|
FTH/GFT FREE W/DIRECT CLOSURE S/A/L 20 SQ CM/<
|
Professional
|
Both
|
$3,050.00
|
|
|
Service Code
|
HCPCS 15220
|
| Hospital Charge Code |
15220
|
| Min. Negotiated Rate |
$501.81 |
| Max. Negotiated Rate |
$3,050.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,989.00
|
| Rate for Payer: Aetna of WY Medicare |
$590.36
|
| Rate for Payer: Beech Street Commercial |
$2,897.50
|
| Rate for Payer: Cash Price |
$2,135.00
|
| Rate for Payer: Cash Price |
$2,135.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,958.50
|
| Rate for Payer: Cigna of WY Commercial |
$2,989.00
|
| Rate for Payer: First Choice Health Commercial |
$2,745.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,897.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$590.36
|
| Rate for Payer: HealthUtah PPO |
$3,050.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,958.50
|
| Rate for Payer: Multiplan Medicare/VA |
$501.81
|
| Rate for Payer: One Health Plan of WY PPO |
$2,989.00
|
| Rate for Payer: PacificSource Commercial |
$2,745.00
|
| Rate for Payer: PHCS PPO |
$2,897.50
|
| Rate for Payer: Three Rivers PPO |
$2,287.50
|
| Rate for Payer: TriWest Veterans Administration |
$590.36
|
| Rate for Payer: United Healthcare Commercial |
$2,653.50
|
| Rate for Payer: United Healthcare Medicare |
$590.36
|
| Rate for Payer: WINHealth Partners Commercial |
$2,592.50
|
|
|
FTH/GFT FR W/DIR CLSR S/A/L EA ADDL 20 SQ CM
|
Professional
|
Both
|
$352.00
|
|
|
Service Code
|
HCPCS 15221
|
| Hospital Charge Code |
15221
|
| Min. Negotiated Rate |
$55.53 |
| Max. Negotiated Rate |
$352.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$344.96
|
| Rate for Payer: Aetna of WY Medicare |
$65.33
|
| Rate for Payer: Beech Street Commercial |
$334.40
|
| Rate for Payer: Cash Price |
$246.40
|
| Rate for Payer: Cash Price |
$246.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$341.44
|
| Rate for Payer: Cigna of WY Commercial |
$344.96
|
| Rate for Payer: First Choice Health Commercial |
$316.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$334.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$65.33
|
| Rate for Payer: HealthUtah PPO |
$352.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$341.44
|
| Rate for Payer: Multiplan Medicare/VA |
$55.53
|
| Rate for Payer: One Health Plan of WY PPO |
$344.96
|
| Rate for Payer: PacificSource Commercial |
$316.80
|
| Rate for Payer: PHCS PPO |
$334.40
|
| Rate for Payer: Three Rivers PPO |
$264.00
|
| Rate for Payer: TriWest Veterans Administration |
$65.33
|
| Rate for Payer: United Healthcare Commercial |
$306.24
|
| Rate for Payer: United Healthcare Medicare |
$65.33
|
| Rate for Payer: WINHealth Partners Commercial |
$299.20
|
|
|
FT INSERT UCB BERKELEY SHELL
|
Professional
|
Both
|
$615.00
|
|
|
Service Code
|
HCPCS L3000
|
| Hospital Charge Code |
L3000
|
| Min. Negotiated Rate |
$317.59 |
| Max. Negotiated Rate |
$615.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$602.70
|
| Rate for Payer: Aetna of WY Medicare |
$373.63
|
| Rate for Payer: Beech Street Commercial |
$584.25
|
| Rate for Payer: Cash Price |
$430.50
|
| Rate for Payer: Cash Price |
$430.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$596.55
|
| Rate for Payer: Cigna of WY Commercial |
$602.70
|
| Rate for Payer: First Choice Health Commercial |
$553.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$584.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$373.63
|
| Rate for Payer: HealthUtah PPO |
$615.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$596.55
|
| Rate for Payer: Multiplan Medicare/VA |
$317.59
|
| Rate for Payer: One Health Plan of WY PPO |
$602.70
|
| Rate for Payer: PacificSource Commercial |
$553.50
|
| Rate for Payer: PHCS PPO |
$584.25
|
| Rate for Payer: Three Rivers PPO |
$461.25
|
| Rate for Payer: TriWest Veterans Administration |
$373.63
|
| Rate for Payer: United Healthcare Commercial |
$535.05
|
| Rate for Payer: United Healthcare Medicare |
$373.63
|
| Rate for Payer: WINHealth Partners Commercial |
$584.25
|
|
|
FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE [23757]
|
Facility
|
OP
|
$95.00
|
|
|
Service Code
|
HCPCS J9395
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$52.34 |
| Max. Negotiated Rate |
$95.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$93.10
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$58.80
|
| Rate for Payer: Aetna of WY Medicare |
$62.70
|
| Rate for Payer: Aetna of WY Medicare |
$39.60
|
| Rate for Payer: Altius Auto/Workers Compensation |
$57.60
|
| Rate for Payer: Altius Auto/Workers Compensation |
$91.20
|
| Rate for Payer: Altius Commercial |
$91.20
|
| Rate for Payer: Altius Commercial |
$57.60
|
| Rate for Payer: Beech Street Commercial |
$58.80
|
| Rate for Payer: Beech Street Commercial |
$93.10
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$78.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$49.26
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Cash Price |
$66.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$92.15
|
| Rate for Payer: ChoiceCare Network Commercial |
$58.20
|
| Rate for Payer: Cigna of WY Commercial |
$58.80
|
| Rate for Payer: Cigna of WY Commercial |
$93.10
|
| Rate for Payer: Entrust Commercial |
$90.25
|
| Rate for Payer: Entrust Commercial |
$57.00
|
| Rate for Payer: First Choice Health Commercial |
$57.00
|
| Rate for Payer: First Choice Health Commercial |
$90.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$57.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$90.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$55.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$34.80
|
| Rate for Payer: HealthUtah PPO |
$60.00
|
| Rate for Payer: HealthUtah PPO |
$95.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$58.20
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$92.15
|
| Rate for Payer: Multiplan Medicare/VA |
$52.34
|
| Rate for Payer: Multiplan Medicare/VA |
$33.06
|
| Rate for Payer: One Health Plan of WY PPO |
$58.80
|
| Rate for Payer: One Health Plan of WY PPO |
$93.10
|
| Rate for Payer: PacificSource Commercial |
$85.50
|
| Rate for Payer: PacificSource Commercial |
$54.00
|
| Rate for Payer: PHCS PPO |
$58.80
|
| Rate for Payer: PHCS PPO |
$93.10
|
| Rate for Payer: Three Rivers PPO |
$45.00
|
| Rate for Payer: Three Rivers PPO |
$71.25
|
| Rate for Payer: TriWest Veterans Administration |
$55.10
|
| Rate for Payer: TriWest Veterans Administration |
$34.80
|
| Rate for Payer: United Healthcare Commercial |
$52.20
|
| Rate for Payer: United Healthcare Commercial |
$82.65
|
| Rate for Payer: United Healthcare Medicare |
$55.10
|
| Rate for Payer: United Healthcare Medicare |
$34.80
|
| Rate for Payer: WINHealth Partners Commercial |
$58.80
|
| Rate for Payer: WINHealth Partners Commercial |
$93.10
|
| Rate for Payer: Wise Provider Network Commercial |
$57.00
|
| Rate for Payer: Wise Provider Network Commercial |
$90.25
|
|
|
FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE [23757]
|
Facility
|
IP
|
$95.00
|
|
|
Service Code
|
HCPCS J9395
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$59.56 |
| Max. Negotiated Rate |
$95.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$93.10
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$58.80
|
| Rate for Payer: Altius Auto/Workers Compensation |
$91.20
|
| Rate for Payer: Altius Auto/Workers Compensation |
$57.60
|
| Rate for Payer: Altius Commercial |
$57.60
|
| Rate for Payer: Altius Commercial |
$91.20
|
| Rate for Payer: Beech Street Commercial |
$93.10
|
| Rate for Payer: Beech Street Commercial |
$58.80
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$49.26
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$78.00
|
| Rate for Payer: Cash Price |
$66.50
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$58.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$92.15
|
| Rate for Payer: Cigna of WY Commercial |
$93.10
|
| Rate for Payer: Cigna of WY Commercial |
$58.80
|
| Rate for Payer: Entrust Commercial |
$57.00
|
| Rate for Payer: Entrust Commercial |
$90.25
|
| Rate for Payer: First Choice Health Commercial |
$57.00
|
| Rate for Payer: First Choice Health Commercial |
$90.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$57.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$90.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$62.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$39.60
|
| Rate for Payer: HealthUtah PPO |
$95.00
|
| Rate for Payer: HealthUtah PPO |
$60.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$58.20
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$92.15
|
| Rate for Payer: Multiplan Medicare/VA |
$59.56
|
| Rate for Payer: Multiplan Medicare/VA |
$37.62
|
| Rate for Payer: One Health Plan of WY PPO |
$93.10
|
| Rate for Payer: One Health Plan of WY PPO |
$58.80
|
| Rate for Payer: PacificSource Commercial |
$85.50
|
| Rate for Payer: PacificSource Commercial |
$54.00
|
| Rate for Payer: PHCS PPO |
$58.80
|
| Rate for Payer: PHCS PPO |
$93.10
|
| Rate for Payer: Three Rivers PPO |
$45.00
|
| Rate for Payer: Three Rivers PPO |
$71.25
|
| Rate for Payer: TriWest Veterans Administration |
$62.70
|
| Rate for Payer: TriWest Veterans Administration |
$39.60
|
| Rate for Payer: United Healthcare Commercial |
$52.20
|
| Rate for Payer: United Healthcare Commercial |
$82.65
|
| Rate for Payer: United Healthcare Medicare |
$62.70
|
| Rate for Payer: United Healthcare Medicare |
$39.60
|
| Rate for Payer: WINHealth Partners Commercial |
$57.00
|
| Rate for Payer: WINHealth Partners Commercial |
$90.25
|
| Rate for Payer: Wise Provider Network Commercial |
$57.00
|
| Rate for Payer: Wise Provider Network Commercial |
$90.25
|
|
|
FUROSEMIDE 10 MG/ML INJECTION SOLUTION [686]
|
Facility
|
OP
|
$17.16
|
|
|
Service Code
|
HCPCS J1940
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.46 |
| Max. Negotiated Rate |
$17.16 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.82
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.87
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$17.54
|
| Rate for Payer: Aetna of WY Medicare |
$11.33
|
| Rate for Payer: Aetna of WY Medicare |
$11.81
|
| Rate for Payer: Aetna of WY Medicare |
$10.69
|
| Rate for Payer: Altius Auto/Workers Compensation |
$16.47
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.54
|
| Rate for Payer: Altius Auto/Workers Compensation |
$17.18
|
| Rate for Payer: Altius Commercial |
$16.47
|
| Rate for Payer: Altius Commercial |
$17.18
|
| Rate for Payer: Altius Commercial |
$15.54
|
| Rate for Payer: Beech Street Commercial |
$16.82
|
| Rate for Payer: Beech Street Commercial |
$17.54
|
| Rate for Payer: Beech Street Commercial |
$15.87
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.09
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.29
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.70
|
| Rate for Payer: Cash Price |
$12.01
|
| Rate for Payer: Cash Price |
$11.33
|
| Rate for Payer: Cash Price |
$12.53
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.65
|
| Rate for Payer: ChoiceCare Network Commercial |
$17.36
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.70
|
| Rate for Payer: Cigna of WY Commercial |
$17.54
|
| Rate for Payer: Cigna of WY Commercial |
$15.87
|
| Rate for Payer: Cigna of WY Commercial |
$16.82
|
| Rate for Payer: Entrust Commercial |
$17.00
|
| Rate for Payer: Entrust Commercial |
$16.30
|
| Rate for Payer: Entrust Commercial |
$15.38
|
| Rate for Payer: First Choice Health Commercial |
$16.30
|
| Rate for Payer: First Choice Health Commercial |
$15.38
|
| Rate for Payer: First Choice Health Commercial |
$17.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.39
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.38
|
| Rate for Payer: HealthUtah PPO |
$16.19
|
| Rate for Payer: HealthUtah PPO |
$17.90
|
| Rate for Payer: HealthUtah PPO |
$17.16
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.36
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.70
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.65
|
| Rate for Payer: Multiplan Medicare/VA |
$8.92
|
| Rate for Payer: Multiplan Medicare/VA |
$9.46
|
| Rate for Payer: Multiplan Medicare/VA |
$9.86
|
| Rate for Payer: One Health Plan of WY PPO |
$15.87
|
| Rate for Payer: One Health Plan of WY PPO |
$17.54
|
| Rate for Payer: One Health Plan of WY PPO |
$16.82
|
| Rate for Payer: PacificSource Commercial |
$16.11
|
| Rate for Payer: PacificSource Commercial |
$15.44
|
| Rate for Payer: PacificSource Commercial |
$14.57
|
| Rate for Payer: PHCS PPO |
$16.82
|
| Rate for Payer: PHCS PPO |
$15.87
|
| Rate for Payer: PHCS PPO |
$17.54
|
| Rate for Payer: Three Rivers PPO |
$12.87
|
| Rate for Payer: Three Rivers PPO |
$12.14
|
| Rate for Payer: Three Rivers PPO |
$13.42
|
| Rate for Payer: TriWest Veterans Administration |
$10.38
|
| Rate for Payer: TriWest Veterans Administration |
$9.95
|
| Rate for Payer: TriWest Veterans Administration |
$9.39
|
| Rate for Payer: United Healthcare Commercial |
$14.09
|
| Rate for Payer: United Healthcare Commercial |
$14.93
|
| Rate for Payer: United Healthcare Commercial |
$15.57
|
| Rate for Payer: United Healthcare Medicare |
$10.38
|
| Rate for Payer: United Healthcare Medicare |
$9.39
|
| Rate for Payer: United Healthcare Medicare |
$9.95
|
| Rate for Payer: WINHealth Partners Commercial |
$17.54
|
| Rate for Payer: WINHealth Partners Commercial |
$15.87
|
| Rate for Payer: WINHealth Partners Commercial |
$16.82
|
| Rate for Payer: Wise Provider Network Commercial |
$15.38
|
| Rate for Payer: Wise Provider Network Commercial |
$17.00
|
| Rate for Payer: Wise Provider Network Commercial |
$16.30
|
|
|
FUROSEMIDE 10 MG/ML INJECTION SOLUTION [686]
|
Facility
|
IP
|
$16.19
|
|
|
Service Code
|
HCPCS J1940
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.15 |
| Max. Negotiated Rate |
$16.19 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.87
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.82
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$17.54
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.54
|
| Rate for Payer: Altius Auto/Workers Compensation |
$16.47
|
| Rate for Payer: Altius Auto/Workers Compensation |
$17.18
|
| Rate for Payer: Altius Commercial |
$16.47
|
| Rate for Payer: Altius Commercial |
$15.54
|
| Rate for Payer: Altius Commercial |
$17.18
|
| Rate for Payer: Beech Street Commercial |
$17.54
|
| Rate for Payer: Beech Street Commercial |
$16.82
|
| Rate for Payer: Beech Street Commercial |
$15.87
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.29
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.70
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.09
|
| Rate for Payer: Cash Price |
$12.01
|
| Rate for Payer: Cash Price |
$11.33
|
| Rate for Payer: Cash Price |
$12.53
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$17.36
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.65
|
| Rate for Payer: Cigna of WY Commercial |
$16.82
|
| Rate for Payer: Cigna of WY Commercial |
$17.54
|
| Rate for Payer: Cigna of WY Commercial |
$15.87
|
| Rate for Payer: Entrust Commercial |
$17.00
|
| Rate for Payer: Entrust Commercial |
$15.38
|
| Rate for Payer: Entrust Commercial |
$16.30
|
| Rate for Payer: First Choice Health Commercial |
$16.30
|
| Rate for Payer: First Choice Health Commercial |
$17.00
|
| Rate for Payer: First Choice Health Commercial |
$15.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.69
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.81
|
| Rate for Payer: HealthUtah PPO |
$16.19
|
| Rate for Payer: HealthUtah PPO |
$17.16
|
| Rate for Payer: HealthUtah PPO |
$17.90
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.36
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.65
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.70
|
| Rate for Payer: Multiplan Medicare/VA |
$11.22
|
| Rate for Payer: Multiplan Medicare/VA |
$10.15
|
| Rate for Payer: Multiplan Medicare/VA |
$10.76
|
| Rate for Payer: One Health Plan of WY PPO |
$15.87
|
| Rate for Payer: One Health Plan of WY PPO |
$16.82
|
| Rate for Payer: One Health Plan of WY PPO |
$17.54
|
| Rate for Payer: PacificSource Commercial |
$16.11
|
| Rate for Payer: PacificSource Commercial |
$14.57
|
| Rate for Payer: PacificSource Commercial |
$15.44
|
| Rate for Payer: PHCS PPO |
$16.82
|
| Rate for Payer: PHCS PPO |
$15.87
|
| Rate for Payer: PHCS PPO |
$17.54
|
| Rate for Payer: Three Rivers PPO |
$12.87
|
| Rate for Payer: Three Rivers PPO |
$12.14
|
| Rate for Payer: Three Rivers PPO |
$13.42
|
| Rate for Payer: TriWest Veterans Administration |
$11.33
|
| Rate for Payer: TriWest Veterans Administration |
$10.69
|
| Rate for Payer: TriWest Veterans Administration |
$11.81
|
| Rate for Payer: United Healthcare Commercial |
$14.09
|
| Rate for Payer: United Healthcare Commercial |
$15.57
|
| Rate for Payer: United Healthcare Commercial |
$14.93
|
| Rate for Payer: United Healthcare Medicare |
$10.69
|
| Rate for Payer: United Healthcare Medicare |
$11.81
|
| Rate for Payer: United Healthcare Medicare |
$11.33
|
| Rate for Payer: WINHealth Partners Commercial |
$16.30
|
| Rate for Payer: WINHealth Partners Commercial |
$15.38
|
| Rate for Payer: WINHealth Partners Commercial |
$17.00
|
| Rate for Payer: Wise Provider Network Commercial |
$17.00
|
| Rate for Payer: Wise Provider Network Commercial |
$15.38
|
| Rate for Payer: Wise Provider Network Commercial |
$16.30
|
|
|
FUROSEMIDE 20 MG TABLET [16605]
|
Facility
|
IP
|
$0.67
|
|
|
Service Code
|
NDC 0054829725
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$0.67 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.66
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.64
|
| Rate for Payer: Altius Commercial |
$0.64
|
| Rate for Payer: Beech Street Commercial |
$0.66
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.55
|
| Rate for Payer: Cash Price |
$0.47
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.65
|
| Rate for Payer: Cigna of WY Commercial |
$0.66
|
| Rate for Payer: Entrust Commercial |
$0.64
|
| Rate for Payer: First Choice Health Commercial |
$0.64
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.64
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.44
|
| Rate for Payer: HealthUtah PPO |
$0.67
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.65
|
| Rate for Payer: Multiplan Medicare/VA |
$0.42
|
| Rate for Payer: One Health Plan of WY PPO |
$0.66
|
| Rate for Payer: PacificSource Commercial |
$0.60
|
| Rate for Payer: PHCS PPO |
$0.66
|
| Rate for Payer: Three Rivers PPO |
$0.50
|
| Rate for Payer: TriWest Veterans Administration |
$0.44
|
| Rate for Payer: United Healthcare Commercial |
$0.58
|
| Rate for Payer: United Healthcare Medicare |
$0.44
|
| Rate for Payer: WINHealth Partners Commercial |
$0.64
|
| Rate for Payer: Wise Provider Network Commercial |
$0.64
|
|
|
FUROSEMIDE 20 MG TABLET [16605]
|
Facility
|
IP
|
$0.15
|
|
|
Service Code
|
NDC 6931511601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.15
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.14
|
| Rate for Payer: Altius Commercial |
$0.14
|
| Rate for Payer: Beech Street Commercial |
$0.15
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.12
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.15
|
| Rate for Payer: Cigna of WY Commercial |
$0.15
|
| Rate for Payer: Entrust Commercial |
$0.14
|
| Rate for Payer: First Choice Health Commercial |
$0.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.10
|
| Rate for Payer: HealthUtah PPO |
$0.15
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.15
|
| Rate for Payer: Multiplan Medicare/VA |
$0.09
|
| Rate for Payer: One Health Plan of WY PPO |
$0.15
|
| Rate for Payer: PacificSource Commercial |
$0.14
|
| Rate for Payer: PHCS PPO |
$0.15
|
| Rate for Payer: Three Rivers PPO |
$0.11
|
| Rate for Payer: TriWest Veterans Administration |
$0.10
|
| Rate for Payer: United Healthcare Commercial |
$0.13
|
| Rate for Payer: United Healthcare Medicare |
$0.10
|
| Rate for Payer: WINHealth Partners Commercial |
$0.14
|
| Rate for Payer: Wise Provider Network Commercial |
$0.14
|
|
|
FUROSEMIDE 20 MG TABLET [16605]
|
Facility
|
OP
|
$0.26
|
|
|
Service Code
|
NDC 5107907220
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.26 |
| 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 |
$0.25
|
| Rate for Payer: Altius Commercial |
$0.25
|
| 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 |
$0.25
|
| Rate for Payer: Cigna of WY Commercial |
$0.25
|
| Rate for Payer: Entrust Commercial |
$0.25
|
| Rate for Payer: First Choice Health Commercial |
$0.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.15
|
| Rate for Payer: HealthUtah PPO |
$0.26
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.25
|
| 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 |
$0.20
|
| Rate for Payer: TriWest Veterans Administration |
$0.15
|
| Rate for Payer: United Healthcare Commercial |
$0.23
|
| Rate for Payer: United Healthcare Medicare |
$0.15
|
| Rate for Payer: WINHealth Partners Commercial |
$0.25
|
| Rate for Payer: Wise Provider Network Commercial |
$0.25
|
|
|
FUROSEMIDE 20 MG TABLET [16605]
|
Facility
|
IP
|
$0.30
|
|
|
Service Code
|
NDC 0904717761
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.29
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.29
|
| Rate for Payer: Altius Commercial |
$0.29
|
| Rate for Payer: Beech Street Commercial |
$0.29
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.25
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.29
|
| Rate for Payer: Cigna of WY Commercial |
$0.29
|
| Rate for Payer: Entrust Commercial |
$0.29
|
| Rate for Payer: First Choice Health Commercial |
$0.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.20
|
| Rate for Payer: HealthUtah PPO |
$0.30
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.29
|
| Rate for Payer: Multiplan Medicare/VA |
$0.19
|
| Rate for Payer: One Health Plan of WY PPO |
$0.29
|
| Rate for Payer: PacificSource Commercial |
$0.27
|
| Rate for Payer: PHCS PPO |
$0.29
|
| Rate for Payer: Three Rivers PPO |
$0.23
|
| Rate for Payer: TriWest Veterans Administration |
$0.20
|
| Rate for Payer: United Healthcare Commercial |
$0.26
|
| Rate for Payer: United Healthcare Medicare |
$0.20
|
| Rate for Payer: WINHealth Partners Commercial |
$0.29
|
| Rate for Payer: Wise Provider Network Commercial |
$0.29
|
|
|
FUROSEMIDE 20 MG TABLET [16605]
|
Facility
|
OP
|
$0.26
|
|
|
Service Code
|
NDC 5107907201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.26 |
| 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 |
$0.25
|
| Rate for Payer: Altius Commercial |
$0.25
|
| 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 |
$0.25
|
| Rate for Payer: Cigna of WY Commercial |
$0.25
|
| Rate for Payer: Entrust Commercial |
$0.25
|
| Rate for Payer: First Choice Health Commercial |
$0.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.15
|
| Rate for Payer: HealthUtah PPO |
$0.26
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.25
|
| 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 |
$0.20
|
| Rate for Payer: TriWest Veterans Administration |
$0.15
|
| Rate for Payer: United Healthcare Commercial |
$0.23
|
| Rate for Payer: United Healthcare Medicare |
$0.15
|
| Rate for Payer: WINHealth Partners Commercial |
$0.25
|
| Rate for Payer: Wise Provider Network Commercial |
$0.25
|
|
|
FUROSEMIDE 20 MG TABLET [16605]
|
Facility
|
IP
|
$0.26
|
|
|
Service Code
|
NDC 5107907220
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.25
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.25
|
| Rate for Payer: Altius Commercial |
$0.25
|
| 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 |
$0.25
|
| Rate for Payer: Cigna of WY Commercial |
$0.25
|
| Rate for Payer: Entrust Commercial |
$0.25
|
| Rate for Payer: First Choice Health Commercial |
$0.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.17
|
| Rate for Payer: HealthUtah PPO |
$0.26
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.25
|
| 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 |
$0.20
|
| Rate for Payer: TriWest Veterans Administration |
$0.17
|
| Rate for Payer: United Healthcare Commercial |
$0.23
|
| Rate for Payer: United Healthcare Medicare |
$0.17
|
| Rate for Payer: WINHealth Partners Commercial |
$0.25
|
| Rate for Payer: Wise Provider Network Commercial |
$0.25
|
|
|
FUROSEMIDE 20 MG TABLET [16605]
|
Facility
|
OP
|
$0.15
|
|
|
Service Code
|
NDC 6931511601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.15
|
| Rate for Payer: Aetna of WY Medicare |
$0.10
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.14
|
| Rate for Payer: Altius Commercial |
$0.14
|
| Rate for Payer: Beech Street Commercial |
$0.15
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.12
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.15
|
| Rate for Payer: Cigna of WY Commercial |
$0.15
|
| Rate for Payer: Entrust Commercial |
$0.14
|
| Rate for Payer: First Choice Health Commercial |
$0.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.09
|
| Rate for Payer: HealthUtah PPO |
$0.15
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.15
|
| Rate for Payer: Multiplan Medicare/VA |
$0.08
|
| Rate for Payer: One Health Plan of WY PPO |
$0.15
|
| Rate for Payer: PacificSource Commercial |
$0.14
|
| Rate for Payer: PHCS PPO |
$0.15
|
| Rate for Payer: Three Rivers PPO |
$0.11
|
| Rate for Payer: TriWest Veterans Administration |
$0.09
|
| Rate for Payer: United Healthcare Commercial |
$0.13
|
| Rate for Payer: United Healthcare Medicare |
$0.09
|
| Rate for Payer: WINHealth Partners Commercial |
$0.15
|
| Rate for Payer: Wise Provider Network Commercial |
$0.14
|
|
|
FUROSEMIDE 20 MG TABLET [16605]
|
Facility
|
OP
|
$0.67
|
|
|
Service Code
|
NDC 0054829725
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$0.67 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.66
|
| Rate for Payer: Aetna of WY Medicare |
$0.44
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.64
|
| Rate for Payer: Altius Commercial |
$0.64
|
| Rate for Payer: Beech Street Commercial |
$0.66
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.55
|
| Rate for Payer: Cash Price |
$0.47
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.65
|
| Rate for Payer: Cigna of WY Commercial |
$0.66
|
| Rate for Payer: Entrust Commercial |
$0.64
|
| Rate for Payer: First Choice Health Commercial |
$0.64
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.64
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.39
|
| Rate for Payer: HealthUtah PPO |
$0.67
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.65
|
| Rate for Payer: Multiplan Medicare/VA |
$0.37
|
| Rate for Payer: One Health Plan of WY PPO |
$0.66
|
| Rate for Payer: PacificSource Commercial |
$0.60
|
| Rate for Payer: PHCS PPO |
$0.66
|
| Rate for Payer: Three Rivers PPO |
$0.50
|
| Rate for Payer: TriWest Veterans Administration |
$0.39
|
| Rate for Payer: United Healthcare Commercial |
$0.58
|
| Rate for Payer: United Healthcare Medicare |
$0.39
|
| Rate for Payer: WINHealth Partners Commercial |
$0.66
|
| Rate for Payer: Wise Provider Network Commercial |
$0.64
|
|
|
FUROSEMIDE 20 MG TABLET [16605]
|
Facility
|
OP
|
$0.30
|
|
|
Service Code
|
NDC 0904717761
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.29
|
| Rate for Payer: Aetna of WY Medicare |
$0.20
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.29
|
| Rate for Payer: Altius Commercial |
$0.29
|
| Rate for Payer: Beech Street Commercial |
$0.29
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.25
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.29
|
| Rate for Payer: Cigna of WY Commercial |
$0.29
|
| Rate for Payer: Entrust Commercial |
$0.29
|
| Rate for Payer: First Choice Health Commercial |
$0.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.17
|
| Rate for Payer: HealthUtah PPO |
$0.30
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.29
|
| Rate for Payer: Multiplan Medicare/VA |
$0.17
|
| Rate for Payer: One Health Plan of WY PPO |
$0.29
|
| Rate for Payer: PacificSource Commercial |
$0.27
|
| Rate for Payer: PHCS PPO |
$0.29
|
| Rate for Payer: Three Rivers PPO |
$0.23
|
| Rate for Payer: TriWest Veterans Administration |
$0.17
|
| Rate for Payer: United Healthcare Commercial |
$0.26
|
| Rate for Payer: United Healthcare Medicare |
$0.17
|
| Rate for Payer: WINHealth Partners Commercial |
$0.29
|
| Rate for Payer: Wise Provider Network Commercial |
$0.29
|
|
|
FUROSEMIDE 20 MG TABLET [16605]
|
Facility
|
IP
|
$0.26
|
|
|
Service Code
|
NDC 5107907201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.25
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.25
|
| Rate for Payer: Altius Commercial |
$0.25
|
| 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 |
$0.25
|
| Rate for Payer: Cigna of WY Commercial |
$0.25
|
| Rate for Payer: Entrust Commercial |
$0.25
|
| Rate for Payer: First Choice Health Commercial |
$0.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.17
|
| Rate for Payer: HealthUtah PPO |
$0.26
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.25
|
| 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 |
$0.20
|
| Rate for Payer: TriWest Veterans Administration |
$0.17
|
| Rate for Payer: United Healthcare Commercial |
$0.23
|
| Rate for Payer: United Healthcare Medicare |
$0.17
|
| Rate for Payer: WINHealth Partners Commercial |
$0.25
|
| Rate for Payer: Wise Provider Network Commercial |
$0.25
|
|
|
FUROSEMIDE 40 MG TABLET [419]
|
Facility
|
IP
|
$0.27
|
|
|
Service Code
|
NDC 5107907320
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.26
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.26
|
| Rate for Payer: Altius Commercial |
$0.26
|
| Rate for Payer: Beech Street Commercial |
$0.26
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.22
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.26
|
| Rate for Payer: Cigna of WY Commercial |
$0.26
|
| Rate for Payer: Entrust Commercial |
$0.26
|
| Rate for Payer: First Choice Health Commercial |
$0.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.18
|
| Rate for Payer: HealthUtah PPO |
$0.27
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.26
|
| Rate for Payer: Multiplan Medicare/VA |
$0.17
|
| Rate for Payer: One Health Plan of WY PPO |
$0.26
|
| Rate for Payer: PacificSource Commercial |
$0.24
|
| Rate for Payer: PHCS PPO |
$0.26
|
| Rate for Payer: Three Rivers PPO |
$0.20
|
| Rate for Payer: TriWest Veterans Administration |
$0.18
|
| Rate for Payer: United Healthcare Commercial |
$0.23
|
| Rate for Payer: United Healthcare Medicare |
$0.18
|
| Rate for Payer: WINHealth Partners Commercial |
$0.26
|
| Rate for Payer: Wise Provider Network Commercial |
$0.26
|
|
|
FUROSEMIDE 40 MG TABLET [419]
|
Facility
|
IP
|
$0.31
|
|
|
Service Code
|
NDC 0904717861
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.30
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.30
|
| Rate for Payer: Altius Commercial |
$0.30
|
| Rate for Payer: Beech Street Commercial |
$0.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.25
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.30
|
| Rate for Payer: Cigna of WY Commercial |
$0.30
|
| Rate for Payer: Entrust Commercial |
$0.29
|
| Rate for Payer: First Choice Health Commercial |
$0.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.20
|
| Rate for Payer: HealthUtah PPO |
$0.31
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.30
|
| Rate for Payer: Multiplan Medicare/VA |
$0.19
|
| Rate for Payer: One Health Plan of WY PPO |
$0.30
|
| Rate for Payer: PacificSource Commercial |
$0.28
|
| Rate for Payer: PHCS PPO |
$0.30
|
| Rate for Payer: Three Rivers PPO |
$0.23
|
| Rate for Payer: TriWest Veterans Administration |
$0.20
|
| Rate for Payer: United Healthcare Commercial |
$0.27
|
| Rate for Payer: United Healthcare Medicare |
$0.20
|
| Rate for Payer: WINHealth Partners Commercial |
$0.29
|
| Rate for Payer: Wise Provider Network Commercial |
$0.29
|
|
|
FUROSEMIDE 40 MG TABLET [419]
|
Facility
|
OP
|
$0.27
|
|
|
Service Code
|
NDC 5107907301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.26
|
| Rate for Payer: Aetna of WY Medicare |
$0.18
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.26
|
| Rate for Payer: Altius Commercial |
$0.26
|
| Rate for Payer: Beech Street Commercial |
$0.26
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.22
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.26
|
| Rate for Payer: Cigna of WY Commercial |
$0.26
|
| Rate for Payer: Entrust Commercial |
$0.26
|
| Rate for Payer: First Choice Health Commercial |
$0.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.16
|
| Rate for Payer: HealthUtah PPO |
$0.27
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.26
|
| Rate for Payer: Multiplan Medicare/VA |
$0.15
|
| Rate for Payer: One Health Plan of WY PPO |
$0.26
|
| Rate for Payer: PacificSource Commercial |
$0.24
|
| Rate for Payer: PHCS PPO |
$0.26
|
| Rate for Payer: Three Rivers PPO |
$0.20
|
| Rate for Payer: TriWest Veterans Administration |
$0.16
|
| Rate for Payer: United Healthcare Commercial |
$0.23
|
| Rate for Payer: United Healthcare Medicare |
$0.16
|
| Rate for Payer: WINHealth Partners Commercial |
$0.26
|
| Rate for Payer: Wise Provider Network Commercial |
$0.26
|
|
|
FUROSEMIDE 40 MG TABLET [419]
|
Facility
|
IP
|
$0.27
|
|
|
Service Code
|
NDC 5107907301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.26
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.26
|
| Rate for Payer: Altius Commercial |
$0.26
|
| Rate for Payer: Beech Street Commercial |
$0.26
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.22
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.26
|
| Rate for Payer: Cigna of WY Commercial |
$0.26
|
| Rate for Payer: Entrust Commercial |
$0.26
|
| Rate for Payer: First Choice Health Commercial |
$0.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.18
|
| Rate for Payer: HealthUtah PPO |
$0.27
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.26
|
| Rate for Payer: Multiplan Medicare/VA |
$0.17
|
| Rate for Payer: One Health Plan of WY PPO |
$0.26
|
| Rate for Payer: PacificSource Commercial |
$0.24
|
| Rate for Payer: PHCS PPO |
$0.26
|
| Rate for Payer: Three Rivers PPO |
$0.20
|
| Rate for Payer: TriWest Veterans Administration |
$0.18
|
| Rate for Payer: United Healthcare Commercial |
$0.23
|
| Rate for Payer: United Healthcare Medicare |
$0.18
|
| Rate for Payer: WINHealth Partners Commercial |
$0.26
|
| Rate for Payer: Wise Provider Network Commercial |
$0.26
|
|
|
FUROSEMIDE 40 MG TABLET [419]
|
Facility
|
OP
|
$0.27
|
|
|
Service Code
|
NDC 5107907320
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.26
|
| Rate for Payer: Aetna of WY Medicare |
$0.18
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.26
|
| Rate for Payer: Altius Commercial |
$0.26
|
| Rate for Payer: Beech Street Commercial |
$0.26
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.22
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.26
|
| Rate for Payer: Cigna of WY Commercial |
$0.26
|
| Rate for Payer: Entrust Commercial |
$0.26
|
| Rate for Payer: First Choice Health Commercial |
$0.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.16
|
| Rate for Payer: HealthUtah PPO |
$0.27
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.26
|
| Rate for Payer: Multiplan Medicare/VA |
$0.15
|
| Rate for Payer: One Health Plan of WY PPO |
$0.26
|
| Rate for Payer: PacificSource Commercial |
$0.24
|
| Rate for Payer: PHCS PPO |
$0.26
|
| Rate for Payer: Three Rivers PPO |
$0.20
|
| Rate for Payer: TriWest Veterans Administration |
$0.16
|
| Rate for Payer: United Healthcare Commercial |
$0.23
|
| Rate for Payer: United Healthcare Medicare |
$0.16
|
| Rate for Payer: WINHealth Partners Commercial |
$0.26
|
| Rate for Payer: Wise Provider Network Commercial |
$0.26
|
|
|
FUROSEMIDE 40 MG TABLET [419]
|
Facility
|
IP
|
$0.75
|
|
|
Service Code
|
NDC 0054829925
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$0.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.74
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.72
|
| Rate for Payer: Altius Commercial |
$0.72
|
| Rate for Payer: Beech Street Commercial |
$0.74
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.62
|
| Rate for Payer: Cash Price |
$0.53
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.73
|
| Rate for Payer: Cigna of WY Commercial |
$0.74
|
| Rate for Payer: Entrust Commercial |
$0.71
|
| Rate for Payer: First Choice Health Commercial |
$0.71
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.71
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.50
|
| Rate for Payer: HealthUtah PPO |
$0.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.73
|
| Rate for Payer: Multiplan Medicare/VA |
$0.47
|
| Rate for Payer: One Health Plan of WY PPO |
$0.74
|
| Rate for Payer: PacificSource Commercial |
$0.68
|
| Rate for Payer: PHCS PPO |
$0.74
|
| Rate for Payer: Three Rivers PPO |
$0.56
|
| Rate for Payer: TriWest Veterans Administration |
$0.50
|
| Rate for Payer: United Healthcare Commercial |
$0.65
|
| Rate for Payer: United Healthcare Medicare |
$0.50
|
| Rate for Payer: WINHealth Partners Commercial |
$0.71
|
| Rate for Payer: Wise Provider Network Commercial |
$0.71
|
|
|
FUROSEMIDE 40 MG TABLET [419]
|
Facility
|
IP
|
$0.16
|
|
|
Service Code
|
NDC 6931511701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.16
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.15
|
| Rate for Payer: Altius Commercial |
$0.15
|
| Rate for Payer: Beech Street Commercial |
$0.16
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.13
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.16
|
| Rate for Payer: Cigna of WY Commercial |
$0.16
|
| Rate for Payer: Entrust Commercial |
$0.15
|
| Rate for Payer: First Choice Health Commercial |
$0.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.11
|
| Rate for Payer: HealthUtah PPO |
$0.16
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.16
|
| Rate for Payer: Multiplan Medicare/VA |
$0.10
|
| Rate for Payer: One Health Plan of WY PPO |
$0.16
|
| Rate for Payer: PacificSource Commercial |
$0.14
|
| Rate for Payer: PHCS PPO |
$0.16
|
| Rate for Payer: Three Rivers PPO |
$0.12
|
| Rate for Payer: TriWest Veterans Administration |
$0.11
|
| Rate for Payer: United Healthcare Commercial |
$0.14
|
| Rate for Payer: United Healthcare Medicare |
$0.11
|
| Rate for Payer: WINHealth Partners Commercial |
$0.15
|
| Rate for Payer: Wise Provider Network Commercial |
$0.15
|
|
|
FUROSEMIDE 40 MG TABLET [419]
|
Facility
|
OP
|
$0.31
|
|
|
Service Code
|
NDC 0904717861
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.30
|
| Rate for Payer: Aetna of WY Medicare |
$0.20
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.30
|
| Rate for Payer: Altius Commercial |
$0.30
|
| Rate for Payer: Beech Street Commercial |
$0.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.25
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.30
|
| Rate for Payer: Cigna of WY Commercial |
$0.30
|
| Rate for Payer: Entrust Commercial |
$0.29
|
| Rate for Payer: First Choice Health Commercial |
$0.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.18
|
| Rate for Payer: HealthUtah PPO |
$0.31
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.30
|
| Rate for Payer: Multiplan Medicare/VA |
$0.17
|
| Rate for Payer: One Health Plan of WY PPO |
$0.30
|
| Rate for Payer: PacificSource Commercial |
$0.28
|
| Rate for Payer: PHCS PPO |
$0.30
|
| Rate for Payer: Three Rivers PPO |
$0.23
|
| Rate for Payer: TriWest Veterans Administration |
$0.18
|
| Rate for Payer: United Healthcare Commercial |
$0.27
|
| Rate for Payer: United Healthcare Medicare |
$0.18
|
| Rate for Payer: WINHealth Partners Commercial |
$0.30
|
| Rate for Payer: Wise Provider Network Commercial |
$0.29
|
|
