|
AMITRIPTYLINE 25 MG TABLET [10227]
|
Facility
|
IP
|
$1.66
|
|
|
Service Code
|
NDC 5026803811
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.04 |
| Max. Negotiated Rate |
$1.66 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.63
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.59
|
| Rate for Payer: Altius Commercial |
$1.59
|
| Rate for Payer: Beech Street Commercial |
$1.63
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.36
|
| Rate for Payer: Cash Price |
$1.16
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.61
|
| Rate for Payer: Cigna of WY Commercial |
$1.63
|
| Rate for Payer: Entrust Commercial |
$1.58
|
| Rate for Payer: First Choice Health Commercial |
$1.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.10
|
| Rate for Payer: HealthUtah PPO |
$1.66
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.61
|
| Rate for Payer: Multiplan Medicare/VA |
$1.04
|
| Rate for Payer: One Health Plan of WY PPO |
$1.63
|
| Rate for Payer: PacificSource Commercial |
$1.49
|
| Rate for Payer: PHCS PPO |
$1.63
|
| Rate for Payer: Three Rivers PPO |
$1.24
|
| Rate for Payer: TriWest Veterans Administration |
$1.10
|
| Rate for Payer: United Healthcare Commercial |
$1.44
|
| Rate for Payer: United Healthcare Medicare |
$1.10
|
| Rate for Payer: WINHealth Partners Commercial |
$1.58
|
| Rate for Payer: Wise Provider Network Commercial |
$1.58
|
|
|
AMITRIPTYLINE 25 MG TABLET [10227]
|
Facility
|
IP
|
$1.72
|
|
|
Service Code
|
NDC 6068743301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.08 |
| Max. Negotiated Rate |
$1.72 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.69
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.65
|
| Rate for Payer: Altius Commercial |
$1.65
|
| Rate for Payer: Beech Street Commercial |
$1.69
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.41
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.67
|
| Rate for Payer: Cigna of WY Commercial |
$1.69
|
| Rate for Payer: Entrust Commercial |
$1.63
|
| Rate for Payer: First Choice Health Commercial |
$1.63
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.63
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.14
|
| Rate for Payer: HealthUtah PPO |
$1.72
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.67
|
| Rate for Payer: Multiplan Medicare/VA |
$1.08
|
| Rate for Payer: One Health Plan of WY PPO |
$1.69
|
| Rate for Payer: PacificSource Commercial |
$1.55
|
| Rate for Payer: PHCS PPO |
$1.69
|
| Rate for Payer: Three Rivers PPO |
$1.29
|
| Rate for Payer: TriWest Veterans Administration |
$1.14
|
| Rate for Payer: United Healthcare Commercial |
$1.50
|
| Rate for Payer: United Healthcare Medicare |
$1.14
|
| Rate for Payer: WINHealth Partners Commercial |
$1.63
|
| Rate for Payer: Wise Provider Network Commercial |
$1.63
|
|
|
AMITRIPTYLINE 25 MG TABLET [10227]
|
Facility
|
OP
|
$1.72
|
|
|
Service Code
|
NDC 6068743311
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.95 |
| Max. Negotiated Rate |
$1.72 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.69
|
| Rate for Payer: Aetna of WY Medicare |
$1.14
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.65
|
| Rate for Payer: Altius Commercial |
$1.65
|
| Rate for Payer: Beech Street Commercial |
$1.69
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.41
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.67
|
| Rate for Payer: Cigna of WY Commercial |
$1.69
|
| Rate for Payer: Entrust Commercial |
$1.63
|
| Rate for Payer: First Choice Health Commercial |
$1.63
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.63
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.00
|
| Rate for Payer: HealthUtah PPO |
$1.72
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.67
|
| Rate for Payer: Multiplan Medicare/VA |
$0.95
|
| Rate for Payer: One Health Plan of WY PPO |
$1.69
|
| Rate for Payer: PacificSource Commercial |
$1.55
|
| Rate for Payer: PHCS PPO |
$1.69
|
| Rate for Payer: Three Rivers PPO |
$1.29
|
| Rate for Payer: TriWest Veterans Administration |
$1.00
|
| Rate for Payer: United Healthcare Commercial |
$1.50
|
| Rate for Payer: United Healthcare Medicare |
$1.00
|
| Rate for Payer: WINHealth Partners Commercial |
$1.69
|
| Rate for Payer: Wise Provider Network Commercial |
$1.63
|
|
|
AMLODIPINE 2.5 MG TABLET [6826]
|
Facility
|
IP
|
$0.56
|
|
|
Service Code
|
NDC 0904636961
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.55
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.54
|
| Rate for Payer: Altius Commercial |
$0.54
|
| Rate for Payer: Beech Street Commercial |
$0.55
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.46
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.54
|
| Rate for Payer: Cigna of WY Commercial |
$0.55
|
| Rate for Payer: Entrust Commercial |
$0.53
|
| Rate for Payer: First Choice Health Commercial |
$0.53
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.53
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.37
|
| Rate for Payer: HealthUtah PPO |
$0.56
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.54
|
| Rate for Payer: Multiplan Medicare/VA |
$0.35
|
| Rate for Payer: One Health Plan of WY PPO |
$0.55
|
| Rate for Payer: PacificSource Commercial |
$0.50
|
| Rate for Payer: PHCS PPO |
$0.55
|
| Rate for Payer: Three Rivers PPO |
$0.42
|
| Rate for Payer: TriWest Veterans Administration |
$0.37
|
| Rate for Payer: United Healthcare Commercial |
$0.49
|
| Rate for Payer: United Healthcare Medicare |
$0.37
|
| Rate for Payer: WINHealth Partners Commercial |
$0.53
|
| Rate for Payer: Wise Provider Network Commercial |
$0.53
|
|
|
AMLODIPINE 2.5 MG TABLET [6826]
|
Facility
|
OP
|
$0.56
|
|
|
Service Code
|
NDC 0904636961
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.55
|
| Rate for Payer: Aetna of WY Medicare |
$0.37
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.54
|
| Rate for Payer: Altius Commercial |
$0.54
|
| Rate for Payer: Beech Street Commercial |
$0.55
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.46
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.54
|
| Rate for Payer: Cigna of WY Commercial |
$0.55
|
| Rate for Payer: Entrust Commercial |
$0.53
|
| Rate for Payer: First Choice Health Commercial |
$0.53
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.53
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.32
|
| Rate for Payer: HealthUtah PPO |
$0.56
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.54
|
| Rate for Payer: Multiplan Medicare/VA |
$0.31
|
| Rate for Payer: One Health Plan of WY PPO |
$0.55
|
| Rate for Payer: PacificSource Commercial |
$0.50
|
| Rate for Payer: PHCS PPO |
$0.55
|
| Rate for Payer: Three Rivers PPO |
$0.42
|
| Rate for Payer: TriWest Veterans Administration |
$0.32
|
| Rate for Payer: United Healthcare Commercial |
$0.49
|
| Rate for Payer: United Healthcare Medicare |
$0.32
|
| Rate for Payer: WINHealth Partners Commercial |
$0.55
|
| Rate for Payer: Wise Provider Network Commercial |
$0.53
|
|
|
AMLODIPINE 5 MG TABLET [7292]
|
Facility
|
IP
|
$0.15
|
|
|
Service Code
|
NDC 6909712705
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.15
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.14
|
| Rate for Payer: Altius Commercial |
$0.14
|
| Rate for Payer: Beech Street Commercial |
$0.15
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.12
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.15
|
| Rate for Payer: Cigna of WY Commercial |
$0.15
|
| Rate for Payer: Entrust Commercial |
$0.14
|
| Rate for Payer: First Choice Health Commercial |
$0.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.10
|
| Rate for Payer: HealthUtah PPO |
$0.15
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.15
|
| Rate for Payer: Multiplan Medicare/VA |
$0.09
|
| Rate for Payer: One Health Plan of WY PPO |
$0.15
|
| Rate for Payer: PacificSource Commercial |
$0.14
|
| Rate for Payer: PHCS PPO |
$0.15
|
| Rate for Payer: Three Rivers PPO |
$0.11
|
| Rate for Payer: TriWest Veterans Administration |
$0.10
|
| Rate for Payer: United Healthcare Commercial |
$0.13
|
| Rate for Payer: United Healthcare Medicare |
$0.10
|
| Rate for Payer: WINHealth Partners Commercial |
$0.14
|
| Rate for Payer: Wise Provider Network Commercial |
$0.14
|
|
|
AMLODIPINE 5 MG TABLET [7292]
|
Facility
|
OP
|
$0.15
|
|
|
Service Code
|
NDC 6909712705
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.15
|
| Rate for Payer: Aetna of WY Medicare |
$0.10
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.14
|
| Rate for Payer: Altius Commercial |
$0.14
|
| Rate for Payer: Beech Street Commercial |
$0.15
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.12
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.15
|
| Rate for Payer: Cigna of WY Commercial |
$0.15
|
| Rate for Payer: Entrust Commercial |
$0.14
|
| Rate for Payer: First Choice Health Commercial |
$0.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.09
|
| Rate for Payer: HealthUtah PPO |
$0.15
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.15
|
| Rate for Payer: Multiplan Medicare/VA |
$0.08
|
| Rate for Payer: One Health Plan of WY PPO |
$0.15
|
| Rate for Payer: PacificSource Commercial |
$0.14
|
| Rate for Payer: PHCS PPO |
$0.15
|
| Rate for Payer: Three Rivers PPO |
$0.11
|
| Rate for Payer: TriWest Veterans Administration |
$0.09
|
| Rate for Payer: United Healthcare Commercial |
$0.13
|
| Rate for Payer: United Healthcare Medicare |
$0.09
|
| Rate for Payer: WINHealth Partners Commercial |
$0.15
|
| Rate for Payer: Wise Provider Network Commercial |
$0.14
|
|
|
AMLODIPINE 5 MG TABLET [7292]
|
Facility
|
IP
|
$0.76
|
|
|
Service Code
|
NDC 6068748811
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$0.76 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.74
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.73
|
| Rate for Payer: Altius Commercial |
$0.73
|
| Rate for Payer: Beech Street Commercial |
$0.74
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.62
|
| Rate for Payer: Cash Price |
$0.53
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.74
|
| Rate for Payer: Cigna of WY Commercial |
$0.74
|
| Rate for Payer: Entrust Commercial |
$0.72
|
| Rate for Payer: First Choice Health Commercial |
$0.72
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.72
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.50
|
| Rate for Payer: HealthUtah PPO |
$0.76
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.74
|
| Rate for Payer: Multiplan Medicare/VA |
$0.48
|
| Rate for Payer: One Health Plan of WY PPO |
$0.74
|
| Rate for Payer: PacificSource Commercial |
$0.68
|
| Rate for Payer: PHCS PPO |
$0.74
|
| Rate for Payer: Three Rivers PPO |
$0.57
|
| Rate for Payer: TriWest Veterans Administration |
$0.50
|
| Rate for Payer: United Healthcare Commercial |
$0.66
|
| Rate for Payer: United Healthcare Medicare |
$0.50
|
| Rate for Payer: WINHealth Partners Commercial |
$0.72
|
| Rate for Payer: Wise Provider Network Commercial |
$0.72
|
|
|
AMLODIPINE 5 MG TABLET [7292]
|
Facility
|
OP
|
$0.63
|
|
|
Service Code
|
NDC 6068748801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$0.63 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.62
|
| Rate for Payer: Aetna of WY Medicare |
$0.42
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.60
|
| Rate for Payer: Altius Commercial |
$0.60
|
| Rate for Payer: Beech Street Commercial |
$0.62
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.52
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.61
|
| Rate for Payer: Cigna of WY Commercial |
$0.62
|
| Rate for Payer: Entrust Commercial |
$0.60
|
| Rate for Payer: First Choice Health Commercial |
$0.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.37
|
| Rate for Payer: HealthUtah PPO |
$0.63
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.61
|
| Rate for Payer: Multiplan Medicare/VA |
$0.35
|
| Rate for Payer: One Health Plan of WY PPO |
$0.62
|
| Rate for Payer: PacificSource Commercial |
$0.57
|
| Rate for Payer: PHCS PPO |
$0.62
|
| Rate for Payer: Three Rivers PPO |
$0.47
|
| Rate for Payer: TriWest Veterans Administration |
$0.37
|
| Rate for Payer: United Healthcare Commercial |
$0.55
|
| Rate for Payer: United Healthcare Medicare |
$0.37
|
| Rate for Payer: WINHealth Partners Commercial |
$0.62
|
| Rate for Payer: Wise Provider Network Commercial |
$0.60
|
|
|
AMLODIPINE 5 MG TABLET [7292]
|
Facility
|
OP
|
$0.76
|
|
|
Service Code
|
NDC 6068748811
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$0.76 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.74
|
| Rate for Payer: Aetna of WY Medicare |
$0.50
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.73
|
| Rate for Payer: Altius Commercial |
$0.73
|
| Rate for Payer: Beech Street Commercial |
$0.74
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.62
|
| Rate for Payer: Cash Price |
$0.53
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.74
|
| Rate for Payer: Cigna of WY Commercial |
$0.74
|
| Rate for Payer: Entrust Commercial |
$0.72
|
| Rate for Payer: First Choice Health Commercial |
$0.72
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.72
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.44
|
| Rate for Payer: HealthUtah PPO |
$0.76
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.74
|
| Rate for Payer: Multiplan Medicare/VA |
$0.42
|
| Rate for Payer: One Health Plan of WY PPO |
$0.74
|
| Rate for Payer: PacificSource Commercial |
$0.68
|
| Rate for Payer: PHCS PPO |
$0.74
|
| Rate for Payer: Three Rivers PPO |
$0.57
|
| Rate for Payer: TriWest Veterans Administration |
$0.44
|
| Rate for Payer: United Healthcare Commercial |
$0.66
|
| Rate for Payer: United Healthcare Medicare |
$0.44
|
| Rate for Payer: WINHealth Partners Commercial |
$0.74
|
| Rate for Payer: Wise Provider Network Commercial |
$0.72
|
|
|
AMLODIPINE 5 MG TABLET [7292]
|
Facility
|
IP
|
$0.63
|
|
|
Service Code
|
NDC 6068748801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$0.63 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.62
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.60
|
| Rate for Payer: Altius Commercial |
$0.60
|
| Rate for Payer: Beech Street Commercial |
$0.62
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.52
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.61
|
| Rate for Payer: Cigna of WY Commercial |
$0.62
|
| Rate for Payer: Entrust Commercial |
$0.60
|
| Rate for Payer: First Choice Health Commercial |
$0.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.42
|
| Rate for Payer: HealthUtah PPO |
$0.63
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.61
|
| Rate for Payer: Multiplan Medicare/VA |
$0.40
|
| Rate for Payer: One Health Plan of WY PPO |
$0.62
|
| Rate for Payer: PacificSource Commercial |
$0.57
|
| Rate for Payer: PHCS PPO |
$0.62
|
| Rate for Payer: Three Rivers PPO |
$0.47
|
| Rate for Payer: TriWest Veterans Administration |
$0.42
|
| Rate for Payer: United Healthcare Commercial |
$0.55
|
| Rate for Payer: United Healthcare Medicare |
$0.42
|
| Rate for Payer: WINHealth Partners Commercial |
$0.60
|
| Rate for Payer: Wise Provider Network Commercial |
$0.60
|
|
|
AMMONIA SOLUTION FOR INHALATION [408138359]
|
Facility
|
IP
|
$1.75
|
|
|
Service Code
|
NDC 9999138359
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.10 |
| Max. Negotiated Rate |
$1.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.72
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.68
|
| Rate for Payer: Altius Commercial |
$1.68
|
| Rate for Payer: Beech Street Commercial |
$1.72
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.44
|
| Rate for Payer: Cash Price |
$1.23
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.70
|
| Rate for Payer: Cigna of WY Commercial |
$1.72
|
| Rate for Payer: Entrust Commercial |
$1.66
|
| Rate for Payer: First Choice Health Commercial |
$1.66
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.66
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.16
|
| Rate for Payer: HealthUtah PPO |
$1.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.70
|
| Rate for Payer: Multiplan Medicare/VA |
$1.10
|
| Rate for Payer: One Health Plan of WY PPO |
$1.72
|
| Rate for Payer: PacificSource Commercial |
$1.58
|
| Rate for Payer: PHCS PPO |
$1.72
|
| Rate for Payer: Three Rivers PPO |
$1.31
|
| Rate for Payer: TriWest Veterans Administration |
$1.16
|
| Rate for Payer: United Healthcare Commercial |
$1.52
|
| Rate for Payer: United Healthcare Medicare |
$1.16
|
| Rate for Payer: WINHealth Partners Commercial |
$1.66
|
| Rate for Payer: Wise Provider Network Commercial |
$1.66
|
|
|
AMMONIA SOLUTION FOR INHALATION [408138359]
|
Facility
|
OP
|
$1.75
|
|
|
Service Code
|
NDC 9999138359
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$1.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.72
|
| Rate for Payer: Aetna of WY Medicare |
$1.16
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.68
|
| Rate for Payer: Altius Commercial |
$1.68
|
| Rate for Payer: Beech Street Commercial |
$1.72
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.44
|
| Rate for Payer: Cash Price |
$1.23
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.70
|
| Rate for Payer: Cigna of WY Commercial |
$1.72
|
| Rate for Payer: Entrust Commercial |
$1.66
|
| Rate for Payer: First Choice Health Commercial |
$1.66
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.66
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.02
|
| Rate for Payer: HealthUtah PPO |
$1.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.70
|
| Rate for Payer: Multiplan Medicare/VA |
$0.96
|
| Rate for Payer: One Health Plan of WY PPO |
$1.72
|
| Rate for Payer: PacificSource Commercial |
$1.58
|
| Rate for Payer: PHCS PPO |
$1.72
|
| Rate for Payer: Three Rivers PPO |
$1.31
|
| Rate for Payer: TriWest Veterans Administration |
$1.02
|
| Rate for Payer: United Healthcare Commercial |
$1.52
|
| Rate for Payer: United Healthcare Medicare |
$1.02
|
| Rate for Payer: WINHealth Partners Commercial |
$1.72
|
| Rate for Payer: Wise Provider Network Commercial |
$1.66
|
|
|
AMMONIUM LACTATE 12 % LOTION [2531]
|
Facility
|
OP
|
$0.07
|
|
|
Service Code
|
NDC 0904598463
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.07
|
| Rate for Payer: Aetna of WY Medicare |
$0.05
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.07
|
| Rate for Payer: Altius Commercial |
$0.07
|
| Rate for Payer: Beech Street Commercial |
$0.07
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.07
|
| Rate for Payer: Cigna of WY Commercial |
$0.07
|
| Rate for Payer: Entrust Commercial |
$0.07
|
| Rate for Payer: First Choice Health Commercial |
$0.07
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.07
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.04
|
| Rate for Payer: HealthUtah PPO |
$0.07
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.07
|
| Rate for Payer: Multiplan Medicare/VA |
$0.04
|
| Rate for Payer: One Health Plan of WY PPO |
$0.07
|
| Rate for Payer: PacificSource Commercial |
$0.06
|
| Rate for Payer: PHCS PPO |
$0.07
|
| Rate for Payer: Three Rivers PPO |
$0.05
|
| Rate for Payer: TriWest Veterans Administration |
$0.04
|
| Rate for Payer: United Healthcare Commercial |
$0.06
|
| Rate for Payer: United Healthcare Medicare |
$0.04
|
| Rate for Payer: WINHealth Partners Commercial |
$0.07
|
| Rate for Payer: Wise Provider Network Commercial |
$0.07
|
|
|
AMMONIUM LACTATE 12 % LOTION [2531]
|
Facility
|
OP
|
$0.07
|
|
|
Service Code
|
NDC 0904598426
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.07
|
| Rate for Payer: Aetna of WY Medicare |
$0.05
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.07
|
| Rate for Payer: Altius Commercial |
$0.07
|
| Rate for Payer: Beech Street Commercial |
$0.07
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.07
|
| Rate for Payer: Cigna of WY Commercial |
$0.07
|
| Rate for Payer: Entrust Commercial |
$0.07
|
| Rate for Payer: First Choice Health Commercial |
$0.07
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.07
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.04
|
| Rate for Payer: HealthUtah PPO |
$0.07
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.07
|
| Rate for Payer: Multiplan Medicare/VA |
$0.04
|
| Rate for Payer: One Health Plan of WY PPO |
$0.07
|
| Rate for Payer: PacificSource Commercial |
$0.06
|
| Rate for Payer: PHCS PPO |
$0.07
|
| Rate for Payer: Three Rivers PPO |
$0.05
|
| Rate for Payer: TriWest Veterans Administration |
$0.04
|
| Rate for Payer: United Healthcare Commercial |
$0.06
|
| Rate for Payer: United Healthcare Medicare |
$0.04
|
| Rate for Payer: WINHealth Partners Commercial |
$0.07
|
| Rate for Payer: Wise Provider Network Commercial |
$0.07
|
|
|
AMMONIUM LACTATE 12 % LOTION [2531]
|
Facility
|
IP
|
$0.07
|
|
|
Service Code
|
NDC 0904598426
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.07
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.07
|
| Rate for Payer: Altius Commercial |
$0.07
|
| Rate for Payer: Beech Street Commercial |
$0.07
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.07
|
| Rate for Payer: Cigna of WY Commercial |
$0.07
|
| Rate for Payer: Entrust Commercial |
$0.07
|
| Rate for Payer: First Choice Health Commercial |
$0.07
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.07
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.05
|
| Rate for Payer: HealthUtah PPO |
$0.07
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.07
|
| Rate for Payer: Multiplan Medicare/VA |
$0.04
|
| Rate for Payer: One Health Plan of WY PPO |
$0.07
|
| Rate for Payer: PacificSource Commercial |
$0.06
|
| Rate for Payer: PHCS PPO |
$0.07
|
| Rate for Payer: Three Rivers PPO |
$0.05
|
| Rate for Payer: TriWest Veterans Administration |
$0.05
|
| Rate for Payer: United Healthcare Commercial |
$0.06
|
| Rate for Payer: United Healthcare Medicare |
$0.05
|
| Rate for Payer: WINHealth Partners Commercial |
$0.07
|
| Rate for Payer: Wise Provider Network Commercial |
$0.07
|
|
|
AMMONIUM LACTATE 12 % LOTION [2531]
|
Facility
|
IP
|
$0.07
|
|
|
Service Code
|
NDC 0904598463
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.07
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.07
|
| Rate for Payer: Altius Commercial |
$0.07
|
| Rate for Payer: Beech Street Commercial |
$0.07
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.07
|
| Rate for Payer: Cigna of WY Commercial |
$0.07
|
| Rate for Payer: Entrust Commercial |
$0.07
|
| Rate for Payer: First Choice Health Commercial |
$0.07
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.07
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.05
|
| Rate for Payer: HealthUtah PPO |
$0.07
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.07
|
| Rate for Payer: Multiplan Medicare/VA |
$0.04
|
| Rate for Payer: One Health Plan of WY PPO |
$0.07
|
| Rate for Payer: PacificSource Commercial |
$0.06
|
| Rate for Payer: PHCS PPO |
$0.07
|
| Rate for Payer: Three Rivers PPO |
$0.05
|
| Rate for Payer: TriWest Veterans Administration |
$0.05
|
| Rate for Payer: United Healthcare Commercial |
$0.06
|
| Rate for Payer: United Healthcare Medicare |
$0.05
|
| Rate for Payer: WINHealth Partners Commercial |
$0.07
|
| Rate for Payer: Wise Provider Network Commercial |
$0.07
|
|
|
AMMONIUM LACTATE 12 % TOPICAL CREAM [16039]
|
Facility
|
IP
|
$0.40
|
|
|
Service Code
|
NDC 4580249398
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.39
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.38
|
| Rate for Payer: Altius Commercial |
$0.38
|
| Rate for Payer: Beech Street Commercial |
$0.39
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.33
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.39
|
| Rate for Payer: Cigna of WY Commercial |
$0.39
|
| Rate for Payer: Entrust Commercial |
$0.38
|
| Rate for Payer: First Choice Health Commercial |
$0.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.26
|
| Rate for Payer: HealthUtah PPO |
$0.40
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.39
|
| Rate for Payer: Multiplan Medicare/VA |
$0.25
|
| Rate for Payer: One Health Plan of WY PPO |
$0.39
|
| Rate for Payer: PacificSource Commercial |
$0.36
|
| Rate for Payer: PHCS PPO |
$0.39
|
| Rate for Payer: Three Rivers PPO |
$0.30
|
| Rate for Payer: TriWest Veterans Administration |
$0.26
|
| Rate for Payer: United Healthcare Commercial |
$0.35
|
| Rate for Payer: United Healthcare Medicare |
$0.26
|
| Rate for Payer: WINHealth Partners Commercial |
$0.38
|
| Rate for Payer: Wise Provider Network Commercial |
$0.38
|
|
|
AMMONIUM LACTATE 12 % TOPICAL CREAM [16039]
|
Facility
|
OP
|
$0.40
|
|
|
Service Code
|
NDC 4580249398
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.39
|
| Rate for Payer: Aetna of WY Medicare |
$0.26
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.38
|
| Rate for Payer: Altius Commercial |
$0.38
|
| Rate for Payer: Beech Street Commercial |
$0.39
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.33
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.39
|
| Rate for Payer: Cigna of WY Commercial |
$0.39
|
| Rate for Payer: Entrust Commercial |
$0.38
|
| Rate for Payer: First Choice Health Commercial |
$0.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.23
|
| Rate for Payer: HealthUtah PPO |
$0.40
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.39
|
| Rate for Payer: Multiplan Medicare/VA |
$0.22
|
| Rate for Payer: One Health Plan of WY PPO |
$0.39
|
| Rate for Payer: PacificSource Commercial |
$0.36
|
| Rate for Payer: PHCS PPO |
$0.39
|
| Rate for Payer: Three Rivers PPO |
$0.30
|
| Rate for Payer: TriWest Veterans Administration |
$0.23
|
| Rate for Payer: United Healthcare Commercial |
$0.35
|
| Rate for Payer: United Healthcare Medicare |
$0.23
|
| Rate for Payer: WINHealth Partners Commercial |
$0.39
|
| Rate for Payer: Wise Provider Network Commercial |
$0.38
|
|
|
AMMONIUM LACTATE 12 % TOPICAL CREAM [16039]
|
Facility
|
OP
|
$0.13
|
|
|
Service Code
|
NDC 0904598348
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.13
|
| Rate for Payer: Aetna of WY Medicare |
$0.09
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.12
|
| Rate for Payer: Altius Commercial |
$0.12
|
| Rate for Payer: Beech Street Commercial |
$0.13
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.11
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.13
|
| Rate for Payer: Cigna of WY Commercial |
$0.13
|
| Rate for Payer: Entrust Commercial |
$0.12
|
| Rate for Payer: First Choice Health Commercial |
$0.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.08
|
| Rate for Payer: HealthUtah PPO |
$0.13
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.13
|
| Rate for Payer: Multiplan Medicare/VA |
$0.07
|
| Rate for Payer: One Health Plan of WY PPO |
$0.13
|
| Rate for Payer: PacificSource Commercial |
$0.12
|
| Rate for Payer: PHCS PPO |
$0.13
|
| Rate for Payer: Three Rivers PPO |
$0.10
|
| Rate for Payer: TriWest Veterans Administration |
$0.08
|
| Rate for Payer: United Healthcare Commercial |
$0.11
|
| Rate for Payer: United Healthcare Medicare |
$0.08
|
| Rate for Payer: WINHealth Partners Commercial |
$0.13
|
| Rate for Payer: Wise Provider Network Commercial |
$0.12
|
|
|
AMMONIUM LACTATE 12 % TOPICAL CREAM [16039]
|
Facility
|
OP
|
$0.19
|
|
|
Service Code
|
NDC 6304440420
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.19
|
| Rate for Payer: Aetna of WY Medicare |
$0.13
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.18
|
| Rate for Payer: Altius Commercial |
$0.18
|
| Rate for Payer: Beech Street Commercial |
$0.19
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.16
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.18
|
| Rate for Payer: Cigna of WY Commercial |
$0.19
|
| Rate for Payer: Entrust Commercial |
$0.18
|
| Rate for Payer: First Choice Health Commercial |
$0.18
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.18
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.11
|
| Rate for Payer: HealthUtah PPO |
$0.19
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.18
|
| Rate for Payer: Multiplan Medicare/VA |
$0.10
|
| Rate for Payer: One Health Plan of WY PPO |
$0.19
|
| Rate for Payer: PacificSource Commercial |
$0.17
|
| Rate for Payer: PHCS PPO |
$0.19
|
| Rate for Payer: Three Rivers PPO |
$0.14
|
| Rate for Payer: TriWest Veterans Administration |
$0.11
|
| Rate for Payer: United Healthcare Commercial |
$0.17
|
| Rate for Payer: United Healthcare Medicare |
$0.11
|
| Rate for Payer: WINHealth Partners Commercial |
$0.19
|
| Rate for Payer: Wise Provider Network Commercial |
$0.18
|
|
|
AMMONIUM LACTATE 12 % TOPICAL CREAM [16039]
|
Facility
|
IP
|
$0.13
|
|
|
Service Code
|
NDC 0904598348
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.13
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.12
|
| Rate for Payer: Altius Commercial |
$0.12
|
| Rate for Payer: Beech Street Commercial |
$0.13
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.11
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.13
|
| Rate for Payer: Cigna of WY Commercial |
$0.13
|
| Rate for Payer: Entrust Commercial |
$0.12
|
| Rate for Payer: First Choice Health Commercial |
$0.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.09
|
| Rate for Payer: HealthUtah PPO |
$0.13
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.13
|
| Rate for Payer: Multiplan Medicare/VA |
$0.08
|
| Rate for Payer: One Health Plan of WY PPO |
$0.13
|
| Rate for Payer: PacificSource Commercial |
$0.12
|
| Rate for Payer: PHCS PPO |
$0.13
|
| Rate for Payer: Three Rivers PPO |
$0.10
|
| Rate for Payer: TriWest Veterans Administration |
$0.09
|
| Rate for Payer: United Healthcare Commercial |
$0.11
|
| Rate for Payer: United Healthcare Medicare |
$0.09
|
| Rate for Payer: WINHealth Partners Commercial |
$0.12
|
| Rate for Payer: Wise Provider Network Commercial |
$0.12
|
|
|
AMMONIUM LACTATE 12 % TOPICAL CREAM [16039]
|
Facility
|
IP
|
$0.19
|
|
|
Service Code
|
NDC 6304440420
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.19
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.18
|
| Rate for Payer: Altius Commercial |
$0.18
|
| Rate for Payer: Beech Street Commercial |
$0.19
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.16
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.18
|
| Rate for Payer: Cigna of WY Commercial |
$0.19
|
| Rate for Payer: Entrust Commercial |
$0.18
|
| Rate for Payer: First Choice Health Commercial |
$0.18
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.18
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.13
|
| Rate for Payer: HealthUtah PPO |
$0.19
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.18
|
| Rate for Payer: Multiplan Medicare/VA |
$0.12
|
| Rate for Payer: One Health Plan of WY PPO |
$0.19
|
| Rate for Payer: PacificSource Commercial |
$0.17
|
| Rate for Payer: PHCS PPO |
$0.19
|
| Rate for Payer: Three Rivers PPO |
$0.14
|
| Rate for Payer: TriWest Veterans Administration |
$0.13
|
| Rate for Payer: United Healthcare Commercial |
$0.17
|
| Rate for Payer: United Healthcare Medicare |
$0.13
|
| Rate for Payer: WINHealth Partners Commercial |
$0.18
|
| Rate for Payer: Wise Provider Network Commercial |
$0.18
|
|
|
AMNIOCENTESIS DIAGNOSIC
|
Professional
|
Both
|
$241.00
|
|
|
Service Code
|
HCPCS 59000
|
| Hospital Charge Code |
59000
|
| Min. Negotiated Rate |
$64.73 |
| Max. Negotiated Rate |
$241.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$236.18
|
| Rate for Payer: Aetna of WY Medicare |
$76.15
|
| Rate for Payer: Beech Street Commercial |
$228.95
|
| Rate for Payer: Cash Price |
$168.70
|
| Rate for Payer: Cash Price |
$168.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$233.77
|
| Rate for Payer: Cigna of WY Commercial |
$236.18
|
| Rate for Payer: First Choice Health Commercial |
$216.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$228.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$76.15
|
| Rate for Payer: HealthUtah PPO |
$241.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$233.77
|
| Rate for Payer: Multiplan Medicare/VA |
$64.73
|
| Rate for Payer: One Health Plan of WY PPO |
$236.18
|
| Rate for Payer: PacificSource Commercial |
$216.90
|
| Rate for Payer: PHCS PPO |
$228.95
|
| Rate for Payer: Three Rivers PPO |
$180.75
|
| Rate for Payer: TriWest Veterans Administration |
$76.15
|
| Rate for Payer: United Healthcare Commercial |
$209.67
|
| Rate for Payer: United Healthcare Medicare |
$76.15
|
| Rate for Payer: WINHealth Partners Commercial |
$204.85
|
|
|
AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION [16449]
|
Facility
|
OP
|
$0.26
|
|
|
Service Code
|
NDC 0781615746
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.26 |
| 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 |
$0.25
|
| Rate for Payer: Altius Commercial |
$0.25
|
| 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 |
$0.25
|
| Rate for Payer: Cigna of WY Commercial |
$0.25
|
| Rate for Payer: Entrust Commercial |
$0.25
|
| Rate for Payer: First Choice Health Commercial |
$0.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.15
|
| Rate for Payer: HealthUtah PPO |
$0.26
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.25
|
| 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 |
$0.20
|
| Rate for Payer: TriWest Veterans Administration |
$0.15
|
| Rate for Payer: United Healthcare Commercial |
$0.23
|
| Rate for Payer: United Healthcare Medicare |
$0.15
|
| Rate for Payer: WINHealth Partners Commercial |
$0.25
|
| Rate for Payer: Wise Provider Network Commercial |
$0.25
|
|
