|
EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION [92614]
|
Facility
|
IP
|
$56.14
|
|
|
Service Code
|
HCPCS J0171
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.20 |
| Max. Negotiated Rate |
$56.14 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$55.02
|
| Rate for Payer: Altius Auto/Workers Compensation |
$53.89
|
| Rate for Payer: Altius Commercial |
$53.89
|
| Rate for Payer: Beech Street Commercial |
$55.02
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$46.09
|
| Rate for Payer: Cash Price |
$39.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$54.46
|
| Rate for Payer: Cigna of WY Commercial |
$55.02
|
| Rate for Payer: Entrust Commercial |
$53.33
|
| Rate for Payer: First Choice Health Commercial |
$53.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$53.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$37.05
|
| Rate for Payer: HealthUtah PPO |
$56.14
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$54.46
|
| Rate for Payer: Multiplan Medicare/VA |
$35.20
|
| Rate for Payer: One Health Plan of WY PPO |
$55.02
|
| Rate for Payer: PacificSource Commercial |
$50.53
|
| Rate for Payer: PHCS PPO |
$55.02
|
| Rate for Payer: Three Rivers PPO |
$42.10
|
| Rate for Payer: TriWest Veterans Administration |
$37.05
|
| Rate for Payer: United Healthcare Commercial |
$48.84
|
| Rate for Payer: United Healthcare Medicare |
$37.05
|
| Rate for Payer: WINHealth Partners Commercial |
$53.33
|
| Rate for Payer: Wise Provider Network Commercial |
$53.33
|
|
|
EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION [92614]
|
Facility
|
OP
|
$56.14
|
|
|
Service Code
|
HCPCS J0171
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.93 |
| Max. Negotiated Rate |
$56.14 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$55.02
|
| Rate for Payer: Aetna of WY Medicare |
$37.05
|
| Rate for Payer: Altius Auto/Workers Compensation |
$53.89
|
| Rate for Payer: Altius Commercial |
$53.89
|
| Rate for Payer: Beech Street Commercial |
$55.02
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$46.09
|
| Rate for Payer: Cash Price |
$39.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$54.46
|
| Rate for Payer: Cigna of WY Commercial |
$55.02
|
| Rate for Payer: Entrust Commercial |
$53.33
|
| Rate for Payer: First Choice Health Commercial |
$53.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$53.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$32.56
|
| Rate for Payer: HealthUtah PPO |
$56.14
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$54.46
|
| Rate for Payer: Multiplan Medicare/VA |
$30.93
|
| Rate for Payer: One Health Plan of WY PPO |
$55.02
|
| Rate for Payer: PacificSource Commercial |
$50.53
|
| Rate for Payer: PHCS PPO |
$55.02
|
| Rate for Payer: Three Rivers PPO |
$42.10
|
| Rate for Payer: TriWest Veterans Administration |
$32.56
|
| Rate for Payer: United Healthcare Commercial |
$48.84
|
| Rate for Payer: United Healthcare Medicare |
$32.56
|
| Rate for Payer: WINHealth Partners Commercial |
$55.02
|
| Rate for Payer: Wise Provider Network Commercial |
$53.33
|
|
|
EPINEPHRINE 1 MG/ML INJECTION SOLUTION [29544]
|
Facility
|
OP
|
$41.25
|
|
|
Service Code
|
HCPCS J0171
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.73 |
| Max. Negotiated Rate |
$41.25 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$40.42
|
| Rate for Payer: Aetna of WY Medicare |
$27.22
|
| Rate for Payer: Altius Auto/Workers Compensation |
$39.60
|
| Rate for Payer: Altius Commercial |
$39.60
|
| Rate for Payer: Beech Street Commercial |
$40.42
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$33.87
|
| Rate for Payer: Cash Price |
$28.87
|
| Rate for Payer: ChoiceCare Network Commercial |
$40.01
|
| Rate for Payer: Cigna of WY Commercial |
$40.42
|
| Rate for Payer: Entrust Commercial |
$39.19
|
| Rate for Payer: First Choice Health Commercial |
$39.19
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$39.19
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$23.92
|
| Rate for Payer: HealthUtah PPO |
$41.25
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$40.01
|
| Rate for Payer: Multiplan Medicare/VA |
$22.73
|
| Rate for Payer: One Health Plan of WY PPO |
$40.42
|
| Rate for Payer: PacificSource Commercial |
$37.12
|
| Rate for Payer: PHCS PPO |
$40.42
|
| Rate for Payer: Three Rivers PPO |
$30.94
|
| Rate for Payer: TriWest Veterans Administration |
$23.92
|
| Rate for Payer: United Healthcare Commercial |
$35.89
|
| Rate for Payer: United Healthcare Medicare |
$23.92
|
| Rate for Payer: WINHealth Partners Commercial |
$40.42
|
| Rate for Payer: Wise Provider Network Commercial |
$39.19
|
|
|
EPINEPHRINE 1 MG/ML INJECTION SOLUTION [29544]
|
Facility
|
IP
|
$41.25
|
|
|
Service Code
|
HCPCS J0171
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.86 |
| Max. Negotiated Rate |
$41.25 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$40.42
|
| Rate for Payer: Altius Auto/Workers Compensation |
$39.60
|
| Rate for Payer: Altius Commercial |
$39.60
|
| Rate for Payer: Beech Street Commercial |
$40.42
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$33.87
|
| Rate for Payer: Cash Price |
$28.87
|
| Rate for Payer: ChoiceCare Network Commercial |
$40.01
|
| Rate for Payer: Cigna of WY Commercial |
$40.42
|
| Rate for Payer: Entrust Commercial |
$39.19
|
| Rate for Payer: First Choice Health Commercial |
$39.19
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$39.19
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$27.22
|
| Rate for Payer: HealthUtah PPO |
$41.25
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$40.01
|
| Rate for Payer: Multiplan Medicare/VA |
$25.86
|
| Rate for Payer: One Health Plan of WY PPO |
$40.42
|
| Rate for Payer: PacificSource Commercial |
$37.12
|
| Rate for Payer: PHCS PPO |
$40.42
|
| Rate for Payer: Three Rivers PPO |
$30.94
|
| Rate for Payer: TriWest Veterans Administration |
$27.22
|
| Rate for Payer: United Healthcare Commercial |
$35.89
|
| Rate for Payer: United Healthcare Medicare |
$27.22
|
| Rate for Payer: WINHealth Partners Commercial |
$39.19
|
| Rate for Payer: Wise Provider Network Commercial |
$39.19
|
|
|
EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION [42727]
|
Facility
|
IP
|
$56.14
|
|
|
Service Code
|
HCPCS J0171
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.20 |
| Max. Negotiated Rate |
$56.14 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$55.02
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$47.04
|
| Rate for Payer: Altius Auto/Workers Compensation |
$53.89
|
| Rate for Payer: Altius Auto/Workers Compensation |
$46.08
|
| Rate for Payer: Altius Commercial |
$46.08
|
| Rate for Payer: Altius Commercial |
$53.89
|
| Rate for Payer: Beech Street Commercial |
$55.02
|
| Rate for Payer: Beech Street Commercial |
$47.04
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$39.41
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$46.09
|
| Rate for Payer: Cash Price |
$39.30
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$46.56
|
| Rate for Payer: ChoiceCare Network Commercial |
$54.46
|
| Rate for Payer: Cigna of WY Commercial |
$55.02
|
| Rate for Payer: Cigna of WY Commercial |
$47.04
|
| Rate for Payer: Entrust Commercial |
$45.60
|
| Rate for Payer: Entrust Commercial |
$53.33
|
| Rate for Payer: First Choice Health Commercial |
$45.60
|
| Rate for Payer: First Choice Health Commercial |
$53.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$45.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$53.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$37.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$31.68
|
| Rate for Payer: HealthUtah PPO |
$56.14
|
| Rate for Payer: HealthUtah PPO |
$48.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$46.56
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$54.46
|
| Rate for Payer: Multiplan Medicare/VA |
$35.20
|
| Rate for Payer: Multiplan Medicare/VA |
$30.10
|
| Rate for Payer: One Health Plan of WY PPO |
$55.02
|
| Rate for Payer: One Health Plan of WY PPO |
$47.04
|
| Rate for Payer: PacificSource Commercial |
$50.53
|
| Rate for Payer: PacificSource Commercial |
$43.20
|
| Rate for Payer: PHCS PPO |
$47.04
|
| Rate for Payer: PHCS PPO |
$55.02
|
| Rate for Payer: Three Rivers PPO |
$36.00
|
| Rate for Payer: Three Rivers PPO |
$42.10
|
| Rate for Payer: TriWest Veterans Administration |
$37.05
|
| Rate for Payer: TriWest Veterans Administration |
$31.68
|
| Rate for Payer: United Healthcare Commercial |
$41.76
|
| Rate for Payer: United Healthcare Commercial |
$48.84
|
| Rate for Payer: United Healthcare Medicare |
$37.05
|
| Rate for Payer: United Healthcare Medicare |
$31.68
|
| Rate for Payer: WINHealth Partners Commercial |
$45.60
|
| Rate for Payer: WINHealth Partners Commercial |
$53.33
|
| Rate for Payer: Wise Provider Network Commercial |
$45.60
|
| Rate for Payer: Wise Provider Network Commercial |
$53.33
|
|
|
EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION [42727]
|
Facility
|
OP
|
$56.14
|
|
|
Service Code
|
HCPCS J0171
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.93 |
| Max. Negotiated Rate |
$56.14 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$55.02
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$47.04
|
| Rate for Payer: Aetna of WY Medicare |
$37.05
|
| Rate for Payer: Aetna of WY Medicare |
$31.68
|
| Rate for Payer: Altius Auto/Workers Compensation |
$46.08
|
| Rate for Payer: Altius Auto/Workers Compensation |
$53.89
|
| Rate for Payer: Altius Commercial |
$53.89
|
| Rate for Payer: Altius Commercial |
$46.08
|
| Rate for Payer: Beech Street Commercial |
$47.04
|
| Rate for Payer: Beech Street Commercial |
$55.02
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$46.09
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$39.41
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cash Price |
$39.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$54.46
|
| Rate for Payer: ChoiceCare Network Commercial |
$46.56
|
| Rate for Payer: Cigna of WY Commercial |
$47.04
|
| Rate for Payer: Cigna of WY Commercial |
$55.02
|
| Rate for Payer: Entrust Commercial |
$53.33
|
| Rate for Payer: Entrust Commercial |
$45.60
|
| Rate for Payer: First Choice Health Commercial |
$45.60
|
| Rate for Payer: First Choice Health Commercial |
$53.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$45.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$53.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$32.56
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$27.84
|
| Rate for Payer: HealthUtah PPO |
$48.00
|
| Rate for Payer: HealthUtah PPO |
$56.14
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$46.56
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$54.46
|
| Rate for Payer: Multiplan Medicare/VA |
$30.93
|
| Rate for Payer: Multiplan Medicare/VA |
$26.45
|
| Rate for Payer: One Health Plan of WY PPO |
$47.04
|
| Rate for Payer: One Health Plan of WY PPO |
$55.02
|
| Rate for Payer: PacificSource Commercial |
$50.53
|
| Rate for Payer: PacificSource Commercial |
$43.20
|
| Rate for Payer: PHCS PPO |
$47.04
|
| Rate for Payer: PHCS PPO |
$55.02
|
| Rate for Payer: Three Rivers PPO |
$36.00
|
| Rate for Payer: Three Rivers PPO |
$42.10
|
| Rate for Payer: TriWest Veterans Administration |
$32.56
|
| Rate for Payer: TriWest Veterans Administration |
$27.84
|
| Rate for Payer: United Healthcare Commercial |
$41.76
|
| Rate for Payer: United Healthcare Commercial |
$48.84
|
| Rate for Payer: United Healthcare Medicare |
$32.56
|
| Rate for Payer: United Healthcare Medicare |
$27.84
|
| Rate for Payer: WINHealth Partners Commercial |
$47.04
|
| Rate for Payer: WINHealth Partners Commercial |
$55.02
|
| Rate for Payer: Wise Provider Network Commercial |
$45.60
|
| Rate for Payer: Wise Provider Network Commercial |
$53.33
|
|
|
EPISIOTOMY/VAG RPR OTH/THN ATTENDING
|
Professional
|
Both
|
$440.00
|
|
|
Service Code
|
HCPCS 59300
|
| Hospital Charge Code |
59300
|
| Min. Negotiated Rate |
$118.48 |
| Max. Negotiated Rate |
$440.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$431.20
|
| Rate for Payer: Aetna of WY Medicare |
$139.39
|
| Rate for Payer: Beech Street Commercial |
$418.00
|
| Rate for Payer: Cash Price |
$308.00
|
| Rate for Payer: Cash Price |
$308.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$426.80
|
| Rate for Payer: Cigna of WY Commercial |
$431.20
|
| Rate for Payer: First Choice Health Commercial |
$396.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$418.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$139.39
|
| Rate for Payer: HealthUtah PPO |
$440.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$426.80
|
| Rate for Payer: Multiplan Medicare/VA |
$118.48
|
| Rate for Payer: One Health Plan of WY PPO |
$431.20
|
| Rate for Payer: PacificSource Commercial |
$396.00
|
| Rate for Payer: PHCS PPO |
$418.00
|
| Rate for Payer: Three Rivers PPO |
$330.00
|
| Rate for Payer: TriWest Veterans Administration |
$139.39
|
| Rate for Payer: United Healthcare Commercial |
$382.80
|
| Rate for Payer: United Healthcare Medicare |
$139.39
|
| Rate for Payer: WINHealth Partners Commercial |
$374.00
|
|
|
EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION [152607]
|
Facility
|
OP
|
$456.20
|
|
|
Service Code
|
HCPCS Q5106
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$251.37 |
| Max. Negotiated Rate |
$456.20 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$447.08
|
| Rate for Payer: Aetna of WY Medicare |
$301.09
|
| Rate for Payer: Altius Auto/Workers Compensation |
$437.95
|
| Rate for Payer: Altius Commercial |
$437.95
|
| Rate for Payer: Beech Street Commercial |
$447.08
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$374.54
|
| Rate for Payer: Cash Price |
$319.34
|
| Rate for Payer: ChoiceCare Network Commercial |
$442.51
|
| Rate for Payer: Cigna of WY Commercial |
$447.08
|
| Rate for Payer: Entrust Commercial |
$433.39
|
| Rate for Payer: First Choice Health Commercial |
$433.39
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$433.39
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$264.60
|
| Rate for Payer: HealthUtah PPO |
$456.20
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$442.51
|
| Rate for Payer: Multiplan Medicare/VA |
$251.37
|
| Rate for Payer: One Health Plan of WY PPO |
$447.08
|
| Rate for Payer: PacificSource Commercial |
$410.58
|
| Rate for Payer: PHCS PPO |
$447.08
|
| Rate for Payer: Three Rivers PPO |
$342.15
|
| Rate for Payer: TriWest Veterans Administration |
$264.60
|
| Rate for Payer: United Healthcare Commercial |
$396.89
|
| Rate for Payer: United Healthcare Medicare |
$264.60
|
| Rate for Payer: WINHealth Partners Commercial |
$447.08
|
| Rate for Payer: Wise Provider Network Commercial |
$433.39
|
|
|
EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION [152607]
|
Facility
|
IP
|
$456.20
|
|
|
Service Code
|
HCPCS Q5106
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$286.04 |
| Max. Negotiated Rate |
$456.20 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$447.08
|
| Rate for Payer: Altius Auto/Workers Compensation |
$437.95
|
| Rate for Payer: Altius Commercial |
$437.95
|
| Rate for Payer: Beech Street Commercial |
$447.08
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$374.54
|
| Rate for Payer: Cash Price |
$319.34
|
| Rate for Payer: ChoiceCare Network Commercial |
$442.51
|
| Rate for Payer: Cigna of WY Commercial |
$447.08
|
| Rate for Payer: Entrust Commercial |
$433.39
|
| Rate for Payer: First Choice Health Commercial |
$433.39
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$433.39
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$301.09
|
| Rate for Payer: HealthUtah PPO |
$456.20
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$442.51
|
| Rate for Payer: Multiplan Medicare/VA |
$286.04
|
| Rate for Payer: One Health Plan of WY PPO |
$447.08
|
| Rate for Payer: PacificSource Commercial |
$410.58
|
| Rate for Payer: PHCS PPO |
$447.08
|
| Rate for Payer: Three Rivers PPO |
$342.15
|
| Rate for Payer: TriWest Veterans Administration |
$301.09
|
| Rate for Payer: United Healthcare Commercial |
$396.89
|
| Rate for Payer: United Healthcare Medicare |
$301.09
|
| Rate for Payer: WINHealth Partners Commercial |
$433.39
|
| Rate for Payer: Wise Provider Network Commercial |
$433.39
|
|
|
EPOETIN ALFA, NON-ESRD
|
Professional
|
Both
|
$25.00
|
|
|
Service Code
|
HCPCS J0885
|
| Hospital Charge Code |
J0885
|
| Min. Negotiated Rate |
$7.03 |
| Max. Negotiated Rate |
$25.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$24.50
|
| Rate for Payer: Aetna of WY Medicare |
$8.27
|
| Rate for Payer: Beech Street Commercial |
$23.75
|
| Rate for Payer: Cash Price |
$17.50
|
| Rate for Payer: Cash Price |
$17.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$24.25
|
| Rate for Payer: Cigna of WY Commercial |
$24.50
|
| Rate for Payer: First Choice Health Commercial |
$22.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$23.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.27
|
| Rate for Payer: HealthUtah PPO |
$25.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.25
|
| Rate for Payer: Multiplan Medicare/VA |
$7.03
|
| Rate for Payer: One Health Plan of WY PPO |
$24.50
|
| Rate for Payer: PacificSource Commercial |
$22.50
|
| Rate for Payer: PHCS PPO |
$23.75
|
| Rate for Payer: Three Rivers PPO |
$18.75
|
| Rate for Payer: TriWest Veterans Administration |
$8.27
|
| Rate for Payer: United Healthcare Commercial |
$21.75
|
| Rate for Payer: United Healthcare Medicare |
$8.27
|
| Rate for Payer: WINHealth Partners Commercial |
$23.75
|
|
|
ERTAPENEM 1 GRAM SOLUTION FOR INJECTION [20796]
|
Facility
|
IP
|
$75.00
|
|
|
Service Code
|
HCPCS J1335
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.02 |
| Max. Negotiated Rate |
$75.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$73.50
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$218.74
|
| Rate for Payer: Altius Auto/Workers Compensation |
$72.00
|
| Rate for Payer: Altius Auto/Workers Compensation |
$214.27
|
| Rate for Payer: Altius Commercial |
$214.27
|
| Rate for Payer: Altius Commercial |
$72.00
|
| Rate for Payer: Beech Street Commercial |
$73.50
|
| Rate for Payer: Beech Street Commercial |
$218.74
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$183.25
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$61.58
|
| Rate for Payer: Cash Price |
$52.50
|
| Rate for Payer: Cash Price |
$156.24
|
| Rate for Payer: ChoiceCare Network Commercial |
$216.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$72.75
|
| Rate for Payer: Cigna of WY Commercial |
$73.50
|
| Rate for Payer: Cigna of WY Commercial |
$218.74
|
| Rate for Payer: Entrust Commercial |
$212.04
|
| Rate for Payer: Entrust Commercial |
$71.25
|
| Rate for Payer: First Choice Health Commercial |
$212.04
|
| Rate for Payer: First Choice Health Commercial |
$71.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$212.04
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$71.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$49.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$147.31
|
| Rate for Payer: HealthUtah PPO |
$75.00
|
| Rate for Payer: HealthUtah PPO |
$223.20
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$216.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$72.75
|
| Rate for Payer: Multiplan Medicare/VA |
$47.02
|
| Rate for Payer: Multiplan Medicare/VA |
$139.95
|
| Rate for Payer: One Health Plan of WY PPO |
$73.50
|
| Rate for Payer: One Health Plan of WY PPO |
$218.74
|
| Rate for Payer: PacificSource Commercial |
$67.50
|
| Rate for Payer: PacificSource Commercial |
$200.88
|
| Rate for Payer: PHCS PPO |
$218.74
|
| Rate for Payer: PHCS PPO |
$73.50
|
| Rate for Payer: Three Rivers PPO |
$167.40
|
| Rate for Payer: Three Rivers PPO |
$56.25
|
| Rate for Payer: TriWest Veterans Administration |
$49.50
|
| Rate for Payer: TriWest Veterans Administration |
$147.31
|
| Rate for Payer: United Healthcare Commercial |
$194.18
|
| Rate for Payer: United Healthcare Commercial |
$65.25
|
| Rate for Payer: United Healthcare Medicare |
$49.50
|
| Rate for Payer: United Healthcare Medicare |
$147.31
|
| Rate for Payer: WINHealth Partners Commercial |
$212.04
|
| Rate for Payer: WINHealth Partners Commercial |
$71.25
|
| Rate for Payer: Wise Provider Network Commercial |
$212.04
|
| Rate for Payer: Wise Provider Network Commercial |
$71.25
|
|
|
ERTAPENEM 1 GRAM SOLUTION FOR INJECTION [20796]
|
Facility
|
OP
|
$75.00
|
|
|
Service Code
|
HCPCS J1335
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$41.32 |
| Max. Negotiated Rate |
$75.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$73.50
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$218.74
|
| Rate for Payer: Aetna of WY Medicare |
$49.50
|
| Rate for Payer: Aetna of WY Medicare |
$147.31
|
| Rate for Payer: Altius Auto/Workers Compensation |
$214.27
|
| Rate for Payer: Altius Auto/Workers Compensation |
$72.00
|
| Rate for Payer: Altius Commercial |
$72.00
|
| Rate for Payer: Altius Commercial |
$214.27
|
| Rate for Payer: Beech Street Commercial |
$218.74
|
| Rate for Payer: Beech Street Commercial |
$73.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$61.58
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$183.25
|
| Rate for Payer: Cash Price |
$156.24
|
| Rate for Payer: Cash Price |
$52.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$72.75
|
| Rate for Payer: ChoiceCare Network Commercial |
$216.50
|
| Rate for Payer: Cigna of WY Commercial |
$218.74
|
| Rate for Payer: Cigna of WY Commercial |
$73.50
|
| Rate for Payer: Entrust Commercial |
$71.25
|
| Rate for Payer: Entrust Commercial |
$212.04
|
| Rate for Payer: First Choice Health Commercial |
$212.04
|
| Rate for Payer: First Choice Health Commercial |
$71.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$212.04
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$71.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$43.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$129.46
|
| Rate for Payer: HealthUtah PPO |
$223.20
|
| Rate for Payer: HealthUtah PPO |
$75.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$216.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$72.75
|
| Rate for Payer: Multiplan Medicare/VA |
$41.32
|
| Rate for Payer: Multiplan Medicare/VA |
$122.98
|
| Rate for Payer: One Health Plan of WY PPO |
$218.74
|
| Rate for Payer: One Health Plan of WY PPO |
$73.50
|
| Rate for Payer: PacificSource Commercial |
$67.50
|
| Rate for Payer: PacificSource Commercial |
$200.88
|
| Rate for Payer: PHCS PPO |
$218.74
|
| Rate for Payer: PHCS PPO |
$73.50
|
| Rate for Payer: Three Rivers PPO |
$167.40
|
| Rate for Payer: Three Rivers PPO |
$56.25
|
| Rate for Payer: TriWest Veterans Administration |
$43.50
|
| Rate for Payer: TriWest Veterans Administration |
$129.46
|
| Rate for Payer: United Healthcare Commercial |
$194.18
|
| Rate for Payer: United Healthcare Commercial |
$65.25
|
| Rate for Payer: United Healthcare Medicare |
$43.50
|
| Rate for Payer: United Healthcare Medicare |
$129.46
|
| Rate for Payer: WINHealth Partners Commercial |
$218.74
|
| Rate for Payer: WINHealth Partners Commercial |
$73.50
|
| Rate for Payer: Wise Provider Network Commercial |
$212.04
|
| Rate for Payer: Wise Provider Network Commercial |
$71.25
|
|
|
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [12186]
|
Facility
|
OP
|
$25.36
|
|
|
Service Code
|
NDC 0574402450
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.97 |
| Max. Negotiated Rate |
$25.36 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$24.85
|
| Rate for Payer: Aetna of WY Medicare |
$16.74
|
| Rate for Payer: Altius Auto/Workers Compensation |
$24.35
|
| Rate for Payer: Altius Commercial |
$24.35
|
| Rate for Payer: Beech Street Commercial |
$24.85
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$20.82
|
| Rate for Payer: Cash Price |
$17.75
|
| Rate for Payer: ChoiceCare Network Commercial |
$24.60
|
| Rate for Payer: Cigna of WY Commercial |
$24.85
|
| Rate for Payer: Entrust Commercial |
$24.09
|
| Rate for Payer: First Choice Health Commercial |
$24.09
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$24.09
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$14.71
|
| Rate for Payer: HealthUtah PPO |
$25.36
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.60
|
| Rate for Payer: Multiplan Medicare/VA |
$13.97
|
| Rate for Payer: One Health Plan of WY PPO |
$24.85
|
| Rate for Payer: PacificSource Commercial |
$22.82
|
| Rate for Payer: PHCS PPO |
$24.85
|
| Rate for Payer: Three Rivers PPO |
$19.02
|
| Rate for Payer: TriWest Veterans Administration |
$14.71
|
| Rate for Payer: United Healthcare Commercial |
$22.06
|
| Rate for Payer: United Healthcare Medicare |
$14.71
|
| Rate for Payer: WINHealth Partners Commercial |
$24.85
|
| Rate for Payer: Wise Provider Network Commercial |
$24.09
|
|
|
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [12186]
|
Facility
|
OP
|
$26.56
|
|
|
Service Code
|
NDC 1747807031
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.63 |
| Max. Negotiated Rate |
$26.56 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$26.03
|
| Rate for Payer: Aetna of WY Medicare |
$17.53
|
| Rate for Payer: Altius Auto/Workers Compensation |
$25.50
|
| Rate for Payer: Altius Commercial |
$25.50
|
| Rate for Payer: Beech Street Commercial |
$26.03
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$21.81
|
| Rate for Payer: Cash Price |
$18.59
|
| Rate for Payer: ChoiceCare Network Commercial |
$25.76
|
| Rate for Payer: Cigna of WY Commercial |
$26.03
|
| Rate for Payer: Entrust Commercial |
$25.23
|
| Rate for Payer: First Choice Health Commercial |
$25.23
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$25.23
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$15.40
|
| Rate for Payer: HealthUtah PPO |
$26.56
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$25.76
|
| Rate for Payer: Multiplan Medicare/VA |
$14.63
|
| Rate for Payer: One Health Plan of WY PPO |
$26.03
|
| Rate for Payer: PacificSource Commercial |
$23.90
|
| Rate for Payer: PHCS PPO |
$26.03
|
| Rate for Payer: Three Rivers PPO |
$19.92
|
| Rate for Payer: TriWest Veterans Administration |
$15.40
|
| Rate for Payer: United Healthcare Commercial |
$23.11
|
| Rate for Payer: United Healthcare Medicare |
$15.40
|
| Rate for Payer: WINHealth Partners Commercial |
$26.03
|
| Rate for Payer: Wise Provider Network Commercial |
$25.23
|
|
|
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [12186]
|
Facility
|
IP
|
$25.36
|
|
|
Service Code
|
NDC 0574402411
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.90 |
| Max. Negotiated Rate |
$25.36 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$24.85
|
| Rate for Payer: Altius Auto/Workers Compensation |
$24.35
|
| Rate for Payer: Altius Commercial |
$24.35
|
| Rate for Payer: Beech Street Commercial |
$24.85
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$20.82
|
| Rate for Payer: Cash Price |
$17.75
|
| Rate for Payer: ChoiceCare Network Commercial |
$24.60
|
| Rate for Payer: Cigna of WY Commercial |
$24.85
|
| Rate for Payer: Entrust Commercial |
$24.09
|
| Rate for Payer: First Choice Health Commercial |
$24.09
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$24.09
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$16.74
|
| Rate for Payer: HealthUtah PPO |
$25.36
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.60
|
| Rate for Payer: Multiplan Medicare/VA |
$15.90
|
| Rate for Payer: One Health Plan of WY PPO |
$24.85
|
| Rate for Payer: PacificSource Commercial |
$22.82
|
| Rate for Payer: PHCS PPO |
$24.85
|
| Rate for Payer: Three Rivers PPO |
$19.02
|
| Rate for Payer: TriWest Veterans Administration |
$16.74
|
| Rate for Payer: United Healthcare Commercial |
$22.06
|
| Rate for Payer: United Healthcare Medicare |
$16.74
|
| Rate for Payer: WINHealth Partners Commercial |
$24.09
|
| Rate for Payer: Wise Provider Network Commercial |
$24.09
|
|
|
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [12186]
|
Facility
|
OP
|
$32.28
|
|
|
Service Code
|
NDC 2420891019
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.79 |
| Max. Negotiated Rate |
$32.28 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$31.63
|
| Rate for Payer: Aetna of WY Medicare |
$21.30
|
| Rate for Payer: Altius Auto/Workers Compensation |
$30.99
|
| Rate for Payer: Altius Commercial |
$30.99
|
| Rate for Payer: Beech Street Commercial |
$31.63
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$26.50
|
| Rate for Payer: Cash Price |
$22.59
|
| Rate for Payer: ChoiceCare Network Commercial |
$31.31
|
| Rate for Payer: Cigna of WY Commercial |
$31.63
|
| Rate for Payer: Entrust Commercial |
$30.67
|
| Rate for Payer: First Choice Health Commercial |
$30.67
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$30.67
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$18.72
|
| Rate for Payer: HealthUtah PPO |
$32.28
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$31.31
|
| Rate for Payer: Multiplan Medicare/VA |
$17.79
|
| Rate for Payer: One Health Plan of WY PPO |
$31.63
|
| Rate for Payer: PacificSource Commercial |
$29.05
|
| Rate for Payer: PHCS PPO |
$31.63
|
| Rate for Payer: Three Rivers PPO |
$24.21
|
| Rate for Payer: TriWest Veterans Administration |
$18.72
|
| Rate for Payer: United Healthcare Commercial |
$28.08
|
| Rate for Payer: United Healthcare Medicare |
$18.72
|
| Rate for Payer: WINHealth Partners Commercial |
$31.63
|
| Rate for Payer: Wise Provider Network Commercial |
$30.67
|
|
|
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [12186]
|
Facility
|
IP
|
$32.28
|
|
|
Service Code
|
NDC 2420891019
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.24 |
| Max. Negotiated Rate |
$32.28 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$31.63
|
| Rate for Payer: Altius Auto/Workers Compensation |
$30.99
|
| Rate for Payer: Altius Commercial |
$30.99
|
| Rate for Payer: Beech Street Commercial |
$31.63
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$26.50
|
| Rate for Payer: Cash Price |
$22.59
|
| Rate for Payer: ChoiceCare Network Commercial |
$31.31
|
| Rate for Payer: Cigna of WY Commercial |
$31.63
|
| Rate for Payer: Entrust Commercial |
$30.67
|
| Rate for Payer: First Choice Health Commercial |
$30.67
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$30.67
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$21.30
|
| Rate for Payer: HealthUtah PPO |
$32.28
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$31.31
|
| Rate for Payer: Multiplan Medicare/VA |
$20.24
|
| Rate for Payer: One Health Plan of WY PPO |
$31.63
|
| Rate for Payer: PacificSource Commercial |
$29.05
|
| Rate for Payer: PHCS PPO |
$31.63
|
| Rate for Payer: Three Rivers PPO |
$24.21
|
| Rate for Payer: TriWest Veterans Administration |
$21.30
|
| Rate for Payer: United Healthcare Commercial |
$28.08
|
| Rate for Payer: United Healthcare Medicare |
$21.30
|
| Rate for Payer: WINHealth Partners Commercial |
$30.67
|
| Rate for Payer: Wise Provider Network Commercial |
$30.67
|
|
|
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [12186]
|
Facility
|
OP
|
$25.36
|
|
|
Service Code
|
NDC 0574402411
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.97 |
| Max. Negotiated Rate |
$25.36 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$24.85
|
| Rate for Payer: Aetna of WY Medicare |
$16.74
|
| Rate for Payer: Altius Auto/Workers Compensation |
$24.35
|
| Rate for Payer: Altius Commercial |
$24.35
|
| Rate for Payer: Beech Street Commercial |
$24.85
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$20.82
|
| Rate for Payer: Cash Price |
$17.75
|
| Rate for Payer: ChoiceCare Network Commercial |
$24.60
|
| Rate for Payer: Cigna of WY Commercial |
$24.85
|
| Rate for Payer: Entrust Commercial |
$24.09
|
| Rate for Payer: First Choice Health Commercial |
$24.09
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$24.09
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$14.71
|
| Rate for Payer: HealthUtah PPO |
$25.36
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.60
|
| Rate for Payer: Multiplan Medicare/VA |
$13.97
|
| Rate for Payer: One Health Plan of WY PPO |
$24.85
|
| Rate for Payer: PacificSource Commercial |
$22.82
|
| Rate for Payer: PHCS PPO |
$24.85
|
| Rate for Payer: Three Rivers PPO |
$19.02
|
| Rate for Payer: TriWest Veterans Administration |
$14.71
|
| Rate for Payer: United Healthcare Commercial |
$22.06
|
| Rate for Payer: United Healthcare Medicare |
$14.71
|
| Rate for Payer: WINHealth Partners Commercial |
$24.85
|
| Rate for Payer: Wise Provider Network Commercial |
$24.09
|
|
|
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [12186]
|
Facility
|
IP
|
$25.36
|
|
|
Service Code
|
NDC 0574402450
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.90 |
| Max. Negotiated Rate |
$25.36 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$24.85
|
| Rate for Payer: Altius Auto/Workers Compensation |
$24.35
|
| Rate for Payer: Altius Commercial |
$24.35
|
| Rate for Payer: Beech Street Commercial |
$24.85
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$20.82
|
| Rate for Payer: Cash Price |
$17.75
|
| Rate for Payer: ChoiceCare Network Commercial |
$24.60
|
| Rate for Payer: Cigna of WY Commercial |
$24.85
|
| Rate for Payer: Entrust Commercial |
$24.09
|
| Rate for Payer: First Choice Health Commercial |
$24.09
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$24.09
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$16.74
|
| Rate for Payer: HealthUtah PPO |
$25.36
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.60
|
| Rate for Payer: Multiplan Medicare/VA |
$15.90
|
| Rate for Payer: One Health Plan of WY PPO |
$24.85
|
| Rate for Payer: PacificSource Commercial |
$22.82
|
| Rate for Payer: PHCS PPO |
$24.85
|
| Rate for Payer: Three Rivers PPO |
$19.02
|
| Rate for Payer: TriWest Veterans Administration |
$16.74
|
| Rate for Payer: United Healthcare Commercial |
$22.06
|
| Rate for Payer: United Healthcare Medicare |
$16.74
|
| Rate for Payer: WINHealth Partners Commercial |
$24.09
|
| Rate for Payer: Wise Provider Network Commercial |
$24.09
|
|
|
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [12186]
|
Facility
|
IP
|
$26.56
|
|
|
Service Code
|
NDC 1747807031
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.65 |
| Max. Negotiated Rate |
$26.56 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$26.03
|
| Rate for Payer: Altius Auto/Workers Compensation |
$25.50
|
| Rate for Payer: Altius Commercial |
$25.50
|
| Rate for Payer: Beech Street Commercial |
$26.03
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$21.81
|
| Rate for Payer: Cash Price |
$18.59
|
| Rate for Payer: ChoiceCare Network Commercial |
$25.76
|
| Rate for Payer: Cigna of WY Commercial |
$26.03
|
| Rate for Payer: Entrust Commercial |
$25.23
|
| Rate for Payer: First Choice Health Commercial |
$25.23
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$25.23
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$17.53
|
| Rate for Payer: HealthUtah PPO |
$26.56
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$25.76
|
| Rate for Payer: Multiplan Medicare/VA |
$16.65
|
| Rate for Payer: One Health Plan of WY PPO |
$26.03
|
| Rate for Payer: PacificSource Commercial |
$23.90
|
| Rate for Payer: PHCS PPO |
$26.03
|
| Rate for Payer: Three Rivers PPO |
$19.92
|
| Rate for Payer: TriWest Veterans Administration |
$17.53
|
| Rate for Payer: United Healthcare Commercial |
$23.11
|
| Rate for Payer: United Healthcare Medicare |
$17.53
|
| Rate for Payer: WINHealth Partners Commercial |
$25.23
|
| Rate for Payer: Wise Provider Network Commercial |
$25.23
|
|
|
ESCITALOPRAM 10 MG TABLET [25995]
|
Facility
|
IP
|
$0.96
|
|
|
Service Code
|
NDC 6808461701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$0.96 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.94
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.92
|
| Rate for Payer: Altius Commercial |
$0.92
|
| Rate for Payer: Beech Street Commercial |
$0.94
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.79
|
| Rate for Payer: Cash Price |
$0.67
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.93
|
| Rate for Payer: Cigna of WY Commercial |
$0.94
|
| Rate for Payer: Entrust Commercial |
$0.91
|
| Rate for Payer: First Choice Health Commercial |
$0.91
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.91
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.63
|
| Rate for Payer: HealthUtah PPO |
$0.96
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.93
|
| Rate for Payer: Multiplan Medicare/VA |
$0.60
|
| Rate for Payer: One Health Plan of WY PPO |
$0.94
|
| Rate for Payer: PacificSource Commercial |
$0.86
|
| Rate for Payer: PHCS PPO |
$0.94
|
| Rate for Payer: Three Rivers PPO |
$0.72
|
| Rate for Payer: TriWest Veterans Administration |
$0.63
|
| Rate for Payer: United Healthcare Commercial |
$0.84
|
| Rate for Payer: United Healthcare Medicare |
$0.63
|
| Rate for Payer: WINHealth Partners Commercial |
$0.91
|
| Rate for Payer: Wise Provider Network Commercial |
$0.91
|
|
|
ESCITALOPRAM 10 MG TABLET [25995]
|
Facility
|
OP
|
$0.96
|
|
|
Service Code
|
NDC 6808461701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$0.96 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.94
|
| Rate for Payer: Aetna of WY Medicare |
$0.63
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.92
|
| Rate for Payer: Altius Commercial |
$0.92
|
| Rate for Payer: Beech Street Commercial |
$0.94
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.79
|
| Rate for Payer: Cash Price |
$0.67
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.93
|
| Rate for Payer: Cigna of WY Commercial |
$0.94
|
| Rate for Payer: Entrust Commercial |
$0.91
|
| Rate for Payer: First Choice Health Commercial |
$0.91
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.91
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.56
|
| Rate for Payer: HealthUtah PPO |
$0.96
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.93
|
| Rate for Payer: Multiplan Medicare/VA |
$0.53
|
| Rate for Payer: One Health Plan of WY PPO |
$0.94
|
| Rate for Payer: PacificSource Commercial |
$0.86
|
| Rate for Payer: PHCS PPO |
$0.94
|
| Rate for Payer: Three Rivers PPO |
$0.72
|
| Rate for Payer: TriWest Veterans Administration |
$0.56
|
| Rate for Payer: United Healthcare Commercial |
$0.84
|
| Rate for Payer: United Healthcare Medicare |
$0.56
|
| Rate for Payer: WINHealth Partners Commercial |
$0.94
|
| Rate for Payer: Wise Provider Network Commercial |
$0.91
|
|
|
ESCITALOPRAM 10 MG TABLET [25995]
|
Facility
|
OP
|
$0.96
|
|
|
Service Code
|
NDC 6808461711
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$0.96 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.94
|
| Rate for Payer: Aetna of WY Medicare |
$0.63
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.92
|
| Rate for Payer: Altius Commercial |
$0.92
|
| Rate for Payer: Beech Street Commercial |
$0.94
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.79
|
| Rate for Payer: Cash Price |
$0.67
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.93
|
| Rate for Payer: Cigna of WY Commercial |
$0.94
|
| Rate for Payer: Entrust Commercial |
$0.91
|
| Rate for Payer: First Choice Health Commercial |
$0.91
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.91
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.56
|
| Rate for Payer: HealthUtah PPO |
$0.96
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.93
|
| Rate for Payer: Multiplan Medicare/VA |
$0.53
|
| Rate for Payer: One Health Plan of WY PPO |
$0.94
|
| Rate for Payer: PacificSource Commercial |
$0.86
|
| Rate for Payer: PHCS PPO |
$0.94
|
| Rate for Payer: Three Rivers PPO |
$0.72
|
| Rate for Payer: TriWest Veterans Administration |
$0.56
|
| Rate for Payer: United Healthcare Commercial |
$0.84
|
| Rate for Payer: United Healthcare Medicare |
$0.56
|
| Rate for Payer: WINHealth Partners Commercial |
$0.94
|
| Rate for Payer: Wise Provider Network Commercial |
$0.91
|
|
|
ESCITALOPRAM 10 MG TABLET [25995]
|
Facility
|
IP
|
$0.96
|
|
|
Service Code
|
NDC 6808461711
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$0.96 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.94
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.92
|
| Rate for Payer: Altius Commercial |
$0.92
|
| Rate for Payer: Beech Street Commercial |
$0.94
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.79
|
| Rate for Payer: Cash Price |
$0.67
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.93
|
| Rate for Payer: Cigna of WY Commercial |
$0.94
|
| Rate for Payer: Entrust Commercial |
$0.91
|
| Rate for Payer: First Choice Health Commercial |
$0.91
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.91
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.63
|
| Rate for Payer: HealthUtah PPO |
$0.96
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.93
|
| Rate for Payer: Multiplan Medicare/VA |
$0.60
|
| Rate for Payer: One Health Plan of WY PPO |
$0.94
|
| Rate for Payer: PacificSource Commercial |
$0.86
|
| Rate for Payer: PHCS PPO |
$0.94
|
| Rate for Payer: Three Rivers PPO |
$0.72
|
| Rate for Payer: TriWest Veterans Administration |
$0.63
|
| Rate for Payer: United Healthcare Commercial |
$0.84
|
| Rate for Payer: United Healthcare Medicare |
$0.63
|
| Rate for Payer: WINHealth Partners Commercial |
$0.91
|
| Rate for Payer: Wise Provider Network Commercial |
$0.91
|
|
|
ESCITALOPRAM 20 MG TABLET [25996]
|
Facility
|
IP
|
$1.27
|
|
|
Service Code
|
NDC 6808461811
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$1.27 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.24
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.22
|
| Rate for Payer: Altius Commercial |
$1.22
|
| Rate for Payer: Beech Street Commercial |
$1.24
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.04
|
| Rate for Payer: Cash Price |
$0.89
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.23
|
| Rate for Payer: Cigna of WY Commercial |
$1.24
|
| Rate for Payer: Entrust Commercial |
$1.21
|
| Rate for Payer: First Choice Health Commercial |
$1.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.84
|
| Rate for Payer: HealthUtah PPO |
$1.27
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.23
|
| Rate for Payer: Multiplan Medicare/VA |
$0.80
|
| Rate for Payer: One Health Plan of WY PPO |
$1.24
|
| Rate for Payer: PacificSource Commercial |
$1.14
|
| Rate for Payer: PHCS PPO |
$1.24
|
| Rate for Payer: Three Rivers PPO |
$0.95
|
| Rate for Payer: TriWest Veterans Administration |
$0.84
|
| Rate for Payer: United Healthcare Commercial |
$1.10
|
| Rate for Payer: United Healthcare Medicare |
$0.84
|
| Rate for Payer: WINHealth Partners Commercial |
$1.21
|
| Rate for Payer: Wise Provider Network Commercial |
$1.21
|
|
