|
DOCUSATE SODIUM 100 MG CAPSULE [14921]
|
Facility
|
IP
|
$15.20
|
|
|
Service Code
|
NDC 0904728080
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.81 |
| Max. Negotiated Rate |
$15.20 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.90
|
| Rate for Payer: Aetna of WY Medicare |
$9.73
|
| Rate for Payer: Altius Commercial |
$14.59
|
| Rate for Payer: Beech Street Commercial |
$14.90
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.74
|
| Rate for Payer: Cash Price |
$10.64
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.74
|
| Rate for Payer: Cigna of WY Commercial |
$14.90
|
| Rate for Payer: Entrust Commercial |
$14.44
|
| Rate for Payer: First Choice Health Commercial |
$14.44
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.44
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.27
|
| Rate for Payer: HealthUtah PPO |
$15.20
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.74
|
| Rate for Payer: Multiplan Medicare/VA |
$8.81
|
| Rate for Payer: One Health Plan of WY PPO |
$14.90
|
| Rate for Payer: PacificSource Commercial |
$13.68
|
| Rate for Payer: PHCS PPO |
$14.90
|
| Rate for Payer: Three Rivers PPO |
$11.40
|
| Rate for Payer: TriWest Veterans Administration |
$9.27
|
| Rate for Payer: United Healthcare Commercial |
$14.52
|
| Rate for Payer: United Healthcare Medicare |
$9.27
|
| Rate for Payer: WINHealth Partners Commercial |
$14.44
|
| Rate for Payer: Wise Provider Network Commercial |
$14.44
|
|
|
DOCUSATE SODIUM 100 MG CAPSULE [14921]
|
Facility
|
OP
|
$15.08
|
|
|
Service Code
|
NDC 0904728060
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.17 |
| Max. Negotiated Rate |
$15.08 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.78
|
| Rate for Payer: Aetna of WY Medicare |
$9.95
|
| Rate for Payer: Altius Commercial |
$14.48
|
| Rate for Payer: Beech Street Commercial |
$14.78
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.63
|
| Rate for Payer: Cash Price |
$10.55
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.63
|
| Rate for Payer: Cigna of WY Commercial |
$14.78
|
| Rate for Payer: Entrust Commercial |
$14.33
|
| Rate for Payer: First Choice Health Commercial |
$14.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.60
|
| Rate for Payer: HealthUtah PPO |
$15.08
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.63
|
| Rate for Payer: Multiplan Medicare/VA |
$8.17
|
| Rate for Payer: One Health Plan of WY PPO |
$14.78
|
| Rate for Payer: PacificSource Commercial |
$13.57
|
| Rate for Payer: PHCS PPO |
$14.78
|
| Rate for Payer: Three Rivers PPO |
$11.31
|
| Rate for Payer: TriWest Veterans Administration |
$8.60
|
| Rate for Payer: United Healthcare Commercial |
$14.40
|
| Rate for Payer: United Healthcare Medicare |
$8.60
|
| Rate for Payer: WINHealth Partners Commercial |
$14.78
|
| Rate for Payer: Wise Provider Network Commercial |
$14.33
|
|
|
DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID [568]
|
Facility
|
IP
|
$15.09
|
|
|
Service Code
|
NDC 0121187000
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.74 |
| Max. Negotiated Rate |
$15.09 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.79
|
| Rate for Payer: Aetna of WY Medicare |
$9.66
|
| Rate for Payer: Altius Commercial |
$14.49
|
| Rate for Payer: Beech Street Commercial |
$14.79
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.64
|
| Rate for Payer: Cash Price |
$10.56
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.64
|
| Rate for Payer: Cigna of WY Commercial |
$14.79
|
| Rate for Payer: Entrust Commercial |
$14.34
|
| Rate for Payer: First Choice Health Commercial |
$14.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.20
|
| Rate for Payer: HealthUtah PPO |
$15.09
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.64
|
| Rate for Payer: Multiplan Medicare/VA |
$8.74
|
| Rate for Payer: One Health Plan of WY PPO |
$14.79
|
| Rate for Payer: PacificSource Commercial |
$13.58
|
| Rate for Payer: PHCS PPO |
$14.79
|
| Rate for Payer: Three Rivers PPO |
$11.32
|
| Rate for Payer: TriWest Veterans Administration |
$9.20
|
| Rate for Payer: United Healthcare Commercial |
$14.41
|
| Rate for Payer: United Healthcare Medicare |
$9.20
|
| Rate for Payer: WINHealth Partners Commercial |
$14.34
|
| Rate for Payer: Wise Provider Network Commercial |
$14.34
|
|
|
DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID [568]
|
Facility
|
IP
|
$15.74
|
|
|
Service Code
|
NDC 9999999568
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.12 |
| Max. Negotiated Rate |
$15.74 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.43
|
| Rate for Payer: Aetna of WY Medicare |
$10.07
|
| Rate for Payer: Altius Commercial |
$15.11
|
| Rate for Payer: Beech Street Commercial |
$15.43
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.27
|
| Rate for Payer: Cash Price |
$11.02
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.27
|
| Rate for Payer: Cigna of WY Commercial |
$15.43
|
| Rate for Payer: Entrust Commercial |
$14.95
|
| Rate for Payer: First Choice Health Commercial |
$14.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.60
|
| Rate for Payer: HealthUtah PPO |
$15.74
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.27
|
| Rate for Payer: Multiplan Medicare/VA |
$9.12
|
| Rate for Payer: One Health Plan of WY PPO |
$15.43
|
| Rate for Payer: PacificSource Commercial |
$14.17
|
| Rate for Payer: PHCS PPO |
$15.43
|
| Rate for Payer: Three Rivers PPO |
$11.80
|
| Rate for Payer: TriWest Veterans Administration |
$9.60
|
| Rate for Payer: United Healthcare Commercial |
$15.03
|
| Rate for Payer: United Healthcare Medicare |
$9.60
|
| Rate for Payer: WINHealth Partners Commercial |
$14.95
|
| Rate for Payer: Wise Provider Network Commercial |
$14.95
|
|
|
DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID [568]
|
Facility
|
OP
|
$15.09
|
|
|
Service Code
|
NDC 0121187000
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.17 |
| Max. Negotiated Rate |
$15.09 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.79
|
| Rate for Payer: Aetna of WY Medicare |
$9.96
|
| Rate for Payer: Altius Commercial |
$14.49
|
| Rate for Payer: Beech Street Commercial |
$14.79
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.64
|
| Rate for Payer: Cash Price |
$10.56
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.64
|
| Rate for Payer: Cigna of WY Commercial |
$14.79
|
| Rate for Payer: Entrust Commercial |
$14.34
|
| Rate for Payer: First Choice Health Commercial |
$14.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.60
|
| Rate for Payer: HealthUtah PPO |
$15.09
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.64
|
| Rate for Payer: Multiplan Medicare/VA |
$8.17
|
| Rate for Payer: One Health Plan of WY PPO |
$14.79
|
| Rate for Payer: PacificSource Commercial |
$13.58
|
| Rate for Payer: PHCS PPO |
$14.79
|
| Rate for Payer: Three Rivers PPO |
$11.32
|
| Rate for Payer: TriWest Veterans Administration |
$8.60
|
| Rate for Payer: United Healthcare Commercial |
$14.41
|
| Rate for Payer: United Healthcare Medicare |
$8.60
|
| Rate for Payer: WINHealth Partners Commercial |
$14.79
|
| Rate for Payer: Wise Provider Network Commercial |
$14.34
|
|
|
DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID [568]
|
Facility
|
IP
|
$15.09
|
|
|
Service Code
|
NDC 0121093516
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.74 |
| Max. Negotiated Rate |
$15.09 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.79
|
| Rate for Payer: Aetna of WY Medicare |
$9.66
|
| Rate for Payer: Altius Commercial |
$14.49
|
| Rate for Payer: Beech Street Commercial |
$14.79
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.64
|
| Rate for Payer: Cash Price |
$10.56
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.64
|
| Rate for Payer: Cigna of WY Commercial |
$14.79
|
| Rate for Payer: Entrust Commercial |
$14.34
|
| Rate for Payer: First Choice Health Commercial |
$14.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.20
|
| Rate for Payer: HealthUtah PPO |
$15.09
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.64
|
| Rate for Payer: Multiplan Medicare/VA |
$8.74
|
| Rate for Payer: One Health Plan of WY PPO |
$14.79
|
| Rate for Payer: PacificSource Commercial |
$13.58
|
| Rate for Payer: PHCS PPO |
$14.79
|
| Rate for Payer: Three Rivers PPO |
$11.32
|
| Rate for Payer: TriWest Veterans Administration |
$9.20
|
| Rate for Payer: United Healthcare Commercial |
$14.41
|
| Rate for Payer: United Healthcare Medicare |
$9.20
|
| Rate for Payer: WINHealth Partners Commercial |
$14.34
|
| Rate for Payer: Wise Provider Network Commercial |
$14.34
|
|
|
DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID [568]
|
Facility
|
OP
|
$15.09
|
|
|
Service Code
|
NDC 0121093516
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.17 |
| Max. Negotiated Rate |
$15.09 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.79
|
| Rate for Payer: Aetna of WY Medicare |
$9.96
|
| Rate for Payer: Altius Commercial |
$14.49
|
| Rate for Payer: Beech Street Commercial |
$14.79
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.64
|
| Rate for Payer: Cash Price |
$10.56
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.64
|
| Rate for Payer: Cigna of WY Commercial |
$14.79
|
| Rate for Payer: Entrust Commercial |
$14.34
|
| Rate for Payer: First Choice Health Commercial |
$14.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.60
|
| Rate for Payer: HealthUtah PPO |
$15.09
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.64
|
| Rate for Payer: Multiplan Medicare/VA |
$8.17
|
| Rate for Payer: One Health Plan of WY PPO |
$14.79
|
| Rate for Payer: PacificSource Commercial |
$13.58
|
| Rate for Payer: PHCS PPO |
$14.79
|
| Rate for Payer: Three Rivers PPO |
$11.32
|
| Rate for Payer: TriWest Veterans Administration |
$8.60
|
| Rate for Payer: United Healthcare Commercial |
$14.41
|
| Rate for Payer: United Healthcare Medicare |
$8.60
|
| Rate for Payer: WINHealth Partners Commercial |
$14.79
|
| Rate for Payer: Wise Provider Network Commercial |
$14.34
|
|
|
DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID [568]
|
Facility
|
OP
|
$15.74
|
|
|
Service Code
|
NDC 9999999568
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.52 |
| Max. Negotiated Rate |
$15.74 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.43
|
| Rate for Payer: Aetna of WY Medicare |
$10.39
|
| Rate for Payer: Altius Commercial |
$15.11
|
| Rate for Payer: Beech Street Commercial |
$15.43
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.27
|
| Rate for Payer: Cash Price |
$11.02
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.27
|
| Rate for Payer: Cigna of WY Commercial |
$15.43
|
| Rate for Payer: Entrust Commercial |
$14.95
|
| Rate for Payer: First Choice Health Commercial |
$14.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.97
|
| Rate for Payer: HealthUtah PPO |
$15.74
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.27
|
| Rate for Payer: Multiplan Medicare/VA |
$8.52
|
| Rate for Payer: One Health Plan of WY PPO |
$15.43
|
| Rate for Payer: PacificSource Commercial |
$14.17
|
| Rate for Payer: PHCS PPO |
$15.43
|
| Rate for Payer: Three Rivers PPO |
$11.80
|
| Rate for Payer: TriWest Veterans Administration |
$8.97
|
| Rate for Payer: United Healthcare Commercial |
$15.03
|
| Rate for Payer: United Healthcare Medicare |
$8.97
|
| Rate for Payer: WINHealth Partners Commercial |
$15.43
|
| Rate for Payer: Wise Provider Network Commercial |
$14.95
|
|
|
DOMICIL/REST HOME NEW PT VISIT HI SEVER 60 MIN
|
Professional
|
Both
|
$259.00
|
|
|
Service Code
|
HCPCS 99327
|
| Min. Negotiated Rate |
$194.25 |
| Max. Negotiated Rate |
$259.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$253.82
|
| Rate for Payer: Beech Street Commercial |
$246.05
|
| Rate for Payer: Cash Price |
$181.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$251.23
|
| Rate for Payer: Cigna of WY Commercial |
$253.82
|
| Rate for Payer: First Choice Health Commercial |
$233.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$246.05
|
| Rate for Payer: HealthUtah PPO |
$259.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$251.23
|
| Rate for Payer: One Health Plan of WY PPO |
$253.82
|
| Rate for Payer: PacificSource Commercial |
$233.10
|
| Rate for Payer: PHCS PPO |
$246.05
|
| Rate for Payer: Three Rivers PPO |
$194.25
|
| Rate for Payer: United Healthcare Commercial |
$246.05
|
| Rate for Payer: WINHealth Partners Commercial |
$246.05
|
|
|
DOM/R-HOME E/M EST PT LW MOD SEVERITY 25 MINUTES
|
Professional
|
Both
|
$130.00
|
|
|
Service Code
|
HCPCS 99335
|
| Min. Negotiated Rate |
$97.50 |
| Max. Negotiated Rate |
$130.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$127.40
|
| Rate for Payer: Beech Street Commercial |
$123.50
|
| Rate for Payer: Cash Price |
$91.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$126.10
|
| Rate for Payer: Cigna of WY Commercial |
$127.40
|
| Rate for Payer: First Choice Health Commercial |
$117.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$123.50
|
| Rate for Payer: HealthUtah PPO |
$130.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$126.10
|
| Rate for Payer: One Health Plan of WY PPO |
$127.40
|
| Rate for Payer: PacificSource Commercial |
$117.00
|
| Rate for Payer: PHCS PPO |
$123.50
|
| Rate for Payer: Three Rivers PPO |
$97.50
|
| Rate for Payer: United Healthcare Commercial |
$123.50
|
| Rate for Payer: WINHealth Partners Commercial |
$123.50
|
|
|
DONEPEZIL 10 MG TABLET [4459]
|
Facility
|
OP
|
$15.67
|
|
|
Service Code
|
NDC 6068730301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.49 |
| Max. Negotiated Rate |
$15.67 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.36
|
| Rate for Payer: Aetna of WY Medicare |
$10.34
|
| Rate for Payer: Altius Commercial |
$15.04
|
| Rate for Payer: Beech Street Commercial |
$15.36
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.20
|
| Rate for Payer: Cash Price |
$10.97
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.20
|
| Rate for Payer: Cigna of WY Commercial |
$15.36
|
| Rate for Payer: Entrust Commercial |
$14.89
|
| Rate for Payer: First Choice Health Commercial |
$14.89
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.89
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.93
|
| Rate for Payer: HealthUtah PPO |
$15.67
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.20
|
| Rate for Payer: Multiplan Medicare/VA |
$8.49
|
| Rate for Payer: One Health Plan of WY PPO |
$15.36
|
| Rate for Payer: PacificSource Commercial |
$14.10
|
| Rate for Payer: PHCS PPO |
$15.36
|
| Rate for Payer: Three Rivers PPO |
$11.75
|
| Rate for Payer: TriWest Veterans Administration |
$8.93
|
| Rate for Payer: United Healthcare Commercial |
$14.96
|
| Rate for Payer: United Healthcare Medicare |
$8.93
|
| Rate for Payer: WINHealth Partners Commercial |
$15.36
|
| Rate for Payer: Wise Provider Network Commercial |
$14.89
|
|
|
DONEPEZIL 10 MG TABLET [4459]
|
Facility
|
IP
|
$15.54
|
|
|
Service Code
|
NDC 4354727611
|
|
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
|
|
|
DONEPEZIL 10 MG TABLET [4459]
|
Facility
|
IP
|
$15.67
|
|
|
Service Code
|
NDC 6068730301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.08 |
| Max. Negotiated Rate |
$15.67 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.36
|
| Rate for Payer: Aetna of WY Medicare |
$10.03
|
| Rate for Payer: Altius Commercial |
$15.04
|
| Rate for Payer: Beech Street Commercial |
$15.36
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.20
|
| Rate for Payer: Cash Price |
$10.97
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.20
|
| Rate for Payer: Cigna of WY Commercial |
$15.36
|
| Rate for Payer: Entrust Commercial |
$14.89
|
| Rate for Payer: First Choice Health Commercial |
$14.89
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.89
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.56
|
| Rate for Payer: HealthUtah PPO |
$15.67
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.20
|
| Rate for Payer: Multiplan Medicare/VA |
$9.08
|
| Rate for Payer: One Health Plan of WY PPO |
$15.36
|
| Rate for Payer: PacificSource Commercial |
$14.10
|
| Rate for Payer: PHCS PPO |
$15.36
|
| Rate for Payer: Three Rivers PPO |
$11.75
|
| Rate for Payer: TriWest Veterans Administration |
$9.56
|
| Rate for Payer: United Healthcare Commercial |
$14.96
|
| Rate for Payer: United Healthcare Medicare |
$9.56
|
| Rate for Payer: WINHealth Partners Commercial |
$14.89
|
| Rate for Payer: Wise Provider Network Commercial |
$14.89
|
|
|
DONEPEZIL 10 MG TABLET [4459]
|
Facility
|
OP
|
$15.54
|
|
|
Service Code
|
NDC 4354727611
|
|
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
|
|
|
DONEPEZIL 5 MG TABLET [1973]
|
Facility
|
OP
|
$15.54
|
|
|
Service Code
|
NDC 0904647761
|
|
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
|
|
|
DONEPEZIL 5 MG TABLET [1973]
|
Facility
|
IP
|
$15.54
|
|
|
Service Code
|
NDC 0904647761
|
|
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
|
|
|
DORZOLAMIDE 2 % EYE DROPS [20314]
|
Facility
|
OP
|
$27.75
|
|
|
Service Code
|
NDC 4257114126
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.03 |
| Max. Negotiated Rate |
$27.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$27.20
|
| Rate for Payer: Aetna of WY Medicare |
$18.32
|
| Rate for Payer: Altius Commercial |
$26.64
|
| Rate for Payer: Beech Street Commercial |
$27.20
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$26.92
|
| Rate for Payer: Cash Price |
$19.42
|
| Rate for Payer: ChoiceCare Network Commercial |
$26.92
|
| Rate for Payer: Cigna of WY Commercial |
$27.20
|
| Rate for Payer: Entrust Commercial |
$26.36
|
| Rate for Payer: First Choice Health Commercial |
$26.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$26.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$15.82
|
| Rate for Payer: HealthUtah PPO |
$27.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$26.92
|
| Rate for Payer: Multiplan Medicare/VA |
$15.03
|
| Rate for Payer: One Health Plan of WY PPO |
$27.20
|
| Rate for Payer: PacificSource Commercial |
$24.98
|
| Rate for Payer: PHCS PPO |
$27.20
|
| Rate for Payer: Three Rivers PPO |
$20.81
|
| Rate for Payer: TriWest Veterans Administration |
$15.82
|
| Rate for Payer: United Healthcare Commercial |
$26.50
|
| Rate for Payer: United Healthcare Medicare |
$15.82
|
| Rate for Payer: WINHealth Partners Commercial |
$27.20
|
| Rate for Payer: Wise Provider Network Commercial |
$26.36
|
|
|
DORZOLAMIDE 2 % EYE DROPS [20314]
|
Facility
|
IP
|
$27.75
|
|
|
Service Code
|
NDC 6131401910
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.08 |
| Max. Negotiated Rate |
$27.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$27.20
|
| Rate for Payer: Aetna of WY Medicare |
$17.76
|
| Rate for Payer: Altius Commercial |
$26.64
|
| Rate for Payer: Beech Street Commercial |
$27.20
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$26.92
|
| Rate for Payer: Cash Price |
$19.42
|
| Rate for Payer: ChoiceCare Network Commercial |
$26.92
|
| Rate for Payer: Cigna of WY Commercial |
$27.20
|
| Rate for Payer: Entrust Commercial |
$26.36
|
| Rate for Payer: First Choice Health Commercial |
$26.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$26.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$16.93
|
| Rate for Payer: HealthUtah PPO |
$27.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$26.92
|
| Rate for Payer: Multiplan Medicare/VA |
$16.08
|
| Rate for Payer: One Health Plan of WY PPO |
$27.20
|
| Rate for Payer: PacificSource Commercial |
$24.98
|
| Rate for Payer: PHCS PPO |
$27.20
|
| Rate for Payer: Three Rivers PPO |
$20.81
|
| Rate for Payer: TriWest Veterans Administration |
$16.93
|
| Rate for Payer: United Healthcare Commercial |
$26.50
|
| Rate for Payer: United Healthcare Medicare |
$16.93
|
| Rate for Payer: WINHealth Partners Commercial |
$26.36
|
| Rate for Payer: Wise Provider Network Commercial |
$26.36
|
|
|
DORZOLAMIDE 2 % EYE DROPS [20314]
|
Facility
|
OP
|
$25.00
|
|
|
Service Code
|
NDC 2420848510
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.54 |
| Max. Negotiated Rate |
$25.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$24.50
|
| Rate for Payer: Aetna of WY Medicare |
$16.50
|
| Rate for Payer: Altius Commercial |
$24.00
|
| Rate for Payer: Beech Street Commercial |
$24.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$24.25
|
| 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: Entrust Commercial |
$23.75
|
| Rate for Payer: First Choice Health Commercial |
$23.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$23.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$14.25
|
| Rate for Payer: HealthUtah PPO |
$25.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.25
|
| Rate for Payer: Multiplan Medicare/VA |
$13.54
|
| Rate for Payer: One Health Plan of WY PPO |
$24.50
|
| Rate for Payer: PacificSource Commercial |
$22.50
|
| Rate for Payer: PHCS PPO |
$24.50
|
| Rate for Payer: Three Rivers PPO |
$18.75
|
| Rate for Payer: TriWest Veterans Administration |
$14.25
|
| Rate for Payer: United Healthcare Commercial |
$23.88
|
| Rate for Payer: United Healthcare Medicare |
$14.25
|
| Rate for Payer: WINHealth Partners Commercial |
$24.50
|
| Rate for Payer: Wise Provider Network Commercial |
$23.75
|
|
|
DORZOLAMIDE 2 % EYE DROPS [20314]
|
Facility
|
IP
|
$25.00
|
|
|
Service Code
|
NDC 2420848510
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.49 |
| Max. Negotiated Rate |
$25.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$24.50
|
| Rate for Payer: Aetna of WY Medicare |
$16.00
|
| Rate for Payer: Altius Commercial |
$24.00
|
| Rate for Payer: Beech Street Commercial |
$24.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$24.25
|
| 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: Entrust Commercial |
$23.75
|
| Rate for Payer: First Choice Health Commercial |
$23.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$23.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$15.25
|
| Rate for Payer: HealthUtah PPO |
$25.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.25
|
| Rate for Payer: Multiplan Medicare/VA |
$14.49
|
| Rate for Payer: One Health Plan of WY PPO |
$24.50
|
| Rate for Payer: PacificSource Commercial |
$22.50
|
| Rate for Payer: PHCS PPO |
$24.50
|
| Rate for Payer: Three Rivers PPO |
$18.75
|
| Rate for Payer: TriWest Veterans Administration |
$15.25
|
| Rate for Payer: United Healthcare Commercial |
$23.88
|
| Rate for Payer: United Healthcare Medicare |
$15.25
|
| Rate for Payer: WINHealth Partners Commercial |
$23.75
|
| Rate for Payer: Wise Provider Network Commercial |
$23.75
|
|
|
DORZOLAMIDE 2 % EYE DROPS [20314]
|
Facility
|
IP
|
$27.75
|
|
|
Service Code
|
NDC 4257114126
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.08 |
| Max. Negotiated Rate |
$27.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$27.20
|
| Rate for Payer: Aetna of WY Medicare |
$17.76
|
| Rate for Payer: Altius Commercial |
$26.64
|
| Rate for Payer: Beech Street Commercial |
$27.20
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$26.92
|
| Rate for Payer: Cash Price |
$19.42
|
| Rate for Payer: ChoiceCare Network Commercial |
$26.92
|
| Rate for Payer: Cigna of WY Commercial |
$27.20
|
| Rate for Payer: Entrust Commercial |
$26.36
|
| Rate for Payer: First Choice Health Commercial |
$26.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$26.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$16.93
|
| Rate for Payer: HealthUtah PPO |
$27.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$26.92
|
| Rate for Payer: Multiplan Medicare/VA |
$16.08
|
| Rate for Payer: One Health Plan of WY PPO |
$27.20
|
| Rate for Payer: PacificSource Commercial |
$24.98
|
| Rate for Payer: PHCS PPO |
$27.20
|
| Rate for Payer: Three Rivers PPO |
$20.81
|
| Rate for Payer: TriWest Veterans Administration |
$16.93
|
| Rate for Payer: United Healthcare Commercial |
$26.50
|
| Rate for Payer: United Healthcare Medicare |
$16.93
|
| Rate for Payer: WINHealth Partners Commercial |
$26.36
|
| Rate for Payer: Wise Provider Network Commercial |
$26.36
|
|
|
DORZOLAMIDE 2 % EYE DROPS [20314]
|
Facility
|
OP
|
$27.75
|
|
|
Service Code
|
NDC 6131401910
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.03 |
| Max. Negotiated Rate |
$27.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$27.20
|
| Rate for Payer: Aetna of WY Medicare |
$18.32
|
| Rate for Payer: Altius Commercial |
$26.64
|
| Rate for Payer: Beech Street Commercial |
$27.20
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$26.92
|
| Rate for Payer: Cash Price |
$19.42
|
| Rate for Payer: ChoiceCare Network Commercial |
$26.92
|
| Rate for Payer: Cigna of WY Commercial |
$27.20
|
| Rate for Payer: Entrust Commercial |
$26.36
|
| Rate for Payer: First Choice Health Commercial |
$26.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$26.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$15.82
|
| Rate for Payer: HealthUtah PPO |
$27.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$26.92
|
| Rate for Payer: Multiplan Medicare/VA |
$15.03
|
| Rate for Payer: One Health Plan of WY PPO |
$27.20
|
| Rate for Payer: PacificSource Commercial |
$24.98
|
| Rate for Payer: PHCS PPO |
$27.20
|
| Rate for Payer: Three Rivers PPO |
$20.81
|
| Rate for Payer: TriWest Veterans Administration |
$15.82
|
| Rate for Payer: United Healthcare Commercial |
$26.50
|
| Rate for Payer: United Healthcare Medicare |
$15.82
|
| Rate for Payer: WINHealth Partners Commercial |
$27.20
|
| Rate for Payer: Wise Provider Network Commercial |
$26.36
|
|
|
DORZOLAMIDE 2 % EYE DROPS [20314]
|
Facility
|
OP
|
$27.75
|
|
|
Service Code
|
NDC 6931530410
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.03 |
| Max. Negotiated Rate |
$27.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$27.20
|
| Rate for Payer: Aetna of WY Medicare |
$18.32
|
| Rate for Payer: Altius Commercial |
$26.64
|
| Rate for Payer: Beech Street Commercial |
$27.20
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$26.92
|
| Rate for Payer: Cash Price |
$19.42
|
| Rate for Payer: ChoiceCare Network Commercial |
$26.92
|
| Rate for Payer: Cigna of WY Commercial |
$27.20
|
| Rate for Payer: Entrust Commercial |
$26.36
|
| Rate for Payer: First Choice Health Commercial |
$26.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$26.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$15.82
|
| Rate for Payer: HealthUtah PPO |
$27.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$26.92
|
| Rate for Payer: Multiplan Medicare/VA |
$15.03
|
| Rate for Payer: One Health Plan of WY PPO |
$27.20
|
| Rate for Payer: PacificSource Commercial |
$24.98
|
| Rate for Payer: PHCS PPO |
$27.20
|
| Rate for Payer: Three Rivers PPO |
$20.81
|
| Rate for Payer: TriWest Veterans Administration |
$15.82
|
| Rate for Payer: United Healthcare Commercial |
$26.50
|
| Rate for Payer: United Healthcare Medicare |
$15.82
|
| Rate for Payer: WINHealth Partners Commercial |
$27.20
|
| Rate for Payer: Wise Provider Network Commercial |
$26.36
|
|
|
DORZOLAMIDE 2 % EYE DROPS [20314]
|
Facility
|
IP
|
$27.75
|
|
|
Service Code
|
NDC 6931530410
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.08 |
| Max. Negotiated Rate |
$27.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$27.20
|
| Rate for Payer: Aetna of WY Medicare |
$17.76
|
| Rate for Payer: Altius Commercial |
$26.64
|
| Rate for Payer: Beech Street Commercial |
$27.20
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$26.92
|
| Rate for Payer: Cash Price |
$19.42
|
| Rate for Payer: ChoiceCare Network Commercial |
$26.92
|
| Rate for Payer: Cigna of WY Commercial |
$27.20
|
| Rate for Payer: Entrust Commercial |
$26.36
|
| Rate for Payer: First Choice Health Commercial |
$26.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$26.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$16.93
|
| Rate for Payer: HealthUtah PPO |
$27.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$26.92
|
| Rate for Payer: Multiplan Medicare/VA |
$16.08
|
| Rate for Payer: One Health Plan of WY PPO |
$27.20
|
| Rate for Payer: PacificSource Commercial |
$24.98
|
| Rate for Payer: PHCS PPO |
$27.20
|
| Rate for Payer: Three Rivers PPO |
$20.81
|
| Rate for Payer: TriWest Veterans Administration |
$16.93
|
| Rate for Payer: United Healthcare Commercial |
$26.50
|
| Rate for Payer: United Healthcare Medicare |
$16.93
|
| Rate for Payer: WINHealth Partners Commercial |
$26.36
|
| Rate for Payer: Wise Provider Network Commercial |
$26.36
|
|
|
DOTAREM INJ 10X10ML VIAL
|
Facility
|
IP
|
$553.00
|
|
| Hospital Charge Code |
6550195
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$320.46 |
| Max. Negotiated Rate |
$553.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$541.94
|
| Rate for Payer: Aetna of WY Medicare |
$353.92
|
| Rate for Payer: Altius Commercial |
$530.88
|
| Rate for Payer: Beech Street Commercial |
$541.94
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$536.41
|
| Rate for Payer: Cash Price |
$387.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$536.41
|
| Rate for Payer: Cigna of WY Commercial |
$541.94
|
| Rate for Payer: Entrust Commercial |
$525.35
|
| Rate for Payer: First Choice Health Commercial |
$525.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$525.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$337.33
|
| Rate for Payer: HealthUtah PPO |
$553.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$536.41
|
| Rate for Payer: Multiplan Medicare/VA |
$320.46
|
| Rate for Payer: One Health Plan of WY PPO |
$541.94
|
| Rate for Payer: PacificSource Commercial |
$497.70
|
| Rate for Payer: PHCS PPO |
$541.94
|
| Rate for Payer: Three Rivers PPO |
$414.75
|
| Rate for Payer: TriWest Veterans Administration |
$337.33
|
| Rate for Payer: United Healthcare Commercial |
$528.12
|
| Rate for Payer: United Healthcare Medicare |
$337.33
|
| Rate for Payer: WINHealth Partners Commercial |
$525.35
|
| Rate for Payer: Wise Provider Network Commercial |
$525.35
|
|
