|
DOCETAXEL 10 MG/ML INTRAVENOUS SOLUTION (WRAPPED) [4000725]
|
Facility
|
OP
|
$57.66
|
|
|
Service Code
|
HCPCS J9171
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.77 |
| Max. Negotiated Rate |
$57.66 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$56.51
|
| Rate for Payer: Aetna of WY Medicare |
$38.06
|
| Rate for Payer: Altius Auto/Workers Compensation |
$55.35
|
| Rate for Payer: Altius Commercial |
$55.35
|
| Rate for Payer: Beech Street Commercial |
$56.51
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$47.34
|
| Rate for Payer: Cash Price |
$40.36
|
| Rate for Payer: ChoiceCare Network Commercial |
$55.93
|
| Rate for Payer: Cigna of WY Commercial |
$56.51
|
| Rate for Payer: Entrust Commercial |
$54.78
|
| Rate for Payer: First Choice Health Commercial |
$54.78
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$54.78
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$33.44
|
| Rate for Payer: HealthUtah PPO |
$57.66
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$55.93
|
| Rate for Payer: Multiplan Medicare/VA |
$31.77
|
| Rate for Payer: One Health Plan of WY PPO |
$56.51
|
| Rate for Payer: PacificSource Commercial |
$51.89
|
| Rate for Payer: PHCS PPO |
$56.51
|
| Rate for Payer: Three Rivers PPO |
$43.24
|
| Rate for Payer: TriWest Veterans Administration |
$33.44
|
| Rate for Payer: United Healthcare Commercial |
$50.16
|
| Rate for Payer: United Healthcare Medicare |
$33.44
|
| Rate for Payer: WINHealth Partners Commercial |
$56.51
|
| Rate for Payer: Wise Provider Network Commercial |
$54.78
|
|
|
DOCETAXEL 10 MG/ML INTRAVENOUS SOLUTION (WRAPPED) [4000725]
|
Facility
|
IP
|
$57.66
|
|
|
Service Code
|
HCPCS J9171
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.15 |
| Max. Negotiated Rate |
$57.66 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$56.51
|
| Rate for Payer: Altius Auto/Workers Compensation |
$55.35
|
| Rate for Payer: Altius Commercial |
$55.35
|
| Rate for Payer: Beech Street Commercial |
$56.51
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$47.34
|
| Rate for Payer: Cash Price |
$40.36
|
| Rate for Payer: ChoiceCare Network Commercial |
$55.93
|
| Rate for Payer: Cigna of WY Commercial |
$56.51
|
| Rate for Payer: Entrust Commercial |
$54.78
|
| Rate for Payer: First Choice Health Commercial |
$54.78
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$54.78
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$38.06
|
| Rate for Payer: HealthUtah PPO |
$57.66
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$55.93
|
| Rate for Payer: Multiplan Medicare/VA |
$36.15
|
| Rate for Payer: One Health Plan of WY PPO |
$56.51
|
| Rate for Payer: PacificSource Commercial |
$51.89
|
| Rate for Payer: PHCS PPO |
$56.51
|
| Rate for Payer: Three Rivers PPO |
$43.24
|
| Rate for Payer: TriWest Veterans Administration |
$38.06
|
| Rate for Payer: United Healthcare Commercial |
$50.16
|
| Rate for Payer: United Healthcare Medicare |
$38.06
|
| Rate for Payer: WINHealth Partners Commercial |
$54.78
|
| Rate for Payer: Wise Provider Network Commercial |
$54.78
|
|
|
DOCETAXEL 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION [90791]
|
Facility
|
IP
|
$57.50
|
|
|
Service Code
|
HCPCS J9171
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.05 |
| Max. Negotiated Rate |
$57.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$56.35
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$149.75
|
| Rate for Payer: Altius Auto/Workers Compensation |
$55.20
|
| Rate for Payer: Altius Auto/Workers Compensation |
$146.70
|
| Rate for Payer: Altius Commercial |
$146.70
|
| Rate for Payer: Altius Commercial |
$55.20
|
| Rate for Payer: Beech Street Commercial |
$56.35
|
| Rate for Payer: Beech Street Commercial |
$149.75
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$125.46
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$47.21
|
| Rate for Payer: Cash Price |
$40.25
|
| Rate for Payer: Cash Price |
$106.97
|
| Rate for Payer: ChoiceCare Network Commercial |
$148.23
|
| Rate for Payer: ChoiceCare Network Commercial |
$55.78
|
| Rate for Payer: Cigna of WY Commercial |
$56.35
|
| Rate for Payer: Cigna of WY Commercial |
$149.75
|
| Rate for Payer: Entrust Commercial |
$145.17
|
| Rate for Payer: Entrust Commercial |
$54.62
|
| Rate for Payer: First Choice Health Commercial |
$145.17
|
| Rate for Payer: First Choice Health Commercial |
$54.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$145.17
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$54.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$37.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$100.85
|
| Rate for Payer: HealthUtah PPO |
$57.50
|
| Rate for Payer: HealthUtah PPO |
$152.81
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$148.23
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$55.78
|
| Rate for Payer: Multiplan Medicare/VA |
$36.05
|
| Rate for Payer: Multiplan Medicare/VA |
$95.81
|
| Rate for Payer: One Health Plan of WY PPO |
$56.35
|
| Rate for Payer: One Health Plan of WY PPO |
$149.75
|
| Rate for Payer: PacificSource Commercial |
$51.75
|
| Rate for Payer: PacificSource Commercial |
$137.53
|
| Rate for Payer: PHCS PPO |
$149.75
|
| Rate for Payer: PHCS PPO |
$56.35
|
| Rate for Payer: Three Rivers PPO |
$114.61
|
| Rate for Payer: Three Rivers PPO |
$43.12
|
| Rate for Payer: TriWest Veterans Administration |
$37.95
|
| Rate for Payer: TriWest Veterans Administration |
$100.85
|
| Rate for Payer: United Healthcare Commercial |
$132.94
|
| Rate for Payer: United Healthcare Commercial |
$50.02
|
| Rate for Payer: United Healthcare Medicare |
$37.95
|
| Rate for Payer: United Healthcare Medicare |
$100.85
|
| Rate for Payer: WINHealth Partners Commercial |
$145.17
|
| Rate for Payer: WINHealth Partners Commercial |
$54.62
|
| Rate for Payer: Wise Provider Network Commercial |
$145.17
|
| Rate for Payer: Wise Provider Network Commercial |
$54.62
|
|
|
DOCETAXEL 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION [90791]
|
Facility
|
OP
|
$57.50
|
|
|
Service Code
|
HCPCS J9171
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.68 |
| Max. Negotiated Rate |
$57.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$56.35
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$149.75
|
| Rate for Payer: Aetna of WY Medicare |
$37.95
|
| Rate for Payer: Aetna of WY Medicare |
$100.85
|
| Rate for Payer: Altius Auto/Workers Compensation |
$146.70
|
| Rate for Payer: Altius Auto/Workers Compensation |
$55.20
|
| Rate for Payer: Altius Commercial |
$55.20
|
| Rate for Payer: Altius Commercial |
$146.70
|
| Rate for Payer: Beech Street Commercial |
$149.75
|
| Rate for Payer: Beech Street Commercial |
$56.35
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$47.21
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$125.46
|
| Rate for Payer: Cash Price |
$106.97
|
| Rate for Payer: Cash Price |
$40.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$55.78
|
| Rate for Payer: ChoiceCare Network Commercial |
$148.23
|
| Rate for Payer: Cigna of WY Commercial |
$149.75
|
| Rate for Payer: Cigna of WY Commercial |
$56.35
|
| Rate for Payer: Entrust Commercial |
$54.62
|
| Rate for Payer: Entrust Commercial |
$145.17
|
| Rate for Payer: First Choice Health Commercial |
$145.17
|
| Rate for Payer: First Choice Health Commercial |
$54.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$145.17
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$54.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$33.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$88.63
|
| Rate for Payer: HealthUtah PPO |
$152.81
|
| Rate for Payer: HealthUtah PPO |
$57.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$148.23
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$55.78
|
| Rate for Payer: Multiplan Medicare/VA |
$31.68
|
| Rate for Payer: Multiplan Medicare/VA |
$84.20
|
| Rate for Payer: One Health Plan of WY PPO |
$149.75
|
| Rate for Payer: One Health Plan of WY PPO |
$56.35
|
| Rate for Payer: PacificSource Commercial |
$51.75
|
| Rate for Payer: PacificSource Commercial |
$137.53
|
| Rate for Payer: PHCS PPO |
$149.75
|
| Rate for Payer: PHCS PPO |
$56.35
|
| Rate for Payer: Three Rivers PPO |
$114.61
|
| Rate for Payer: Three Rivers PPO |
$43.12
|
| Rate for Payer: TriWest Veterans Administration |
$33.35
|
| Rate for Payer: TriWest Veterans Administration |
$88.63
|
| Rate for Payer: United Healthcare Commercial |
$132.94
|
| Rate for Payer: United Healthcare Commercial |
$50.02
|
| Rate for Payer: United Healthcare Medicare |
$33.35
|
| Rate for Payer: United Healthcare Medicare |
$88.63
|
| Rate for Payer: WINHealth Partners Commercial |
$149.75
|
| Rate for Payer: WINHealth Partners Commercial |
$56.35
|
| Rate for Payer: Wise Provider Network Commercial |
$145.17
|
| Rate for Payer: Wise Provider Network Commercial |
$54.62
|
|
|
DOCOSANOL 10 % TOPICAL CREAM [925]
|
Facility
|
OP
|
$28.76
|
|
|
Service Code
|
NDC 0135020001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.85 |
| Max. Negotiated Rate |
$28.76 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$28.18
|
| Rate for Payer: Aetna of WY Medicare |
$18.98
|
| Rate for Payer: Altius Auto/Workers Compensation |
$27.61
|
| Rate for Payer: Altius Commercial |
$27.61
|
| Rate for Payer: Beech Street Commercial |
$28.18
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$23.61
|
| Rate for Payer: Cash Price |
$20.13
|
| Rate for Payer: ChoiceCare Network Commercial |
$27.90
|
| Rate for Payer: Cigna of WY Commercial |
$28.18
|
| Rate for Payer: Entrust Commercial |
$27.32
|
| Rate for Payer: First Choice Health Commercial |
$27.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$27.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$16.68
|
| Rate for Payer: HealthUtah PPO |
$28.76
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$27.90
|
| Rate for Payer: Multiplan Medicare/VA |
$15.85
|
| Rate for Payer: One Health Plan of WY PPO |
$28.18
|
| Rate for Payer: PacificSource Commercial |
$25.88
|
| Rate for Payer: PHCS PPO |
$28.18
|
| Rate for Payer: Three Rivers PPO |
$21.57
|
| Rate for Payer: TriWest Veterans Administration |
$16.68
|
| Rate for Payer: United Healthcare Commercial |
$25.02
|
| Rate for Payer: United Healthcare Medicare |
$16.68
|
| Rate for Payer: WINHealth Partners Commercial |
$28.18
|
| Rate for Payer: Wise Provider Network Commercial |
$27.32
|
|
|
DOCOSANOL 10 % TOPICAL CREAM [925]
|
Facility
|
IP
|
$28.76
|
|
|
Service Code
|
NDC 0135020001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.03 |
| Max. Negotiated Rate |
$28.76 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$28.18
|
| Rate for Payer: Altius Auto/Workers Compensation |
$27.61
|
| Rate for Payer: Altius Commercial |
$27.61
|
| Rate for Payer: Beech Street Commercial |
$28.18
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$23.61
|
| Rate for Payer: Cash Price |
$20.13
|
| Rate for Payer: ChoiceCare Network Commercial |
$27.90
|
| Rate for Payer: Cigna of WY Commercial |
$28.18
|
| Rate for Payer: Entrust Commercial |
$27.32
|
| Rate for Payer: First Choice Health Commercial |
$27.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$27.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$18.98
|
| Rate for Payer: HealthUtah PPO |
$28.76
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$27.90
|
| Rate for Payer: Multiplan Medicare/VA |
$18.03
|
| Rate for Payer: One Health Plan of WY PPO |
$28.18
|
| Rate for Payer: PacificSource Commercial |
$25.88
|
| Rate for Payer: PHCS PPO |
$28.18
|
| Rate for Payer: Three Rivers PPO |
$21.57
|
| Rate for Payer: TriWest Veterans Administration |
$18.98
|
| Rate for Payer: United Healthcare Commercial |
$25.02
|
| Rate for Payer: United Healthcare Medicare |
$18.98
|
| Rate for Payer: WINHealth Partners Commercial |
$27.32
|
| Rate for Payer: Wise Provider Network Commercial |
$27.32
|
|
|
DOCUSATE SODIUM 100 MG CAPSULE [14921]
|
Facility
|
OP
|
$0.09
|
|
|
Service Code
|
NDC 0904728060
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.09
|
| Rate for Payer: Aetna of WY Medicare |
$0.06
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.09
|
| Rate for Payer: Altius Commercial |
$0.09
|
| Rate for Payer: Beech Street Commercial |
$0.09
|
| 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 |
$0.09
|
| Rate for Payer: Cigna of WY Commercial |
$0.09
|
| Rate for Payer: Entrust Commercial |
$0.09
|
| Rate for Payer: First Choice Health Commercial |
$0.09
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.09
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.05
|
| Rate for Payer: HealthUtah PPO |
$0.09
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.09
|
| Rate for Payer: Multiplan Medicare/VA |
$0.05
|
| Rate for Payer: One Health Plan of WY PPO |
$0.09
|
| Rate for Payer: PacificSource Commercial |
$0.08
|
| Rate for Payer: PHCS PPO |
$0.09
|
| Rate for Payer: Three Rivers PPO |
$0.07
|
| Rate for Payer: TriWest Veterans Administration |
$0.05
|
| Rate for Payer: United Healthcare Commercial |
$0.08
|
| Rate for Payer: United Healthcare Medicare |
$0.05
|
| Rate for Payer: WINHealth Partners Commercial |
$0.09
|
| Rate for Payer: Wise Provider Network Commercial |
$0.09
|
|
|
DOCUSATE SODIUM 100 MG CAPSULE [14921]
|
Facility
|
OP
|
$0.07
|
|
|
Service Code
|
NDC 0904728080
|
|
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
|
|
|
DOCUSATE SODIUM 100 MG CAPSULE [14921]
|
Facility
|
IP
|
$0.20
|
|
|
Service Code
|
NDC 0904718361
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.20
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.19
|
| Rate for Payer: Altius Commercial |
$0.19
|
| Rate for Payer: Beech Street Commercial |
$0.20
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.16
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.19
|
| Rate for Payer: Cigna of WY Commercial |
$0.20
|
| Rate for Payer: Entrust Commercial |
$0.19
|
| Rate for Payer: First Choice Health Commercial |
$0.19
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.19
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.13
|
| Rate for Payer: HealthUtah PPO |
$0.20
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.19
|
| Rate for Payer: Multiplan Medicare/VA |
$0.13
|
| Rate for Payer: One Health Plan of WY PPO |
$0.20
|
| Rate for Payer: PacificSource Commercial |
$0.18
|
| Rate for Payer: PHCS PPO |
$0.20
|
| Rate for Payer: Three Rivers PPO |
$0.15
|
| 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 |
$0.19
|
| Rate for Payer: Wise Provider Network Commercial |
$0.19
|
|
|
DOCUSATE SODIUM 100 MG CAPSULE [14921]
|
Facility
|
IP
|
$0.07
|
|
|
Service Code
|
NDC 0904728080
|
|
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
|
|
|
DOCUSATE SODIUM 100 MG CAPSULE [14921]
|
Facility
|
OP
|
$0.20
|
|
|
Service Code
|
NDC 0904718361
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.20
|
| Rate for Payer: Aetna of WY Medicare |
$0.13
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.19
|
| Rate for Payer: Altius Commercial |
$0.19
|
| Rate for Payer: Beech Street Commercial |
$0.20
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.16
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.19
|
| Rate for Payer: Cigna of WY Commercial |
$0.20
|
| Rate for Payer: Entrust Commercial |
$0.19
|
| Rate for Payer: First Choice Health Commercial |
$0.19
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.19
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.12
|
| Rate for Payer: HealthUtah PPO |
$0.20
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.19
|
| Rate for Payer: Multiplan Medicare/VA |
$0.11
|
| Rate for Payer: One Health Plan of WY PPO |
$0.20
|
| Rate for Payer: PacificSource Commercial |
$0.18
|
| Rate for Payer: PHCS PPO |
$0.20
|
| Rate for Payer: Three Rivers PPO |
$0.15
|
| Rate for Payer: TriWest Veterans Administration |
$0.12
|
| Rate for Payer: United Healthcare Commercial |
$0.17
|
| Rate for Payer: United Healthcare Medicare |
$0.12
|
| Rate for Payer: WINHealth Partners Commercial |
$0.20
|
| Rate for Payer: Wise Provider Network Commercial |
$0.19
|
|
|
DOCUSATE SODIUM 100 MG CAPSULE [14921]
|
Facility
|
IP
|
$0.09
|
|
|
Service Code
|
NDC 0904728060
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.09
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.09
|
| Rate for Payer: Altius Commercial |
$0.09
|
| Rate for Payer: Beech Street Commercial |
$0.09
|
| 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 |
$0.09
|
| Rate for Payer: Cigna of WY Commercial |
$0.09
|
| Rate for Payer: Entrust Commercial |
$0.09
|
| Rate for Payer: First Choice Health Commercial |
$0.09
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.09
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.06
|
| Rate for Payer: HealthUtah PPO |
$0.09
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.09
|
| Rate for Payer: Multiplan Medicare/VA |
$0.06
|
| Rate for Payer: One Health Plan of WY PPO |
$0.09
|
| Rate for Payer: PacificSource Commercial |
$0.08
|
| Rate for Payer: PHCS PPO |
$0.09
|
| Rate for Payer: Three Rivers PPO |
$0.07
|
| Rate for Payer: TriWest Veterans Administration |
$0.06
|
| Rate for Payer: United Healthcare Commercial |
$0.08
|
| Rate for Payer: United Healthcare Medicare |
$0.06
|
| Rate for Payer: WINHealth Partners Commercial |
$0.09
|
| Rate for Payer: Wise Provider Network Commercial |
$0.09
|
|
|
DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID [568]
|
Facility
|
OP
|
$0.46
|
|
|
Service Code
|
NDC 0904727966
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$0.46 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.45
|
| Rate for Payer: Aetna of WY Medicare |
$0.30
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.44
|
| Rate for Payer: Altius Commercial |
$0.44
|
| Rate for Payer: Beech Street Commercial |
$0.45
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.38
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.45
|
| Rate for Payer: Cigna of WY Commercial |
$0.45
|
| Rate for Payer: Entrust Commercial |
$0.44
|
| Rate for Payer: First Choice Health Commercial |
$0.44
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.44
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.27
|
| Rate for Payer: HealthUtah PPO |
$0.46
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.45
|
| Rate for Payer: Multiplan Medicare/VA |
$0.25
|
| Rate for Payer: One Health Plan of WY PPO |
$0.45
|
| Rate for Payer: PacificSource Commercial |
$0.41
|
| Rate for Payer: PHCS PPO |
$0.45
|
| Rate for Payer: Three Rivers PPO |
$0.35
|
| Rate for Payer: TriWest Veterans Administration |
$0.27
|
| Rate for Payer: United Healthcare Commercial |
$0.40
|
| Rate for Payer: United Healthcare Medicare |
$0.27
|
| Rate for Payer: WINHealth Partners Commercial |
$0.45
|
| Rate for Payer: Wise Provider Network Commercial |
$0.44
|
|
|
DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID [568]
|
Facility
|
OP
|
$0.46
|
|
|
Service Code
|
NDC 0904727972
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$0.46 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.45
|
| Rate for Payer: Aetna of WY Medicare |
$0.30
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.44
|
| Rate for Payer: Altius Commercial |
$0.44
|
| Rate for Payer: Beech Street Commercial |
$0.45
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.38
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.45
|
| Rate for Payer: Cigna of WY Commercial |
$0.45
|
| Rate for Payer: Entrust Commercial |
$0.44
|
| Rate for Payer: First Choice Health Commercial |
$0.44
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.44
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.27
|
| Rate for Payer: HealthUtah PPO |
$0.46
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.45
|
| Rate for Payer: Multiplan Medicare/VA |
$0.25
|
| Rate for Payer: One Health Plan of WY PPO |
$0.45
|
| Rate for Payer: PacificSource Commercial |
$0.41
|
| Rate for Payer: PHCS PPO |
$0.45
|
| Rate for Payer: Three Rivers PPO |
$0.35
|
| Rate for Payer: TriWest Veterans Administration |
$0.27
|
| Rate for Payer: United Healthcare Commercial |
$0.40
|
| Rate for Payer: United Healthcare Medicare |
$0.27
|
| Rate for Payer: WINHealth Partners Commercial |
$0.45
|
| Rate for Payer: Wise Provider Network Commercial |
$0.44
|
|
|
DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID [568]
|
Facility
|
IP
|
$0.46
|
|
|
Service Code
|
NDC 0904727972
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$0.46 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.45
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.44
|
| Rate for Payer: Altius Commercial |
$0.44
|
| Rate for Payer: Beech Street Commercial |
$0.45
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.38
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.45
|
| Rate for Payer: Cigna of WY Commercial |
$0.45
|
| Rate for Payer: Entrust Commercial |
$0.44
|
| Rate for Payer: First Choice Health Commercial |
$0.44
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.44
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.30
|
| Rate for Payer: HealthUtah PPO |
$0.46
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.45
|
| Rate for Payer: Multiplan Medicare/VA |
$0.29
|
| Rate for Payer: One Health Plan of WY PPO |
$0.45
|
| Rate for Payer: PacificSource Commercial |
$0.41
|
| Rate for Payer: PHCS PPO |
$0.45
|
| Rate for Payer: Three Rivers PPO |
$0.35
|
| Rate for Payer: TriWest Veterans Administration |
$0.30
|
| Rate for Payer: United Healthcare Commercial |
$0.40
|
| Rate for Payer: United Healthcare Medicare |
$0.30
|
| Rate for Payer: WINHealth Partners Commercial |
$0.44
|
| Rate for Payer: Wise Provider Network Commercial |
$0.44
|
|
|
DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID [568]
|
Facility
|
OP
|
$0.09
|
|
|
Service Code
|
NDC 9999999568
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.09
|
| Rate for Payer: Aetna of WY Medicare |
$0.06
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.09
|
| Rate for Payer: Altius Commercial |
$0.09
|
| Rate for Payer: Beech Street Commercial |
$0.09
|
| 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 |
$0.09
|
| Rate for Payer: Cigna of WY Commercial |
$0.09
|
| Rate for Payer: Entrust Commercial |
$0.09
|
| Rate for Payer: First Choice Health Commercial |
$0.09
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.09
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.05
|
| Rate for Payer: HealthUtah PPO |
$0.09
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.09
|
| Rate for Payer: Multiplan Medicare/VA |
$0.05
|
| Rate for Payer: One Health Plan of WY PPO |
$0.09
|
| Rate for Payer: PacificSource Commercial |
$0.08
|
| Rate for Payer: PHCS PPO |
$0.09
|
| Rate for Payer: Three Rivers PPO |
$0.07
|
| Rate for Payer: TriWest Veterans Administration |
$0.05
|
| Rate for Payer: United Healthcare Commercial |
$0.08
|
| Rate for Payer: United Healthcare Medicare |
$0.05
|
| Rate for Payer: WINHealth Partners Commercial |
$0.09
|
| Rate for Payer: Wise Provider Network Commercial |
$0.09
|
|
|
DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID [568]
|
Facility
|
IP
|
$0.09
|
|
|
Service Code
|
NDC 9999999568
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.09
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.09
|
| Rate for Payer: Altius Commercial |
$0.09
|
| Rate for Payer: Beech Street Commercial |
$0.09
|
| 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 |
$0.09
|
| Rate for Payer: Cigna of WY Commercial |
$0.09
|
| Rate for Payer: Entrust Commercial |
$0.09
|
| Rate for Payer: First Choice Health Commercial |
$0.09
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.09
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.06
|
| Rate for Payer: HealthUtah PPO |
$0.09
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.09
|
| Rate for Payer: Multiplan Medicare/VA |
$0.06
|
| Rate for Payer: One Health Plan of WY PPO |
$0.09
|
| Rate for Payer: PacificSource Commercial |
$0.08
|
| Rate for Payer: PHCS PPO |
$0.09
|
| Rate for Payer: Three Rivers PPO |
$0.07
|
| Rate for Payer: TriWest Veterans Administration |
$0.06
|
| Rate for Payer: United Healthcare Commercial |
$0.08
|
| Rate for Payer: United Healthcare Medicare |
$0.06
|
| Rate for Payer: WINHealth Partners Commercial |
$0.09
|
| Rate for Payer: Wise Provider Network Commercial |
$0.09
|
|
|
DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID [568]
|
Facility
|
IP
|
$0.46
|
|
|
Service Code
|
NDC 0904727966
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$0.46 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.45
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.44
|
| Rate for Payer: Altius Commercial |
$0.44
|
| Rate for Payer: Beech Street Commercial |
$0.45
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.38
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.45
|
| Rate for Payer: Cigna of WY Commercial |
$0.45
|
| Rate for Payer: Entrust Commercial |
$0.44
|
| Rate for Payer: First Choice Health Commercial |
$0.44
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.44
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.30
|
| Rate for Payer: HealthUtah PPO |
$0.46
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.45
|
| Rate for Payer: Multiplan Medicare/VA |
$0.29
|
| Rate for Payer: One Health Plan of WY PPO |
$0.45
|
| Rate for Payer: PacificSource Commercial |
$0.41
|
| Rate for Payer: PHCS PPO |
$0.45
|
| Rate for Payer: Three Rivers PPO |
$0.35
|
| Rate for Payer: TriWest Veterans Administration |
$0.30
|
| Rate for Payer: United Healthcare Commercial |
$0.40
|
| Rate for Payer: United Healthcare Medicare |
$0.30
|
| Rate for Payer: WINHealth Partners Commercial |
$0.44
|
| Rate for Payer: Wise Provider Network Commercial |
$0.44
|
|
|
DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID [568]
|
Facility
|
IP
|
$0.09
|
|
|
Service Code
|
NDC 0121093516
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.09
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.09
|
| Rate for Payer: Altius Commercial |
$0.09
|
| Rate for Payer: Beech Street Commercial |
$0.09
|
| 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 |
$0.09
|
| Rate for Payer: Cigna of WY Commercial |
$0.09
|
| Rate for Payer: Entrust Commercial |
$0.09
|
| Rate for Payer: First Choice Health Commercial |
$0.09
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.09
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.06
|
| Rate for Payer: HealthUtah PPO |
$0.09
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.09
|
| Rate for Payer: Multiplan Medicare/VA |
$0.06
|
| Rate for Payer: One Health Plan of WY PPO |
$0.09
|
| Rate for Payer: PacificSource Commercial |
$0.08
|
| Rate for Payer: PHCS PPO |
$0.09
|
| Rate for Payer: Three Rivers PPO |
$0.07
|
| Rate for Payer: TriWest Veterans Administration |
$0.06
|
| Rate for Payer: United Healthcare Commercial |
$0.08
|
| Rate for Payer: United Healthcare Medicare |
$0.06
|
| Rate for Payer: WINHealth Partners Commercial |
$0.09
|
| Rate for Payer: Wise Provider Network Commercial |
$0.09
|
|
|
DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID [568]
|
Facility
|
OP
|
$0.74
|
|
|
Service Code
|
NDC 0121187000
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$0.74 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.73
|
| Rate for Payer: Aetna of WY Medicare |
$0.49
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.71
|
| Rate for Payer: Altius Commercial |
$0.71
|
| Rate for Payer: Beech Street Commercial |
$0.73
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.61
|
| Rate for Payer: Cash Price |
$0.52
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.72
|
| Rate for Payer: Cigna of WY Commercial |
$0.73
|
| Rate for Payer: Entrust Commercial |
$0.70
|
| Rate for Payer: First Choice Health Commercial |
$0.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.43
|
| Rate for Payer: HealthUtah PPO |
$0.74
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.72
|
| Rate for Payer: Multiplan Medicare/VA |
$0.41
|
| Rate for Payer: One Health Plan of WY PPO |
$0.73
|
| Rate for Payer: PacificSource Commercial |
$0.67
|
| Rate for Payer: PHCS PPO |
$0.73
|
| Rate for Payer: Three Rivers PPO |
$0.56
|
| Rate for Payer: TriWest Veterans Administration |
$0.43
|
| Rate for Payer: United Healthcare Commercial |
$0.64
|
| Rate for Payer: United Healthcare Medicare |
$0.43
|
| Rate for Payer: WINHealth Partners Commercial |
$0.73
|
| Rate for Payer: Wise Provider Network Commercial |
$0.70
|
|
|
DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID [568]
|
Facility
|
OP
|
$0.09
|
|
|
Service Code
|
NDC 0121093516
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.09
|
| Rate for Payer: Aetna of WY Medicare |
$0.06
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.09
|
| Rate for Payer: Altius Commercial |
$0.09
|
| Rate for Payer: Beech Street Commercial |
$0.09
|
| 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 |
$0.09
|
| Rate for Payer: Cigna of WY Commercial |
$0.09
|
| Rate for Payer: Entrust Commercial |
$0.09
|
| Rate for Payer: First Choice Health Commercial |
$0.09
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.09
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.05
|
| Rate for Payer: HealthUtah PPO |
$0.09
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.09
|
| Rate for Payer: Multiplan Medicare/VA |
$0.05
|
| Rate for Payer: One Health Plan of WY PPO |
$0.09
|
| Rate for Payer: PacificSource Commercial |
$0.08
|
| Rate for Payer: PHCS PPO |
$0.09
|
| Rate for Payer: Three Rivers PPO |
$0.07
|
| Rate for Payer: TriWest Veterans Administration |
$0.05
|
| Rate for Payer: United Healthcare Commercial |
$0.08
|
| Rate for Payer: United Healthcare Medicare |
$0.05
|
| Rate for Payer: WINHealth Partners Commercial |
$0.09
|
| Rate for Payer: Wise Provider Network Commercial |
$0.09
|
|
|
DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID [568]
|
Facility
|
IP
|
$0.74
|
|
|
Service Code
|
NDC 0121187000
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$0.74 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.73
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.71
|
| Rate for Payer: Altius Commercial |
$0.71
|
| Rate for Payer: Beech Street Commercial |
$0.73
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.61
|
| Rate for Payer: Cash Price |
$0.52
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.72
|
| Rate for Payer: Cigna of WY Commercial |
$0.73
|
| Rate for Payer: Entrust Commercial |
$0.70
|
| Rate for Payer: First Choice Health Commercial |
$0.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.49
|
| Rate for Payer: HealthUtah PPO |
$0.74
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.72
|
| Rate for Payer: Multiplan Medicare/VA |
$0.46
|
| Rate for Payer: One Health Plan of WY PPO |
$0.73
|
| Rate for Payer: PacificSource Commercial |
$0.67
|
| Rate for Payer: PHCS PPO |
$0.73
|
| Rate for Payer: Three Rivers PPO |
$0.56
|
| Rate for Payer: TriWest Veterans Administration |
$0.49
|
| Rate for Payer: United Healthcare Commercial |
$0.64
|
| Rate for Payer: United Healthcare Medicare |
$0.49
|
| Rate for Payer: WINHealth Partners Commercial |
$0.70
|
| Rate for Payer: Wise Provider Network Commercial |
$0.70
|
|
|
DOMICIL/REST HOME NEW PT VISIT HI SEVER 60 MIN
|
Professional
|
Both
|
$303.00
|
|
|
Service Code
|
HCPCS 99327
|
| Hospital Charge Code |
99327
|
| Min. Negotiated Rate |
$227.25 |
| Max. Negotiated Rate |
$303.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$296.94
|
| Rate for Payer: Beech Street Commercial |
$287.85
|
| Rate for Payer: Cash Price |
$212.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$293.91
|
| Rate for Payer: Cigna of WY Commercial |
$296.94
|
| Rate for Payer: First Choice Health Commercial |
$272.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$287.85
|
| Rate for Payer: HealthUtah PPO |
$303.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$293.91
|
| Rate for Payer: One Health Plan of WY PPO |
$296.94
|
| Rate for Payer: PacificSource Commercial |
$272.70
|
| Rate for Payer: PHCS PPO |
$287.85
|
| Rate for Payer: Three Rivers PPO |
$227.25
|
| Rate for Payer: United Healthcare Commercial |
$263.61
|
| Rate for Payer: WINHealth Partners Commercial |
$287.85
|
|
|
DOM/R-HOME E/M EST PT LW MOD SEVERITY 25 MINUTES
|
Professional
|
Both
|
$152.00
|
|
|
Service Code
|
HCPCS 99335
|
| Hospital Charge Code |
99335
|
| Min. Negotiated Rate |
$114.00 |
| Max. Negotiated Rate |
$152.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$148.96
|
| Rate for Payer: Beech Street Commercial |
$144.40
|
| Rate for Payer: Cash Price |
$106.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$147.44
|
| Rate for Payer: Cigna of WY Commercial |
$148.96
|
| Rate for Payer: First Choice Health Commercial |
$136.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$144.40
|
| Rate for Payer: HealthUtah PPO |
$152.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$147.44
|
| Rate for Payer: One Health Plan of WY PPO |
$148.96
|
| Rate for Payer: PacificSource Commercial |
$136.80
|
| Rate for Payer: PHCS PPO |
$144.40
|
| Rate for Payer: Three Rivers PPO |
$114.00
|
| Rate for Payer: United Healthcare Commercial |
$132.24
|
| Rate for Payer: WINHealth Partners Commercial |
$144.40
|
|
|
DONEPEZIL 10 MG TABLET [4459]
|
Facility
|
OP
|
$0.67
|
|
|
Service Code
|
NDC 4354727611
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$0.67 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.66
|
| Rate for Payer: Aetna of WY Medicare |
$0.44
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.64
|
| Rate for Payer: Altius Commercial |
$0.64
|
| Rate for Payer: Beech Street Commercial |
$0.66
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.55
|
| Rate for Payer: Cash Price |
$0.47
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.65
|
| Rate for Payer: Cigna of WY Commercial |
$0.66
|
| Rate for Payer: Entrust Commercial |
$0.64
|
| Rate for Payer: First Choice Health Commercial |
$0.64
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.64
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.39
|
| Rate for Payer: HealthUtah PPO |
$0.67
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.65
|
| Rate for Payer: Multiplan Medicare/VA |
$0.37
|
| Rate for Payer: One Health Plan of WY PPO |
$0.66
|
| Rate for Payer: PacificSource Commercial |
$0.60
|
| Rate for Payer: PHCS PPO |
$0.66
|
| Rate for Payer: Three Rivers PPO |
$0.50
|
| Rate for Payer: TriWest Veterans Administration |
$0.39
|
| Rate for Payer: United Healthcare Commercial |
$0.58
|
| Rate for Payer: United Healthcare Medicare |
$0.39
|
| Rate for Payer: WINHealth Partners Commercial |
$0.66
|
| Rate for Payer: Wise Provider Network Commercial |
$0.64
|
|
