|
FLUOXETINE 10 MG CAPSULE [14508]
|
Facility
|
IP
|
$0.22
|
|
|
Service Code
|
NDC 4254372501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.22
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.21
|
| Rate for Payer: Altius Commercial |
$0.21
|
| Rate for Payer: Beech Street Commercial |
$0.22
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.18
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.21
|
| Rate for Payer: Cigna of WY Commercial |
$0.22
|
| Rate for Payer: Entrust Commercial |
$0.21
|
| Rate for Payer: First Choice Health Commercial |
$0.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.15
|
| Rate for Payer: HealthUtah PPO |
$0.22
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.21
|
| Rate for Payer: Multiplan Medicare/VA |
$0.14
|
| Rate for Payer: One Health Plan of WY PPO |
$0.22
|
| Rate for Payer: PacificSource Commercial |
$0.20
|
| Rate for Payer: PHCS PPO |
$0.22
|
| Rate for Payer: Three Rivers PPO |
$0.17
|
| Rate for Payer: TriWest Veterans Administration |
$0.15
|
| Rate for Payer: United Healthcare Commercial |
$0.19
|
| Rate for Payer: United Healthcare Medicare |
$0.15
|
| Rate for Payer: WINHealth Partners Commercial |
$0.21
|
| Rate for Payer: Wise Provider Network Commercial |
$0.21
|
|
|
FLUOXETINE 20 MG CAPSULE [18922]
|
Facility
|
OP
|
$0.23
|
|
|
Service Code
|
NDC 4254372601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.23
|
| Rate for Payer: Aetna of WY Medicare |
$0.15
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.22
|
| Rate for Payer: Altius Commercial |
$0.22
|
| Rate for Payer: Beech Street Commercial |
$0.23
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.19
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.22
|
| Rate for Payer: Cigna of WY Commercial |
$0.23
|
| Rate for Payer: Entrust Commercial |
$0.22
|
| Rate for Payer: First Choice Health Commercial |
$0.22
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.22
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.13
|
| Rate for Payer: HealthUtah PPO |
$0.23
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.22
|
| Rate for Payer: Multiplan Medicare/VA |
$0.13
|
| Rate for Payer: One Health Plan of WY PPO |
$0.23
|
| Rate for Payer: PacificSource Commercial |
$0.21
|
| Rate for Payer: PHCS PPO |
$0.23
|
| Rate for Payer: Three Rivers PPO |
$0.17
|
| Rate for Payer: TriWest Veterans Administration |
$0.13
|
| Rate for Payer: United Healthcare Commercial |
$0.20
|
| Rate for Payer: United Healthcare Medicare |
$0.13
|
| Rate for Payer: WINHealth Partners Commercial |
$0.23
|
| Rate for Payer: Wise Provider Network Commercial |
$0.22
|
|
|
FLUOXETINE 20 MG CAPSULE [18922]
|
Facility
|
IP
|
$0.38
|
|
|
Service Code
|
NDC 0904578561
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.37
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.36
|
| Rate for Payer: Altius Commercial |
$0.36
|
| Rate for Payer: Beech Street Commercial |
$0.37
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.31
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.37
|
| Rate for Payer: Cigna of WY Commercial |
$0.37
|
| Rate for Payer: Entrust Commercial |
$0.36
|
| Rate for Payer: First Choice Health Commercial |
$0.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.25
|
| Rate for Payer: HealthUtah PPO |
$0.38
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.37
|
| Rate for Payer: Multiplan Medicare/VA |
$0.24
|
| Rate for Payer: One Health Plan of WY PPO |
$0.37
|
| Rate for Payer: PacificSource Commercial |
$0.34
|
| Rate for Payer: PHCS PPO |
$0.37
|
| Rate for Payer: Three Rivers PPO |
$0.29
|
| Rate for Payer: TriWest Veterans Administration |
$0.25
|
| Rate for Payer: United Healthcare Commercial |
$0.33
|
| Rate for Payer: United Healthcare Medicare |
$0.25
|
| Rate for Payer: WINHealth Partners Commercial |
$0.36
|
| Rate for Payer: Wise Provider Network Commercial |
$0.36
|
|
|
FLUOXETINE 20 MG CAPSULE [18922]
|
Facility
|
IP
|
$0.23
|
|
|
Service Code
|
NDC 4254372601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.23
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.22
|
| Rate for Payer: Altius Commercial |
$0.22
|
| Rate for Payer: Beech Street Commercial |
$0.23
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.19
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.22
|
| Rate for Payer: Cigna of WY Commercial |
$0.23
|
| Rate for Payer: Entrust Commercial |
$0.22
|
| Rate for Payer: First Choice Health Commercial |
$0.22
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.22
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.15
|
| Rate for Payer: HealthUtah PPO |
$0.23
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.22
|
| Rate for Payer: Multiplan Medicare/VA |
$0.14
|
| Rate for Payer: One Health Plan of WY PPO |
$0.23
|
| Rate for Payer: PacificSource Commercial |
$0.21
|
| Rate for Payer: PHCS PPO |
$0.23
|
| Rate for Payer: Three Rivers PPO |
$0.17
|
| Rate for Payer: TriWest Veterans Administration |
$0.15
|
| Rate for Payer: United Healthcare Commercial |
$0.20
|
| Rate for Payer: United Healthcare Medicare |
$0.15
|
| Rate for Payer: WINHealth Partners Commercial |
$0.22
|
| Rate for Payer: Wise Provider Network Commercial |
$0.22
|
|
|
FLUOXETINE 20 MG CAPSULE [18922]
|
Facility
|
IP
|
$0.23
|
|
|
Service Code
|
NDC 5011164801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.23
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.22
|
| Rate for Payer: Altius Commercial |
$0.22
|
| Rate for Payer: Beech Street Commercial |
$0.23
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.19
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.22
|
| Rate for Payer: Cigna of WY Commercial |
$0.23
|
| Rate for Payer: Entrust Commercial |
$0.22
|
| Rate for Payer: First Choice Health Commercial |
$0.22
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.22
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.15
|
| Rate for Payer: HealthUtah PPO |
$0.23
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.22
|
| Rate for Payer: Multiplan Medicare/VA |
$0.14
|
| Rate for Payer: One Health Plan of WY PPO |
$0.23
|
| Rate for Payer: PacificSource Commercial |
$0.21
|
| Rate for Payer: PHCS PPO |
$0.23
|
| Rate for Payer: Three Rivers PPO |
$0.17
|
| Rate for Payer: TriWest Veterans Administration |
$0.15
|
| Rate for Payer: United Healthcare Commercial |
$0.20
|
| Rate for Payer: United Healthcare Medicare |
$0.15
|
| Rate for Payer: WINHealth Partners Commercial |
$0.22
|
| Rate for Payer: Wise Provider Network Commercial |
$0.22
|
|
|
FLUOXETINE 20 MG CAPSULE [18922]
|
Facility
|
OP
|
$0.23
|
|
|
Service Code
|
NDC 5011164801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.23
|
| Rate for Payer: Aetna of WY Medicare |
$0.15
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.22
|
| Rate for Payer: Altius Commercial |
$0.22
|
| Rate for Payer: Beech Street Commercial |
$0.23
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.19
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.22
|
| Rate for Payer: Cigna of WY Commercial |
$0.23
|
| Rate for Payer: Entrust Commercial |
$0.22
|
| Rate for Payer: First Choice Health Commercial |
$0.22
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.22
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.13
|
| Rate for Payer: HealthUtah PPO |
$0.23
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.22
|
| Rate for Payer: Multiplan Medicare/VA |
$0.13
|
| Rate for Payer: One Health Plan of WY PPO |
$0.23
|
| Rate for Payer: PacificSource Commercial |
$0.21
|
| Rate for Payer: PHCS PPO |
$0.23
|
| Rate for Payer: Three Rivers PPO |
$0.17
|
| Rate for Payer: TriWest Veterans Administration |
$0.13
|
| Rate for Payer: United Healthcare Commercial |
$0.20
|
| Rate for Payer: United Healthcare Medicare |
$0.13
|
| Rate for Payer: WINHealth Partners Commercial |
$0.23
|
| Rate for Payer: Wise Provider Network Commercial |
$0.22
|
|
|
FLUOXETINE 20 MG CAPSULE [18922]
|
Facility
|
OP
|
$0.38
|
|
|
Service Code
|
NDC 0904734661
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.37
|
| Rate for Payer: Aetna of WY Medicare |
$0.25
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.36
|
| Rate for Payer: Altius Commercial |
$0.36
|
| Rate for Payer: Beech Street Commercial |
$0.37
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.31
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.37
|
| Rate for Payer: Cigna of WY Commercial |
$0.37
|
| Rate for Payer: Entrust Commercial |
$0.36
|
| Rate for Payer: First Choice Health Commercial |
$0.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.22
|
| Rate for Payer: HealthUtah PPO |
$0.38
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.37
|
| Rate for Payer: Multiplan Medicare/VA |
$0.21
|
| Rate for Payer: One Health Plan of WY PPO |
$0.37
|
| Rate for Payer: PacificSource Commercial |
$0.34
|
| Rate for Payer: PHCS PPO |
$0.37
|
| Rate for Payer: Three Rivers PPO |
$0.29
|
| Rate for Payer: TriWest Veterans Administration |
$0.22
|
| Rate for Payer: United Healthcare Commercial |
$0.33
|
| Rate for Payer: United Healthcare Medicare |
$0.22
|
| Rate for Payer: WINHealth Partners Commercial |
$0.37
|
| Rate for Payer: Wise Provider Network Commercial |
$0.36
|
|
|
FLUOXETINE 20 MG CAPSULE [18922]
|
Facility
|
IP
|
$0.38
|
|
|
Service Code
|
NDC 0904734661
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.37
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.36
|
| Rate for Payer: Altius Commercial |
$0.36
|
| Rate for Payer: Beech Street Commercial |
$0.37
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.31
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.37
|
| Rate for Payer: Cigna of WY Commercial |
$0.37
|
| Rate for Payer: Entrust Commercial |
$0.36
|
| Rate for Payer: First Choice Health Commercial |
$0.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.25
|
| Rate for Payer: HealthUtah PPO |
$0.38
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.37
|
| Rate for Payer: Multiplan Medicare/VA |
$0.24
|
| Rate for Payer: One Health Plan of WY PPO |
$0.37
|
| Rate for Payer: PacificSource Commercial |
$0.34
|
| Rate for Payer: PHCS PPO |
$0.37
|
| Rate for Payer: Three Rivers PPO |
$0.29
|
| Rate for Payer: TriWest Veterans Administration |
$0.25
|
| Rate for Payer: United Healthcare Commercial |
$0.33
|
| Rate for Payer: United Healthcare Medicare |
$0.25
|
| Rate for Payer: WINHealth Partners Commercial |
$0.36
|
| Rate for Payer: Wise Provider Network Commercial |
$0.36
|
|
|
FLUOXETINE 20 MG CAPSULE [18922]
|
Facility
|
OP
|
$0.38
|
|
|
Service Code
|
NDC 0904578561
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.37
|
| Rate for Payer: Aetna of WY Medicare |
$0.25
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.36
|
| Rate for Payer: Altius Commercial |
$0.36
|
| Rate for Payer: Beech Street Commercial |
$0.37
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.31
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.37
|
| Rate for Payer: Cigna of WY Commercial |
$0.37
|
| Rate for Payer: Entrust Commercial |
$0.36
|
| Rate for Payer: First Choice Health Commercial |
$0.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.22
|
| Rate for Payer: HealthUtah PPO |
$0.38
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.37
|
| Rate for Payer: Multiplan Medicare/VA |
$0.21
|
| Rate for Payer: One Health Plan of WY PPO |
$0.37
|
| Rate for Payer: PacificSource Commercial |
$0.34
|
| Rate for Payer: PHCS PPO |
$0.37
|
| Rate for Payer: Three Rivers PPO |
$0.29
|
| Rate for Payer: TriWest Veterans Administration |
$0.22
|
| Rate for Payer: United Healthcare Commercial |
$0.33
|
| Rate for Payer: United Healthcare Medicare |
$0.22
|
| Rate for Payer: WINHealth Partners Commercial |
$0.37
|
| Rate for Payer: Wise Provider Network Commercial |
$0.36
|
|
|
FLUOXETINE 40 MG CAPSULE [256]
|
Facility
|
OP
|
$0.25
|
|
|
Service Code
|
NDC 5022811505
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.25
|
| Rate for Payer: Aetna of WY Medicare |
$0.17
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.24
|
| Rate for Payer: Altius Commercial |
$0.24
|
| Rate for Payer: Beech Street Commercial |
$0.25
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.21
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.24
|
| Rate for Payer: Cigna of WY Commercial |
$0.25
|
| Rate for Payer: Entrust Commercial |
$0.24
|
| Rate for Payer: First Choice Health Commercial |
$0.24
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.24
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.15
|
| Rate for Payer: HealthUtah PPO |
$0.25
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.24
|
| Rate for Payer: Multiplan Medicare/VA |
$0.14
|
| Rate for Payer: One Health Plan of WY PPO |
$0.25
|
| Rate for Payer: PacificSource Commercial |
$0.23
|
| Rate for Payer: PHCS PPO |
$0.25
|
| Rate for Payer: Three Rivers PPO |
$0.19
|
| Rate for Payer: TriWest Veterans Administration |
$0.15
|
| Rate for Payer: United Healthcare Commercial |
$0.22
|
| Rate for Payer: United Healthcare Medicare |
$0.15
|
| Rate for Payer: WINHealth Partners Commercial |
$0.25
|
| Rate for Payer: Wise Provider Network Commercial |
$0.24
|
|
|
FLUOXETINE 40 MG CAPSULE [256]
|
Facility
|
IP
|
$2.32
|
|
|
Service Code
|
NDC 6068765911
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.45 |
| Max. Negotiated Rate |
$2.32 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.27
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.23
|
| Rate for Payer: Altius Commercial |
$2.23
|
| Rate for Payer: Beech Street Commercial |
$2.27
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.90
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.25
|
| Rate for Payer: Cigna of WY Commercial |
$2.27
|
| Rate for Payer: Entrust Commercial |
$2.20
|
| Rate for Payer: First Choice Health Commercial |
$2.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.53
|
| Rate for Payer: HealthUtah PPO |
$2.32
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.25
|
| Rate for Payer: Multiplan Medicare/VA |
$1.45
|
| Rate for Payer: One Health Plan of WY PPO |
$2.27
|
| Rate for Payer: PacificSource Commercial |
$2.09
|
| Rate for Payer: PHCS PPO |
$2.27
|
| Rate for Payer: Three Rivers PPO |
$1.74
|
| Rate for Payer: TriWest Veterans Administration |
$1.53
|
| Rate for Payer: United Healthcare Commercial |
$2.02
|
| Rate for Payer: United Healthcare Medicare |
$1.53
|
| Rate for Payer: WINHealth Partners Commercial |
$2.20
|
| Rate for Payer: Wise Provider Network Commercial |
$2.20
|
|
|
FLUOXETINE 40 MG CAPSULE [256]
|
Facility
|
OP
|
$2.32
|
|
|
Service Code
|
NDC 6068765911
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.28 |
| Max. Negotiated Rate |
$2.32 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.27
|
| Rate for Payer: Aetna of WY Medicare |
$1.53
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.23
|
| Rate for Payer: Altius Commercial |
$2.23
|
| Rate for Payer: Beech Street Commercial |
$2.27
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.90
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.25
|
| Rate for Payer: Cigna of WY Commercial |
$2.27
|
| Rate for Payer: Entrust Commercial |
$2.20
|
| Rate for Payer: First Choice Health Commercial |
$2.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.35
|
| Rate for Payer: HealthUtah PPO |
$2.32
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.25
|
| Rate for Payer: Multiplan Medicare/VA |
$1.28
|
| Rate for Payer: One Health Plan of WY PPO |
$2.27
|
| Rate for Payer: PacificSource Commercial |
$2.09
|
| Rate for Payer: PHCS PPO |
$2.27
|
| Rate for Payer: Three Rivers PPO |
$1.74
|
| Rate for Payer: TriWest Veterans Administration |
$1.35
|
| Rate for Payer: United Healthcare Commercial |
$2.02
|
| Rate for Payer: United Healthcare Medicare |
$1.35
|
| Rate for Payer: WINHealth Partners Commercial |
$2.27
|
| Rate for Payer: Wise Provider Network Commercial |
$2.20
|
|
|
FLUOXETINE 40 MG CAPSULE [256]
|
Facility
|
IP
|
$0.25
|
|
|
Service Code
|
NDC 5022811505
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.25
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.24
|
| Rate for Payer: Altius Commercial |
$0.24
|
| Rate for Payer: Beech Street Commercial |
$0.25
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.21
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.24
|
| Rate for Payer: Cigna of WY Commercial |
$0.25
|
| Rate for Payer: Entrust Commercial |
$0.24
|
| Rate for Payer: First Choice Health Commercial |
$0.24
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.24
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.17
|
| Rate for Payer: HealthUtah PPO |
$0.25
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.24
|
| Rate for Payer: Multiplan Medicare/VA |
$0.16
|
| Rate for Payer: One Health Plan of WY PPO |
$0.25
|
| Rate for Payer: PacificSource Commercial |
$0.23
|
| Rate for Payer: PHCS PPO |
$0.25
|
| Rate for Payer: Three Rivers PPO |
$0.19
|
| Rate for Payer: TriWest Veterans Administration |
$0.17
|
| Rate for Payer: United Healthcare Commercial |
$0.22
|
| Rate for Payer: United Healthcare Medicare |
$0.17
|
| Rate for Payer: WINHealth Partners Commercial |
$0.24
|
| Rate for Payer: Wise Provider Network Commercial |
$0.24
|
|
|
FLUTICASONE FUR. 100 MCG-UMECLID 62.5 MCG-VILANT 25 MCG INHALAT.POWDER [150586]
|
Facility
|
OP
|
$33.83
|
|
|
Service Code
|
NDC 0173088714
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.64 |
| Max. Negotiated Rate |
$33.83 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$33.15
|
| Rate for Payer: Aetna of WY Medicare |
$22.33
|
| Rate for Payer: Altius Auto/Workers Compensation |
$32.48
|
| Rate for Payer: Altius Commercial |
$32.48
|
| Rate for Payer: Beech Street Commercial |
$33.15
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$27.77
|
| Rate for Payer: Cash Price |
$23.68
|
| Rate for Payer: ChoiceCare Network Commercial |
$32.82
|
| Rate for Payer: Cigna of WY Commercial |
$33.15
|
| Rate for Payer: Entrust Commercial |
$32.14
|
| Rate for Payer: First Choice Health Commercial |
$32.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$32.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$19.62
|
| Rate for Payer: HealthUtah PPO |
$33.83
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$32.82
|
| Rate for Payer: Multiplan Medicare/VA |
$18.64
|
| Rate for Payer: One Health Plan of WY PPO |
$33.15
|
| Rate for Payer: PacificSource Commercial |
$30.45
|
| Rate for Payer: PHCS PPO |
$33.15
|
| Rate for Payer: Three Rivers PPO |
$25.37
|
| Rate for Payer: TriWest Veterans Administration |
$19.62
|
| Rate for Payer: United Healthcare Commercial |
$29.43
|
| Rate for Payer: United Healthcare Medicare |
$19.62
|
| Rate for Payer: WINHealth Partners Commercial |
$33.15
|
| Rate for Payer: Wise Provider Network Commercial |
$32.14
|
|
|
FLUTICASONE FUR. 100 MCG-UMECLID 62.5 MCG-VILANT 25 MCG INHALAT.POWDER [150586]
|
Facility
|
IP
|
$33.83
|
|
|
Service Code
|
NDC 0173088714
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.21 |
| Max. Negotiated Rate |
$33.83 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$33.15
|
| Rate for Payer: Altius Auto/Workers Compensation |
$32.48
|
| Rate for Payer: Altius Commercial |
$32.48
|
| Rate for Payer: Beech Street Commercial |
$33.15
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$27.77
|
| Rate for Payer: Cash Price |
$23.68
|
| Rate for Payer: ChoiceCare Network Commercial |
$32.82
|
| Rate for Payer: Cigna of WY Commercial |
$33.15
|
| Rate for Payer: Entrust Commercial |
$32.14
|
| Rate for Payer: First Choice Health Commercial |
$32.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$32.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$22.33
|
| Rate for Payer: HealthUtah PPO |
$33.83
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$32.82
|
| Rate for Payer: Multiplan Medicare/VA |
$21.21
|
| Rate for Payer: One Health Plan of WY PPO |
$33.15
|
| Rate for Payer: PacificSource Commercial |
$30.45
|
| Rate for Payer: PHCS PPO |
$33.15
|
| Rate for Payer: Three Rivers PPO |
$25.37
|
| Rate for Payer: TriWest Veterans Administration |
$22.33
|
| Rate for Payer: United Healthcare Commercial |
$29.43
|
| Rate for Payer: United Healthcare Medicare |
$22.33
|
| Rate for Payer: WINHealth Partners Commercial |
$32.14
|
| Rate for Payer: Wise Provider Network Commercial |
$32.14
|
|
|
FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER [19837]
|
Facility
|
IP
|
$40.79
|
|
|
Service Code
|
NDC 6699307996
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.58 |
| Max. Negotiated Rate |
$40.79 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$39.97
|
| Rate for Payer: Altius Auto/Workers Compensation |
$39.16
|
| Rate for Payer: Altius Commercial |
$39.16
|
| Rate for Payer: Beech Street Commercial |
$39.97
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$33.49
|
| Rate for Payer: Cash Price |
$28.55
|
| Rate for Payer: ChoiceCare Network Commercial |
$39.57
|
| Rate for Payer: Cigna of WY Commercial |
$39.97
|
| Rate for Payer: Entrust Commercial |
$38.75
|
| Rate for Payer: First Choice Health Commercial |
$38.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$38.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$26.92
|
| Rate for Payer: HealthUtah PPO |
$40.79
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$39.57
|
| Rate for Payer: Multiplan Medicare/VA |
$25.58
|
| Rate for Payer: One Health Plan of WY PPO |
$39.97
|
| Rate for Payer: PacificSource Commercial |
$36.71
|
| Rate for Payer: PHCS PPO |
$39.97
|
| Rate for Payer: Three Rivers PPO |
$30.59
|
| Rate for Payer: TriWest Veterans Administration |
$26.92
|
| Rate for Payer: United Healthcare Commercial |
$35.49
|
| Rate for Payer: United Healthcare Medicare |
$26.92
|
| Rate for Payer: WINHealth Partners Commercial |
$38.75
|
| Rate for Payer: Wise Provider Network Commercial |
$38.75
|
|
|
FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER [19837]
|
Facility
|
OP
|
$40.79
|
|
|
Service Code
|
NDC 6699307996
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.48 |
| Max. Negotiated Rate |
$40.79 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$39.97
|
| Rate for Payer: Aetna of WY Medicare |
$26.92
|
| Rate for Payer: Altius Auto/Workers Compensation |
$39.16
|
| Rate for Payer: Altius Commercial |
$39.16
|
| Rate for Payer: Beech Street Commercial |
$39.97
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$33.49
|
| Rate for Payer: Cash Price |
$28.55
|
| Rate for Payer: ChoiceCare Network Commercial |
$39.57
|
| Rate for Payer: Cigna of WY Commercial |
$39.97
|
| Rate for Payer: Entrust Commercial |
$38.75
|
| Rate for Payer: First Choice Health Commercial |
$38.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$38.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$23.66
|
| Rate for Payer: HealthUtah PPO |
$40.79
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$39.57
|
| Rate for Payer: Multiplan Medicare/VA |
$22.48
|
| Rate for Payer: One Health Plan of WY PPO |
$39.97
|
| Rate for Payer: PacificSource Commercial |
$36.71
|
| Rate for Payer: PHCS PPO |
$39.97
|
| Rate for Payer: Three Rivers PPO |
$30.59
|
| Rate for Payer: TriWest Veterans Administration |
$23.66
|
| Rate for Payer: United Healthcare Commercial |
$35.49
|
| Rate for Payer: United Healthcare Medicare |
$23.66
|
| Rate for Payer: WINHealth Partners Commercial |
$39.97
|
| Rate for Payer: Wise Provider Network Commercial |
$38.75
|
|
|
FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION [18925]
|
Facility
|
IP
|
$18.65
|
|
|
Service Code
|
NDC 6050508291
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.69 |
| Max. Negotiated Rate |
$18.65 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18.28
|
| Rate for Payer: Altius Auto/Workers Compensation |
$17.90
|
| Rate for Payer: Altius Commercial |
$17.90
|
| Rate for Payer: Beech Street Commercial |
$18.28
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.31
|
| Rate for Payer: Cash Price |
$13.06
|
| Rate for Payer: ChoiceCare Network Commercial |
$18.09
|
| Rate for Payer: Cigna of WY Commercial |
$18.28
|
| Rate for Payer: Entrust Commercial |
$17.72
|
| Rate for Payer: First Choice Health Commercial |
$17.72
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.72
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$12.31
|
| Rate for Payer: HealthUtah PPO |
$18.65
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$18.09
|
| Rate for Payer: Multiplan Medicare/VA |
$11.69
|
| Rate for Payer: One Health Plan of WY PPO |
$18.28
|
| Rate for Payer: PacificSource Commercial |
$16.78
|
| Rate for Payer: PHCS PPO |
$18.28
|
| Rate for Payer: Three Rivers PPO |
$13.99
|
| Rate for Payer: TriWest Veterans Administration |
$12.31
|
| Rate for Payer: United Healthcare Commercial |
$16.23
|
| Rate for Payer: United Healthcare Medicare |
$12.31
|
| Rate for Payer: WINHealth Partners Commercial |
$17.72
|
| Rate for Payer: Wise Provider Network Commercial |
$17.72
|
|
|
FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION [18925]
|
Facility
|
OP
|
$18.65
|
|
|
Service Code
|
NDC 6050508291
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.28 |
| Max. Negotiated Rate |
$18.65 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18.28
|
| Rate for Payer: Aetna of WY Medicare |
$12.31
|
| Rate for Payer: Altius Auto/Workers Compensation |
$17.90
|
| Rate for Payer: Altius Commercial |
$17.90
|
| Rate for Payer: Beech Street Commercial |
$18.28
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.31
|
| Rate for Payer: Cash Price |
$13.06
|
| Rate for Payer: ChoiceCare Network Commercial |
$18.09
|
| Rate for Payer: Cigna of WY Commercial |
$18.28
|
| Rate for Payer: Entrust Commercial |
$17.72
|
| Rate for Payer: First Choice Health Commercial |
$17.72
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.72
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.82
|
| Rate for Payer: HealthUtah PPO |
$18.65
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$18.09
|
| Rate for Payer: Multiplan Medicare/VA |
$10.28
|
| Rate for Payer: One Health Plan of WY PPO |
$18.28
|
| Rate for Payer: PacificSource Commercial |
$16.78
|
| Rate for Payer: PHCS PPO |
$18.28
|
| Rate for Payer: Three Rivers PPO |
$13.99
|
| Rate for Payer: TriWest Veterans Administration |
$10.82
|
| Rate for Payer: United Healthcare Commercial |
$16.23
|
| Rate for Payer: United Healthcare Medicare |
$10.82
|
| Rate for Payer: WINHealth Partners Commercial |
$18.28
|
| Rate for Payer: Wise Provider Network Commercial |
$17.72
|
|
|
FLU VACC 2024-25(65YR UP)-MF59C(PF) 45 MCG(15 MCGX3)/0.5 ML IM SYRINGE [185940]
|
Facility
|
OP
|
$232.84
|
|
|
Service Code
|
HCPCS 90653
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.00 |
| Max. Negotiated Rate |
$232.84 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$228.18
|
| Rate for Payer: Aetna of WY Medicare |
$153.67
|
| Rate for Payer: Altius Auto/Workers Compensation |
$223.53
|
| Rate for Payer: Altius Commercial |
$223.53
|
| Rate for Payer: Beech Street Commercial |
$228.18
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$191.16
|
| Rate for Payer: Cash Price |
$162.99
|
| Rate for Payer: Cash Price |
$162.99
|
| Rate for Payer: ChoiceCare Network Commercial |
$225.85
|
| Rate for Payer: Cigna of WY Commercial |
$228.18
|
| Rate for Payer: Entrust Commercial |
$221.20
|
| Rate for Payer: First Choice Health Commercial |
$221.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$221.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$135.05
|
| Rate for Payer: HealthUtah PPO |
$232.84
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$225.85
|
| Rate for Payer: Multiplan Medicare/VA |
$128.29
|
| Rate for Payer: One Health Plan of WY PPO |
$228.18
|
| Rate for Payer: PacificSource Commercial |
$209.56
|
| Rate for Payer: PHCS PPO |
$228.18
|
| Rate for Payer: Three Rivers PPO |
$174.63
|
| Rate for Payer: TriWest Veterans Administration |
$20.00
|
| Rate for Payer: United Healthcare Commercial |
$202.57
|
| Rate for Payer: United Healthcare Medicare |
$135.05
|
| Rate for Payer: WINHealth Partners Commercial |
$228.18
|
| Rate for Payer: Wise Provider Network Commercial |
$221.20
|
|
|
FLU VACC 2024-25(65YR UP)-MF59C(PF) 45 MCG(15 MCGX3)/0.5 ML IM SYRINGE [185940]
|
Facility
|
IP
|
$232.84
|
|
|
Service Code
|
HCPCS 90653
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$145.99 |
| Max. Negotiated Rate |
$232.84 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$228.18
|
| Rate for Payer: Altius Auto/Workers Compensation |
$223.53
|
| Rate for Payer: Altius Commercial |
$223.53
|
| Rate for Payer: Beech Street Commercial |
$228.18
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$191.16
|
| Rate for Payer: Cash Price |
$162.99
|
| Rate for Payer: ChoiceCare Network Commercial |
$225.85
|
| Rate for Payer: Cigna of WY Commercial |
$228.18
|
| Rate for Payer: Entrust Commercial |
$221.20
|
| Rate for Payer: First Choice Health Commercial |
$221.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$221.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$153.67
|
| Rate for Payer: HealthUtah PPO |
$232.84
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$225.85
|
| Rate for Payer: Multiplan Medicare/VA |
$145.99
|
| Rate for Payer: One Health Plan of WY PPO |
$228.18
|
| Rate for Payer: PacificSource Commercial |
$209.56
|
| Rate for Payer: PHCS PPO |
$228.18
|
| Rate for Payer: Three Rivers PPO |
$174.63
|
| Rate for Payer: TriWest Veterans Administration |
$153.67
|
| Rate for Payer: United Healthcare Commercial |
$202.57
|
| Rate for Payer: United Healthcare Medicare |
$153.67
|
| Rate for Payer: WINHealth Partners Commercial |
$221.20
|
| Rate for Payer: Wise Provider Network Commercial |
$221.20
|
|
|
FLU VACCINE TS2024-25(65YR UP)(PF)180 MCG/0.5 ML INTRAMUSCULAR SYRINGE [186096]
|
Facility
|
IP
|
$232.84
|
|
|
Service Code
|
HCPCS 90662
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$145.99 |
| Max. Negotiated Rate |
$232.84 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$228.18
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$228.17
|
| Rate for Payer: Altius Auto/Workers Compensation |
$223.53
|
| Rate for Payer: Altius Auto/Workers Compensation |
$223.52
|
| Rate for Payer: Altius Commercial |
$223.52
|
| Rate for Payer: Altius Commercial |
$223.53
|
| Rate for Payer: Beech Street Commercial |
$228.18
|
| Rate for Payer: Beech Street Commercial |
$228.17
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$191.15
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$191.16
|
| Rate for Payer: Cash Price |
$162.99
|
| Rate for Payer: Cash Price |
$162.98
|
| Rate for Payer: ChoiceCare Network Commercial |
$225.85
|
| Rate for Payer: ChoiceCare Network Commercial |
$225.85
|
| Rate for Payer: Cigna of WY Commercial |
$228.18
|
| Rate for Payer: Cigna of WY Commercial |
$228.17
|
| Rate for Payer: Entrust Commercial |
$221.19
|
| Rate for Payer: Entrust Commercial |
$221.20
|
| Rate for Payer: First Choice Health Commercial |
$221.19
|
| Rate for Payer: First Choice Health Commercial |
$221.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$221.19
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$221.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$153.67
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$153.67
|
| Rate for Payer: HealthUtah PPO |
$232.84
|
| Rate for Payer: HealthUtah PPO |
$232.83
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$225.85
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$225.85
|
| Rate for Payer: Multiplan Medicare/VA |
$145.99
|
| Rate for Payer: Multiplan Medicare/VA |
$145.98
|
| Rate for Payer: One Health Plan of WY PPO |
$228.18
|
| Rate for Payer: One Health Plan of WY PPO |
$228.17
|
| Rate for Payer: PacificSource Commercial |
$209.56
|
| Rate for Payer: PacificSource Commercial |
$209.55
|
| Rate for Payer: PHCS PPO |
$228.17
|
| Rate for Payer: PHCS PPO |
$228.18
|
| Rate for Payer: Three Rivers PPO |
$174.62
|
| Rate for Payer: Three Rivers PPO |
$174.63
|
| Rate for Payer: TriWest Veterans Administration |
$153.67
|
| Rate for Payer: TriWest Veterans Administration |
$153.67
|
| Rate for Payer: United Healthcare Commercial |
$202.56
|
| Rate for Payer: United Healthcare Commercial |
$202.57
|
| Rate for Payer: United Healthcare Medicare |
$153.67
|
| Rate for Payer: United Healthcare Medicare |
$153.67
|
| Rate for Payer: WINHealth Partners Commercial |
$221.19
|
| Rate for Payer: WINHealth Partners Commercial |
$221.20
|
| Rate for Payer: Wise Provider Network Commercial |
$221.19
|
| Rate for Payer: Wise Provider Network Commercial |
$221.20
|
|
|
FLU VACCINE TS2024-25(65YR UP)(PF)180 MCG/0.5 ML INTRAMUSCULAR SYRINGE [186096]
|
Facility
|
OP
|
$232.83
|
|
|
Service Code
|
HCPCS 90662
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.00 |
| Max. Negotiated Rate |
$232.83 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$228.17
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$228.18
|
| Rate for Payer: Aetna of WY Medicare |
$153.67
|
| Rate for Payer: Aetna of WY Medicare |
$153.67
|
| Rate for Payer: Altius Auto/Workers Compensation |
$223.53
|
| Rate for Payer: Altius Auto/Workers Compensation |
$223.52
|
| Rate for Payer: Altius Commercial |
$223.53
|
| Rate for Payer: Altius Commercial |
$223.52
|
| Rate for Payer: Beech Street Commercial |
$228.17
|
| Rate for Payer: Beech Street Commercial |
$228.18
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$191.15
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$191.16
|
| Rate for Payer: Cash Price |
$162.98
|
| Rate for Payer: Cash Price |
$162.98
|
| Rate for Payer: Cash Price |
$162.98
|
| Rate for Payer: Cash Price |
$162.99
|
| Rate for Payer: Cash Price |
$162.99
|
| Rate for Payer: Cash Price |
$162.99
|
| Rate for Payer: ChoiceCare Network Commercial |
$225.85
|
| Rate for Payer: ChoiceCare Network Commercial |
$225.85
|
| Rate for Payer: Cigna of WY Commercial |
$228.17
|
| Rate for Payer: Cigna of WY Commercial |
$228.18
|
| Rate for Payer: Entrust Commercial |
$221.20
|
| Rate for Payer: Entrust Commercial |
$221.19
|
| Rate for Payer: First Choice Health Commercial |
$221.19
|
| Rate for Payer: First Choice Health Commercial |
$221.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$221.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$221.19
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$135.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$135.04
|
| Rate for Payer: HealthUtah PPO |
$232.84
|
| Rate for Payer: HealthUtah PPO |
$232.83
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$225.85
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$225.85
|
| Rate for Payer: Multiplan Medicare/VA |
$128.29
|
| Rate for Payer: Multiplan Medicare/VA |
$128.29
|
| Rate for Payer: One Health Plan of WY PPO |
$228.18
|
| Rate for Payer: One Health Plan of WY PPO |
$228.17
|
| Rate for Payer: PacificSource Commercial |
$209.56
|
| Rate for Payer: PacificSource Commercial |
$209.55
|
| Rate for Payer: PHCS PPO |
$228.18
|
| Rate for Payer: PHCS PPO |
$228.17
|
| Rate for Payer: Three Rivers PPO |
$174.62
|
| Rate for Payer: Three Rivers PPO |
$174.63
|
| Rate for Payer: TriWest Veterans Administration |
$20.00
|
| Rate for Payer: TriWest Veterans Administration |
$20.00
|
| Rate for Payer: United Healthcare Commercial |
$202.56
|
| Rate for Payer: United Healthcare Commercial |
$202.57
|
| Rate for Payer: United Healthcare Medicare |
$73.40
|
| Rate for Payer: United Healthcare Medicare |
$73.40
|
| Rate for Payer: WINHealth Partners Commercial |
$228.17
|
| Rate for Payer: WINHealth Partners Commercial |
$228.18
|
| Rate for Payer: Wise Provider Network Commercial |
$221.19
|
| Rate for Payer: Wise Provider Network Commercial |
$221.20
|
|
|
FLU VACCINE TS 2024-25(6MOS UP)(PF) 45 MCG(15MCG X3)/0.5 ML IM SYRINGE [186091]
|
Facility
|
OP
|
$94.72
|
|
|
Service Code
|
HCPCS 90656
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.00 |
| Max. Negotiated Rate |
$94.72 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$92.83
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$89.10
|
| Rate for Payer: Aetna of WY Medicare |
$62.52
|
| Rate for Payer: Aetna of WY Medicare |
$60.01
|
| Rate for Payer: Altius Auto/Workers Compensation |
$90.93
|
| Rate for Payer: Altius Auto/Workers Compensation |
$87.28
|
| Rate for Payer: Altius Commercial |
$90.93
|
| Rate for Payer: Altius Commercial |
$87.28
|
| Rate for Payer: Beech Street Commercial |
$89.10
|
| Rate for Payer: Beech Street Commercial |
$92.83
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$74.65
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$77.77
|
| Rate for Payer: Cash Price |
$63.64
|
| Rate for Payer: Cash Price |
$63.64
|
| Rate for Payer: Cash Price |
$66.30
|
| Rate for Payer: Cash Price |
$66.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$88.19
|
| Rate for Payer: ChoiceCare Network Commercial |
$91.88
|
| Rate for Payer: Cigna of WY Commercial |
$92.83
|
| Rate for Payer: Cigna of WY Commercial |
$89.10
|
| Rate for Payer: Entrust Commercial |
$86.37
|
| Rate for Payer: Entrust Commercial |
$89.98
|
| Rate for Payer: First Choice Health Commercial |
$89.98
|
| Rate for Payer: First Choice Health Commercial |
$86.37
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$89.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$86.37
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$52.73
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$54.94
|
| Rate for Payer: HealthUtah PPO |
$90.92
|
| Rate for Payer: HealthUtah PPO |
$94.72
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$88.19
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$91.88
|
| Rate for Payer: Multiplan Medicare/VA |
$52.19
|
| Rate for Payer: Multiplan Medicare/VA |
$50.10
|
| Rate for Payer: One Health Plan of WY PPO |
$92.83
|
| Rate for Payer: One Health Plan of WY PPO |
$89.10
|
| Rate for Payer: PacificSource Commercial |
$81.83
|
| Rate for Payer: PacificSource Commercial |
$85.25
|
| Rate for Payer: PHCS PPO |
$92.83
|
| Rate for Payer: PHCS PPO |
$89.10
|
| Rate for Payer: Three Rivers PPO |
$68.19
|
| Rate for Payer: Three Rivers PPO |
$71.04
|
| Rate for Payer: TriWest Veterans Administration |
$20.00
|
| Rate for Payer: TriWest Veterans Administration |
$20.00
|
| Rate for Payer: United Healthcare Commercial |
$79.10
|
| Rate for Payer: United Healthcare Commercial |
$82.41
|
| Rate for Payer: United Healthcare Medicare |
$54.94
|
| Rate for Payer: United Healthcare Medicare |
$52.73
|
| Rate for Payer: WINHealth Partners Commercial |
$89.10
|
| Rate for Payer: WINHealth Partners Commercial |
$92.83
|
| Rate for Payer: Wise Provider Network Commercial |
$86.37
|
| Rate for Payer: Wise Provider Network Commercial |
$89.98
|
|
|
FLU VACCINE TS 2024-25(6MOS UP)(PF) 45 MCG(15MCG X3)/0.5 ML IM SYRINGE [186091]
|
Facility
|
IP
|
$94.72
|
|
|
Service Code
|
HCPCS 90656
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$59.39 |
| Max. Negotiated Rate |
$94.72 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$92.83
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$89.10
|
| Rate for Payer: Altius Auto/Workers Compensation |
$90.93
|
| Rate for Payer: Altius Auto/Workers Compensation |
$87.28
|
| Rate for Payer: Altius Commercial |
$87.28
|
| Rate for Payer: Altius Commercial |
$90.93
|
| Rate for Payer: Beech Street Commercial |
$92.83
|
| Rate for Payer: Beech Street Commercial |
$89.10
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$74.65
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$77.77
|
| Rate for Payer: Cash Price |
$66.30
|
| Rate for Payer: Cash Price |
$63.64
|
| Rate for Payer: ChoiceCare Network Commercial |
$88.19
|
| Rate for Payer: ChoiceCare Network Commercial |
$91.88
|
| Rate for Payer: Cigna of WY Commercial |
$92.83
|
| Rate for Payer: Cigna of WY Commercial |
$89.10
|
| Rate for Payer: Entrust Commercial |
$86.37
|
| Rate for Payer: Entrust Commercial |
$89.98
|
| Rate for Payer: First Choice Health Commercial |
$86.37
|
| Rate for Payer: First Choice Health Commercial |
$89.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$86.37
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$89.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$62.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$60.01
|
| Rate for Payer: HealthUtah PPO |
$94.72
|
| Rate for Payer: HealthUtah PPO |
$90.92
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$88.19
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$91.88
|
| Rate for Payer: Multiplan Medicare/VA |
$59.39
|
| Rate for Payer: Multiplan Medicare/VA |
$57.01
|
| Rate for Payer: One Health Plan of WY PPO |
$92.83
|
| Rate for Payer: One Health Plan of WY PPO |
$89.10
|
| Rate for Payer: PacificSource Commercial |
$85.25
|
| Rate for Payer: PacificSource Commercial |
$81.83
|
| Rate for Payer: PHCS PPO |
$89.10
|
| Rate for Payer: PHCS PPO |
$92.83
|
| Rate for Payer: Three Rivers PPO |
$68.19
|
| Rate for Payer: Three Rivers PPO |
$71.04
|
| Rate for Payer: TriWest Veterans Administration |
$62.52
|
| Rate for Payer: TriWest Veterans Administration |
$60.01
|
| Rate for Payer: United Healthcare Commercial |
$79.10
|
| Rate for Payer: United Healthcare Commercial |
$82.41
|
| Rate for Payer: United Healthcare Medicare |
$62.52
|
| Rate for Payer: United Healthcare Medicare |
$60.01
|
| Rate for Payer: WINHealth Partners Commercial |
$86.37
|
| Rate for Payer: WINHealth Partners Commercial |
$89.98
|
| Rate for Payer: Wise Provider Network Commercial |
$86.37
|
| Rate for Payer: Wise Provider Network Commercial |
$89.98
|
|
