|
DONEPEZIL 10 MG TABLET [4459]
|
Facility
|
OP
|
$0.54
|
|
|
Service Code
|
NDC 6068730311
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.53
|
| Rate for Payer: Aetna of WY Medicare |
$0.36
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.52
|
| Rate for Payer: Altius Commercial |
$0.52
|
| Rate for Payer: Beech Street Commercial |
$0.53
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.44
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.52
|
| Rate for Payer: Cigna of WY Commercial |
$0.53
|
| Rate for Payer: Entrust Commercial |
$0.51
|
| Rate for Payer: First Choice Health Commercial |
$0.51
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.51
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.31
|
| Rate for Payer: HealthUtah PPO |
$0.54
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.52
|
| Rate for Payer: Multiplan Medicare/VA |
$0.30
|
| Rate for Payer: One Health Plan of WY PPO |
$0.53
|
| Rate for Payer: PacificSource Commercial |
$0.49
|
| Rate for Payer: PHCS PPO |
$0.53
|
| Rate for Payer: Three Rivers PPO |
$0.41
|
| Rate for Payer: TriWest Veterans Administration |
$0.31
|
| Rate for Payer: United Healthcare Commercial |
$0.47
|
| Rate for Payer: United Healthcare Medicare |
$0.31
|
| Rate for Payer: WINHealth Partners Commercial |
$0.53
|
| Rate for Payer: Wise Provider Network Commercial |
$0.51
|
|
|
DONEPEZIL 10 MG TABLET [4459]
|
Facility
|
IP
|
$0.54
|
|
|
Service Code
|
NDC 6068730301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.53
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.52
|
| Rate for Payer: Altius Commercial |
$0.52
|
| Rate for Payer: Beech Street Commercial |
$0.53
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.44
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.52
|
| Rate for Payer: Cigna of WY Commercial |
$0.53
|
| Rate for Payer: Entrust Commercial |
$0.51
|
| Rate for Payer: First Choice Health Commercial |
$0.51
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.51
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.36
|
| Rate for Payer: HealthUtah PPO |
$0.54
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.52
|
| Rate for Payer: Multiplan Medicare/VA |
$0.34
|
| Rate for Payer: One Health Plan of WY PPO |
$0.53
|
| Rate for Payer: PacificSource Commercial |
$0.49
|
| Rate for Payer: PHCS PPO |
$0.53
|
| Rate for Payer: Three Rivers PPO |
$0.41
|
| Rate for Payer: TriWest Veterans Administration |
$0.36
|
| Rate for Payer: United Healthcare Commercial |
$0.47
|
| Rate for Payer: United Healthcare Medicare |
$0.36
|
| Rate for Payer: WINHealth Partners Commercial |
$0.51
|
| Rate for Payer: Wise Provider Network Commercial |
$0.51
|
|
|
DONEPEZIL 10 MG TABLET [4459]
|
Facility
|
IP
|
$0.67
|
|
|
Service Code
|
NDC 4354727611
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$0.67 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.66
|
| 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 |
$0.44
|
| Rate for Payer: HealthUtah PPO |
$0.67
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.65
|
| Rate for Payer: Multiplan Medicare/VA |
$0.42
|
| 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 |
$0.44
|
| Rate for Payer: United Healthcare Commercial |
$0.58
|
| Rate for Payer: United Healthcare Medicare |
$0.44
|
| Rate for Payer: WINHealth Partners Commercial |
$0.64
|
| Rate for Payer: Wise Provider Network Commercial |
$0.64
|
|
|
DONEPEZIL 10 MG TABLET [4459]
|
Facility
|
IP
|
$0.54
|
|
|
Service Code
|
NDC 6068730311
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.53
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.52
|
| Rate for Payer: Altius Commercial |
$0.52
|
| Rate for Payer: Beech Street Commercial |
$0.53
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.44
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.52
|
| Rate for Payer: Cigna of WY Commercial |
$0.53
|
| Rate for Payer: Entrust Commercial |
$0.51
|
| Rate for Payer: First Choice Health Commercial |
$0.51
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.51
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.36
|
| Rate for Payer: HealthUtah PPO |
$0.54
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.52
|
| Rate for Payer: Multiplan Medicare/VA |
$0.34
|
| Rate for Payer: One Health Plan of WY PPO |
$0.53
|
| Rate for Payer: PacificSource Commercial |
$0.49
|
| Rate for Payer: PHCS PPO |
$0.53
|
| Rate for Payer: Three Rivers PPO |
$0.41
|
| Rate for Payer: TriWest Veterans Administration |
$0.36
|
| Rate for Payer: United Healthcare Commercial |
$0.47
|
| Rate for Payer: United Healthcare Medicare |
$0.36
|
| Rate for Payer: WINHealth Partners Commercial |
$0.51
|
| Rate for Payer: Wise Provider Network Commercial |
$0.51
|
|
|
DONEPEZIL 10 MG TABLET [4459]
|
Facility
|
OP
|
$0.54
|
|
|
Service Code
|
NDC 6068730301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.53
|
| Rate for Payer: Aetna of WY Medicare |
$0.36
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.52
|
| Rate for Payer: Altius Commercial |
$0.52
|
| Rate for Payer: Beech Street Commercial |
$0.53
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.44
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.52
|
| Rate for Payer: Cigna of WY Commercial |
$0.53
|
| Rate for Payer: Entrust Commercial |
$0.51
|
| Rate for Payer: First Choice Health Commercial |
$0.51
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.51
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.31
|
| Rate for Payer: HealthUtah PPO |
$0.54
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.52
|
| Rate for Payer: Multiplan Medicare/VA |
$0.30
|
| Rate for Payer: One Health Plan of WY PPO |
$0.53
|
| Rate for Payer: PacificSource Commercial |
$0.49
|
| Rate for Payer: PHCS PPO |
$0.53
|
| Rate for Payer: Three Rivers PPO |
$0.41
|
| Rate for Payer: TriWest Veterans Administration |
$0.31
|
| Rate for Payer: United Healthcare Commercial |
$0.47
|
| Rate for Payer: United Healthcare Medicare |
$0.31
|
| Rate for Payer: WINHealth Partners Commercial |
$0.53
|
| Rate for Payer: Wise Provider Network Commercial |
$0.51
|
|
|
DONEPEZIL 5 MG TABLET [1973]
|
Facility
|
IP
|
$0.54
|
|
|
Service Code
|
NDC 0904647761
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.53
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.52
|
| Rate for Payer: Altius Commercial |
$0.52
|
| Rate for Payer: Beech Street Commercial |
$0.53
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.44
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.52
|
| Rate for Payer: Cigna of WY Commercial |
$0.53
|
| Rate for Payer: Entrust Commercial |
$0.51
|
| Rate for Payer: First Choice Health Commercial |
$0.51
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.51
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.36
|
| Rate for Payer: HealthUtah PPO |
$0.54
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.52
|
| Rate for Payer: Multiplan Medicare/VA |
$0.34
|
| Rate for Payer: One Health Plan of WY PPO |
$0.53
|
| Rate for Payer: PacificSource Commercial |
$0.49
|
| Rate for Payer: PHCS PPO |
$0.53
|
| Rate for Payer: Three Rivers PPO |
$0.41
|
| Rate for Payer: TriWest Veterans Administration |
$0.36
|
| Rate for Payer: United Healthcare Commercial |
$0.47
|
| Rate for Payer: United Healthcare Medicare |
$0.36
|
| Rate for Payer: WINHealth Partners Commercial |
$0.51
|
| Rate for Payer: Wise Provider Network Commercial |
$0.51
|
|
|
DONEPEZIL 5 MG TABLET [1973]
|
Facility
|
OP
|
$0.54
|
|
|
Service Code
|
NDC 0904647761
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$0.54 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.53
|
| Rate for Payer: Aetna of WY Medicare |
$0.36
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.52
|
| Rate for Payer: Altius Commercial |
$0.52
|
| Rate for Payer: Beech Street Commercial |
$0.53
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.44
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.52
|
| Rate for Payer: Cigna of WY Commercial |
$0.53
|
| Rate for Payer: Entrust Commercial |
$0.51
|
| Rate for Payer: First Choice Health Commercial |
$0.51
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.51
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.31
|
| Rate for Payer: HealthUtah PPO |
$0.54
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.52
|
| Rate for Payer: Multiplan Medicare/VA |
$0.30
|
| Rate for Payer: One Health Plan of WY PPO |
$0.53
|
| Rate for Payer: PacificSource Commercial |
$0.49
|
| Rate for Payer: PHCS PPO |
$0.53
|
| Rate for Payer: Three Rivers PPO |
$0.41
|
| Rate for Payer: TriWest Veterans Administration |
$0.31
|
| Rate for Payer: United Healthcare Commercial |
$0.47
|
| Rate for Payer: United Healthcare Medicare |
$0.31
|
| Rate for Payer: WINHealth Partners Commercial |
$0.53
|
| Rate for Payer: Wise Provider Network Commercial |
$0.51
|
|
|
DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN [54840]
|
Facility
|
OP
|
$15.25
|
|
|
Service Code
|
HCPCS J1265
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.40 |
| Max. Negotiated Rate |
$15.25 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.94
|
| Rate for Payer: Aetna of WY Medicare |
$10.06
|
| Rate for Payer: Altius Auto/Workers Compensation |
$14.64
|
| Rate for Payer: Altius Commercial |
$14.64
|
| Rate for Payer: Beech Street Commercial |
$14.94
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.52
|
| Rate for Payer: Cash Price |
$10.68
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.79
|
| Rate for Payer: Cigna of WY Commercial |
$14.94
|
| Rate for Payer: Entrust Commercial |
$14.49
|
| Rate for Payer: First Choice Health Commercial |
$14.49
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.49
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.84
|
| Rate for Payer: HealthUtah PPO |
$15.25
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.79
|
| Rate for Payer: Multiplan Medicare/VA |
$8.40
|
| Rate for Payer: One Health Plan of WY PPO |
$14.94
|
| Rate for Payer: PacificSource Commercial |
$13.72
|
| Rate for Payer: PHCS PPO |
$14.94
|
| Rate for Payer: Three Rivers PPO |
$11.44
|
| Rate for Payer: TriWest Veterans Administration |
$8.84
|
| Rate for Payer: United Healthcare Commercial |
$13.27
|
| Rate for Payer: United Healthcare Medicare |
$8.84
|
| Rate for Payer: WINHealth Partners Commercial |
$14.94
|
| Rate for Payer: Wise Provider Network Commercial |
$14.49
|
|
|
DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN [54840]
|
Facility
|
IP
|
$15.25
|
|
|
Service Code
|
HCPCS J1265
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$15.25 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.94
|
| Rate for Payer: Altius Auto/Workers Compensation |
$14.64
|
| Rate for Payer: Altius Commercial |
$14.64
|
| Rate for Payer: Beech Street Commercial |
$14.94
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.52
|
| Rate for Payer: Cash Price |
$10.68
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.79
|
| Rate for Payer: Cigna of WY Commercial |
$14.94
|
| Rate for Payer: Entrust Commercial |
$14.49
|
| Rate for Payer: First Choice Health Commercial |
$14.49
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.49
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.06
|
| Rate for Payer: HealthUtah PPO |
$15.25
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.79
|
| Rate for Payer: Multiplan Medicare/VA |
$9.56
|
| Rate for Payer: One Health Plan of WY PPO |
$14.94
|
| Rate for Payer: PacificSource Commercial |
$13.72
|
| Rate for Payer: PHCS PPO |
$14.94
|
| Rate for Payer: Three Rivers PPO |
$11.44
|
| Rate for Payer: TriWest Veterans Administration |
$10.06
|
| Rate for Payer: United Healthcare Commercial |
$13.27
|
| Rate for Payer: United Healthcare Medicare |
$10.06
|
| Rate for Payer: WINHealth Partners Commercial |
$14.49
|
| Rate for Payer: Wise Provider Network Commercial |
$14.49
|
|
|
DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS [15886]
|
Facility
|
IP
|
$18.75
|
|
|
Service Code
|
NDC 2420848610
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.76 |
| Max. Negotiated Rate |
$18.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18.38
|
| Rate for Payer: Altius Auto/Workers Compensation |
$18.00
|
| Rate for Payer: Altius Commercial |
$18.00
|
| Rate for Payer: Beech Street Commercial |
$18.38
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.39
|
| Rate for Payer: Cash Price |
$13.12
|
| Rate for Payer: ChoiceCare Network Commercial |
$18.19
|
| Rate for Payer: Cigna of WY Commercial |
$18.38
|
| Rate for Payer: Entrust Commercial |
$17.81
|
| Rate for Payer: First Choice Health Commercial |
$17.81
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.81
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$12.38
|
| Rate for Payer: HealthUtah PPO |
$18.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$18.19
|
| Rate for Payer: Multiplan Medicare/VA |
$11.76
|
| Rate for Payer: One Health Plan of WY PPO |
$18.38
|
| Rate for Payer: PacificSource Commercial |
$16.88
|
| Rate for Payer: PHCS PPO |
$18.38
|
| Rate for Payer: Three Rivers PPO |
$14.06
|
| Rate for Payer: TriWest Veterans Administration |
$12.38
|
| Rate for Payer: United Healthcare Commercial |
$16.31
|
| Rate for Payer: United Healthcare Medicare |
$12.38
|
| Rate for Payer: WINHealth Partners Commercial |
$17.81
|
| Rate for Payer: Wise Provider Network Commercial |
$17.81
|
|
|
DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS [15886]
|
Facility
|
OP
|
$18.75
|
|
|
Service Code
|
NDC 2420848610
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.33 |
| Max. Negotiated Rate |
$18.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18.38
|
| Rate for Payer: Aetna of WY Medicare |
$12.38
|
| Rate for Payer: Altius Auto/Workers Compensation |
$18.00
|
| Rate for Payer: Altius Commercial |
$18.00
|
| Rate for Payer: Beech Street Commercial |
$18.38
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.39
|
| Rate for Payer: Cash Price |
$13.12
|
| Rate for Payer: ChoiceCare Network Commercial |
$18.19
|
| Rate for Payer: Cigna of WY Commercial |
$18.38
|
| Rate for Payer: Entrust Commercial |
$17.81
|
| Rate for Payer: First Choice Health Commercial |
$17.81
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.81
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.88
|
| Rate for Payer: HealthUtah PPO |
$18.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$18.19
|
| Rate for Payer: Multiplan Medicare/VA |
$10.33
|
| Rate for Payer: One Health Plan of WY PPO |
$18.38
|
| Rate for Payer: PacificSource Commercial |
$16.88
|
| Rate for Payer: PHCS PPO |
$18.38
|
| Rate for Payer: Three Rivers PPO |
$14.06
|
| Rate for Payer: TriWest Veterans Administration |
$10.88
|
| Rate for Payer: United Healthcare Commercial |
$16.31
|
| Rate for Payer: United Healthcare Medicare |
$10.88
|
| Rate for Payer: WINHealth Partners Commercial |
$18.38
|
| Rate for Payer: Wise Provider Network Commercial |
$17.81
|
|
|
DORZOLAMIDE 2 % EYE DROPS [20314]
|
Facility
|
IP
|
$10.00
|
|
|
Service Code
|
NDC 6131401910
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.27 |
| Max. Negotiated Rate |
$10.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$9.80
|
| Rate for Payer: Altius Auto/Workers Compensation |
$9.60
|
| Rate for Payer: Altius Commercial |
$9.60
|
| Rate for Payer: Beech Street Commercial |
$9.80
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$8.21
|
| Rate for Payer: Cash Price |
$7.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$9.70
|
| Rate for Payer: Cigna of WY Commercial |
$9.80
|
| Rate for Payer: Entrust Commercial |
$9.50
|
| Rate for Payer: First Choice Health Commercial |
$9.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$9.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$6.60
|
| Rate for Payer: HealthUtah PPO |
$10.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$9.70
|
| Rate for Payer: Multiplan Medicare/VA |
$6.27
|
| Rate for Payer: One Health Plan of WY PPO |
$9.80
|
| Rate for Payer: PacificSource Commercial |
$9.00
|
| Rate for Payer: PHCS PPO |
$9.80
|
| Rate for Payer: Three Rivers PPO |
$7.50
|
| Rate for Payer: TriWest Veterans Administration |
$6.60
|
| Rate for Payer: United Healthcare Commercial |
$8.70
|
| Rate for Payer: United Healthcare Medicare |
$6.60
|
| Rate for Payer: WINHealth Partners Commercial |
$9.50
|
| Rate for Payer: Wise Provider Network Commercial |
$9.50
|
|
|
DORZOLAMIDE 2 % EYE DROPS [20314]
|
Facility
|
OP
|
$12.75
|
|
|
Service Code
|
NDC 2420848510
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.03 |
| Max. Negotiated Rate |
$12.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$12.50
|
| Rate for Payer: Aetna of WY Medicare |
$8.42
|
| Rate for Payer: Altius Auto/Workers Compensation |
$12.24
|
| Rate for Payer: Altius Commercial |
$12.24
|
| Rate for Payer: Beech Street Commercial |
$12.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$10.47
|
| Rate for Payer: Cash Price |
$8.92
|
| Rate for Payer: ChoiceCare Network Commercial |
$12.37
|
| Rate for Payer: Cigna of WY Commercial |
$12.50
|
| Rate for Payer: Entrust Commercial |
$12.11
|
| Rate for Payer: First Choice Health Commercial |
$12.11
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$12.11
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$7.40
|
| Rate for Payer: HealthUtah PPO |
$12.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$12.37
|
| Rate for Payer: Multiplan Medicare/VA |
$7.03
|
| Rate for Payer: One Health Plan of WY PPO |
$12.50
|
| Rate for Payer: PacificSource Commercial |
$11.48
|
| Rate for Payer: PHCS PPO |
$12.50
|
| Rate for Payer: Three Rivers PPO |
$9.56
|
| Rate for Payer: TriWest Veterans Administration |
$7.40
|
| Rate for Payer: United Healthcare Commercial |
$11.09
|
| Rate for Payer: United Healthcare Medicare |
$7.40
|
| Rate for Payer: WINHealth Partners Commercial |
$12.50
|
| Rate for Payer: Wise Provider Network Commercial |
$12.11
|
|
|
DORZOLAMIDE 2 % EYE DROPS [20314]
|
Facility
|
OP
|
$12.75
|
|
|
Service Code
|
NDC 6931530410
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.03 |
| Max. Negotiated Rate |
$12.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$12.50
|
| Rate for Payer: Aetna of WY Medicare |
$8.42
|
| Rate for Payer: Altius Auto/Workers Compensation |
$12.24
|
| Rate for Payer: Altius Commercial |
$12.24
|
| Rate for Payer: Beech Street Commercial |
$12.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$10.47
|
| Rate for Payer: Cash Price |
$8.92
|
| Rate for Payer: ChoiceCare Network Commercial |
$12.37
|
| Rate for Payer: Cigna of WY Commercial |
$12.50
|
| Rate for Payer: Entrust Commercial |
$12.11
|
| Rate for Payer: First Choice Health Commercial |
$12.11
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$12.11
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$7.40
|
| Rate for Payer: HealthUtah PPO |
$12.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$12.37
|
| Rate for Payer: Multiplan Medicare/VA |
$7.03
|
| Rate for Payer: One Health Plan of WY PPO |
$12.50
|
| Rate for Payer: PacificSource Commercial |
$11.48
|
| Rate for Payer: PHCS PPO |
$12.50
|
| Rate for Payer: Three Rivers PPO |
$9.56
|
| Rate for Payer: TriWest Veterans Administration |
$7.40
|
| Rate for Payer: United Healthcare Commercial |
$11.09
|
| Rate for Payer: United Healthcare Medicare |
$7.40
|
| Rate for Payer: WINHealth Partners Commercial |
$12.50
|
| Rate for Payer: Wise Provider Network Commercial |
$12.11
|
|
|
DORZOLAMIDE 2 % EYE DROPS [20314]
|
Facility
|
IP
|
$12.75
|
|
|
Service Code
|
NDC 2420848510
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.99 |
| Max. Negotiated Rate |
$12.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$12.50
|
| Rate for Payer: Altius Auto/Workers Compensation |
$12.24
|
| Rate for Payer: Altius Commercial |
$12.24
|
| Rate for Payer: Beech Street Commercial |
$12.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$10.47
|
| Rate for Payer: Cash Price |
$8.92
|
| Rate for Payer: ChoiceCare Network Commercial |
$12.37
|
| Rate for Payer: Cigna of WY Commercial |
$12.50
|
| Rate for Payer: Entrust Commercial |
$12.11
|
| Rate for Payer: First Choice Health Commercial |
$12.11
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$12.11
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.42
|
| Rate for Payer: HealthUtah PPO |
$12.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$12.37
|
| Rate for Payer: Multiplan Medicare/VA |
$7.99
|
| Rate for Payer: One Health Plan of WY PPO |
$12.50
|
| Rate for Payer: PacificSource Commercial |
$11.48
|
| Rate for Payer: PHCS PPO |
$12.50
|
| Rate for Payer: Three Rivers PPO |
$9.56
|
| Rate for Payer: TriWest Veterans Administration |
$8.42
|
| Rate for Payer: United Healthcare Commercial |
$11.09
|
| Rate for Payer: United Healthcare Medicare |
$8.42
|
| Rate for Payer: WINHealth Partners Commercial |
$12.11
|
| Rate for Payer: Wise Provider Network Commercial |
$12.11
|
|
|
DORZOLAMIDE 2 % EYE DROPS [20314]
|
Facility
|
OP
|
$12.75
|
|
|
Service Code
|
NDC 4257114126
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.03 |
| Max. Negotiated Rate |
$12.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$12.50
|
| Rate for Payer: Aetna of WY Medicare |
$8.42
|
| Rate for Payer: Altius Auto/Workers Compensation |
$12.24
|
| Rate for Payer: Altius Commercial |
$12.24
|
| Rate for Payer: Beech Street Commercial |
$12.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$10.47
|
| Rate for Payer: Cash Price |
$8.92
|
| Rate for Payer: ChoiceCare Network Commercial |
$12.37
|
| Rate for Payer: Cigna of WY Commercial |
$12.50
|
| Rate for Payer: Entrust Commercial |
$12.11
|
| Rate for Payer: First Choice Health Commercial |
$12.11
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$12.11
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$7.40
|
| Rate for Payer: HealthUtah PPO |
$12.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$12.37
|
| Rate for Payer: Multiplan Medicare/VA |
$7.03
|
| Rate for Payer: One Health Plan of WY PPO |
$12.50
|
| Rate for Payer: PacificSource Commercial |
$11.48
|
| Rate for Payer: PHCS PPO |
$12.50
|
| Rate for Payer: Three Rivers PPO |
$9.56
|
| Rate for Payer: TriWest Veterans Administration |
$7.40
|
| Rate for Payer: United Healthcare Commercial |
$11.09
|
| Rate for Payer: United Healthcare Medicare |
$7.40
|
| Rate for Payer: WINHealth Partners Commercial |
$12.50
|
| Rate for Payer: Wise Provider Network Commercial |
$12.11
|
|
|
DORZOLAMIDE 2 % EYE DROPS [20314]
|
Facility
|
IP
|
$12.75
|
|
|
Service Code
|
NDC 6931530410
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.99 |
| Max. Negotiated Rate |
$12.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$12.50
|
| Rate for Payer: Altius Auto/Workers Compensation |
$12.24
|
| Rate for Payer: Altius Commercial |
$12.24
|
| Rate for Payer: Beech Street Commercial |
$12.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$10.47
|
| Rate for Payer: Cash Price |
$8.92
|
| Rate for Payer: ChoiceCare Network Commercial |
$12.37
|
| Rate for Payer: Cigna of WY Commercial |
$12.50
|
| Rate for Payer: Entrust Commercial |
$12.11
|
| Rate for Payer: First Choice Health Commercial |
$12.11
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$12.11
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.42
|
| Rate for Payer: HealthUtah PPO |
$12.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$12.37
|
| Rate for Payer: Multiplan Medicare/VA |
$7.99
|
| Rate for Payer: One Health Plan of WY PPO |
$12.50
|
| Rate for Payer: PacificSource Commercial |
$11.48
|
| Rate for Payer: PHCS PPO |
$12.50
|
| Rate for Payer: Three Rivers PPO |
$9.56
|
| Rate for Payer: TriWest Veterans Administration |
$8.42
|
| Rate for Payer: United Healthcare Commercial |
$11.09
|
| Rate for Payer: United Healthcare Medicare |
$8.42
|
| Rate for Payer: WINHealth Partners Commercial |
$12.11
|
| Rate for Payer: Wise Provider Network Commercial |
$12.11
|
|
|
DORZOLAMIDE 2 % EYE DROPS [20314]
|
Facility
|
IP
|
$12.75
|
|
|
Service Code
|
NDC 4257114126
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.99 |
| Max. Negotiated Rate |
$12.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$12.50
|
| Rate for Payer: Altius Auto/Workers Compensation |
$12.24
|
| Rate for Payer: Altius Commercial |
$12.24
|
| Rate for Payer: Beech Street Commercial |
$12.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$10.47
|
| Rate for Payer: Cash Price |
$8.92
|
| Rate for Payer: ChoiceCare Network Commercial |
$12.37
|
| Rate for Payer: Cigna of WY Commercial |
$12.50
|
| Rate for Payer: Entrust Commercial |
$12.11
|
| Rate for Payer: First Choice Health Commercial |
$12.11
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$12.11
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.42
|
| Rate for Payer: HealthUtah PPO |
$12.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$12.37
|
| Rate for Payer: Multiplan Medicare/VA |
$7.99
|
| Rate for Payer: One Health Plan of WY PPO |
$12.50
|
| Rate for Payer: PacificSource Commercial |
$11.48
|
| Rate for Payer: PHCS PPO |
$12.50
|
| Rate for Payer: Three Rivers PPO |
$9.56
|
| Rate for Payer: TriWest Veterans Administration |
$8.42
|
| Rate for Payer: United Healthcare Commercial |
$11.09
|
| Rate for Payer: United Healthcare Medicare |
$8.42
|
| Rate for Payer: WINHealth Partners Commercial |
$12.11
|
| Rate for Payer: Wise Provider Network Commercial |
$12.11
|
|
|
DORZOLAMIDE 2 % EYE DROPS [20314]
|
Facility
|
OP
|
$10.00
|
|
|
Service Code
|
NDC 6131401910
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.51 |
| Max. Negotiated Rate |
$10.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$9.80
|
| Rate for Payer: Aetna of WY Medicare |
$6.60
|
| Rate for Payer: Altius Auto/Workers Compensation |
$9.60
|
| Rate for Payer: Altius Commercial |
$9.60
|
| Rate for Payer: Beech Street Commercial |
$9.80
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$8.21
|
| Rate for Payer: Cash Price |
$7.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$9.70
|
| Rate for Payer: Cigna of WY Commercial |
$9.80
|
| Rate for Payer: Entrust Commercial |
$9.50
|
| Rate for Payer: First Choice Health Commercial |
$9.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$9.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$5.80
|
| Rate for Payer: HealthUtah PPO |
$10.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$9.70
|
| Rate for Payer: Multiplan Medicare/VA |
$5.51
|
| Rate for Payer: One Health Plan of WY PPO |
$9.80
|
| Rate for Payer: PacificSource Commercial |
$9.00
|
| Rate for Payer: PHCS PPO |
$9.80
|
| Rate for Payer: Three Rivers PPO |
$7.50
|
| Rate for Payer: TriWest Veterans Administration |
$5.80
|
| Rate for Payer: United Healthcare Commercial |
$8.70
|
| Rate for Payer: United Healthcare Medicare |
$5.80
|
| Rate for Payer: WINHealth Partners Commercial |
$9.80
|
| Rate for Payer: Wise Provider Network Commercial |
$9.50
|
|
|
DOTAREM INJ 10X10ML VIAL
|
Facility
|
IP
|
$55.30
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$34.67 |
| Max. Negotiated Rate |
$55.30 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$54.19
|
| Rate for Payer: Altius Auto/Workers Compensation |
$53.09
|
| Rate for Payer: Altius Commercial |
$53.09
|
| Rate for Payer: Beech Street Commercial |
$54.19
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$45.40
|
| Rate for Payer: Cash Price |
$38.71
|
| Rate for Payer: ChoiceCare Network Commercial |
$53.64
|
| Rate for Payer: Cigna of WY Commercial |
$54.19
|
| Rate for Payer: Entrust Commercial |
$52.54
|
| Rate for Payer: First Choice Health Commercial |
$52.54
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$52.54
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$36.50
|
| Rate for Payer: HealthUtah PPO |
$55.30
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$53.64
|
| Rate for Payer: Multiplan Medicare/VA |
$34.67
|
| Rate for Payer: One Health Plan of WY PPO |
$54.19
|
| Rate for Payer: PacificSource Commercial |
$49.77
|
| Rate for Payer: PHCS PPO |
$54.19
|
| Rate for Payer: Three Rivers PPO |
$41.48
|
| Rate for Payer: TriWest Veterans Administration |
$36.50
|
| Rate for Payer: United Healthcare Commercial |
$48.11
|
| Rate for Payer: United Healthcare Medicare |
$36.50
|
| Rate for Payer: WINHealth Partners Commercial |
$52.54
|
| Rate for Payer: Wise Provider Network Commercial |
$52.54
|
|
|
DOTAREM INJ 10X10ML VIAL
|
Facility
|
OP
|
$55.30
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$30.47 |
| Max. Negotiated Rate |
$55.30 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$54.19
|
| Rate for Payer: Aetna of WY Medicare |
$36.50
|
| Rate for Payer: Altius Auto/Workers Compensation |
$53.09
|
| Rate for Payer: Altius Commercial |
$53.09
|
| Rate for Payer: Beech Street Commercial |
$54.19
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$45.40
|
| Rate for Payer: Cash Price |
$38.71
|
| Rate for Payer: ChoiceCare Network Commercial |
$53.64
|
| Rate for Payer: Cigna of WY Commercial |
$54.19
|
| Rate for Payer: Entrust Commercial |
$52.54
|
| Rate for Payer: First Choice Health Commercial |
$52.54
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$52.54
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$32.07
|
| Rate for Payer: HealthUtah PPO |
$55.30
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$53.64
|
| Rate for Payer: Multiplan Medicare/VA |
$30.47
|
| Rate for Payer: One Health Plan of WY PPO |
$54.19
|
| Rate for Payer: PacificSource Commercial |
$49.77
|
| Rate for Payer: PHCS PPO |
$54.19
|
| Rate for Payer: Three Rivers PPO |
$41.48
|
| Rate for Payer: TriWest Veterans Administration |
$32.07
|
| Rate for Payer: United Healthcare Commercial |
$48.11
|
| Rate for Payer: United Healthcare Medicare |
$32.07
|
| Rate for Payer: WINHealth Partners Commercial |
$54.19
|
| Rate for Payer: Wise Provider Network Commercial |
$52.54
|
|
|
DOTAREM INJ 10X15ML VIAL
|
Facility
|
OP
|
$107.10
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$59.01 |
| Max. Negotiated Rate |
$107.10 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$104.96
|
| Rate for Payer: Aetna of WY Medicare |
$70.69
|
| Rate for Payer: Altius Auto/Workers Compensation |
$102.82
|
| Rate for Payer: Altius Commercial |
$102.82
|
| Rate for Payer: Beech Street Commercial |
$104.96
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$87.93
|
| Rate for Payer: Cash Price |
$74.97
|
| Rate for Payer: ChoiceCare Network Commercial |
$103.89
|
| Rate for Payer: Cigna of WY Commercial |
$104.96
|
| Rate for Payer: Entrust Commercial |
$101.74
|
| Rate for Payer: First Choice Health Commercial |
$101.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$101.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$62.12
|
| Rate for Payer: HealthUtah PPO |
$107.10
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$103.89
|
| Rate for Payer: Multiplan Medicare/VA |
$59.01
|
| Rate for Payer: One Health Plan of WY PPO |
$104.96
|
| Rate for Payer: PacificSource Commercial |
$96.39
|
| Rate for Payer: PHCS PPO |
$104.96
|
| Rate for Payer: Three Rivers PPO |
$80.32
|
| Rate for Payer: TriWest Veterans Administration |
$62.12
|
| Rate for Payer: United Healthcare Commercial |
$93.18
|
| Rate for Payer: United Healthcare Medicare |
$62.12
|
| Rate for Payer: WINHealth Partners Commercial |
$104.96
|
| Rate for Payer: Wise Provider Network Commercial |
$101.74
|
|
|
DOTAREM INJ 10X15ML VIAL
|
Facility
|
IP
|
$107.10
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$67.15 |
| Max. Negotiated Rate |
$107.10 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$104.96
|
| Rate for Payer: Altius Auto/Workers Compensation |
$102.82
|
| Rate for Payer: Altius Commercial |
$102.82
|
| Rate for Payer: Beech Street Commercial |
$104.96
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$87.93
|
| Rate for Payer: Cash Price |
$74.97
|
| Rate for Payer: ChoiceCare Network Commercial |
$103.89
|
| Rate for Payer: Cigna of WY Commercial |
$104.96
|
| Rate for Payer: Entrust Commercial |
$101.74
|
| Rate for Payer: First Choice Health Commercial |
$101.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$101.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$70.69
|
| Rate for Payer: HealthUtah PPO |
$107.10
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$103.89
|
| Rate for Payer: Multiplan Medicare/VA |
$67.15
|
| Rate for Payer: One Health Plan of WY PPO |
$104.96
|
| Rate for Payer: PacificSource Commercial |
$96.39
|
| Rate for Payer: PHCS PPO |
$104.96
|
| Rate for Payer: Three Rivers PPO |
$80.32
|
| Rate for Payer: TriWest Veterans Administration |
$70.69
|
| Rate for Payer: United Healthcare Commercial |
$93.18
|
| Rate for Payer: United Healthcare Medicare |
$70.69
|
| Rate for Payer: WINHealth Partners Commercial |
$101.74
|
| Rate for Payer: Wise Provider Network Commercial |
$101.74
|
|
|
DOTAREM INJ 10X20ML VIAL
|
Facility
|
IP
|
$107.10
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$67.15 |
| Max. Negotiated Rate |
$107.10 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$104.96
|
| Rate for Payer: Altius Auto/Workers Compensation |
$102.82
|
| Rate for Payer: Altius Commercial |
$102.82
|
| Rate for Payer: Beech Street Commercial |
$104.96
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$87.93
|
| Rate for Payer: Cash Price |
$74.97
|
| Rate for Payer: ChoiceCare Network Commercial |
$103.89
|
| Rate for Payer: Cigna of WY Commercial |
$104.96
|
| Rate for Payer: Entrust Commercial |
$101.74
|
| Rate for Payer: First Choice Health Commercial |
$101.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$101.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$70.69
|
| Rate for Payer: HealthUtah PPO |
$107.10
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$103.89
|
| Rate for Payer: Multiplan Medicare/VA |
$67.15
|
| Rate for Payer: One Health Plan of WY PPO |
$104.96
|
| Rate for Payer: PacificSource Commercial |
$96.39
|
| Rate for Payer: PHCS PPO |
$104.96
|
| Rate for Payer: Three Rivers PPO |
$80.32
|
| Rate for Payer: TriWest Veterans Administration |
$70.69
|
| Rate for Payer: United Healthcare Commercial |
$93.18
|
| Rate for Payer: United Healthcare Medicare |
$70.69
|
| Rate for Payer: WINHealth Partners Commercial |
$101.74
|
| Rate for Payer: Wise Provider Network Commercial |
$101.74
|
|
|
DOTAREM INJ 10X20ML VIAL
|
Facility
|
OP
|
$107.10
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$59.01 |
| Max. Negotiated Rate |
$107.10 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$104.96
|
| Rate for Payer: Aetna of WY Medicare |
$70.69
|
| Rate for Payer: Altius Auto/Workers Compensation |
$102.82
|
| Rate for Payer: Altius Commercial |
$102.82
|
| Rate for Payer: Beech Street Commercial |
$104.96
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$87.93
|
| Rate for Payer: Cash Price |
$74.97
|
| Rate for Payer: ChoiceCare Network Commercial |
$103.89
|
| Rate for Payer: Cigna of WY Commercial |
$104.96
|
| Rate for Payer: Entrust Commercial |
$101.74
|
| Rate for Payer: First Choice Health Commercial |
$101.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$101.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$62.12
|
| Rate for Payer: HealthUtah PPO |
$107.10
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$103.89
|
| Rate for Payer: Multiplan Medicare/VA |
$59.01
|
| Rate for Payer: One Health Plan of WY PPO |
$104.96
|
| Rate for Payer: PacificSource Commercial |
$96.39
|
| Rate for Payer: PHCS PPO |
$104.96
|
| Rate for Payer: Three Rivers PPO |
$80.32
|
| Rate for Payer: TriWest Veterans Administration |
$62.12
|
| Rate for Payer: United Healthcare Commercial |
$93.18
|
| Rate for Payer: United Healthcare Medicare |
$62.12
|
| Rate for Payer: WINHealth Partners Commercial |
$104.96
|
| Rate for Payer: Wise Provider Network Commercial |
$101.74
|
|
