|
CHOLECYSTECTOMY
|
Professional
|
Both
|
$4,736.00
|
|
|
Service Code
|
HCPCS 47600 AS
|
| Min. Negotiated Rate |
$863.85 |
| Max. Negotiated Rate |
$4,736.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4,641.28
|
| Rate for Payer: Beech Street Commercial |
$4,499.20
|
| Rate for Payer: Cash Price |
$3,315.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$4,593.92
|
| Rate for Payer: Cigna of WY Commercial |
$4,641.28
|
| Rate for Payer: First Choice Health Commercial |
$4,262.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,499.20
|
| Rate for Payer: HealthUtah PPO |
$4,736.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4,593.92
|
| Rate for Payer: One Health Plan of WY PPO |
$4,641.28
|
| Rate for Payer: PacificSource Commercial |
$4,262.40
|
| Rate for Payer: PHCS PPO |
$4,499.20
|
| Rate for Payer: Three Rivers PPO |
$3,552.00
|
| Rate for Payer: United Healthcare Commercial |
$4,499.20
|
| Rate for Payer: WINHealth Partners Commercial |
$4,025.60
|
|
|
CHOLECYSTECTOMY W/CHOLANGIOGRAPHY
|
Professional
|
Both
|
$9,102.00
|
|
|
Service Code
|
HCPCS 47605
|
| Min. Negotiated Rate |
$908.98 |
| Max. Negotiated Rate |
$9,102.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$8,919.96
|
| Rate for Payer: Aetna of WY Medicare |
$1,069.39
|
| Rate for Payer: Beech Street Commercial |
$8,646.90
|
| Rate for Payer: Cash Price |
$6,371.40
|
| Rate for Payer: Cash Price |
$6,371.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$8,828.94
|
| Rate for Payer: Cigna of WY Commercial |
$8,919.96
|
| Rate for Payer: First Choice Health Commercial |
$8,191.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$8,646.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,069.39
|
| Rate for Payer: HealthUtah PPO |
$9,102.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$8,828.94
|
| Rate for Payer: Multiplan Medicare/VA |
$908.98
|
| Rate for Payer: One Health Plan of WY PPO |
$8,919.96
|
| Rate for Payer: PacificSource Commercial |
$8,191.80
|
| Rate for Payer: PHCS PPO |
$8,646.90
|
| Rate for Payer: Three Rivers PPO |
$6,826.50
|
| Rate for Payer: TriWest Veterans Administration |
$1,069.39
|
| Rate for Payer: United Healthcare Commercial |
$8,646.90
|
| Rate for Payer: WINHealth Partners Commercial |
$7,736.70
|
|
|
CHOLECYSTECTOMY W/CHOLANGIOGRAPHY
|
Professional
|
Both
|
$9,102.00
|
|
|
Service Code
|
HCPCS 47605 80
|
| Min. Negotiated Rate |
$908.98 |
| Max. Negotiated Rate |
$9,102.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$8,919.96
|
| Rate for Payer: Beech Street Commercial |
$8,646.90
|
| Rate for Payer: Cash Price |
$6,371.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$8,828.94
|
| Rate for Payer: Cigna of WY Commercial |
$8,919.96
|
| Rate for Payer: First Choice Health Commercial |
$8,191.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$8,646.90
|
| Rate for Payer: HealthUtah PPO |
$9,102.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$8,828.94
|
| Rate for Payer: One Health Plan of WY PPO |
$8,919.96
|
| Rate for Payer: PacificSource Commercial |
$8,191.80
|
| Rate for Payer: PHCS PPO |
$8,646.90
|
| Rate for Payer: Three Rivers PPO |
$6,826.50
|
| Rate for Payer: United Healthcare Commercial |
$8,646.90
|
| Rate for Payer: WINHealth Partners Commercial |
$7,736.70
|
|
|
CHORIONIC GONADOTROPIN/1000U
|
Professional
|
Both
|
$32.00
|
|
|
Service Code
|
HCPCS J0725
|
| Min. Negotiated Rate |
$19.80 |
| Max. Negotiated Rate |
$32.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$31.36
|
| Rate for Payer: Aetna of WY Medicare |
$23.29
|
| Rate for Payer: Beech Street Commercial |
$30.40
|
| Rate for Payer: Cash Price |
$22.40
|
| Rate for Payer: Cash Price |
$22.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$31.04
|
| Rate for Payer: Cigna of WY Commercial |
$31.36
|
| Rate for Payer: First Choice Health Commercial |
$28.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$30.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$23.29
|
| Rate for Payer: HealthUtah PPO |
$32.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$31.04
|
| Rate for Payer: Multiplan Medicare/VA |
$19.80
|
| Rate for Payer: One Health Plan of WY PPO |
$31.36
|
| Rate for Payer: PacificSource Commercial |
$28.80
|
| Rate for Payer: PHCS PPO |
$30.40
|
| Rate for Payer: Three Rivers PPO |
$24.00
|
| Rate for Payer: TriWest Veterans Administration |
$23.29
|
| Rate for Payer: United Healthcare Commercial |
$30.40
|
| Rate for Payer: WINHealth Partners Commercial |
$30.40
|
|
|
CHROMOTUBATION OVIDUCT W/MATERIALS
|
Professional
|
Both
|
$1,888.00
|
|
|
Service Code
|
HCPCS 58350
|
| Min. Negotiated Rate |
$78.85 |
| Max. Negotiated Rate |
$1,888.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,850.24
|
| Rate for Payer: Aetna of WY Medicare |
$92.76
|
| Rate for Payer: Beech Street Commercial |
$1,793.60
|
| Rate for Payer: Cash Price |
$1,321.60
|
| Rate for Payer: Cash Price |
$1,321.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,831.36
|
| Rate for Payer: Cigna of WY Commercial |
$1,850.24
|
| Rate for Payer: First Choice Health Commercial |
$1,699.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,793.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$92.76
|
| Rate for Payer: HealthUtah PPO |
$1,888.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,831.36
|
| Rate for Payer: Multiplan Medicare/VA |
$78.85
|
| Rate for Payer: One Health Plan of WY PPO |
$1,850.24
|
| Rate for Payer: PacificSource Commercial |
$1,699.20
|
| Rate for Payer: PHCS PPO |
$1,793.60
|
| Rate for Payer: Three Rivers PPO |
$1,416.00
|
| Rate for Payer: TriWest Veterans Administration |
$92.76
|
| Rate for Payer: United Healthcare Commercial |
$1,793.60
|
| Rate for Payer: WINHealth Partners Commercial |
$1,604.80
|
|
|
CHRONIC CARE MGMT SVC PHYS 1ST 30 MIN CAL MONTH
|
Professional
|
Both
|
$347.00
|
|
|
Service Code
|
HCPCS 99491
|
| Min. Negotiated Rate |
$61.62 |
| Max. Negotiated Rate |
$347.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$340.06
|
| Rate for Payer: Aetna of WY Medicare |
$72.49
|
| Rate for Payer: Beech Street Commercial |
$329.65
|
| Rate for Payer: Cash Price |
$242.90
|
| Rate for Payer: Cash Price |
$242.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$336.59
|
| Rate for Payer: Cigna of WY Commercial |
$340.06
|
| Rate for Payer: First Choice Health Commercial |
$312.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$329.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$72.49
|
| Rate for Payer: HealthUtah PPO |
$347.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$336.59
|
| Rate for Payer: Multiplan Medicare/VA |
$61.62
|
| Rate for Payer: One Health Plan of WY PPO |
$340.06
|
| Rate for Payer: PacificSource Commercial |
$312.30
|
| Rate for Payer: PHCS PPO |
$329.65
|
| Rate for Payer: Three Rivers PPO |
$260.25
|
| Rate for Payer: TriWest Veterans Administration |
$72.49
|
| Rate for Payer: United Healthcare Commercial |
$329.65
|
| Rate for Payer: WINHealth Partners Commercial |
$329.65
|
|
|
CHRONIC CARE MGMT SVCS STAFF 1ST 20 MIN CAL MO
|
Professional
|
Both
|
$105.00
|
|
|
Service Code
|
HCPCS 99490
|
| Min. Negotiated Rate |
$40.96 |
| Max. Negotiated Rate |
$105.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$102.90
|
| Rate for Payer: Aetna of WY Medicare |
$48.19
|
| Rate for Payer: Beech Street Commercial |
$99.75
|
| Rate for Payer: Cash Price |
$73.50
|
| Rate for Payer: Cash Price |
$73.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$101.85
|
| Rate for Payer: Cigna of WY Commercial |
$102.90
|
| Rate for Payer: First Choice Health Commercial |
$94.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$99.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$48.19
|
| Rate for Payer: HealthUtah PPO |
$105.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$101.85
|
| Rate for Payer: Multiplan Medicare/VA |
$40.96
|
| Rate for Payer: One Health Plan of WY PPO |
$102.90
|
| Rate for Payer: PacificSource Commercial |
$94.50
|
| Rate for Payer: PHCS PPO |
$99.75
|
| Rate for Payer: Three Rivers PPO |
$78.75
|
| Rate for Payer: TriWest Veterans Administration |
$48.19
|
| Rate for Payer: United Healthcare Commercial |
$99.75
|
| Rate for Payer: WINHealth Partners Commercial |
$99.75
|
|
|
CHRONIC CARE MGMT SVC STAF EA ADDL 20 MIN CAL MO
|
Professional
|
Both
|
$152.00
|
|
|
Service Code
|
HCPCS 99439
|
| Min. Negotiated Rate |
$28.59 |
| Max. Negotiated Rate |
$152.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$148.96
|
| Rate for Payer: Aetna of WY Medicare |
$33.63
|
| Rate for Payer: Beech Street Commercial |
$144.40
|
| Rate for Payer: Cash Price |
$106.40
|
| 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: Government Employees Health Association (GEHA) Medicare |
$33.63
|
| Rate for Payer: HealthUtah PPO |
$152.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$147.44
|
| Rate for Payer: Multiplan Medicare/VA |
$28.59
|
| 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: TriWest Veterans Administration |
$33.63
|
| Rate for Payer: United Healthcare Commercial |
$144.40
|
| Rate for Payer: WINHealth Partners Commercial |
$144.40
|
|
|
CICA CARE SILICONE PAD 5"X6"
|
Facility
|
IP
|
$59.50
|
|
| Hospital Charge Code |
2000085
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$34.48 |
| Max. Negotiated Rate |
$59.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$58.31
|
| Rate for Payer: Aetna of WY Medicare |
$38.08
|
| Rate for Payer: Altius Commercial |
$57.12
|
| Rate for Payer: Beech Street Commercial |
$58.31
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$57.72
|
| Rate for Payer: Cash Price |
$41.65
|
| Rate for Payer: ChoiceCare Network Commercial |
$57.72
|
| Rate for Payer: Cigna of WY Commercial |
$58.31
|
| Rate for Payer: Entrust Commercial |
$56.52
|
| Rate for Payer: First Choice Health Commercial |
$56.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$56.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$36.30
|
| Rate for Payer: HealthUtah PPO |
$59.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$57.72
|
| Rate for Payer: Multiplan Medicare/VA |
$34.48
|
| Rate for Payer: One Health Plan of WY PPO |
$58.31
|
| Rate for Payer: PacificSource Commercial |
$53.55
|
| Rate for Payer: PHCS PPO |
$58.31
|
| Rate for Payer: Three Rivers PPO |
$44.62
|
| Rate for Payer: TriWest Veterans Administration |
$36.30
|
| Rate for Payer: United Healthcare Commercial |
$56.82
|
| Rate for Payer: United Healthcare Medicare |
$36.30
|
| Rate for Payer: WINHealth Partners Commercial |
$56.52
|
| Rate for Payer: Wise Provider Network Commercial |
$56.52
|
|
|
CICA CARE SILICONE PAD 5"X6"
|
Facility
|
OP
|
$59.50
|
|
| Hospital Charge Code |
2000085
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$32.22 |
| Max. Negotiated Rate |
$59.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$58.31
|
| Rate for Payer: Aetna of WY Medicare |
$39.27
|
| Rate for Payer: Altius Commercial |
$57.12
|
| Rate for Payer: Beech Street Commercial |
$58.31
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$57.72
|
| Rate for Payer: Cash Price |
$41.65
|
| Rate for Payer: ChoiceCare Network Commercial |
$57.72
|
| Rate for Payer: Cigna of WY Commercial |
$58.31
|
| Rate for Payer: Entrust Commercial |
$56.52
|
| Rate for Payer: First Choice Health Commercial |
$56.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$56.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$33.92
|
| Rate for Payer: HealthUtah PPO |
$59.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$57.72
|
| Rate for Payer: Multiplan Medicare/VA |
$32.22
|
| Rate for Payer: One Health Plan of WY PPO |
$58.31
|
| Rate for Payer: PacificSource Commercial |
$53.55
|
| Rate for Payer: PHCS PPO |
$58.31
|
| Rate for Payer: Three Rivers PPO |
$44.62
|
| Rate for Payer: TriWest Veterans Administration |
$33.92
|
| Rate for Payer: United Healthcare Commercial |
$56.82
|
| Rate for Payer: United Healthcare Medicare |
$33.92
|
| Rate for Payer: WINHealth Partners Commercial |
$58.31
|
| Rate for Payer: Wise Provider Network Commercial |
$56.52
|
|
|
CIDOFOVIR 75 MG/ML INTRAVENOUS SOLUTION [15924]
|
Facility
|
IP
|
$311.62
|
|
|
Service Code
|
HCPCS J0740
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$180.58 |
| Max. Negotiated Rate |
$311.62 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$305.39
|
| Rate for Payer: Aetna of WY Medicare |
$199.44
|
| Rate for Payer: Altius Commercial |
$299.16
|
| Rate for Payer: Beech Street Commercial |
$305.39
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$302.27
|
| Rate for Payer: Cash Price |
$218.13
|
| Rate for Payer: ChoiceCare Network Commercial |
$302.27
|
| Rate for Payer: Cigna of WY Commercial |
$305.39
|
| Rate for Payer: Entrust Commercial |
$296.04
|
| Rate for Payer: First Choice Health Commercial |
$296.04
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$296.04
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$190.09
|
| Rate for Payer: HealthUtah PPO |
$311.62
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$302.27
|
| Rate for Payer: Multiplan Medicare/VA |
$180.58
|
| Rate for Payer: One Health Plan of WY PPO |
$305.39
|
| Rate for Payer: PacificSource Commercial |
$280.46
|
| Rate for Payer: PHCS PPO |
$305.39
|
| Rate for Payer: Three Rivers PPO |
$233.72
|
| Rate for Payer: TriWest Veterans Administration |
$190.09
|
| Rate for Payer: United Healthcare Commercial |
$297.60
|
| Rate for Payer: United Healthcare Medicare |
$190.09
|
| Rate for Payer: WINHealth Partners Commercial |
$296.04
|
| Rate for Payer: Wise Provider Network Commercial |
$296.04
|
|
|
CIDOFOVIR 75 MG/ML INTRAVENOUS SOLUTION [15924]
|
Facility
|
OP
|
$311.62
|
|
|
Service Code
|
HCPCS J0740
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$168.74 |
| Max. Negotiated Rate |
$311.62 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$305.39
|
| Rate for Payer: Aetna of WY Medicare |
$205.67
|
| Rate for Payer: Altius Commercial |
$299.16
|
| Rate for Payer: Beech Street Commercial |
$305.39
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$302.27
|
| Rate for Payer: Cash Price |
$218.13
|
| Rate for Payer: ChoiceCare Network Commercial |
$302.27
|
| Rate for Payer: Cigna of WY Commercial |
$305.39
|
| Rate for Payer: Entrust Commercial |
$296.04
|
| Rate for Payer: First Choice Health Commercial |
$296.04
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$296.04
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$177.62
|
| Rate for Payer: HealthUtah PPO |
$311.62
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$302.27
|
| Rate for Payer: Multiplan Medicare/VA |
$168.74
|
| Rate for Payer: One Health Plan of WY PPO |
$305.39
|
| Rate for Payer: PacificSource Commercial |
$280.46
|
| Rate for Payer: PHCS PPO |
$305.39
|
| Rate for Payer: Three Rivers PPO |
$233.72
|
| Rate for Payer: TriWest Veterans Administration |
$177.62
|
| Rate for Payer: United Healthcare Commercial |
$297.60
|
| Rate for Payer: United Healthcare Medicare |
$177.62
|
| Rate for Payer: WINHealth Partners Commercial |
$305.39
|
| Rate for Payer: Wise Provider Network Commercial |
$296.04
|
|
|
CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION [29359]
|
Facility
|
IP
|
$74.78
|
|
|
Service Code
|
NDC 4359832675
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$43.34 |
| Max. Negotiated Rate |
$74.78 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$73.28
|
| Rate for Payer: Aetna of WY Medicare |
$47.86
|
| Rate for Payer: Altius Commercial |
$71.79
|
| Rate for Payer: Beech Street Commercial |
$73.28
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$72.54
|
| Rate for Payer: Cash Price |
$52.35
|
| Rate for Payer: ChoiceCare Network Commercial |
$72.54
|
| Rate for Payer: Cigna of WY Commercial |
$73.28
|
| Rate for Payer: Entrust Commercial |
$71.04
|
| Rate for Payer: First Choice Health Commercial |
$71.04
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$71.04
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$45.62
|
| Rate for Payer: HealthUtah PPO |
$74.78
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$72.54
|
| Rate for Payer: Multiplan Medicare/VA |
$43.34
|
| Rate for Payer: One Health Plan of WY PPO |
$73.28
|
| Rate for Payer: PacificSource Commercial |
$67.30
|
| Rate for Payer: PHCS PPO |
$73.28
|
| Rate for Payer: Three Rivers PPO |
$56.08
|
| Rate for Payer: TriWest Veterans Administration |
$45.62
|
| Rate for Payer: United Healthcare Commercial |
$71.41
|
| Rate for Payer: United Healthcare Medicare |
$45.62
|
| Rate for Payer: WINHealth Partners Commercial |
$71.04
|
| Rate for Payer: Wise Provider Network Commercial |
$71.04
|
|
|
CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION [29359]
|
Facility
|
IP
|
$61.67
|
|
|
Service Code
|
NDC 0781618667
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.74 |
| Max. Negotiated Rate |
$61.67 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$60.44
|
| Rate for Payer: Aetna of WY Medicare |
$39.47
|
| Rate for Payer: Altius Commercial |
$59.20
|
| Rate for Payer: Beech Street Commercial |
$60.44
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$59.82
|
| Rate for Payer: Cash Price |
$43.17
|
| Rate for Payer: ChoiceCare Network Commercial |
$59.82
|
| Rate for Payer: Cigna of WY Commercial |
$60.44
|
| Rate for Payer: Entrust Commercial |
$58.59
|
| Rate for Payer: First Choice Health Commercial |
$58.59
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$58.59
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$37.62
|
| Rate for Payer: HealthUtah PPO |
$61.67
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$59.82
|
| Rate for Payer: Multiplan Medicare/VA |
$35.74
|
| Rate for Payer: One Health Plan of WY PPO |
$60.44
|
| Rate for Payer: PacificSource Commercial |
$55.50
|
| Rate for Payer: PHCS PPO |
$60.44
|
| Rate for Payer: Three Rivers PPO |
$46.25
|
| Rate for Payer: TriWest Veterans Administration |
$37.62
|
| Rate for Payer: United Healthcare Commercial |
$58.89
|
| Rate for Payer: United Healthcare Medicare |
$37.62
|
| Rate for Payer: WINHealth Partners Commercial |
$58.59
|
| Rate for Payer: Wise Provider Network Commercial |
$58.59
|
|
|
CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION [29359]
|
Facility
|
OP
|
$74.78
|
|
|
Service Code
|
NDC 4359832675
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$40.49 |
| Max. Negotiated Rate |
$74.78 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$73.28
|
| Rate for Payer: Aetna of WY Medicare |
$49.35
|
| Rate for Payer: Altius Commercial |
$71.79
|
| Rate for Payer: Beech Street Commercial |
$73.28
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$72.54
|
| Rate for Payer: Cash Price |
$52.35
|
| Rate for Payer: ChoiceCare Network Commercial |
$72.54
|
| Rate for Payer: Cigna of WY Commercial |
$73.28
|
| Rate for Payer: Entrust Commercial |
$71.04
|
| Rate for Payer: First Choice Health Commercial |
$71.04
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$71.04
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$42.62
|
| Rate for Payer: HealthUtah PPO |
$74.78
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$72.54
|
| Rate for Payer: Multiplan Medicare/VA |
$40.49
|
| Rate for Payer: One Health Plan of WY PPO |
$73.28
|
| Rate for Payer: PacificSource Commercial |
$67.30
|
| Rate for Payer: PHCS PPO |
$73.28
|
| Rate for Payer: Three Rivers PPO |
$56.08
|
| Rate for Payer: TriWest Veterans Administration |
$42.62
|
| Rate for Payer: United Healthcare Commercial |
$71.41
|
| Rate for Payer: United Healthcare Medicare |
$42.62
|
| Rate for Payer: WINHealth Partners Commercial |
$73.28
|
| Rate for Payer: Wise Provider Network Commercial |
$71.04
|
|
|
CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION [29359]
|
Facility
|
IP
|
$74.78
|
|
|
Service Code
|
NDC 6275642790
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$43.34 |
| Max. Negotiated Rate |
$74.78 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$73.28
|
| Rate for Payer: Aetna of WY Medicare |
$47.86
|
| Rate for Payer: Altius Commercial |
$71.79
|
| Rate for Payer: Beech Street Commercial |
$73.28
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$72.54
|
| Rate for Payer: Cash Price |
$52.35
|
| Rate for Payer: ChoiceCare Network Commercial |
$72.54
|
| Rate for Payer: Cigna of WY Commercial |
$73.28
|
| Rate for Payer: Entrust Commercial |
$71.04
|
| Rate for Payer: First Choice Health Commercial |
$71.04
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$71.04
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$45.62
|
| Rate for Payer: HealthUtah PPO |
$74.78
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$72.54
|
| Rate for Payer: Multiplan Medicare/VA |
$43.34
|
| Rate for Payer: One Health Plan of WY PPO |
$73.28
|
| Rate for Payer: PacificSource Commercial |
$67.30
|
| Rate for Payer: PHCS PPO |
$73.28
|
| Rate for Payer: Three Rivers PPO |
$56.08
|
| Rate for Payer: TriWest Veterans Administration |
$45.62
|
| Rate for Payer: United Healthcare Commercial |
$71.41
|
| Rate for Payer: United Healthcare Medicare |
$45.62
|
| Rate for Payer: WINHealth Partners Commercial |
$71.04
|
| Rate for Payer: Wise Provider Network Commercial |
$71.04
|
|
|
CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION [29359]
|
Facility
|
OP
|
$61.67
|
|
|
Service Code
|
NDC 0781618667
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$33.39 |
| Max. Negotiated Rate |
$61.67 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$60.44
|
| Rate for Payer: Aetna of WY Medicare |
$40.70
|
| Rate for Payer: Altius Commercial |
$59.20
|
| Rate for Payer: Beech Street Commercial |
$60.44
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$59.82
|
| Rate for Payer: Cash Price |
$43.17
|
| Rate for Payer: ChoiceCare Network Commercial |
$59.82
|
| Rate for Payer: Cigna of WY Commercial |
$60.44
|
| Rate for Payer: Entrust Commercial |
$58.59
|
| Rate for Payer: First Choice Health Commercial |
$58.59
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$58.59
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$35.15
|
| Rate for Payer: HealthUtah PPO |
$61.67
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$59.82
|
| Rate for Payer: Multiplan Medicare/VA |
$33.39
|
| Rate for Payer: One Health Plan of WY PPO |
$60.44
|
| Rate for Payer: PacificSource Commercial |
$55.50
|
| Rate for Payer: PHCS PPO |
$60.44
|
| Rate for Payer: Three Rivers PPO |
$46.25
|
| Rate for Payer: TriWest Veterans Administration |
$35.15
|
| Rate for Payer: United Healthcare Commercial |
$58.89
|
| Rate for Payer: United Healthcare Medicare |
$35.15
|
| Rate for Payer: WINHealth Partners Commercial |
$60.44
|
| Rate for Payer: Wise Provider Network Commercial |
$58.59
|
|
|
CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION [29359]
|
Facility
|
OP
|
$74.78
|
|
|
Service Code
|
NDC 6275642790
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$40.49 |
| Max. Negotiated Rate |
$74.78 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$73.28
|
| Rate for Payer: Aetna of WY Medicare |
$49.35
|
| Rate for Payer: Altius Commercial |
$71.79
|
| Rate for Payer: Beech Street Commercial |
$73.28
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$72.54
|
| Rate for Payer: Cash Price |
$52.35
|
| Rate for Payer: ChoiceCare Network Commercial |
$72.54
|
| Rate for Payer: Cigna of WY Commercial |
$73.28
|
| Rate for Payer: Entrust Commercial |
$71.04
|
| Rate for Payer: First Choice Health Commercial |
$71.04
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$71.04
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$42.62
|
| Rate for Payer: HealthUtah PPO |
$74.78
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$72.54
|
| Rate for Payer: Multiplan Medicare/VA |
$40.49
|
| Rate for Payer: One Health Plan of WY PPO |
$73.28
|
| Rate for Payer: PacificSource Commercial |
$67.30
|
| Rate for Payer: PHCS PPO |
$73.28
|
| Rate for Payer: Three Rivers PPO |
$56.08
|
| Rate for Payer: TriWest Veterans Administration |
$42.62
|
| Rate for Payer: United Healthcare Commercial |
$71.41
|
| Rate for Payer: United Healthcare Medicare |
$42.62
|
| Rate for Payer: WINHealth Partners Commercial |
$73.28
|
| Rate for Payer: Wise Provider Network Commercial |
$71.04
|
|
|
CIPROFLOXACIN 0.3 % EYE DROPS [11373]
|
Facility
|
OP
|
$25.50
|
|
|
Service Code
|
NDC 6131465605
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.81 |
| Max. Negotiated Rate |
$25.50 |
| Rate for Payer: United Healthcare Commercial |
$24.35
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$24.99
|
| Rate for Payer: Aetna of WY Medicare |
$16.83
|
| Rate for Payer: Altius Commercial |
$24.48
|
| Rate for Payer: Beech Street Commercial |
$24.99
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$24.74
|
| Rate for Payer: Cash Price |
$17.85
|
| Rate for Payer: ChoiceCare Network Commercial |
$24.74
|
| Rate for Payer: Cigna of WY Commercial |
$24.99
|
| Rate for Payer: Entrust Commercial |
$24.22
|
| Rate for Payer: First Choice Health Commercial |
$24.22
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$24.22
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$14.54
|
| Rate for Payer: HealthUtah PPO |
$25.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.74
|
| Rate for Payer: Multiplan Medicare/VA |
$13.81
|
| Rate for Payer: One Health Plan of WY PPO |
$24.99
|
| Rate for Payer: PacificSource Commercial |
$22.95
|
| Rate for Payer: PHCS PPO |
$24.99
|
| Rate for Payer: Three Rivers PPO |
$19.12
|
| Rate for Payer: TriWest Veterans Administration |
$14.54
|
| Rate for Payer: United Healthcare Medicare |
$14.54
|
| Rate for Payer: WINHealth Partners Commercial |
$24.99
|
| Rate for Payer: Wise Provider Network Commercial |
$24.22
|
|
|
CIPROFLOXACIN 0.3 % EYE DROPS [11373]
|
Facility
|
IP
|
$25.50
|
|
|
Service Code
|
NDC 6131465605
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.78 |
| Max. Negotiated Rate |
$25.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$24.99
|
| Rate for Payer: Aetna of WY Medicare |
$16.32
|
| Rate for Payer: Altius Commercial |
$24.48
|
| Rate for Payer: Beech Street Commercial |
$24.99
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$24.74
|
| Rate for Payer: Cash Price |
$17.85
|
| Rate for Payer: ChoiceCare Network Commercial |
$24.74
|
| Rate for Payer: Cigna of WY Commercial |
$24.99
|
| Rate for Payer: Entrust Commercial |
$24.22
|
| Rate for Payer: First Choice Health Commercial |
$24.22
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$24.22
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$15.56
|
| Rate for Payer: HealthUtah PPO |
$25.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.74
|
| Rate for Payer: Multiplan Medicare/VA |
$14.78
|
| Rate for Payer: One Health Plan of WY PPO |
$24.99
|
| Rate for Payer: PacificSource Commercial |
$22.95
|
| Rate for Payer: PHCS PPO |
$24.99
|
| Rate for Payer: Three Rivers PPO |
$19.12
|
| Rate for Payer: TriWest Veterans Administration |
$15.56
|
| Rate for Payer: United Healthcare Commercial |
$24.35
|
| Rate for Payer: United Healthcare Medicare |
$15.56
|
| Rate for Payer: WINHealth Partners Commercial |
$24.22
|
| Rate for Payer: Wise Provider Network Commercial |
$24.22
|
|
|
CIPROFLOXACIN 0.3 % EYE DROPS [11373]
|
Facility
|
IP
|
$30.75
|
|
|
Service Code
|
NDC 6131465625
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.82 |
| Max. Negotiated Rate |
$30.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$30.14
|
| Rate for Payer: Aetna of WY Medicare |
$19.68
|
| Rate for Payer: Altius Commercial |
$29.52
|
| Rate for Payer: Beech Street Commercial |
$30.14
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$29.83
|
| Rate for Payer: Cash Price |
$21.52
|
| Rate for Payer: ChoiceCare Network Commercial |
$29.83
|
| Rate for Payer: Cigna of WY Commercial |
$30.14
|
| Rate for Payer: Entrust Commercial |
$29.21
|
| Rate for Payer: First Choice Health Commercial |
$29.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$29.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$18.76
|
| Rate for Payer: HealthUtah PPO |
$30.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$29.83
|
| Rate for Payer: Multiplan Medicare/VA |
$17.82
|
| Rate for Payer: One Health Plan of WY PPO |
$30.14
|
| Rate for Payer: PacificSource Commercial |
$27.68
|
| Rate for Payer: PHCS PPO |
$30.14
|
| Rate for Payer: Three Rivers PPO |
$23.06
|
| Rate for Payer: TriWest Veterans Administration |
$18.76
|
| Rate for Payer: United Healthcare Commercial |
$29.37
|
| Rate for Payer: United Healthcare Medicare |
$18.76
|
| Rate for Payer: WINHealth Partners Commercial |
$29.21
|
| Rate for Payer: Wise Provider Network Commercial |
$29.21
|
|
|
CIPROFLOXACIN 0.3 % EYE DROPS [11373]
|
Facility
|
OP
|
$30.75
|
|
|
Service Code
|
NDC 6131465625
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.65 |
| Max. Negotiated Rate |
$30.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$30.14
|
| Rate for Payer: Aetna of WY Medicare |
$20.30
|
| Rate for Payer: Altius Commercial |
$29.52
|
| Rate for Payer: Beech Street Commercial |
$30.14
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$29.83
|
| Rate for Payer: Cash Price |
$21.52
|
| Rate for Payer: ChoiceCare Network Commercial |
$29.83
|
| Rate for Payer: Cigna of WY Commercial |
$30.14
|
| Rate for Payer: Entrust Commercial |
$29.21
|
| Rate for Payer: First Choice Health Commercial |
$29.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$29.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$17.53
|
| Rate for Payer: HealthUtah PPO |
$30.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$29.83
|
| Rate for Payer: Multiplan Medicare/VA |
$16.65
|
| Rate for Payer: One Health Plan of WY PPO |
$30.14
|
| Rate for Payer: PacificSource Commercial |
$27.68
|
| Rate for Payer: PHCS PPO |
$30.14
|
| Rate for Payer: Three Rivers PPO |
$23.06
|
| Rate for Payer: TriWest Veterans Administration |
$17.53
|
| Rate for Payer: United Healthcare Commercial |
$29.37
|
| Rate for Payer: United Healthcare Medicare |
$17.53
|
| Rate for Payer: WINHealth Partners Commercial |
$30.14
|
| Rate for Payer: Wise Provider Network Commercial |
$29.21
|
|
|
CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [5086]
|
Facility
|
OP
|
$15.07
|
|
|
Service Code
|
HCPCS J0744
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.16 |
| Max. Negotiated Rate |
$15.07 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.77
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.75
|
| Rate for Payer: Aetna of WY Medicare |
$9.95
|
| Rate for Payer: Aetna of WY Medicare |
$9.93
|
| Rate for Payer: Altius Commercial |
$14.47
|
| Rate for Payer: Altius Commercial |
$14.45
|
| Rate for Payer: Beech Street Commercial |
$14.77
|
| Rate for Payer: Beech Street Commercial |
$14.75
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.62
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.60
|
| Rate for Payer: Cash Price |
$10.55
|
| Rate for Payer: Cash Price |
$10.53
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.62
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.60
|
| Rate for Payer: Cigna of WY Commercial |
$14.77
|
| Rate for Payer: Cigna of WY Commercial |
$14.75
|
| Rate for Payer: Entrust Commercial |
$14.32
|
| Rate for Payer: Entrust Commercial |
$14.30
|
| Rate for Payer: First Choice Health Commercial |
$14.30
|
| Rate for Payer: First Choice Health Commercial |
$14.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.59
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.58
|
| Rate for Payer: HealthUtah PPO |
$15.05
|
| Rate for Payer: HealthUtah PPO |
$15.07
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.62
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.60
|
| Rate for Payer: Multiplan Medicare/VA |
$8.16
|
| Rate for Payer: Multiplan Medicare/VA |
$8.15
|
| Rate for Payer: One Health Plan of WY PPO |
$14.75
|
| Rate for Payer: One Health Plan of WY PPO |
$14.77
|
| Rate for Payer: PacificSource Commercial |
$13.54
|
| Rate for Payer: PacificSource Commercial |
$13.56
|
| Rate for Payer: PHCS PPO |
$14.77
|
| Rate for Payer: PHCS PPO |
$14.75
|
| Rate for Payer: Three Rivers PPO |
$11.29
|
| Rate for Payer: Three Rivers PPO |
$11.30
|
| Rate for Payer: TriWest Veterans Administration |
$8.58
|
| Rate for Payer: TriWest Veterans Administration |
$8.59
|
| Rate for Payer: United Healthcare Commercial |
$14.39
|
| Rate for Payer: United Healthcare Commercial |
$14.37
|
| Rate for Payer: United Healthcare Medicare |
$8.59
|
| Rate for Payer: United Healthcare Medicare |
$8.58
|
| Rate for Payer: WINHealth Partners Commercial |
$14.75
|
| Rate for Payer: WINHealth Partners Commercial |
$14.77
|
| Rate for Payer: Wise Provider Network Commercial |
$14.32
|
| Rate for Payer: Wise Provider Network Commercial |
$14.30
|
|
|
CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [5086]
|
Facility
|
IP
|
$15.05
|
|
|
Service Code
|
HCPCS J0744
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.72 |
| Max. Negotiated Rate |
$15.05 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.75
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.77
|
| Rate for Payer: Aetna of WY Medicare |
$9.64
|
| Rate for Payer: Aetna of WY Medicare |
$9.63
|
| Rate for Payer: Altius Commercial |
$14.45
|
| Rate for Payer: Altius Commercial |
$14.47
|
| Rate for Payer: Beech Street Commercial |
$14.77
|
| Rate for Payer: Beech Street Commercial |
$14.75
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.62
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.60
|
| Rate for Payer: Cash Price |
$10.55
|
| Rate for Payer: Cash Price |
$10.53
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.62
|
| Rate for Payer: Cigna of WY Commercial |
$14.77
|
| Rate for Payer: Cigna of WY Commercial |
$14.75
|
| Rate for Payer: Entrust Commercial |
$14.30
|
| Rate for Payer: Entrust Commercial |
$14.32
|
| Rate for Payer: First Choice Health Commercial |
$14.32
|
| Rate for Payer: First Choice Health Commercial |
$14.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.19
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.18
|
| Rate for Payer: HealthUtah PPO |
$15.07
|
| Rate for Payer: HealthUtah PPO |
$15.05
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.62
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.60
|
| Rate for Payer: Multiplan Medicare/VA |
$8.73
|
| Rate for Payer: Multiplan Medicare/VA |
$8.72
|
| Rate for Payer: One Health Plan of WY PPO |
$14.75
|
| Rate for Payer: One Health Plan of WY PPO |
$14.77
|
| Rate for Payer: PacificSource Commercial |
$13.56
|
| Rate for Payer: PacificSource Commercial |
$13.54
|
| Rate for Payer: PHCS PPO |
$14.75
|
| Rate for Payer: PHCS PPO |
$14.77
|
| Rate for Payer: Three Rivers PPO |
$11.30
|
| Rate for Payer: Three Rivers PPO |
$11.29
|
| Rate for Payer: TriWest Veterans Administration |
$9.19
|
| Rate for Payer: TriWest Veterans Administration |
$9.18
|
| Rate for Payer: United Healthcare Commercial |
$14.37
|
| Rate for Payer: United Healthcare Commercial |
$14.39
|
| Rate for Payer: United Healthcare Medicare |
$9.19
|
| Rate for Payer: United Healthcare Medicare |
$9.18
|
| Rate for Payer: WINHealth Partners Commercial |
$14.30
|
| Rate for Payer: WINHealth Partners Commercial |
$14.32
|
| Rate for Payer: Wise Provider Network Commercial |
$14.32
|
| Rate for Payer: Wise Provider Network Commercial |
$14.30
|
|
|
CIPROFLOXACIN 500 MG TABLET [7555]
|
Facility
|
IP
|
$15.84
|
|
|
Service Code
|
NDC 0143992801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.18 |
| Max. Negotiated Rate |
$15.84 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.52
|
| Rate for Payer: Aetna of WY Medicare |
$10.14
|
| Rate for Payer: Altius Commercial |
$15.21
|
| Rate for Payer: Beech Street Commercial |
$15.52
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.36
|
| Rate for Payer: Cash Price |
$11.09
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.36
|
| Rate for Payer: Cigna of WY Commercial |
$15.52
|
| Rate for Payer: Entrust Commercial |
$15.05
|
| Rate for Payer: First Choice Health Commercial |
$15.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.66
|
| Rate for Payer: HealthUtah PPO |
$15.84
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.36
|
| Rate for Payer: Multiplan Medicare/VA |
$9.18
|
| Rate for Payer: One Health Plan of WY PPO |
$15.52
|
| Rate for Payer: PacificSource Commercial |
$14.26
|
| Rate for Payer: PHCS PPO |
$15.52
|
| Rate for Payer: Three Rivers PPO |
$11.88
|
| Rate for Payer: TriWest Veterans Administration |
$9.66
|
| Rate for Payer: United Healthcare Commercial |
$15.13
|
| Rate for Payer: United Healthcare Medicare |
$9.66
|
| Rate for Payer: WINHealth Partners Commercial |
$15.05
|
| Rate for Payer: Wise Provider Network Commercial |
$15.05
|
|
