|
DICLOFENAC 1 % TOPICAL GEL [52825]
|
Facility
|
OP
|
$15.39
|
|
|
Service Code
|
NDC 0067815203
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.33 |
| Max. Negotiated Rate |
$15.39 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.08
|
| Rate for Payer: Aetna of WY Medicare |
$10.16
|
| Rate for Payer: Altius Commercial |
$14.77
|
| Rate for Payer: Beech Street Commercial |
$15.08
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.93
|
| Rate for Payer: Cash Price |
$10.77
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.93
|
| Rate for Payer: Cigna of WY Commercial |
$15.08
|
| Rate for Payer: Entrust Commercial |
$14.62
|
| Rate for Payer: First Choice Health Commercial |
$14.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.77
|
| Rate for Payer: HealthUtah PPO |
$15.39
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.93
|
| Rate for Payer: Multiplan Medicare/VA |
$8.33
|
| Rate for Payer: One Health Plan of WY PPO |
$15.08
|
| Rate for Payer: PacificSource Commercial |
$13.85
|
| Rate for Payer: PHCS PPO |
$15.08
|
| Rate for Payer: Three Rivers PPO |
$11.54
|
| Rate for Payer: TriWest Veterans Administration |
$8.77
|
| Rate for Payer: United Healthcare Commercial |
$14.70
|
| Rate for Payer: United Healthcare Medicare |
$8.77
|
| Rate for Payer: WINHealth Partners Commercial |
$15.08
|
| Rate for Payer: Wise Provider Network Commercial |
$14.62
|
|
|
DICLOFENAC 1 % TOPICAL GEL [52825]
|
Facility
|
IP
|
$15.60
|
|
|
Service Code
|
NDC 4612275252
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.04 |
| Max. Negotiated Rate |
$15.60 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.29
|
| Rate for Payer: Aetna of WY Medicare |
$9.98
|
| Rate for Payer: Altius Commercial |
$14.98
|
| Rate for Payer: Beech Street Commercial |
$15.29
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.13
|
| Rate for Payer: Cash Price |
$10.92
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.13
|
| Rate for Payer: Cigna of WY Commercial |
$15.29
|
| Rate for Payer: Entrust Commercial |
$14.82
|
| Rate for Payer: First Choice Health Commercial |
$14.82
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.82
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.52
|
| Rate for Payer: HealthUtah PPO |
$15.60
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.13
|
| Rate for Payer: Multiplan Medicare/VA |
$9.04
|
| Rate for Payer: One Health Plan of WY PPO |
$15.29
|
| Rate for Payer: PacificSource Commercial |
$14.04
|
| Rate for Payer: PHCS PPO |
$15.29
|
| Rate for Payer: Three Rivers PPO |
$11.70
|
| Rate for Payer: TriWest Veterans Administration |
$9.52
|
| Rate for Payer: United Healthcare Commercial |
$14.90
|
| Rate for Payer: United Healthcare Medicare |
$9.52
|
| Rate for Payer: WINHealth Partners Commercial |
$14.82
|
| Rate for Payer: Wise Provider Network Commercial |
$14.82
|
|
|
DICLOFENAC 1 % TOPICAL GEL [52825]
|
Facility
|
IP
|
$15.54
|
|
|
Service Code
|
NDC 4580216000
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.01 |
| Max. Negotiated Rate |
$15.54 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.23
|
| Rate for Payer: Aetna of WY Medicare |
$9.95
|
| Rate for Payer: Altius Commercial |
$14.92
|
| Rate for Payer: Beech Street Commercial |
$15.23
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.07
|
| Rate for Payer: Cash Price |
$10.88
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.07
|
| Rate for Payer: Cigna of WY Commercial |
$15.23
|
| Rate for Payer: Entrust Commercial |
$14.76
|
| Rate for Payer: First Choice Health Commercial |
$14.76
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.76
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.48
|
| Rate for Payer: HealthUtah PPO |
$15.54
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.07
|
| Rate for Payer: Multiplan Medicare/VA |
$9.01
|
| Rate for Payer: One Health Plan of WY PPO |
$15.23
|
| Rate for Payer: PacificSource Commercial |
$13.99
|
| Rate for Payer: PHCS PPO |
$15.23
|
| Rate for Payer: Three Rivers PPO |
$11.66
|
| Rate for Payer: TriWest Veterans Administration |
$9.48
|
| Rate for Payer: United Healthcare Commercial |
$14.84
|
| Rate for Payer: United Healthcare Medicare |
$9.48
|
| Rate for Payer: WINHealth Partners Commercial |
$14.76
|
| Rate for Payer: Wise Provider Network Commercial |
$14.76
|
|
|
DICLOFENAC 1 % TOPICAL GEL [52825]
|
Facility
|
IP
|
$15.49
|
|
|
Service Code
|
NDC 2192200909
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.98 |
| Max. Negotiated Rate |
$15.49 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.18
|
| Rate for Payer: Aetna of WY Medicare |
$9.91
|
| Rate for Payer: Altius Commercial |
$14.87
|
| Rate for Payer: Beech Street Commercial |
$15.18
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.03
|
| Rate for Payer: Cash Price |
$10.84
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.03
|
| Rate for Payer: Cigna of WY Commercial |
$15.18
|
| Rate for Payer: Entrust Commercial |
$14.72
|
| Rate for Payer: First Choice Health Commercial |
$14.72
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.72
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.45
|
| Rate for Payer: HealthUtah PPO |
$15.49
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.03
|
| Rate for Payer: Multiplan Medicare/VA |
$8.98
|
| Rate for Payer: One Health Plan of WY PPO |
$15.18
|
| Rate for Payer: PacificSource Commercial |
$13.94
|
| Rate for Payer: PHCS PPO |
$15.18
|
| Rate for Payer: Three Rivers PPO |
$11.62
|
| Rate for Payer: TriWest Veterans Administration |
$9.45
|
| Rate for Payer: United Healthcare Commercial |
$14.79
|
| Rate for Payer: United Healthcare Medicare |
$9.45
|
| Rate for Payer: WINHealth Partners Commercial |
$14.72
|
| Rate for Payer: Wise Provider Network Commercial |
$14.72
|
|
|
DICLOFENAC 1 % TOPICAL GEL [52825]
|
Facility
|
OP
|
$15.60
|
|
|
Service Code
|
NDC 4580295301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.45 |
| Max. Negotiated Rate |
$15.60 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.29
|
| Rate for Payer: Aetna of WY Medicare |
$10.30
|
| Rate for Payer: Altius Commercial |
$14.98
|
| Rate for Payer: Beech Street Commercial |
$15.29
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.13
|
| Rate for Payer: Cash Price |
$10.92
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.13
|
| Rate for Payer: Cigna of WY Commercial |
$15.29
|
| Rate for Payer: Entrust Commercial |
$14.82
|
| Rate for Payer: First Choice Health Commercial |
$14.82
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.82
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.89
|
| Rate for Payer: HealthUtah PPO |
$15.60
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.13
|
| Rate for Payer: Multiplan Medicare/VA |
$8.45
|
| Rate for Payer: One Health Plan of WY PPO |
$15.29
|
| Rate for Payer: PacificSource Commercial |
$14.04
|
| Rate for Payer: PHCS PPO |
$15.29
|
| Rate for Payer: Three Rivers PPO |
$11.70
|
| Rate for Payer: TriWest Veterans Administration |
$8.89
|
| Rate for Payer: United Healthcare Commercial |
$14.90
|
| Rate for Payer: United Healthcare Medicare |
$8.89
|
| Rate for Payer: WINHealth Partners Commercial |
$15.29
|
| Rate for Payer: Wise Provider Network Commercial |
$14.82
|
|
|
DICLOFENAC 1 % TOPICAL GEL [52825]
|
Facility
|
IP
|
$15.39
|
|
|
Service Code
|
NDC 0067815203
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.92 |
| Max. Negotiated Rate |
$15.39 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.08
|
| Rate for Payer: Aetna of WY Medicare |
$9.85
|
| Rate for Payer: Altius Commercial |
$14.77
|
| Rate for Payer: Beech Street Commercial |
$15.08
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.93
|
| Rate for Payer: Cash Price |
$10.77
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.93
|
| Rate for Payer: Cigna of WY Commercial |
$15.08
|
| Rate for Payer: Entrust Commercial |
$14.62
|
| Rate for Payer: First Choice Health Commercial |
$14.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.39
|
| Rate for Payer: HealthUtah PPO |
$15.39
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.93
|
| Rate for Payer: Multiplan Medicare/VA |
$8.92
|
| Rate for Payer: One Health Plan of WY PPO |
$15.08
|
| Rate for Payer: PacificSource Commercial |
$13.85
|
| Rate for Payer: PHCS PPO |
$15.08
|
| Rate for Payer: Three Rivers PPO |
$11.54
|
| Rate for Payer: TriWest Veterans Administration |
$9.39
|
| Rate for Payer: United Healthcare Commercial |
$14.70
|
| Rate for Payer: United Healthcare Medicare |
$9.39
|
| Rate for Payer: WINHealth Partners Commercial |
$14.62
|
| Rate for Payer: Wise Provider Network Commercial |
$14.62
|
|
|
DICLOFENAC 1 % TOPICAL GEL [52825]
|
Facility
|
OP
|
$15.60
|
|
|
Service Code
|
NDC 4612275252
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.45 |
| Max. Negotiated Rate |
$15.60 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.29
|
| Rate for Payer: Aetna of WY Medicare |
$10.30
|
| Rate for Payer: Altius Commercial |
$14.98
|
| Rate for Payer: Beech Street Commercial |
$15.29
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.13
|
| Rate for Payer: Cash Price |
$10.92
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.13
|
| Rate for Payer: Cigna of WY Commercial |
$15.29
|
| Rate for Payer: Entrust Commercial |
$14.82
|
| Rate for Payer: First Choice Health Commercial |
$14.82
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.82
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.89
|
| Rate for Payer: HealthUtah PPO |
$15.60
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.13
|
| Rate for Payer: Multiplan Medicare/VA |
$8.45
|
| Rate for Payer: One Health Plan of WY PPO |
$15.29
|
| Rate for Payer: PacificSource Commercial |
$14.04
|
| Rate for Payer: PHCS PPO |
$15.29
|
| Rate for Payer: Three Rivers PPO |
$11.70
|
| Rate for Payer: TriWest Veterans Administration |
$8.89
|
| Rate for Payer: United Healthcare Commercial |
$14.90
|
| Rate for Payer: United Healthcare Medicare |
$8.89
|
| Rate for Payer: WINHealth Partners Commercial |
$15.29
|
| Rate for Payer: Wise Provider Network Commercial |
$14.82
|
|
|
DICLOFENAC 1 % TOPICAL GEL [52825]
|
Facility
|
OP
|
$15.54
|
|
|
Service Code
|
NDC 4580216000
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.41 |
| Max. Negotiated Rate |
$15.54 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.23
|
| Rate for Payer: Aetna of WY Medicare |
$10.26
|
| Rate for Payer: Altius Commercial |
$14.92
|
| Rate for Payer: Beech Street Commercial |
$15.23
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.07
|
| Rate for Payer: Cash Price |
$10.88
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.07
|
| Rate for Payer: Cigna of WY Commercial |
$15.23
|
| Rate for Payer: Entrust Commercial |
$14.76
|
| Rate for Payer: First Choice Health Commercial |
$14.76
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.76
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.86
|
| Rate for Payer: HealthUtah PPO |
$15.54
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.07
|
| Rate for Payer: Multiplan Medicare/VA |
$8.41
|
| Rate for Payer: One Health Plan of WY PPO |
$15.23
|
| Rate for Payer: PacificSource Commercial |
$13.99
|
| Rate for Payer: PHCS PPO |
$15.23
|
| Rate for Payer: Three Rivers PPO |
$11.66
|
| Rate for Payer: TriWest Veterans Administration |
$8.86
|
| Rate for Payer: United Healthcare Commercial |
$14.84
|
| Rate for Payer: United Healthcare Medicare |
$8.86
|
| Rate for Payer: WINHealth Partners Commercial |
$15.23
|
| Rate for Payer: Wise Provider Network Commercial |
$14.76
|
|
|
DICLOFENAC 1 % TOPICAL GEL [52825]
|
Facility
|
OP
|
$15.80
|
|
|
Service Code
|
NDC 6909752444
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.56 |
| Max. Negotiated Rate |
$15.80 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.48
|
| Rate for Payer: Aetna of WY Medicare |
$10.43
|
| Rate for Payer: Altius Commercial |
$15.17
|
| Rate for Payer: Beech Street Commercial |
$15.48
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.33
|
| Rate for Payer: Cash Price |
$11.06
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.33
|
| Rate for Payer: Cigna of WY Commercial |
$15.48
|
| Rate for Payer: Entrust Commercial |
$15.01
|
| Rate for Payer: First Choice Health Commercial |
$15.01
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.01
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.01
|
| Rate for Payer: HealthUtah PPO |
$15.80
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.33
|
| Rate for Payer: Multiplan Medicare/VA |
$8.56
|
| Rate for Payer: One Health Plan of WY PPO |
$15.48
|
| Rate for Payer: PacificSource Commercial |
$14.22
|
| Rate for Payer: PHCS PPO |
$15.48
|
| Rate for Payer: Three Rivers PPO |
$11.85
|
| Rate for Payer: TriWest Veterans Administration |
$9.01
|
| Rate for Payer: United Healthcare Commercial |
$15.09
|
| Rate for Payer: United Healthcare Medicare |
$9.01
|
| Rate for Payer: WINHealth Partners Commercial |
$15.48
|
| Rate for Payer: Wise Provider Network Commercial |
$15.01
|
|
|
DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION [1399]
|
Facility
|
IP
|
$58.88
|
|
|
Service Code
|
HCPCS J0500
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.12 |
| Max. Negotiated Rate |
$58.88 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$57.70
|
| Rate for Payer: Aetna of WY Medicare |
$37.68
|
| Rate for Payer: Altius Commercial |
$56.52
|
| Rate for Payer: Beech Street Commercial |
$57.70
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$57.11
|
| Rate for Payer: Cash Price |
$41.21
|
| Rate for Payer: ChoiceCare Network Commercial |
$57.11
|
| Rate for Payer: Cigna of WY Commercial |
$57.70
|
| Rate for Payer: Entrust Commercial |
$55.94
|
| Rate for Payer: First Choice Health Commercial |
$55.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$55.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$35.92
|
| Rate for Payer: HealthUtah PPO |
$58.88
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$57.11
|
| Rate for Payer: Multiplan Medicare/VA |
$34.12
|
| Rate for Payer: One Health Plan of WY PPO |
$57.70
|
| Rate for Payer: PacificSource Commercial |
$52.99
|
| Rate for Payer: PHCS PPO |
$57.70
|
| Rate for Payer: Three Rivers PPO |
$44.16
|
| Rate for Payer: TriWest Veterans Administration |
$35.92
|
| Rate for Payer: United Healthcare Commercial |
$56.23
|
| Rate for Payer: United Healthcare Medicare |
$35.92
|
| Rate for Payer: WINHealth Partners Commercial |
$55.94
|
| Rate for Payer: Wise Provider Network Commercial |
$55.94
|
|
|
DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION [1399]
|
Facility
|
OP
|
$58.88
|
|
|
Service Code
|
HCPCS J0500
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.88 |
| Max. Negotiated Rate |
$58.88 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$57.70
|
| Rate for Payer: Aetna of WY Medicare |
$38.86
|
| Rate for Payer: Altius Commercial |
$56.52
|
| Rate for Payer: Beech Street Commercial |
$57.70
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$57.11
|
| Rate for Payer: Cash Price |
$41.21
|
| Rate for Payer: ChoiceCare Network Commercial |
$57.11
|
| Rate for Payer: Cigna of WY Commercial |
$57.70
|
| Rate for Payer: Entrust Commercial |
$55.94
|
| Rate for Payer: First Choice Health Commercial |
$55.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$55.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$33.56
|
| Rate for Payer: HealthUtah PPO |
$58.88
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$57.11
|
| Rate for Payer: Multiplan Medicare/VA |
$31.88
|
| Rate for Payer: One Health Plan of WY PPO |
$57.70
|
| Rate for Payer: PacificSource Commercial |
$52.99
|
| Rate for Payer: PHCS PPO |
$57.70
|
| Rate for Payer: Three Rivers PPO |
$44.16
|
| Rate for Payer: TriWest Veterans Administration |
$33.56
|
| Rate for Payer: United Healthcare Commercial |
$56.23
|
| Rate for Payer: United Healthcare Medicare |
$33.56
|
| Rate for Payer: WINHealth Partners Commercial |
$57.70
|
| Rate for Payer: Wise Provider Network Commercial |
$55.94
|
|
|
DICYCLOMINE 20 MG TABLET [11184]
|
Facility
|
OP
|
$16.81
|
|
|
Service Code
|
NDC 6068738001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.10 |
| Max. Negotiated Rate |
$16.81 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.47
|
| Rate for Payer: Aetna of WY Medicare |
$11.09
|
| Rate for Payer: Altius Commercial |
$16.14
|
| Rate for Payer: Beech Street Commercial |
$16.47
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.31
|
| Rate for Payer: Cash Price |
$11.77
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.31
|
| Rate for Payer: Cigna of WY Commercial |
$16.47
|
| Rate for Payer: Entrust Commercial |
$15.97
|
| Rate for Payer: First Choice Health Commercial |
$15.97
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.97
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.58
|
| Rate for Payer: HealthUtah PPO |
$16.81
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.31
|
| Rate for Payer: Multiplan Medicare/VA |
$9.10
|
| Rate for Payer: One Health Plan of WY PPO |
$16.47
|
| Rate for Payer: PacificSource Commercial |
$15.13
|
| Rate for Payer: PHCS PPO |
$16.47
|
| Rate for Payer: Three Rivers PPO |
$12.61
|
| Rate for Payer: TriWest Veterans Administration |
$9.58
|
| Rate for Payer: United Healthcare Commercial |
$16.05
|
| Rate for Payer: United Healthcare Medicare |
$9.58
|
| Rate for Payer: WINHealth Partners Commercial |
$16.47
|
| Rate for Payer: Wise Provider Network Commercial |
$15.97
|
|
|
DICYCLOMINE 20 MG TABLET [11184]
|
Facility
|
IP
|
$16.81
|
|
|
Service Code
|
NDC 6068738011
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.74 |
| Max. Negotiated Rate |
$16.81 |
| Rate for Payer: United Healthcare Commercial |
$16.05
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.47
|
| Rate for Payer: Aetna of WY Medicare |
$10.76
|
| Rate for Payer: Altius Commercial |
$16.14
|
| Rate for Payer: Beech Street Commercial |
$16.47
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.31
|
| Rate for Payer: Cash Price |
$11.77
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.31
|
| Rate for Payer: Cigna of WY Commercial |
$16.47
|
| Rate for Payer: Entrust Commercial |
$15.97
|
| Rate for Payer: First Choice Health Commercial |
$15.97
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.97
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.25
|
| Rate for Payer: HealthUtah PPO |
$16.81
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.31
|
| Rate for Payer: Multiplan Medicare/VA |
$9.74
|
| Rate for Payer: One Health Plan of WY PPO |
$16.47
|
| Rate for Payer: PacificSource Commercial |
$15.13
|
| Rate for Payer: PHCS PPO |
$16.47
|
| Rate for Payer: Three Rivers PPO |
$12.61
|
| Rate for Payer: TriWest Veterans Administration |
$10.25
|
| Rate for Payer: United Healthcare Medicare |
$10.25
|
| Rate for Payer: WINHealth Partners Commercial |
$15.97
|
| Rate for Payer: Wise Provider Network Commercial |
$15.97
|
|
|
DICYCLOMINE 20 MG TABLET [11184]
|
Facility
|
OP
|
$16.81
|
|
|
Service Code
|
NDC 6068738011
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.10 |
| Max. Negotiated Rate |
$16.81 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.47
|
| Rate for Payer: Aetna of WY Medicare |
$11.09
|
| Rate for Payer: Altius Commercial |
$16.14
|
| Rate for Payer: Beech Street Commercial |
$16.47
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.31
|
| Rate for Payer: Cash Price |
$11.77
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.31
|
| Rate for Payer: Cigna of WY Commercial |
$16.47
|
| Rate for Payer: Entrust Commercial |
$15.97
|
| Rate for Payer: First Choice Health Commercial |
$15.97
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.97
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.58
|
| Rate for Payer: HealthUtah PPO |
$16.81
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.31
|
| Rate for Payer: Multiplan Medicare/VA |
$9.10
|
| Rate for Payer: One Health Plan of WY PPO |
$16.47
|
| Rate for Payer: PacificSource Commercial |
$15.13
|
| Rate for Payer: PHCS PPO |
$16.47
|
| Rate for Payer: Three Rivers PPO |
$12.61
|
| Rate for Payer: TriWest Veterans Administration |
$9.58
|
| Rate for Payer: United Healthcare Commercial |
$16.05
|
| Rate for Payer: United Healthcare Medicare |
$9.58
|
| Rate for Payer: WINHealth Partners Commercial |
$16.47
|
| Rate for Payer: Wise Provider Network Commercial |
$15.97
|
|
|
DICYCLOMINE 20 MG TABLET [11184]
|
Facility
|
IP
|
$16.81
|
|
|
Service Code
|
NDC 6068738001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.74 |
| Max. Negotiated Rate |
$16.81 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.47
|
| Rate for Payer: Aetna of WY Medicare |
$10.76
|
| Rate for Payer: Altius Commercial |
$16.14
|
| Rate for Payer: Beech Street Commercial |
$16.47
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.31
|
| Rate for Payer: Cash Price |
$11.77
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.31
|
| Rate for Payer: Cigna of WY Commercial |
$16.47
|
| Rate for Payer: Entrust Commercial |
$15.97
|
| Rate for Payer: First Choice Health Commercial |
$15.97
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.97
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.25
|
| Rate for Payer: HealthUtah PPO |
$16.81
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.31
|
| Rate for Payer: Multiplan Medicare/VA |
$9.74
|
| Rate for Payer: One Health Plan of WY PPO |
$16.47
|
| Rate for Payer: PacificSource Commercial |
$15.13
|
| Rate for Payer: PHCS PPO |
$16.47
|
| Rate for Payer: Three Rivers PPO |
$12.61
|
| Rate for Payer: TriWest Veterans Administration |
$10.25
|
| Rate for Payer: United Healthcare Commercial |
$16.05
|
| Rate for Payer: United Healthcare Medicare |
$10.25
|
| Rate for Payer: WINHealth Partners Commercial |
$15.97
|
| Rate for Payer: Wise Provider Network Commercial |
$15.97
|
|
|
DIGOXIN 125 MCG (0.125 MG) TABLET [16534]
|
Facility
|
IP
|
$19.63
|
|
|
Service Code
|
NDC 6068754011
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.38 |
| Max. Negotiated Rate |
$19.63 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$19.24
|
| Rate for Payer: Aetna of WY Medicare |
$12.56
|
| Rate for Payer: Altius Commercial |
$18.84
|
| Rate for Payer: Beech Street Commercial |
$19.24
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$19.04
|
| Rate for Payer: Cash Price |
$13.74
|
| Rate for Payer: ChoiceCare Network Commercial |
$19.04
|
| Rate for Payer: Cigna of WY Commercial |
$19.24
|
| Rate for Payer: Entrust Commercial |
$18.65
|
| Rate for Payer: First Choice Health Commercial |
$18.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$18.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.97
|
| Rate for Payer: HealthUtah PPO |
$19.63
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$19.04
|
| Rate for Payer: Multiplan Medicare/VA |
$11.38
|
| Rate for Payer: One Health Plan of WY PPO |
$19.24
|
| Rate for Payer: PacificSource Commercial |
$17.67
|
| Rate for Payer: PHCS PPO |
$19.24
|
| Rate for Payer: Three Rivers PPO |
$14.72
|
| Rate for Payer: TriWest Veterans Administration |
$11.97
|
| Rate for Payer: United Healthcare Commercial |
$18.75
|
| Rate for Payer: United Healthcare Medicare |
$11.97
|
| Rate for Payer: WINHealth Partners Commercial |
$18.65
|
| Rate for Payer: Wise Provider Network Commercial |
$18.65
|
|
|
DIGOXIN 125 MCG (0.125 MG) TABLET [16534]
|
Facility
|
OP
|
$19.63
|
|
|
Service Code
|
NDC 6068754011
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.63 |
| Max. Negotiated Rate |
$19.63 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$19.24
|
| Rate for Payer: Aetna of WY Medicare |
$12.96
|
| Rate for Payer: Altius Commercial |
$18.84
|
| Rate for Payer: Beech Street Commercial |
$19.24
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$19.04
|
| Rate for Payer: Cash Price |
$13.74
|
| Rate for Payer: ChoiceCare Network Commercial |
$19.04
|
| Rate for Payer: Cigna of WY Commercial |
$19.24
|
| Rate for Payer: Entrust Commercial |
$18.65
|
| Rate for Payer: First Choice Health Commercial |
$18.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$18.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.19
|
| Rate for Payer: HealthUtah PPO |
$19.63
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$19.04
|
| Rate for Payer: Multiplan Medicare/VA |
$10.63
|
| Rate for Payer: One Health Plan of WY PPO |
$19.24
|
| Rate for Payer: PacificSource Commercial |
$17.67
|
| Rate for Payer: PHCS PPO |
$19.24
|
| Rate for Payer: Three Rivers PPO |
$14.72
|
| Rate for Payer: TriWest Veterans Administration |
$11.19
|
| Rate for Payer: United Healthcare Commercial |
$18.75
|
| Rate for Payer: United Healthcare Medicare |
$11.19
|
| Rate for Payer: WINHealth Partners Commercial |
$19.24
|
| Rate for Payer: Wise Provider Network Commercial |
$18.65
|
|
|
DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION [7819]
|
Facility
|
IP
|
$25.31
|
|
|
Service Code
|
HCPCS J1160
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.67 |
| Max. Negotiated Rate |
$25.31 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$24.80
|
| Rate for Payer: Aetna of WY Medicare |
$16.20
|
| Rate for Payer: Altius Commercial |
$24.30
|
| Rate for Payer: Beech Street Commercial |
$24.80
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$24.55
|
| Rate for Payer: Cash Price |
$17.72
|
| Rate for Payer: ChoiceCare Network Commercial |
$24.55
|
| Rate for Payer: Cigna of WY Commercial |
$24.80
|
| Rate for Payer: Entrust Commercial |
$24.04
|
| Rate for Payer: First Choice Health Commercial |
$24.04
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$24.04
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$15.44
|
| Rate for Payer: HealthUtah PPO |
$25.31
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.55
|
| Rate for Payer: Multiplan Medicare/VA |
$14.67
|
| Rate for Payer: One Health Plan of WY PPO |
$24.80
|
| Rate for Payer: PacificSource Commercial |
$22.78
|
| Rate for Payer: PHCS PPO |
$24.80
|
| Rate for Payer: Three Rivers PPO |
$18.98
|
| Rate for Payer: TriWest Veterans Administration |
$15.44
|
| Rate for Payer: United Healthcare Commercial |
$24.17
|
| Rate for Payer: United Healthcare Medicare |
$15.44
|
| Rate for Payer: WINHealth Partners Commercial |
$24.04
|
| Rate for Payer: Wise Provider Network Commercial |
$24.04
|
|
|
DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION [7819]
|
Facility
|
OP
|
$25.31
|
|
|
Service Code
|
HCPCS J1160
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.71 |
| Max. Negotiated Rate |
$25.31 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$24.80
|
| Rate for Payer: Aetna of WY Medicare |
$16.70
|
| Rate for Payer: Altius Commercial |
$24.30
|
| Rate for Payer: Beech Street Commercial |
$24.80
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$24.55
|
| Rate for Payer: Cash Price |
$17.72
|
| Rate for Payer: ChoiceCare Network Commercial |
$24.55
|
| Rate for Payer: Cigna of WY Commercial |
$24.80
|
| Rate for Payer: Entrust Commercial |
$24.04
|
| Rate for Payer: First Choice Health Commercial |
$24.04
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$24.04
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$14.43
|
| Rate for Payer: HealthUtah PPO |
$25.31
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.55
|
| Rate for Payer: Multiplan Medicare/VA |
$13.71
|
| Rate for Payer: One Health Plan of WY PPO |
$24.80
|
| Rate for Payer: PacificSource Commercial |
$22.78
|
| Rate for Payer: PHCS PPO |
$24.80
|
| Rate for Payer: Three Rivers PPO |
$18.98
|
| Rate for Payer: TriWest Veterans Administration |
$14.43
|
| Rate for Payer: United Healthcare Commercial |
$24.17
|
| Rate for Payer: United Healthcare Medicare |
$14.43
|
| Rate for Payer: WINHealth Partners Commercial |
$24.80
|
| Rate for Payer: Wise Provider Network Commercial |
$24.04
|
|
|
DILATION CERVICAL CANAL INSTRUMENTAL SPX
|
Professional
|
Both
|
$497.00
|
|
|
Service Code
|
HCPCS 57800
|
| Min. Negotiated Rate |
$39.41 |
| Max. Negotiated Rate |
$497.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$487.06
|
| Rate for Payer: Aetna of WY Medicare |
$46.37
|
| Rate for Payer: Beech Street Commercial |
$472.15
|
| Rate for Payer: Cash Price |
$347.90
|
| Rate for Payer: Cash Price |
$347.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$482.09
|
| Rate for Payer: Cigna of WY Commercial |
$487.06
|
| Rate for Payer: First Choice Health Commercial |
$447.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$472.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$46.37
|
| Rate for Payer: HealthUtah PPO |
$497.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$482.09
|
| Rate for Payer: Multiplan Medicare/VA |
$39.41
|
| Rate for Payer: One Health Plan of WY PPO |
$487.06
|
| Rate for Payer: PacificSource Commercial |
$447.30
|
| Rate for Payer: PHCS PPO |
$472.15
|
| Rate for Payer: Three Rivers PPO |
$372.75
|
| Rate for Payer: TriWest Veterans Administration |
$46.37
|
| Rate for Payer: United Healthcare Commercial |
$472.15
|
| Rate for Payer: WINHealth Partners Commercial |
$422.45
|
|
|
DILATION & CURETTAGE DX&/THER NONOBSTETRIC
|
Professional
|
Both
|
$1,004.00
|
|
|
Service Code
|
HCPCS 58120
|
| Min. Negotiated Rate |
$192.14 |
| Max. Negotiated Rate |
$1,004.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$983.92
|
| Rate for Payer: Aetna of WY Medicare |
$226.05
|
| Rate for Payer: Beech Street Commercial |
$953.80
|
| Rate for Payer: Cash Price |
$702.80
|
| Rate for Payer: Cash Price |
$702.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$973.88
|
| Rate for Payer: Cigna of WY Commercial |
$983.92
|
| Rate for Payer: First Choice Health Commercial |
$903.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$953.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$226.05
|
| Rate for Payer: HealthUtah PPO |
$1,004.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$973.88
|
| Rate for Payer: Multiplan Medicare/VA |
$192.14
|
| Rate for Payer: One Health Plan of WY PPO |
$983.92
|
| Rate for Payer: PacificSource Commercial |
$903.60
|
| Rate for Payer: PHCS PPO |
$953.80
|
| Rate for Payer: Three Rivers PPO |
$753.00
|
| Rate for Payer: TriWest Veterans Administration |
$226.05
|
| Rate for Payer: United Healthcare Commercial |
$953.80
|
| Rate for Payer: WINHealth Partners Commercial |
$853.40
|
|
|
DILTIAZEM 30 MG TABLET [17930]
|
Facility
|
IP
|
$15.60
|
|
|
Service Code
|
NDC 0093031801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.04 |
| Max. Negotiated Rate |
$15.60 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.29
|
| Rate for Payer: Aetna of WY Medicare |
$9.98
|
| Rate for Payer: Altius Commercial |
$14.98
|
| Rate for Payer: Beech Street Commercial |
$15.29
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.13
|
| Rate for Payer: Cash Price |
$10.92
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.13
|
| Rate for Payer: Cigna of WY Commercial |
$15.29
|
| Rate for Payer: Entrust Commercial |
$14.82
|
| Rate for Payer: First Choice Health Commercial |
$14.82
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.82
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.52
|
| Rate for Payer: HealthUtah PPO |
$15.60
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.13
|
| Rate for Payer: Multiplan Medicare/VA |
$9.04
|
| Rate for Payer: One Health Plan of WY PPO |
$15.29
|
| Rate for Payer: PacificSource Commercial |
$14.04
|
| Rate for Payer: PHCS PPO |
$15.29
|
| Rate for Payer: Three Rivers PPO |
$11.70
|
| Rate for Payer: TriWest Veterans Administration |
$9.52
|
| Rate for Payer: United Healthcare Commercial |
$14.90
|
| Rate for Payer: United Healthcare Medicare |
$9.52
|
| Rate for Payer: WINHealth Partners Commercial |
$14.82
|
| Rate for Payer: Wise Provider Network Commercial |
$14.82
|
|
|
DILTIAZEM 30 MG TABLET [17930]
|
Facility
|
OP
|
$15.60
|
|
|
Service Code
|
NDC 0093031801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.45 |
| Max. Negotiated Rate |
$15.60 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.29
|
| Rate for Payer: Aetna of WY Medicare |
$10.30
|
| Rate for Payer: Altius Commercial |
$14.98
|
| Rate for Payer: Beech Street Commercial |
$15.29
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.13
|
| Rate for Payer: Cash Price |
$10.92
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.13
|
| Rate for Payer: Cigna of WY Commercial |
$15.29
|
| Rate for Payer: Entrust Commercial |
$14.82
|
| Rate for Payer: First Choice Health Commercial |
$14.82
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.82
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.89
|
| Rate for Payer: HealthUtah PPO |
$15.60
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.13
|
| Rate for Payer: Multiplan Medicare/VA |
$8.45
|
| Rate for Payer: One Health Plan of WY PPO |
$15.29
|
| Rate for Payer: PacificSource Commercial |
$14.04
|
| Rate for Payer: PHCS PPO |
$15.29
|
| Rate for Payer: Three Rivers PPO |
$11.70
|
| Rate for Payer: TriWest Veterans Administration |
$8.89
|
| Rate for Payer: United Healthcare Commercial |
$14.90
|
| Rate for Payer: United Healthcare Medicare |
$8.89
|
| Rate for Payer: WINHealth Partners Commercial |
$15.29
|
| Rate for Payer: Wise Provider Network Commercial |
$14.82
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION [1034]
|
Facility
|
IP
|
$17.74
|
|
|
Service Code
|
HCPCS J3490
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.28 |
| Max. Negotiated Rate |
$17.74 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$17.39
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.13
|
| Rate for Payer: Aetna of WY Medicare |
$10.53
|
| Rate for Payer: Aetna of WY Medicare |
$11.35
|
| Rate for Payer: Altius Commercial |
$15.80
|
| Rate for Payer: Altius Commercial |
$17.03
|
| Rate for Payer: Beech Street Commercial |
$17.39
|
| Rate for Payer: Beech Street Commercial |
$16.13
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.97
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$17.21
|
| Rate for Payer: Cash Price |
$11.52
|
| Rate for Payer: Cash Price |
$12.42
|
| Rate for Payer: ChoiceCare Network Commercial |
$17.21
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.97
|
| Rate for Payer: Cigna of WY Commercial |
$17.39
|
| Rate for Payer: Cigna of WY Commercial |
$16.13
|
| Rate for Payer: Entrust Commercial |
$16.85
|
| Rate for Payer: Entrust Commercial |
$15.64
|
| Rate for Payer: First Choice Health Commercial |
$16.85
|
| Rate for Payer: First Choice Health Commercial |
$15.64
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.64
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.04
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.82
|
| Rate for Payer: HealthUtah PPO |
$17.74
|
| Rate for Payer: HealthUtah PPO |
$16.46
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.97
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.21
|
| Rate for Payer: Multiplan Medicare/VA |
$10.28
|
| Rate for Payer: Multiplan Medicare/VA |
$9.54
|
| Rate for Payer: One Health Plan of WY PPO |
$16.13
|
| Rate for Payer: One Health Plan of WY PPO |
$17.39
|
| Rate for Payer: PacificSource Commercial |
$14.81
|
| Rate for Payer: PacificSource Commercial |
$15.97
|
| Rate for Payer: PHCS PPO |
$16.13
|
| Rate for Payer: PHCS PPO |
$17.39
|
| Rate for Payer: Three Rivers PPO |
$13.30
|
| Rate for Payer: Three Rivers PPO |
$12.34
|
| Rate for Payer: TriWest Veterans Administration |
$10.04
|
| Rate for Payer: TriWest Veterans Administration |
$10.82
|
| Rate for Payer: United Healthcare Commercial |
$16.94
|
| Rate for Payer: United Healthcare Commercial |
$15.72
|
| Rate for Payer: United Healthcare Medicare |
$10.04
|
| Rate for Payer: United Healthcare Medicare |
$10.82
|
| Rate for Payer: WINHealth Partners Commercial |
$15.64
|
| Rate for Payer: WINHealth Partners Commercial |
$16.85
|
| Rate for Payer: Wise Provider Network Commercial |
$15.64
|
| Rate for Payer: Wise Provider Network Commercial |
$16.85
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION [1034]
|
Facility
|
OP
|
$17.74
|
|
|
Service Code
|
HCPCS J3490
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.61 |
| Max. Negotiated Rate |
$17.74 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$17.39
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.13
|
| Rate for Payer: Aetna of WY Medicare |
$10.86
|
| Rate for Payer: Aetna of WY Medicare |
$11.71
|
| Rate for Payer: Altius Commercial |
$15.80
|
| Rate for Payer: Altius Commercial |
$17.03
|
| Rate for Payer: Beech Street Commercial |
$17.39
|
| Rate for Payer: Beech Street Commercial |
$16.13
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$17.21
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.97
|
| Rate for Payer: Cash Price |
$12.42
|
| Rate for Payer: Cash Price |
$11.52
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.97
|
| Rate for Payer: ChoiceCare Network Commercial |
$17.21
|
| Rate for Payer: Cigna of WY Commercial |
$16.13
|
| Rate for Payer: Cigna of WY Commercial |
$17.39
|
| Rate for Payer: Entrust Commercial |
$15.64
|
| Rate for Payer: Entrust Commercial |
$16.85
|
| Rate for Payer: First Choice Health Commercial |
$16.85
|
| Rate for Payer: First Choice Health Commercial |
$15.64
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.64
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.11
|
| Rate for Payer: HealthUtah PPO |
$17.74
|
| Rate for Payer: HealthUtah PPO |
$16.46
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.97
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.21
|
| Rate for Payer: Multiplan Medicare/VA |
$9.61
|
| Rate for Payer: Multiplan Medicare/VA |
$8.91
|
| Rate for Payer: One Health Plan of WY PPO |
$17.39
|
| Rate for Payer: One Health Plan of WY PPO |
$16.13
|
| Rate for Payer: PacificSource Commercial |
$14.81
|
| Rate for Payer: PacificSource Commercial |
$15.97
|
| Rate for Payer: PHCS PPO |
$17.39
|
| Rate for Payer: PHCS PPO |
$16.13
|
| Rate for Payer: Three Rivers PPO |
$13.30
|
| Rate for Payer: Three Rivers PPO |
$12.34
|
| Rate for Payer: TriWest Veterans Administration |
$9.38
|
| Rate for Payer: TriWest Veterans Administration |
$10.11
|
| Rate for Payer: United Healthcare Commercial |
$15.72
|
| Rate for Payer: United Healthcare Commercial |
$16.94
|
| Rate for Payer: United Healthcare Medicare |
$10.11
|
| Rate for Payer: United Healthcare Medicare |
$9.38
|
| Rate for Payer: WINHealth Partners Commercial |
$16.13
|
| Rate for Payer: WINHealth Partners Commercial |
$17.39
|
| Rate for Payer: Wise Provider Network Commercial |
$15.64
|
| Rate for Payer: Wise Provider Network Commercial |
$16.85
|
|
