|
DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [13530]
|
Facility
|
OP
|
$25.12
|
|
|
Service Code
|
NDC 5515020902
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.60 |
| Max. Negotiated Rate |
$25.12 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$24.62
|
| Rate for Payer: Aetna of WY Medicare |
$16.58
|
| Rate for Payer: Altius Commercial |
$24.12
|
| Rate for Payer: Beech Street Commercial |
$24.62
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$24.37
|
| Rate for Payer: Cash Price |
$17.59
|
| Rate for Payer: ChoiceCare Network Commercial |
$24.37
|
| Rate for Payer: Cigna of WY Commercial |
$24.62
|
| Rate for Payer: Entrust Commercial |
$23.86
|
| Rate for Payer: First Choice Health Commercial |
$23.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$23.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$14.32
|
| Rate for Payer: HealthUtah PPO |
$25.12
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.37
|
| Rate for Payer: Multiplan Medicare/VA |
$13.60
|
| Rate for Payer: One Health Plan of WY PPO |
$24.62
|
| Rate for Payer: PacificSource Commercial |
$22.61
|
| Rate for Payer: PHCS PPO |
$24.62
|
| Rate for Payer: Three Rivers PPO |
$18.84
|
| Rate for Payer: TriWest Veterans Administration |
$14.32
|
| Rate for Payer: United Healthcare Commercial |
$23.99
|
| Rate for Payer: United Healthcare Medicare |
$14.32
|
| Rate for Payer: WINHealth Partners Commercial |
$24.62
|
| Rate for Payer: Wise Provider Network Commercial |
$23.86
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP [7159]
|
Facility
|
IP
|
$15.92
|
|
|
Service Code
|
NDC 0121127610
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.23 |
| Max. Negotiated Rate |
$15.92 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.60
|
| Rate for Payer: Aetna of WY Medicare |
$10.19
|
| Rate for Payer: Altius Commercial |
$15.28
|
| Rate for Payer: Beech Street Commercial |
$15.60
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.44
|
| Rate for Payer: Cash Price |
$11.15
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.44
|
| Rate for Payer: Cigna of WY Commercial |
$15.60
|
| Rate for Payer: Entrust Commercial |
$15.12
|
| Rate for Payer: First Choice Health Commercial |
$15.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.71
|
| Rate for Payer: HealthUtah PPO |
$15.92
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.44
|
| Rate for Payer: Multiplan Medicare/VA |
$9.23
|
| Rate for Payer: One Health Plan of WY PPO |
$15.60
|
| Rate for Payer: PacificSource Commercial |
$14.33
|
| Rate for Payer: PHCS PPO |
$15.60
|
| Rate for Payer: Three Rivers PPO |
$11.94
|
| Rate for Payer: TriWest Veterans Administration |
$9.71
|
| Rate for Payer: United Healthcare Commercial |
$15.20
|
| Rate for Payer: United Healthcare Medicare |
$9.71
|
| Rate for Payer: WINHealth Partners Commercial |
$15.12
|
| Rate for Payer: Wise Provider Network Commercial |
$15.12
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP [7159]
|
Facility
|
OP
|
$15.92
|
|
|
Service Code
|
NDC 0121127610
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.62 |
| Max. Negotiated Rate |
$15.92 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.60
|
| Rate for Payer: Aetna of WY Medicare |
$10.51
|
| Rate for Payer: Altius Commercial |
$15.28
|
| Rate for Payer: Beech Street Commercial |
$15.60
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.44
|
| Rate for Payer: Cash Price |
$11.15
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.44
|
| Rate for Payer: Cigna of WY Commercial |
$15.60
|
| Rate for Payer: Entrust Commercial |
$15.12
|
| Rate for Payer: First Choice Health Commercial |
$15.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.07
|
| Rate for Payer: HealthUtah PPO |
$15.92
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.44
|
| Rate for Payer: Multiplan Medicare/VA |
$8.62
|
| Rate for Payer: One Health Plan of WY PPO |
$15.60
|
| Rate for Payer: PacificSource Commercial |
$14.33
|
| Rate for Payer: PHCS PPO |
$15.60
|
| Rate for Payer: Three Rivers PPO |
$11.94
|
| Rate for Payer: TriWest Veterans Administration |
$9.07
|
| Rate for Payer: United Healthcare Commercial |
$15.20
|
| Rate for Payer: United Healthcare Medicare |
$9.07
|
| Rate for Payer: WINHealth Partners Commercial |
$15.60
|
| Rate for Payer: Wise Provider Network Commercial |
$15.12
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR [17761]
|
Facility
|
OP
|
$17.24
|
|
|
Service Code
|
NDC 6068765111
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.34 |
| Max. Negotiated Rate |
$17.24 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.90
|
| Rate for Payer: Aetna of WY Medicare |
$11.38
|
| Rate for Payer: Altius Commercial |
$16.55
|
| Rate for Payer: Beech Street Commercial |
$16.90
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.72
|
| Rate for Payer: Cash Price |
$12.07
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.72
|
| Rate for Payer: Cigna of WY Commercial |
$16.90
|
| Rate for Payer: Entrust Commercial |
$16.38
|
| Rate for Payer: First Choice Health Commercial |
$16.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.83
|
| Rate for Payer: HealthUtah PPO |
$17.24
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.72
|
| Rate for Payer: Multiplan Medicare/VA |
$9.34
|
| Rate for Payer: One Health Plan of WY PPO |
$16.90
|
| Rate for Payer: PacificSource Commercial |
$15.52
|
| Rate for Payer: PHCS PPO |
$16.90
|
| Rate for Payer: Three Rivers PPO |
$12.93
|
| Rate for Payer: TriWest Veterans Administration |
$9.83
|
| Rate for Payer: United Healthcare Commercial |
$16.46
|
| Rate for Payer: United Healthcare Medicare |
$9.83
|
| Rate for Payer: WINHealth Partners Commercial |
$16.90
|
| Rate for Payer: Wise Provider Network Commercial |
$16.38
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR [17761]
|
Facility
|
IP
|
$20.17
|
|
|
Service Code
|
NDC 6382405634
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.69 |
| Max. Negotiated Rate |
$20.17 |
| Rate for Payer: United Healthcare Commercial |
$19.26
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$19.77
|
| Rate for Payer: Aetna of WY Medicare |
$12.91
|
| Rate for Payer: Altius Commercial |
$19.36
|
| Rate for Payer: Beech Street Commercial |
$19.77
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$19.56
|
| Rate for Payer: Cash Price |
$14.12
|
| Rate for Payer: ChoiceCare Network Commercial |
$19.56
|
| Rate for Payer: Cigna of WY Commercial |
$19.77
|
| Rate for Payer: Entrust Commercial |
$19.16
|
| Rate for Payer: First Choice Health Commercial |
$19.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$19.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$12.30
|
| Rate for Payer: HealthUtah PPO |
$20.17
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$19.56
|
| Rate for Payer: Multiplan Medicare/VA |
$11.69
|
| Rate for Payer: One Health Plan of WY PPO |
$19.77
|
| Rate for Payer: PacificSource Commercial |
$18.15
|
| Rate for Payer: PHCS PPO |
$19.77
|
| Rate for Payer: Three Rivers PPO |
$15.13
|
| Rate for Payer: TriWest Veterans Administration |
$12.30
|
| Rate for Payer: United Healthcare Medicare |
$12.30
|
| Rate for Payer: WINHealth Partners Commercial |
$19.16
|
| Rate for Payer: Wise Provider Network Commercial |
$19.16
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR [17761]
|
Facility
|
OP
|
$20.17
|
|
|
Service Code
|
NDC 6382405634
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.92 |
| Max. Negotiated Rate |
$20.17 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$19.77
|
| Rate for Payer: Aetna of WY Medicare |
$13.31
|
| Rate for Payer: Altius Commercial |
$19.36
|
| Rate for Payer: Beech Street Commercial |
$19.77
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$19.56
|
| Rate for Payer: Cash Price |
$14.12
|
| Rate for Payer: ChoiceCare Network Commercial |
$19.56
|
| Rate for Payer: Cigna of WY Commercial |
$19.77
|
| Rate for Payer: Entrust Commercial |
$19.16
|
| Rate for Payer: First Choice Health Commercial |
$19.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$19.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.50
|
| Rate for Payer: HealthUtah PPO |
$20.17
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$19.56
|
| Rate for Payer: Multiplan Medicare/VA |
$10.92
|
| Rate for Payer: One Health Plan of WY PPO |
$19.77
|
| Rate for Payer: PacificSource Commercial |
$18.15
|
| Rate for Payer: PHCS PPO |
$19.77
|
| Rate for Payer: Three Rivers PPO |
$15.13
|
| Rate for Payer: TriWest Veterans Administration |
$11.50
|
| Rate for Payer: United Healthcare Commercial |
$19.26
|
| Rate for Payer: United Healthcare Medicare |
$11.50
|
| Rate for Payer: WINHealth Partners Commercial |
$19.77
|
| Rate for Payer: Wise Provider Network Commercial |
$19.16
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR [17761]
|
Facility
|
IP
|
$17.24
|
|
|
Service Code
|
NDC 6068765111
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.99 |
| Max. Negotiated Rate |
$17.24 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.90
|
| Rate for Payer: Aetna of WY Medicare |
$11.03
|
| Rate for Payer: Altius Commercial |
$16.55
|
| Rate for Payer: Beech Street Commercial |
$16.90
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.72
|
| Rate for Payer: Cash Price |
$12.07
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.72
|
| Rate for Payer: Cigna of WY Commercial |
$16.90
|
| Rate for Payer: Entrust Commercial |
$16.38
|
| Rate for Payer: First Choice Health Commercial |
$16.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.52
|
| Rate for Payer: HealthUtah PPO |
$17.24
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.72
|
| Rate for Payer: Multiplan Medicare/VA |
$9.99
|
| Rate for Payer: One Health Plan of WY PPO |
$16.90
|
| Rate for Payer: PacificSource Commercial |
$15.52
|
| Rate for Payer: PHCS PPO |
$16.90
|
| Rate for Payer: Three Rivers PPO |
$12.93
|
| Rate for Payer: TriWest Veterans Administration |
$10.52
|
| Rate for Payer: United Healthcare Commercial |
$16.46
|
| Rate for Payer: United Healthcare Medicare |
$10.52
|
| Rate for Payer: WINHealth Partners Commercial |
$16.38
|
| Rate for Payer: Wise Provider Network Commercial |
$16.38
|
|
|
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION [25390]
|
Facility
|
IP
|
$15.04
|
|
|
Service Code
|
NDC 6332382425
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.72 |
| Max. Negotiated Rate |
$15.04 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.74
|
| Rate for Payer: Aetna of WY Medicare |
$9.63
|
| Rate for Payer: Altius Commercial |
$14.44
|
| Rate for Payer: Beech Street Commercial |
$14.74
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.59
|
| Rate for Payer: Cash Price |
$10.53
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.59
|
| Rate for Payer: Cigna of WY Commercial |
$14.74
|
| Rate for Payer: Entrust Commercial |
$14.29
|
| Rate for Payer: First Choice Health Commercial |
$14.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.17
|
| Rate for Payer: HealthUtah PPO |
$15.04
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.59
|
| Rate for Payer: Multiplan Medicare/VA |
$8.72
|
| Rate for Payer: One Health Plan of WY PPO |
$14.74
|
| Rate for Payer: PacificSource Commercial |
$13.54
|
| Rate for Payer: PHCS PPO |
$14.74
|
| Rate for Payer: Three Rivers PPO |
$11.28
|
| Rate for Payer: TriWest Veterans Administration |
$9.17
|
| Rate for Payer: United Healthcare Commercial |
$14.36
|
| Rate for Payer: United Healthcare Medicare |
$9.17
|
| Rate for Payer: WINHealth Partners Commercial |
$14.29
|
| Rate for Payer: Wise Provider Network Commercial |
$14.29
|
|
|
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION [25390]
|
Facility
|
IP
|
$15.04
|
|
|
Service Code
|
NDC 0264752010
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.72 |
| Max. Negotiated Rate |
$15.04 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.74
|
| Rate for Payer: Aetna of WY Medicare |
$9.63
|
| Rate for Payer: Altius Commercial |
$14.44
|
| Rate for Payer: Beech Street Commercial |
$14.74
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.59
|
| Rate for Payer: Cash Price |
$10.52
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.59
|
| Rate for Payer: Cigna of WY Commercial |
$14.74
|
| Rate for Payer: Entrust Commercial |
$14.29
|
| Rate for Payer: First Choice Health Commercial |
$14.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.17
|
| Rate for Payer: HealthUtah PPO |
$15.04
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.59
|
| Rate for Payer: Multiplan Medicare/VA |
$8.72
|
| Rate for Payer: One Health Plan of WY PPO |
$14.74
|
| Rate for Payer: PacificSource Commercial |
$13.54
|
| Rate for Payer: PHCS PPO |
$14.74
|
| Rate for Payer: Three Rivers PPO |
$11.28
|
| Rate for Payer: TriWest Veterans Administration |
$9.17
|
| Rate for Payer: United Healthcare Commercial |
$14.36
|
| Rate for Payer: United Healthcare Medicare |
$9.17
|
| Rate for Payer: WINHealth Partners Commercial |
$14.29
|
| Rate for Payer: Wise Provider Network Commercial |
$14.29
|
|
|
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION [25390]
|
Facility
|
OP
|
$15.04
|
|
|
Service Code
|
NDC 0264752010
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.14 |
| Max. Negotiated Rate |
$15.04 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.74
|
| Rate for Payer: Aetna of WY Medicare |
$9.93
|
| Rate for Payer: Altius Commercial |
$14.44
|
| Rate for Payer: Beech Street Commercial |
$14.74
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.59
|
| Rate for Payer: Cash Price |
$10.52
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.59
|
| Rate for Payer: Cigna of WY Commercial |
$14.74
|
| Rate for Payer: Entrust Commercial |
$14.29
|
| Rate for Payer: First Choice Health Commercial |
$14.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.57
|
| Rate for Payer: HealthUtah PPO |
$15.04
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.59
|
| Rate for Payer: Multiplan Medicare/VA |
$8.14
|
| Rate for Payer: One Health Plan of WY PPO |
$14.74
|
| Rate for Payer: PacificSource Commercial |
$13.54
|
| Rate for Payer: PHCS PPO |
$14.74
|
| Rate for Payer: Three Rivers PPO |
$11.28
|
| Rate for Payer: TriWest Veterans Administration |
$8.57
|
| Rate for Payer: United Healthcare Commercial |
$14.36
|
| Rate for Payer: United Healthcare Medicare |
$8.57
|
| Rate for Payer: WINHealth Partners Commercial |
$14.74
|
| Rate for Payer: Wise Provider Network Commercial |
$14.29
|
|
|
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION [25390]
|
Facility
|
OP
|
$15.04
|
|
|
Service Code
|
NDC 6332382425
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.14 |
| Max. Negotiated Rate |
$15.04 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.74
|
| Rate for Payer: Aetna of WY Medicare |
$9.93
|
| Rate for Payer: Altius Commercial |
$14.44
|
| Rate for Payer: Beech Street Commercial |
$14.74
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.59
|
| Rate for Payer: Cash Price |
$10.53
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.59
|
| Rate for Payer: Cigna of WY Commercial |
$14.74
|
| Rate for Payer: Entrust Commercial |
$14.29
|
| Rate for Payer: First Choice Health Commercial |
$14.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.57
|
| Rate for Payer: HealthUtah PPO |
$15.04
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.59
|
| Rate for Payer: Multiplan Medicare/VA |
$8.14
|
| Rate for Payer: One Health Plan of WY PPO |
$14.74
|
| Rate for Payer: PacificSource Commercial |
$13.54
|
| Rate for Payer: PHCS PPO |
$14.74
|
| Rate for Payer: Three Rivers PPO |
$11.28
|
| Rate for Payer: TriWest Veterans Administration |
$8.57
|
| Rate for Payer: United Healthcare Commercial |
$14.36
|
| Rate for Payer: United Healthcare Medicare |
$8.57
|
| Rate for Payer: WINHealth Partners Commercial |
$14.74
|
| Rate for Payer: Wise Provider Network Commercial |
$14.29
|
|
|
DEXTROSE 10 % IV BOLUS [400302]
|
Facility
|
IP
|
$15.04
|
|
|
Service Code
|
NDC 6332382425
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.72 |
| Max. Negotiated Rate |
$15.04 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.74
|
| Rate for Payer: Aetna of WY Medicare |
$9.63
|
| Rate for Payer: Altius Commercial |
$14.44
|
| Rate for Payer: Beech Street Commercial |
$14.74
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.59
|
| Rate for Payer: Cash Price |
$10.53
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.59
|
| Rate for Payer: Cigna of WY Commercial |
$14.74
|
| Rate for Payer: Entrust Commercial |
$14.29
|
| Rate for Payer: First Choice Health Commercial |
$14.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.17
|
| Rate for Payer: HealthUtah PPO |
$15.04
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.59
|
| Rate for Payer: Multiplan Medicare/VA |
$8.72
|
| Rate for Payer: One Health Plan of WY PPO |
$14.74
|
| Rate for Payer: PacificSource Commercial |
$13.54
|
| Rate for Payer: PHCS PPO |
$14.74
|
| Rate for Payer: Three Rivers PPO |
$11.28
|
| Rate for Payer: TriWest Veterans Administration |
$9.17
|
| Rate for Payer: United Healthcare Commercial |
$14.36
|
| Rate for Payer: United Healthcare Medicare |
$9.17
|
| Rate for Payer: WINHealth Partners Commercial |
$14.29
|
| Rate for Payer: Wise Provider Network Commercial |
$14.29
|
|
|
DEXTROSE 10 % IV BOLUS [400302]
|
Facility
|
OP
|
$15.04
|
|
|
Service Code
|
NDC 0264752010
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.14 |
| Max. Negotiated Rate |
$15.04 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.74
|
| Rate for Payer: Aetna of WY Medicare |
$9.93
|
| Rate for Payer: Altius Commercial |
$14.44
|
| Rate for Payer: Beech Street Commercial |
$14.74
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.59
|
| Rate for Payer: Cash Price |
$10.52
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.59
|
| Rate for Payer: Cigna of WY Commercial |
$14.74
|
| Rate for Payer: Entrust Commercial |
$14.29
|
| Rate for Payer: First Choice Health Commercial |
$14.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.57
|
| Rate for Payer: HealthUtah PPO |
$15.04
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.59
|
| Rate for Payer: Multiplan Medicare/VA |
$8.14
|
| Rate for Payer: One Health Plan of WY PPO |
$14.74
|
| Rate for Payer: PacificSource Commercial |
$13.54
|
| Rate for Payer: PHCS PPO |
$14.74
|
| Rate for Payer: Three Rivers PPO |
$11.28
|
| Rate for Payer: TriWest Veterans Administration |
$8.57
|
| Rate for Payer: United Healthcare Commercial |
$14.36
|
| Rate for Payer: United Healthcare Medicare |
$8.57
|
| Rate for Payer: WINHealth Partners Commercial |
$14.74
|
| Rate for Payer: Wise Provider Network Commercial |
$14.29
|
|
|
DEXTROSE 10 % IV BOLUS [400302]
|
Facility
|
IP
|
$15.04
|
|
|
Service Code
|
NDC 0264752010
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.72 |
| Max. Negotiated Rate |
$15.04 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.74
|
| Rate for Payer: Aetna of WY Medicare |
$9.63
|
| Rate for Payer: Altius Commercial |
$14.44
|
| Rate for Payer: Beech Street Commercial |
$14.74
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.59
|
| Rate for Payer: Cash Price |
$10.52
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.59
|
| Rate for Payer: Cigna of WY Commercial |
$14.74
|
| Rate for Payer: Entrust Commercial |
$14.29
|
| Rate for Payer: First Choice Health Commercial |
$14.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.17
|
| Rate for Payer: HealthUtah PPO |
$15.04
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.59
|
| Rate for Payer: Multiplan Medicare/VA |
$8.72
|
| Rate for Payer: One Health Plan of WY PPO |
$14.74
|
| Rate for Payer: PacificSource Commercial |
$13.54
|
| Rate for Payer: PHCS PPO |
$14.74
|
| Rate for Payer: Three Rivers PPO |
$11.28
|
| Rate for Payer: TriWest Veterans Administration |
$9.17
|
| Rate for Payer: United Healthcare Commercial |
$14.36
|
| Rate for Payer: United Healthcare Medicare |
$9.17
|
| Rate for Payer: WINHealth Partners Commercial |
$14.29
|
| Rate for Payer: Wise Provider Network Commercial |
$14.29
|
|
|
DEXTROSE 10 % IV BOLUS [400302]
|
Facility
|
OP
|
$15.04
|
|
|
Service Code
|
NDC 6332382425
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.14 |
| Max. Negotiated Rate |
$15.04 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.74
|
| Rate for Payer: Aetna of WY Medicare |
$9.93
|
| Rate for Payer: Altius Commercial |
$14.44
|
| Rate for Payer: Beech Street Commercial |
$14.74
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.59
|
| Rate for Payer: Cash Price |
$10.53
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.59
|
| Rate for Payer: Cigna of WY Commercial |
$14.74
|
| Rate for Payer: Entrust Commercial |
$14.29
|
| Rate for Payer: First Choice Health Commercial |
$14.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.57
|
| Rate for Payer: HealthUtah PPO |
$15.04
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.59
|
| Rate for Payer: Multiplan Medicare/VA |
$8.14
|
| Rate for Payer: One Health Plan of WY PPO |
$14.74
|
| Rate for Payer: PacificSource Commercial |
$13.54
|
| Rate for Payer: PHCS PPO |
$14.74
|
| Rate for Payer: Three Rivers PPO |
$11.28
|
| Rate for Payer: TriWest Veterans Administration |
$8.57
|
| Rate for Payer: United Healthcare Commercial |
$14.36
|
| Rate for Payer: United Healthcare Medicare |
$8.57
|
| Rate for Payer: WINHealth Partners Commercial |
$14.74
|
| Rate for Payer: Wise Provider Network Commercial |
$14.29
|
|
|
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE [25348]
|
Facility
|
OP
|
$15.98
|
|
|
Service Code
|
NDC 0409751766
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.65 |
| Max. Negotiated Rate |
$15.98 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.66
|
| Rate for Payer: Aetna of WY Medicare |
$10.55
|
| Rate for Payer: Altius Commercial |
$15.34
|
| Rate for Payer: Beech Street Commercial |
$15.66
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.50
|
| Rate for Payer: Cash Price |
$11.19
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.50
|
| Rate for Payer: Cigna of WY Commercial |
$15.66
|
| Rate for Payer: Entrust Commercial |
$15.18
|
| Rate for Payer: First Choice Health Commercial |
$15.18
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.18
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.11
|
| Rate for Payer: HealthUtah PPO |
$15.98
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.50
|
| Rate for Payer: Multiplan Medicare/VA |
$8.65
|
| Rate for Payer: One Health Plan of WY PPO |
$15.66
|
| Rate for Payer: PacificSource Commercial |
$14.38
|
| Rate for Payer: PHCS PPO |
$15.66
|
| Rate for Payer: Three Rivers PPO |
$11.98
|
| Rate for Payer: TriWest Veterans Administration |
$9.11
|
| Rate for Payer: United Healthcare Commercial |
$15.26
|
| Rate for Payer: United Healthcare Medicare |
$9.11
|
| Rate for Payer: WINHealth Partners Commercial |
$15.66
|
| Rate for Payer: Wise Provider Network Commercial |
$15.18
|
|
|
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE [25348]
|
Facility
|
IP
|
$16.34
|
|
|
Service Code
|
NDC 7632933021
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.47 |
| Max. Negotiated Rate |
$16.34 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.01
|
| Rate for Payer: Aetna of WY Medicare |
$10.46
|
| Rate for Payer: Altius Commercial |
$15.69
|
| Rate for Payer: Beech Street Commercial |
$16.01
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.85
|
| Rate for Payer: Cash Price |
$11.44
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.85
|
| Rate for Payer: Cigna of WY Commercial |
$16.01
|
| Rate for Payer: Entrust Commercial |
$15.52
|
| Rate for Payer: First Choice Health Commercial |
$15.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.97
|
| Rate for Payer: HealthUtah PPO |
$16.34
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.85
|
| Rate for Payer: Multiplan Medicare/VA |
$9.47
|
| Rate for Payer: One Health Plan of WY PPO |
$16.01
|
| Rate for Payer: PacificSource Commercial |
$14.71
|
| Rate for Payer: PHCS PPO |
$16.01
|
| Rate for Payer: Three Rivers PPO |
$12.26
|
| Rate for Payer: TriWest Veterans Administration |
$9.97
|
| Rate for Payer: United Healthcare Commercial |
$15.60
|
| Rate for Payer: United Healthcare Medicare |
$9.97
|
| Rate for Payer: WINHealth Partners Commercial |
$15.52
|
| Rate for Payer: Wise Provider Network Commercial |
$15.52
|
|
|
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE [25348]
|
Facility
|
IP
|
$15.98
|
|
|
Service Code
|
NDC 0409751766
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.26 |
| Max. Negotiated Rate |
$15.98 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.66
|
| Rate for Payer: Aetna of WY Medicare |
$10.23
|
| Rate for Payer: Altius Commercial |
$15.34
|
| Rate for Payer: Beech Street Commercial |
$15.66
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.50
|
| Rate for Payer: Cash Price |
$11.19
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.50
|
| Rate for Payer: Cigna of WY Commercial |
$15.66
|
| Rate for Payer: Entrust Commercial |
$15.18
|
| Rate for Payer: First Choice Health Commercial |
$15.18
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.18
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.75
|
| Rate for Payer: HealthUtah PPO |
$15.98
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.50
|
| Rate for Payer: Multiplan Medicare/VA |
$9.26
|
| Rate for Payer: One Health Plan of WY PPO |
$15.66
|
| Rate for Payer: PacificSource Commercial |
$14.38
|
| Rate for Payer: PHCS PPO |
$15.66
|
| Rate for Payer: Three Rivers PPO |
$11.98
|
| Rate for Payer: TriWest Veterans Administration |
$9.75
|
| Rate for Payer: United Healthcare Commercial |
$15.26
|
| Rate for Payer: United Healthcare Medicare |
$9.75
|
| Rate for Payer: WINHealth Partners Commercial |
$15.18
|
| Rate for Payer: Wise Provider Network Commercial |
$15.18
|
|
|
DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE [25348]
|
Facility
|
OP
|
$16.34
|
|
|
Service Code
|
NDC 7632933021
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.85 |
| Max. Negotiated Rate |
$16.34 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.01
|
| Rate for Payer: Aetna of WY Medicare |
$10.78
|
| Rate for Payer: Altius Commercial |
$15.69
|
| Rate for Payer: Beech Street Commercial |
$16.01
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.85
|
| Rate for Payer: Cash Price |
$11.44
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.85
|
| Rate for Payer: Cigna of WY Commercial |
$16.01
|
| Rate for Payer: Entrust Commercial |
$15.52
|
| Rate for Payer: First Choice Health Commercial |
$15.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.31
|
| Rate for Payer: HealthUtah PPO |
$16.34
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.85
|
| Rate for Payer: Multiplan Medicare/VA |
$8.85
|
| Rate for Payer: One Health Plan of WY PPO |
$16.01
|
| Rate for Payer: PacificSource Commercial |
$14.71
|
| Rate for Payer: PHCS PPO |
$16.01
|
| Rate for Payer: Three Rivers PPO |
$12.26
|
| Rate for Payer: TriWest Veterans Administration |
$9.31
|
| Rate for Payer: United Healthcare Commercial |
$15.60
|
| Rate for Payer: United Healthcare Medicare |
$9.31
|
| Rate for Payer: WINHealth Partners Commercial |
$16.01
|
| Rate for Payer: Wise Provider Network Commercial |
$15.52
|
|
|
DEXTROSE 5 % AND 0.45 % NACL IV BOLUS [400295]
|
Facility
|
IP
|
$15.01
|
|
|
Service Code
|
NDC 0264761200
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.70 |
| Max. Negotiated Rate |
$15.01 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.71
|
| Rate for Payer: Aetna of WY Medicare |
$9.61
|
| Rate for Payer: Altius Commercial |
$14.41
|
| Rate for Payer: Beech Street Commercial |
$14.71
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.56
|
| Rate for Payer: Cash Price |
$10.51
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.56
|
| Rate for Payer: Cigna of WY Commercial |
$14.71
|
| Rate for Payer: Entrust Commercial |
$14.26
|
| Rate for Payer: First Choice Health Commercial |
$14.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.16
|
| Rate for Payer: HealthUtah PPO |
$15.01
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.56
|
| Rate for Payer: Multiplan Medicare/VA |
$8.70
|
| Rate for Payer: One Health Plan of WY PPO |
$14.71
|
| Rate for Payer: PacificSource Commercial |
$13.51
|
| Rate for Payer: PHCS PPO |
$14.71
|
| Rate for Payer: Three Rivers PPO |
$11.26
|
| Rate for Payer: TriWest Veterans Administration |
$9.16
|
| Rate for Payer: United Healthcare Commercial |
$14.33
|
| Rate for Payer: United Healthcare Medicare |
$9.16
|
| Rate for Payer: WINHealth Partners Commercial |
$14.26
|
| Rate for Payer: Wise Provider Network Commercial |
$14.26
|
|
|
DEXTROSE 5 % AND 0.45 % NACL IV BOLUS [400295]
|
Facility
|
OP
|
$15.01
|
|
|
Service Code
|
NDC 0264761200
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.13 |
| Max. Negotiated Rate |
$15.01 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.71
|
| Rate for Payer: Aetna of WY Medicare |
$9.91
|
| Rate for Payer: Altius Commercial |
$14.41
|
| Rate for Payer: Beech Street Commercial |
$14.71
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.56
|
| Rate for Payer: Cash Price |
$10.51
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.56
|
| Rate for Payer: Cigna of WY Commercial |
$14.71
|
| Rate for Payer: Entrust Commercial |
$14.26
|
| Rate for Payer: First Choice Health Commercial |
$14.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.56
|
| Rate for Payer: HealthUtah PPO |
$15.01
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.56
|
| Rate for Payer: Multiplan Medicare/VA |
$8.13
|
| Rate for Payer: One Health Plan of WY PPO |
$14.71
|
| Rate for Payer: PacificSource Commercial |
$13.51
|
| Rate for Payer: PHCS PPO |
$14.71
|
| Rate for Payer: Three Rivers PPO |
$11.26
|
| Rate for Payer: TriWest Veterans Administration |
$8.56
|
| Rate for Payer: United Healthcare Commercial |
$14.33
|
| Rate for Payer: United Healthcare Medicare |
$8.56
|
| Rate for Payer: WINHealth Partners Commercial |
$14.71
|
| Rate for Payer: Wise Provider Network Commercial |
$14.26
|
|
|
DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION [19093]
|
Facility
|
OP
|
$15.01
|
|
|
Service Code
|
NDC 0264761200
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.13 |
| Max. Negotiated Rate |
$15.01 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.71
|
| Rate for Payer: Aetna of WY Medicare |
$9.91
|
| Rate for Payer: Altius Commercial |
$14.41
|
| Rate for Payer: Beech Street Commercial |
$14.71
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.56
|
| Rate for Payer: Cash Price |
$10.51
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.56
|
| Rate for Payer: Cigna of WY Commercial |
$14.71
|
| Rate for Payer: Entrust Commercial |
$14.26
|
| Rate for Payer: First Choice Health Commercial |
$14.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.56
|
| Rate for Payer: HealthUtah PPO |
$15.01
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.56
|
| Rate for Payer: Multiplan Medicare/VA |
$8.13
|
| Rate for Payer: One Health Plan of WY PPO |
$14.71
|
| Rate for Payer: PacificSource Commercial |
$13.51
|
| Rate for Payer: PHCS PPO |
$14.71
|
| Rate for Payer: Three Rivers PPO |
$11.26
|
| Rate for Payer: TriWest Veterans Administration |
$8.56
|
| Rate for Payer: United Healthcare Commercial |
$14.33
|
| Rate for Payer: United Healthcare Medicare |
$8.56
|
| Rate for Payer: WINHealth Partners Commercial |
$14.71
|
| Rate for Payer: Wise Provider Network Commercial |
$14.26
|
|
|
DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION [19093]
|
Facility
|
IP
|
$15.01
|
|
|
Service Code
|
NDC 0264761200
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.70 |
| Max. Negotiated Rate |
$15.01 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.71
|
| Rate for Payer: Aetna of WY Medicare |
$9.61
|
| Rate for Payer: Altius Commercial |
$14.41
|
| Rate for Payer: Beech Street Commercial |
$14.71
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.56
|
| Rate for Payer: Cash Price |
$10.51
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.56
|
| Rate for Payer: Cigna of WY Commercial |
$14.71
|
| Rate for Payer: Entrust Commercial |
$14.26
|
| Rate for Payer: First Choice Health Commercial |
$14.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.16
|
| Rate for Payer: HealthUtah PPO |
$15.01
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.56
|
| Rate for Payer: Multiplan Medicare/VA |
$8.70
|
| Rate for Payer: One Health Plan of WY PPO |
$14.71
|
| Rate for Payer: PacificSource Commercial |
$13.51
|
| Rate for Payer: PHCS PPO |
$14.71
|
| Rate for Payer: Three Rivers PPO |
$11.26
|
| Rate for Payer: TriWest Veterans Administration |
$9.16
|
| Rate for Payer: United Healthcare Commercial |
$14.33
|
| Rate for Payer: United Healthcare Medicare |
$9.16
|
| Rate for Payer: WINHealth Partners Commercial |
$14.26
|
| Rate for Payer: Wise Provider Network Commercial |
$14.26
|
|
|
DEXTROSE 5 % AND 0.9 % NACL IV BOLUS [400294]
|
Facility
|
IP
|
$15.02
|
|
|
Service Code
|
NDC 0264761000
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.70 |
| Max. Negotiated Rate |
$15.02 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.72
|
| Rate for Payer: Aetna of WY Medicare |
$9.61
|
| Rate for Payer: Altius Commercial |
$14.42
|
| Rate for Payer: Beech Street Commercial |
$14.72
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.57
|
| Rate for Payer: Cash Price |
$10.51
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.57
|
| Rate for Payer: Cigna of WY Commercial |
$14.72
|
| Rate for Payer: Entrust Commercial |
$14.27
|
| Rate for Payer: First Choice Health Commercial |
$14.27
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.27
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.16
|
| Rate for Payer: HealthUtah PPO |
$15.02
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.57
|
| Rate for Payer: Multiplan Medicare/VA |
$8.70
|
| Rate for Payer: One Health Plan of WY PPO |
$14.72
|
| Rate for Payer: PacificSource Commercial |
$13.52
|
| Rate for Payer: PHCS PPO |
$14.72
|
| Rate for Payer: Three Rivers PPO |
$11.26
|
| Rate for Payer: TriWest Veterans Administration |
$9.16
|
| Rate for Payer: United Healthcare Commercial |
$14.34
|
| Rate for Payer: United Healthcare Medicare |
$9.16
|
| Rate for Payer: WINHealth Partners Commercial |
$14.27
|
| Rate for Payer: Wise Provider Network Commercial |
$14.27
|
|
|
DEXTROSE 5 % AND 0.9 % NACL IV BOLUS [400294]
|
Facility
|
OP
|
$15.02
|
|
|
Service Code
|
NDC 0264761000
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.13 |
| Max. Negotiated Rate |
$15.02 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.72
|
| Rate for Payer: Aetna of WY Medicare |
$9.91
|
| Rate for Payer: Altius Commercial |
$14.42
|
| Rate for Payer: Beech Street Commercial |
$14.72
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.57
|
| Rate for Payer: Cash Price |
$10.51
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.57
|
| Rate for Payer: Cigna of WY Commercial |
$14.72
|
| Rate for Payer: Entrust Commercial |
$14.27
|
| Rate for Payer: First Choice Health Commercial |
$14.27
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.27
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.56
|
| Rate for Payer: HealthUtah PPO |
$15.02
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.57
|
| Rate for Payer: Multiplan Medicare/VA |
$8.13
|
| Rate for Payer: One Health Plan of WY PPO |
$14.72
|
| Rate for Payer: PacificSource Commercial |
$13.52
|
| Rate for Payer: PHCS PPO |
$14.72
|
| Rate for Payer: Three Rivers PPO |
$11.26
|
| Rate for Payer: TriWest Veterans Administration |
$8.56
|
| Rate for Payer: United Healthcare Commercial |
$14.34
|
| Rate for Payer: United Healthcare Medicare |
$8.56
|
| Rate for Payer: WINHealth Partners Commercial |
$14.72
|
| Rate for Payer: Wise Provider Network Commercial |
$14.27
|
|
