|
DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [13530]
|
Facility
|
IP
|
$25.12
|
|
|
Service Code
|
NDC 1672923993
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.75 |
| Max. Negotiated Rate |
$25.12 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$24.62
|
| Rate for Payer: Altius Auto/Workers Compensation |
$24.12
|
| Rate for Payer: Altius Commercial |
$24.12
|
| Rate for Payer: Beech Street Commercial |
$24.62
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$20.62
|
| Rate for Payer: Cash Price |
$17.59
|
| Rate for Payer: ChoiceCare Network Commercial |
$24.37
|
| Rate for Payer: Cigna of WY Commercial |
$24.62
|
| Rate for Payer: Entrust Commercial |
$23.86
|
| Rate for Payer: First Choice Health Commercial |
$23.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$23.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$16.58
|
| Rate for Payer: HealthUtah PPO |
$25.12
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.37
|
| Rate for Payer: Multiplan Medicare/VA |
$15.75
|
| Rate for Payer: One Health Plan of WY PPO |
$24.62
|
| Rate for Payer: PacificSource Commercial |
$22.61
|
| Rate for Payer: PHCS PPO |
$24.62
|
| Rate for Payer: Three Rivers PPO |
$18.84
|
| Rate for Payer: TriWest Veterans Administration |
$16.58
|
| Rate for Payer: United Healthcare Commercial |
$21.85
|
| Rate for Payer: United Healthcare Medicare |
$16.58
|
| Rate for Payer: WINHealth Partners Commercial |
$23.86
|
| Rate for Payer: Wise Provider Network Commercial |
$23.86
|
|
|
DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [13530]
|
Facility
|
OP
|
$25.12
|
|
|
Service Code
|
NDC 1672923930
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.84 |
| Max. Negotiated Rate |
$25.12 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$24.62
|
| Rate for Payer: Aetna of WY Medicare |
$16.58
|
| Rate for Payer: Altius Auto/Workers Compensation |
$24.12
|
| Rate for Payer: Altius Commercial |
$24.12
|
| Rate for Payer: Beech Street Commercial |
$24.62
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$20.62
|
| Rate for Payer: Cash Price |
$17.59
|
| Rate for Payer: ChoiceCare Network Commercial |
$24.37
|
| Rate for Payer: Cigna of WY Commercial |
$24.62
|
| Rate for Payer: Entrust Commercial |
$23.86
|
| Rate for Payer: First Choice Health Commercial |
$23.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$23.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$14.57
|
| Rate for Payer: HealthUtah PPO |
$25.12
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.37
|
| Rate for Payer: Multiplan Medicare/VA |
$13.84
|
| Rate for Payer: One Health Plan of WY PPO |
$24.62
|
| Rate for Payer: PacificSource Commercial |
$22.61
|
| Rate for Payer: PHCS PPO |
$24.62
|
| Rate for Payer: Three Rivers PPO |
$18.84
|
| Rate for Payer: TriWest Veterans Administration |
$14.57
|
| Rate for Payer: United Healthcare Commercial |
$21.85
|
| Rate for Payer: United Healthcare Medicare |
$14.57
|
| Rate for Payer: WINHealth Partners Commercial |
$24.62
|
| Rate for Payer: Wise Provider Network Commercial |
$23.86
|
|
|
DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [13530]
|
Facility
|
OP
|
$25.12
|
|
|
Service Code
|
NDC 7128850502
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.84 |
| Max. Negotiated Rate |
$25.12 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$24.62
|
| Rate for Payer: Aetna of WY Medicare |
$16.58
|
| Rate for Payer: Altius Auto/Workers Compensation |
$24.12
|
| Rate for Payer: Altius Commercial |
$24.12
|
| Rate for Payer: Beech Street Commercial |
$24.62
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$20.62
|
| Rate for Payer: Cash Price |
$17.59
|
| Rate for Payer: ChoiceCare Network Commercial |
$24.37
|
| Rate for Payer: Cigna of WY Commercial |
$24.62
|
| Rate for Payer: Entrust Commercial |
$23.86
|
| Rate for Payer: First Choice Health Commercial |
$23.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$23.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$14.57
|
| Rate for Payer: HealthUtah PPO |
$25.12
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.37
|
| Rate for Payer: Multiplan Medicare/VA |
$13.84
|
| Rate for Payer: One Health Plan of WY PPO |
$24.62
|
| Rate for Payer: PacificSource Commercial |
$22.61
|
| Rate for Payer: PHCS PPO |
$24.62
|
| Rate for Payer: Three Rivers PPO |
$18.84
|
| Rate for Payer: TriWest Veterans Administration |
$14.57
|
| Rate for Payer: United Healthcare Commercial |
$21.85
|
| Rate for Payer: United Healthcare Medicare |
$14.57
|
| Rate for Payer: WINHealth Partners Commercial |
$24.62
|
| Rate for Payer: Wise Provider Network Commercial |
$23.86
|
|
|
DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [13530]
|
Facility
|
OP
|
$25.12
|
|
|
Service Code
|
NDC 1672923993
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.84 |
| Max. Negotiated Rate |
$25.12 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$24.62
|
| Rate for Payer: Aetna of WY Medicare |
$16.58
|
| Rate for Payer: Altius Auto/Workers Compensation |
$24.12
|
| Rate for Payer: Altius Commercial |
$24.12
|
| Rate for Payer: Beech Street Commercial |
$24.62
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$20.62
|
| Rate for Payer: Cash Price |
$17.59
|
| Rate for Payer: ChoiceCare Network Commercial |
$24.37
|
| Rate for Payer: Cigna of WY Commercial |
$24.62
|
| Rate for Payer: Entrust Commercial |
$23.86
|
| Rate for Payer: First Choice Health Commercial |
$23.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$23.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$14.57
|
| Rate for Payer: HealthUtah PPO |
$25.12
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.37
|
| Rate for Payer: Multiplan Medicare/VA |
$13.84
|
| Rate for Payer: One Health Plan of WY PPO |
$24.62
|
| Rate for Payer: PacificSource Commercial |
$22.61
|
| Rate for Payer: PHCS PPO |
$24.62
|
| Rate for Payer: Three Rivers PPO |
$18.84
|
| Rate for Payer: TriWest Veterans Administration |
$14.57
|
| Rate for Payer: United Healthcare Commercial |
$21.85
|
| Rate for Payer: United Healthcare Medicare |
$14.57
|
| Rate for Payer: WINHealth Partners Commercial |
$24.62
|
| Rate for Payer: Wise Provider Network Commercial |
$23.86
|
|
|
DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [13530]
|
Facility
|
IP
|
$25.12
|
|
|
Service Code
|
NDC 7128850502
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.75 |
| Max. Negotiated Rate |
$25.12 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$24.62
|
| Rate for Payer: Altius Auto/Workers Compensation |
$24.12
|
| Rate for Payer: Altius Commercial |
$24.12
|
| Rate for Payer: Beech Street Commercial |
$24.62
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$20.62
|
| Rate for Payer: Cash Price |
$17.59
|
| Rate for Payer: ChoiceCare Network Commercial |
$24.37
|
| Rate for Payer: Cigna of WY Commercial |
$24.62
|
| Rate for Payer: Entrust Commercial |
$23.86
|
| Rate for Payer: First Choice Health Commercial |
$23.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$23.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$16.58
|
| Rate for Payer: HealthUtah PPO |
$25.12
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.37
|
| Rate for Payer: Multiplan Medicare/VA |
$15.75
|
| Rate for Payer: One Health Plan of WY PPO |
$24.62
|
| Rate for Payer: PacificSource Commercial |
$22.61
|
| Rate for Payer: PHCS PPO |
$24.62
|
| Rate for Payer: Three Rivers PPO |
$18.84
|
| Rate for Payer: TriWest Veterans Administration |
$16.58
|
| Rate for Payer: United Healthcare Commercial |
$21.85
|
| Rate for Payer: United Healthcare Medicare |
$16.58
|
| Rate for Payer: WINHealth Partners Commercial |
$23.86
|
| Rate for Payer: Wise Provider Network Commercial |
$23.86
|
|
|
DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [13530]
|
Facility
|
OP
|
$28.50
|
|
|
Service Code
|
NDC 5515020902
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.70 |
| Max. Negotiated Rate |
$28.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$27.93
|
| Rate for Payer: Aetna of WY Medicare |
$18.81
|
| Rate for Payer: Altius Auto/Workers Compensation |
$27.36
|
| Rate for Payer: Altius Commercial |
$27.36
|
| Rate for Payer: Beech Street Commercial |
$27.93
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$23.40
|
| Rate for Payer: Cash Price |
$19.95
|
| Rate for Payer: ChoiceCare Network Commercial |
$27.64
|
| Rate for Payer: Cigna of WY Commercial |
$27.93
|
| Rate for Payer: Entrust Commercial |
$27.08
|
| Rate for Payer: First Choice Health Commercial |
$27.08
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$27.08
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$16.53
|
| Rate for Payer: HealthUtah PPO |
$28.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$27.64
|
| Rate for Payer: Multiplan Medicare/VA |
$15.70
|
| Rate for Payer: One Health Plan of WY PPO |
$27.93
|
| Rate for Payer: PacificSource Commercial |
$25.65
|
| Rate for Payer: PHCS PPO |
$27.93
|
| Rate for Payer: Three Rivers PPO |
$21.38
|
| Rate for Payer: TriWest Veterans Administration |
$16.53
|
| Rate for Payer: United Healthcare Commercial |
$24.80
|
| Rate for Payer: United Healthcare Medicare |
$16.53
|
| Rate for Payer: WINHealth Partners Commercial |
$27.93
|
| Rate for Payer: Wise Provider Network Commercial |
$27.08
|
|
|
DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [13530]
|
Facility
|
IP
|
$25.12
|
|
|
Service Code
|
NDC 1672923930
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.75 |
| Max. Negotiated Rate |
$25.12 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$24.62
|
| Rate for Payer: Altius Auto/Workers Compensation |
$24.12
|
| Rate for Payer: Altius Commercial |
$24.12
|
| Rate for Payer: Beech Street Commercial |
$24.62
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$20.62
|
| Rate for Payer: Cash Price |
$17.59
|
| Rate for Payer: ChoiceCare Network Commercial |
$24.37
|
| Rate for Payer: Cigna of WY Commercial |
$24.62
|
| Rate for Payer: Entrust Commercial |
$23.86
|
| Rate for Payer: First Choice Health Commercial |
$23.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$23.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$16.58
|
| Rate for Payer: HealthUtah PPO |
$25.12
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.37
|
| Rate for Payer: Multiplan Medicare/VA |
$15.75
|
| Rate for Payer: One Health Plan of WY PPO |
$24.62
|
| Rate for Payer: PacificSource Commercial |
$22.61
|
| Rate for Payer: PHCS PPO |
$24.62
|
| Rate for Payer: Three Rivers PPO |
$18.84
|
| Rate for Payer: TriWest Veterans Administration |
$16.58
|
| Rate for Payer: United Healthcare Commercial |
$21.85
|
| Rate for Payer: United Healthcare Medicare |
$16.58
|
| Rate for Payer: WINHealth Partners Commercial |
$23.86
|
| Rate for Payer: Wise Provider Network Commercial |
$23.86
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP [7159]
|
Facility
|
OP
|
$0.92
|
|
|
Service Code
|
NDC 0121127610
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$0.92 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.90
|
| Rate for Payer: Aetna of WY Medicare |
$0.61
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.88
|
| Rate for Payer: Altius Commercial |
$0.88
|
| Rate for Payer: Beech Street Commercial |
$0.90
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.76
|
| Rate for Payer: Cash Price |
$0.65
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.89
|
| Rate for Payer: Cigna of WY Commercial |
$0.90
|
| Rate for Payer: Entrust Commercial |
$0.87
|
| Rate for Payer: First Choice Health Commercial |
$0.87
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.87
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.53
|
| Rate for Payer: HealthUtah PPO |
$0.92
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.89
|
| Rate for Payer: Multiplan Medicare/VA |
$0.51
|
| Rate for Payer: One Health Plan of WY PPO |
$0.90
|
| Rate for Payer: PacificSource Commercial |
$0.83
|
| Rate for Payer: PHCS PPO |
$0.90
|
| Rate for Payer: Three Rivers PPO |
$0.69
|
| Rate for Payer: TriWest Veterans Administration |
$0.53
|
| Rate for Payer: United Healthcare Commercial |
$0.80
|
| Rate for Payer: United Healthcare Medicare |
$0.53
|
| Rate for Payer: WINHealth Partners Commercial |
$0.90
|
| Rate for Payer: Wise Provider Network Commercial |
$0.87
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP [7159]
|
Facility
|
IP
|
$0.92
|
|
|
Service Code
|
NDC 0121127610
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$0.92 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.90
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.88
|
| Rate for Payer: Altius Commercial |
$0.88
|
| Rate for Payer: Beech Street Commercial |
$0.90
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.76
|
| Rate for Payer: Cash Price |
$0.65
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.89
|
| Rate for Payer: Cigna of WY Commercial |
$0.90
|
| Rate for Payer: Entrust Commercial |
$0.87
|
| Rate for Payer: First Choice Health Commercial |
$0.87
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.87
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.61
|
| Rate for Payer: HealthUtah PPO |
$0.92
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.89
|
| Rate for Payer: Multiplan Medicare/VA |
$0.58
|
| Rate for Payer: One Health Plan of WY PPO |
$0.90
|
| Rate for Payer: PacificSource Commercial |
$0.83
|
| Rate for Payer: PHCS PPO |
$0.90
|
| Rate for Payer: Three Rivers PPO |
$0.69
|
| Rate for Payer: TriWest Veterans Administration |
$0.61
|
| Rate for Payer: United Healthcare Commercial |
$0.80
|
| Rate for Payer: United Healthcare Medicare |
$0.61
|
| Rate for Payer: WINHealth Partners Commercial |
$0.87
|
| Rate for Payer: Wise Provider Network Commercial |
$0.87
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR [17761]
|
Facility
|
IP
|
$1.88
|
|
|
Service Code
|
NDC 6382405640
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.18 |
| Max. Negotiated Rate |
$1.88 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.84
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.80
|
| Rate for Payer: Altius Commercial |
$1.80
|
| Rate for Payer: Beech Street Commercial |
$1.84
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.54
|
| Rate for Payer: Cash Price |
$1.32
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.82
|
| Rate for Payer: Cigna of WY Commercial |
$1.84
|
| Rate for Payer: Entrust Commercial |
$1.79
|
| Rate for Payer: First Choice Health Commercial |
$1.79
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.79
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.24
|
| Rate for Payer: HealthUtah PPO |
$1.88
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.82
|
| Rate for Payer: Multiplan Medicare/VA |
$1.18
|
| Rate for Payer: One Health Plan of WY PPO |
$1.84
|
| Rate for Payer: PacificSource Commercial |
$1.69
|
| Rate for Payer: PHCS PPO |
$1.84
|
| Rate for Payer: Three Rivers PPO |
$1.41
|
| Rate for Payer: TriWest Veterans Administration |
$1.24
|
| Rate for Payer: United Healthcare Commercial |
$1.64
|
| Rate for Payer: United Healthcare Medicare |
$1.24
|
| Rate for Payer: WINHealth Partners Commercial |
$1.79
|
| Rate for Payer: Wise Provider Network Commercial |
$1.79
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR [17761]
|
Facility
|
IP
|
$2.24
|
|
|
Service Code
|
NDC 6382405634
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$2.24 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.20
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.15
|
| Rate for Payer: Altius Commercial |
$2.15
|
| Rate for Payer: Beech Street Commercial |
$2.20
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.84
|
| Rate for Payer: Cash Price |
$1.57
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.17
|
| Rate for Payer: Cigna of WY Commercial |
$2.20
|
| Rate for Payer: Entrust Commercial |
$2.13
|
| Rate for Payer: First Choice Health Commercial |
$2.13
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.13
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.48
|
| Rate for Payer: HealthUtah PPO |
$2.24
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.17
|
| Rate for Payer: Multiplan Medicare/VA |
$1.40
|
| Rate for Payer: One Health Plan of WY PPO |
$2.20
|
| Rate for Payer: PacificSource Commercial |
$2.02
|
| Rate for Payer: PHCS PPO |
$2.20
|
| Rate for Payer: Three Rivers PPO |
$1.68
|
| Rate for Payer: TriWest Veterans Administration |
$1.48
|
| Rate for Payer: United Healthcare Commercial |
$1.95
|
| Rate for Payer: United Healthcare Medicare |
$1.48
|
| Rate for Payer: WINHealth Partners Commercial |
$2.13
|
| Rate for Payer: Wise Provider Network Commercial |
$2.13
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR [17761]
|
Facility
|
OP
|
$2.24
|
|
|
Service Code
|
NDC 6382405634
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.23 |
| Max. Negotiated Rate |
$2.24 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.20
|
| Rate for Payer: Aetna of WY Medicare |
$1.48
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.15
|
| Rate for Payer: Altius Commercial |
$2.15
|
| Rate for Payer: Beech Street Commercial |
$2.20
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.84
|
| Rate for Payer: Cash Price |
$1.57
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.17
|
| Rate for Payer: Cigna of WY Commercial |
$2.20
|
| Rate for Payer: Entrust Commercial |
$2.13
|
| Rate for Payer: First Choice Health Commercial |
$2.13
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.13
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.30
|
| Rate for Payer: HealthUtah PPO |
$2.24
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.17
|
| Rate for Payer: Multiplan Medicare/VA |
$1.23
|
| Rate for Payer: One Health Plan of WY PPO |
$2.20
|
| Rate for Payer: PacificSource Commercial |
$2.02
|
| Rate for Payer: PHCS PPO |
$2.20
|
| Rate for Payer: Three Rivers PPO |
$1.68
|
| Rate for Payer: TriWest Veterans Administration |
$1.30
|
| Rate for Payer: United Healthcare Commercial |
$1.95
|
| Rate for Payer: United Healthcare Medicare |
$1.30
|
| Rate for Payer: WINHealth Partners Commercial |
$2.20
|
| Rate for Payer: Wise Provider Network Commercial |
$2.13
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR [17761]
|
Facility
|
OP
|
$1.88
|
|
|
Service Code
|
NDC 6382405640
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.04 |
| Max. Negotiated Rate |
$1.88 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.84
|
| Rate for Payer: Aetna of WY Medicare |
$1.24
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.80
|
| Rate for Payer: Altius Commercial |
$1.80
|
| Rate for Payer: Beech Street Commercial |
$1.84
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.54
|
| Rate for Payer: Cash Price |
$1.32
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.82
|
| Rate for Payer: Cigna of WY Commercial |
$1.84
|
| Rate for Payer: Entrust Commercial |
$1.79
|
| Rate for Payer: First Choice Health Commercial |
$1.79
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.79
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.09
|
| Rate for Payer: HealthUtah PPO |
$1.88
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.82
|
| Rate for Payer: Multiplan Medicare/VA |
$1.04
|
| Rate for Payer: One Health Plan of WY PPO |
$1.84
|
| Rate for Payer: PacificSource Commercial |
$1.69
|
| Rate for Payer: PHCS PPO |
$1.84
|
| Rate for Payer: Three Rivers PPO |
$1.41
|
| Rate for Payer: TriWest Veterans Administration |
$1.09
|
| Rate for Payer: United Healthcare Commercial |
$1.64
|
| Rate for Payer: United Healthcare Medicare |
$1.09
|
| Rate for Payer: WINHealth Partners Commercial |
$1.84
|
| Rate for Payer: Wise Provider Network Commercial |
$1.79
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR [17761]
|
Facility
|
OP
|
$5.17
|
|
|
Service Code
|
NDC 6068765111
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.85 |
| Max. Negotiated Rate |
$5.17 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5.07
|
| Rate for Payer: Aetna of WY Medicare |
$3.41
|
| Rate for Payer: Altius Auto/Workers Compensation |
$4.96
|
| Rate for Payer: Altius Commercial |
$4.96
|
| Rate for Payer: Beech Street Commercial |
$5.07
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$4.24
|
| Rate for Payer: Cash Price |
$3.62
|
| Rate for Payer: ChoiceCare Network Commercial |
$5.01
|
| Rate for Payer: Cigna of WY Commercial |
$5.07
|
| Rate for Payer: Entrust Commercial |
$4.91
|
| Rate for Payer: First Choice Health Commercial |
$4.91
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4.91
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3.00
|
| Rate for Payer: HealthUtah PPO |
$5.17
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5.01
|
| Rate for Payer: Multiplan Medicare/VA |
$2.85
|
| Rate for Payer: One Health Plan of WY PPO |
$5.07
|
| Rate for Payer: PacificSource Commercial |
$4.65
|
| Rate for Payer: PHCS PPO |
$5.07
|
| Rate for Payer: Three Rivers PPO |
$3.88
|
| Rate for Payer: TriWest Veterans Administration |
$3.00
|
| Rate for Payer: United Healthcare Commercial |
$4.50
|
| Rate for Payer: United Healthcare Medicare |
$3.00
|
| Rate for Payer: WINHealth Partners Commercial |
$5.07
|
| Rate for Payer: Wise Provider Network Commercial |
$4.91
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR [17761]
|
Facility
|
IP
|
$5.17
|
|
|
Service Code
|
NDC 6068765111
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.24 |
| Max. Negotiated Rate |
$5.17 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5.07
|
| Rate for Payer: Altius Auto/Workers Compensation |
$4.96
|
| Rate for Payer: Altius Commercial |
$4.96
|
| Rate for Payer: Beech Street Commercial |
$5.07
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$4.24
|
| Rate for Payer: Cash Price |
$3.62
|
| Rate for Payer: ChoiceCare Network Commercial |
$5.01
|
| Rate for Payer: Cigna of WY Commercial |
$5.07
|
| Rate for Payer: Entrust Commercial |
$4.91
|
| Rate for Payer: First Choice Health Commercial |
$4.91
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4.91
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3.41
|
| Rate for Payer: HealthUtah PPO |
$5.17
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5.01
|
| Rate for Payer: Multiplan Medicare/VA |
$3.24
|
| Rate for Payer: One Health Plan of WY PPO |
$5.07
|
| Rate for Payer: PacificSource Commercial |
$4.65
|
| Rate for Payer: PHCS PPO |
$5.07
|
| Rate for Payer: Three Rivers PPO |
$3.88
|
| Rate for Payer: TriWest Veterans Administration |
$3.41
|
| Rate for Payer: United Healthcare Commercial |
$4.50
|
| Rate for Payer: United Healthcare Medicare |
$3.41
|
| Rate for Payer: WINHealth Partners Commercial |
$4.91
|
| Rate for Payer: Wise Provider Network Commercial |
$4.91
|
|
|
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION [25390]
|
Facility
|
IP
|
$15.04
|
|
|
Service Code
|
NDC 6332382425
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.43 |
| Max. Negotiated Rate |
$15.04 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.74
|
| Rate for Payer: Altius Auto/Workers Compensation |
$14.44
|
| Rate for Payer: Altius Commercial |
$14.44
|
| Rate for Payer: Beech Street Commercial |
$14.74
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.35
|
| Rate for Payer: Cash Price |
$10.53
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.59
|
| Rate for Payer: Cigna of WY Commercial |
$14.74
|
| Rate for Payer: Entrust Commercial |
$14.29
|
| Rate for Payer: First Choice Health Commercial |
$14.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.93
|
| Rate for Payer: HealthUtah PPO |
$15.04
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.59
|
| Rate for Payer: Multiplan Medicare/VA |
$9.43
|
| Rate for Payer: One Health Plan of WY PPO |
$14.74
|
| Rate for Payer: PacificSource Commercial |
$13.54
|
| Rate for Payer: PHCS PPO |
$14.74
|
| Rate for Payer: Three Rivers PPO |
$11.28
|
| Rate for Payer: TriWest Veterans Administration |
$9.93
|
| Rate for Payer: United Healthcare Commercial |
$13.08
|
| Rate for Payer: United Healthcare Medicare |
$9.93
|
| Rate for Payer: WINHealth Partners Commercial |
$14.29
|
| Rate for Payer: Wise Provider Network Commercial |
$14.29
|
|
|
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION [25390]
|
Facility
|
IP
|
$15.04
|
|
|
Service Code
|
NDC 0264752010
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.43 |
| Max. Negotiated Rate |
$15.04 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.74
|
| Rate for Payer: Altius Auto/Workers Compensation |
$14.44
|
| Rate for Payer: Altius Commercial |
$14.44
|
| Rate for Payer: Beech Street Commercial |
$14.74
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.35
|
| Rate for Payer: Cash Price |
$10.52
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.59
|
| Rate for Payer: Cigna of WY Commercial |
$14.74
|
| Rate for Payer: Entrust Commercial |
$14.29
|
| Rate for Payer: First Choice Health Commercial |
$14.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.93
|
| Rate for Payer: HealthUtah PPO |
$15.04
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.59
|
| Rate for Payer: Multiplan Medicare/VA |
$9.43
|
| Rate for Payer: One Health Plan of WY PPO |
$14.74
|
| Rate for Payer: PacificSource Commercial |
$13.54
|
| Rate for Payer: PHCS PPO |
$14.74
|
| Rate for Payer: Three Rivers PPO |
$11.28
|
| Rate for Payer: TriWest Veterans Administration |
$9.93
|
| Rate for Payer: United Healthcare Commercial |
$13.08
|
| Rate for Payer: United Healthcare Medicare |
$9.93
|
| Rate for Payer: WINHealth Partners Commercial |
$14.29
|
| Rate for Payer: Wise Provider Network Commercial |
$14.29
|
|
|
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION [25390]
|
Facility
|
OP
|
$15.04
|
|
|
Service Code
|
NDC 6332382425
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.29 |
| Max. Negotiated Rate |
$15.04 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.74
|
| Rate for Payer: Aetna of WY Medicare |
$9.93
|
| Rate for Payer: Altius Auto/Workers Compensation |
$14.44
|
| Rate for Payer: Altius Commercial |
$14.44
|
| Rate for Payer: Beech Street Commercial |
$14.74
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.35
|
| Rate for Payer: Cash Price |
$10.53
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.59
|
| Rate for Payer: Cigna of WY Commercial |
$14.74
|
| Rate for Payer: Entrust Commercial |
$14.29
|
| Rate for Payer: First Choice Health Commercial |
$14.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.72
|
| Rate for Payer: HealthUtah PPO |
$15.04
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.59
|
| Rate for Payer: Multiplan Medicare/VA |
$8.29
|
| Rate for Payer: One Health Plan of WY PPO |
$14.74
|
| Rate for Payer: PacificSource Commercial |
$13.54
|
| Rate for Payer: PHCS PPO |
$14.74
|
| Rate for Payer: Three Rivers PPO |
$11.28
|
| Rate for Payer: TriWest Veterans Administration |
$8.72
|
| Rate for Payer: United Healthcare Commercial |
$13.08
|
| Rate for Payer: United Healthcare Medicare |
$8.72
|
| Rate for Payer: WINHealth Partners Commercial |
$14.74
|
| Rate for Payer: Wise Provider Network Commercial |
$14.29
|
|
|
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION [25390]
|
Facility
|
OP
|
$15.04
|
|
|
Service Code
|
NDC 0264752010
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.29 |
| Max. Negotiated Rate |
$15.04 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.74
|
| Rate for Payer: Aetna of WY Medicare |
$9.93
|
| Rate for Payer: Altius Auto/Workers Compensation |
$14.44
|
| Rate for Payer: Altius Commercial |
$14.44
|
| Rate for Payer: Beech Street Commercial |
$14.74
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.35
|
| Rate for Payer: Cash Price |
$10.52
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.59
|
| Rate for Payer: Cigna of WY Commercial |
$14.74
|
| Rate for Payer: Entrust Commercial |
$14.29
|
| Rate for Payer: First Choice Health Commercial |
$14.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.72
|
| Rate for Payer: HealthUtah PPO |
$15.04
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.59
|
| Rate for Payer: Multiplan Medicare/VA |
$8.29
|
| Rate for Payer: One Health Plan of WY PPO |
$14.74
|
| Rate for Payer: PacificSource Commercial |
$13.54
|
| Rate for Payer: PHCS PPO |
$14.74
|
| Rate for Payer: Three Rivers PPO |
$11.28
|
| Rate for Payer: TriWest Veterans Administration |
$8.72
|
| Rate for Payer: United Healthcare Commercial |
$13.08
|
| Rate for Payer: United Healthcare Medicare |
$8.72
|
| Rate for Payer: WINHealth Partners Commercial |
$14.74
|
| Rate for Payer: Wise Provider Network Commercial |
$14.29
|
|
|
DEXTROSE 10 % IV BOLUS [400302]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 6332382425
|
|
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
|
|
|
DEXTROSE 10 % IV BOLUS [400302]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 0264752010
|
|
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 |
$0.02
|
| 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
|
|
|
DEXTROSE 10 % IV BOLUS [400302]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 6332382425
|
|
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
|
|
|
DEXTROSE 10 % IV BOLUS [400302]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 0264752010
|
|
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 |
$0.02
|
| 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
|
|
|
DEXTROSE 40 % ORAL GEL [5163]
|
Facility
|
OP
|
$0.34
|
|
|
Service Code
|
NDC 0574006915
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.33
|
| Rate for Payer: Aetna of WY Medicare |
$0.22
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.33
|
| Rate for Payer: Altius Commercial |
$0.33
|
| Rate for Payer: Beech Street Commercial |
$0.33
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.28
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.33
|
| Rate for Payer: Cigna of WY Commercial |
$0.33
|
| Rate for Payer: Entrust Commercial |
$0.32
|
| Rate for Payer: First Choice Health Commercial |
$0.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.20
|
| Rate for Payer: HealthUtah PPO |
$0.34
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.33
|
| Rate for Payer: Multiplan Medicare/VA |
$0.19
|
| Rate for Payer: One Health Plan of WY PPO |
$0.33
|
| Rate for Payer: PacificSource Commercial |
$0.31
|
| Rate for Payer: PHCS PPO |
$0.33
|
| Rate for Payer: Three Rivers PPO |
$0.26
|
| Rate for Payer: TriWest Veterans Administration |
$0.20
|
| Rate for Payer: United Healthcare Commercial |
$0.30
|
| Rate for Payer: United Healthcare Medicare |
$0.20
|
| Rate for Payer: WINHealth Partners Commercial |
$0.33
|
| Rate for Payer: Wise Provider Network Commercial |
$0.32
|
|
|
DEXTROSE 40 % ORAL GEL [5163]
|
Facility
|
IP
|
$0.34
|
|
|
Service Code
|
NDC 0574006915
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.33
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.33
|
| Rate for Payer: Altius Commercial |
$0.33
|
| Rate for Payer: Beech Street Commercial |
$0.33
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.28
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.33
|
| Rate for Payer: Cigna of WY Commercial |
$0.33
|
| Rate for Payer: Entrust Commercial |
$0.32
|
| Rate for Payer: First Choice Health Commercial |
$0.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.22
|
| Rate for Payer: HealthUtah PPO |
$0.34
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.33
|
| Rate for Payer: Multiplan Medicare/VA |
$0.21
|
| Rate for Payer: One Health Plan of WY PPO |
$0.33
|
| Rate for Payer: PacificSource Commercial |
$0.31
|
| Rate for Payer: PHCS PPO |
$0.33
|
| Rate for Payer: Three Rivers PPO |
$0.26
|
| Rate for Payer: TriWest Veterans Administration |
$0.22
|
| Rate for Payer: United Healthcare Commercial |
$0.30
|
| Rate for Payer: United Healthcare Medicare |
$0.22
|
| Rate for Payer: WINHealth Partners Commercial |
$0.32
|
| Rate for Payer: Wise Provider Network Commercial |
$0.32
|
|
