|
DIPHENHYDRAMINE 25 MG CAPSULE [12248]
|
Facility
|
OP
|
$0.16
|
|
|
Service Code
|
NDC 0904723761
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.16
|
| Rate for Payer: Aetna of WY Medicare |
$0.11
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.15
|
| Rate for Payer: Altius Commercial |
$0.15
|
| Rate for Payer: Beech Street Commercial |
$0.16
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.13
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.16
|
| Rate for Payer: Cigna of WY Commercial |
$0.16
|
| Rate for Payer: Entrust Commercial |
$0.15
|
| Rate for Payer: First Choice Health Commercial |
$0.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.09
|
| Rate for Payer: HealthUtah PPO |
$0.16
|
| 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 |
$0.16
|
| Rate for Payer: PacificSource Commercial |
$0.14
|
| Rate for Payer: PHCS PPO |
$0.16
|
| Rate for Payer: Three Rivers PPO |
$0.12
|
| Rate for Payer: TriWest Veterans Administration |
$0.09
|
| Rate for Payer: United Healthcare Commercial |
$0.14
|
| Rate for Payer: United Healthcare Medicare |
$0.09
|
| Rate for Payer: WINHealth Partners Commercial |
$0.16
|
| Rate for Payer: Wise Provider Network Commercial |
$0.15
|
|
|
DIPHENHYDRAMINE 25 MG CAPSULE [12248]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 0904530661
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.14
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.13
|
| Rate for Payer: Altius Commercial |
$0.13
|
| Rate for Payer: Beech Street Commercial |
$0.14
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.11
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.14
|
| Rate for Payer: Cigna of WY Commercial |
$0.14
|
| Rate for Payer: Entrust Commercial |
$0.13
|
| Rate for Payer: First Choice Health Commercial |
$0.13
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.13
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.09
|
| Rate for Payer: HealthUtah PPO |
$0.14
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.14
|
| Rate for Payer: Multiplan Medicare/VA |
$0.09
|
| Rate for Payer: One Health Plan of WY PPO |
$0.14
|
| Rate for Payer: PacificSource Commercial |
$0.13
|
| Rate for Payer: PHCS PPO |
$0.14
|
| Rate for Payer: Three Rivers PPO |
$0.11
|
| Rate for Payer: TriWest Veterans Administration |
$0.09
|
| Rate for Payer: United Healthcare Commercial |
$0.12
|
| Rate for Payer: United Healthcare Medicare |
$0.09
|
| Rate for Payer: WINHealth Partners Commercial |
$0.13
|
| Rate for Payer: Wise Provider Network Commercial |
$0.13
|
|
|
DIPHENHYDRAMINE 25 MG CAPSULE [12248]
|
Facility
|
IP
|
$0.16
|
|
|
Service Code
|
NDC 0904723761
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.16
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.15
|
| Rate for Payer: Altius Commercial |
$0.15
|
| Rate for Payer: Beech Street Commercial |
$0.16
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.13
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.16
|
| Rate for Payer: Cigna of WY Commercial |
$0.16
|
| Rate for Payer: Entrust Commercial |
$0.15
|
| Rate for Payer: First Choice Health Commercial |
$0.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.11
|
| Rate for Payer: HealthUtah PPO |
$0.16
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.16
|
| Rate for Payer: Multiplan Medicare/VA |
$0.10
|
| Rate for Payer: One Health Plan of WY PPO |
$0.16
|
| Rate for Payer: PacificSource Commercial |
$0.14
|
| Rate for Payer: PHCS PPO |
$0.16
|
| Rate for Payer: Three Rivers PPO |
$0.12
|
| Rate for Payer: TriWest Veterans Administration |
$0.11
|
| Rate for Payer: United Healthcare Commercial |
$0.14
|
| Rate for Payer: United Healthcare Medicare |
$0.11
|
| Rate for Payer: WINHealth Partners Commercial |
$0.15
|
| Rate for Payer: Wise Provider Network Commercial |
$0.15
|
|
|
DIPHENHYDRAMINE 25 MG CAPSULE [12248]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 0904530661
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.14
|
| Rate for Payer: Aetna of WY Medicare |
$0.09
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.13
|
| Rate for Payer: Altius Commercial |
$0.13
|
| Rate for Payer: Beech Street Commercial |
$0.14
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.11
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.14
|
| Rate for Payer: Cigna of WY Commercial |
$0.14
|
| Rate for Payer: Entrust Commercial |
$0.13
|
| Rate for Payer: First Choice Health Commercial |
$0.13
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.13
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.08
|
| Rate for Payer: HealthUtah PPO |
$0.14
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.14
|
| Rate for Payer: Multiplan Medicare/VA |
$0.08
|
| Rate for Payer: One Health Plan of WY PPO |
$0.14
|
| Rate for Payer: PacificSource Commercial |
$0.13
|
| Rate for Payer: PHCS PPO |
$0.14
|
| Rate for Payer: Three Rivers PPO |
$0.11
|
| Rate for Payer: TriWest Veterans Administration |
$0.08
|
| Rate for Payer: United Healthcare Commercial |
$0.12
|
| Rate for Payer: United Healthcare Medicare |
$0.08
|
| Rate for Payer: WINHealth Partners Commercial |
$0.14
|
| Rate for Payer: Wise Provider Network Commercial |
$0.13
|
|
|
DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION [10256]
|
Facility
|
IP
|
$26.29
|
|
|
Service Code
|
HCPCS J1200
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.48 |
| Max. Negotiated Rate |
$26.29 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$25.76
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$19.30
|
| Rate for Payer: Altius Auto/Workers Compensation |
$25.24
|
| Rate for Payer: Altius Auto/Workers Compensation |
$18.90
|
| Rate for Payer: Altius Commercial |
$18.90
|
| Rate for Payer: Altius Commercial |
$25.24
|
| Rate for Payer: Beech Street Commercial |
$25.76
|
| Rate for Payer: Beech Street Commercial |
$19.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.17
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$21.58
|
| Rate for Payer: Cash Price |
$18.40
|
| Rate for Payer: Cash Price |
$13.78
|
| Rate for Payer: ChoiceCare Network Commercial |
$19.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$25.50
|
| Rate for Payer: Cigna of WY Commercial |
$25.76
|
| Rate for Payer: Cigna of WY Commercial |
$19.30
|
| Rate for Payer: Entrust Commercial |
$18.71
|
| Rate for Payer: Entrust Commercial |
$24.98
|
| Rate for Payer: First Choice Health Commercial |
$18.71
|
| Rate for Payer: First Choice Health Commercial |
$24.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$18.71
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$24.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$17.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$13.00
|
| Rate for Payer: HealthUtah PPO |
$26.29
|
| Rate for Payer: HealthUtah PPO |
$19.69
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$19.10
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$25.50
|
| Rate for Payer: Multiplan Medicare/VA |
$16.48
|
| Rate for Payer: Multiplan Medicare/VA |
$12.35
|
| Rate for Payer: One Health Plan of WY PPO |
$25.76
|
| Rate for Payer: One Health Plan of WY PPO |
$19.30
|
| Rate for Payer: PacificSource Commercial |
$23.66
|
| Rate for Payer: PacificSource Commercial |
$17.72
|
| Rate for Payer: PHCS PPO |
$19.30
|
| Rate for Payer: PHCS PPO |
$25.76
|
| Rate for Payer: Three Rivers PPO |
$14.77
|
| Rate for Payer: Three Rivers PPO |
$19.72
|
| Rate for Payer: TriWest Veterans Administration |
$17.35
|
| Rate for Payer: TriWest Veterans Administration |
$13.00
|
| Rate for Payer: United Healthcare Commercial |
$17.13
|
| Rate for Payer: United Healthcare Commercial |
$22.87
|
| Rate for Payer: United Healthcare Medicare |
$17.35
|
| Rate for Payer: United Healthcare Medicare |
$13.00
|
| Rate for Payer: WINHealth Partners Commercial |
$18.71
|
| Rate for Payer: WINHealth Partners Commercial |
$24.98
|
| Rate for Payer: Wise Provider Network Commercial |
$18.71
|
| Rate for Payer: Wise Provider Network Commercial |
$24.98
|
|
|
DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION [10256]
|
Facility
|
OP
|
$26.29
|
|
|
Service Code
|
HCPCS J1200
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.49 |
| Max. Negotiated Rate |
$26.29 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$25.76
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$19.30
|
| Rate for Payer: Aetna of WY Medicare |
$17.35
|
| Rate for Payer: Aetna of WY Medicare |
$13.00
|
| Rate for Payer: Altius Auto/Workers Compensation |
$18.90
|
| Rate for Payer: Altius Auto/Workers Compensation |
$25.24
|
| Rate for Payer: Altius Commercial |
$25.24
|
| Rate for Payer: Altius Commercial |
$18.90
|
| Rate for Payer: Beech Street Commercial |
$19.30
|
| Rate for Payer: Beech Street Commercial |
$25.76
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$21.58
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.17
|
| Rate for Payer: Cash Price |
$13.78
|
| Rate for Payer: Cash Price |
$18.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$25.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$19.10
|
| Rate for Payer: Cigna of WY Commercial |
$19.30
|
| Rate for Payer: Cigna of WY Commercial |
$25.76
|
| Rate for Payer: Entrust Commercial |
$24.98
|
| Rate for Payer: Entrust Commercial |
$18.71
|
| Rate for Payer: First Choice Health Commercial |
$18.71
|
| Rate for Payer: First Choice Health Commercial |
$24.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$18.71
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$24.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$15.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.42
|
| Rate for Payer: HealthUtah PPO |
$19.69
|
| Rate for Payer: HealthUtah PPO |
$26.29
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$19.10
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$25.50
|
| Rate for Payer: Multiplan Medicare/VA |
$14.49
|
| Rate for Payer: Multiplan Medicare/VA |
$10.85
|
| Rate for Payer: One Health Plan of WY PPO |
$19.30
|
| Rate for Payer: One Health Plan of WY PPO |
$25.76
|
| Rate for Payer: PacificSource Commercial |
$23.66
|
| Rate for Payer: PacificSource Commercial |
$17.72
|
| Rate for Payer: PHCS PPO |
$19.30
|
| Rate for Payer: PHCS PPO |
$25.76
|
| Rate for Payer: Three Rivers PPO |
$14.77
|
| Rate for Payer: Three Rivers PPO |
$19.72
|
| Rate for Payer: TriWest Veterans Administration |
$15.25
|
| Rate for Payer: TriWest Veterans Administration |
$11.42
|
| Rate for Payer: United Healthcare Commercial |
$17.13
|
| Rate for Payer: United Healthcare Commercial |
$22.87
|
| Rate for Payer: United Healthcare Medicare |
$15.25
|
| Rate for Payer: United Healthcare Medicare |
$11.42
|
| Rate for Payer: WINHealth Partners Commercial |
$19.30
|
| Rate for Payer: WINHealth Partners Commercial |
$25.76
|
| Rate for Payer: Wise Provider Network Commercial |
$18.71
|
| Rate for Payer: Wise Provider Network Commercial |
$24.98
|
|
|
DIPHENHYDRAMINE HCL INJECTIO
|
Professional
|
Both
|
$30.00
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
J1200
|
| Min. Negotiated Rate |
$0.70 |
| Max. Negotiated Rate |
$30.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$29.40
|
| Rate for Payer: Aetna of WY Medicare |
$0.82
|
| Rate for Payer: Beech Street Commercial |
$28.50
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$29.10
|
| Rate for Payer: Cigna of WY Commercial |
$29.40
|
| Rate for Payer: First Choice Health Commercial |
$27.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$28.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.82
|
| Rate for Payer: HealthUtah PPO |
$30.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$29.10
|
| Rate for Payer: Multiplan Medicare/VA |
$0.70
|
| Rate for Payer: One Health Plan of WY PPO |
$29.40
|
| Rate for Payer: PacificSource Commercial |
$27.00
|
| Rate for Payer: PHCS PPO |
$28.50
|
| Rate for Payer: Three Rivers PPO |
$22.50
|
| Rate for Payer: TriWest Veterans Administration |
$0.82
|
| Rate for Payer: United Healthcare Commercial |
$26.10
|
| Rate for Payer: United Healthcare Medicare |
$0.82
|
| Rate for Payer: WINHealth Partners Commercial |
$28.50
|
|
|
DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM [8707]
|
Facility
|
OP
|
$0.29
|
|
|
Service Code
|
NDC 2438521003
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.28
|
| Rate for Payer: Aetna of WY Medicare |
$0.19
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.28
|
| Rate for Payer: Altius Commercial |
$0.28
|
| Rate for Payer: Beech Street Commercial |
$0.28
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.24
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.28
|
| Rate for Payer: Cigna of WY Commercial |
$0.28
|
| Rate for Payer: Entrust Commercial |
$0.28
|
| Rate for Payer: First Choice Health Commercial |
$0.28
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.28
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.17
|
| Rate for Payer: HealthUtah PPO |
$0.29
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.28
|
| Rate for Payer: Multiplan Medicare/VA |
$0.16
|
| Rate for Payer: One Health Plan of WY PPO |
$0.28
|
| Rate for Payer: PacificSource Commercial |
$0.26
|
| Rate for Payer: PHCS PPO |
$0.28
|
| Rate for Payer: Three Rivers PPO |
$0.22
|
| Rate for Payer: TriWest Veterans Administration |
$0.17
|
| Rate for Payer: United Healthcare Commercial |
$0.25
|
| Rate for Payer: United Healthcare Medicare |
$0.17
|
| Rate for Payer: WINHealth Partners Commercial |
$0.28
|
| Rate for Payer: Wise Provider Network Commercial |
$0.28
|
|
|
DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM [8707]
|
Facility
|
IP
|
$0.31
|
|
|
Service Code
|
NDC 4580235803
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.30
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.30
|
| Rate for Payer: Altius Commercial |
$0.30
|
| Rate for Payer: Beech Street Commercial |
$0.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.25
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.30
|
| Rate for Payer: Cigna of WY Commercial |
$0.30
|
| Rate for Payer: Entrust Commercial |
$0.29
|
| Rate for Payer: First Choice Health Commercial |
$0.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.20
|
| Rate for Payer: HealthUtah PPO |
$0.31
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.30
|
| Rate for Payer: Multiplan Medicare/VA |
$0.19
|
| Rate for Payer: One Health Plan of WY PPO |
$0.30
|
| Rate for Payer: PacificSource Commercial |
$0.28
|
| Rate for Payer: PHCS PPO |
$0.30
|
| Rate for Payer: Three Rivers PPO |
$0.23
|
| Rate for Payer: TriWest Veterans Administration |
$0.20
|
| Rate for Payer: United Healthcare Commercial |
$0.27
|
| Rate for Payer: United Healthcare Medicare |
$0.20
|
| Rate for Payer: WINHealth Partners Commercial |
$0.29
|
| Rate for Payer: Wise Provider Network Commercial |
$0.29
|
|
|
DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM [8707]
|
Facility
|
IP
|
$0.29
|
|
|
Service Code
|
NDC 2438521003
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.28
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.28
|
| Rate for Payer: Altius Commercial |
$0.28
|
| Rate for Payer: Beech Street Commercial |
$0.28
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.24
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.28
|
| Rate for Payer: Cigna of WY Commercial |
$0.28
|
| Rate for Payer: Entrust Commercial |
$0.28
|
| Rate for Payer: First Choice Health Commercial |
$0.28
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.28
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.19
|
| Rate for Payer: HealthUtah PPO |
$0.29
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.28
|
| Rate for Payer: Multiplan Medicare/VA |
$0.18
|
| Rate for Payer: One Health Plan of WY PPO |
$0.28
|
| Rate for Payer: PacificSource Commercial |
$0.26
|
| Rate for Payer: PHCS PPO |
$0.28
|
| Rate for Payer: Three Rivers PPO |
$0.22
|
| Rate for Payer: TriWest Veterans Administration |
$0.19
|
| Rate for Payer: United Healthcare Commercial |
$0.25
|
| Rate for Payer: United Healthcare Medicare |
$0.19
|
| Rate for Payer: WINHealth Partners Commercial |
$0.28
|
| Rate for Payer: Wise Provider Network Commercial |
$0.28
|
|
|
DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM [8707]
|
Facility
|
OP
|
$0.31
|
|
|
Service Code
|
NDC 4580235803
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.30
|
| Rate for Payer: Aetna of WY Medicare |
$0.20
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.30
|
| Rate for Payer: Altius Commercial |
$0.30
|
| Rate for Payer: Beech Street Commercial |
$0.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.25
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.30
|
| Rate for Payer: Cigna of WY Commercial |
$0.30
|
| Rate for Payer: Entrust Commercial |
$0.29
|
| Rate for Payer: First Choice Health Commercial |
$0.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.18
|
| Rate for Payer: HealthUtah PPO |
$0.31
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.30
|
| Rate for Payer: Multiplan Medicare/VA |
$0.17
|
| Rate for Payer: One Health Plan of WY PPO |
$0.30
|
| Rate for Payer: PacificSource Commercial |
$0.28
|
| Rate for Payer: PHCS PPO |
$0.30
|
| Rate for Payer: Three Rivers PPO |
$0.23
|
| Rate for Payer: TriWest Veterans Administration |
$0.18
|
| Rate for Payer: United Healthcare Commercial |
$0.27
|
| Rate for Payer: United Healthcare Medicare |
$0.18
|
| Rate for Payer: WINHealth Partners Commercial |
$0.30
|
| Rate for Payer: Wise Provider Network Commercial |
$0.29
|
|
|
DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM [8707]
|
Facility
|
IP
|
$0.29
|
|
|
Service Code
|
NDC 8770155284
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.28
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.28
|
| Rate for Payer: Altius Commercial |
$0.28
|
| Rate for Payer: Beech Street Commercial |
$0.28
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.24
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.28
|
| Rate for Payer: Cigna of WY Commercial |
$0.28
|
| Rate for Payer: Entrust Commercial |
$0.28
|
| Rate for Payer: First Choice Health Commercial |
$0.28
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.28
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.19
|
| Rate for Payer: HealthUtah PPO |
$0.29
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.28
|
| Rate for Payer: Multiplan Medicare/VA |
$0.18
|
| Rate for Payer: One Health Plan of WY PPO |
$0.28
|
| Rate for Payer: PacificSource Commercial |
$0.26
|
| Rate for Payer: PHCS PPO |
$0.28
|
| Rate for Payer: Three Rivers PPO |
$0.22
|
| Rate for Payer: TriWest Veterans Administration |
$0.19
|
| Rate for Payer: United Healthcare Commercial |
$0.25
|
| Rate for Payer: United Healthcare Medicare |
$0.19
|
| Rate for Payer: WINHealth Partners Commercial |
$0.28
|
| Rate for Payer: Wise Provider Network Commercial |
$0.28
|
|
|
DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM [8707]
|
Facility
|
OP
|
$0.25
|
|
|
Service Code
|
NDC 0904535431
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.25
|
| Rate for Payer: Aetna of WY Medicare |
$0.17
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.24
|
| Rate for Payer: Altius Commercial |
$0.24
|
| Rate for Payer: Beech Street Commercial |
$0.25
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.21
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.24
|
| Rate for Payer: Cigna of WY Commercial |
$0.25
|
| Rate for Payer: Entrust Commercial |
$0.24
|
| Rate for Payer: First Choice Health Commercial |
$0.24
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.24
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.15
|
| Rate for Payer: HealthUtah PPO |
$0.25
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.24
|
| Rate for Payer: Multiplan Medicare/VA |
$0.14
|
| Rate for Payer: One Health Plan of WY PPO |
$0.25
|
| Rate for Payer: PacificSource Commercial |
$0.23
|
| Rate for Payer: PHCS PPO |
$0.25
|
| Rate for Payer: Three Rivers PPO |
$0.19
|
| Rate for Payer: TriWest Veterans Administration |
$0.15
|
| Rate for Payer: United Healthcare Commercial |
$0.22
|
| Rate for Payer: United Healthcare Medicare |
$0.15
|
| Rate for Payer: WINHealth Partners Commercial |
$0.25
|
| Rate for Payer: Wise Provider Network Commercial |
$0.24
|
|
|
DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM [8707]
|
Facility
|
IP
|
$0.25
|
|
|
Service Code
|
NDC 0904535431
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.25
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.24
|
| Rate for Payer: Altius Commercial |
$0.24
|
| Rate for Payer: Beech Street Commercial |
$0.25
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.21
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.24
|
| Rate for Payer: Cigna of WY Commercial |
$0.25
|
| Rate for Payer: Entrust Commercial |
$0.24
|
| Rate for Payer: First Choice Health Commercial |
$0.24
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.24
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.17
|
| Rate for Payer: HealthUtah PPO |
$0.25
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.24
|
| Rate for Payer: Multiplan Medicare/VA |
$0.16
|
| Rate for Payer: One Health Plan of WY PPO |
$0.25
|
| Rate for Payer: PacificSource Commercial |
$0.23
|
| Rate for Payer: PHCS PPO |
$0.25
|
| Rate for Payer: Three Rivers PPO |
$0.19
|
| Rate for Payer: TriWest Veterans Administration |
$0.17
|
| Rate for Payer: United Healthcare Commercial |
$0.22
|
| Rate for Payer: United Healthcare Medicare |
$0.17
|
| Rate for Payer: WINHealth Partners Commercial |
$0.24
|
| Rate for Payer: Wise Provider Network Commercial |
$0.24
|
|
|
DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM [8707]
|
Facility
|
OP
|
$0.29
|
|
|
Service Code
|
NDC 8770155284
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.28
|
| Rate for Payer: Aetna of WY Medicare |
$0.19
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.28
|
| Rate for Payer: Altius Commercial |
$0.28
|
| Rate for Payer: Beech Street Commercial |
$0.28
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.24
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.28
|
| Rate for Payer: Cigna of WY Commercial |
$0.28
|
| Rate for Payer: Entrust Commercial |
$0.28
|
| Rate for Payer: First Choice Health Commercial |
$0.28
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.28
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.17
|
| Rate for Payer: HealthUtah PPO |
$0.29
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.28
|
| Rate for Payer: Multiplan Medicare/VA |
$0.16
|
| Rate for Payer: One Health Plan of WY PPO |
$0.28
|
| Rate for Payer: PacificSource Commercial |
$0.26
|
| Rate for Payer: PHCS PPO |
$0.28
|
| Rate for Payer: Three Rivers PPO |
$0.22
|
| Rate for Payer: TriWest Veterans Administration |
$0.17
|
| Rate for Payer: United Healthcare Commercial |
$0.25
|
| Rate for Payer: United Healthcare Medicare |
$0.17
|
| Rate for Payer: WINHealth Partners Commercial |
$0.28
|
| Rate for Payer: Wise Provider Network Commercial |
$0.28
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET [6299]
|
Facility
|
IP
|
$0.68
|
|
|
Service Code
|
NDC 6255949001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$0.68 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.67
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.65
|
| Rate for Payer: Altius Commercial |
$0.65
|
| Rate for Payer: Beech Street Commercial |
$0.67
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.56
|
| Rate for Payer: Cash Price |
$0.48
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.66
|
| Rate for Payer: Cigna of WY Commercial |
$0.67
|
| Rate for Payer: Entrust Commercial |
$0.65
|
| Rate for Payer: First Choice Health Commercial |
$0.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.45
|
| Rate for Payer: HealthUtah PPO |
$0.68
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.66
|
| Rate for Payer: Multiplan Medicare/VA |
$0.43
|
| Rate for Payer: One Health Plan of WY PPO |
$0.67
|
| Rate for Payer: PacificSource Commercial |
$0.61
|
| Rate for Payer: PHCS PPO |
$0.67
|
| Rate for Payer: Three Rivers PPO |
$0.51
|
| Rate for Payer: TriWest Veterans Administration |
$0.45
|
| Rate for Payer: United Healthcare Commercial |
$0.59
|
| Rate for Payer: United Healthcare Medicare |
$0.45
|
| Rate for Payer: WINHealth Partners Commercial |
$0.65
|
| Rate for Payer: Wise Provider Network Commercial |
$0.65
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET [6299]
|
Facility
|
OP
|
$0.68
|
|
|
Service Code
|
NDC 6255949001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$0.68 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.67
|
| Rate for Payer: Aetna of WY Medicare |
$0.45
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.65
|
| Rate for Payer: Altius Commercial |
$0.65
|
| Rate for Payer: Beech Street Commercial |
$0.67
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.56
|
| Rate for Payer: Cash Price |
$0.48
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.66
|
| Rate for Payer: Cigna of WY Commercial |
$0.67
|
| Rate for Payer: Entrust Commercial |
$0.65
|
| Rate for Payer: First Choice Health Commercial |
$0.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.39
|
| Rate for Payer: HealthUtah PPO |
$0.68
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.66
|
| Rate for Payer: Multiplan Medicare/VA |
$0.37
|
| Rate for Payer: One Health Plan of WY PPO |
$0.67
|
| Rate for Payer: PacificSource Commercial |
$0.61
|
| Rate for Payer: PHCS PPO |
$0.67
|
| Rate for Payer: Three Rivers PPO |
$0.51
|
| Rate for Payer: TriWest Veterans Administration |
$0.39
|
| Rate for Payer: United Healthcare Commercial |
$0.59
|
| Rate for Payer: United Healthcare Medicare |
$0.39
|
| Rate for Payer: WINHealth Partners Commercial |
$0.67
|
| Rate for Payer: Wise Provider Network Commercial |
$0.65
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET [6299]
|
Facility
|
OP
|
$1.86
|
|
|
Service Code
|
NDC 6931591001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$1.86 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.82
|
| Rate for Payer: Aetna of WY Medicare |
$1.23
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.79
|
| Rate for Payer: Altius Commercial |
$1.79
|
| Rate for Payer: Beech Street Commercial |
$1.82
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.53
|
| Rate for Payer: Cash Price |
$1.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.80
|
| Rate for Payer: Cigna of WY Commercial |
$1.82
|
| Rate for Payer: Entrust Commercial |
$1.77
|
| Rate for Payer: First Choice Health Commercial |
$1.77
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.77
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.08
|
| Rate for Payer: HealthUtah PPO |
$1.86
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.80
|
| Rate for Payer: Multiplan Medicare/VA |
$1.02
|
| Rate for Payer: One Health Plan of WY PPO |
$1.82
|
| Rate for Payer: PacificSource Commercial |
$1.67
|
| Rate for Payer: PHCS PPO |
$1.82
|
| Rate for Payer: Three Rivers PPO |
$1.40
|
| Rate for Payer: TriWest Veterans Administration |
$1.08
|
| Rate for Payer: United Healthcare Commercial |
$1.62
|
| Rate for Payer: United Healthcare Medicare |
$1.08
|
| Rate for Payer: WINHealth Partners Commercial |
$1.82
|
| Rate for Payer: Wise Provider Network Commercial |
$1.77
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET [6299]
|
Facility
|
IP
|
$1.86
|
|
|
Service Code
|
NDC 6931591001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.17 |
| Max. Negotiated Rate |
$1.86 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.82
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.79
|
| Rate for Payer: Altius Commercial |
$1.79
|
| Rate for Payer: Beech Street Commercial |
$1.82
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.53
|
| Rate for Payer: Cash Price |
$1.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.80
|
| Rate for Payer: Cigna of WY Commercial |
$1.82
|
| Rate for Payer: Entrust Commercial |
$1.77
|
| Rate for Payer: First Choice Health Commercial |
$1.77
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.77
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.23
|
| Rate for Payer: HealthUtah PPO |
$1.86
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.80
|
| Rate for Payer: Multiplan Medicare/VA |
$1.17
|
| Rate for Payer: One Health Plan of WY PPO |
$1.82
|
| Rate for Payer: PacificSource Commercial |
$1.67
|
| Rate for Payer: PHCS PPO |
$1.82
|
| Rate for Payer: Three Rivers PPO |
$1.40
|
| Rate for Payer: TriWest Veterans Administration |
$1.23
|
| Rate for Payer: United Healthcare Commercial |
$1.62
|
| Rate for Payer: United Healthcare Medicare |
$1.23
|
| Rate for Payer: WINHealth Partners Commercial |
$1.77
|
| Rate for Payer: Wise Provider Network Commercial |
$1.77
|
|
|
DIPH,PERTUS(ACELL),TET,POLIO (PF) 25 LF-58 MCG-10 LF/0.5 ML IM SYRINGE [53510]
|
Facility
|
OP
|
$194.46
|
|
|
Service Code
|
NDC 5816081252
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$107.15 |
| Max. Negotiated Rate |
$194.46 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$190.57
|
| Rate for Payer: Aetna of WY Medicare |
$128.34
|
| Rate for Payer: Altius Auto/Workers Compensation |
$186.68
|
| Rate for Payer: Altius Commercial |
$186.68
|
| Rate for Payer: Beech Street Commercial |
$190.57
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$159.65
|
| Rate for Payer: Cash Price |
$136.12
|
| Rate for Payer: ChoiceCare Network Commercial |
$188.63
|
| Rate for Payer: Cigna of WY Commercial |
$190.57
|
| Rate for Payer: Entrust Commercial |
$184.74
|
| Rate for Payer: First Choice Health Commercial |
$184.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$184.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$112.79
|
| Rate for Payer: HealthUtah PPO |
$194.46
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$188.63
|
| Rate for Payer: Multiplan Medicare/VA |
$107.15
|
| Rate for Payer: One Health Plan of WY PPO |
$190.57
|
| Rate for Payer: PacificSource Commercial |
$175.01
|
| Rate for Payer: PHCS PPO |
$190.57
|
| Rate for Payer: Three Rivers PPO |
$145.84
|
| Rate for Payer: TriWest Veterans Administration |
$112.79
|
| Rate for Payer: United Healthcare Commercial |
$169.18
|
| Rate for Payer: United Healthcare Medicare |
$112.79
|
| Rate for Payer: WINHealth Partners Commercial |
$190.57
|
| Rate for Payer: Wise Provider Network Commercial |
$184.74
|
|
|
DIPH,PERTUS(ACELL),TET,POLIO (PF) 25 LF-58 MCG-10 LF/0.5 ML IM SYRINGE [53510]
|
Facility
|
IP
|
$194.46
|
|
|
Service Code
|
NDC 5816081243
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$121.93 |
| Max. Negotiated Rate |
$194.46 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$190.57
|
| Rate for Payer: Altius Auto/Workers Compensation |
$186.68
|
| Rate for Payer: Altius Commercial |
$186.68
|
| Rate for Payer: Beech Street Commercial |
$190.57
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$159.65
|
| Rate for Payer: Cash Price |
$136.12
|
| Rate for Payer: ChoiceCare Network Commercial |
$188.63
|
| Rate for Payer: Cigna of WY Commercial |
$190.57
|
| Rate for Payer: Entrust Commercial |
$184.74
|
| Rate for Payer: First Choice Health Commercial |
$184.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$184.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$128.34
|
| Rate for Payer: HealthUtah PPO |
$194.46
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$188.63
|
| Rate for Payer: Multiplan Medicare/VA |
$121.93
|
| Rate for Payer: One Health Plan of WY PPO |
$190.57
|
| Rate for Payer: PacificSource Commercial |
$175.01
|
| Rate for Payer: PHCS PPO |
$190.57
|
| Rate for Payer: Three Rivers PPO |
$145.84
|
| Rate for Payer: TriWest Veterans Administration |
$128.34
|
| Rate for Payer: United Healthcare Commercial |
$169.18
|
| Rate for Payer: United Healthcare Medicare |
$128.34
|
| Rate for Payer: WINHealth Partners Commercial |
$184.74
|
| Rate for Payer: Wise Provider Network Commercial |
$184.74
|
|
|
DIPH,PERTUS(ACELL),TET,POLIO (PF) 25 LF-58 MCG-10 LF/0.5 ML IM SYRINGE [53510]
|
Facility
|
IP
|
$194.46
|
|
|
Service Code
|
NDC 5816081252
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$121.93 |
| Max. Negotiated Rate |
$194.46 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$190.57
|
| Rate for Payer: Altius Auto/Workers Compensation |
$186.68
|
| Rate for Payer: Altius Commercial |
$186.68
|
| Rate for Payer: Beech Street Commercial |
$190.57
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$159.65
|
| Rate for Payer: Cash Price |
$136.12
|
| Rate for Payer: ChoiceCare Network Commercial |
$188.63
|
| Rate for Payer: Cigna of WY Commercial |
$190.57
|
| Rate for Payer: Entrust Commercial |
$184.74
|
| Rate for Payer: First Choice Health Commercial |
$184.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$184.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$128.34
|
| Rate for Payer: HealthUtah PPO |
$194.46
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$188.63
|
| Rate for Payer: Multiplan Medicare/VA |
$121.93
|
| Rate for Payer: One Health Plan of WY PPO |
$190.57
|
| Rate for Payer: PacificSource Commercial |
$175.01
|
| Rate for Payer: PHCS PPO |
$190.57
|
| Rate for Payer: Three Rivers PPO |
$145.84
|
| Rate for Payer: TriWest Veterans Administration |
$128.34
|
| Rate for Payer: United Healthcare Commercial |
$169.18
|
| Rate for Payer: United Healthcare Medicare |
$128.34
|
| Rate for Payer: WINHealth Partners Commercial |
$184.74
|
| Rate for Payer: Wise Provider Network Commercial |
$184.74
|
|
|
DIPH,PERTUS(ACELL),TET,POLIO (PF) 25 LF-58 MCG-10 LF/0.5 ML IM SYRINGE [53510]
|
Facility
|
OP
|
$194.46
|
|
|
Service Code
|
NDC 5816081243
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$107.15 |
| Max. Negotiated Rate |
$194.46 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$190.57
|
| Rate for Payer: Aetna of WY Medicare |
$128.34
|
| Rate for Payer: Altius Auto/Workers Compensation |
$186.68
|
| Rate for Payer: Altius Commercial |
$186.68
|
| Rate for Payer: Beech Street Commercial |
$190.57
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$159.65
|
| Rate for Payer: Cash Price |
$136.12
|
| Rate for Payer: ChoiceCare Network Commercial |
$188.63
|
| Rate for Payer: Cigna of WY Commercial |
$190.57
|
| Rate for Payer: Entrust Commercial |
$184.74
|
| Rate for Payer: First Choice Health Commercial |
$184.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$184.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$112.79
|
| Rate for Payer: HealthUtah PPO |
$194.46
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$188.63
|
| Rate for Payer: Multiplan Medicare/VA |
$107.15
|
| Rate for Payer: One Health Plan of WY PPO |
$190.57
|
| Rate for Payer: PacificSource Commercial |
$175.01
|
| Rate for Payer: PHCS PPO |
$190.57
|
| Rate for Payer: Three Rivers PPO |
$145.84
|
| Rate for Payer: TriWest Veterans Administration |
$112.79
|
| Rate for Payer: United Healthcare Commercial |
$169.18
|
| Rate for Payer: United Healthcare Medicare |
$112.79
|
| Rate for Payer: WINHealth Partners Commercial |
$190.57
|
| Rate for Payer: Wise Provider Network Commercial |
$184.74
|
|
|
DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE [45972]
|
Facility
|
IP
|
$110.69
|
|
|
Service Code
|
NDC 5816081052
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$69.40 |
| Max. Negotiated Rate |
$110.69 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$108.48
|
| Rate for Payer: Altius Auto/Workers Compensation |
$106.26
|
| Rate for Payer: Altius Commercial |
$106.26
|
| Rate for Payer: Beech Street Commercial |
$108.48
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$90.88
|
| Rate for Payer: Cash Price |
$77.49
|
| Rate for Payer: ChoiceCare Network Commercial |
$107.37
|
| Rate for Payer: Cigna of WY Commercial |
$108.48
|
| Rate for Payer: Entrust Commercial |
$105.16
|
| Rate for Payer: First Choice Health Commercial |
$105.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$105.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$73.06
|
| Rate for Payer: HealthUtah PPO |
$110.69
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$107.37
|
| Rate for Payer: Multiplan Medicare/VA |
$69.40
|
| Rate for Payer: One Health Plan of WY PPO |
$108.48
|
| Rate for Payer: PacificSource Commercial |
$99.62
|
| Rate for Payer: PHCS PPO |
$108.48
|
| Rate for Payer: Three Rivers PPO |
$83.02
|
| Rate for Payer: TriWest Veterans Administration |
$73.06
|
| Rate for Payer: United Healthcare Commercial |
$96.30
|
| Rate for Payer: United Healthcare Medicare |
$73.06
|
| Rate for Payer: WINHealth Partners Commercial |
$105.16
|
| Rate for Payer: Wise Provider Network Commercial |
$105.16
|
|
|
DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE [45972]
|
Facility
|
OP
|
$110.69
|
|
|
Service Code
|
NDC 5816081052
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$60.99 |
| Max. Negotiated Rate |
$110.69 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$108.48
|
| Rate for Payer: Aetna of WY Medicare |
$73.06
|
| Rate for Payer: Altius Auto/Workers Compensation |
$106.26
|
| Rate for Payer: Altius Commercial |
$106.26
|
| Rate for Payer: Beech Street Commercial |
$108.48
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$90.88
|
| Rate for Payer: Cash Price |
$77.49
|
| Rate for Payer: ChoiceCare Network Commercial |
$107.37
|
| Rate for Payer: Cigna of WY Commercial |
$108.48
|
| Rate for Payer: Entrust Commercial |
$105.16
|
| Rate for Payer: First Choice Health Commercial |
$105.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$105.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$64.20
|
| Rate for Payer: HealthUtah PPO |
$110.69
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$107.37
|
| Rate for Payer: Multiplan Medicare/VA |
$60.99
|
| Rate for Payer: One Health Plan of WY PPO |
$108.48
|
| Rate for Payer: PacificSource Commercial |
$99.62
|
| Rate for Payer: PHCS PPO |
$108.48
|
| Rate for Payer: Three Rivers PPO |
$83.02
|
| Rate for Payer: TriWest Veterans Administration |
$64.20
|
| Rate for Payer: United Healthcare Commercial |
$96.30
|
| Rate for Payer: United Healthcare Medicare |
$64.20
|
| Rate for Payer: WINHealth Partners Commercial |
$108.48
|
| Rate for Payer: Wise Provider Network Commercial |
$105.16
|
|
