.69
|
|
|
Service Code
|
NDC 6699345730
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.75 |
| Max. Negotiated Rate |
$34.69 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$34.00
|
| Rate for Payer: Altius Auto/Workers Compensation |
$33.30
|
| Rate for Payer: Altius Commercial |
$33.30
|
| Rate for Payer: Beech Street Commercial |
$34.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$28.48
|
| Rate for Payer: Cash Price |
$24.28
|
| Rate for Payer: ChoiceCare Network Commercial |
$33.65
|
| Rate for Payer: Cigna of WY Commercial |
$34.00
|
| Rate for Payer: Entrust Commercial |
$32.96
|
| Rate for Payer: First Choice Health Commercial |
$32.96
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$32.96
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$22.90
|
| Rate for Payer: HealthUtah PPO |
$34.69
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$33.65
|
| Rate for Payer: Multiplan Medicare/VA |
$21.75
|
| Rate for Payer: One Health Plan of WY PPO |
$34.00
|
| Rate for Payer: PacificSource Commercial |
$31.22
|
| Rate for Payer: PHCS PPO |
$34.00
|
| Rate for Payer: Three Rivers PPO |
$26.02
|
| Rate for Payer: TriWest Veterans Administration |
$22.90
|
| Rate for Payer: United Healthcare Commercial |
$30.18
|
| Rate for Payer: United Healthcare Medicare |
$22.90
|
| Rate for Payer: WINHealth Partners Commercial |
$32.96
|
| Rate for Payer: Wise Provider Network Commercial |
$32.96
|
|
|
DAPAGLIFLOZIN PROPANEDIOL 10 MG TABLET [131704]
|
Facility
|
IP
|
$44.98
|
|
|
Service Code
|
NDC 0310621039
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.20 |
| Max. Negotiated Rate |
$44.98 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$44.08
|
| Rate for Payer: Altius Auto/Workers Compensation |
$43.18
|
| Rate for Payer: Altius Commercial |
$43.18
|
| Rate for Payer: Beech Street Commercial |
$44.08
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$36.93
|
| Rate for Payer: Cash Price |
$31.49
|
| Rate for Payer: ChoiceCare Network Commercial |
$43.63
|
| Rate for Payer: Cigna of WY Commercial |
$44.08
|
| Rate for Payer: Entrust Commercial |
$42.73
|
| Rate for Payer: First Choice Health Commercial |
$42.73
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$42.73
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$29.69
|
| Rate for Payer: HealthUtah PPO |
$44.98
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$43.63
|
| Rate for Payer: Multiplan Medicare/VA |
$28.20
|
| Rate for Payer: One Health Plan of WY PPO |
$44.08
|
| Rate for Payer: PacificSource Commercial |
$40.48
|
| Rate for Payer: PHCS PPO |
$44.08
|
| Rate for Payer: Three Rivers PPO |
$33.74
|
| Rate for Payer: TriWest Veterans Administration |
$29.69
|
| Rate for Payer: United Healthcare Commercial |
$39.13
|
| Rate for Payer: United Healthcare Medicare |
$29.69
|
| Rate for Payer: WINHealth Partners Commercial |
$42.73
|
| Rate for Payer: Wise Provider Network Commercial |
$42.73
|
|
|
DAPAGLIFLOZIN PROPANEDIOL 10 MG TABLET [131704]
|
Facility
|
IP
|
$44.98
|
|
|
Service Code
|
NDC 0310621030
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.20 |
| Max. Negotiated Rate |
$44.98 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$44.08
|
| Rate for Payer: Altius Auto/Workers Compensation |
$43.18
|
| Rate for Payer: Altius Commercial |
$43.18
|
| Rate for Payer: Beech Street Commercial |
$44.08
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$36.93
|
| Rate for Payer: Cash Price |
$31.49
|
| Rate for Payer: ChoiceCare Network Commercial |
$43.63
|
| Rate for Payer: Cigna of WY Commercial |
$44.08
|
| Rate for Payer: Entrust Commercial |
$42.73
|
| Rate for Payer: First Choice Health Commercial |
$42.73
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$42.73
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$29.69
|
| Rate for Payer: HealthUtah PPO |
$44.98
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$43.63
|
| Rate for Payer: Multiplan Medicare/VA |
$28.20
|
| Rate for Payer: One Health Plan of WY PPO |
$44.08
|
| Rate for Payer: PacificSource Commercial |
$40.48
|
| Rate for Payer: PHCS PPO |
$44.08
|
| Rate for Payer: Three Rivers PPO |
$33.74
|
| Rate for Payer: TriWest Veterans Administration |
$29.69
|
| Rate for Payer: United Healthcare Commercial |
$39.13
|
| Rate for Payer: United Healthcare Medicare |
$29.69
|
| Rate for Payer: WINHealth Partners Commercial |
$42.73
|
| Rate for Payer: Wise Provider Network Commercial |
$42.73
|
|
|
DAPAGLIFLOZIN PROPANEDIOL 10 MG TABLET [131704]
|
Facility
|
OP
|
$44.98
|
|
|
Service Code
|
NDC 0310621030
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.78 |
| Max. Negotiated Rate |
$44.98 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$44.08
|
| Rate for Payer: Aetna of WY Medicare |
$29.69
|
| Rate for Payer: Altius Auto/Workers Compensation |
$43.18
|
| Rate for Payer: Altius Commercial |
$43.18
|
| Rate for Payer: Beech Street Commercial |
$44.08
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$36.93
|
| Rate for Payer: Cash Price |
$31.49
|
| Rate for Payer: ChoiceCare Network Commercial |
$43.63
|
| Rate for Payer: Cigna of WY Commercial |
$44.08
|
| Rate for Payer: Entrust Commercial |
$42.73
|
| Rate for Payer: First Choice Health Commercial |
$42.73
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$42.73
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$26.09
|
| Rate for Payer: HealthUtah PPO |
$44.98
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$43.63
|
| Rate for Payer: Multiplan Medicare/VA |
$24.78
|
| Rate for Payer: One Health Plan of WY PPO |
$44.08
|
| Rate for Payer: PacificSource Commercial |
$40.48
|
| Rate for Payer: PHCS PPO |
$44.08
|
| Rate for Payer: Three Rivers PPO |
$33.74
|
| Rate for Payer: TriWest Veterans Administration |
$26.09
|
| Rate for Payer: United Healthcare Commercial |
$39.13
|
| Rate for Payer: United Healthcare Medicare |
$26.09
|
| Rate for Payer: WINHealth Partners Commercial |
$44.08
|
| Rate for Payer: Wise Provider Network Commercial |
$42.73
|
|
|
DAPAGLIFLOZIN PROPANEDIOL 10 MG TABLET [131704]
|
Facility
|
OP
|
$34.69
|
|
|
Service Code
|
NDC 6699345730
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.11 |
| Max. Negotiated Rate |
$34.69 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$34.00
|
| Rate for Payer: Aetna of WY Medicare |
$22.90
|
| Rate for Payer: Altius Auto/Workers Compensation |
$33.30
|
| Rate for Payer: Altius Commercial |
$33.30
|
| Rate for Payer: Beech Street Commercial |
$34.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$28.48
|
| Rate for Payer: Cash Price |
$24.28
|
| Rate for Payer: ChoiceCare Network Commercial |
$33.65
|
| Rate for Payer: Cigna of WY Commercial |
$34.00
|
| Rate for Payer: Entrust Commercial |
$32.96
|
| Rate for Payer: First Choice Health Commercial |
$32.96
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$32.96
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$20.12
|
| Rate for Payer: HealthUtah PPO |
$34.69
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$33.65
|
| Rate for Payer: Multiplan Medicare/VA |
$19.11
|
| Rate for Payer: One Health Plan of WY PPO |
$34.00
|
| Rate for Payer: PacificSource Commercial |
$31.22
|
| Rate for Payer: PHCS PPO |
$34.00
|
| Rate for Payer: Three Rivers PPO |
$26.02
|
| Rate for Payer: TriWest Veterans Administration |
$20.12
|
| Rate for Payer: United Healthcare Commercial |
$30.18
|
| Rate for Payer: United Healthcare Medicare |
$20.12
|
| Rate for Payer: WINHealth Partners Commercial |
$34.00
|
| Rate for Payer: Wise Provider Network Commercial |
$32.96
|
|
|
DAPAGLIFLOZIN PROPANEDIOL 10 MG TABLET [131704]
|
Facility
|
OP
|
$44.98
|
|
|
Service Code
|
NDC 0310621039
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.78 |
| Max. Negotiated Rate |
$44.98 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$44.08
|
| Rate for Payer: Aetna of WY Medicare |
$29.69
|
| Rate for Payer: Altius Auto/Workers Compensation |
$43.18
|
| Rate for Payer: Altius Commercial |
$43.18
|
| Rate for Payer: Beech Street Commercial |
$44.08
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$36.93
|
| Rate for Payer: Cash Price |
$31.49
|
| Rate for Payer: ChoiceCare Network Commercial |
$43.63
|
| Rate for Payer: Cigna of WY Commercial |
$44.08
|
| Rate for Payer: Entrust Commercial |
$42.73
|
| Rate for Payer: First Choice Health Commercial |
$42.73
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$42.73
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$26.09
|
| Rate for Payer: HealthUtah PPO |
$44.98
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$43.63
|
| Rate for Payer: Multiplan Medicare/VA |
$24.78
|
| Rate for Payer: One Health Plan of WY PPO |
$44.08
|
| Rate for Payer: PacificSource Commercial |
$40.48
|
| Rate for Payer: PHCS PPO |
$44.08
|
| Rate for Payer: Three Rivers PPO |
$33.74
|
| Rate for Payer: TriWest Veterans Administration |
$26.09
|
| Rate for Payer: United Healthcare Commercial |
$39.13
|
| Rate for Payer: United Healthcare Medicare |
$26.09
|
| Rate for Payer: WINHealth Partners Commercial |
$44.08
|
| Rate for Payer: Wise Provider Network Commercial |
$42.73
|
|
|
DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION [30872]
|
Facility
|
IP
|
$75.00
|
|
|
Service Code
|
HCPCS J0878
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.02 |
| Max. Negotiated Rate |
$75.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$73.50
|
| Rate for Payer: Altius Auto/Workers Compensation |
$72.00
|
| Rate for Payer: Altius Commercial |
$72.00
|
| Rate for Payer: Beech Street Commercial |
$73.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$61.58
|
| Rate for Payer: Cash Price |
$52.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$72.75
|
| Rate for Payer: Cigna of WY Commercial |
$73.50
|
| Rate for Payer: Entrust Commercial |
$71.25
|
| Rate for Payer: First Choice Health Commercial |
$71.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$71.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$49.50
|
| Rate for Payer: HealthUtah PPO |
$75.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$72.75
|
| Rate for Payer: Multiplan Medicare/VA |
$47.02
|
| Rate for Payer: One Health Plan of WY PPO |
$73.50
|
| Rate for Payer: PacificSource Commercial |
$67.50
|
| Rate for Payer: PHCS PPO |
$73.50
|
| Rate for Payer: Three Rivers PPO |
$56.25
|
| Rate for Payer: TriWest Veterans Administration |
$49.50
|
| Rate for Payer: United Healthcare Commercial |
$65.25
|
| Rate for Payer: United Healthcare Medicare |
$49.50
|
| Rate for Payer: WINHealth Partners Commercial |
$71.25
|
| Rate for Payer: Wise Provider Network Commercial |
$71.25
|
|
|
DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION [30872]
|
Facility
|
OP
|
$75.00
|
|
|
Service Code
|
HCPCS J0878
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$41.32 |
| Max. Negotiated Rate |
$75.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$73.50
|
| Rate for Payer: Aetna of WY Medicare |
$49.50
|
| Rate for Payer: Altius Auto/Workers Compensation |
$72.00
|
| Rate for Payer: Altius Commercial |
$72.00
|
| Rate for Payer: Beech Street Commercial |
$73.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$61.58
|
| Rate for Payer: Cash Price |
$52.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$72.75
|
| Rate for Payer: Cigna of WY Commercial |
$73.50
|
| Rate for Payer: Entrust Commercial |
$71.25
|
| Rate for Payer: First Choice Health Commercial |
$71.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$71.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$43.50
|
| Rate for Payer: HealthUtah PPO |
$75.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$72.75
|
| Rate for Payer: Multiplan Medicare/VA |
$41.32
|
| Rate for Payer: One Health Plan of WY PPO |
$73.50
|
| Rate for Payer: PacificSource Commercial |
$67.50
|
| Rate for Payer: PHCS PPO |
$73.50
|
| Rate for Payer: Three Rivers PPO |
$56.25
|
| Rate for Payer: TriWest Veterans Administration |
$43.50
|
| Rate for Payer: United Healthcare Commercial |
$65.25
|
| Rate for Payer: United Healthcare Medicare |
$43.50
|
| Rate for Payer: WINHealth Partners Commercial |
$73.50
|
| Rate for Payer: Wise Provider Network Commercial |
$71.25
|
|
|
DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN [158862]
|
Facility
|
IP
|
$607.91
|
|
|
Service Code
|
HCPCS J9144
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$381.16 |
| Max. Negotiated Rate |
$607.91 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$595.75
|
| Rate for Payer: Altius Auto/Workers Compensation |
$583.59
|
| Rate for Payer: Altius Commercial |
$583.59
|
| Rate for Payer: Beech Street Commercial |
$595.75
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$499.09
|
| Rate for Payer: Cash Price |
$425.53
|
| Rate for Payer: ChoiceCare Network Commercial |
$589.67
|
| Rate for Payer: Cigna of WY Commercial |
$595.75
|
| Rate for Payer: Entrust Commercial |
$577.51
|
| Rate for Payer: First Choice Health Commercial |
$577.51
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$577.51
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$401.22
|
| Rate for Payer: HealthUtah PPO |
$607.91
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$589.67
|
| Rate for Payer: Multiplan Medicare/VA |
$381.16
|
| Rate for Payer: One Health Plan of WY PPO |
$595.75
|
| Rate for Payer: PacificSource Commercial |
$547.12
|
| Rate for Payer: PHCS PPO |
$595.75
|
| Rate for Payer: Three Rivers PPO |
$455.93
|
| Rate for Payer: TriWest Veterans Administration |
$401.22
|
| Rate for Payer: United Healthcare Commercial |
$528.88
|
| Rate for Payer: United Healthcare Medicare |
$401.22
|
| Rate for Payer: WINHealth Partners Commercial |
$577.51
|
| Rate for Payer: Wise Provider Network Commercial |
$577.51
|
|
|
DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN [158862]
|
Facility
|
OP
|
$607.91
|
|
|
Service Code
|
HCPCS J9144
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$334.96 |
| Max. Negotiated Rate |
$607.91 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$595.75
|
| Rate for Payer: Aetna of WY Medicare |
$401.22
|
| Rate for Payer: Altius Auto/Workers Compensation |
$583.59
|
| Rate for Payer: Altius Commercial |
$583.59
|
| Rate for Payer: Beech Street Commercial |
$595.75
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$499.09
|
| Rate for Payer: Cash Price |
$425.53
|
| Rate for Payer: ChoiceCare Network Commercial |
$589.67
|
| Rate for Payer: Cigna of WY Commercial |
$595.75
|
| Rate for Payer: Entrust Commercial |
$577.51
|
| Rate for Payer: First Choice Health Commercial |
$577.51
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$577.51
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$352.59
|
| Rate for Payer: HealthUtah PPO |
$607.91
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$589.67
|
| Rate for Payer: Multiplan Medicare/VA |
$334.96
|
| Rate for Payer: One Health Plan of WY PPO |
$595.75
|
| Rate for Payer: PacificSource Commercial |
$547.12
|
| Rate for Payer: PHCS PPO |
$595.75
|
| Rate for Payer: Three Rivers PPO |
$455.93
|
| Rate for Payer: TriWest Veterans Administration |
$352.59
|
| Rate for Payer: United Healthcare Commercial |
$528.88
|
| Rate for Payer: United Healthcare Medicare |
$352.59
|
| Rate for Payer: WINHealth Partners Commercial |
$595.75
|
| Rate for Payer: Wise Provider Network Commercial |
$577.51
|
|
|
DARBEPOETIN ALFA 100 MCG/ML IN POLYSORBATE INJECTION [41905]
|
Facility
|
IP
|
$789.00
|
|
|
Service Code
|
HCPCS J0881
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$494.70 |
| Max. Negotiated Rate |
$789.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$773.22
|
| Rate for Payer: Altius Auto/Workers Compensation |
$757.44
|
| Rate for Payer: Altius Commercial |
$757.44
|
| Rate for Payer: Beech Street Commercial |
$773.22
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$647.77
|
| Rate for Payer: Cash Price |
$552.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$765.33
|
| Rate for Payer: Cigna of WY Commercial |
$773.22
|
| Rate for Payer: Entrust Commercial |
$749.55
|
| Rate for Payer: First Choice Health Commercial |
$749.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$749.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$520.74
|
| Rate for Payer: HealthUtah PPO |
$789.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$765.33
|
| Rate for Payer: Multiplan Medicare/VA |
$494.70
|
| Rate for Payer: One Health Plan of WY PPO |
$773.22
|
| Rate for Payer: PacificSource Commercial |
$710.10
|
| Rate for Payer: PHCS PPO |
$773.22
|
| Rate for Payer: Three Rivers PPO |
$591.75
|
| Rate for Payer: TriWest Veterans Administration |
$520.74
|
| Rate for Payer: United Healthcare Commercial |
$686.43
|
| Rate for Payer: United Healthcare Medicare |
$520.74
|
| Rate for Payer: WINHealth Partners Commercial |
$749.55
|
| Rate for Payer: Wise Provider Network Commercial |
$749.55
|
|
|
DARBEPOETIN ALFA 100 MCG/ML IN POLYSORBATE INJECTION [41905]
|
Facility
|
OP
|
$789.00
|
|
|
Service Code
|
HCPCS J0881
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$434.74 |
| Max. Negotiated Rate |
$789.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$773.22
|
| Rate for Payer: Aetna of WY Medicare |
$520.74
|
| Rate for Payer: Altius Auto/Workers Compensation |
$757.44
|
| Rate for Payer: Altius Commercial |
$757.44
|
| Rate for Payer: Beech Street Commercial |
$773.22
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$647.77
|
| Rate for Payer: Cash Price |
$552.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$765.33
|
| Rate for Payer: Cigna of WY Commercial |
$773.22
|
| Rate for Payer: Entrust Commercial |
$749.55
|
| Rate for Payer: First Choice Health Commercial |
$749.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$749.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$457.62
|
| Rate for Payer: HealthUtah PPO |
$789.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$765.33
|
| Rate for Payer: Multiplan Medicare/VA |
$434.74
|
| Rate for Payer: One Health Plan of WY PPO |
$773.22
|
| Rate for Payer: PacificSource Commercial |
$710.10
|
| Rate for Payer: PHCS PPO |
$773.22
|
| Rate for Payer: Three Rivers PPO |
$591.75
|
| Rate for Payer: TriWest Veterans Administration |
$457.62
|
| Rate for Payer: United Healthcare Commercial |
$686.43
|
| Rate for Payer: United Healthcare Medicare |
$457.62
|
| Rate for Payer: WINHealth Partners Commercial |
$773.22
|
| Rate for Payer: Wise Provider Network Commercial |
$749.55
|
|
|
DARBEPOETIN ALFA 10 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE [140288]
|
Facility
|
OP
|
$305.25
|
|
|
Service Code
|
HCPCS J0881
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$168.19 |
| Max. Negotiated Rate |
$305.25 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$299.14
|
| Rate for Payer: Aetna of WY Medicare |
$201.46
|
| Rate for Payer: Altius Auto/Workers Compensation |
$293.04
|
| Rate for Payer: Altius Commercial |
$293.04
|
| Rate for Payer: Beech Street Commercial |
$299.14
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$250.61
|
| Rate for Payer: Cash Price |
$213.67
|
| Rate for Payer: ChoiceCare Network Commercial |
$296.09
|
| Rate for Payer: Cigna of WY Commercial |
$299.14
|
| Rate for Payer: Entrust Commercial |
$289.99
|
| Rate for Payer: First Choice Health Commercial |
$289.99
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$289.99
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$177.04
|
| Rate for Payer: HealthUtah PPO |
$305.25
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$296.09
|
| Rate for Payer: Multiplan Medicare/VA |
$168.19
|
| Rate for Payer: One Health Plan of WY PPO |
$299.14
|
| Rate for Payer: PacificSource Commercial |
$274.72
|
| Rate for Payer: PHCS PPO |
$299.14
|
| Rate for Payer: Three Rivers PPO |
$228.94
|
| Rate for Payer: TriWest Veterans Administration |
$177.04
|
| Rate for Payer: United Healthcare Commercial |
$265.57
|
| Rate for Payer: United Healthcare Medicare |
$177.04
|
| Rate for Payer: WINHealth Partners Commercial |
$299.14
|
| Rate for Payer: Wise Provider Network Commercial |
$289.99
|
|
|
DARBEPOETIN ALFA 10 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE [140288]
|
Facility
|
IP
|
$305.25
|
|
|
Service Code
|
HCPCS J0881
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$191.39 |
| Max. Negotiated Rate |
$305.25 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$299.14
|
| Rate for Payer: Altius Auto/Workers Compensation |
$293.04
|
| Rate for Payer: Altius Commercial |
$293.04
|
| Rate for Payer: Beech Street Commercial |
$299.14
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$250.61
|
| Rate for Payer: Cash Price |
$213.67
|
| Rate for Payer: ChoiceCare Network Commercial |
$296.09
|
| Rate for Payer: Cigna of WY Commercial |
$299.14
|
| Rate for Payer: Entrust Commercial |
$289.99
|
| Rate for Payer: First Choice Health Commercial |
$289.99
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$289.99
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$201.46
|
| Rate for Payer: HealthUtah PPO |
$305.25
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$296.09
|
| Rate for Payer: Multiplan Medicare/VA |
$191.39
|
| Rate for Payer: One Health Plan of WY PPO |
$299.14
|
| Rate for Payer: PacificSource Commercial |
$274.72
|
| Rate for Payer: PHCS PPO |
$299.14
|
| Rate for Payer: Three Rivers PPO |
$228.94
|
| Rate for Payer: TriWest Veterans Administration |
$201.46
|
| Rate for Payer: United Healthcare Commercial |
$265.57
|
| Rate for Payer: United Healthcare Medicare |
$201.46
|
| Rate for Payer: WINHealth Partners Commercial |
$289.99
|
| Rate for Payer: Wise Provider Network Commercial |
$289.99
|
|
|
DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE [41766]
|
Facility
|
OP
|
$5,820.00
|
|
|
Service Code
|
HCPCS J0881
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,206.82 |
| Max. Negotiated Rate |
$5,820.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5,703.60
|
| Rate for Payer: Aetna of WY Medicare |
$3,841.20
|
| Rate for Payer: Altius Auto/Workers Compensation |
$5,587.20
|
| Rate for Payer: Altius Commercial |
$5,587.20
|
| Rate for Payer: Beech Street Commercial |
$5,703.60
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$4,778.22
|
| Rate for Payer: Cash Price |
$4,074.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$5,645.40
|
| Rate for Payer: Cigna of WY Commercial |
$5,703.60
|
| Rate for Payer: Entrust Commercial |
$5,529.00
|
| Rate for Payer: First Choice Health Commercial |
$5,529.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5,529.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3,375.60
|
| Rate for Payer: HealthUtah PPO |
$5,820.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5,645.40
|
| Rate for Payer: Multiplan Medicare/VA |
$3,206.82
|
| Rate for Payer: One Health Plan of WY PPO |
$5,703.60
|
| Rate for Payer: PacificSource Commercial |
$5,238.00
|
| Rate for Payer: PHCS PPO |
$5,703.60
|
| Rate for Payer: Three Rivers PPO |
$4,365.00
|
| Rate for Payer: TriWest Veterans Administration |
$3,375.60
|
| Rate for Payer: United Healthcare Commercial |
$5,063.40
|
| Rate for Payer: United Healthcare Medicare |
$3,375.60
|
| Rate for Payer: WINHealth Partners Commercial |
$5,703.60
|
| Rate for Payer: Wise Provider Network Commercial |
$5,529.00
|
|
