|
CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION [9812]
|
Facility
|
IP
|
$21.09
|
|
|
Service Code
|
HCPCS J0696
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.22 |
| Max. Negotiated Rate |
$21.09 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$20.67
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$27.56
|
| Rate for Payer: Aetna of WY Medicare |
$18.00
|
| Rate for Payer: Aetna of WY Medicare |
$13.50
|
| Rate for Payer: Altius Commercial |
$27.00
|
| Rate for Payer: Altius Commercial |
$20.25
|
| Rate for Payer: Beech Street Commercial |
$20.67
|
| Rate for Payer: Beech Street Commercial |
$27.56
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$20.46
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$27.28
|
| Rate for Payer: Cash Price |
$19.69
|
| Rate for Payer: Cash Price |
$14.76
|
| Rate for Payer: ChoiceCare Network Commercial |
$20.46
|
| Rate for Payer: ChoiceCare Network Commercial |
$27.28
|
| Rate for Payer: Cigna of WY Commercial |
$27.56
|
| Rate for Payer: Cigna of WY Commercial |
$20.67
|
| Rate for Payer: Entrust Commercial |
$20.04
|
| Rate for Payer: Entrust Commercial |
$26.71
|
| Rate for Payer: First Choice Health Commercial |
$26.71
|
| Rate for Payer: First Choice Health Commercial |
$20.04
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$26.71
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$20.04
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$17.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$12.86
|
| Rate for Payer: HealthUtah PPO |
$28.12
|
| Rate for Payer: HealthUtah PPO |
$21.09
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$20.46
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$27.28
|
| Rate for Payer: Multiplan Medicare/VA |
$12.22
|
| Rate for Payer: Multiplan Medicare/VA |
$16.30
|
| Rate for Payer: One Health Plan of WY PPO |
$27.56
|
| Rate for Payer: One Health Plan of WY PPO |
$20.67
|
| Rate for Payer: PacificSource Commercial |
$25.31
|
| Rate for Payer: PacificSource Commercial |
$18.98
|
| Rate for Payer: PHCS PPO |
$27.56
|
| Rate for Payer: PHCS PPO |
$20.67
|
| Rate for Payer: Three Rivers PPO |
$15.82
|
| Rate for Payer: Three Rivers PPO |
$21.09
|
| Rate for Payer: TriWest Veterans Administration |
$12.86
|
| Rate for Payer: TriWest Veterans Administration |
$17.15
|
| Rate for Payer: United Healthcare Commercial |
$20.14
|
| Rate for Payer: United Healthcare Commercial |
$26.85
|
| Rate for Payer: United Healthcare Medicare |
$12.86
|
| Rate for Payer: United Healthcare Medicare |
$17.15
|
| Rate for Payer: WINHealth Partners Commercial |
$20.04
|
| Rate for Payer: WINHealth Partners Commercial |
$26.71
|
| Rate for Payer: Wise Provider Network Commercial |
$20.04
|
| Rate for Payer: Wise Provider Network Commercial |
$26.71
|
|
|
CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION [9812]
|
Facility
|
OP
|
$28.12
|
|
|
Service Code
|
HCPCS J0696
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.23 |
| Max. Negotiated Rate |
$28.12 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$27.56
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$20.67
|
| Rate for Payer: Aetna of WY Medicare |
$18.56
|
| Rate for Payer: Aetna of WY Medicare |
$13.92
|
| Rate for Payer: Altius Commercial |
$20.25
|
| Rate for Payer: Altius Commercial |
$27.00
|
| Rate for Payer: Beech Street Commercial |
$27.56
|
| Rate for Payer: Beech Street Commercial |
$20.67
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$27.28
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$20.46
|
| Rate for Payer: Cash Price |
$19.69
|
| Rate for Payer: Cash Price |
$14.76
|
| Rate for Payer: ChoiceCare Network Commercial |
$27.28
|
| Rate for Payer: ChoiceCare Network Commercial |
$20.46
|
| Rate for Payer: Cigna of WY Commercial |
$20.67
|
| Rate for Payer: Cigna of WY Commercial |
$27.56
|
| Rate for Payer: Entrust Commercial |
$26.71
|
| Rate for Payer: Entrust Commercial |
$20.04
|
| Rate for Payer: First Choice Health Commercial |
$26.71
|
| Rate for Payer: First Choice Health Commercial |
$20.04
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$20.04
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$26.71
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$12.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$16.03
|
| Rate for Payer: HealthUtah PPO |
$28.12
|
| Rate for Payer: HealthUtah PPO |
$21.09
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$20.46
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$27.28
|
| Rate for Payer: Multiplan Medicare/VA |
$11.42
|
| Rate for Payer: Multiplan Medicare/VA |
$15.23
|
| Rate for Payer: One Health Plan of WY PPO |
$27.56
|
| Rate for Payer: One Health Plan of WY PPO |
$20.67
|
| Rate for Payer: PacificSource Commercial |
$18.98
|
| Rate for Payer: PacificSource Commercial |
$25.31
|
| Rate for Payer: PHCS PPO |
$27.56
|
| Rate for Payer: PHCS PPO |
$20.67
|
| Rate for Payer: Three Rivers PPO |
$21.09
|
| Rate for Payer: Three Rivers PPO |
$15.82
|
| Rate for Payer: TriWest Veterans Administration |
$16.03
|
| Rate for Payer: TriWest Veterans Administration |
$12.02
|
| Rate for Payer: United Healthcare Commercial |
$20.14
|
| Rate for Payer: United Healthcare Commercial |
$26.85
|
| Rate for Payer: United Healthcare Medicare |
$12.02
|
| Rate for Payer: United Healthcare Medicare |
$16.03
|
| Rate for Payer: WINHealth Partners Commercial |
$27.56
|
| Rate for Payer: WINHealth Partners Commercial |
$20.67
|
| Rate for Payer: Wise Provider Network Commercial |
$26.71
|
| Rate for Payer: Wise Provider Network Commercial |
$20.04
|
|
|
CEFTRIAXONE 250 MG SOLUTION FOR INJECTION [4824]
|
Facility
|
OP
|
$20.58
|
|
|
Service Code
|
HCPCS J0696
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.14 |
| Max. Negotiated Rate |
$20.58 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$20.17
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$21.32
|
| Rate for Payer: Aetna of WY Medicare |
$13.58
|
| Rate for Payer: Aetna of WY Medicare |
$14.36
|
| Rate for Payer: Altius Commercial |
$20.89
|
| Rate for Payer: Altius Commercial |
$19.76
|
| Rate for Payer: Beech Street Commercial |
$20.17
|
| Rate for Payer: Beech Street Commercial |
$21.32
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$19.96
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$21.11
|
| Rate for Payer: Cash Price |
$15.23
|
| Rate for Payer: Cash Price |
$14.41
|
| Rate for Payer: ChoiceCare Network Commercial |
$21.11
|
| Rate for Payer: ChoiceCare Network Commercial |
$19.96
|
| Rate for Payer: Cigna of WY Commercial |
$20.17
|
| Rate for Payer: Cigna of WY Commercial |
$21.32
|
| Rate for Payer: Entrust Commercial |
$20.67
|
| Rate for Payer: Entrust Commercial |
$19.55
|
| Rate for Payer: First Choice Health Commercial |
$20.67
|
| Rate for Payer: First Choice Health Commercial |
$19.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$19.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$20.67
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.73
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$12.40
|
| Rate for Payer: HealthUtah PPO |
$21.76
|
| Rate for Payer: HealthUtah PPO |
$20.58
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$19.96
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$21.11
|
| Rate for Payer: Multiplan Medicare/VA |
$11.78
|
| Rate for Payer: Multiplan Medicare/VA |
$11.14
|
| Rate for Payer: One Health Plan of WY PPO |
$21.32
|
| Rate for Payer: One Health Plan of WY PPO |
$20.17
|
| Rate for Payer: PacificSource Commercial |
$19.58
|
| Rate for Payer: PacificSource Commercial |
$18.52
|
| Rate for Payer: PHCS PPO |
$21.32
|
| Rate for Payer: PHCS PPO |
$20.17
|
| Rate for Payer: Three Rivers PPO |
$15.44
|
| Rate for Payer: Three Rivers PPO |
$16.32
|
| Rate for Payer: TriWest Veterans Administration |
$12.40
|
| Rate for Payer: TriWest Veterans Administration |
$11.73
|
| Rate for Payer: United Healthcare Commercial |
$19.65
|
| Rate for Payer: United Healthcare Commercial |
$20.78
|
| Rate for Payer: United Healthcare Medicare |
$11.73
|
| Rate for Payer: United Healthcare Medicare |
$12.40
|
| Rate for Payer: WINHealth Partners Commercial |
$20.17
|
| Rate for Payer: WINHealth Partners Commercial |
$21.32
|
| Rate for Payer: Wise Provider Network Commercial |
$19.55
|
| Rate for Payer: Wise Provider Network Commercial |
$20.67
|
|
|
CEFTRIAXONE 250 MG SOLUTION FOR INJECTION [4824]
|
Facility
|
IP
|
$20.58
|
|
|
Service Code
|
HCPCS J0696
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.93 |
| Max. Negotiated Rate |
$20.58 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$20.17
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$21.32
|
| Rate for Payer: Aetna of WY Medicare |
$13.93
|
| Rate for Payer: Aetna of WY Medicare |
$13.17
|
| Rate for Payer: Altius Commercial |
$19.76
|
| Rate for Payer: Altius Commercial |
$20.89
|
| Rate for Payer: Beech Street Commercial |
$20.17
|
| Rate for Payer: Beech Street Commercial |
$21.32
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$19.96
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$21.11
|
| Rate for Payer: Cash Price |
$15.23
|
| Rate for Payer: Cash Price |
$14.41
|
| Rate for Payer: ChoiceCare Network Commercial |
$19.96
|
| Rate for Payer: ChoiceCare Network Commercial |
$21.11
|
| Rate for Payer: Cigna of WY Commercial |
$21.32
|
| Rate for Payer: Cigna of WY Commercial |
$20.17
|
| Rate for Payer: Entrust Commercial |
$20.67
|
| Rate for Payer: Entrust Commercial |
$19.55
|
| Rate for Payer: First Choice Health Commercial |
$20.67
|
| Rate for Payer: First Choice Health Commercial |
$19.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$20.67
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$19.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$12.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$13.27
|
| Rate for Payer: HealthUtah PPO |
$21.76
|
| Rate for Payer: HealthUtah PPO |
$20.58
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$21.11
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$19.96
|
| Rate for Payer: Multiplan Medicare/VA |
$12.61
|
| Rate for Payer: Multiplan Medicare/VA |
$11.93
|
| Rate for Payer: One Health Plan of WY PPO |
$20.17
|
| Rate for Payer: One Health Plan of WY PPO |
$21.32
|
| Rate for Payer: PacificSource Commercial |
$18.52
|
| Rate for Payer: PacificSource Commercial |
$19.58
|
| Rate for Payer: PHCS PPO |
$20.17
|
| Rate for Payer: PHCS PPO |
$21.32
|
| Rate for Payer: Three Rivers PPO |
$15.44
|
| Rate for Payer: Three Rivers PPO |
$16.32
|
| Rate for Payer: TriWest Veterans Administration |
$13.27
|
| Rate for Payer: TriWest Veterans Administration |
$12.55
|
| Rate for Payer: United Healthcare Commercial |
$19.65
|
| Rate for Payer: United Healthcare Commercial |
$20.78
|
| Rate for Payer: United Healthcare Medicare |
$13.27
|
| Rate for Payer: United Healthcare Medicare |
$12.55
|
| Rate for Payer: WINHealth Partners Commercial |
$19.55
|
| Rate for Payer: WINHealth Partners Commercial |
$20.67
|
| Rate for Payer: Wise Provider Network Commercial |
$19.55
|
| Rate for Payer: Wise Provider Network Commercial |
$20.67
|
|
|
CEFTRIAXONE 2 GRAM/50 ML IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK [38959]
|
Facility
|
OP
|
$67.48
|
|
|
Service Code
|
HCPCS J0696
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.54 |
| Max. Negotiated Rate |
$67.48 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$66.13
|
| Rate for Payer: Aetna of WY Medicare |
$44.54
|
| Rate for Payer: Altius Commercial |
$64.78
|
| Rate for Payer: Beech Street Commercial |
$66.13
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$65.46
|
| Rate for Payer: Cash Price |
$47.24
|
| Rate for Payer: ChoiceCare Network Commercial |
$65.46
|
| Rate for Payer: Cigna of WY Commercial |
$66.13
|
| Rate for Payer: Entrust Commercial |
$64.11
|
| Rate for Payer: First Choice Health Commercial |
$64.11
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$64.11
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$38.46
|
| Rate for Payer: HealthUtah PPO |
$67.48
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$65.46
|
| Rate for Payer: Multiplan Medicare/VA |
$36.54
|
| Rate for Payer: One Health Plan of WY PPO |
$66.13
|
| Rate for Payer: PacificSource Commercial |
$60.73
|
| Rate for Payer: PHCS PPO |
$66.13
|
| Rate for Payer: Three Rivers PPO |
$50.61
|
| Rate for Payer: TriWest Veterans Administration |
$38.46
|
| Rate for Payer: United Healthcare Commercial |
$64.44
|
| Rate for Payer: United Healthcare Medicare |
$38.46
|
| Rate for Payer: WINHealth Partners Commercial |
$66.13
|
| Rate for Payer: Wise Provider Network Commercial |
$64.11
|
|
|
CEFTRIAXONE 2 GRAM/50 ML IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK [38959]
|
Facility
|
IP
|
$67.48
|
|
|
Service Code
|
HCPCS J0696
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$39.10 |
| Max. Negotiated Rate |
$67.48 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$66.13
|
| Rate for Payer: Aetna of WY Medicare |
$43.19
|
| Rate for Payer: Altius Commercial |
$64.78
|
| Rate for Payer: Beech Street Commercial |
$66.13
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$65.46
|
| Rate for Payer: Cash Price |
$47.24
|
| Rate for Payer: ChoiceCare Network Commercial |
$65.46
|
| Rate for Payer: Cigna of WY Commercial |
$66.13
|
| Rate for Payer: Entrust Commercial |
$64.11
|
| Rate for Payer: First Choice Health Commercial |
$64.11
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$64.11
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$41.16
|
| Rate for Payer: HealthUtah PPO |
$67.48
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$65.46
|
| Rate for Payer: Multiplan Medicare/VA |
$39.10
|
| Rate for Payer: One Health Plan of WY PPO |
$66.13
|
| Rate for Payer: PacificSource Commercial |
$60.73
|
| Rate for Payer: PHCS PPO |
$66.13
|
| Rate for Payer: Three Rivers PPO |
$50.61
|
| Rate for Payer: TriWest Veterans Administration |
$41.16
|
| Rate for Payer: United Healthcare Commercial |
$64.44
|
| Rate for Payer: United Healthcare Medicare |
$41.16
|
| Rate for Payer: WINHealth Partners Commercial |
$64.11
|
| Rate for Payer: Wise Provider Network Commercial |
$64.11
|
|
|
CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION [20361]
|
Facility
|
OP
|
$36.00
|
|
|
Service Code
|
HCPCS J0696
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.49 |
| Max. Negotiated Rate |
$36.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$35.28
|
| Rate for Payer: Aetna of WY Medicare |
$23.76
|
| Rate for Payer: Altius Commercial |
$34.56
|
| Rate for Payer: Beech Street Commercial |
$35.28
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$34.92
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$34.92
|
| Rate for Payer: Cigna of WY Commercial |
$35.28
|
| Rate for Payer: Entrust Commercial |
$34.20
|
| Rate for Payer: First Choice Health Commercial |
$34.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$34.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$20.52
|
| Rate for Payer: HealthUtah PPO |
$36.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$34.92
|
| Rate for Payer: Multiplan Medicare/VA |
$19.49
|
| Rate for Payer: One Health Plan of WY PPO |
$35.28
|
| Rate for Payer: PacificSource Commercial |
$32.40
|
| Rate for Payer: PHCS PPO |
$35.28
|
| Rate for Payer: Three Rivers PPO |
$27.00
|
| Rate for Payer: TriWest Veterans Administration |
$20.52
|
| Rate for Payer: United Healthcare Commercial |
$34.38
|
| Rate for Payer: United Healthcare Medicare |
$20.52
|
| Rate for Payer: WINHealth Partners Commercial |
$35.28
|
| Rate for Payer: Wise Provider Network Commercial |
$34.20
|
|
|
CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION [20361]
|
Facility
|
IP
|
$36.00
|
|
|
Service Code
|
HCPCS J0696
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.86 |
| Max. Negotiated Rate |
$36.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$35.28
|
| Rate for Payer: Aetna of WY Medicare |
$23.04
|
| Rate for Payer: Altius Commercial |
$34.56
|
| Rate for Payer: Beech Street Commercial |
$35.28
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$34.92
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$34.92
|
| Rate for Payer: Cigna of WY Commercial |
$35.28
|
| Rate for Payer: Entrust Commercial |
$34.20
|
| Rate for Payer: First Choice Health Commercial |
$34.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$34.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$21.96
|
| Rate for Payer: HealthUtah PPO |
$36.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$34.92
|
| Rate for Payer: Multiplan Medicare/VA |
$20.86
|
| Rate for Payer: One Health Plan of WY PPO |
$35.28
|
| Rate for Payer: PacificSource Commercial |
$32.40
|
| Rate for Payer: PHCS PPO |
$35.28
|
| Rate for Payer: Three Rivers PPO |
$27.00
|
| Rate for Payer: TriWest Veterans Administration |
$21.96
|
| Rate for Payer: United Healthcare Commercial |
$34.38
|
| Rate for Payer: United Healthcare Medicare |
$21.96
|
| Rate for Payer: WINHealth Partners Commercial |
$34.20
|
| Rate for Payer: Wise Provider Network Commercial |
$34.20
|
|
|
CEFTRIAXONE 500 MG SOLUTION FOR INJECTION [16208]
|
Facility
|
IP
|
$24.00
|
|
|
Service Code
|
HCPCS J0696
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.91 |
| Max. Negotiated Rate |
$24.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$23.52
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$24.76
|
| Rate for Payer: Aetna of WY Medicare |
$16.17
|
| Rate for Payer: Aetna of WY Medicare |
$15.36
|
| Rate for Payer: Altius Commercial |
$23.04
|
| Rate for Payer: Altius Commercial |
$24.26
|
| Rate for Payer: Beech Street Commercial |
$24.76
|
| Rate for Payer: Beech Street Commercial |
$23.52
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$23.28
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$24.51
|
| Rate for Payer: Cash Price |
$17.69
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$24.51
|
| Rate for Payer: ChoiceCare Network Commercial |
$23.28
|
| Rate for Payer: Cigna of WY Commercial |
$23.52
|
| Rate for Payer: Cigna of WY Commercial |
$24.76
|
| Rate for Payer: Entrust Commercial |
$22.80
|
| Rate for Payer: Entrust Commercial |
$24.01
|
| Rate for Payer: First Choice Health Commercial |
$24.01
|
| Rate for Payer: First Choice Health Commercial |
$22.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$22.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$24.01
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$15.41
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$14.64
|
| Rate for Payer: HealthUtah PPO |
$25.27
|
| Rate for Payer: HealthUtah PPO |
$24.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$23.28
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.51
|
| Rate for Payer: Multiplan Medicare/VA |
$14.64
|
| Rate for Payer: Multiplan Medicare/VA |
$13.91
|
| Rate for Payer: One Health Plan of WY PPO |
$23.52
|
| Rate for Payer: One Health Plan of WY PPO |
$24.76
|
| Rate for Payer: PacificSource Commercial |
$22.74
|
| Rate for Payer: PacificSource Commercial |
$21.60
|
| Rate for Payer: PHCS PPO |
$23.52
|
| Rate for Payer: PHCS PPO |
$24.76
|
| Rate for Payer: Three Rivers PPO |
$18.95
|
| Rate for Payer: Three Rivers PPO |
$18.00
|
| Rate for Payer: TriWest Veterans Administration |
$15.41
|
| Rate for Payer: TriWest Veterans Administration |
$14.64
|
| Rate for Payer: United Healthcare Commercial |
$22.92
|
| Rate for Payer: United Healthcare Commercial |
$24.13
|
| Rate for Payer: United Healthcare Medicare |
$15.41
|
| Rate for Payer: United Healthcare Medicare |
$14.64
|
| Rate for Payer: WINHealth Partners Commercial |
$22.80
|
| Rate for Payer: WINHealth Partners Commercial |
$24.01
|
| Rate for Payer: Wise Provider Network Commercial |
$24.01
|
| Rate for Payer: Wise Provider Network Commercial |
$22.80
|
|
|
CEFTRIAXONE 500 MG SOLUTION FOR INJECTION [16208]
|
Facility
|
OP
|
$25.27
|
|
|
Service Code
|
HCPCS J0696
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.68 |
| Max. Negotiated Rate |
$25.27 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$24.76
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$23.52
|
| Rate for Payer: Aetna of WY Medicare |
$15.84
|
| Rate for Payer: Aetna of WY Medicare |
$16.68
|
| Rate for Payer: Altius Commercial |
$23.04
|
| Rate for Payer: Altius Commercial |
$24.26
|
| Rate for Payer: Beech Street Commercial |
$23.52
|
| Rate for Payer: Beech Street Commercial |
$24.76
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$24.51
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$23.28
|
| Rate for Payer: Cash Price |
$17.69
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$23.28
|
| Rate for Payer: ChoiceCare Network Commercial |
$24.51
|
| Rate for Payer: Cigna of WY Commercial |
$24.76
|
| Rate for Payer: Cigna of WY Commercial |
$23.52
|
| Rate for Payer: Entrust Commercial |
$22.80
|
| Rate for Payer: Entrust Commercial |
$24.01
|
| Rate for Payer: First Choice Health Commercial |
$24.01
|
| Rate for Payer: First Choice Health Commercial |
$22.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$22.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$24.01
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$13.68
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$14.40
|
| Rate for Payer: HealthUtah PPO |
$25.27
|
| Rate for Payer: HealthUtah PPO |
$24.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$23.28
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.51
|
| Rate for Payer: Multiplan Medicare/VA |
$13.68
|
| Rate for Payer: Multiplan Medicare/VA |
$13.00
|
| Rate for Payer: One Health Plan of WY PPO |
$23.52
|
| Rate for Payer: One Health Plan of WY PPO |
$24.76
|
| Rate for Payer: PacificSource Commercial |
$22.74
|
| Rate for Payer: PacificSource Commercial |
$21.60
|
| Rate for Payer: PHCS PPO |
$23.52
|
| Rate for Payer: PHCS PPO |
$24.76
|
| Rate for Payer: Three Rivers PPO |
$18.00
|
| Rate for Payer: Three Rivers PPO |
$18.95
|
| Rate for Payer: TriWest Veterans Administration |
$14.40
|
| Rate for Payer: TriWest Veterans Administration |
$13.68
|
| Rate for Payer: United Healthcare Commercial |
$22.92
|
| Rate for Payer: United Healthcare Commercial |
$24.13
|
| Rate for Payer: United Healthcare Medicare |
$14.40
|
| Rate for Payer: United Healthcare Medicare |
$13.68
|
| Rate for Payer: WINHealth Partners Commercial |
$24.76
|
| Rate for Payer: WINHealth Partners Commercial |
$23.52
|
| Rate for Payer: Wise Provider Network Commercial |
$22.80
|
| Rate for Payer: Wise Provider Network Commercial |
$24.01
|
|
|
CEFTRIAXONE SODIUM INJECTION
|
Professional
|
Both
|
$10.00
|
|
|
Service Code
|
HCPCS J0696
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$10.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$9.80
|
| Rate for Payer: Aetna of WY Medicare |
$0.45
|
| Rate for Payer: Beech Street Commercial |
$9.50
|
| Rate for Payer: Cash Price |
$7.00
|
| Rate for Payer: Cash Price |
$7.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$9.70
|
| Rate for Payer: Cigna of WY Commercial |
$9.80
|
| Rate for Payer: First Choice Health Commercial |
$9.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$9.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.45
|
| Rate for Payer: HealthUtah PPO |
$10.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$9.70
|
| Rate for Payer: Multiplan Medicare/VA |
$0.39
|
| Rate for Payer: One Health Plan of WY PPO |
$9.80
|
| Rate for Payer: PacificSource Commercial |
$9.00
|
| Rate for Payer: PHCS PPO |
$9.50
|
| Rate for Payer: Three Rivers PPO |
$7.50
|
| Rate for Payer: TriWest Veterans Administration |
$0.45
|
| Rate for Payer: United Healthcare Commercial |
$9.50
|
| Rate for Payer: WINHealth Partners Commercial |
$9.50
|
|
|
CEFUROXIME AXETIL 500 MG TABLET [17555]
|
Facility
|
IP
|
$21.65
|
|
|
Service Code
|
NDC 6787721620
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.55 |
| Max. Negotiated Rate |
$21.65 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$21.22
|
| Rate for Payer: Aetna of WY Medicare |
$13.86
|
| Rate for Payer: Altius Commercial |
$20.78
|
| Rate for Payer: Beech Street Commercial |
$21.22
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$21.00
|
| Rate for Payer: Cash Price |
$15.15
|
| Rate for Payer: ChoiceCare Network Commercial |
$21.00
|
| Rate for Payer: Cigna of WY Commercial |
$21.22
|
| Rate for Payer: Entrust Commercial |
$20.57
|
| Rate for Payer: First Choice Health Commercial |
$20.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$20.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$13.21
|
| Rate for Payer: HealthUtah PPO |
$21.65
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$21.00
|
| Rate for Payer: Multiplan Medicare/VA |
$12.55
|
| Rate for Payer: One Health Plan of WY PPO |
$21.22
|
| Rate for Payer: PacificSource Commercial |
$19.48
|
| Rate for Payer: PHCS PPO |
$21.22
|
| Rate for Payer: Three Rivers PPO |
$16.24
|
| Rate for Payer: TriWest Veterans Administration |
$13.21
|
| Rate for Payer: United Healthcare Commercial |
$20.68
|
| Rate for Payer: United Healthcare Medicare |
$13.21
|
| Rate for Payer: WINHealth Partners Commercial |
$20.57
|
| Rate for Payer: Wise Provider Network Commercial |
$20.57
|
|
|
CEFUROXIME AXETIL 500 MG TABLET [17555]
|
Facility
|
OP
|
$21.65
|
|
|
Service Code
|
NDC 6787721620
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.72 |
| Max. Negotiated Rate |
$21.65 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$21.22
|
| Rate for Payer: Aetna of WY Medicare |
$14.29
|
| Rate for Payer: Altius Commercial |
$20.78
|
| Rate for Payer: Beech Street Commercial |
$21.22
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$21.00
|
| Rate for Payer: Cash Price |
$15.15
|
| Rate for Payer: ChoiceCare Network Commercial |
$21.00
|
| Rate for Payer: Cigna of WY Commercial |
$21.22
|
| Rate for Payer: Entrust Commercial |
$20.57
|
| Rate for Payer: First Choice Health Commercial |
$20.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$20.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$12.34
|
| Rate for Payer: HealthUtah PPO |
$21.65
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$21.00
|
| Rate for Payer: Multiplan Medicare/VA |
$11.72
|
| Rate for Payer: One Health Plan of WY PPO |
$21.22
|
| Rate for Payer: PacificSource Commercial |
$19.48
|
| Rate for Payer: PHCS PPO |
$21.22
|
| Rate for Payer: Three Rivers PPO |
$16.24
|
| Rate for Payer: TriWest Veterans Administration |
$12.34
|
| Rate for Payer: United Healthcare Commercial |
$20.68
|
| Rate for Payer: United Healthcare Medicare |
$12.34
|
| Rate for Payer: WINHealth Partners Commercial |
$21.22
|
| Rate for Payer: Wise Provider Network Commercial |
$20.57
|
|
|
CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION [16955]
|
Facility
|
OP
|
$33.99
|
|
|
Service Code
|
HCPCS J0697
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.41 |
| Max. Negotiated Rate |
$33.99 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$33.31
|
| Rate for Payer: Aetna of WY Medicare |
$22.43
|
| Rate for Payer: Altius Commercial |
$32.63
|
| Rate for Payer: Beech Street Commercial |
$33.31
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$32.97
|
| Rate for Payer: Cash Price |
$23.79
|
| Rate for Payer: ChoiceCare Network Commercial |
$32.97
|
| Rate for Payer: Cigna of WY Commercial |
$33.31
|
| Rate for Payer: Entrust Commercial |
$32.29
|
| Rate for Payer: First Choice Health Commercial |
$32.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$32.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$19.37
|
| Rate for Payer: HealthUtah PPO |
$33.99
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$32.97
|
| Rate for Payer: Multiplan Medicare/VA |
$18.41
|
| Rate for Payer: One Health Plan of WY PPO |
$33.31
|
| Rate for Payer: PacificSource Commercial |
$30.59
|
| Rate for Payer: PHCS PPO |
$33.31
|
| Rate for Payer: Three Rivers PPO |
$25.49
|
| Rate for Payer: TriWest Veterans Administration |
$19.37
|
| Rate for Payer: United Healthcare Commercial |
$32.46
|
| Rate for Payer: United Healthcare Medicare |
$19.37
|
| Rate for Payer: WINHealth Partners Commercial |
$33.31
|
| Rate for Payer: Wise Provider Network Commercial |
$32.29
|
|
|
CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION [16955]
|
Facility
|
IP
|
$33.99
|
|
|
Service Code
|
HCPCS J0697
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.70 |
| Max. Negotiated Rate |
$33.99 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$33.31
|
| Rate for Payer: Aetna of WY Medicare |
$21.75
|
| Rate for Payer: Altius Commercial |
$32.63
|
| Rate for Payer: Beech Street Commercial |
$33.31
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$32.97
|
| Rate for Payer: Cash Price |
$23.79
|
| Rate for Payer: ChoiceCare Network Commercial |
$32.97
|
| Rate for Payer: Cigna of WY Commercial |
$33.31
|
| Rate for Payer: Entrust Commercial |
$32.29
|
| Rate for Payer: First Choice Health Commercial |
$32.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$32.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$20.73
|
| Rate for Payer: HealthUtah PPO |
$33.99
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$32.97
|
| Rate for Payer: Multiplan Medicare/VA |
$19.70
|
| Rate for Payer: One Health Plan of WY PPO |
$33.31
|
| Rate for Payer: PacificSource Commercial |
$30.59
|
| Rate for Payer: PHCS PPO |
$33.31
|
| Rate for Payer: Three Rivers PPO |
$25.49
|
| Rate for Payer: TriWest Veterans Administration |
$20.73
|
| Rate for Payer: United Healthcare Commercial |
$32.46
|
| Rate for Payer: United Healthcare Medicare |
$20.73
|
| Rate for Payer: WINHealth Partners Commercial |
$32.29
|
| Rate for Payer: Wise Provider Network Commercial |
$32.29
|
|
|
CELECOXIB 100 MG CAPSULE [18181]
|
Facility
|
IP
|
$16.20
|
|
|
Service Code
|
NDC 6233214131
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.39 |
| Max. Negotiated Rate |
$16.20 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.88
|
| Rate for Payer: Aetna of WY Medicare |
$10.37
|
| Rate for Payer: Altius Commercial |
$15.55
|
| Rate for Payer: Beech Street Commercial |
$15.88
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.71
|
| Rate for Payer: Cash Price |
$11.34
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.71
|
| Rate for Payer: Cigna of WY Commercial |
$15.88
|
| Rate for Payer: Entrust Commercial |
$15.39
|
| Rate for Payer: First Choice Health Commercial |
$15.39
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.39
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.88
|
| Rate for Payer: HealthUtah PPO |
$16.20
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.71
|
| Rate for Payer: Multiplan Medicare/VA |
$9.39
|
| Rate for Payer: One Health Plan of WY PPO |
$15.88
|
| Rate for Payer: PacificSource Commercial |
$14.58
|
| Rate for Payer: PHCS PPO |
$15.88
|
| Rate for Payer: Three Rivers PPO |
$12.15
|
| Rate for Payer: TriWest Veterans Administration |
$9.88
|
| Rate for Payer: United Healthcare Commercial |
$15.47
|
| Rate for Payer: United Healthcare Medicare |
$9.88
|
| Rate for Payer: WINHealth Partners Commercial |
$15.39
|
| Rate for Payer: Wise Provider Network Commercial |
$15.39
|
|
|
CELECOXIB 100 MG CAPSULE [18181]
|
Facility
|
OP
|
$16.20
|
|
|
Service Code
|
NDC 6233214131
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.77 |
| Max. Negotiated Rate |
$16.20 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.88
|
| Rate for Payer: Aetna of WY Medicare |
$10.69
|
| Rate for Payer: Altius Commercial |
$15.55
|
| Rate for Payer: Beech Street Commercial |
$15.88
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.71
|
| Rate for Payer: Cash Price |
$11.34
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.71
|
| Rate for Payer: Cigna of WY Commercial |
$15.88
|
| Rate for Payer: Entrust Commercial |
$15.39
|
| Rate for Payer: First Choice Health Commercial |
$15.39
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.39
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.23
|
| Rate for Payer: HealthUtah PPO |
$16.20
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.71
|
| Rate for Payer: Multiplan Medicare/VA |
$8.77
|
| Rate for Payer: One Health Plan of WY PPO |
$15.88
|
| Rate for Payer: PacificSource Commercial |
$14.58
|
| Rate for Payer: PHCS PPO |
$15.88
|
| Rate for Payer: Three Rivers PPO |
$12.15
|
| Rate for Payer: TriWest Veterans Administration |
$9.23
|
| Rate for Payer: United Healthcare Commercial |
$15.47
|
| Rate for Payer: United Healthcare Medicare |
$9.23
|
| Rate for Payer: WINHealth Partners Commercial |
$15.88
|
| Rate for Payer: Wise Provider Network Commercial |
$15.39
|
|
|
CELECOXIB 200 MG CAPSULE [160]
|
Facility
|
IP
|
$23.09
|
|
|
Service Code
|
NDC 6068744701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.38 |
| Max. Negotiated Rate |
$23.09 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$22.63
|
| Rate for Payer: Aetna of WY Medicare |
$14.78
|
| Rate for Payer: Altius Commercial |
$22.17
|
| Rate for Payer: Beech Street Commercial |
$22.63
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$22.40
|
| Rate for Payer: Cash Price |
$16.17
|
| Rate for Payer: ChoiceCare Network Commercial |
$22.40
|
| Rate for Payer: Cigna of WY Commercial |
$22.63
|
| Rate for Payer: Entrust Commercial |
$21.94
|
| Rate for Payer: First Choice Health Commercial |
$21.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$21.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$14.08
|
| Rate for Payer: HealthUtah PPO |
$23.09
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$22.40
|
| Rate for Payer: Multiplan Medicare/VA |
$13.38
|
| Rate for Payer: One Health Plan of WY PPO |
$22.63
|
| Rate for Payer: PacificSource Commercial |
$20.78
|
| Rate for Payer: PHCS PPO |
$22.63
|
| Rate for Payer: Three Rivers PPO |
$17.32
|
| Rate for Payer: TriWest Veterans Administration |
$14.08
|
| Rate for Payer: United Healthcare Commercial |
$22.05
|
| Rate for Payer: United Healthcare Medicare |
$14.08
|
| Rate for Payer: WINHealth Partners Commercial |
$21.94
|
| Rate for Payer: Wise Provider Network Commercial |
$21.94
|
|
|
CELECOXIB 200 MG CAPSULE [160]
|
Facility
|
OP
|
$23.09
|
|
|
Service Code
|
NDC 6068744701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.50 |
| Max. Negotiated Rate |
$23.09 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$22.63
|
| Rate for Payer: Aetna of WY Medicare |
$15.24
|
| Rate for Payer: Altius Commercial |
$22.17
|
| Rate for Payer: Beech Street Commercial |
$22.63
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$22.40
|
| Rate for Payer: Cash Price |
$16.17
|
| Rate for Payer: ChoiceCare Network Commercial |
$22.40
|
| Rate for Payer: Cigna of WY Commercial |
$22.63
|
| Rate for Payer: Entrust Commercial |
$21.94
|
| Rate for Payer: First Choice Health Commercial |
$21.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$21.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$13.16
|
| Rate for Payer: HealthUtah PPO |
$23.09
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$22.40
|
| Rate for Payer: Multiplan Medicare/VA |
$12.50
|
| Rate for Payer: One Health Plan of WY PPO |
$22.63
|
| Rate for Payer: PacificSource Commercial |
$20.78
|
| Rate for Payer: PHCS PPO |
$22.63
|
| Rate for Payer: Three Rivers PPO |
$17.32
|
| Rate for Payer: TriWest Veterans Administration |
$13.16
|
| Rate for Payer: United Healthcare Commercial |
$22.05
|
| Rate for Payer: United Healthcare Medicare |
$13.16
|
| Rate for Payer: WINHealth Partners Commercial |
$22.63
|
| Rate for Payer: Wise Provider Network Commercial |
$21.94
|
|
|
CELECOXIB 200 MG CAPSULE [160]
|
Facility
|
IP
|
$23.09
|
|
|
Service Code
|
NDC 6068744711
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.38 |
| Max. Negotiated Rate |
$23.09 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$22.63
|
| Rate for Payer: Aetna of WY Medicare |
$14.78
|
| Rate for Payer: Altius Commercial |
$22.17
|
| Rate for Payer: Beech Street Commercial |
$22.63
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$22.40
|
| Rate for Payer: Cash Price |
$16.17
|
| Rate for Payer: ChoiceCare Network Commercial |
$22.40
|
| Rate for Payer: Cigna of WY Commercial |
$22.63
|
| Rate for Payer: Entrust Commercial |
$21.94
|
| Rate for Payer: First Choice Health Commercial |
$21.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$21.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$14.08
|
| Rate for Payer: HealthUtah PPO |
$23.09
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$22.40
|
| Rate for Payer: Multiplan Medicare/VA |
$13.38
|
| Rate for Payer: One Health Plan of WY PPO |
$22.63
|
| Rate for Payer: PacificSource Commercial |
$20.78
|
| Rate for Payer: PHCS PPO |
$22.63
|
| Rate for Payer: Three Rivers PPO |
$17.32
|
| Rate for Payer: TriWest Veterans Administration |
$14.08
|
| Rate for Payer: United Healthcare Commercial |
$22.05
|
| Rate for Payer: United Healthcare Medicare |
$14.08
|
| Rate for Payer: WINHealth Partners Commercial |
$21.94
|
| Rate for Payer: Wise Provider Network Commercial |
$21.94
|
|
|
CELECOXIB 200 MG CAPSULE [160]
|
Facility
|
OP
|
$23.09
|
|
|
Service Code
|
NDC 6068744711
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.50 |
| Max. Negotiated Rate |
$23.09 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$22.63
|
| Rate for Payer: Aetna of WY Medicare |
$15.24
|
| Rate for Payer: Altius Commercial |
$22.17
|
| Rate for Payer: Beech Street Commercial |
$22.63
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$22.40
|
| Rate for Payer: Cash Price |
$16.17
|
| Rate for Payer: ChoiceCare Network Commercial |
$22.40
|
| Rate for Payer: Cigna of WY Commercial |
$22.63
|
| Rate for Payer: Entrust Commercial |
$21.94
|
| Rate for Payer: First Choice Health Commercial |
$21.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$21.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$13.16
|
| Rate for Payer: HealthUtah PPO |
$23.09
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$22.40
|
| Rate for Payer: Multiplan Medicare/VA |
$12.50
|
| Rate for Payer: One Health Plan of WY PPO |
$22.63
|
| Rate for Payer: PacificSource Commercial |
$20.78
|
| Rate for Payer: PHCS PPO |
$22.63
|
| Rate for Payer: Three Rivers PPO |
$17.32
|
| Rate for Payer: TriWest Veterans Administration |
$13.16
|
| Rate for Payer: United Healthcare Commercial |
$22.05
|
| Rate for Payer: United Healthcare Medicare |
$13.16
|
| Rate for Payer: WINHealth Partners Commercial |
$22.63
|
| Rate for Payer: Wise Provider Network Commercial |
$21.94
|
|
|
CEM BONE NOZZLE FLEXIBLE
|
Facility
|
OP
|
$972.65
|
|
| Hospital Charge Code |
3001152
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$526.69 |
| Max. Negotiated Rate |
$972.65 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$953.20
|
| Rate for Payer: Aetna of WY Medicare |
$641.95
|
| Rate for Payer: Altius Commercial |
$933.74
|
| Rate for Payer: Beech Street Commercial |
$953.20
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$943.47
|
| Rate for Payer: Cash Price |
$680.85
|
| Rate for Payer: ChoiceCare Network Commercial |
$943.47
|
| Rate for Payer: Cigna of WY Commercial |
$953.20
|
| Rate for Payer: Entrust Commercial |
$924.02
|
| Rate for Payer: First Choice Health Commercial |
$924.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$924.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$554.41
|
| Rate for Payer: HealthUtah PPO |
$972.65
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$943.47
|
| Rate for Payer: Multiplan Medicare/VA |
$526.69
|
| Rate for Payer: One Health Plan of WY PPO |
$953.20
|
| Rate for Payer: PacificSource Commercial |
$875.38
|
| Rate for Payer: PHCS PPO |
$953.20
|
| Rate for Payer: Three Rivers PPO |
$729.49
|
| Rate for Payer: TriWest Veterans Administration |
$554.41
|
| Rate for Payer: United Healthcare Commercial |
$928.88
|
| Rate for Payer: United Healthcare Medicare |
$554.41
|
| Rate for Payer: WINHealth Partners Commercial |
$953.20
|
| Rate for Payer: Wise Provider Network Commercial |
$924.02
|
|
|
CEM BONE NOZZLE FLEXIBLE
|
Facility
|
IP
|
$972.65
|
|
| Hospital Charge Code |
3001152
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$563.65 |
| Max. Negotiated Rate |
$972.65 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$953.20
|
| Rate for Payer: Aetna of WY Medicare |
$622.50
|
| Rate for Payer: Altius Commercial |
$933.74
|
| Rate for Payer: Beech Street Commercial |
$953.20
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$943.47
|
| Rate for Payer: Cash Price |
$680.85
|
| Rate for Payer: ChoiceCare Network Commercial |
$943.47
|
| Rate for Payer: Cigna of WY Commercial |
$953.20
|
| Rate for Payer: Entrust Commercial |
$924.02
|
| Rate for Payer: First Choice Health Commercial |
$924.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$924.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$593.32
|
| Rate for Payer: HealthUtah PPO |
$972.65
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$943.47
|
| Rate for Payer: Multiplan Medicare/VA |
$563.65
|
| Rate for Payer: One Health Plan of WY PPO |
$953.20
|
| Rate for Payer: PacificSource Commercial |
$875.38
|
| Rate for Payer: PHCS PPO |
$953.20
|
| Rate for Payer: Three Rivers PPO |
$729.49
|
| Rate for Payer: TriWest Veterans Administration |
$593.32
|
| Rate for Payer: United Healthcare Commercial |
$928.88
|
| Rate for Payer: United Healthcare Medicare |
$593.32
|
| Rate for Payer: WINHealth Partners Commercial |
$924.02
|
| Rate for Payer: Wise Provider Network Commercial |
$924.02
|
|
|
CEM BONE NOZZLE TAPERED
|
Facility
|
IP
|
$93.10
|
|
| Hospital Charge Code |
3001149
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$53.95 |
| Max. Negotiated Rate |
$93.10 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$91.24
|
| Rate for Payer: Aetna of WY Medicare |
$59.58
|
| Rate for Payer: Altius Commercial |
$89.38
|
| Rate for Payer: Beech Street Commercial |
$91.24
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$90.31
|
| Rate for Payer: Cash Price |
$65.17
|
| Rate for Payer: ChoiceCare Network Commercial |
$90.31
|
| Rate for Payer: Cigna of WY Commercial |
$91.24
|
| Rate for Payer: Entrust Commercial |
$88.44
|
| Rate for Payer: First Choice Health Commercial |
$88.44
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$88.44
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$56.79
|
| Rate for Payer: HealthUtah PPO |
$93.10
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$90.31
|
| Rate for Payer: Multiplan Medicare/VA |
$53.95
|
| Rate for Payer: One Health Plan of WY PPO |
$91.24
|
| Rate for Payer: PacificSource Commercial |
$83.79
|
| Rate for Payer: PHCS PPO |
$91.24
|
| Rate for Payer: Three Rivers PPO |
$69.82
|
| Rate for Payer: TriWest Veterans Administration |
$56.79
|
| Rate for Payer: United Healthcare Commercial |
$88.91
|
| Rate for Payer: United Healthcare Medicare |
$56.79
|
| Rate for Payer: WINHealth Partners Commercial |
$88.44
|
| Rate for Payer: Wise Provider Network Commercial |
$88.44
|
|
|
CEM BONE NOZZLE TAPERED
|
Facility
|
OP
|
$93.10
|
|
| Hospital Charge Code |
3001149
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$50.41 |
| Max. Negotiated Rate |
$93.10 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$91.24
|
| Rate for Payer: Aetna of WY Medicare |
$61.45
|
| Rate for Payer: Altius Commercial |
$89.38
|
| Rate for Payer: Beech Street Commercial |
$91.24
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$90.31
|
| Rate for Payer: Cash Price |
$65.17
|
| Rate for Payer: ChoiceCare Network Commercial |
$90.31
|
| Rate for Payer: Cigna of WY Commercial |
$91.24
|
| Rate for Payer: Entrust Commercial |
$88.44
|
| Rate for Payer: First Choice Health Commercial |
$88.44
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$88.44
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$53.07
|
| Rate for Payer: HealthUtah PPO |
$93.10
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$90.31
|
| Rate for Payer: Multiplan Medicare/VA |
$50.41
|
| Rate for Payer: One Health Plan of WY PPO |
$91.24
|
| Rate for Payer: PacificSource Commercial |
$83.79
|
| Rate for Payer: PHCS PPO |
$91.24
|
| Rate for Payer: Three Rivers PPO |
$69.82
|
| Rate for Payer: TriWest Veterans Administration |
$53.07
|
| Rate for Payer: United Healthcare Commercial |
$88.91
|
| Rate for Payer: United Healthcare Medicare |
$53.07
|
| Rate for Payer: WINHealth Partners Commercial |
$91.24
|
| Rate for Payer: Wise Provider Network Commercial |
$88.44
|
|
