|
AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION [16449]
|
Facility
|
IP
|
$0.26
|
|
|
Service Code
|
NDC 0143988701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.25
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.25
|
| Rate for Payer: Altius Commercial |
$0.25
|
| Rate for Payer: Beech Street Commercial |
$0.25
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.21
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.25
|
| Rate for Payer: Cigna of WY Commercial |
$0.25
|
| Rate for Payer: Entrust Commercial |
$0.25
|
| Rate for Payer: First Choice Health Commercial |
$0.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.17
|
| Rate for Payer: HealthUtah PPO |
$0.26
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.25
|
| Rate for Payer: Multiplan Medicare/VA |
$0.16
|
| Rate for Payer: One Health Plan of WY PPO |
$0.25
|
| Rate for Payer: PacificSource Commercial |
$0.23
|
| Rate for Payer: PHCS PPO |
$0.25
|
| Rate for Payer: Three Rivers PPO |
$0.20
|
| Rate for Payer: TriWest Veterans Administration |
$0.17
|
| Rate for Payer: United Healthcare Commercial |
$0.23
|
| Rate for Payer: United Healthcare Medicare |
$0.17
|
| Rate for Payer: WINHealth Partners Commercial |
$0.25
|
| Rate for Payer: Wise Provider Network Commercial |
$0.25
|
|
|
AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION [16449]
|
Facility
|
OP
|
$0.26
|
|
|
Service Code
|
NDC 0143988701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.25
|
| Rate for Payer: Aetna of WY Medicare |
$0.17
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.25
|
| Rate for Payer: Altius Commercial |
$0.25
|
| Rate for Payer: Beech Street Commercial |
$0.25
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.21
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.25
|
| Rate for Payer: Cigna of WY Commercial |
$0.25
|
| Rate for Payer: Entrust Commercial |
$0.25
|
| Rate for Payer: First Choice Health Commercial |
$0.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.15
|
| Rate for Payer: HealthUtah PPO |
$0.26
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.25
|
| Rate for Payer: Multiplan Medicare/VA |
$0.14
|
| Rate for Payer: One Health Plan of WY PPO |
$0.25
|
| Rate for Payer: PacificSource Commercial |
$0.23
|
| Rate for Payer: PHCS PPO |
$0.25
|
| Rate for Payer: Three Rivers PPO |
$0.20
|
| Rate for Payer: TriWest Veterans Administration |
$0.15
|
| Rate for Payer: United Healthcare Commercial |
$0.23
|
| Rate for Payer: United Healthcare Medicare |
$0.15
|
| Rate for Payer: WINHealth Partners Commercial |
$0.25
|
| Rate for Payer: Wise Provider Network Commercial |
$0.25
|
|
|
AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION [16449]
|
Facility
|
IP
|
$0.26
|
|
|
Service Code
|
NDC 6586207101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.25
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.25
|
| Rate for Payer: Altius Commercial |
$0.25
|
| Rate for Payer: Beech Street Commercial |
$0.25
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.21
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.25
|
| Rate for Payer: Cigna of WY Commercial |
$0.25
|
| Rate for Payer: Entrust Commercial |
$0.25
|
| Rate for Payer: First Choice Health Commercial |
$0.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.17
|
| Rate for Payer: HealthUtah PPO |
$0.26
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.25
|
| Rate for Payer: Multiplan Medicare/VA |
$0.16
|
| Rate for Payer: One Health Plan of WY PPO |
$0.25
|
| Rate for Payer: PacificSource Commercial |
$0.23
|
| Rate for Payer: PHCS PPO |
$0.25
|
| Rate for Payer: Three Rivers PPO |
$0.20
|
| Rate for Payer: TriWest Veterans Administration |
$0.17
|
| Rate for Payer: United Healthcare Commercial |
$0.23
|
| Rate for Payer: United Healthcare Medicare |
$0.17
|
| Rate for Payer: WINHealth Partners Commercial |
$0.25
|
| Rate for Payer: Wise Provider Network Commercial |
$0.25
|
|
|
AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION [16449]
|
Facility
|
OP
|
$0.26
|
|
|
Service Code
|
NDC 0781615746
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.25
|
| Rate for Payer: Aetna of WY Medicare |
$0.17
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.25
|
| Rate for Payer: Altius Commercial |
$0.25
|
| Rate for Payer: Beech Street Commercial |
$0.25
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.21
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.25
|
| Rate for Payer: Cigna of WY Commercial |
$0.25
|
| Rate for Payer: Entrust Commercial |
$0.25
|
| Rate for Payer: First Choice Health Commercial |
$0.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.15
|
| Rate for Payer: HealthUtah PPO |
$0.26
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.25
|
| Rate for Payer: Multiplan Medicare/VA |
$0.14
|
| Rate for Payer: One Health Plan of WY PPO |
$0.25
|
| Rate for Payer: PacificSource Commercial |
$0.23
|
| Rate for Payer: PHCS PPO |
$0.25
|
| Rate for Payer: Three Rivers PPO |
$0.20
|
| Rate for Payer: TriWest Veterans Administration |
$0.15
|
| Rate for Payer: United Healthcare Commercial |
$0.23
|
| Rate for Payer: United Healthcare Medicare |
$0.15
|
| Rate for Payer: WINHealth Partners Commercial |
$0.25
|
| Rate for Payer: Wise Provider Network Commercial |
$0.25
|
|
|
AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION [16449]
|
Facility
|
OP
|
$0.26
|
|
|
Service Code
|
NDC 6586207101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.25
|
| Rate for Payer: Aetna of WY Medicare |
$0.17
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.25
|
| Rate for Payer: Altius Commercial |
$0.25
|
| Rate for Payer: Beech Street Commercial |
$0.25
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.21
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.25
|
| Rate for Payer: Cigna of WY Commercial |
$0.25
|
| Rate for Payer: Entrust Commercial |
$0.25
|
| Rate for Payer: First Choice Health Commercial |
$0.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.15
|
| Rate for Payer: HealthUtah PPO |
$0.26
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.25
|
| Rate for Payer: Multiplan Medicare/VA |
$0.14
|
| Rate for Payer: One Health Plan of WY PPO |
$0.25
|
| Rate for Payer: PacificSource Commercial |
$0.23
|
| Rate for Payer: PHCS PPO |
$0.25
|
| Rate for Payer: Three Rivers PPO |
$0.20
|
| Rate for Payer: TriWest Veterans Administration |
$0.15
|
| Rate for Payer: United Healthcare Commercial |
$0.23
|
| Rate for Payer: United Healthcare Medicare |
$0.15
|
| Rate for Payer: WINHealth Partners Commercial |
$0.25
|
| Rate for Payer: Wise Provider Network Commercial |
$0.25
|
|
|
AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION [16449]
|
Facility
|
IP
|
$0.26
|
|
|
Service Code
|
NDC 0781615746
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.25
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.25
|
| Rate for Payer: Altius Commercial |
$0.25
|
| Rate for Payer: Beech Street Commercial |
$0.25
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.21
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.25
|
| Rate for Payer: Cigna of WY Commercial |
$0.25
|
| Rate for Payer: Entrust Commercial |
$0.25
|
| Rate for Payer: First Choice Health Commercial |
$0.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.17
|
| Rate for Payer: HealthUtah PPO |
$0.26
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.25
|
| Rate for Payer: Multiplan Medicare/VA |
$0.16
|
| Rate for Payer: One Health Plan of WY PPO |
$0.25
|
| Rate for Payer: PacificSource Commercial |
$0.23
|
| Rate for Payer: PHCS PPO |
$0.25
|
| Rate for Payer: Three Rivers PPO |
$0.20
|
| Rate for Payer: TriWest Veterans Administration |
$0.17
|
| Rate for Payer: United Healthcare Commercial |
$0.23
|
| Rate for Payer: United Healthcare Medicare |
$0.17
|
| Rate for Payer: WINHealth Partners Commercial |
$0.25
|
| Rate for Payer: Wise Provider Network Commercial |
$0.25
|
|
|
AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION [16449]
|
Facility
|
OP
|
$0.31
|
|
|
Service Code
|
NDC 0093416173
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.30
|
| Rate for Payer: Aetna of WY Medicare |
$0.20
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.30
|
| Rate for Payer: Altius Commercial |
$0.30
|
| Rate for Payer: Beech Street Commercial |
$0.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.25
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.30
|
| Rate for Payer: Cigna of WY Commercial |
$0.30
|
| Rate for Payer: Entrust Commercial |
$0.29
|
| Rate for Payer: First Choice Health Commercial |
$0.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.18
|
| Rate for Payer: HealthUtah PPO |
$0.31
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.30
|
| Rate for Payer: Multiplan Medicare/VA |
$0.17
|
| Rate for Payer: One Health Plan of WY PPO |
$0.30
|
| Rate for Payer: PacificSource Commercial |
$0.28
|
| Rate for Payer: PHCS PPO |
$0.30
|
| Rate for Payer: Three Rivers PPO |
$0.23
|
| Rate for Payer: TriWest Veterans Administration |
$0.18
|
| Rate for Payer: United Healthcare Commercial |
$0.27
|
| Rate for Payer: United Healthcare Medicare |
$0.18
|
| Rate for Payer: WINHealth Partners Commercial |
$0.30
|
| Rate for Payer: Wise Provider Network Commercial |
$0.29
|
|
|
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION [8974]
|
Facility
|
IP
|
$0.58
|
|
|
Service Code
|
NDC 6586253401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$0.58 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.57
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.56
|
| Rate for Payer: Altius Commercial |
$0.56
|
| Rate for Payer: Beech Street Commercial |
$0.57
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.48
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.56
|
| Rate for Payer: Cigna of WY Commercial |
$0.57
|
| Rate for Payer: Entrust Commercial |
$0.55
|
| Rate for Payer: First Choice Health Commercial |
$0.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.38
|
| Rate for Payer: HealthUtah PPO |
$0.58
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.56
|
| Rate for Payer: Multiplan Medicare/VA |
$0.36
|
| Rate for Payer: One Health Plan of WY PPO |
$0.57
|
| Rate for Payer: PacificSource Commercial |
$0.52
|
| Rate for Payer: PHCS PPO |
$0.57
|
| Rate for Payer: Three Rivers PPO |
$0.44
|
| Rate for Payer: TriWest Veterans Administration |
$0.38
|
| Rate for Payer: United Healthcare Commercial |
$0.50
|
| Rate for Payer: United Healthcare Medicare |
$0.38
|
| Rate for Payer: WINHealth Partners Commercial |
$0.55
|
| Rate for Payer: Wise Provider Network Commercial |
$0.55
|
|
|
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION [8974]
|
Facility
|
OP
|
$0.58
|
|
|
Service Code
|
NDC 6586253401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.58 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.57
|
| Rate for Payer: Aetna of WY Medicare |
$0.38
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.56
|
| Rate for Payer: Altius Commercial |
$0.56
|
| Rate for Payer: Beech Street Commercial |
$0.57
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.48
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.56
|
| Rate for Payer: Cigna of WY Commercial |
$0.57
|
| Rate for Payer: Entrust Commercial |
$0.55
|
| Rate for Payer: First Choice Health Commercial |
$0.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.34
|
| Rate for Payer: HealthUtah PPO |
$0.58
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.56
|
| Rate for Payer: Multiplan Medicare/VA |
$0.32
|
| Rate for Payer: One Health Plan of WY PPO |
$0.57
|
| Rate for Payer: PacificSource Commercial |
$0.52
|
| Rate for Payer: PHCS PPO |
$0.57
|
| Rate for Payer: Three Rivers PPO |
$0.44
|
| Rate for Payer: TriWest Veterans Administration |
$0.34
|
| Rate for Payer: United Healthcare Commercial |
$0.50
|
| Rate for Payer: United Healthcare Medicare |
$0.34
|
| Rate for Payer: WINHealth Partners Commercial |
$0.57
|
| Rate for Payer: Wise Provider Network Commercial |
$0.55
|
|
|
AMOXICILLIN 500 MG CAPSULE [389]
|
Facility
|
IP
|
$0.71
|
|
|
Service Code
|
NDC 0781261301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$0.71 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.70
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.68
|
| Rate for Payer: Altius Commercial |
$0.68
|
| Rate for Payer: Beech Street Commercial |
$0.70
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.58
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.69
|
| Rate for Payer: Cigna of WY Commercial |
$0.70
|
| Rate for Payer: Entrust Commercial |
$0.67
|
| Rate for Payer: First Choice Health Commercial |
$0.67
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.67
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.47
|
| Rate for Payer: HealthUtah PPO |
$0.71
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.69
|
| Rate for Payer: Multiplan Medicare/VA |
$0.45
|
| Rate for Payer: One Health Plan of WY PPO |
$0.70
|
| Rate for Payer: PacificSource Commercial |
$0.64
|
| Rate for Payer: PHCS PPO |
$0.70
|
| Rate for Payer: Three Rivers PPO |
$0.53
|
| Rate for Payer: TriWest Veterans Administration |
$0.47
|
| Rate for Payer: United Healthcare Commercial |
$0.62
|
| Rate for Payer: United Healthcare Medicare |
$0.47
|
| Rate for Payer: WINHealth Partners Commercial |
$0.67
|
| Rate for Payer: Wise Provider Network Commercial |
$0.67
|
|
|
AMOXICILLIN 500 MG CAPSULE [389]
|
Facility
|
OP
|
$0.35
|
|
|
Service Code
|
NDC 8196420501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.34
|
| Rate for Payer: Aetna of WY Medicare |
$0.23
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.34
|
| Rate for Payer: Altius Commercial |
$0.34
|
| Rate for Payer: Beech Street Commercial |
$0.34
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.29
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.34
|
| Rate for Payer: Cigna of WY Commercial |
$0.34
|
| Rate for Payer: Entrust Commercial |
$0.33
|
| Rate for Payer: First Choice Health Commercial |
$0.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.20
|
| Rate for Payer: HealthUtah PPO |
$0.35
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.34
|
| Rate for Payer: Multiplan Medicare/VA |
$0.19
|
| Rate for Payer: One Health Plan of WY PPO |
$0.34
|
| Rate for Payer: PacificSource Commercial |
$0.32
|
| Rate for Payer: PHCS PPO |
$0.34
|
| Rate for Payer: Three Rivers PPO |
$0.26
|
| Rate for Payer: TriWest Veterans Administration |
$0.20
|
| Rate for Payer: United Healthcare Commercial |
$0.30
|
| Rate for Payer: United Healthcare Medicare |
$0.20
|
| Rate for Payer: WINHealth Partners Commercial |
$0.34
|
| Rate for Payer: Wise Provider Network Commercial |
$0.33
|
|
|
AMOXICILLIN 500 MG CAPSULE [389]
|
Facility
|
OP
|
$0.71
|
|
|
Service Code
|
NDC 0781261301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$0.71 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.70
|
| Rate for Payer: Aetna of WY Medicare |
$0.47
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.68
|
| Rate for Payer: Altius Commercial |
$0.68
|
| Rate for Payer: Beech Street Commercial |
$0.70
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.58
|
| Rate for Payer: Cash Price |
$0.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.69
|
| Rate for Payer: Cigna of WY Commercial |
$0.70
|
| Rate for Payer: Entrust Commercial |
$0.67
|
| Rate for Payer: First Choice Health Commercial |
$0.67
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.67
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.41
|
| Rate for Payer: HealthUtah PPO |
$0.71
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.69
|
| Rate for Payer: Multiplan Medicare/VA |
$0.39
|
| Rate for Payer: One Health Plan of WY PPO |
$0.70
|
| Rate for Payer: PacificSource Commercial |
$0.64
|
| Rate for Payer: PHCS PPO |
$0.70
|
| Rate for Payer: Three Rivers PPO |
$0.53
|
| Rate for Payer: TriWest Veterans Administration |
$0.41
|
| Rate for Payer: United Healthcare Commercial |
$0.62
|
| Rate for Payer: United Healthcare Medicare |
$0.41
|
| Rate for Payer: WINHealth Partners Commercial |
$0.70
|
| Rate for Payer: Wise Provider Network Commercial |
$0.67
|
|
|
AMOXICILLIN 500 MG CAPSULE [389]
|
Facility
|
IP
|
$0.36
|
|
|
Service Code
|
NDC 6586201701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.35
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.35
|
| Rate for Payer: Altius Commercial |
$0.35
|
| Rate for Payer: Beech Street Commercial |
$0.35
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.30
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.35
|
| Rate for Payer: Cigna of WY Commercial |
$0.35
|
| Rate for Payer: Entrust Commercial |
$0.34
|
| Rate for Payer: First Choice Health Commercial |
$0.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.24
|
| Rate for Payer: HealthUtah PPO |
$0.36
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.35
|
| Rate for Payer: Multiplan Medicare/VA |
$0.23
|
| Rate for Payer: One Health Plan of WY PPO |
$0.35
|
| Rate for Payer: PacificSource Commercial |
$0.32
|
| Rate for Payer: PHCS PPO |
$0.35
|
| Rate for Payer: Three Rivers PPO |
$0.27
|
| Rate for Payer: TriWest Veterans Administration |
$0.24
|
| Rate for Payer: United Healthcare Commercial |
$0.31
|
| Rate for Payer: United Healthcare Medicare |
$0.24
|
| Rate for Payer: WINHealth Partners Commercial |
$0.34
|
| Rate for Payer: Wise Provider Network Commercial |
$0.34
|
|
|
AMOXICILLIN 500 MG CAPSULE [389]
|
Facility
|
IP
|
$0.35
|
|
|
Service Code
|
NDC 8196420501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.34
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.34
|
| Rate for Payer: Altius Commercial |
$0.34
|
| Rate for Payer: Beech Street Commercial |
$0.34
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.29
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.34
|
| Rate for Payer: Cigna of WY Commercial |
$0.34
|
| Rate for Payer: Entrust Commercial |
$0.33
|
| Rate for Payer: First Choice Health Commercial |
$0.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.23
|
| Rate for Payer: HealthUtah PPO |
$0.35
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.34
|
| Rate for Payer: Multiplan Medicare/VA |
$0.22
|
| Rate for Payer: One Health Plan of WY PPO |
$0.34
|
| Rate for Payer: PacificSource Commercial |
$0.32
|
| Rate for Payer: PHCS PPO |
$0.34
|
| Rate for Payer: Three Rivers PPO |
$0.26
|
| Rate for Payer: TriWest Veterans Administration |
$0.23
|
| Rate for Payer: United Healthcare Commercial |
$0.30
|
| Rate for Payer: United Healthcare Medicare |
$0.23
|
| Rate for Payer: WINHealth Partners Commercial |
$0.33
|
| Rate for Payer: Wise Provider Network Commercial |
$0.33
|
|
|
AMOXICILLIN 500 MG CAPSULE [389]
|
Facility
|
OP
|
$0.36
|
|
|
Service Code
|
NDC 6586201701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.35
|
| Rate for Payer: Aetna of WY Medicare |
$0.24
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.35
|
| Rate for Payer: Altius Commercial |
$0.35
|
| Rate for Payer: Beech Street Commercial |
$0.35
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.30
|
| Rate for Payer: Cash Price |
$0.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.35
|
| Rate for Payer: Cigna of WY Commercial |
$0.35
|
| Rate for Payer: Entrust Commercial |
$0.34
|
| Rate for Payer: First Choice Health Commercial |
$0.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.21
|
| Rate for Payer: HealthUtah PPO |
$0.36
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.35
|
| Rate for Payer: Multiplan Medicare/VA |
$0.20
|
| Rate for Payer: One Health Plan of WY PPO |
$0.35
|
| Rate for Payer: PacificSource Commercial |
$0.32
|
| Rate for Payer: PHCS PPO |
$0.35
|
| Rate for Payer: Three Rivers PPO |
$0.27
|
| Rate for Payer: TriWest Veterans Administration |
$0.21
|
| Rate for Payer: United Healthcare Commercial |
$0.31
|
| Rate for Payer: United Healthcare Medicare |
$0.21
|
| Rate for Payer: WINHealth Partners Commercial |
$0.35
|
| Rate for Payer: Wise Provider Network Commercial |
$0.34
|
|
|
AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET [20367]
|
Facility
|
OP
|
$1.76
|
|
|
Service Code
|
NDC 6586250220
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.97 |
| Max. Negotiated Rate |
$1.76 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.72
|
| Rate for Payer: Aetna of WY Medicare |
$1.16
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.69
|
| Rate for Payer: Altius Commercial |
$1.69
|
| Rate for Payer: Beech Street Commercial |
$1.72
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.44
|
| Rate for Payer: Cash Price |
$1.23
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.71
|
| Rate for Payer: Cigna of WY Commercial |
$1.72
|
| Rate for Payer: Entrust Commercial |
$1.67
|
| Rate for Payer: First Choice Health Commercial |
$1.67
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.67
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.02
|
| Rate for Payer: HealthUtah PPO |
$1.76
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.71
|
| Rate for Payer: Multiplan Medicare/VA |
$0.97
|
| Rate for Payer: One Health Plan of WY PPO |
$1.72
|
| Rate for Payer: PacificSource Commercial |
$1.58
|
| Rate for Payer: PHCS PPO |
$1.72
|
| Rate for Payer: Three Rivers PPO |
$1.32
|
| Rate for Payer: TriWest Veterans Administration |
$1.02
|
| Rate for Payer: United Healthcare Commercial |
$1.53
|
| Rate for Payer: United Healthcare Medicare |
$1.02
|
| Rate for Payer: WINHealth Partners Commercial |
$1.72
|
| Rate for Payer: Wise Provider Network Commercial |
$1.67
|
|
|
AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET [20367]
|
Facility
|
IP
|
$1.76
|
|
|
Service Code
|
NDC 6586250220
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.10 |
| Max. Negotiated Rate |
$1.76 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.72
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.69
|
| Rate for Payer: Altius Commercial |
$1.69
|
| Rate for Payer: Beech Street Commercial |
$1.72
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.44
|
| Rate for Payer: Cash Price |
$1.23
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.71
|
| Rate for Payer: Cigna of WY Commercial |
$1.72
|
| Rate for Payer: Entrust Commercial |
$1.67
|
| Rate for Payer: First Choice Health Commercial |
$1.67
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.67
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.16
|
| Rate for Payer: HealthUtah PPO |
$1.76
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.71
|
| Rate for Payer: Multiplan Medicare/VA |
$1.10
|
| Rate for Payer: One Health Plan of WY PPO |
$1.72
|
| Rate for Payer: PacificSource Commercial |
$1.58
|
| Rate for Payer: PHCS PPO |
$1.72
|
| Rate for Payer: Three Rivers PPO |
$1.32
|
| Rate for Payer: TriWest Veterans Administration |
$1.16
|
| Rate for Payer: United Healthcare Commercial |
$1.53
|
| Rate for Payer: United Healthcare Medicare |
$1.16
|
| Rate for Payer: WINHealth Partners Commercial |
$1.67
|
| Rate for Payer: Wise Provider Network Commercial |
$1.67
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET [20218]
|
Facility
|
IP
|
$1.45
|
|
|
Service Code
|
NDC 6586250320
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.91 |
| Max. Negotiated Rate |
$1.45 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.42
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.39
|
| Rate for Payer: Altius Commercial |
$1.39
|
| Rate for Payer: Beech Street Commercial |
$1.42
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.19
|
| Rate for Payer: Cash Price |
$1.01
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.41
|
| Rate for Payer: Cigna of WY Commercial |
$1.42
|
| Rate for Payer: Entrust Commercial |
$1.38
|
| Rate for Payer: First Choice Health Commercial |
$1.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.96
|
| Rate for Payer: HealthUtah PPO |
$1.45
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.41
|
| Rate for Payer: Multiplan Medicare/VA |
$0.91
|
| Rate for Payer: One Health Plan of WY PPO |
$1.42
|
| Rate for Payer: PacificSource Commercial |
$1.30
|
| Rate for Payer: PHCS PPO |
$1.42
|
| Rate for Payer: Three Rivers PPO |
$1.09
|
| Rate for Payer: TriWest Veterans Administration |
$0.96
|
| Rate for Payer: United Healthcare Commercial |
$1.26
|
| Rate for Payer: United Healthcare Medicare |
$0.96
|
| Rate for Payer: WINHealth Partners Commercial |
$1.38
|
| Rate for Payer: Wise Provider Network Commercial |
$1.38
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET [20218]
|
Facility
|
OP
|
$1.45
|
|
|
Service Code
|
NDC 6586250320
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$1.45 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.42
|
| Rate for Payer: Aetna of WY Medicare |
$0.96
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.39
|
| Rate for Payer: Altius Commercial |
$1.39
|
| Rate for Payer: Beech Street Commercial |
$1.42
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.19
|
| Rate for Payer: Cash Price |
$1.01
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.41
|
| Rate for Payer: Cigna of WY Commercial |
$1.42
|
| Rate for Payer: Entrust Commercial |
$1.38
|
| Rate for Payer: First Choice Health Commercial |
$1.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.84
|
| Rate for Payer: HealthUtah PPO |
$1.45
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.41
|
| Rate for Payer: Multiplan Medicare/VA |
$0.80
|
| Rate for Payer: One Health Plan of WY PPO |
$1.42
|
| Rate for Payer: PacificSource Commercial |
$1.30
|
| Rate for Payer: PHCS PPO |
$1.42
|
| Rate for Payer: Three Rivers PPO |
$1.09
|
| Rate for Payer: TriWest Veterans Administration |
$0.84
|
| Rate for Payer: United Healthcare Commercial |
$1.26
|
| Rate for Payer: United Healthcare Medicare |
$0.84
|
| Rate for Payer: WINHealth Partners Commercial |
$1.42
|
| Rate for Payer: Wise Provider Network Commercial |
$1.38
|
|
|
AMP F/TH 1/2 JT/PHALANX W/NEURECT LOCAL FLAP
|
Professional
|
Both
|
$2,393.00
|
|
|
Service Code
|
HCPCS 26952 80
|
| Hospital Charge Code |
26952
|
| Min. Negotiated Rate |
$569.98 |
| Max. Negotiated Rate |
$2,393.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,345.14
|
| Rate for Payer: Aetna of WY Medicare |
$670.57
|
| Rate for Payer: Beech Street Commercial |
$2,273.35
|
| Rate for Payer: Cash Price |
$1,675.10
|
| Rate for Payer: Cash Price |
$1,675.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,321.21
|
| Rate for Payer: Cigna of WY Commercial |
$2,345.14
|
| Rate for Payer: First Choice Health Commercial |
$2,153.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,273.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$670.57
|
| Rate for Payer: HealthUtah PPO |
$2,393.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,321.21
|
| Rate for Payer: Multiplan Medicare/VA |
$569.98
|
| Rate for Payer: One Health Plan of WY PPO |
$2,345.14
|
| Rate for Payer: PacificSource Commercial |
$2,153.70
|
| Rate for Payer: PHCS PPO |
$2,273.35
|
| Rate for Payer: Three Rivers PPO |
$1,794.75
|
| Rate for Payer: TriWest Veterans Administration |
$670.57
|
| Rate for Payer: United Healthcare Commercial |
$2,081.91
|
| Rate for Payer: United Healthcare Medicare |
$670.57
|
| Rate for Payer: WINHealth Partners Commercial |
$2,034.05
|
|
|
AMP F/TH 1/2 JT/PHALANX W/NEURECT LOCAL FLAP
|
Professional
|
Both
|
$2,393.00
|
|
|
Service Code
|
HCPCS 26952
|
| Hospital Charge Code |
26952
|
| Min. Negotiated Rate |
$569.98 |
| Max. Negotiated Rate |
$2,393.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,345.14
|
| Rate for Payer: Aetna of WY Medicare |
$670.57
|
| Rate for Payer: Beech Street Commercial |
$2,273.35
|
| Rate for Payer: Cash Price |
$1,675.10
|
| Rate for Payer: Cash Price |
$1,675.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,321.21
|
| Rate for Payer: Cigna of WY Commercial |
$2,345.14
|
| Rate for Payer: First Choice Health Commercial |
$2,153.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,273.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$670.57
|
| Rate for Payer: HealthUtah PPO |
$2,393.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,321.21
|
| Rate for Payer: Multiplan Medicare/VA |
$569.98
|
| Rate for Payer: One Health Plan of WY PPO |
$2,345.14
|
| Rate for Payer: PacificSource Commercial |
$2,153.70
|
| Rate for Payer: PHCS PPO |
$2,273.35
|
| Rate for Payer: Three Rivers PPO |
$1,794.75
|
| Rate for Payer: TriWest Veterans Administration |
$670.57
|
| Rate for Payer: United Healthcare Commercial |
$2,081.91
|
| Rate for Payer: United Healthcare Medicare |
$670.57
|
| Rate for Payer: WINHealth Partners Commercial |
$2,034.05
|
|
|
AMP F/TH 1/2 JT/PHALANX W/NEURECT W/DIR CLSR
|
Professional
|
Both
|
$2,464.00
|
|
|
Service Code
|
HCPCS 26951
|
| Hospital Charge Code |
26951
|
| Min. Negotiated Rate |
$586.90 |
| Max. Negotiated Rate |
$2,464.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,414.72
|
| Rate for Payer: Aetna of WY Medicare |
$690.47
|
| Rate for Payer: Beech Street Commercial |
$2,340.80
|
| Rate for Payer: Cash Price |
$1,724.80
|
| Rate for Payer: Cash Price |
$1,724.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,390.08
|
| Rate for Payer: Cigna of WY Commercial |
$2,414.72
|
| Rate for Payer: First Choice Health Commercial |
$2,217.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,340.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$690.47
|
| Rate for Payer: HealthUtah PPO |
$2,464.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,390.08
|
| Rate for Payer: Multiplan Medicare/VA |
$586.90
|
| Rate for Payer: One Health Plan of WY PPO |
$2,414.72
|
| Rate for Payer: PacificSource Commercial |
$2,217.60
|
| Rate for Payer: PHCS PPO |
$2,340.80
|
| Rate for Payer: Three Rivers PPO |
$1,848.00
|
| Rate for Payer: TriWest Veterans Administration |
$690.47
|
| Rate for Payer: United Healthcare Commercial |
$2,143.68
|
| Rate for Payer: United Healthcare Medicare |
$690.47
|
| Rate for Payer: WINHealth Partners Commercial |
$2,094.40
|
|
|
AMP F/TH 1/2 JT/PHALANX W/NEURECT W/DIR CLSR
|
Professional
|
Both
|
$2,464.00
|
|
|
Service Code
|
HCPCS 26951 80
|
| Hospital Charge Code |
26951
|
| Min. Negotiated Rate |
$586.90 |
| Max. Negotiated Rate |
$2,464.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,414.72
|
| Rate for Payer: Aetna of WY Medicare |
$690.47
|
| Rate for Payer: Beech Street Commercial |
$2,340.80
|
| Rate for Payer: Cash Price |
$1,724.80
|
| Rate for Payer: Cash Price |
$1,724.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,390.08
|
| Rate for Payer: Cigna of WY Commercial |
$2,414.72
|
| Rate for Payer: First Choice Health Commercial |
$2,217.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,340.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$690.47
|
| Rate for Payer: HealthUtah PPO |
$2,464.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,390.08
|
| Rate for Payer: Multiplan Medicare/VA |
$586.90
|
| Rate for Payer: One Health Plan of WY PPO |
$2,414.72
|
| Rate for Payer: PacificSource Commercial |
$2,217.60
|
| Rate for Payer: PHCS PPO |
$2,340.80
|
| Rate for Payer: Three Rivers PPO |
$1,848.00
|
| Rate for Payer: TriWest Veterans Administration |
$690.47
|
| Rate for Payer: United Healthcare Commercial |
$2,143.68
|
| Rate for Payer: United Healthcare Medicare |
$690.47
|
| Rate for Payer: WINHealth Partners Commercial |
$2,094.40
|
|
|
AMPICILLIN 1 GRAM SOLUTION FOR INJECTION [16206]
|
Facility
|
IP
|
$33.19
|
|
|
Service Code
|
HCPCS J0290
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.81 |
| Max. Negotiated Rate |
$33.19 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$32.53
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$32.51
|
| Rate for Payer: Altius Auto/Workers Compensation |
$31.86
|
| Rate for Payer: Altius Auto/Workers Compensation |
$31.84
|
| Rate for Payer: Altius Commercial |
$31.84
|
| Rate for Payer: Altius Commercial |
$31.86
|
| Rate for Payer: Beech Street Commercial |
$32.53
|
| Rate for Payer: Beech Street Commercial |
$32.51
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$27.23
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$27.25
|
| Rate for Payer: Cash Price |
$23.23
|
| Rate for Payer: Cash Price |
$23.22
|
| Rate for Payer: ChoiceCare Network Commercial |
$32.17
|
| Rate for Payer: ChoiceCare Network Commercial |
$32.19
|
| Rate for Payer: Cigna of WY Commercial |
$32.53
|
| Rate for Payer: Cigna of WY Commercial |
$32.51
|
| Rate for Payer: Entrust Commercial |
$31.51
|
| Rate for Payer: Entrust Commercial |
$31.53
|
| Rate for Payer: First Choice Health Commercial |
$31.51
|
| Rate for Payer: First Choice Health Commercial |
$31.53
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$31.51
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$31.53
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$21.91
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$21.89
|
| Rate for Payer: HealthUtah PPO |
$33.19
|
| Rate for Payer: HealthUtah PPO |
$33.17
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$32.17
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$32.19
|
| Rate for Payer: Multiplan Medicare/VA |
$20.81
|
| Rate for Payer: Multiplan Medicare/VA |
$20.80
|
| Rate for Payer: One Health Plan of WY PPO |
$32.53
|
| Rate for Payer: One Health Plan of WY PPO |
$32.51
|
| Rate for Payer: PacificSource Commercial |
$29.87
|
| Rate for Payer: PacificSource Commercial |
$29.85
|
| Rate for Payer: PHCS PPO |
$32.51
|
| Rate for Payer: PHCS PPO |
$32.53
|
| Rate for Payer: Three Rivers PPO |
$24.88
|
| Rate for Payer: Three Rivers PPO |
$24.89
|
| Rate for Payer: TriWest Veterans Administration |
$21.91
|
| Rate for Payer: TriWest Veterans Administration |
$21.89
|
| Rate for Payer: United Healthcare Commercial |
$28.86
|
| Rate for Payer: United Healthcare Commercial |
$28.88
|
| Rate for Payer: United Healthcare Medicare |
$21.91
|
| Rate for Payer: United Healthcare Medicare |
$21.89
|
| Rate for Payer: WINHealth Partners Commercial |
$31.51
|
| Rate for Payer: WINHealth Partners Commercial |
$31.53
|
| Rate for Payer: Wise Provider Network Commercial |
$31.51
|
| Rate for Payer: Wise Provider Network Commercial |
$31.53
|
|
|
AMPICILLIN 1 GRAM SOLUTION FOR INJECTION [16206]
|
Facility
|
OP
|
$33.19
|
|
|
Service Code
|
HCPCS J0290
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.29 |
| Max. Negotiated Rate |
$33.19 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$32.53
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$32.51
|
| Rate for Payer: Aetna of WY Medicare |
$21.91
|
| Rate for Payer: Aetna of WY Medicare |
$21.89
|
| Rate for Payer: Altius Auto/Workers Compensation |
$31.84
|
| Rate for Payer: Altius Auto/Workers Compensation |
$31.86
|
| Rate for Payer: Altius Commercial |
$31.86
|
| Rate for Payer: Altius Commercial |
$31.84
|
| Rate for Payer: Beech Street Commercial |
$32.51
|
| Rate for Payer: Beech Street Commercial |
$32.53
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$27.25
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$27.23
|
| Rate for Payer: Cash Price |
$23.22
|
| Rate for Payer: Cash Price |
$23.23
|
| Rate for Payer: ChoiceCare Network Commercial |
$32.19
|
| Rate for Payer: ChoiceCare Network Commercial |
$32.17
|
| Rate for Payer: Cigna of WY Commercial |
$32.51
|
| Rate for Payer: Cigna of WY Commercial |
$32.53
|
| Rate for Payer: Entrust Commercial |
$31.53
|
| Rate for Payer: Entrust Commercial |
$31.51
|
| Rate for Payer: First Choice Health Commercial |
$31.51
|
| Rate for Payer: First Choice Health Commercial |
$31.53
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$31.51
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$31.53
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$19.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$19.24
|
| Rate for Payer: HealthUtah PPO |
$33.17
|
| Rate for Payer: HealthUtah PPO |
$33.19
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$32.17
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$32.19
|
| Rate for Payer: Multiplan Medicare/VA |
$18.29
|
| Rate for Payer: Multiplan Medicare/VA |
$18.28
|
| Rate for Payer: One Health Plan of WY PPO |
$32.51
|
| Rate for Payer: One Health Plan of WY PPO |
$32.53
|
| Rate for Payer: PacificSource Commercial |
$29.87
|
| Rate for Payer: PacificSource Commercial |
$29.85
|
| Rate for Payer: PHCS PPO |
$32.51
|
| Rate for Payer: PHCS PPO |
$32.53
|
| Rate for Payer: Three Rivers PPO |
$24.88
|
| Rate for Payer: Three Rivers PPO |
$24.89
|
| Rate for Payer: TriWest Veterans Administration |
$19.25
|
| Rate for Payer: TriWest Veterans Administration |
$19.24
|
| Rate for Payer: United Healthcare Commercial |
$28.86
|
| Rate for Payer: United Healthcare Commercial |
$28.88
|
| Rate for Payer: United Healthcare Medicare |
$19.25
|
| Rate for Payer: United Healthcare Medicare |
$19.24
|
| Rate for Payer: WINHealth Partners Commercial |
$32.51
|
| Rate for Payer: WINHealth Partners Commercial |
$32.53
|
| Rate for Payer: Wise Provider Network Commercial |
$31.51
|
| Rate for Payer: Wise Provider Network Commercial |
$31.53
|
|
