|
DICLOFENAC 1 % TOPICAL GEL [52825]
|
Facility
|
OP
|
$0.39
|
|
|
Service Code
|
NDC 4612275252
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.39 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.38
|
| Rate for Payer: Aetna of WY Medicare |
$0.26
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.37
|
| Rate for Payer: Altius Commercial |
$0.37
|
| Rate for Payer: Beech Street Commercial |
$0.38
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.32
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.38
|
| Rate for Payer: Cigna of WY Commercial |
$0.38
|
| Rate for Payer: Entrust Commercial |
$0.37
|
| Rate for Payer: First Choice Health Commercial |
$0.37
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.37
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.23
|
| Rate for Payer: HealthUtah PPO |
$0.39
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.38
|
| Rate for Payer: Multiplan Medicare/VA |
$0.21
|
| Rate for Payer: One Health Plan of WY PPO |
$0.38
|
| Rate for Payer: PacificSource Commercial |
$0.35
|
| Rate for Payer: PHCS PPO |
$0.38
|
| Rate for Payer: Three Rivers PPO |
$0.29
|
| Rate for Payer: TriWest Veterans Administration |
$0.23
|
| Rate for Payer: United Healthcare Commercial |
$0.34
|
| Rate for Payer: United Healthcare Medicare |
$0.23
|
| Rate for Payer: WINHealth Partners Commercial |
$0.38
|
| Rate for Payer: Wise Provider Network Commercial |
$0.37
|
|
|
DICLOFENAC 1 % TOPICAL GEL [52825]
|
Facility
|
IP
|
$0.49
|
|
|
Service Code
|
NDC 4580295301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.49 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.48
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.47
|
| Rate for Payer: Altius Commercial |
$0.47
|
| Rate for Payer: Beech Street Commercial |
$0.48
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.40
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.48
|
| Rate for Payer: Cigna of WY Commercial |
$0.48
|
| Rate for Payer: Entrust Commercial |
$0.47
|
| Rate for Payer: First Choice Health Commercial |
$0.47
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.47
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.32
|
| Rate for Payer: HealthUtah PPO |
$0.49
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.48
|
| Rate for Payer: Multiplan Medicare/VA |
$0.31
|
| Rate for Payer: One Health Plan of WY PPO |
$0.48
|
| Rate for Payer: PacificSource Commercial |
$0.44
|
| Rate for Payer: PHCS PPO |
$0.48
|
| Rate for Payer: Three Rivers PPO |
$0.37
|
| Rate for Payer: TriWest Veterans Administration |
$0.32
|
| Rate for Payer: United Healthcare Commercial |
$0.43
|
| Rate for Payer: United Healthcare Medicare |
$0.32
|
| Rate for Payer: WINHealth Partners Commercial |
$0.47
|
| Rate for Payer: Wise Provider Network Commercial |
$0.47
|
|
|
DICLOFENAC 1 % TOPICAL GEL [52825]
|
Facility
|
IP
|
$0.60
|
|
|
Service Code
|
NDC 4580216000
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.59
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.58
|
| Rate for Payer: Altius Commercial |
$0.58
|
| Rate for Payer: Beech Street Commercial |
$0.59
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.49
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.58
|
| Rate for Payer: Cigna of WY Commercial |
$0.59
|
| Rate for Payer: Entrust Commercial |
$0.57
|
| Rate for Payer: First Choice Health Commercial |
$0.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.40
|
| Rate for Payer: HealthUtah PPO |
$0.60
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.58
|
| Rate for Payer: Multiplan Medicare/VA |
$0.38
|
| Rate for Payer: One Health Plan of WY PPO |
$0.59
|
| Rate for Payer: PacificSource Commercial |
$0.54
|
| Rate for Payer: PHCS PPO |
$0.59
|
| Rate for Payer: Three Rivers PPO |
$0.45
|
| Rate for Payer: TriWest Veterans Administration |
$0.40
|
| Rate for Payer: United Healthcare Commercial |
$0.52
|
| Rate for Payer: United Healthcare Medicare |
$0.40
|
| Rate for Payer: WINHealth Partners Commercial |
$0.57
|
| Rate for Payer: Wise Provider Network Commercial |
$0.57
|
|
|
DICLOFENAC 1 % TOPICAL GEL [52825]
|
Facility
|
OP
|
$0.57
|
|
|
Service Code
|
NDC 0067815203
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.57 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.56
|
| Rate for Payer: Aetna of WY Medicare |
$0.38
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.55
|
| Rate for Payer: Altius Commercial |
$0.55
|
| Rate for Payer: Beech Street Commercial |
$0.56
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.47
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.55
|
| Rate for Payer: Cigna of WY Commercial |
$0.56
|
| Rate for Payer: Entrust Commercial |
$0.54
|
| Rate for Payer: First Choice Health Commercial |
$0.54
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.54
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.33
|
| Rate for Payer: HealthUtah PPO |
$0.57
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.55
|
| Rate for Payer: Multiplan Medicare/VA |
$0.31
|
| Rate for Payer: One Health Plan of WY PPO |
$0.56
|
| Rate for Payer: PacificSource Commercial |
$0.51
|
| Rate for Payer: PHCS PPO |
$0.56
|
| Rate for Payer: Three Rivers PPO |
$0.43
|
| Rate for Payer: TriWest Veterans Administration |
$0.33
|
| Rate for Payer: United Healthcare Commercial |
$0.50
|
| Rate for Payer: United Healthcare Medicare |
$0.33
|
| Rate for Payer: WINHealth Partners Commercial |
$0.56
|
| Rate for Payer: Wise Provider Network Commercial |
$0.54
|
|
|
DICLOFENAC 1 % TOPICAL GEL [52825]
|
Facility
|
OP
|
$0.80
|
|
|
Service Code
|
NDC 2192200909
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.44 |
| Max. Negotiated Rate |
$0.80 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.78
|
| Rate for Payer: Aetna of WY Medicare |
$0.53
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.77
|
| Rate for Payer: Altius Commercial |
$0.77
|
| Rate for Payer: Beech Street Commercial |
$0.78
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.66
|
| Rate for Payer: Cash Price |
$0.56
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.78
|
| Rate for Payer: Cigna of WY Commercial |
$0.78
|
| Rate for Payer: Entrust Commercial |
$0.76
|
| Rate for Payer: First Choice Health Commercial |
$0.76
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.76
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.46
|
| Rate for Payer: HealthUtah PPO |
$0.80
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.78
|
| Rate for Payer: Multiplan Medicare/VA |
$0.44
|
| Rate for Payer: One Health Plan of WY PPO |
$0.78
|
| Rate for Payer: PacificSource Commercial |
$0.72
|
| Rate for Payer: PHCS PPO |
$0.78
|
| Rate for Payer: Three Rivers PPO |
$0.60
|
| Rate for Payer: TriWest Veterans Administration |
$0.46
|
| Rate for Payer: United Healthcare Commercial |
$0.70
|
| Rate for Payer: United Healthcare Medicare |
$0.46
|
| Rate for Payer: WINHealth Partners Commercial |
$0.78
|
| Rate for Payer: Wise Provider Network Commercial |
$0.76
|
|
|
DICLOFENAC 1 % TOPICAL GEL [52825]
|
Facility
|
IP
|
$0.57
|
|
|
Service Code
|
NDC 0067815203
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$0.57 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.56
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.55
|
| Rate for Payer: Altius Commercial |
$0.55
|
| Rate for Payer: Beech Street Commercial |
$0.56
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.47
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.55
|
| Rate for Payer: Cigna of WY Commercial |
$0.56
|
| Rate for Payer: Entrust Commercial |
$0.54
|
| Rate for Payer: First Choice Health Commercial |
$0.54
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.54
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.38
|
| Rate for Payer: HealthUtah PPO |
$0.57
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.55
|
| Rate for Payer: Multiplan Medicare/VA |
$0.36
|
| Rate for Payer: One Health Plan of WY PPO |
$0.56
|
| Rate for Payer: PacificSource Commercial |
$0.51
|
| Rate for Payer: PHCS PPO |
$0.56
|
| Rate for Payer: Three Rivers PPO |
$0.43
|
| Rate for Payer: TriWest Veterans Administration |
$0.38
|
| Rate for Payer: United Healthcare Commercial |
$0.50
|
| Rate for Payer: United Healthcare Medicare |
$0.38
|
| Rate for Payer: WINHealth Partners Commercial |
$0.54
|
| Rate for Payer: Wise Provider Network Commercial |
$0.54
|
|
|
DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION [1399]
|
Facility
|
OP
|
$58.88
|
|
|
Service Code
|
HCPCS J0500
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.44 |
| Max. Negotiated Rate |
$58.88 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$57.70
|
| Rate for Payer: Aetna of WY Medicare |
$38.86
|
| Rate for Payer: Altius Auto/Workers Compensation |
$56.52
|
| Rate for Payer: Altius Commercial |
$56.52
|
| Rate for Payer: Beech Street Commercial |
$57.70
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$48.34
|
| Rate for Payer: Cash Price |
$41.21
|
| Rate for Payer: ChoiceCare Network Commercial |
$57.11
|
| Rate for Payer: Cigna of WY Commercial |
$57.70
|
| Rate for Payer: Entrust Commercial |
$55.94
|
| Rate for Payer: First Choice Health Commercial |
$55.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$55.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$34.15
|
| Rate for Payer: HealthUtah PPO |
$58.88
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$57.11
|
| Rate for Payer: Multiplan Medicare/VA |
$32.44
|
| Rate for Payer: One Health Plan of WY PPO |
$57.70
|
| Rate for Payer: PacificSource Commercial |
$52.99
|
| Rate for Payer: PHCS PPO |
$57.70
|
| Rate for Payer: Three Rivers PPO |
$44.16
|
| Rate for Payer: TriWest Veterans Administration |
$34.15
|
| Rate for Payer: United Healthcare Commercial |
$51.23
|
| Rate for Payer: United Healthcare Medicare |
$34.15
|
| Rate for Payer: WINHealth Partners Commercial |
$57.70
|
| Rate for Payer: Wise Provider Network Commercial |
$55.94
|
|
|
DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION [1399]
|
Facility
|
IP
|
$58.88
|
|
|
Service Code
|
HCPCS J0500
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.92 |
| Max. Negotiated Rate |
$58.88 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$57.70
|
| Rate for Payer: Altius Auto/Workers Compensation |
$56.52
|
| Rate for Payer: Altius Commercial |
$56.52
|
| Rate for Payer: Beech Street Commercial |
$57.70
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$48.34
|
| Rate for Payer: Cash Price |
$41.21
|
| Rate for Payer: ChoiceCare Network Commercial |
$57.11
|
| Rate for Payer: Cigna of WY Commercial |
$57.70
|
| Rate for Payer: Entrust Commercial |
$55.94
|
| Rate for Payer: First Choice Health Commercial |
$55.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$55.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$38.86
|
| Rate for Payer: HealthUtah PPO |
$58.88
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$57.11
|
| Rate for Payer: Multiplan Medicare/VA |
$36.92
|
| Rate for Payer: One Health Plan of WY PPO |
$57.70
|
| Rate for Payer: PacificSource Commercial |
$52.99
|
| Rate for Payer: PHCS PPO |
$57.70
|
| Rate for Payer: Three Rivers PPO |
$44.16
|
| Rate for Payer: TriWest Veterans Administration |
$38.86
|
| Rate for Payer: United Healthcare Commercial |
$51.23
|
| Rate for Payer: United Healthcare Medicare |
$38.86
|
| Rate for Payer: WINHealth Partners Commercial |
$55.94
|
| Rate for Payer: Wise Provider Network Commercial |
$55.94
|
|
|
DICYCLOMINE 20 MG TABLET [11184]
|
Facility
|
OP
|
$1.81
|
|
|
Service Code
|
NDC 6068738011
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$1.81 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.77
|
| Rate for Payer: Aetna of WY Medicare |
$1.19
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.74
|
| Rate for Payer: Altius Commercial |
$1.74
|
| Rate for Payer: Beech Street Commercial |
$1.77
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.49
|
| Rate for Payer: Cash Price |
$1.27
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.76
|
| Rate for Payer: Cigna of WY Commercial |
$1.77
|
| Rate for Payer: Entrust Commercial |
$1.72
|
| Rate for Payer: First Choice Health Commercial |
$1.72
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.72
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.05
|
| Rate for Payer: HealthUtah PPO |
$1.81
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.76
|
| Rate for Payer: Multiplan Medicare/VA |
$1.00
|
| Rate for Payer: One Health Plan of WY PPO |
$1.77
|
| Rate for Payer: PacificSource Commercial |
$1.63
|
| Rate for Payer: PHCS PPO |
$1.77
|
| Rate for Payer: Three Rivers PPO |
$1.36
|
| Rate for Payer: TriWest Veterans Administration |
$1.05
|
| Rate for Payer: United Healthcare Commercial |
$1.57
|
| Rate for Payer: United Healthcare Medicare |
$1.05
|
| Rate for Payer: WINHealth Partners Commercial |
$1.77
|
| Rate for Payer: Wise Provider Network Commercial |
$1.72
|
|
|
DICYCLOMINE 20 MG TABLET [11184]
|
Facility
|
IP
|
$1.81
|
|
|
Service Code
|
NDC 6068738001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.13 |
| Max. Negotiated Rate |
$1.81 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.77
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.74
|
| Rate for Payer: Altius Commercial |
$1.74
|
| Rate for Payer: Beech Street Commercial |
$1.77
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.49
|
| Rate for Payer: Cash Price |
$1.27
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.76
|
| Rate for Payer: Cigna of WY Commercial |
$1.77
|
| Rate for Payer: Entrust Commercial |
$1.72
|
| Rate for Payer: First Choice Health Commercial |
$1.72
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.72
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.19
|
| Rate for Payer: HealthUtah PPO |
$1.81
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.76
|
| Rate for Payer: Multiplan Medicare/VA |
$1.13
|
| Rate for Payer: One Health Plan of WY PPO |
$1.77
|
| Rate for Payer: PacificSource Commercial |
$1.63
|
| Rate for Payer: PHCS PPO |
$1.77
|
| Rate for Payer: Three Rivers PPO |
$1.36
|
| Rate for Payer: TriWest Veterans Administration |
$1.19
|
| Rate for Payer: United Healthcare Commercial |
$1.57
|
| Rate for Payer: United Healthcare Medicare |
$1.19
|
| Rate for Payer: WINHealth Partners Commercial |
$1.72
|
| Rate for Payer: Wise Provider Network Commercial |
$1.72
|
|
|
DICYCLOMINE 20 MG TABLET [11184]
|
Facility
|
OP
|
$1.81
|
|
|
Service Code
|
NDC 6068738001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$1.81 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.77
|
| Rate for Payer: Aetna of WY Medicare |
$1.19
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.74
|
| Rate for Payer: Altius Commercial |
$1.74
|
| Rate for Payer: Beech Street Commercial |
$1.77
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.49
|
| Rate for Payer: Cash Price |
$1.27
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.76
|
| Rate for Payer: Cigna of WY Commercial |
$1.77
|
| Rate for Payer: Entrust Commercial |
$1.72
|
| Rate for Payer: First Choice Health Commercial |
$1.72
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.72
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.05
|
| Rate for Payer: HealthUtah PPO |
$1.81
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.76
|
| Rate for Payer: Multiplan Medicare/VA |
$1.00
|
| Rate for Payer: One Health Plan of WY PPO |
$1.77
|
| Rate for Payer: PacificSource Commercial |
$1.63
|
| Rate for Payer: PHCS PPO |
$1.77
|
| Rate for Payer: Three Rivers PPO |
$1.36
|
| Rate for Payer: TriWest Veterans Administration |
$1.05
|
| Rate for Payer: United Healthcare Commercial |
$1.57
|
| Rate for Payer: United Healthcare Medicare |
$1.05
|
| Rate for Payer: WINHealth Partners Commercial |
$1.77
|
| Rate for Payer: Wise Provider Network Commercial |
$1.72
|
|
|
DICYCLOMINE 20 MG TABLET [11184]
|
Facility
|
IP
|
$1.81
|
|
|
Service Code
|
NDC 6068738011
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.13 |
| Max. Negotiated Rate |
$1.81 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.77
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.74
|
| Rate for Payer: Altius Commercial |
$1.74
|
| Rate for Payer: Beech Street Commercial |
$1.77
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.49
|
| Rate for Payer: Cash Price |
$1.27
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.76
|
| Rate for Payer: Cigna of WY Commercial |
$1.77
|
| Rate for Payer: Entrust Commercial |
$1.72
|
| Rate for Payer: First Choice Health Commercial |
$1.72
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.72
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.19
|
| Rate for Payer: HealthUtah PPO |
$1.81
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.76
|
| Rate for Payer: Multiplan Medicare/VA |
$1.13
|
| Rate for Payer: One Health Plan of WY PPO |
$1.77
|
| Rate for Payer: PacificSource Commercial |
$1.63
|
| Rate for Payer: PHCS PPO |
$1.77
|
| Rate for Payer: Three Rivers PPO |
$1.36
|
| Rate for Payer: TriWest Veterans Administration |
$1.19
|
| Rate for Payer: United Healthcare Commercial |
$1.57
|
| Rate for Payer: United Healthcare Medicare |
$1.19
|
| Rate for Payer: WINHealth Partners Commercial |
$1.72
|
| Rate for Payer: Wise Provider Network Commercial |
$1.72
|
|
|
DIGOXIN 125 MCG (0.125 MG) TABLET [16534]
|
Facility
|
OP
|
$4.63
|
|
|
Service Code
|
NDC 6068754011
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$4.63 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4.54
|
| Rate for Payer: Aetna of WY Medicare |
$3.06
|
| Rate for Payer: Altius Auto/Workers Compensation |
$4.44
|
| Rate for Payer: Altius Commercial |
$4.44
|
| Rate for Payer: Beech Street Commercial |
$4.54
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3.80
|
| Rate for Payer: Cash Price |
$3.24
|
| Rate for Payer: ChoiceCare Network Commercial |
$4.49
|
| Rate for Payer: Cigna of WY Commercial |
$4.54
|
| Rate for Payer: Entrust Commercial |
$4.40
|
| Rate for Payer: First Choice Health Commercial |
$4.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2.69
|
| Rate for Payer: HealthUtah PPO |
$4.63
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4.49
|
| Rate for Payer: Multiplan Medicare/VA |
$2.55
|
| Rate for Payer: One Health Plan of WY PPO |
$4.54
|
| Rate for Payer: PacificSource Commercial |
$4.17
|
| Rate for Payer: PHCS PPO |
$4.54
|
| Rate for Payer: Three Rivers PPO |
$3.47
|
| Rate for Payer: TriWest Veterans Administration |
$2.69
|
| Rate for Payer: United Healthcare Commercial |
$4.03
|
| Rate for Payer: United Healthcare Medicare |
$2.69
|
| Rate for Payer: WINHealth Partners Commercial |
$4.54
|
| Rate for Payer: Wise Provider Network Commercial |
$4.40
|
|
|
DIGOXIN 125 MCG (0.125 MG) TABLET [16534]
|
Facility
|
IP
|
$4.63
|
|
|
Service Code
|
NDC 6068754011
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.90 |
| Max. Negotiated Rate |
$4.63 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4.54
|
| Rate for Payer: Altius Auto/Workers Compensation |
$4.44
|
| Rate for Payer: Altius Commercial |
$4.44
|
| Rate for Payer: Beech Street Commercial |
$4.54
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3.80
|
| Rate for Payer: Cash Price |
$3.24
|
| Rate for Payer: ChoiceCare Network Commercial |
$4.49
|
| Rate for Payer: Cigna of WY Commercial |
$4.54
|
| Rate for Payer: Entrust Commercial |
$4.40
|
| Rate for Payer: First Choice Health Commercial |
$4.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3.06
|
| Rate for Payer: HealthUtah PPO |
$4.63
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4.49
|
| Rate for Payer: Multiplan Medicare/VA |
$2.90
|
| Rate for Payer: One Health Plan of WY PPO |
$4.54
|
| Rate for Payer: PacificSource Commercial |
$4.17
|
| Rate for Payer: PHCS PPO |
$4.54
|
| Rate for Payer: Three Rivers PPO |
$3.47
|
| Rate for Payer: TriWest Veterans Administration |
$3.06
|
| Rate for Payer: United Healthcare Commercial |
$4.03
|
| Rate for Payer: United Healthcare Medicare |
$3.06
|
| Rate for Payer: WINHealth Partners Commercial |
$4.40
|
| Rate for Payer: Wise Provider Network Commercial |
$4.40
|
|
|
DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION [7819]
|
Facility
|
OP
|
$25.31
|
|
|
Service Code
|
HCPCS J1160
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.95 |
| Max. Negotiated Rate |
$25.31 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$24.80
|
| Rate for Payer: Aetna of WY Medicare |
$16.70
|
| Rate for Payer: Altius Auto/Workers Compensation |
$24.30
|
| Rate for Payer: Altius Commercial |
$24.30
|
| Rate for Payer: Beech Street Commercial |
$24.80
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$20.78
|
| Rate for Payer: Cash Price |
$17.72
|
| Rate for Payer: ChoiceCare Network Commercial |
$24.55
|
| Rate for Payer: Cigna of WY Commercial |
$24.80
|
| Rate for Payer: Entrust Commercial |
$24.04
|
| Rate for Payer: First Choice Health Commercial |
$24.04
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$24.04
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$14.68
|
| Rate for Payer: HealthUtah PPO |
$25.31
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.55
|
| Rate for Payer: Multiplan Medicare/VA |
$13.95
|
| Rate for Payer: One Health Plan of WY PPO |
$24.80
|
| Rate for Payer: PacificSource Commercial |
$22.78
|
| Rate for Payer: PHCS PPO |
$24.80
|
| Rate for Payer: Three Rivers PPO |
$18.98
|
| Rate for Payer: TriWest Veterans Administration |
$14.68
|
| Rate for Payer: United Healthcare Commercial |
$22.02
|
| Rate for Payer: United Healthcare Medicare |
$14.68
|
| Rate for Payer: WINHealth Partners Commercial |
$24.80
|
| Rate for Payer: Wise Provider Network Commercial |
$24.04
|
|
|
DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION [7819]
|
Facility
|
IP
|
$25.31
|
|
|
Service Code
|
HCPCS J1160
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.87 |
| Max. Negotiated Rate |
$25.31 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$24.80
|
| Rate for Payer: Altius Auto/Workers Compensation |
$24.30
|
| Rate for Payer: Altius Commercial |
$24.30
|
| Rate for Payer: Beech Street Commercial |
$24.80
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$20.78
|
| Rate for Payer: Cash Price |
$17.72
|
| Rate for Payer: ChoiceCare Network Commercial |
$24.55
|
| Rate for Payer: Cigna of WY Commercial |
$24.80
|
| Rate for Payer: Entrust Commercial |
$24.04
|
| Rate for Payer: First Choice Health Commercial |
$24.04
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$24.04
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$16.70
|
| Rate for Payer: HealthUtah PPO |
$25.31
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.55
|
| Rate for Payer: Multiplan Medicare/VA |
$15.87
|
| Rate for Payer: One Health Plan of WY PPO |
$24.80
|
| Rate for Payer: PacificSource Commercial |
$22.78
|
| Rate for Payer: PHCS PPO |
$24.80
|
| Rate for Payer: Three Rivers PPO |
$18.98
|
| Rate for Payer: TriWest Veterans Administration |
$16.70
|
| Rate for Payer: United Healthcare Commercial |
$22.02
|
| Rate for Payer: United Healthcare Medicare |
$16.70
|
| Rate for Payer: WINHealth Partners Commercial |
$24.04
|
| Rate for Payer: Wise Provider Network Commercial |
$24.04
|
|
|
DILATION CERVICAL CANAL INSTRUMENTAL SPX
|
Professional
|
Both
|
$581.00
|
|
|
Service Code
|
HCPCS 57800
|
| Hospital Charge Code |
57800
|
| Min. Negotiated Rate |
$39.41 |
| Max. Negotiated Rate |
$581.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$569.38
|
| Rate for Payer: Aetna of WY Medicare |
$46.37
|
| Rate for Payer: Beech Street Commercial |
$551.95
|
| Rate for Payer: Cash Price |
$406.70
|
| Rate for Payer: Cash Price |
$406.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$563.57
|
| Rate for Payer: Cigna of WY Commercial |
$569.38
|
| Rate for Payer: First Choice Health Commercial |
$522.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$551.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$46.37
|
| Rate for Payer: HealthUtah PPO |
$581.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$563.57
|
| Rate for Payer: Multiplan Medicare/VA |
$39.41
|
| Rate for Payer: One Health Plan of WY PPO |
$569.38
|
| Rate for Payer: PacificSource Commercial |
$522.90
|
| Rate for Payer: PHCS PPO |
$551.95
|
| Rate for Payer: Three Rivers PPO |
$435.75
|
| Rate for Payer: TriWest Veterans Administration |
$46.37
|
| Rate for Payer: United Healthcare Commercial |
$505.47
|
| Rate for Payer: United Healthcare Medicare |
$46.37
|
| Rate for Payer: WINHealth Partners Commercial |
$493.85
|
|
|
DILATION & CURETTAGE DX&/THER NONOBSTETRIC
|
Professional
|
Both
|
$1,175.00
|
|
|
Service Code
|
HCPCS 58120
|
| Hospital Charge Code |
58120
|
| Min. Negotiated Rate |
$192.14 |
| Max. Negotiated Rate |
$1,175.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,151.50
|
| Rate for Payer: Aetna of WY Medicare |
$226.05
|
| Rate for Payer: Beech Street Commercial |
$1,116.25
|
| Rate for Payer: Cash Price |
$822.50
|
| Rate for Payer: Cash Price |
$822.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,139.75
|
| Rate for Payer: Cigna of WY Commercial |
$1,151.50
|
| Rate for Payer: First Choice Health Commercial |
$1,057.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,116.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$226.05
|
| Rate for Payer: HealthUtah PPO |
$1,175.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,139.75
|
| Rate for Payer: Multiplan Medicare/VA |
$192.14
|
| Rate for Payer: One Health Plan of WY PPO |
$1,151.50
|
| Rate for Payer: PacificSource Commercial |
$1,057.50
|
| Rate for Payer: PHCS PPO |
$1,116.25
|
| Rate for Payer: Three Rivers PPO |
$881.25
|
| Rate for Payer: TriWest Veterans Administration |
$226.05
|
| Rate for Payer: United Healthcare Commercial |
$1,022.25
|
| Rate for Payer: United Healthcare Medicare |
$226.05
|
| Rate for Payer: WINHealth Partners Commercial |
$998.75
|
|
|
DILTIAZEM 30 MG TABLET [17930]
|
Facility
|
OP
|
$3.33
|
|
|
Service Code
|
NDC 6868200610
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.83 |
| Max. Negotiated Rate |
$3.33 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3.26
|
| Rate for Payer: Aetna of WY Medicare |
$2.20
|
| Rate for Payer: Altius Auto/Workers Compensation |
$3.20
|
| Rate for Payer: Altius Commercial |
$3.20
|
| Rate for Payer: Beech Street Commercial |
$3.26
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.73
|
| Rate for Payer: Cash Price |
$2.33
|
| Rate for Payer: ChoiceCare Network Commercial |
$3.23
|
| Rate for Payer: Cigna of WY Commercial |
$3.26
|
| Rate for Payer: Entrust Commercial |
$3.16
|
| Rate for Payer: First Choice Health Commercial |
$3.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.93
|
| Rate for Payer: HealthUtah PPO |
$3.33
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3.23
|
| Rate for Payer: Multiplan Medicare/VA |
$1.83
|
| Rate for Payer: One Health Plan of WY PPO |
$3.26
|
| Rate for Payer: PacificSource Commercial |
$3.00
|
| Rate for Payer: PHCS PPO |
$3.26
|
| Rate for Payer: Three Rivers PPO |
$2.50
|
| Rate for Payer: TriWest Veterans Administration |
$1.93
|
| Rate for Payer: United Healthcare Commercial |
$2.90
|
| Rate for Payer: United Healthcare Medicare |
$1.93
|
| Rate for Payer: WINHealth Partners Commercial |
$3.26
|
| Rate for Payer: Wise Provider Network Commercial |
$3.16
|
|
|
DILTIAZEM 30 MG TABLET [17930]
|
Facility
|
IP
|
$0.60
|
|
|
Service Code
|
NDC 0093031801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.59
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.58
|
| Rate for Payer: Altius Commercial |
$0.58
|
| Rate for Payer: Beech Street Commercial |
$0.59
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.49
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.58
|
| Rate for Payer: Cigna of WY Commercial |
$0.59
|
| Rate for Payer: Entrust Commercial |
$0.57
|
| Rate for Payer: First Choice Health Commercial |
$0.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.40
|
| Rate for Payer: HealthUtah PPO |
$0.60
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.58
|
| Rate for Payer: Multiplan Medicare/VA |
$0.38
|
| Rate for Payer: One Health Plan of WY PPO |
$0.59
|
| Rate for Payer: PacificSource Commercial |
$0.54
|
| Rate for Payer: PHCS PPO |
$0.59
|
| Rate for Payer: Three Rivers PPO |
$0.45
|
| Rate for Payer: TriWest Veterans Administration |
$0.40
|
| Rate for Payer: United Healthcare Commercial |
$0.52
|
| Rate for Payer: United Healthcare Medicare |
$0.40
|
| Rate for Payer: WINHealth Partners Commercial |
$0.57
|
| Rate for Payer: Wise Provider Network Commercial |
$0.57
|
|
|
DILTIAZEM 30 MG TABLET [17930]
|
Facility
|
OP
|
$0.60
|
|
|
Service Code
|
NDC 0093031801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.59
|
| Rate for Payer: Aetna of WY Medicare |
$0.40
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.58
|
| Rate for Payer: Altius Commercial |
$0.58
|
| Rate for Payer: Beech Street Commercial |
$0.59
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.49
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.58
|
| Rate for Payer: Cigna of WY Commercial |
$0.59
|
| Rate for Payer: Entrust Commercial |
$0.57
|
| Rate for Payer: First Choice Health Commercial |
$0.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.35
|
| Rate for Payer: HealthUtah PPO |
$0.60
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.58
|
| Rate for Payer: Multiplan Medicare/VA |
$0.33
|
| Rate for Payer: One Health Plan of WY PPO |
$0.59
|
| Rate for Payer: PacificSource Commercial |
$0.54
|
| Rate for Payer: PHCS PPO |
$0.59
|
| Rate for Payer: Three Rivers PPO |
$0.45
|
| Rate for Payer: TriWest Veterans Administration |
$0.35
|
| Rate for Payer: United Healthcare Commercial |
$0.52
|
| Rate for Payer: United Healthcare Medicare |
$0.35
|
| Rate for Payer: WINHealth Partners Commercial |
$0.59
|
| Rate for Payer: Wise Provider Network Commercial |
$0.57
|
|
|
DILTIAZEM 30 MG TABLET [17930]
|
Facility
|
IP
|
$3.33
|
|
|
Service Code
|
NDC 6868200610
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.09 |
| Max. Negotiated Rate |
$3.33 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3.26
|
| Rate for Payer: Altius Auto/Workers Compensation |
$3.20
|
| Rate for Payer: Altius Commercial |
$3.20
|
| Rate for Payer: Beech Street Commercial |
$3.26
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.73
|
| Rate for Payer: Cash Price |
$2.33
|
| Rate for Payer: ChoiceCare Network Commercial |
$3.23
|
| Rate for Payer: Cigna of WY Commercial |
$3.26
|
| Rate for Payer: Entrust Commercial |
$3.16
|
| Rate for Payer: First Choice Health Commercial |
$3.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2.20
|
| Rate for Payer: HealthUtah PPO |
$3.33
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3.23
|
| Rate for Payer: Multiplan Medicare/VA |
$2.09
|
| Rate for Payer: One Health Plan of WY PPO |
$3.26
|
| Rate for Payer: PacificSource Commercial |
$3.00
|
| Rate for Payer: PHCS PPO |
$3.26
|
| Rate for Payer: Three Rivers PPO |
$2.50
|
| Rate for Payer: TriWest Veterans Administration |
$2.20
|
| Rate for Payer: United Healthcare Commercial |
$2.90
|
| Rate for Payer: United Healthcare Medicare |
$2.20
|
| Rate for Payer: WINHealth Partners Commercial |
$3.16
|
| Rate for Payer: Wise Provider Network Commercial |
$3.16
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION [1034]
|
Facility
|
OP
|
$17.74
|
|
|
Service Code
|
NDC 0641601310
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.77 |
| Max. Negotiated Rate |
$17.74 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$17.39
|
| Rate for Payer: Aetna of WY Medicare |
$11.71
|
| Rate for Payer: Altius Auto/Workers Compensation |
$17.03
|
| Rate for Payer: Altius Commercial |
$17.03
|
| Rate for Payer: Beech Street Commercial |
$17.39
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.56
|
| Rate for Payer: Cash Price |
$12.42
|
| Rate for Payer: ChoiceCare Network Commercial |
$17.21
|
| Rate for Payer: Cigna of WY Commercial |
$17.39
|
| Rate for Payer: Entrust Commercial |
$16.85
|
| Rate for Payer: First Choice Health Commercial |
$16.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.29
|
| Rate for Payer: HealthUtah PPO |
$17.74
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.21
|
| Rate for Payer: Multiplan Medicare/VA |
$9.77
|
| Rate for Payer: One Health Plan of WY PPO |
$17.39
|
| Rate for Payer: PacificSource Commercial |
$15.97
|
| Rate for Payer: PHCS PPO |
$17.39
|
| Rate for Payer: Three Rivers PPO |
$13.30
|
| Rate for Payer: TriWest Veterans Administration |
$10.29
|
| Rate for Payer: United Healthcare Commercial |
$15.43
|
| Rate for Payer: United Healthcare Medicare |
$10.29
|
| Rate for Payer: WINHealth Partners Commercial |
$17.39
|
| Rate for Payer: Wise Provider Network Commercial |
$16.85
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION [1034]
|
Facility
|
OP
|
$17.74
|
|
|
Service Code
|
NDC 0641601301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.77 |
| Max. Negotiated Rate |
$17.74 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$17.39
|
| Rate for Payer: Aetna of WY Medicare |
$11.71
|
| Rate for Payer: Altius Auto/Workers Compensation |
$17.03
|
| Rate for Payer: Altius Commercial |
$17.03
|
| Rate for Payer: Beech Street Commercial |
$17.39
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.56
|
| Rate for Payer: Cash Price |
$12.42
|
| Rate for Payer: ChoiceCare Network Commercial |
$17.21
|
| Rate for Payer: Cigna of WY Commercial |
$17.39
|
| Rate for Payer: Entrust Commercial |
$16.85
|
| Rate for Payer: First Choice Health Commercial |
$16.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.29
|
| Rate for Payer: HealthUtah PPO |
$17.74
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.21
|
| Rate for Payer: Multiplan Medicare/VA |
$9.77
|
| Rate for Payer: One Health Plan of WY PPO |
$17.39
|
| Rate for Payer: PacificSource Commercial |
$15.97
|
| Rate for Payer: PHCS PPO |
$17.39
|
| Rate for Payer: Three Rivers PPO |
$13.30
|
| Rate for Payer: TriWest Veterans Administration |
$10.29
|
| Rate for Payer: United Healthcare Commercial |
$15.43
|
| Rate for Payer: United Healthcare Medicare |
$10.29
|
| Rate for Payer: WINHealth Partners Commercial |
$17.39
|
| Rate for Payer: Wise Provider Network Commercial |
$16.85
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION [1034]
|
Facility
|
OP
|
$16.46
|
|
|
Service Code
|
NDC 0641601501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.07 |
| Max. Negotiated Rate |
$16.46 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.13
|
| Rate for Payer: Aetna of WY Medicare |
$10.86
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.80
|
| Rate for Payer: Altius Commercial |
$15.80
|
| Rate for Payer: Beech Street Commercial |
$16.13
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.51
|
| Rate for Payer: Cash Price |
$11.52
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.97
|
| Rate for Payer: Cigna of WY Commercial |
$16.13
|
| Rate for Payer: Entrust Commercial |
$15.64
|
| Rate for Payer: First Choice Health Commercial |
$15.64
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.64
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.55
|
| Rate for Payer: HealthUtah PPO |
$16.46
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.97
|
| Rate for Payer: Multiplan Medicare/VA |
$9.07
|
| Rate for Payer: One Health Plan of WY PPO |
$16.13
|
| Rate for Payer: PacificSource Commercial |
$14.81
|
| Rate for Payer: PHCS PPO |
$16.13
|
| Rate for Payer: Three Rivers PPO |
$12.34
|
| Rate for Payer: TriWest Veterans Administration |
$9.55
|
| Rate for Payer: United Healthcare Commercial |
$14.32
|
| Rate for Payer: United Healthcare Medicare |
$9.55
|
| Rate for Payer: WINHealth Partners Commercial |
$16.13
|
| Rate for Payer: Wise Provider Network Commercial |
$15.64
|
|
