|
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
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION [1034]
|
Facility
|
IP
|
$17.74
|
|
|
Service Code
|
NDC 0641601310
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.12 |
| Max. Negotiated Rate |
$17.74 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$17.39
|
| 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 |
$11.71
|
| Rate for Payer: HealthUtah PPO |
$17.74
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.21
|
| Rate for Payer: Multiplan Medicare/VA |
$11.12
|
| 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 |
$11.71
|
| Rate for Payer: United Healthcare Commercial |
$15.43
|
| Rate for Payer: United Healthcare Medicare |
$11.71
|
| Rate for Payer: WINHealth Partners Commercial |
$16.85
|
| Rate for Payer: Wise Provider Network Commercial |
$16.85
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION [1034]
|
Facility
|
IP
|
$16.46
|
|
|
Service Code
|
NDC 0641601501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.32 |
| Max. Negotiated Rate |
$16.46 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.13
|
| 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 |
$10.86
|
| Rate for Payer: HealthUtah PPO |
$16.46
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.97
|
| Rate for Payer: Multiplan Medicare/VA |
$10.32
|
| 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 |
$10.86
|
| Rate for Payer: United Healthcare Commercial |
$14.32
|
| Rate for Payer: United Healthcare Medicare |
$10.86
|
| Rate for Payer: WINHealth Partners Commercial |
$15.64
|
| Rate for Payer: Wise Provider Network Commercial |
$15.64
|
|
|
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 0641601510
|
|
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
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION [1034]
|
Facility
|
IP
|
$17.74
|
|
|
Service Code
|
NDC 0641601301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.12 |
| Max. Negotiated Rate |
$17.74 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$17.39
|
| 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 |
$11.71
|
| Rate for Payer: HealthUtah PPO |
$17.74
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.21
|
| Rate for Payer: Multiplan Medicare/VA |
$11.12
|
| 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 |
$11.71
|
| Rate for Payer: United Healthcare Commercial |
$15.43
|
| Rate for Payer: United Healthcare Medicare |
$11.71
|
| Rate for Payer: WINHealth Partners Commercial |
$16.85
|
| Rate for Payer: Wise Provider Network Commercial |
$16.85
|
|
|
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 CD 120 MG CAPSULE,EXTENDED RELEASE 24 HR [15728]
|
Facility
|
IP
|
$3.22
|
|
|
Service Code
|
NDC 6068719511
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.02 |
| Max. Negotiated Rate |
$3.22 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3.16
|
| Rate for Payer: Altius Auto/Workers Compensation |
$3.09
|
| Rate for Payer: Altius Commercial |
$3.09
|
| Rate for Payer: Beech Street Commercial |
$3.16
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.64
|
| Rate for Payer: Cash Price |
$2.26
|
| Rate for Payer: ChoiceCare Network Commercial |
$3.12
|
| Rate for Payer: Cigna of WY Commercial |
$3.16
|
| Rate for Payer: Entrust Commercial |
$3.06
|
| Rate for Payer: First Choice Health Commercial |
$3.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2.13
|
| Rate for Payer: HealthUtah PPO |
$3.22
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3.12
|
| Rate for Payer: Multiplan Medicare/VA |
$2.02
|
| Rate for Payer: One Health Plan of WY PPO |
$3.16
|
| Rate for Payer: PacificSource Commercial |
$2.90
|
| Rate for Payer: PHCS PPO |
$3.16
|
| Rate for Payer: Three Rivers PPO |
$2.42
|
| Rate for Payer: TriWest Veterans Administration |
$2.13
|
| Rate for Payer: United Healthcare Commercial |
$2.80
|
| Rate for Payer: United Healthcare Medicare |
$2.13
|
| Rate for Payer: WINHealth Partners Commercial |
$3.06
|
| Rate for Payer: Wise Provider Network Commercial |
$3.06
|
|
|
DILTIAZEM CD 120 MG CAPSULE,EXTENDED RELEASE 24 HR [15728]
|
Facility
|
OP
|
$3.22
|
|
|
Service Code
|
NDC 6068719511
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.77 |
| Max. Negotiated Rate |
$3.22 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3.16
|
| Rate for Payer: Aetna of WY Medicare |
$2.13
|
| Rate for Payer: Altius Auto/Workers Compensation |
$3.09
|
| Rate for Payer: Altius Commercial |
$3.09
|
| Rate for Payer: Beech Street Commercial |
$3.16
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.64
|
| Rate for Payer: Cash Price |
$2.26
|
| Rate for Payer: ChoiceCare Network Commercial |
$3.12
|
| Rate for Payer: Cigna of WY Commercial |
$3.16
|
| Rate for Payer: Entrust Commercial |
$3.06
|
| Rate for Payer: First Choice Health Commercial |
$3.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.87
|
| Rate for Payer: HealthUtah PPO |
$3.22
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3.12
|
| Rate for Payer: Multiplan Medicare/VA |
$1.77
|
| Rate for Payer: One Health Plan of WY PPO |
$3.16
|
| Rate for Payer: PacificSource Commercial |
$2.90
|
| Rate for Payer: PHCS PPO |
$3.16
|
| Rate for Payer: Three Rivers PPO |
$2.42
|
| Rate for Payer: TriWest Veterans Administration |
$1.87
|
| Rate for Payer: United Healthcare Commercial |
$2.80
|
| Rate for Payer: United Healthcare Medicare |
$1.87
|
| Rate for Payer: WINHealth Partners Commercial |
$3.16
|
| Rate for Payer: Wise Provider Network Commercial |
$3.06
|
|
|
DILTIAZEM CD 180 MG CAPSULE,EXTENDED RELEASE 24 HR [3311]
|
Facility
|
IP
|
$3.22
|
|
|
Service Code
|
NDC 6068720611
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.02 |
| Max. Negotiated Rate |
$3.22 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3.16
|
| Rate for Payer: Altius Auto/Workers Compensation |
$3.09
|
| Rate for Payer: Altius Commercial |
$3.09
|
| Rate for Payer: Beech Street Commercial |
$3.16
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.64
|
| Rate for Payer: Cash Price |
$2.26
|
| Rate for Payer: ChoiceCare Network Commercial |
$3.12
|
| Rate for Payer: Cigna of WY Commercial |
$3.16
|
| Rate for Payer: Entrust Commercial |
$3.06
|
| Rate for Payer: First Choice Health Commercial |
$3.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2.13
|
| Rate for Payer: HealthUtah PPO |
$3.22
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3.12
|
| Rate for Payer: Multiplan Medicare/VA |
$2.02
|
| Rate for Payer: One Health Plan of WY PPO |
$3.16
|
| Rate for Payer: PacificSource Commercial |
$2.90
|
| Rate for Payer: PHCS PPO |
$3.16
|
| Rate for Payer: Three Rivers PPO |
$2.42
|
| Rate for Payer: TriWest Veterans Administration |
$2.13
|
| Rate for Payer: United Healthcare Commercial |
$2.80
|
| Rate for Payer: United Healthcare Medicare |
$2.13
|
| Rate for Payer: WINHealth Partners Commercial |
$3.06
|
| Rate for Payer: Wise Provider Network Commercial |
$3.06
|
|
|
DILTIAZEM CD 180 MG CAPSULE,EXTENDED RELEASE 24 HR [3311]
|
Facility
|
OP
|
$3.22
|
|
|
Service Code
|
NDC 6068720601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.77 |
| Max. Negotiated Rate |
$3.22 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3.16
|
| Rate for Payer: Aetna of WY Medicare |
$2.13
|
| Rate for Payer: Altius Auto/Workers Compensation |
$3.09
|
| Rate for Payer: Altius Commercial |
$3.09
|
| Rate for Payer: Beech Street Commercial |
$3.16
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.64
|
| Rate for Payer: Cash Price |
$2.26
|
| Rate for Payer: ChoiceCare Network Commercial |
$3.12
|
| Rate for Payer: Cigna of WY Commercial |
$3.16
|
| Rate for Payer: Entrust Commercial |
$3.06
|
| Rate for Payer: First Choice Health Commercial |
$3.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.87
|
| Rate for Payer: HealthUtah PPO |
$3.22
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3.12
|
| Rate for Payer: Multiplan Medicare/VA |
$1.77
|
| Rate for Payer: One Health Plan of WY PPO |
$3.16
|
| Rate for Payer: PacificSource Commercial |
$2.90
|
| Rate for Payer: PHCS PPO |
$3.16
|
| Rate for Payer: Three Rivers PPO |
$2.42
|
| Rate for Payer: TriWest Veterans Administration |
$1.87
|
| Rate for Payer: United Healthcare Commercial |
$2.80
|
| Rate for Payer: United Healthcare Medicare |
$1.87
|
| Rate for Payer: WINHealth Partners Commercial |
$3.16
|
| Rate for Payer: Wise Provider Network Commercial |
$3.06
|
|
|
DILTIAZEM CD 180 MG CAPSULE,EXTENDED RELEASE 24 HR [3311]
|
Facility
|
IP
|
$3.22
|
|
|
Service Code
|
NDC 6068720601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.02 |
| Max. Negotiated Rate |
$3.22 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3.16
|
| Rate for Payer: Altius Auto/Workers Compensation |
$3.09
|
| Rate for Payer: Altius Commercial |
$3.09
|
| Rate for Payer: Beech Street Commercial |
$3.16
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.64
|
| Rate for Payer: Cash Price |
$2.26
|
| Rate for Payer: ChoiceCare Network Commercial |
$3.12
|
| Rate for Payer: Cigna of WY Commercial |
$3.16
|
| Rate for Payer: Entrust Commercial |
$3.06
|
| Rate for Payer: First Choice Health Commercial |
$3.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2.13
|
| Rate for Payer: HealthUtah PPO |
$3.22
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3.12
|
| Rate for Payer: Multiplan Medicare/VA |
$2.02
|
| Rate for Payer: One Health Plan of WY PPO |
$3.16
|
| Rate for Payer: PacificSource Commercial |
$2.90
|
| Rate for Payer: PHCS PPO |
$3.16
|
| Rate for Payer: Three Rivers PPO |
$2.42
|
| Rate for Payer: TriWest Veterans Administration |
$2.13
|
| Rate for Payer: United Healthcare Commercial |
$2.80
|
| Rate for Payer: United Healthcare Medicare |
$2.13
|
| Rate for Payer: WINHealth Partners Commercial |
$3.06
|
| Rate for Payer: Wise Provider Network Commercial |
$3.06
|
|
|
DILTIAZEM CD 180 MG CAPSULE,EXTENDED RELEASE 24 HR [3311]
|
Facility
|
OP
|
$3.22
|
|
|
Service Code
|
NDC 6068720611
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.77 |
| Max. Negotiated Rate |
$3.22 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3.16
|
| Rate for Payer: Aetna of WY Medicare |
$2.13
|
| Rate for Payer: Altius Auto/Workers Compensation |
$3.09
|
| Rate for Payer: Altius Commercial |
$3.09
|
| Rate for Payer: Beech Street Commercial |
$3.16
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.64
|
| Rate for Payer: Cash Price |
$2.26
|
| Rate for Payer: ChoiceCare Network Commercial |
$3.12
|
| Rate for Payer: Cigna of WY Commercial |
$3.16
|
| Rate for Payer: Entrust Commercial |
$3.06
|
| Rate for Payer: First Choice Health Commercial |
$3.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.87
|
| Rate for Payer: HealthUtah PPO |
$3.22
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3.12
|
| Rate for Payer: Multiplan Medicare/VA |
$1.77
|
| Rate for Payer: One Health Plan of WY PPO |
$3.16
|
| Rate for Payer: PacificSource Commercial |
$2.90
|
| Rate for Payer: PHCS PPO |
$3.16
|
| Rate for Payer: Three Rivers PPO |
$2.42
|
| Rate for Payer: TriWest Veterans Administration |
$1.87
|
| Rate for Payer: United Healthcare Commercial |
$2.80
|
| Rate for Payer: United Healthcare Medicare |
$1.87
|
| Rate for Payer: WINHealth Partners Commercial |
$3.16
|
| Rate for Payer: Wise Provider Network Commercial |
$3.06
|
|
|
DINOPROSTONE ER 10 MG VAGINAL INSERT,CONTROLLED RELEASE [14224]
|
Facility
|
IP
|
$479.84
|
|
|
Service Code
|
NDC 5556628001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$300.86 |
| Max. Negotiated Rate |
$479.84 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$470.24
|
| Rate for Payer: Altius Auto/Workers Compensation |
$460.65
|
| Rate for Payer: Altius Commercial |
$460.65
|
| Rate for Payer: Beech Street Commercial |
$470.24
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$393.95
|
| Rate for Payer: Cash Price |
$335.89
|
| Rate for Payer: ChoiceCare Network Commercial |
$465.44
|
| Rate for Payer: Cigna of WY Commercial |
$470.24
|
| Rate for Payer: Entrust Commercial |
$455.85
|
| Rate for Payer: First Choice Health Commercial |
$455.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$455.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$316.69
|
| Rate for Payer: HealthUtah PPO |
$479.84
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$465.44
|
| Rate for Payer: Multiplan Medicare/VA |
$300.86
|
| Rate for Payer: One Health Plan of WY PPO |
$470.24
|
| Rate for Payer: PacificSource Commercial |
$431.86
|
| Rate for Payer: PHCS PPO |
$470.24
|
| Rate for Payer: Three Rivers PPO |
$359.88
|
| Rate for Payer: TriWest Veterans Administration |
$316.69
|
| Rate for Payer: United Healthcare Commercial |
$417.46
|
| Rate for Payer: United Healthcare Medicare |
$316.69
|
| Rate for Payer: WINHealth Partners Commercial |
$455.85
|
| Rate for Payer: Wise Provider Network Commercial |
$455.85
|
|
|
DINOPROSTONE ER 10 MG VAGINAL INSERT,CONTROLLED RELEASE [14224]
|
Facility
|
IP
|
$479.84
|
|
|
Service Code
|
NDC 5556628000
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$300.86 |
| Max. Negotiated Rate |
$479.84 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$470.24
|
| Rate for Payer: Altius Auto/Workers Compensation |
$460.65
|
| Rate for Payer: Altius Commercial |
$460.65
|
| Rate for Payer: Beech Street Commercial |
$470.24
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$393.95
|
| Rate for Payer: Cash Price |
$335.89
|
| Rate for Payer: ChoiceCare Network Commercial |
$465.44
|
| Rate for Payer: Cigna of WY Commercial |
$470.24
|
| Rate for Payer: Entrust Commercial |
$455.85
|
| Rate for Payer: First Choice Health Commercial |
$455.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$455.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$316.69
|
| Rate for Payer: HealthUtah PPO |
$479.84
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$465.44
|
| Rate for Payer: Multiplan Medicare/VA |
$300.86
|
| Rate for Payer: One Health Plan of WY PPO |
$470.24
|
| Rate for Payer: PacificSource Commercial |
$431.86
|
| Rate for Payer: PHCS PPO |
$470.24
|
| Rate for Payer: Three Rivers PPO |
$359.88
|
| Rate for Payer: TriWest Veterans Administration |
$316.69
|
| Rate for Payer: United Healthcare Commercial |
$417.46
|
| Rate for Payer: United Healthcare Medicare |
$316.69
|
| Rate for Payer: WINHealth Partners Commercial |
$455.85
|
| Rate for Payer: Wise Provider Network Commercial |
$455.85
|
|
|
DINOPROSTONE ER 10 MG VAGINAL INSERT,CONTROLLED RELEASE [14224]
|
Facility
|
OP
|
$479.84
|
|
|
Service Code
|
NDC 5556628000
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$264.39 |
| Max. Negotiated Rate |
$479.84 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$470.24
|
| Rate for Payer: Aetna of WY Medicare |
$316.69
|
| Rate for Payer: Altius Auto/Workers Compensation |
$460.65
|
| Rate for Payer: Altius Commercial |
$460.65
|
| Rate for Payer: Beech Street Commercial |
$470.24
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$393.95
|
| Rate for Payer: Cash Price |
$335.89
|
| Rate for Payer: ChoiceCare Network Commercial |
$465.44
|
| Rate for Payer: Cigna of WY Commercial |
$470.24
|
| Rate for Payer: Entrust Commercial |
$455.85
|
| Rate for Payer: First Choice Health Commercial |
$455.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$455.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$278.31
|
| Rate for Payer: HealthUtah PPO |
$479.84
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$465.44
|
| Rate for Payer: Multiplan Medicare/VA |
$264.39
|
| Rate for Payer: One Health Plan of WY PPO |
$470.24
|
| Rate for Payer: PacificSource Commercial |
$431.86
|
| Rate for Payer: PHCS PPO |
$470.24
|
| Rate for Payer: Three Rivers PPO |
$359.88
|
| Rate for Payer: TriWest Veterans Administration |
$278.31
|
| Rate for Payer: United Healthcare Commercial |
$417.46
|
| Rate for Payer: United Healthcare Medicare |
$278.31
|
| Rate for Payer: WINHealth Partners Commercial |
$470.24
|
| Rate for Payer: Wise Provider Network Commercial |
$455.85
|
|
|
DINOPROSTONE ER 10 MG VAGINAL INSERT,CONTROLLED RELEASE [14224]
|
Facility
|
OP
|
$479.84
|
|
|
Service Code
|
NDC 5556628001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$264.39 |
| Max. Negotiated Rate |
$479.84 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$470.24
|
| Rate for Payer: Aetna of WY Medicare |
$316.69
|
| Rate for Payer: Altius Auto/Workers Compensation |
$460.65
|
| Rate for Payer: Altius Commercial |
$460.65
|
| Rate for Payer: Beech Street Commercial |
$470.24
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$393.95
|
| Rate for Payer: Cash Price |
$335.89
|
| Rate for Payer: ChoiceCare Network Commercial |
$465.44
|
| Rate for Payer: Cigna of WY Commercial |
$470.24
|
| Rate for Payer: Entrust Commercial |
$455.85
|
| Rate for Payer: First Choice Health Commercial |
$455.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$455.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$278.31
|
| Rate for Payer: HealthUtah PPO |
$479.84
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$465.44
|
| Rate for Payer: Multiplan Medicare/VA |
$264.39
|
| Rate for Payer: One Health Plan of WY PPO |
$470.24
|
| Rate for Payer: PacificSource Commercial |
$431.86
|
| Rate for Payer: PHCS PPO |
$470.24
|
| Rate for Payer: Three Rivers PPO |
$359.88
|
| Rate for Payer: TriWest Veterans Administration |
$278.31
|
| Rate for Payer: United Healthcare Commercial |
$417.46
|
| Rate for Payer: United Healthcare Medicare |
$278.31
|
| Rate for Payer: WINHealth Partners Commercial |
$470.24
|
| Rate for Payer: Wise Provider Network Commercial |
$455.85
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID [800]
|
Facility
|
OP
|
$0.97
|
|
|
Service Code
|
NDC 6933915201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.95
|
| Rate for Payer: Aetna of WY Medicare |
$0.64
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.93
|
| Rate for Payer: Altius Commercial |
$0.93
|
| Rate for Payer: Beech Street Commercial |
$0.95
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.80
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.94
|
| Rate for Payer: Cigna of WY Commercial |
$0.95
|
| Rate for Payer: Entrust Commercial |
$0.92
|
| Rate for Payer: First Choice Health Commercial |
$0.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.56
|
| Rate for Payer: HealthUtah PPO |
$0.97
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.94
|
| Rate for Payer: Multiplan Medicare/VA |
$0.53
|
| Rate for Payer: One Health Plan of WY PPO |
$0.95
|
| Rate for Payer: PacificSource Commercial |
$0.87
|
| Rate for Payer: PHCS PPO |
$0.95
|
| Rate for Payer: Three Rivers PPO |
$0.73
|
| Rate for Payer: TriWest Veterans Administration |
$0.56
|
| Rate for Payer: United Healthcare Commercial |
$0.84
|
| Rate for Payer: United Healthcare Medicare |
$0.56
|
| Rate for Payer: WINHealth Partners Commercial |
$0.95
|
| Rate for Payer: Wise Provider Network Commercial |
$0.92
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID [800]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 0904698520
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.08
|
| Rate for Payer: Aetna of WY Medicare |
$0.05
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.08
|
| Rate for Payer: Altius Commercial |
$0.08
|
| Rate for Payer: Beech Street Commercial |
$0.08
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.07
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.08
|
| Rate for Payer: Cigna of WY Commercial |
$0.08
|
| Rate for Payer: Entrust Commercial |
$0.08
|
| Rate for Payer: First Choice Health Commercial |
$0.08
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.08
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.05
|
| Rate for Payer: HealthUtah PPO |
$0.08
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.08
|
| Rate for Payer: Multiplan Medicare/VA |
$0.04
|
| Rate for Payer: One Health Plan of WY PPO |
$0.08
|
| Rate for Payer: PacificSource Commercial |
$0.07
|
| Rate for Payer: PHCS PPO |
$0.08
|
| Rate for Payer: Three Rivers PPO |
$0.06
|
| Rate for Payer: TriWest Veterans Administration |
$0.05
|
| Rate for Payer: United Healthcare Commercial |
$0.07
|
| Rate for Payer: United Healthcare Medicare |
$0.05
|
| Rate for Payer: WINHealth Partners Commercial |
$0.08
|
| Rate for Payer: Wise Provider Network Commercial |
$0.08
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID [800]
|
Facility
|
OP
|
$0.77
|
|
|
Service Code
|
NDC 6809402459
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$0.77 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.75
|
| Rate for Payer: Aetna of WY Medicare |
$0.51
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.74
|
| Rate for Payer: Altius Commercial |
$0.74
|
| Rate for Payer: Beech Street Commercial |
$0.75
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.63
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.75
|
| Rate for Payer: Cigna of WY Commercial |
$0.75
|
| Rate for Payer: Entrust Commercial |
$0.73
|
| Rate for Payer: First Choice Health Commercial |
$0.73
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.73
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.45
|
| Rate for Payer: HealthUtah PPO |
$0.77
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.75
|
| Rate for Payer: Multiplan Medicare/VA |
$0.42
|
| Rate for Payer: One Health Plan of WY PPO |
$0.75
|
| Rate for Payer: PacificSource Commercial |
$0.69
|
| Rate for Payer: PHCS PPO |
$0.75
|
| Rate for Payer: Three Rivers PPO |
$0.58
|
| Rate for Payer: TriWest Veterans Administration |
$0.45
|
| Rate for Payer: United Healthcare Commercial |
$0.67
|
| Rate for Payer: United Healthcare Medicare |
$0.45
|
| Rate for Payer: WINHealth Partners Commercial |
$0.75
|
| Rate for Payer: Wise Provider Network Commercial |
$0.73
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID [800]
|
Facility
|
IP
|
$0.77
|
|
|
Service Code
|
NDC 6809402459
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$0.77 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.75
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.74
|
| Rate for Payer: Altius Commercial |
$0.74
|
| Rate for Payer: Beech Street Commercial |
$0.75
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.63
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.75
|
| Rate for Payer: Cigna of WY Commercial |
$0.75
|
| Rate for Payer: Entrust Commercial |
$0.73
|
| Rate for Payer: First Choice Health Commercial |
$0.73
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.73
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.51
|
| Rate for Payer: HealthUtah PPO |
$0.77
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.75
|
| Rate for Payer: Multiplan Medicare/VA |
$0.48
|
| Rate for Payer: One Health Plan of WY PPO |
$0.75
|
| Rate for Payer: PacificSource Commercial |
$0.69
|
| Rate for Payer: PHCS PPO |
$0.75
|
| Rate for Payer: Three Rivers PPO |
$0.58
|
| Rate for Payer: TriWest Veterans Administration |
$0.51
|
| Rate for Payer: United Healthcare Commercial |
$0.67
|
| Rate for Payer: United Healthcare Medicare |
$0.51
|
| Rate for Payer: WINHealth Partners Commercial |
$0.73
|
| Rate for Payer: Wise Provider Network Commercial |
$0.73
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID [800]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 0904698520
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.08
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.08
|
| Rate for Payer: Altius Commercial |
$0.08
|
| Rate for Payer: Beech Street Commercial |
$0.08
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.07
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.08
|
| Rate for Payer: Cigna of WY Commercial |
$0.08
|
| Rate for Payer: Entrust Commercial |
$0.08
|
| Rate for Payer: First Choice Health Commercial |
$0.08
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.08
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.05
|
| Rate for Payer: HealthUtah PPO |
$0.08
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.08
|
| Rate for Payer: Multiplan Medicare/VA |
$0.05
|
| Rate for Payer: One Health Plan of WY PPO |
$0.08
|
| Rate for Payer: PacificSource Commercial |
$0.07
|
| Rate for Payer: PHCS PPO |
$0.08
|
| Rate for Payer: Three Rivers PPO |
$0.06
|
| Rate for Payer: TriWest Veterans Administration |
$0.05
|
| Rate for Payer: United Healthcare Commercial |
$0.07
|
| Rate for Payer: United Healthcare Medicare |
$0.05
|
| Rate for Payer: WINHealth Partners Commercial |
$0.08
|
| Rate for Payer: Wise Provider Network Commercial |
$0.08
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID [800]
|
Facility
|
IP
|
$0.97
|
|
|
Service Code
|
NDC 6933915201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.95
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.93
|
| Rate for Payer: Altius Commercial |
$0.93
|
| Rate for Payer: Beech Street Commercial |
$0.95
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.80
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.94
|
| Rate for Payer: Cigna of WY Commercial |
$0.95
|
| Rate for Payer: Entrust Commercial |
$0.92
|
| Rate for Payer: First Choice Health Commercial |
$0.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.64
|
| Rate for Payer: HealthUtah PPO |
$0.97
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.94
|
| Rate for Payer: Multiplan Medicare/VA |
$0.61
|
| Rate for Payer: One Health Plan of WY PPO |
$0.95
|
| Rate for Payer: PacificSource Commercial |
$0.87
|
| Rate for Payer: PHCS PPO |
$0.95
|
| Rate for Payer: Three Rivers PPO |
$0.73
|
| Rate for Payer: TriWest Veterans Administration |
$0.64
|
| Rate for Payer: United Healthcare Commercial |
$0.84
|
| Rate for Payer: United Healthcare Medicare |
$0.64
|
| Rate for Payer: WINHealth Partners Commercial |
$0.92
|
| Rate for Payer: Wise Provider Network Commercial |
$0.92
|
|
|
DIPHENHYDRAMINE 25 MG-ACETAMINOPHEN 500 MG TABLET [17907]
|
Facility
|
IP
|
$0.17
|
|
|
Service Code
|
NDC 0904673151
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.17
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.16
|
| Rate for Payer: Altius Commercial |
$0.16
|
| Rate for Payer: Beech Street Commercial |
$0.17
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.14
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.16
|
| Rate for Payer: Cigna of WY Commercial |
$0.17
|
| Rate for Payer: Entrust Commercial |
$0.16
|
| Rate for Payer: First Choice Health Commercial |
$0.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.11
|
| Rate for Payer: HealthUtah PPO |
$0.17
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.16
|
| Rate for Payer: Multiplan Medicare/VA |
$0.11
|
| Rate for Payer: One Health Plan of WY PPO |
$0.17
|
| Rate for Payer: PacificSource Commercial |
$0.15
|
| Rate for Payer: PHCS PPO |
$0.17
|
| Rate for Payer: Three Rivers PPO |
$0.13
|
| Rate for Payer: TriWest Veterans Administration |
$0.11
|
| Rate for Payer: United Healthcare Commercial |
$0.15
|
| Rate for Payer: United Healthcare Medicare |
$0.11
|
| Rate for Payer: WINHealth Partners Commercial |
$0.16
|
| Rate for Payer: Wise Provider Network Commercial |
$0.16
|
|
|
DIPHENHYDRAMINE 25 MG-ACETAMINOPHEN 500 MG TABLET [17907]
|
Facility
|
OP
|
$0.17
|
|
|
Service Code
|
NDC 0904673151
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.17
|
| Rate for Payer: Aetna of WY Medicare |
$0.11
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.16
|
| Rate for Payer: Altius Commercial |
$0.16
|
| Rate for Payer: Beech Street Commercial |
$0.17
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.14
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.16
|
| Rate for Payer: Cigna of WY Commercial |
$0.17
|
| Rate for Payer: Entrust Commercial |
$0.16
|
| Rate for Payer: First Choice Health Commercial |
$0.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.10
|
| Rate for Payer: HealthUtah PPO |
$0.17
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.16
|
| Rate for Payer: Multiplan Medicare/VA |
$0.09
|
| Rate for Payer: One Health Plan of WY PPO |
$0.17
|
| Rate for Payer: PacificSource Commercial |
$0.15
|
| Rate for Payer: PHCS PPO |
$0.17
|
| Rate for Payer: Three Rivers PPO |
$0.13
|
| Rate for Payer: TriWest Veterans Administration |
$0.10
|
| Rate for Payer: United Healthcare Commercial |
$0.15
|
| Rate for Payer: United Healthcare Medicare |
$0.10
|
| Rate for Payer: WINHealth Partners Commercial |
$0.17
|
| Rate for Payer: Wise Provider Network Commercial |
$0.16
|
|
