|
ALUMI-HAND XL STUCKI
|
Facility
|
OP
|
$154.00
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$84.85 |
| Max. Negotiated Rate |
$154.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$150.92
|
| Rate for Payer: Aetna of WY Medicare |
$101.64
|
| Rate for Payer: Altius Auto/Workers Compensation |
$147.84
|
| Rate for Payer: Altius Commercial |
$147.84
|
| Rate for Payer: Beech Street Commercial |
$150.92
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$126.43
|
| Rate for Payer: Cash Price |
$107.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$149.38
|
| Rate for Payer: Cigna of WY Commercial |
$150.92
|
| Rate for Payer: Entrust Commercial |
$146.30
|
| Rate for Payer: First Choice Health Commercial |
$146.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$146.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$89.32
|
| Rate for Payer: HealthUtah PPO |
$154.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$149.38
|
| Rate for Payer: Multiplan Medicare/VA |
$84.85
|
| Rate for Payer: One Health Plan of WY PPO |
$150.92
|
| Rate for Payer: PacificSource Commercial |
$138.60
|
| Rate for Payer: PHCS PPO |
$150.92
|
| Rate for Payer: Three Rivers PPO |
$115.50
|
| Rate for Payer: TriWest Veterans Administration |
$89.32
|
| Rate for Payer: United Healthcare Commercial |
$133.98
|
| Rate for Payer: United Healthcare Medicare |
$89.32
|
| Rate for Payer: WINHealth Partners Commercial |
$150.92
|
| Rate for Payer: Wise Provider Network Commercial |
$146.30
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP [19884]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 0904572514
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.04
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.04
|
| Rate for Payer: Altius Commercial |
$0.04
|
| Rate for Payer: Beech Street Commercial |
$0.04
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.03
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.04
|
| Rate for Payer: Cigna of WY Commercial |
$0.04
|
| Rate for Payer: Entrust Commercial |
$0.04
|
| Rate for Payer: First Choice Health Commercial |
$0.04
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.04
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.03
|
| Rate for Payer: HealthUtah PPO |
$0.04
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.04
|
| Rate for Payer: Multiplan Medicare/VA |
$0.03
|
| Rate for Payer: One Health Plan of WY PPO |
$0.04
|
| Rate for Payer: PacificSource Commercial |
$0.04
|
| Rate for Payer: PHCS PPO |
$0.04
|
| Rate for Payer: Three Rivers PPO |
$0.03
|
| Rate for Payer: TriWest Veterans Administration |
$0.03
|
| Rate for Payer: United Healthcare Commercial |
$0.03
|
| Rate for Payer: United Healthcare Medicare |
$0.03
|
| Rate for Payer: WINHealth Partners Commercial |
$0.04
|
| Rate for Payer: Wise Provider Network Commercial |
$0.04
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP [19884]
|
Facility
|
OP
|
$0.50
|
|
|
Service Code
|
NDC 0121176230
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.49
|
| Rate for Payer: Aetna of WY Medicare |
$0.33
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.48
|
| Rate for Payer: Altius Commercial |
$0.48
|
| Rate for Payer: Beech Street Commercial |
$0.49
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.41
|
| Rate for Payer: Cash Price |
$0.35
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.49
|
| Rate for Payer: Cigna of WY Commercial |
$0.49
|
| Rate for Payer: Entrust Commercial |
$0.48
|
| Rate for Payer: First Choice Health Commercial |
$0.48
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.48
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.29
|
| Rate for Payer: HealthUtah PPO |
$0.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.49
|
| Rate for Payer: Multiplan Medicare/VA |
$0.28
|
| Rate for Payer: One Health Plan of WY PPO |
$0.49
|
| Rate for Payer: PacificSource Commercial |
$0.45
|
| Rate for Payer: PHCS PPO |
$0.49
|
| Rate for Payer: Three Rivers PPO |
$0.38
|
| Rate for Payer: TriWest Veterans Administration |
$0.29
|
| Rate for Payer: United Healthcare Commercial |
$0.44
|
| Rate for Payer: United Healthcare Medicare |
$0.29
|
| Rate for Payer: WINHealth Partners Commercial |
$0.49
|
| Rate for Payer: Wise Provider Network Commercial |
$0.48
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP [19884]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 0904572514
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.04
|
| Rate for Payer: Aetna of WY Medicare |
$0.03
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.04
|
| Rate for Payer: Altius Commercial |
$0.04
|
| Rate for Payer: Beech Street Commercial |
$0.04
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.03
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.04
|
| Rate for Payer: Cigna of WY Commercial |
$0.04
|
| Rate for Payer: Entrust Commercial |
$0.04
|
| Rate for Payer: First Choice Health Commercial |
$0.04
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.04
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.02
|
| Rate for Payer: HealthUtah PPO |
$0.04
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.04
|
| Rate for Payer: Multiplan Medicare/VA |
$0.02
|
| Rate for Payer: One Health Plan of WY PPO |
$0.04
|
| Rate for Payer: PacificSource Commercial |
$0.04
|
| Rate for Payer: PHCS PPO |
$0.04
|
| Rate for Payer: Three Rivers PPO |
$0.03
|
| Rate for Payer: TriWest Veterans Administration |
$0.02
|
| Rate for Payer: United Healthcare Commercial |
$0.03
|
| Rate for Payer: United Healthcare Medicare |
$0.02
|
| Rate for Payer: WINHealth Partners Commercial |
$0.04
|
| Rate for Payer: Wise Provider Network Commercial |
$0.04
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP [19884]
|
Facility
|
IP
|
$0.50
|
|
|
Service Code
|
NDC 0121176230
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.49
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.48
|
| Rate for Payer: Altius Commercial |
$0.48
|
| Rate for Payer: Beech Street Commercial |
$0.49
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.41
|
| Rate for Payer: Cash Price |
$0.35
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.49
|
| Rate for Payer: Cigna of WY Commercial |
$0.49
|
| Rate for Payer: Entrust Commercial |
$0.48
|
| Rate for Payer: First Choice Health Commercial |
$0.48
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.48
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.33
|
| Rate for Payer: HealthUtah PPO |
$0.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.49
|
| Rate for Payer: Multiplan Medicare/VA |
$0.31
|
| Rate for Payer: One Health Plan of WY PPO |
$0.49
|
| Rate for Payer: PacificSource Commercial |
$0.45
|
| Rate for Payer: PHCS PPO |
$0.49
|
| Rate for Payer: Three Rivers PPO |
$0.38
|
| Rate for Payer: TriWest Veterans Administration |
$0.33
|
| Rate for Payer: United Healthcare Commercial |
$0.44
|
| Rate for Payer: United Healthcare Medicare |
$0.33
|
| Rate for Payer: WINHealth Partners Commercial |
$0.48
|
| Rate for Payer: Wise Provider Network Commercial |
$0.48
|
|
|
ALVIMOPAN 12 MG CAPSULE [54040]
|
Facility
|
IP
|
$248.76
|
|
|
Service Code
|
NDC 0054066882
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$155.97 |
| Max. Negotiated Rate |
$248.76 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$243.78
|
| Rate for Payer: Altius Auto/Workers Compensation |
$238.81
|
| Rate for Payer: Altius Commercial |
$238.81
|
| Rate for Payer: Beech Street Commercial |
$243.78
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$204.23
|
| Rate for Payer: Cash Price |
$174.13
|
| Rate for Payer: ChoiceCare Network Commercial |
$241.30
|
| Rate for Payer: Cigna of WY Commercial |
$243.78
|
| Rate for Payer: Entrust Commercial |
$236.32
|
| Rate for Payer: First Choice Health Commercial |
$236.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$236.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$164.18
|
| Rate for Payer: HealthUtah PPO |
$248.76
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$241.30
|
| Rate for Payer: Multiplan Medicare/VA |
$155.97
|
| Rate for Payer: One Health Plan of WY PPO |
$243.78
|
| Rate for Payer: PacificSource Commercial |
$223.88
|
| Rate for Payer: PHCS PPO |
$243.78
|
| Rate for Payer: Three Rivers PPO |
$186.57
|
| Rate for Payer: TriWest Veterans Administration |
$164.18
|
| Rate for Payer: United Healthcare Commercial |
$216.42
|
| Rate for Payer: United Healthcare Medicare |
$164.18
|
| Rate for Payer: WINHealth Partners Commercial |
$236.32
|
| Rate for Payer: Wise Provider Network Commercial |
$236.32
|
|
|
ALVIMOPAN 12 MG CAPSULE [54040]
|
Facility
|
IP
|
$235.66
|
|
|
Service Code
|
NDC 0591231245
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$147.76 |
| Max. Negotiated Rate |
$235.66 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$230.95
|
| Rate for Payer: Altius Auto/Workers Compensation |
$226.23
|
| Rate for Payer: Altius Commercial |
$226.23
|
| Rate for Payer: Beech Street Commercial |
$230.95
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$193.48
|
| Rate for Payer: Cash Price |
$164.97
|
| Rate for Payer: ChoiceCare Network Commercial |
$228.59
|
| Rate for Payer: Cigna of WY Commercial |
$230.95
|
| Rate for Payer: Entrust Commercial |
$223.88
|
| Rate for Payer: First Choice Health Commercial |
$223.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$223.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$155.54
|
| Rate for Payer: HealthUtah PPO |
$235.66
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$228.59
|
| Rate for Payer: Multiplan Medicare/VA |
$147.76
|
| Rate for Payer: One Health Plan of WY PPO |
$230.95
|
| Rate for Payer: PacificSource Commercial |
$212.09
|
| Rate for Payer: PHCS PPO |
$230.95
|
| Rate for Payer: Three Rivers PPO |
$176.74
|
| Rate for Payer: TriWest Veterans Administration |
$155.54
|
| Rate for Payer: United Healthcare Commercial |
$205.02
|
| Rate for Payer: United Healthcare Medicare |
$155.54
|
| Rate for Payer: WINHealth Partners Commercial |
$223.88
|
| Rate for Payer: Wise Provider Network Commercial |
$223.88
|
|
|
ALVIMOPAN 12 MG CAPSULE [54040]
|
Facility
|
OP
|
$248.76
|
|
|
Service Code
|
NDC 0054066882
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$137.07 |
| Max. Negotiated Rate |
$248.76 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$243.78
|
| Rate for Payer: Aetna of WY Medicare |
$164.18
|
| Rate for Payer: Altius Auto/Workers Compensation |
$238.81
|
| Rate for Payer: Altius Commercial |
$238.81
|
| Rate for Payer: Beech Street Commercial |
$243.78
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$204.23
|
| Rate for Payer: Cash Price |
$174.13
|
| Rate for Payer: ChoiceCare Network Commercial |
$241.30
|
| Rate for Payer: Cigna of WY Commercial |
$243.78
|
| Rate for Payer: Entrust Commercial |
$236.32
|
| Rate for Payer: First Choice Health Commercial |
$236.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$236.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$144.28
|
| Rate for Payer: HealthUtah PPO |
$248.76
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$241.30
|
| Rate for Payer: Multiplan Medicare/VA |
$137.07
|
| Rate for Payer: One Health Plan of WY PPO |
$243.78
|
| Rate for Payer: PacificSource Commercial |
$223.88
|
| Rate for Payer: PHCS PPO |
$243.78
|
| Rate for Payer: Three Rivers PPO |
$186.57
|
| Rate for Payer: TriWest Veterans Administration |
$144.28
|
| Rate for Payer: United Healthcare Commercial |
$216.42
|
| Rate for Payer: United Healthcare Medicare |
$144.28
|
| Rate for Payer: WINHealth Partners Commercial |
$243.78
|
| Rate for Payer: Wise Provider Network Commercial |
$236.32
|
|
|
ALVIMOPAN 12 MG CAPSULE [54040]
|
Facility
|
OP
|
$235.66
|
|
|
Service Code
|
NDC 0591231245
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$129.85 |
| Max. Negotiated Rate |
$235.66 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$230.95
|
| Rate for Payer: Aetna of WY Medicare |
$155.54
|
| Rate for Payer: Altius Auto/Workers Compensation |
$226.23
|
| Rate for Payer: Altius Commercial |
$226.23
|
| Rate for Payer: Beech Street Commercial |
$230.95
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$193.48
|
| Rate for Payer: Cash Price |
$164.97
|
| Rate for Payer: ChoiceCare Network Commercial |
$228.59
|
| Rate for Payer: Cigna of WY Commercial |
$230.95
|
| Rate for Payer: Entrust Commercial |
$223.88
|
| Rate for Payer: First Choice Health Commercial |
$223.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$223.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$136.68
|
| Rate for Payer: HealthUtah PPO |
$235.66
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$228.59
|
| Rate for Payer: Multiplan Medicare/VA |
$129.85
|
| Rate for Payer: One Health Plan of WY PPO |
$230.95
|
| Rate for Payer: PacificSource Commercial |
$212.09
|
| Rate for Payer: PHCS PPO |
$230.95
|
| Rate for Payer: Three Rivers PPO |
$176.74
|
| Rate for Payer: TriWest Veterans Administration |
$136.68
|
| Rate for Payer: United Healthcare Commercial |
$205.02
|
| Rate for Payer: United Healthcare Medicare |
$136.68
|
| Rate for Payer: WINHealth Partners Commercial |
$230.95
|
| Rate for Payer: Wise Provider Network Commercial |
$223.88
|
|
|
AMBULATORY SURGICAL BOOT EAC
|
Professional
|
Both
|
$66.00
|
|
|
Service Code
|
HCPCS L3260
|
| Hospital Charge Code |
L3260
|
| Min. Negotiated Rate |
$49.50 |
| Max. Negotiated Rate |
$66.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$64.68
|
| Rate for Payer: Beech Street Commercial |
$62.70
|
| Rate for Payer: Cash Price |
$46.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$64.02
|
| Rate for Payer: Cigna of WY Commercial |
$64.68
|
| Rate for Payer: First Choice Health Commercial |
$59.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$62.70
|
| Rate for Payer: HealthUtah PPO |
$66.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$64.02
|
| Rate for Payer: One Health Plan of WY PPO |
$64.68
|
| Rate for Payer: PacificSource Commercial |
$59.40
|
| Rate for Payer: PHCS PPO |
$62.70
|
| Rate for Payer: Three Rivers PPO |
$49.50
|
| Rate for Payer: United Healthcare Commercial |
$57.42
|
| Rate for Payer: WINHealth Partners Commercial |
$62.70
|
|
|
AMINO ACID 5 % NO.6-DEXTROSE 15 %-ELECTROLYTES NO.23 IV SOLUTION [17747]
|
Facility
|
IP
|
$0.17
|
|
|
Service Code
|
NDC 0338112304
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.17
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.16
|
| Rate for Payer: Altius Commercial |
$0.16
|
| Rate for Payer: Beech Street Commercial |
$0.17
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.14
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.16
|
| Rate for Payer: Cigna of WY Commercial |
$0.17
|
| Rate for Payer: Entrust Commercial |
$0.16
|
| Rate for Payer: First Choice Health Commercial |
$0.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.11
|
| Rate for Payer: HealthUtah PPO |
$0.17
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.16
|
| Rate for Payer: Multiplan Medicare/VA |
$0.11
|
| Rate for Payer: One Health Plan of WY PPO |
$0.17
|
| Rate for Payer: PacificSource Commercial |
$0.15
|
| Rate for Payer: PHCS PPO |
$0.17
|
| Rate for Payer: Three Rivers PPO |
$0.13
|
| Rate for Payer: TriWest Veterans Administration |
$0.11
|
| Rate for Payer: United Healthcare Commercial |
$0.15
|
| Rate for Payer: United Healthcare Medicare |
$0.11
|
| Rate for Payer: WINHealth Partners Commercial |
$0.16
|
| Rate for Payer: Wise Provider Network Commercial |
$0.16
|
|
|
AMINO ACID 5 % NO.6-DEXTROSE 15 %-ELECTROLYTES NO.23 IV SOLUTION [17747]
|
Facility
|
OP
|
$0.17
|
|
|
Service Code
|
NDC 0338112304
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.17
|
| Rate for Payer: Aetna of WY Medicare |
$0.11
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.16
|
| Rate for Payer: Altius Commercial |
$0.16
|
| Rate for Payer: Beech Street Commercial |
$0.17
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.14
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.16
|
| Rate for Payer: Cigna of WY Commercial |
$0.17
|
| Rate for Payer: Entrust Commercial |
$0.16
|
| Rate for Payer: First Choice Health Commercial |
$0.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.10
|
| Rate for Payer: HealthUtah PPO |
$0.17
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.16
|
| Rate for Payer: Multiplan Medicare/VA |
$0.09
|
| Rate for Payer: One Health Plan of WY PPO |
$0.17
|
| Rate for Payer: PacificSource Commercial |
$0.15
|
| Rate for Payer: PHCS PPO |
$0.17
|
| Rate for Payer: Three Rivers PPO |
$0.13
|
| Rate for Payer: TriWest Veterans Administration |
$0.10
|
| Rate for Payer: United Healthcare Commercial |
$0.15
|
| Rate for Payer: United Healthcare Medicare |
$0.10
|
| Rate for Payer: WINHealth Partners Commercial |
$0.17
|
| Rate for Payer: Wise Provider Network Commercial |
$0.16
|
|
|
AMINO ACIDS 8 %-DEXTROSE 14 %-ELECTROLYTES INTRAVENOUS SOLUTION [160321]
|
Facility
|
IP
|
$15.24
|
|
|
Service Code
|
NDC 0338020601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$15.24 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.94
|
| Rate for Payer: Altius Auto/Workers Compensation |
$14.63
|
| Rate for Payer: Altius Commercial |
$14.63
|
| Rate for Payer: Beech Street Commercial |
$14.94
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.51
|
| Rate for Payer: Cash Price |
$10.67
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.78
|
| Rate for Payer: Cigna of WY Commercial |
$14.94
|
| Rate for Payer: Entrust Commercial |
$14.48
|
| Rate for Payer: First Choice Health Commercial |
$14.48
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.48
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.06
|
| Rate for Payer: HealthUtah PPO |
$15.24
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.78
|
| Rate for Payer: Multiplan Medicare/VA |
$9.56
|
| Rate for Payer: One Health Plan of WY PPO |
$14.94
|
| Rate for Payer: PacificSource Commercial |
$13.72
|
| Rate for Payer: PHCS PPO |
$14.94
|
| Rate for Payer: Three Rivers PPO |
$11.43
|
| Rate for Payer: TriWest Veterans Administration |
$10.06
|
| Rate for Payer: United Healthcare Commercial |
$13.26
|
| Rate for Payer: United Healthcare Medicare |
$10.06
|
| Rate for Payer: WINHealth Partners Commercial |
$14.48
|
| Rate for Payer: Wise Provider Network Commercial |
$14.48
|
|
|
AMINO ACIDS 8 %-DEXTROSE 14 %-ELECTROLYTES INTRAVENOUS SOLUTION [160321]
|
Facility
|
OP
|
$15.24
|
|
|
Service Code
|
NDC 0338020601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.40 |
| Max. Negotiated Rate |
$15.24 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.94
|
| Rate for Payer: Aetna of WY Medicare |
$10.06
|
| Rate for Payer: Altius Auto/Workers Compensation |
$14.63
|
| Rate for Payer: Altius Commercial |
$14.63
|
| Rate for Payer: Beech Street Commercial |
$14.94
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.51
|
| Rate for Payer: Cash Price |
$10.67
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.78
|
| Rate for Payer: Cigna of WY Commercial |
$14.94
|
| Rate for Payer: Entrust Commercial |
$14.48
|
| Rate for Payer: First Choice Health Commercial |
$14.48
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.48
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.84
|
| Rate for Payer: HealthUtah PPO |
$15.24
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.78
|
| Rate for Payer: Multiplan Medicare/VA |
$8.40
|
| Rate for Payer: One Health Plan of WY PPO |
$14.94
|
| Rate for Payer: PacificSource Commercial |
$13.72
|
| Rate for Payer: PHCS PPO |
$14.94
|
| Rate for Payer: Three Rivers PPO |
$11.43
|
| Rate for Payer: TriWest Veterans Administration |
$8.84
|
| Rate for Payer: United Healthcare Commercial |
$13.26
|
| Rate for Payer: United Healthcare Medicare |
$8.84
|
| Rate for Payer: WINHealth Partners Commercial |
$14.94
|
| Rate for Payer: Wise Provider Network Commercial |
$14.48
|
|
|
AMINOPHYLLINE 25 MG/ML INTRAVENOUS SOLUTION (WRAPPED) [4000723]
|
Facility
|
IP
|
$22.27
|
|
|
Service Code
|
HCPCS J0280
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.96 |
| Max. Negotiated Rate |
$22.27 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$21.82
|
| Rate for Payer: Altius Auto/Workers Compensation |
$21.38
|
| Rate for Payer: Altius Commercial |
$21.38
|
| Rate for Payer: Beech Street Commercial |
$21.82
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$18.28
|
| Rate for Payer: Cash Price |
$15.59
|
| Rate for Payer: ChoiceCare Network Commercial |
$21.60
|
| Rate for Payer: Cigna of WY Commercial |
$21.82
|
| Rate for Payer: Entrust Commercial |
$21.16
|
| Rate for Payer: First Choice Health Commercial |
$21.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$21.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$14.70
|
| Rate for Payer: HealthUtah PPO |
$22.27
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$21.60
|
| Rate for Payer: Multiplan Medicare/VA |
$13.96
|
| Rate for Payer: One Health Plan of WY PPO |
$21.82
|
| Rate for Payer: PacificSource Commercial |
$20.04
|
| Rate for Payer: PHCS PPO |
$21.82
|
| Rate for Payer: Three Rivers PPO |
$16.70
|
| Rate for Payer: TriWest Veterans Administration |
$14.70
|
| Rate for Payer: United Healthcare Commercial |
$19.37
|
| Rate for Payer: United Healthcare Medicare |
$14.70
|
| Rate for Payer: WINHealth Partners Commercial |
$21.16
|
| Rate for Payer: Wise Provider Network Commercial |
$21.16
|
|
|
AMINOPHYLLINE 25 MG/ML INTRAVENOUS SOLUTION (WRAPPED) [4000723]
|
Facility
|
OP
|
$22.27
|
|
|
Service Code
|
HCPCS J0280
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.27 |
| Max. Negotiated Rate |
$22.27 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$21.82
|
| Rate for Payer: Aetna of WY Medicare |
$14.70
|
| Rate for Payer: Altius Auto/Workers Compensation |
$21.38
|
| Rate for Payer: Altius Commercial |
$21.38
|
| Rate for Payer: Beech Street Commercial |
$21.82
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$18.28
|
| Rate for Payer: Cash Price |
$15.59
|
| Rate for Payer: ChoiceCare Network Commercial |
$21.60
|
| Rate for Payer: Cigna of WY Commercial |
$21.82
|
| Rate for Payer: Entrust Commercial |
$21.16
|
| Rate for Payer: First Choice Health Commercial |
$21.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$21.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$12.92
|
| Rate for Payer: HealthUtah PPO |
$22.27
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$21.60
|
| Rate for Payer: Multiplan Medicare/VA |
$12.27
|
| Rate for Payer: One Health Plan of WY PPO |
$21.82
|
| Rate for Payer: PacificSource Commercial |
$20.04
|
| Rate for Payer: PHCS PPO |
$21.82
|
| Rate for Payer: Three Rivers PPO |
$16.70
|
| Rate for Payer: TriWest Veterans Administration |
$12.92
|
| Rate for Payer: United Healthcare Commercial |
$19.37
|
| Rate for Payer: United Healthcare Medicare |
$12.92
|
| Rate for Payer: WINHealth Partners Commercial |
$21.82
|
| Rate for Payer: Wise Provider Network Commercial |
$21.16
|
|
|
AMIODARONE 200 MG TABLET [3536]
|
Facility
|
OP
|
$1.48
|
|
|
Service Code
|
NDC 6068743711
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$1.48 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.45
|
| Rate for Payer: Aetna of WY Medicare |
$0.98
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.42
|
| Rate for Payer: Altius Commercial |
$1.42
|
| Rate for Payer: Beech Street Commercial |
$1.45
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.22
|
| Rate for Payer: Cash Price |
$1.03
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.44
|
| Rate for Payer: Cigna of WY Commercial |
$1.45
|
| Rate for Payer: Entrust Commercial |
$1.41
|
| Rate for Payer: First Choice Health Commercial |
$1.41
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.41
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.86
|
| Rate for Payer: HealthUtah PPO |
$1.48
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.44
|
| Rate for Payer: Multiplan Medicare/VA |
$0.82
|
| Rate for Payer: One Health Plan of WY PPO |
$1.45
|
| Rate for Payer: PacificSource Commercial |
$1.33
|
| Rate for Payer: PHCS PPO |
$1.45
|
| Rate for Payer: Three Rivers PPO |
$1.11
|
| Rate for Payer: TriWest Veterans Administration |
$0.86
|
| Rate for Payer: United Healthcare Commercial |
$1.29
|
| Rate for Payer: United Healthcare Medicare |
$0.86
|
| Rate for Payer: WINHealth Partners Commercial |
$1.45
|
| Rate for Payer: Wise Provider Network Commercial |
$1.41
|
|
|
AMIODARONE 200 MG TABLET [3536]
|
Facility
|
IP
|
$1.48
|
|
|
Service Code
|
NDC 6068743711
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$1.48 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.45
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.42
|
| Rate for Payer: Altius Commercial |
$1.42
|
| Rate for Payer: Beech Street Commercial |
$1.45
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.22
|
| Rate for Payer: Cash Price |
$1.03
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.44
|
| Rate for Payer: Cigna of WY Commercial |
$1.45
|
| Rate for Payer: Entrust Commercial |
$1.41
|
| Rate for Payer: First Choice Health Commercial |
$1.41
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.41
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.98
|
| Rate for Payer: HealthUtah PPO |
$1.48
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.44
|
| Rate for Payer: Multiplan Medicare/VA |
$0.93
|
| Rate for Payer: One Health Plan of WY PPO |
$1.45
|
| Rate for Payer: PacificSource Commercial |
$1.33
|
| Rate for Payer: PHCS PPO |
$1.45
|
| Rate for Payer: Three Rivers PPO |
$1.11
|
| Rate for Payer: TriWest Veterans Administration |
$0.98
|
| Rate for Payer: United Healthcare Commercial |
$1.29
|
| Rate for Payer: United Healthcare Medicare |
$0.98
|
| Rate for Payer: WINHealth Partners Commercial |
$1.41
|
| Rate for Payer: Wise Provider Network Commercial |
$1.41
|
|
|
AMIODARONE 200 MG TABLET [3536]
|
Facility
|
IP
|
$1.48
|
|
|
Service Code
|
NDC 6068743701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$1.48 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.45
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.42
|
| Rate for Payer: Altius Commercial |
$1.42
|
| Rate for Payer: Beech Street Commercial |
$1.45
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.22
|
| Rate for Payer: Cash Price |
$1.03
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.44
|
| Rate for Payer: Cigna of WY Commercial |
$1.45
|
| Rate for Payer: Entrust Commercial |
$1.41
|
| Rate for Payer: First Choice Health Commercial |
$1.41
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.41
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.98
|
| Rate for Payer: HealthUtah PPO |
$1.48
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.44
|
| Rate for Payer: Multiplan Medicare/VA |
$0.93
|
| Rate for Payer: One Health Plan of WY PPO |
$1.45
|
| Rate for Payer: PacificSource Commercial |
$1.33
|
| Rate for Payer: PHCS PPO |
$1.45
|
| Rate for Payer: Three Rivers PPO |
$1.11
|
| Rate for Payer: TriWest Veterans Administration |
$0.98
|
| Rate for Payer: United Healthcare Commercial |
$1.29
|
| Rate for Payer: United Healthcare Medicare |
$0.98
|
| Rate for Payer: WINHealth Partners Commercial |
$1.41
|
| Rate for Payer: Wise Provider Network Commercial |
$1.41
|
|
|
AMIODARONE 200 MG TABLET [3536]
|
Facility
|
OP
|
$1.48
|
|
|
Service Code
|
NDC 6068743701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$1.48 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.45
|
| Rate for Payer: Aetna of WY Medicare |
$0.98
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.42
|
| Rate for Payer: Altius Commercial |
$1.42
|
| Rate for Payer: Beech Street Commercial |
$1.45
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.22
|
| Rate for Payer: Cash Price |
$1.03
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.44
|
| Rate for Payer: Cigna of WY Commercial |
$1.45
|
| Rate for Payer: Entrust Commercial |
$1.41
|
| Rate for Payer: First Choice Health Commercial |
$1.41
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.41
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.86
|
| Rate for Payer: HealthUtah PPO |
$1.48
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.44
|
| Rate for Payer: Multiplan Medicare/VA |
$0.82
|
| Rate for Payer: One Health Plan of WY PPO |
$1.45
|
| Rate for Payer: PacificSource Commercial |
$1.33
|
| Rate for Payer: PHCS PPO |
$1.45
|
| Rate for Payer: Three Rivers PPO |
$1.11
|
| Rate for Payer: TriWest Veterans Administration |
$0.86
|
| Rate for Payer: United Healthcare Commercial |
$1.29
|
| Rate for Payer: United Healthcare Medicare |
$0.86
|
| Rate for Payer: WINHealth Partners Commercial |
$1.45
|
| Rate for Payer: Wise Provider Network Commercial |
$1.41
|
|
|
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION [17698]
|
Facility
|
OP
|
$17.67
|
|
|
Service Code
|
HCPCS J0282
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.74 |
| Max. Negotiated Rate |
$17.67 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$17.32
|
| Rate for Payer: Aetna of WY Medicare |
$11.66
|
| Rate for Payer: Altius Auto/Workers Compensation |
$16.96
|
| Rate for Payer: Altius Commercial |
$16.96
|
| Rate for Payer: Beech Street Commercial |
$17.32
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.51
|
| Rate for Payer: Cash Price |
$12.37
|
| Rate for Payer: ChoiceCare Network Commercial |
$17.14
|
| Rate for Payer: Cigna of WY Commercial |
$17.32
|
| Rate for Payer: Entrust Commercial |
$16.79
|
| Rate for Payer: First Choice Health Commercial |
$16.79
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.79
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.25
|
| Rate for Payer: HealthUtah PPO |
$17.67
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.14
|
| Rate for Payer: Multiplan Medicare/VA |
$9.74
|
| Rate for Payer: One Health Plan of WY PPO |
$17.32
|
| Rate for Payer: PacificSource Commercial |
$15.90
|
| Rate for Payer: PHCS PPO |
$17.32
|
| Rate for Payer: Three Rivers PPO |
$13.25
|
| Rate for Payer: TriWest Veterans Administration |
$10.25
|
| Rate for Payer: United Healthcare Commercial |
$15.37
|
| Rate for Payer: United Healthcare Medicare |
$10.25
|
| Rate for Payer: WINHealth Partners Commercial |
$17.32
|
| Rate for Payer: Wise Provider Network Commercial |
$16.79
|
|
|
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION [17698]
|
Facility
|
IP
|
$17.67
|
|
|
Service Code
|
HCPCS J0282
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.08 |
| Max. Negotiated Rate |
$17.67 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$17.32
|
| Rate for Payer: Altius Auto/Workers Compensation |
$16.96
|
| Rate for Payer: Altius Commercial |
$16.96
|
| Rate for Payer: Beech Street Commercial |
$17.32
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.51
|
| Rate for Payer: Cash Price |
$12.37
|
| Rate for Payer: ChoiceCare Network Commercial |
$17.14
|
| Rate for Payer: Cigna of WY Commercial |
$17.32
|
| Rate for Payer: Entrust Commercial |
$16.79
|
| Rate for Payer: First Choice Health Commercial |
$16.79
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.79
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.66
|
| Rate for Payer: HealthUtah PPO |
$17.67
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.14
|
| Rate for Payer: Multiplan Medicare/VA |
$11.08
|
| Rate for Payer: One Health Plan of WY PPO |
$17.32
|
| Rate for Payer: PacificSource Commercial |
$15.90
|
| Rate for Payer: PHCS PPO |
$17.32
|
| Rate for Payer: Three Rivers PPO |
$13.25
|
| Rate for Payer: TriWest Veterans Administration |
$11.66
|
| Rate for Payer: United Healthcare Commercial |
$15.37
|
| Rate for Payer: United Healthcare Medicare |
$11.66
|
| Rate for Payer: WINHealth Partners Commercial |
$16.79
|
| Rate for Payer: Wise Provider Network Commercial |
$16.79
|
|
|
AMITRIPTYLINE 25 MG TABLET [10227]
|
Facility
|
OP
|
$1.72
|
|
|
Service Code
|
NDC 6068743311
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.95 |
| Max. Negotiated Rate |
$1.72 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.69
|
| Rate for Payer: Aetna of WY Medicare |
$1.14
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.65
|
| Rate for Payer: Altius Commercial |
$1.65
|
| Rate for Payer: Beech Street Commercial |
$1.69
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.41
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.67
|
| Rate for Payer: Cigna of WY Commercial |
$1.69
|
| Rate for Payer: Entrust Commercial |
$1.63
|
| Rate for Payer: First Choice Health Commercial |
$1.63
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.63
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.00
|
| Rate for Payer: HealthUtah PPO |
$1.72
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.67
|
| Rate for Payer: Multiplan Medicare/VA |
$0.95
|
| Rate for Payer: One Health Plan of WY PPO |
$1.69
|
| Rate for Payer: PacificSource Commercial |
$1.55
|
| Rate for Payer: PHCS PPO |
$1.69
|
| Rate for Payer: Three Rivers PPO |
$1.29
|
| Rate for Payer: TriWest Veterans Administration |
$1.00
|
| Rate for Payer: United Healthcare Commercial |
$1.50
|
| Rate for Payer: United Healthcare Medicare |
$1.00
|
| Rate for Payer: WINHealth Partners Commercial |
$1.69
|
| Rate for Payer: Wise Provider Network Commercial |
$1.63
|
|
|
AMITRIPTYLINE 25 MG TABLET [10227]
|
Facility
|
OP
|
$1.66
|
|
|
Service Code
|
NDC 5026803811
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.91 |
| Max. Negotiated Rate |
$1.66 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.63
|
| Rate for Payer: Aetna of WY Medicare |
$1.10
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.59
|
| Rate for Payer: Altius Commercial |
$1.59
|
| Rate for Payer: Beech Street Commercial |
$1.63
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.36
|
| Rate for Payer: Cash Price |
$1.16
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.61
|
| Rate for Payer: Cigna of WY Commercial |
$1.63
|
| Rate for Payer: Entrust Commercial |
$1.58
|
| Rate for Payer: First Choice Health Commercial |
$1.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.96
|
| Rate for Payer: HealthUtah PPO |
$1.66
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.61
|
| Rate for Payer: Multiplan Medicare/VA |
$0.91
|
| Rate for Payer: One Health Plan of WY PPO |
$1.63
|
| Rate for Payer: PacificSource Commercial |
$1.49
|
| Rate for Payer: PHCS PPO |
$1.63
|
| Rate for Payer: Three Rivers PPO |
$1.24
|
| Rate for Payer: TriWest Veterans Administration |
$0.96
|
| Rate for Payer: United Healthcare Commercial |
$1.44
|
| Rate for Payer: United Healthcare Medicare |
$0.96
|
| Rate for Payer: WINHealth Partners Commercial |
$1.63
|
| Rate for Payer: Wise Provider Network Commercial |
$1.58
|
|
|
AMITRIPTYLINE 25 MG TABLET [10227]
|
Facility
|
IP
|
$1.72
|
|
|
Service Code
|
NDC 6068743301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.08 |
| Max. Negotiated Rate |
$1.72 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.69
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.65
|
| Rate for Payer: Altius Commercial |
$1.65
|
| Rate for Payer: Beech Street Commercial |
$1.69
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.41
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.67
|
| Rate for Payer: Cigna of WY Commercial |
$1.69
|
| Rate for Payer: Entrust Commercial |
$1.63
|
| Rate for Payer: First Choice Health Commercial |
$1.63
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.63
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.14
|
| Rate for Payer: HealthUtah PPO |
$1.72
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.67
|
| Rate for Payer: Multiplan Medicare/VA |
$1.08
|
| Rate for Payer: One Health Plan of WY PPO |
$1.69
|
| Rate for Payer: PacificSource Commercial |
$1.55
|
| Rate for Payer: PHCS PPO |
$1.69
|
| Rate for Payer: Three Rivers PPO |
$1.29
|
| Rate for Payer: TriWest Veterans Administration |
$1.14
|
| Rate for Payer: United Healthcare Commercial |
$1.50
|
| Rate for Payer: United Healthcare Medicare |
$1.14
|
| Rate for Payer: WINHealth Partners Commercial |
$1.63
|
| Rate for Payer: Wise Provider Network Commercial |
$1.63
|
|
