|
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE [25348]
|
Facility
|
OP
|
$16.34
|
|
|
Service Code
|
NDC 7632933021
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.00 |
| Max. Negotiated Rate |
$16.34 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.01
|
| Rate for Payer: Aetna of WY Medicare |
$10.78
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.69
|
| Rate for Payer: Altius Commercial |
$15.69
|
| Rate for Payer: Beech Street Commercial |
$16.01
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.42
|
| Rate for Payer: Cash Price |
$11.44
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.85
|
| Rate for Payer: Cigna of WY Commercial |
$16.01
|
| Rate for Payer: Entrust Commercial |
$15.52
|
| Rate for Payer: First Choice Health Commercial |
$15.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.48
|
| Rate for Payer: HealthUtah PPO |
$16.34
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.85
|
| Rate for Payer: Multiplan Medicare/VA |
$9.00
|
| Rate for Payer: One Health Plan of WY PPO |
$16.01
|
| Rate for Payer: PacificSource Commercial |
$14.71
|
| Rate for Payer: PHCS PPO |
$16.01
|
| Rate for Payer: Three Rivers PPO |
$12.26
|
| Rate for Payer: TriWest Veterans Administration |
$9.48
|
| Rate for Payer: United Healthcare Commercial |
$14.22
|
| Rate for Payer: United Healthcare Medicare |
$9.48
|
| Rate for Payer: WINHealth Partners Commercial |
$16.01
|
| Rate for Payer: Wise Provider Network Commercial |
$15.52
|
|
|
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE [25348]
|
Facility
|
OP
|
$15.98
|
|
|
Service Code
|
NDC 0409751766
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.80 |
| Max. Negotiated Rate |
$15.98 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.66
|
| Rate for Payer: Aetna of WY Medicare |
$10.55
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.34
|
| Rate for Payer: Altius Commercial |
$15.34
|
| Rate for Payer: Beech Street Commercial |
$15.66
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.12
|
| Rate for Payer: Cash Price |
$11.19
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.50
|
| Rate for Payer: Cigna of WY Commercial |
$15.66
|
| Rate for Payer: Entrust Commercial |
$15.18
|
| Rate for Payer: First Choice Health Commercial |
$15.18
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.18
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.27
|
| Rate for Payer: HealthUtah PPO |
$15.98
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.50
|
| Rate for Payer: Multiplan Medicare/VA |
$8.80
|
| Rate for Payer: One Health Plan of WY PPO |
$15.66
|
| Rate for Payer: PacificSource Commercial |
$14.38
|
| Rate for Payer: PHCS PPO |
$15.66
|
| Rate for Payer: Three Rivers PPO |
$11.98
|
| Rate for Payer: TriWest Veterans Administration |
$9.27
|
| Rate for Payer: United Healthcare Commercial |
$13.90
|
| Rate for Payer: United Healthcare Medicare |
$9.27
|
| Rate for Payer: WINHealth Partners Commercial |
$15.66
|
| Rate for Payer: Wise Provider Network Commercial |
$15.18
|
|
|
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE [25348]
|
Facility
|
IP
|
$16.34
|
|
|
Service Code
|
NDC 7632933021
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.25 |
| Max. Negotiated Rate |
$16.34 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.01
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.69
|
| Rate for Payer: Altius Commercial |
$15.69
|
| Rate for Payer: Beech Street Commercial |
$16.01
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.42
|
| Rate for Payer: Cash Price |
$11.44
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.85
|
| Rate for Payer: Cigna of WY Commercial |
$16.01
|
| Rate for Payer: Entrust Commercial |
$15.52
|
| Rate for Payer: First Choice Health Commercial |
$15.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.78
|
| Rate for Payer: HealthUtah PPO |
$16.34
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.85
|
| Rate for Payer: Multiplan Medicare/VA |
$10.25
|
| Rate for Payer: One Health Plan of WY PPO |
$16.01
|
| Rate for Payer: PacificSource Commercial |
$14.71
|
| Rate for Payer: PHCS PPO |
$16.01
|
| Rate for Payer: Three Rivers PPO |
$12.26
|
| Rate for Payer: TriWest Veterans Administration |
$10.78
|
| Rate for Payer: United Healthcare Commercial |
$14.22
|
| Rate for Payer: United Healthcare Medicare |
$10.78
|
| Rate for Payer: WINHealth Partners Commercial |
$15.52
|
| Rate for Payer: Wise Provider Network Commercial |
$15.52
|
|
|
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE [25348]
|
Facility
|
IP
|
$15.98
|
|
|
Service Code
|
NDC 0409751766
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.02 |
| Max. Negotiated Rate |
$15.98 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.66
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.34
|
| Rate for Payer: Altius Commercial |
$15.34
|
| Rate for Payer: Beech Street Commercial |
$15.66
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.12
|
| Rate for Payer: Cash Price |
$11.19
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.50
|
| Rate for Payer: Cigna of WY Commercial |
$15.66
|
| Rate for Payer: Entrust Commercial |
$15.18
|
| Rate for Payer: First Choice Health Commercial |
$15.18
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.18
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.55
|
| Rate for Payer: HealthUtah PPO |
$15.98
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.50
|
| Rate for Payer: Multiplan Medicare/VA |
$10.02
|
| Rate for Payer: One Health Plan of WY PPO |
$15.66
|
| Rate for Payer: PacificSource Commercial |
$14.38
|
| Rate for Payer: PHCS PPO |
$15.66
|
| Rate for Payer: Three Rivers PPO |
$11.98
|
| Rate for Payer: TriWest Veterans Administration |
$10.55
|
| Rate for Payer: United Healthcare Commercial |
$13.90
|
| Rate for Payer: United Healthcare Medicare |
$10.55
|
| Rate for Payer: WINHealth Partners Commercial |
$15.18
|
| Rate for Payer: Wise Provider Network Commercial |
$15.18
|
|
|
DEXTROSE 5 % AND 0.45 % NACL IV BOLUS [400295]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 0264761200
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.01
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.01
|
| Rate for Payer: Altius Commercial |
$0.01
|
| Rate for Payer: Beech Street Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.01
|
| Rate for Payer: Cigna of WY Commercial |
$0.01
|
| Rate for Payer: Entrust Commercial |
$0.01
|
| Rate for Payer: First Choice Health Commercial |
$0.01
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.01
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.01
|
| Rate for Payer: HealthUtah PPO |
$0.01
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.01
|
| Rate for Payer: Multiplan Medicare/VA |
$0.01
|
| Rate for Payer: One Health Plan of WY PPO |
$0.01
|
| Rate for Payer: PacificSource Commercial |
$0.01
|
| Rate for Payer: PHCS PPO |
$0.01
|
| Rate for Payer: Three Rivers PPO |
$0.01
|
| Rate for Payer: TriWest Veterans Administration |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
| Rate for Payer: United Healthcare Medicare |
$0.01
|
| Rate for Payer: WINHealth Partners Commercial |
$0.01
|
| Rate for Payer: Wise Provider Network Commercial |
$0.01
|
|
|
DEXTROSE 5 % AND 0.45 % NACL IV BOLUS [400295]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 0264761200
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.01
|
| Rate for Payer: Aetna of WY Medicare |
$0.01
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.01
|
| Rate for Payer: Altius Commercial |
$0.01
|
| Rate for Payer: Beech Street Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.01
|
| Rate for Payer: Cigna of WY Commercial |
$0.01
|
| Rate for Payer: Entrust Commercial |
$0.01
|
| Rate for Payer: First Choice Health Commercial |
$0.01
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.01
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.01
|
| Rate for Payer: HealthUtah PPO |
$0.01
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.01
|
| Rate for Payer: Multiplan Medicare/VA |
$0.01
|
| Rate for Payer: One Health Plan of WY PPO |
$0.01
|
| Rate for Payer: PacificSource Commercial |
$0.01
|
| Rate for Payer: PHCS PPO |
$0.01
|
| Rate for Payer: Three Rivers PPO |
$0.01
|
| Rate for Payer: TriWest Veterans Administration |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
| Rate for Payer: United Healthcare Medicare |
$0.01
|
| Rate for Payer: WINHealth Partners Commercial |
$0.01
|
| Rate for Payer: Wise Provider Network Commercial |
$0.01
|
|
|
DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION [19093]
|
Facility
|
OP
|
$15.01
|
|
|
Service Code
|
NDC 0264761200
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.27 |
| Max. Negotiated Rate |
$15.01 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.71
|
| Rate for Payer: Aetna of WY Medicare |
$9.91
|
| Rate for Payer: Altius Auto/Workers Compensation |
$14.41
|
| Rate for Payer: Altius Commercial |
$14.41
|
| Rate for Payer: Beech Street Commercial |
$14.71
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.32
|
| Rate for Payer: Cash Price |
$10.51
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.56
|
| Rate for Payer: Cigna of WY Commercial |
$14.71
|
| Rate for Payer: Entrust Commercial |
$14.26
|
| Rate for Payer: First Choice Health Commercial |
$14.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.71
|
| Rate for Payer: HealthUtah PPO |
$15.01
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.56
|
| Rate for Payer: Multiplan Medicare/VA |
$8.27
|
| Rate for Payer: One Health Plan of WY PPO |
$14.71
|
| Rate for Payer: PacificSource Commercial |
$13.51
|
| Rate for Payer: PHCS PPO |
$14.71
|
| Rate for Payer: Three Rivers PPO |
$11.26
|
| Rate for Payer: TriWest Veterans Administration |
$8.71
|
| Rate for Payer: United Healthcare Commercial |
$13.06
|
| Rate for Payer: United Healthcare Medicare |
$8.71
|
| Rate for Payer: WINHealth Partners Commercial |
$14.71
|
| Rate for Payer: Wise Provider Network Commercial |
$14.26
|
|
|
DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION [19093]
|
Facility
|
IP
|
$15.01
|
|
|
Service Code
|
NDC 0264761200
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.41 |
| Max. Negotiated Rate |
$15.01 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.71
|
| Rate for Payer: Altius Auto/Workers Compensation |
$14.41
|
| Rate for Payer: Altius Commercial |
$14.41
|
| Rate for Payer: Beech Street Commercial |
$14.71
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.32
|
| Rate for Payer: Cash Price |
$10.51
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.56
|
| Rate for Payer: Cigna of WY Commercial |
$14.71
|
| Rate for Payer: Entrust Commercial |
$14.26
|
| Rate for Payer: First Choice Health Commercial |
$14.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.91
|
| Rate for Payer: HealthUtah PPO |
$15.01
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.56
|
| Rate for Payer: Multiplan Medicare/VA |
$9.41
|
| Rate for Payer: One Health Plan of WY PPO |
$14.71
|
| Rate for Payer: PacificSource Commercial |
$13.51
|
| Rate for Payer: PHCS PPO |
$14.71
|
| Rate for Payer: Three Rivers PPO |
$11.26
|
| Rate for Payer: TriWest Veterans Administration |
$9.91
|
| Rate for Payer: United Healthcare Commercial |
$13.06
|
| Rate for Payer: United Healthcare Medicare |
$9.91
|
| Rate for Payer: WINHealth Partners Commercial |
$14.26
|
| Rate for Payer: Wise Provider Network Commercial |
$14.26
|
|
|
DEXTROSE 5 % AND 0.9 % NACL IV BOLUS [400294]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 0264761000
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.02
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.02
|
| Rate for Payer: Altius Commercial |
$0.02
|
| Rate for Payer: Beech Street Commercial |
$0.02
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.02
|
| Rate for Payer: Cigna of WY Commercial |
$0.02
|
| Rate for Payer: Entrust Commercial |
$0.02
|
| Rate for Payer: First Choice Health Commercial |
$0.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.01
|
| Rate for Payer: HealthUtah PPO |
$0.02
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.02
|
| Rate for Payer: Multiplan Medicare/VA |
$0.01
|
| Rate for Payer: One Health Plan of WY PPO |
$0.02
|
| Rate for Payer: PacificSource Commercial |
$0.02
|
| Rate for Payer: PHCS PPO |
$0.02
|
| Rate for Payer: Three Rivers PPO |
$0.02
|
| Rate for Payer: TriWest Veterans Administration |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.02
|
| Rate for Payer: United Healthcare Medicare |
$0.01
|
| Rate for Payer: WINHealth Partners Commercial |
$0.02
|
| Rate for Payer: Wise Provider Network Commercial |
$0.02
|
|
|
DEXTROSE 5 % AND 0.9 % NACL IV BOLUS [400294]
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 0264761000
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.02
|
| Rate for Payer: Aetna of WY Medicare |
$0.01
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.02
|
| Rate for Payer: Altius Commercial |
$0.02
|
| Rate for Payer: Beech Street Commercial |
$0.02
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.02
|
| Rate for Payer: Cigna of WY Commercial |
$0.02
|
| Rate for Payer: Entrust Commercial |
$0.02
|
| Rate for Payer: First Choice Health Commercial |
$0.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.01
|
| Rate for Payer: HealthUtah PPO |
$0.02
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.02
|
| Rate for Payer: Multiplan Medicare/VA |
$0.01
|
| Rate for Payer: One Health Plan of WY PPO |
$0.02
|
| Rate for Payer: PacificSource Commercial |
$0.02
|
| Rate for Payer: PHCS PPO |
$0.02
|
| Rate for Payer: Three Rivers PPO |
$0.02
|
| Rate for Payer: TriWest Veterans Administration |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.02
|
| Rate for Payer: United Healthcare Medicare |
$0.01
|
| Rate for Payer: WINHealth Partners Commercial |
$0.02
|
| Rate for Payer: Wise Provider Network Commercial |
$0.02
|
|
|
DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION [12118]
|
Facility
|
OP
|
$15.02
|
|
|
Service Code
|
NDC 0264761000
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.28 |
| Max. Negotiated Rate |
$15.02 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.72
|
| Rate for Payer: Aetna of WY Medicare |
$9.91
|
| Rate for Payer: Altius Auto/Workers Compensation |
$14.42
|
| Rate for Payer: Altius Commercial |
$14.42
|
| Rate for Payer: Beech Street Commercial |
$14.72
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.33
|
| Rate for Payer: Cash Price |
$10.51
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.57
|
| Rate for Payer: Cigna of WY Commercial |
$14.72
|
| Rate for Payer: Entrust Commercial |
$14.27
|
| Rate for Payer: First Choice Health Commercial |
$14.27
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.27
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.71
|
| Rate for Payer: HealthUtah PPO |
$15.02
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.57
|
| Rate for Payer: Multiplan Medicare/VA |
$8.28
|
| Rate for Payer: One Health Plan of WY PPO |
$14.72
|
| Rate for Payer: PacificSource Commercial |
$13.52
|
| Rate for Payer: PHCS PPO |
$14.72
|
| Rate for Payer: Three Rivers PPO |
$11.26
|
| Rate for Payer: TriWest Veterans Administration |
$8.71
|
| Rate for Payer: United Healthcare Commercial |
$13.07
|
| Rate for Payer: United Healthcare Medicare |
$8.71
|
| Rate for Payer: WINHealth Partners Commercial |
$14.72
|
| Rate for Payer: Wise Provider Network Commercial |
$14.27
|
|
|
DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION [12118]
|
Facility
|
IP
|
$15.02
|
|
|
Service Code
|
NDC 0264761000
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.42 |
| Max. Negotiated Rate |
$15.02 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.72
|
| Rate for Payer: Altius Auto/Workers Compensation |
$14.42
|
| Rate for Payer: Altius Commercial |
$14.42
|
| Rate for Payer: Beech Street Commercial |
$14.72
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.33
|
| Rate for Payer: Cash Price |
$10.51
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.57
|
| Rate for Payer: Cigna of WY Commercial |
$14.72
|
| Rate for Payer: Entrust Commercial |
$14.27
|
| Rate for Payer: First Choice Health Commercial |
$14.27
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.27
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.91
|
| Rate for Payer: HealthUtah PPO |
$15.02
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.57
|
| Rate for Payer: Multiplan Medicare/VA |
$9.42
|
| Rate for Payer: One Health Plan of WY PPO |
$14.72
|
| Rate for Payer: PacificSource Commercial |
$13.52
|
| Rate for Payer: PHCS PPO |
$14.72
|
| Rate for Payer: Three Rivers PPO |
$11.26
|
| Rate for Payer: TriWest Veterans Administration |
$9.91
|
| Rate for Payer: United Healthcare Commercial |
$13.07
|
| Rate for Payer: United Healthcare Medicare |
$9.91
|
| Rate for Payer: WINHealth Partners Commercial |
$14.27
|
| Rate for Payer: Wise Provider Network Commercial |
$14.27
|
|
|
DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION [8337]
|
Facility
|
IP
|
$15.01
|
|
|
Service Code
|
NDC 0264775100
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.41 |
| Max. Negotiated Rate |
$15.01 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.71
|
| Rate for Payer: Altius Auto/Workers Compensation |
$14.41
|
| Rate for Payer: Altius Commercial |
$14.41
|
| Rate for Payer: Beech Street Commercial |
$14.71
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.32
|
| Rate for Payer: Cash Price |
$10.51
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.56
|
| Rate for Payer: Cigna of WY Commercial |
$14.71
|
| Rate for Payer: Entrust Commercial |
$14.26
|
| Rate for Payer: First Choice Health Commercial |
$14.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.91
|
| Rate for Payer: HealthUtah PPO |
$15.01
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.56
|
| Rate for Payer: Multiplan Medicare/VA |
$9.41
|
| Rate for Payer: One Health Plan of WY PPO |
$14.71
|
| Rate for Payer: PacificSource Commercial |
$13.51
|
| Rate for Payer: PHCS PPO |
$14.71
|
| Rate for Payer: Three Rivers PPO |
$11.26
|
| Rate for Payer: TriWest Veterans Administration |
$9.91
|
| Rate for Payer: United Healthcare Commercial |
$13.06
|
| Rate for Payer: United Healthcare Medicare |
$9.91
|
| Rate for Payer: WINHealth Partners Commercial |
$14.26
|
| Rate for Payer: Wise Provider Network Commercial |
$14.26
|
|
|
DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION [8337]
|
Facility
|
OP
|
$15.01
|
|
|
Service Code
|
NDC 0264775100
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.27 |
| Max. Negotiated Rate |
$15.01 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.71
|
| Rate for Payer: Aetna of WY Medicare |
$9.91
|
| Rate for Payer: Altius Auto/Workers Compensation |
$14.41
|
| Rate for Payer: Altius Commercial |
$14.41
|
| Rate for Payer: Beech Street Commercial |
$14.71
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.32
|
| Rate for Payer: Cash Price |
$10.51
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.56
|
| Rate for Payer: Cigna of WY Commercial |
$14.71
|
| Rate for Payer: Entrust Commercial |
$14.26
|
| Rate for Payer: First Choice Health Commercial |
$14.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.71
|
| Rate for Payer: HealthUtah PPO |
$15.01
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.56
|
| Rate for Payer: Multiplan Medicare/VA |
$8.27
|
| Rate for Payer: One Health Plan of WY PPO |
$14.71
|
| Rate for Payer: PacificSource Commercial |
$13.51
|
| Rate for Payer: PHCS PPO |
$14.71
|
| Rate for Payer: Three Rivers PPO |
$11.26
|
| Rate for Payer: TriWest Veterans Administration |
$8.71
|
| Rate for Payer: United Healthcare Commercial |
$13.06
|
| Rate for Payer: United Healthcare Medicare |
$8.71
|
| Rate for Payer: WINHealth Partners Commercial |
$14.71
|
| Rate for Payer: Wise Provider Network Commercial |
$14.26
|
|
|
DEXTROSE 5 % IN LACTATED RINGERS IV BOLUS [400297]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 0264775100
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.01
|
| Rate for Payer: Aetna of WY Medicare |
$0.01
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.01
|
| Rate for Payer: Altius Commercial |
$0.01
|
| Rate for Payer: Beech Street Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.01
|
| Rate for Payer: Cigna of WY Commercial |
$0.01
|
| Rate for Payer: Entrust Commercial |
$0.01
|
| Rate for Payer: First Choice Health Commercial |
$0.01
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.01
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.01
|
| Rate for Payer: HealthUtah PPO |
$0.01
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.01
|
| Rate for Payer: Multiplan Medicare/VA |
$0.01
|
| Rate for Payer: One Health Plan of WY PPO |
$0.01
|
| Rate for Payer: PacificSource Commercial |
$0.01
|
| Rate for Payer: PHCS PPO |
$0.01
|
| Rate for Payer: Three Rivers PPO |
$0.01
|
| Rate for Payer: TriWest Veterans Administration |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
| Rate for Payer: United Healthcare Medicare |
$0.01
|
| Rate for Payer: WINHealth Partners Commercial |
$0.01
|
| Rate for Payer: Wise Provider Network Commercial |
$0.01
|
|
|
DEXTROSE 5 % IN LACTATED RINGERS IV BOLUS [400297]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 0264775100
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.01
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.01
|
| Rate for Payer: Altius Commercial |
$0.01
|
| Rate for Payer: Beech Street Commercial |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.01
|
| Rate for Payer: Cigna of WY Commercial |
$0.01
|
| Rate for Payer: Entrust Commercial |
$0.01
|
| Rate for Payer: First Choice Health Commercial |
$0.01
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.01
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.01
|
| Rate for Payer: HealthUtah PPO |
$0.01
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.01
|
| Rate for Payer: Multiplan Medicare/VA |
$0.01
|
| Rate for Payer: One Health Plan of WY PPO |
$0.01
|
| Rate for Payer: PacificSource Commercial |
$0.01
|
| Rate for Payer: PHCS PPO |
$0.01
|
| Rate for Payer: Three Rivers PPO |
$0.01
|
| Rate for Payer: TriWest Veterans Administration |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
| Rate for Payer: United Healthcare Medicare |
$0.01
|
| Rate for Payer: WINHealth Partners Commercial |
$0.01
|
| Rate for Payer: Wise Provider Network Commercial |
$0.01
|
|
|
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION [25389]
|
Facility
|
IP
|
$15.09
|
|
|
Service Code
|
HCPCS J7060
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.46 |
| Max. Negotiated Rate |
$15.09 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.79
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.73
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.72
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.80
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.75
|
| Rate for Payer: Altius Auto/Workers Compensation |
$14.49
|
| Rate for Payer: Altius Auto/Workers Compensation |
$14.45
|
| Rate for Payer: Altius Auto/Workers Compensation |
$14.42
|
| Rate for Payer: Altius Auto/Workers Compensation |
$14.43
|
| Rate for Payer: Altius Auto/Workers Compensation |
$14.50
|
| Rate for Payer: Altius Commercial |
$14.50
|
| Rate for Payer: Altius Commercial |
$14.43
|
| Rate for Payer: Altius Commercial |
$14.49
|
| Rate for Payer: Altius Commercial |
$14.45
|
| Rate for Payer: Altius Commercial |
$14.42
|
| Rate for Payer: Beech Street Commercial |
$14.79
|
| Rate for Payer: Beech Street Commercial |
$14.80
|
| Rate for Payer: Beech Street Commercial |
$14.72
|
| Rate for Payer: Beech Street Commercial |
$14.73
|
| Rate for Payer: Beech Street Commercial |
$14.75
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.34
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.33
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.36
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.39
|
| Rate for Payer: Cash Price |
$10.57
|
| Rate for Payer: Cash Price |
$10.51
|
| Rate for Payer: Cash Price |
$10.52
|
| Rate for Payer: Cash Price |
$10.52
|
| Rate for Payer: Cash Price |
$10.53
|
| Rate for Payer: Cash Price |
$10.56
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.57
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.65
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.64
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.58
|
| Rate for Payer: Cigna of WY Commercial |
$14.72
|
| Rate for Payer: Cigna of WY Commercial |
$14.80
|
| Rate for Payer: Cigna of WY Commercial |
$14.79
|
| Rate for Payer: Cigna of WY Commercial |
$14.73
|
| Rate for Payer: Cigna of WY Commercial |
$14.75
|
| Rate for Payer: Entrust Commercial |
$14.27
|
| Rate for Payer: Entrust Commercial |
$14.30
|
| Rate for Payer: Entrust Commercial |
$14.34
|
| Rate for Payer: Entrust Commercial |
$14.34
|
| Rate for Payer: Entrust Commercial |
$14.28
|
| Rate for Payer: First Choice Health Commercial |
$14.28
|
| Rate for Payer: First Choice Health Commercial |
$14.27
|
| Rate for Payer: First Choice Health Commercial |
$14.30
|
| Rate for Payer: First Choice Health Commercial |
$14.34
|
| Rate for Payer: First Choice Health Commercial |
$14.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.28
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.27
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.97
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.96
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.93
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.91
|
| Rate for Payer: HealthUtah PPO |
$15.10
|
| Rate for Payer: HealthUtah PPO |
$15.05
|
| Rate for Payer: HealthUtah PPO |
$15.03
|
| Rate for Payer: HealthUtah PPO |
$15.02
|
| Rate for Payer: HealthUtah PPO |
$15.09
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.64
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.60
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.57
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.58
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.65
|
| Rate for Payer: Multiplan Medicare/VA |
$9.44
|
| Rate for Payer: Multiplan Medicare/VA |
$9.42
|
| Rate for Payer: Multiplan Medicare/VA |
$9.42
|
| Rate for Payer: Multiplan Medicare/VA |
$9.46
|
| Rate for Payer: Multiplan Medicare/VA |
$9.47
|
| Rate for Payer: One Health Plan of WY PPO |
$14.73
|
| Rate for Payer: One Health Plan of WY PPO |
$14.80
|
| Rate for Payer: One Health Plan of WY PPO |
$14.75
|
| Rate for Payer: One Health Plan of WY PPO |
$14.79
|
| Rate for Payer: One Health Plan of WY PPO |
$14.72
|
| Rate for Payer: PacificSource Commercial |
$13.54
|
| Rate for Payer: PacificSource Commercial |
$13.59
|
| Rate for Payer: PacificSource Commercial |
$13.53
|
| Rate for Payer: PacificSource Commercial |
$13.58
|
| Rate for Payer: PacificSource Commercial |
$13.52
|
| Rate for Payer: PHCS PPO |
$14.72
|
| Rate for Payer: PHCS PPO |
$14.73
|
| Rate for Payer: PHCS PPO |
$14.79
|
| Rate for Payer: PHCS PPO |
$14.80
|
| Rate for Payer: PHCS PPO |
$14.75
|
| Rate for Payer: Three Rivers PPO |
$11.32
|
| Rate for Payer: Three Rivers PPO |
$11.29
|
| Rate for Payer: Three Rivers PPO |
$11.27
|
| Rate for Payer: Three Rivers PPO |
$11.26
|
| Rate for Payer: Three Rivers PPO |
$11.32
|
| Rate for Payer: TriWest Veterans Administration |
$9.92
|
| Rate for Payer: TriWest Veterans Administration |
$9.97
|
| Rate for Payer: TriWest Veterans Administration |
$9.96
|
| Rate for Payer: TriWest Veterans Administration |
$9.93
|
| Rate for Payer: TriWest Veterans Administration |
$9.91
|
| Rate for Payer: United Healthcare Commercial |
$13.07
|
| Rate for Payer: United Healthcare Commercial |
$13.09
|
| Rate for Payer: United Healthcare Commercial |
$13.13
|
| Rate for Payer: United Healthcare Commercial |
$13.08
|
| Rate for Payer: United Healthcare Commercial |
$13.14
|
| Rate for Payer: United Healthcare Medicare |
$9.91
|
| Rate for Payer: United Healthcare Medicare |
$9.96
|
| Rate for Payer: United Healthcare Medicare |
$9.92
|
| Rate for Payer: United Healthcare Medicare |
$9.97
|
| Rate for Payer: United Healthcare Medicare |
$9.93
|
| Rate for Payer: WINHealth Partners Commercial |
$14.27
|
| Rate for Payer: WINHealth Partners Commercial |
$14.28
|
| Rate for Payer: WINHealth Partners Commercial |
$14.34
|
| Rate for Payer: WINHealth Partners Commercial |
$14.30
|
| Rate for Payer: WINHealth Partners Commercial |
$14.34
|
| Rate for Payer: Wise Provider Network Commercial |
$14.28
|
| Rate for Payer: Wise Provider Network Commercial |
$14.30
|
| Rate for Payer: Wise Provider Network Commercial |
$14.27
|
| Rate for Payer: Wise Provider Network Commercial |
$14.34
|
| Rate for Payer: Wise Provider Network Commercial |
$14.34
|
|
|
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION [25389]
|
Facility
|
OP
|
$15.09
|
|
|
Service Code
|
HCPCS J7060
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.31 |
| Max. Negotiated Rate |
$15.09 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.79
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.75
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.73
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.80
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.72
|
| Rate for Payer: Aetna of WY Medicare |
$9.96
|
| Rate for Payer: Aetna of WY Medicare |
$9.97
|
| Rate for Payer: Aetna of WY Medicare |
$9.93
|
| Rate for Payer: Aetna of WY Medicare |
$9.91
|
| Rate for Payer: Aetna of WY Medicare |
$9.92
|
| Rate for Payer: Altius Auto/Workers Compensation |
$14.49
|
| Rate for Payer: Altius Auto/Workers Compensation |
$14.45
|
| Rate for Payer: Altius Auto/Workers Compensation |
$14.43
|
| Rate for Payer: Altius Auto/Workers Compensation |
$14.42
|
| Rate for Payer: Altius Auto/Workers Compensation |
$14.50
|
| Rate for Payer: Altius Commercial |
$14.50
|
| Rate for Payer: Altius Commercial |
$14.42
|
| Rate for Payer: Altius Commercial |
$14.45
|
| Rate for Payer: Altius Commercial |
$14.43
|
| Rate for Payer: Altius Commercial |
$14.49
|
| Rate for Payer: Beech Street Commercial |
$14.79
|
| Rate for Payer: Beech Street Commercial |
$14.72
|
| Rate for Payer: Beech Street Commercial |
$14.75
|
| Rate for Payer: Beech Street Commercial |
$14.73
|
| Rate for Payer: Beech Street Commercial |
$14.80
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.39
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.33
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.36
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.34
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.40
|
| Rate for Payer: Cash Price |
$10.52
|
| Rate for Payer: Cash Price |
$10.56
|
| Rate for Payer: Cash Price |
$10.57
|
| Rate for Payer: Cash Price |
$10.51
|
| Rate for Payer: Cash Price |
$10.53
|
| Rate for Payer: Cash Price |
$10.52
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.58
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.57
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.65
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.64
|
| Rate for Payer: Cigna of WY Commercial |
$14.80
|
| Rate for Payer: Cigna of WY Commercial |
$14.79
|
| Rate for Payer: Cigna of WY Commercial |
$14.72
|
| Rate for Payer: Cigna of WY Commercial |
$14.75
|
| Rate for Payer: Cigna of WY Commercial |
$14.73
|
| Rate for Payer: Entrust Commercial |
$14.28
|
| Rate for Payer: Entrust Commercial |
$14.30
|
| Rate for Payer: Entrust Commercial |
$14.34
|
| Rate for Payer: Entrust Commercial |
$14.34
|
| Rate for Payer: Entrust Commercial |
$14.27
|
| Rate for Payer: First Choice Health Commercial |
$14.28
|
| Rate for Payer: First Choice Health Commercial |
$14.30
|
| Rate for Payer: First Choice Health Commercial |
$14.34
|
| Rate for Payer: First Choice Health Commercial |
$14.27
|
| Rate for Payer: First Choice Health Commercial |
$14.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.28
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.27
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.76
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.72
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.73
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.71
|
| Rate for Payer: HealthUtah PPO |
$15.09
|
| Rate for Payer: HealthUtah PPO |
$15.10
|
| Rate for Payer: HealthUtah PPO |
$15.03
|
| Rate for Payer: HealthUtah PPO |
$15.02
|
| Rate for Payer: HealthUtah PPO |
$15.05
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.65
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.58
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.57
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.60
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.64
|
| Rate for Payer: Multiplan Medicare/VA |
$8.31
|
| Rate for Payer: Multiplan Medicare/VA |
$8.29
|
| Rate for Payer: Multiplan Medicare/VA |
$8.28
|
| Rate for Payer: Multiplan Medicare/VA |
$8.32
|
| Rate for Payer: Multiplan Medicare/VA |
$8.28
|
| Rate for Payer: One Health Plan of WY PPO |
$14.72
|
| Rate for Payer: One Health Plan of WY PPO |
$14.73
|
| Rate for Payer: One Health Plan of WY PPO |
$14.75
|
| Rate for Payer: One Health Plan of WY PPO |
$14.79
|
| Rate for Payer: One Health Plan of WY PPO |
$14.80
|
| Rate for Payer: PacificSource Commercial |
$13.54
|
| Rate for Payer: PacificSource Commercial |
$13.52
|
| Rate for Payer: PacificSource Commercial |
$13.58
|
| Rate for Payer: PacificSource Commercial |
$13.59
|
| Rate for Payer: PacificSource Commercial |
$13.53
|
| Rate for Payer: PHCS PPO |
$14.80
|
| Rate for Payer: PHCS PPO |
$14.73
|
| Rate for Payer: PHCS PPO |
$14.75
|
| Rate for Payer: PHCS PPO |
$14.79
|
| Rate for Payer: PHCS PPO |
$14.72
|
| Rate for Payer: Three Rivers PPO |
$11.27
|
| Rate for Payer: Three Rivers PPO |
$11.29
|
| Rate for Payer: Three Rivers PPO |
$11.26
|
| Rate for Payer: Three Rivers PPO |
$11.32
|
| Rate for Payer: Three Rivers PPO |
$11.32
|
| Rate for Payer: TriWest Veterans Administration |
$8.71
|
| Rate for Payer: TriWest Veterans Administration |
$8.75
|
| Rate for Payer: TriWest Veterans Administration |
$8.76
|
| Rate for Payer: TriWest Veterans Administration |
$8.73
|
| Rate for Payer: TriWest Veterans Administration |
$8.72
|
| Rate for Payer: United Healthcare Commercial |
$13.13
|
| Rate for Payer: United Healthcare Commercial |
$13.08
|
| Rate for Payer: United Healthcare Commercial |
$13.07
|
| Rate for Payer: United Healthcare Commercial |
$13.09
|
| Rate for Payer: United Healthcare Commercial |
$13.14
|
| Rate for Payer: United Healthcare Medicare |
$8.73
|
| Rate for Payer: United Healthcare Medicare |
$8.75
|
| Rate for Payer: United Healthcare Medicare |
$8.72
|
| Rate for Payer: United Healthcare Medicare |
$8.71
|
| Rate for Payer: United Healthcare Medicare |
$8.76
|
| Rate for Payer: WINHealth Partners Commercial |
$14.73
|
| Rate for Payer: WINHealth Partners Commercial |
$14.79
|
| Rate for Payer: WINHealth Partners Commercial |
$14.80
|
| Rate for Payer: WINHealth Partners Commercial |
$14.75
|
| Rate for Payer: WINHealth Partners Commercial |
$14.72
|
| Rate for Payer: Wise Provider Network Commercial |
$14.30
|
| Rate for Payer: Wise Provider Network Commercial |
$14.34
|
| Rate for Payer: Wise Provider Network Commercial |
$14.27
|
| Rate for Payer: Wise Provider Network Commercial |
$14.28
|
| Rate for Payer: Wise Provider Network Commercial |
$14.34
|
|
|
DEXTROSE 5 % IV BOLUS [400293]
|
Facility
|
OP
|
$0.24
|
|
|
Service Code
|
NDC 0990792336
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.24 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.24
|
| Rate for Payer: Aetna of WY Medicare |
$0.16
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.23
|
| Rate for Payer: Altius Commercial |
$0.23
|
| Rate for Payer: Beech Street Commercial |
$0.24
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.20
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.23
|
| Rate for Payer: Cigna of WY Commercial |
$0.24
|
| Rate for Payer: Entrust Commercial |
$0.23
|
| Rate for Payer: First Choice Health Commercial |
$0.23
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.23
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.14
|
| Rate for Payer: HealthUtah PPO |
$0.24
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.23
|
| Rate for Payer: Multiplan Medicare/VA |
$0.13
|
| Rate for Payer: One Health Plan of WY PPO |
$0.24
|
| Rate for Payer: PacificSource Commercial |
$0.22
|
| Rate for Payer: PHCS PPO |
$0.24
|
| Rate for Payer: Three Rivers PPO |
$0.18
|
| Rate for Payer: TriWest Veterans Administration |
$0.14
|
| Rate for Payer: United Healthcare Commercial |
$0.21
|
| Rate for Payer: United Healthcare Medicare |
$0.14
|
| Rate for Payer: WINHealth Partners Commercial |
$0.24
|
| Rate for Payer: Wise Provider Network Commercial |
$0.23
|
|
|
DEXTROSE 5 % IV BOLUS [400293]
|
Facility
|
IP
|
$0.24
|
|
|
Service Code
|
NDC 0990792336
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.24 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.24
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.23
|
| Rate for Payer: Altius Commercial |
$0.23
|
| Rate for Payer: Beech Street Commercial |
$0.24
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.20
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.23
|
| Rate for Payer: Cigna of WY Commercial |
$0.24
|
| Rate for Payer: Entrust Commercial |
$0.23
|
| Rate for Payer: First Choice Health Commercial |
$0.23
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.23
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.16
|
| Rate for Payer: HealthUtah PPO |
$0.24
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.23
|
| Rate for Payer: Multiplan Medicare/VA |
$0.15
|
| Rate for Payer: One Health Plan of WY PPO |
$0.24
|
| Rate for Payer: PacificSource Commercial |
$0.22
|
| Rate for Payer: PHCS PPO |
$0.24
|
| Rate for Payer: Three Rivers PPO |
$0.18
|
| Rate for Payer: TriWest Veterans Administration |
$0.16
|
| Rate for Payer: United Healthcare Commercial |
$0.21
|
| Rate for Payer: United Healthcare Medicare |
$0.16
|
| Rate for Payer: WINHealth Partners Commercial |
$0.23
|
| Rate for Payer: Wise Provider Network Commercial |
$0.23
|
|
|
DEXTROSE 5 % IV BOLUS [400293]
|
Facility
|
IP
|
$0.05
|
|
|
Service Code
|
NDC 6332362404
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.05
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.05
|
| Rate for Payer: Altius Commercial |
$0.05
|
| Rate for Payer: Beech Street Commercial |
$0.05
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.05
|
| Rate for Payer: Cigna of WY Commercial |
$0.05
|
| Rate for Payer: Entrust Commercial |
$0.05
|
| Rate for Payer: First Choice Health Commercial |
$0.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.03
|
| Rate for Payer: HealthUtah PPO |
$0.05
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.05
|
| Rate for Payer: Multiplan Medicare/VA |
$0.03
|
| Rate for Payer: One Health Plan of WY PPO |
$0.05
|
| Rate for Payer: PacificSource Commercial |
$0.05
|
| Rate for Payer: PHCS PPO |
$0.05
|
| Rate for Payer: Three Rivers PPO |
$0.04
|
| Rate for Payer: TriWest Veterans Administration |
$0.03
|
| Rate for Payer: United Healthcare Commercial |
$0.04
|
| Rate for Payer: United Healthcare Medicare |
$0.03
|
| Rate for Payer: WINHealth Partners Commercial |
$0.05
|
| Rate for Payer: Wise Provider Network Commercial |
$0.05
|
|
|
DEXTROSE 5 % IV BOLUS [400293]
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 0338001704
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.02
|
| Rate for Payer: Aetna of WY Medicare |
$0.01
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.02
|
| Rate for Payer: Altius Commercial |
$0.02
|
| Rate for Payer: Beech Street Commercial |
$0.02
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.02
|
| Rate for Payer: Cigna of WY Commercial |
$0.02
|
| Rate for Payer: Entrust Commercial |
$0.02
|
| Rate for Payer: First Choice Health Commercial |
$0.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.01
|
| Rate for Payer: HealthUtah PPO |
$0.02
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.02
|
| Rate for Payer: Multiplan Medicare/VA |
$0.01
|
| Rate for Payer: One Health Plan of WY PPO |
$0.02
|
| Rate for Payer: PacificSource Commercial |
$0.02
|
| Rate for Payer: PHCS PPO |
$0.02
|
| Rate for Payer: Three Rivers PPO |
$0.02
|
| Rate for Payer: TriWest Veterans Administration |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.02
|
| Rate for Payer: United Healthcare Medicare |
$0.01
|
| Rate for Payer: WINHealth Partners Commercial |
$0.02
|
| Rate for Payer: Wise Provider Network Commercial |
$0.02
|
|
|
DEXTROSE 5 % IV BOLUS [400293]
|
Facility
|
OP
|
$0.05
|
|
|
Service Code
|
NDC 6332362404
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.05
|
| Rate for Payer: Aetna of WY Medicare |
$0.03
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.05
|
| Rate for Payer: Altius Commercial |
$0.05
|
| Rate for Payer: Beech Street Commercial |
$0.05
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.05
|
| Rate for Payer: Cigna of WY Commercial |
$0.05
|
| Rate for Payer: Entrust Commercial |
$0.05
|
| Rate for Payer: First Choice Health Commercial |
$0.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.03
|
| Rate for Payer: HealthUtah PPO |
$0.05
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.05
|
| Rate for Payer: Multiplan Medicare/VA |
$0.03
|
| Rate for Payer: One Health Plan of WY PPO |
$0.05
|
| Rate for Payer: PacificSource Commercial |
$0.05
|
| Rate for Payer: PHCS PPO |
$0.05
|
| Rate for Payer: Three Rivers PPO |
$0.04
|
| Rate for Payer: TriWest Veterans Administration |
$0.03
|
| Rate for Payer: United Healthcare Commercial |
$0.04
|
| Rate for Payer: United Healthcare Medicare |
$0.03
|
| Rate for Payer: WINHealth Partners Commercial |
$0.05
|
| Rate for Payer: Wise Provider Network Commercial |
$0.05
|
|
|
DEXTROSE 5 % IV BOLUS [400293]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 0338001704
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.02
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.02
|
| Rate for Payer: Altius Commercial |
$0.02
|
| Rate for Payer: Beech Street Commercial |
$0.02
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.02
|
| Rate for Payer: Cigna of WY Commercial |
$0.02
|
| Rate for Payer: Entrust Commercial |
$0.02
|
| Rate for Payer: First Choice Health Commercial |
$0.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.01
|
| Rate for Payer: HealthUtah PPO |
$0.02
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.02
|
| Rate for Payer: Multiplan Medicare/VA |
$0.01
|
| Rate for Payer: One Health Plan of WY PPO |
$0.02
|
| Rate for Payer: PacificSource Commercial |
$0.02
|
| Rate for Payer: PHCS PPO |
$0.02
|
| Rate for Payer: Three Rivers PPO |
$0.02
|
| Rate for Payer: TriWest Veterans Administration |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.02
|
| Rate for Payer: United Healthcare Medicare |
$0.01
|
| Rate for Payer: WINHealth Partners Commercial |
$0.02
|
| Rate for Payer: Wise Provider Network Commercial |
$0.02
|
|
|
DIAB MANAGE TRN IND/GROUP
|
Professional
|
Both
|
$63.00
|
|
|
Service Code
|
HCPCS G0109
|
| Hospital Charge Code |
G0109
|
| Min. Negotiated Rate |
$13.00 |
| Max. Negotiated Rate |
$63.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$61.74
|
| Rate for Payer: Aetna of WY Medicare |
$15.30
|
| Rate for Payer: Beech Street Commercial |
$59.85
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$61.11
|
| Rate for Payer: Cigna of WY Commercial |
$61.74
|
| Rate for Payer: First Choice Health Commercial |
$56.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$59.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$15.30
|
| Rate for Payer: HealthUtah PPO |
$63.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$61.11
|
| Rate for Payer: Multiplan Medicare/VA |
$13.00
|
| Rate for Payer: One Health Plan of WY PPO |
$61.74
|
| Rate for Payer: PacificSource Commercial |
$56.70
|
| Rate for Payer: PHCS PPO |
$59.85
|
| Rate for Payer: Three Rivers PPO |
$47.25
|
| Rate for Payer: TriWest Veterans Administration |
$15.30
|
| Rate for Payer: United Healthcare Commercial |
$54.81
|
| Rate for Payer: United Healthcare Medicare |
$15.30
|
| Rate for Payer: WINHealth Partners Commercial |
$59.85
|
|
