|
FUROSEMIDE 40 MG TABLET [419]
|
Facility
|
OP
|
$0.75
|
|
|
Service Code
|
NDC 0054829925
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$0.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.74
|
| Rate for Payer: Aetna of WY Medicare |
$0.50
|
| 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 |
$0.44
|
| Rate for Payer: HealthUtah PPO |
$0.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.73
|
| Rate for Payer: Multiplan Medicare/VA |
$0.41
|
| 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 |
$0.44
|
| Rate for Payer: United Healthcare Commercial |
$0.65
|
| Rate for Payer: United Healthcare Medicare |
$0.44
|
| Rate for Payer: WINHealth Partners Commercial |
$0.74
|
| Rate for Payer: Wise Provider Network Commercial |
$0.71
|
|
|
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
|
|
|
FUROSEMIDE INJECTION
|
Professional
|
Both
|
$4.00
|
|
|
Service Code
|
HCPCS J1940
|
| Hospital Charge Code |
J1940
|
| Min. Negotiated Rate |
$0.52 |
| Max. Negotiated Rate |
$4.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3.92
|
| Rate for Payer: Aetna of WY Medicare |
$0.61
|
| Rate for Payer: Beech Street Commercial |
$3.80
|
| Rate for Payer: Cash Price |
$2.80
|
| Rate for Payer: Cash Price |
$2.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$3.88
|
| Rate for Payer: Cigna of WY Commercial |
$3.92
|
| Rate for Payer: First Choice Health Commercial |
$3.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.61
|
| Rate for Payer: HealthUtah PPO |
$4.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3.88
|
| Rate for Payer: Multiplan Medicare/VA |
$0.52
|
| Rate for Payer: One Health Plan of WY PPO |
$3.92
|
| Rate for Payer: PacificSource Commercial |
$3.60
|
| Rate for Payer: PHCS PPO |
$3.80
|
| Rate for Payer: Three Rivers PPO |
$3.00
|
| Rate for Payer: TriWest Veterans Administration |
$0.61
|
| Rate for Payer: United Healthcare Commercial |
$3.48
|
| Rate for Payer: United Healthcare Medicare |
$0.61
|
| Rate for Payer: WINHealth Partners Commercial |
$3.80
|
|
|
FUSION BLADE QUADCUT 4.3X13
|
Facility
|
OP
|
$1,213.20
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$668.47 |
| Max. Negotiated Rate |
$1,213.20 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,188.94
|
| Rate for Payer: Aetna of WY Medicare |
$800.71
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,164.67
|
| Rate for Payer: Altius Commercial |
$1,164.67
|
| Rate for Payer: Beech Street Commercial |
$1,188.94
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$996.04
|
| Rate for Payer: Cash Price |
$849.24
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,176.80
|
| Rate for Payer: Cigna of WY Commercial |
$1,188.94
|
| Rate for Payer: Entrust Commercial |
$1,152.54
|
| Rate for Payer: First Choice Health Commercial |
$1,152.54
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,152.54
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$703.66
|
| Rate for Payer: HealthUtah PPO |
$1,213.20
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,176.80
|
| Rate for Payer: Multiplan Medicare/VA |
$668.47
|
| Rate for Payer: One Health Plan of WY PPO |
$1,188.94
|
| Rate for Payer: PacificSource Commercial |
$1,091.88
|
| Rate for Payer: PHCS PPO |
$1,188.94
|
| Rate for Payer: Three Rivers PPO |
$909.90
|
| Rate for Payer: TriWest Veterans Administration |
$703.66
|
| Rate for Payer: United Healthcare Commercial |
$1,055.48
|
| Rate for Payer: United Healthcare Medicare |
$703.66
|
| Rate for Payer: WINHealth Partners Commercial |
$1,188.94
|
| Rate for Payer: Wise Provider Network Commercial |
$1,152.54
|
|
|
FUSION BLADE QUADCUT 4.3X13
|
Facility
|
IP
|
$1,213.20
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$760.68 |
| Max. Negotiated Rate |
$1,213.20 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,188.94
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,164.67
|
| Rate for Payer: Altius Commercial |
$1,164.67
|
| Rate for Payer: Beech Street Commercial |
$1,188.94
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$996.04
|
| Rate for Payer: Cash Price |
$849.24
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,176.80
|
| Rate for Payer: Cigna of WY Commercial |
$1,188.94
|
| Rate for Payer: Entrust Commercial |
$1,152.54
|
| Rate for Payer: First Choice Health Commercial |
$1,152.54
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,152.54
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$800.71
|
| Rate for Payer: HealthUtah PPO |
$1,213.20
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,176.80
|
| Rate for Payer: Multiplan Medicare/VA |
$760.68
|
| Rate for Payer: One Health Plan of WY PPO |
$1,188.94
|
| Rate for Payer: PacificSource Commercial |
$1,091.88
|
| Rate for Payer: PHCS PPO |
$1,188.94
|
| Rate for Payer: Three Rivers PPO |
$909.90
|
| Rate for Payer: TriWest Veterans Administration |
$800.71
|
| Rate for Payer: United Healthcare Commercial |
$1,055.48
|
| Rate for Payer: United Healthcare Medicare |
$800.71
|
| Rate for Payer: WINHealth Partners Commercial |
$1,152.54
|
| Rate for Payer: Wise Provider Network Commercial |
$1,152.54
|
|
|
GABAPENTIN 100 MG CAPSULE [16747]
|
Facility
|
OP
|
$0.50
|
|
|
Service Code
|
NDC 6068758011
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.49
|
| Rate for Payer: Aetna of WY Medicare |
$0.33
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.48
|
| Rate for Payer: Altius Commercial |
$0.48
|
| Rate for Payer: Beech Street Commercial |
$0.49
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.41
|
| Rate for Payer: Cash Price |
$0.35
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.49
|
| Rate for Payer: Cigna of WY Commercial |
$0.49
|
| Rate for Payer: Entrust Commercial |
$0.48
|
| Rate for Payer: First Choice Health Commercial |
$0.48
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.48
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.29
|
| Rate for Payer: HealthUtah PPO |
$0.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.49
|
| Rate for Payer: Multiplan Medicare/VA |
$0.28
|
| Rate for Payer: One Health Plan of WY PPO |
$0.49
|
| Rate for Payer: PacificSource Commercial |
$0.45
|
| Rate for Payer: PHCS PPO |
$0.49
|
| Rate for Payer: Three Rivers PPO |
$0.38
|
| Rate for Payer: TriWest Veterans Administration |
$0.29
|
| Rate for Payer: United Healthcare Commercial |
$0.44
|
| Rate for Payer: United Healthcare Medicare |
$0.29
|
| Rate for Payer: WINHealth Partners Commercial |
$0.49
|
| Rate for Payer: Wise Provider Network Commercial |
$0.48
|
|
|
GABAPENTIN 100 MG CAPSULE [16747]
|
Facility
|
IP
|
$0.47
|
|
|
Service Code
|
NDC 0904666561
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.46
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.45
|
| Rate for Payer: Altius Commercial |
$0.45
|
| Rate for Payer: Beech Street Commercial |
$0.46
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.39
|
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.46
|
| Rate for Payer: Cigna of WY Commercial |
$0.46
|
| Rate for Payer: Entrust Commercial |
$0.45
|
| Rate for Payer: First Choice Health Commercial |
$0.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.31
|
| Rate for Payer: HealthUtah PPO |
$0.47
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.46
|
| Rate for Payer: Multiplan Medicare/VA |
$0.29
|
| Rate for Payer: One Health Plan of WY PPO |
$0.46
|
| Rate for Payer: PacificSource Commercial |
$0.42
|
| Rate for Payer: PHCS PPO |
$0.46
|
| Rate for Payer: Three Rivers PPO |
$0.35
|
| Rate for Payer: TriWest Veterans Administration |
$0.31
|
| Rate for Payer: United Healthcare Commercial |
$0.41
|
| Rate for Payer: United Healthcare Medicare |
$0.31
|
| Rate for Payer: WINHealth Partners Commercial |
$0.45
|
| Rate for Payer: Wise Provider Network Commercial |
$0.45
|
|
|
GABAPENTIN 100 MG CAPSULE [16747]
|
Facility
|
IP
|
$0.50
|
|
|
Service Code
|
NDC 6068758011
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.49
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.48
|
| Rate for Payer: Altius Commercial |
$0.48
|
| Rate for Payer: Beech Street Commercial |
$0.49
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.41
|
| Rate for Payer: Cash Price |
$0.35
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.49
|
| Rate for Payer: Cigna of WY Commercial |
$0.49
|
| Rate for Payer: Entrust Commercial |
$0.48
|
| Rate for Payer: First Choice Health Commercial |
$0.48
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.48
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.33
|
| Rate for Payer: HealthUtah PPO |
$0.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.49
|
| Rate for Payer: Multiplan Medicare/VA |
$0.31
|
| Rate for Payer: One Health Plan of WY PPO |
$0.49
|
| Rate for Payer: PacificSource Commercial |
$0.45
|
| Rate for Payer: PHCS PPO |
$0.49
|
| Rate for Payer: Three Rivers PPO |
$0.38
|
| Rate for Payer: TriWest Veterans Administration |
$0.33
|
| Rate for Payer: United Healthcare Commercial |
$0.44
|
| Rate for Payer: United Healthcare Medicare |
$0.33
|
| Rate for Payer: WINHealth Partners Commercial |
$0.48
|
| Rate for Payer: Wise Provider Network Commercial |
$0.48
|
|
|
GABAPENTIN 100 MG CAPSULE [16747]
|
Facility
|
OP
|
$0.47
|
|
|
Service Code
|
NDC 0904666561
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.46
|
| Rate for Payer: Aetna of WY Medicare |
$0.31
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.45
|
| Rate for Payer: Altius Commercial |
$0.45
|
| Rate for Payer: Beech Street Commercial |
$0.46
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.39
|
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.46
|
| Rate for Payer: Cigna of WY Commercial |
$0.46
|
| Rate for Payer: Entrust Commercial |
$0.45
|
| Rate for Payer: First Choice Health Commercial |
$0.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.27
|
| Rate for Payer: HealthUtah PPO |
$0.47
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.46
|
| Rate for Payer: Multiplan Medicare/VA |
$0.26
|
| Rate for Payer: One Health Plan of WY PPO |
$0.46
|
| Rate for Payer: PacificSource Commercial |
$0.42
|
| Rate for Payer: PHCS PPO |
$0.46
|
| Rate for Payer: Three Rivers PPO |
$0.35
|
| Rate for Payer: TriWest Veterans Administration |
$0.27
|
| Rate for Payer: United Healthcare Commercial |
$0.41
|
| Rate for Payer: United Healthcare Medicare |
$0.27
|
| Rate for Payer: WINHealth Partners Commercial |
$0.46
|
| Rate for Payer: Wise Provider Network Commercial |
$0.45
|
|
|
GABAPENTIN 300 MG CAPSULE [15024]
|
Facility
|
OP
|
$0.38
|
|
|
Service Code
|
NDC 6516210210
|
|
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
|
|
|
GABAPENTIN 300 MG CAPSULE [15024]
|
Facility
|
IP
|
$0.65
|
|
|
Service Code
|
NDC 0904666661
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$0.65 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.64
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.62
|
| Rate for Payer: Altius Commercial |
$0.62
|
| Rate for Payer: Beech Street Commercial |
$0.64
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.53
|
| Rate for Payer: Cash Price |
$0.46
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.63
|
| Rate for Payer: Cigna of WY Commercial |
$0.64
|
| Rate for Payer: Entrust Commercial |
$0.62
|
| Rate for Payer: First Choice Health Commercial |
$0.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.43
|
| Rate for Payer: HealthUtah PPO |
$0.65
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.63
|
| Rate for Payer: Multiplan Medicare/VA |
$0.41
|
| Rate for Payer: One Health Plan of WY PPO |
$0.64
|
| Rate for Payer: PacificSource Commercial |
$0.59
|
| Rate for Payer: PHCS PPO |
$0.64
|
| Rate for Payer: Three Rivers PPO |
$0.49
|
| Rate for Payer: TriWest Veterans Administration |
$0.43
|
| Rate for Payer: United Healthcare Commercial |
$0.57
|
| Rate for Payer: United Healthcare Medicare |
$0.43
|
| Rate for Payer: WINHealth Partners Commercial |
$0.62
|
| Rate for Payer: Wise Provider Network Commercial |
$0.62
|
|
|
GABAPENTIN 300 MG CAPSULE [15024]
|
Facility
|
OP
|
$0.56
|
|
|
Service Code
|
NDC 6068759111
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.55
|
| Rate for Payer: Aetna of WY Medicare |
$0.37
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.54
|
| Rate for Payer: Altius Commercial |
$0.54
|
| Rate for Payer: Beech Street Commercial |
$0.55
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.46
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.54
|
| Rate for Payer: Cigna of WY Commercial |
$0.55
|
| Rate for Payer: Entrust Commercial |
$0.53
|
| Rate for Payer: First Choice Health Commercial |
$0.53
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.53
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.32
|
| Rate for Payer: HealthUtah PPO |
$0.56
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.54
|
| Rate for Payer: Multiplan Medicare/VA |
$0.31
|
| Rate for Payer: One Health Plan of WY PPO |
$0.55
|
| Rate for Payer: PacificSource Commercial |
$0.50
|
| Rate for Payer: PHCS PPO |
$0.55
|
| Rate for Payer: Three Rivers PPO |
$0.42
|
| Rate for Payer: TriWest Veterans Administration |
$0.32
|
| Rate for Payer: United Healthcare Commercial |
$0.49
|
| Rate for Payer: United Healthcare Medicare |
$0.32
|
| Rate for Payer: WINHealth Partners Commercial |
$0.55
|
| Rate for Payer: Wise Provider Network Commercial |
$0.53
|
|
|
GABAPENTIN 300 MG CAPSULE [15024]
|
Facility
|
IP
|
$0.38
|
|
|
Service Code
|
NDC 6516210210
|
|
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
|
|
|
GABAPENTIN 300 MG CAPSULE [15024]
|
Facility
|
IP
|
$0.56
|
|
|
Service Code
|
NDC 6068759111
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.55
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.54
|
| Rate for Payer: Altius Commercial |
$0.54
|
| Rate for Payer: Beech Street Commercial |
$0.55
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.46
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.54
|
| Rate for Payer: Cigna of WY Commercial |
$0.55
|
| Rate for Payer: Entrust Commercial |
$0.53
|
| Rate for Payer: First Choice Health Commercial |
$0.53
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.53
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.37
|
| Rate for Payer: HealthUtah PPO |
$0.56
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.54
|
| Rate for Payer: Multiplan Medicare/VA |
$0.35
|
| Rate for Payer: One Health Plan of WY PPO |
$0.55
|
| Rate for Payer: PacificSource Commercial |
$0.50
|
| Rate for Payer: PHCS PPO |
$0.55
|
| Rate for Payer: Three Rivers PPO |
$0.42
|
| Rate for Payer: TriWest Veterans Administration |
$0.37
|
| Rate for Payer: United Healthcare Commercial |
$0.49
|
| Rate for Payer: United Healthcare Medicare |
$0.37
|
| Rate for Payer: WINHealth Partners Commercial |
$0.53
|
| Rate for Payer: Wise Provider Network Commercial |
$0.53
|
|
|
GABAPENTIN 300 MG CAPSULE [15024]
|
Facility
|
OP
|
$0.65
|
|
|
Service Code
|
NDC 0904666661
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$0.65 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.64
|
| Rate for Payer: Aetna of WY Medicare |
$0.43
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.62
|
| Rate for Payer: Altius Commercial |
$0.62
|
| Rate for Payer: Beech Street Commercial |
$0.64
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.53
|
| Rate for Payer: Cash Price |
$0.46
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.63
|
| Rate for Payer: Cigna of WY Commercial |
$0.64
|
| Rate for Payer: Entrust Commercial |
$0.62
|
| Rate for Payer: First Choice Health Commercial |
$0.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.38
|
| Rate for Payer: HealthUtah PPO |
$0.65
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.63
|
| Rate for Payer: Multiplan Medicare/VA |
$0.36
|
| Rate for Payer: One Health Plan of WY PPO |
$0.64
|
| Rate for Payer: PacificSource Commercial |
$0.59
|
| Rate for Payer: PHCS PPO |
$0.64
|
| Rate for Payer: Three Rivers PPO |
$0.49
|
| Rate for Payer: TriWest Veterans Administration |
$0.38
|
| Rate for Payer: United Healthcare Commercial |
$0.57
|
| Rate for Payer: United Healthcare Medicare |
$0.38
|
| Rate for Payer: WINHealth Partners Commercial |
$0.64
|
| Rate for Payer: Wise Provider Network Commercial |
$0.62
|
|
|
GABAPENTIN 400 MG CAPSULE [5211]
|
Facility
|
IP
|
$0.82
|
|
|
Service Code
|
NDC 0904666761
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$0.82 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.80
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.79
|
| Rate for Payer: Altius Commercial |
$0.79
|
| Rate for Payer: Beech Street Commercial |
$0.80
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.67
|
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.80
|
| Rate for Payer: Cigna of WY Commercial |
$0.80
|
| Rate for Payer: Entrust Commercial |
$0.78
|
| Rate for Payer: First Choice Health Commercial |
$0.78
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.78
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.54
|
| Rate for Payer: HealthUtah PPO |
$0.82
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.80
|
| Rate for Payer: Multiplan Medicare/VA |
$0.51
|
| Rate for Payer: One Health Plan of WY PPO |
$0.80
|
| Rate for Payer: PacificSource Commercial |
$0.74
|
| Rate for Payer: PHCS PPO |
$0.80
|
| Rate for Payer: Three Rivers PPO |
$0.62
|
| Rate for Payer: TriWest Veterans Administration |
$0.54
|
| Rate for Payer: United Healthcare Commercial |
$0.71
|
| Rate for Payer: United Healthcare Medicare |
$0.54
|
| Rate for Payer: WINHealth Partners Commercial |
$0.78
|
| Rate for Payer: Wise Provider Network Commercial |
$0.78
|
|
|
GABAPENTIN 400 MG CAPSULE [5211]
|
Facility
|
OP
|
$0.82
|
|
|
Service Code
|
NDC 0904666761
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$0.82 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.80
|
| Rate for Payer: Aetna of WY Medicare |
$0.54
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.79
|
| Rate for Payer: Altius Commercial |
$0.79
|
| Rate for Payer: Beech Street Commercial |
$0.80
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.67
|
| Rate for Payer: Cash Price |
$0.57
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.80
|
| Rate for Payer: Cigna of WY Commercial |
$0.80
|
| Rate for Payer: Entrust Commercial |
$0.78
|
| Rate for Payer: First Choice Health Commercial |
$0.78
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.78
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.48
|
| Rate for Payer: HealthUtah PPO |
$0.82
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.80
|
| Rate for Payer: Multiplan Medicare/VA |
$0.45
|
| Rate for Payer: One Health Plan of WY PPO |
$0.80
|
| Rate for Payer: PacificSource Commercial |
$0.74
|
| Rate for Payer: PHCS PPO |
$0.80
|
| Rate for Payer: Three Rivers PPO |
$0.62
|
| Rate for Payer: TriWest Veterans Administration |
$0.48
|
| Rate for Payer: United Healthcare Commercial |
$0.71
|
| Rate for Payer: United Healthcare Medicare |
$0.48
|
| Rate for Payer: WINHealth Partners Commercial |
$0.80
|
| Rate for Payer: Wise Provider Network Commercial |
$0.78
|
|
|
GABAPENTIN 600 MG TABLET [1692]
|
Facility
|
IP
|
$2.62
|
|
|
Service Code
|
NDC 6068750701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.64 |
| Max. Negotiated Rate |
$2.62 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.57
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.52
|
| Rate for Payer: Altius Commercial |
$2.52
|
| Rate for Payer: Beech Street Commercial |
$2.57
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.15
|
| Rate for Payer: Cash Price |
$1.83
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.54
|
| Rate for Payer: Cigna of WY Commercial |
$2.57
|
| Rate for Payer: Entrust Commercial |
$2.49
|
| Rate for Payer: First Choice Health Commercial |
$2.49
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.49
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.73
|
| Rate for Payer: HealthUtah PPO |
$2.62
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.54
|
| Rate for Payer: Multiplan Medicare/VA |
$1.64
|
| Rate for Payer: One Health Plan of WY PPO |
$2.57
|
| Rate for Payer: PacificSource Commercial |
$2.36
|
| Rate for Payer: PHCS PPO |
$2.57
|
| Rate for Payer: Three Rivers PPO |
$1.96
|
| Rate for Payer: TriWest Veterans Administration |
$1.73
|
| Rate for Payer: United Healthcare Commercial |
$2.28
|
| Rate for Payer: United Healthcare Medicare |
$1.73
|
| Rate for Payer: WINHealth Partners Commercial |
$2.49
|
| Rate for Payer: Wise Provider Network Commercial |
$2.49
|
|
|
GABAPENTIN 600 MG TABLET [1692]
|
Facility
|
IP
|
$2.62
|
|
|
Service Code
|
NDC 6068750711
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.64 |
| Max. Negotiated Rate |
$2.62 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.57
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.52
|
| Rate for Payer: Altius Commercial |
$2.52
|
| Rate for Payer: Beech Street Commercial |
$2.57
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.15
|
| Rate for Payer: Cash Price |
$1.83
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.54
|
| Rate for Payer: Cigna of WY Commercial |
$2.57
|
| Rate for Payer: Entrust Commercial |
$2.49
|
| Rate for Payer: First Choice Health Commercial |
$2.49
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.49
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.73
|
| Rate for Payer: HealthUtah PPO |
$2.62
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.54
|
| Rate for Payer: Multiplan Medicare/VA |
$1.64
|
| Rate for Payer: One Health Plan of WY PPO |
$2.57
|
| Rate for Payer: PacificSource Commercial |
$2.36
|
| Rate for Payer: PHCS PPO |
$2.57
|
| Rate for Payer: Three Rivers PPO |
$1.96
|
| Rate for Payer: TriWest Veterans Administration |
$1.73
|
| Rate for Payer: United Healthcare Commercial |
$2.28
|
| Rate for Payer: United Healthcare Medicare |
$1.73
|
| Rate for Payer: WINHealth Partners Commercial |
$2.49
|
| Rate for Payer: Wise Provider Network Commercial |
$2.49
|
|
|
GABAPENTIN 600 MG TABLET [1692]
|
Facility
|
OP
|
$2.62
|
|
|
Service Code
|
NDC 6068750711
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.44 |
| Max. Negotiated Rate |
$2.62 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.57
|
| Rate for Payer: Aetna of WY Medicare |
$1.73
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.52
|
| Rate for Payer: Altius Commercial |
$2.52
|
| Rate for Payer: Beech Street Commercial |
$2.57
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.15
|
| Rate for Payer: Cash Price |
$1.83
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.54
|
| Rate for Payer: Cigna of WY Commercial |
$2.57
|
| Rate for Payer: Entrust Commercial |
$2.49
|
| Rate for Payer: First Choice Health Commercial |
$2.49
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.49
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.52
|
| Rate for Payer: HealthUtah PPO |
$2.62
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.54
|
| Rate for Payer: Multiplan Medicare/VA |
$1.44
|
| Rate for Payer: One Health Plan of WY PPO |
$2.57
|
| Rate for Payer: PacificSource Commercial |
$2.36
|
| Rate for Payer: PHCS PPO |
$2.57
|
| Rate for Payer: Three Rivers PPO |
$1.96
|
| Rate for Payer: TriWest Veterans Administration |
$1.52
|
| Rate for Payer: United Healthcare Commercial |
$2.28
|
| Rate for Payer: United Healthcare Medicare |
$1.52
|
| Rate for Payer: WINHealth Partners Commercial |
$2.57
|
| Rate for Payer: Wise Provider Network Commercial |
$2.49
|
|
|
GABAPENTIN 600 MG TABLET [1692]
|
Facility
|
OP
|
$2.62
|
|
|
Service Code
|
NDC 6068750701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.44 |
| Max. Negotiated Rate |
$2.62 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.57
|
| Rate for Payer: Aetna of WY Medicare |
$1.73
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.52
|
| Rate for Payer: Altius Commercial |
$2.52
|
| Rate for Payer: Beech Street Commercial |
$2.57
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.15
|
| Rate for Payer: Cash Price |
$1.83
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.54
|
| Rate for Payer: Cigna of WY Commercial |
$2.57
|
| Rate for Payer: Entrust Commercial |
$2.49
|
| Rate for Payer: First Choice Health Commercial |
$2.49
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.49
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.52
|
| Rate for Payer: HealthUtah PPO |
$2.62
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.54
|
| Rate for Payer: Multiplan Medicare/VA |
$1.44
|
| Rate for Payer: One Health Plan of WY PPO |
$2.57
|
| Rate for Payer: PacificSource Commercial |
$2.36
|
| Rate for Payer: PHCS PPO |
$2.57
|
| Rate for Payer: Three Rivers PPO |
$1.96
|
| Rate for Payer: TriWest Veterans Administration |
$1.52
|
| Rate for Payer: United Healthcare Commercial |
$2.28
|
| Rate for Payer: United Healthcare Medicare |
$1.52
|
| Rate for Payer: WINHealth Partners Commercial |
$2.57
|
| Rate for Payer: Wise Provider Network Commercial |
$2.49
|
|
|
GADAVIST 2 ML VIAL INJ-MRI
|
Facility
|
IP
|
$116.40
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$72.98 |
| Max. Negotiated Rate |
$116.40 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$114.07
|
| Rate for Payer: Altius Auto/Workers Compensation |
$111.74
|
| Rate for Payer: Altius Commercial |
$111.74
|
| Rate for Payer: Beech Street Commercial |
$114.07
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$95.56
|
| Rate for Payer: Cash Price |
$81.48
|
| Rate for Payer: ChoiceCare Network Commercial |
$112.91
|
| Rate for Payer: Cigna of WY Commercial |
$114.07
|
| Rate for Payer: Entrust Commercial |
$110.58
|
| Rate for Payer: First Choice Health Commercial |
$110.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$110.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$76.82
|
| Rate for Payer: HealthUtah PPO |
$116.40
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$112.91
|
| Rate for Payer: Multiplan Medicare/VA |
$72.98
|
| Rate for Payer: One Health Plan of WY PPO |
$114.07
|
| Rate for Payer: PacificSource Commercial |
$104.76
|
| Rate for Payer: PHCS PPO |
$114.07
|
| Rate for Payer: Three Rivers PPO |
$87.30
|
| Rate for Payer: TriWest Veterans Administration |
$76.82
|
| Rate for Payer: United Healthcare Commercial |
$101.27
|
| Rate for Payer: United Healthcare Medicare |
$76.82
|
| Rate for Payer: WINHealth Partners Commercial |
$110.58
|
| Rate for Payer: Wise Provider Network Commercial |
$110.58
|
|
|
GADAVIST 2 ML VIAL INJ-MRI
|
Facility
|
OP
|
$116.40
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$64.14 |
| Max. Negotiated Rate |
$116.40 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$114.07
|
| Rate for Payer: Aetna of WY Medicare |
$76.82
|
| Rate for Payer: Altius Auto/Workers Compensation |
$111.74
|
| Rate for Payer: Altius Commercial |
$111.74
|
| Rate for Payer: Beech Street Commercial |
$114.07
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$95.56
|
| Rate for Payer: Cash Price |
$81.48
|
| Rate for Payer: ChoiceCare Network Commercial |
$112.91
|
| Rate for Payer: Cigna of WY Commercial |
$114.07
|
| Rate for Payer: Entrust Commercial |
$110.58
|
| Rate for Payer: First Choice Health Commercial |
$110.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$110.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$67.51
|
| Rate for Payer: HealthUtah PPO |
$116.40
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$112.91
|
| Rate for Payer: Multiplan Medicare/VA |
$64.14
|
| Rate for Payer: One Health Plan of WY PPO |
$114.07
|
| Rate for Payer: PacificSource Commercial |
$104.76
|
| Rate for Payer: PHCS PPO |
$114.07
|
| Rate for Payer: Three Rivers PPO |
$87.30
|
| Rate for Payer: TriWest Veterans Administration |
$67.51
|
| Rate for Payer: United Healthcare Commercial |
$101.27
|
| Rate for Payer: United Healthcare Medicare |
$67.51
|
| Rate for Payer: WINHealth Partners Commercial |
$114.07
|
| Rate for Payer: Wise Provider Network Commercial |
$110.58
|
|
|
GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION [42881]
|
Facility
|
OP
|
$35.75
|
|
|
Service Code
|
HCPCS A9578
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.70 |
| Max. Negotiated Rate |
$35.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$35.04
|
| Rate for Payer: Aetna of WY Medicare |
$23.60
|
| Rate for Payer: Altius Auto/Workers Compensation |
$34.32
|
| Rate for Payer: Altius Commercial |
$34.32
|
| Rate for Payer: Beech Street Commercial |
$35.04
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$29.35
|
| Rate for Payer: Cash Price |
$25.03
|
| Rate for Payer: ChoiceCare Network Commercial |
$34.68
|
| Rate for Payer: Cigna of WY Commercial |
$35.04
|
| Rate for Payer: Entrust Commercial |
$33.96
|
| Rate for Payer: First Choice Health Commercial |
$33.96
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$33.96
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$20.74
|
| Rate for Payer: HealthUtah PPO |
$35.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$34.68
|
| Rate for Payer: Multiplan Medicare/VA |
$19.70
|
| Rate for Payer: One Health Plan of WY PPO |
$35.04
|
| Rate for Payer: PacificSource Commercial |
$32.18
|
| Rate for Payer: PHCS PPO |
$35.04
|
| Rate for Payer: Three Rivers PPO |
$26.81
|
| Rate for Payer: TriWest Veterans Administration |
$20.74
|
| Rate for Payer: United Healthcare Commercial |
$31.10
|
| Rate for Payer: United Healthcare Medicare |
$20.74
|
| Rate for Payer: WINHealth Partners Commercial |
$35.04
|
| Rate for Payer: Wise Provider Network Commercial |
$33.96
|
|
|
GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION [42881]
|
Facility
|
IP
|
$35.75
|
|
|
Service Code
|
HCPCS A9578
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.42 |
| Max. Negotiated Rate |
$35.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$35.04
|
| Rate for Payer: Altius Auto/Workers Compensation |
$34.32
|
| Rate for Payer: Altius Commercial |
$34.32
|
| Rate for Payer: Beech Street Commercial |
$35.04
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$29.35
|
| Rate for Payer: Cash Price |
$25.03
|
| Rate for Payer: ChoiceCare Network Commercial |
$34.68
|
| Rate for Payer: Cigna of WY Commercial |
$35.04
|
| Rate for Payer: Entrust Commercial |
$33.96
|
| Rate for Payer: First Choice Health Commercial |
$33.96
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$33.96
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$23.60
|
| Rate for Payer: HealthUtah PPO |
$35.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$34.68
|
| Rate for Payer: Multiplan Medicare/VA |
$22.42
|
| Rate for Payer: One Health Plan of WY PPO |
$35.04
|
| Rate for Payer: PacificSource Commercial |
$32.18
|
| Rate for Payer: PHCS PPO |
$35.04
|
| Rate for Payer: Three Rivers PPO |
$26.81
|
| Rate for Payer: TriWest Veterans Administration |
$23.60
|
| Rate for Payer: United Healthcare Commercial |
$31.10
|
| Rate for Payer: United Healthcare Medicare |
$23.60
|
| Rate for Payer: WINHealth Partners Commercial |
$33.96
|
| Rate for Payer: Wise Provider Network Commercial |
$33.96
|
|
