|
GLIDESCOPE SZ 4 LOPRO SPECTRUM
|
Facility
|
IP
|
$133.00
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$83.39 |
| Max. Negotiated Rate |
$133.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$130.34
|
| Rate for Payer: Altius Auto/Workers Compensation |
$127.68
|
| Rate for Payer: Altius Commercial |
$127.68
|
| Rate for Payer: Beech Street Commercial |
$130.34
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$109.19
|
| Rate for Payer: Cash Price |
$93.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$129.01
|
| Rate for Payer: Cigna of WY Commercial |
$130.34
|
| Rate for Payer: Entrust Commercial |
$126.35
|
| Rate for Payer: First Choice Health Commercial |
$126.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$126.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$87.78
|
| Rate for Payer: HealthUtah PPO |
$133.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$129.01
|
| Rate for Payer: Multiplan Medicare/VA |
$83.39
|
| Rate for Payer: One Health Plan of WY PPO |
$130.34
|
| Rate for Payer: PacificSource Commercial |
$119.70
|
| Rate for Payer: PHCS PPO |
$130.34
|
| Rate for Payer: Three Rivers PPO |
$99.75
|
| Rate for Payer: TriWest Veterans Administration |
$87.78
|
| Rate for Payer: United Healthcare Commercial |
$115.71
|
| Rate for Payer: United Healthcare Medicare |
$87.78
|
| Rate for Payer: WINHealth Partners Commercial |
$126.35
|
| Rate for Payer: Wise Provider Network Commercial |
$126.35
|
|
|
GLIDESCOPE SZ 4 LOPRO SPECTRUM
|
Facility
|
OP
|
$133.00
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$73.28 |
| Max. Negotiated Rate |
$133.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$130.34
|
| Rate for Payer: Aetna of WY Medicare |
$87.78
|
| Rate for Payer: Altius Auto/Workers Compensation |
$127.68
|
| Rate for Payer: Altius Commercial |
$127.68
|
| Rate for Payer: Beech Street Commercial |
$130.34
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$109.19
|
| Rate for Payer: Cash Price |
$93.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$129.01
|
| Rate for Payer: Cigna of WY Commercial |
$130.34
|
| Rate for Payer: Entrust Commercial |
$126.35
|
| Rate for Payer: First Choice Health Commercial |
$126.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$126.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$77.14
|
| Rate for Payer: HealthUtah PPO |
$133.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$129.01
|
| Rate for Payer: Multiplan Medicare/VA |
$73.28
|
| Rate for Payer: One Health Plan of WY PPO |
$130.34
|
| Rate for Payer: PacificSource Commercial |
$119.70
|
| Rate for Payer: PHCS PPO |
$130.34
|
| Rate for Payer: Three Rivers PPO |
$99.75
|
| Rate for Payer: TriWest Veterans Administration |
$77.14
|
| Rate for Payer: United Healthcare Commercial |
$115.71
|
| Rate for Payer: United Healthcare Medicare |
$77.14
|
| Rate for Payer: WINHealth Partners Commercial |
$130.34
|
| Rate for Payer: Wise Provider Network Commercial |
$126.35
|
|
|
GLIMEPIRIDE 2 MG TABLET [8242]
|
Facility
|
OP
|
$2.16
|
|
|
Service Code
|
NDC 6808432601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.19 |
| Max. Negotiated Rate |
$2.16 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.12
|
| Rate for Payer: Aetna of WY Medicare |
$1.43
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.07
|
| Rate for Payer: Altius Commercial |
$2.07
|
| Rate for Payer: Beech Street Commercial |
$2.12
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.77
|
| Rate for Payer: Cash Price |
$1.52
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.10
|
| Rate for Payer: Cigna of WY Commercial |
$2.12
|
| Rate for Payer: Entrust Commercial |
$2.05
|
| Rate for Payer: First Choice Health Commercial |
$2.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.25
|
| Rate for Payer: HealthUtah PPO |
$2.16
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.10
|
| Rate for Payer: Multiplan Medicare/VA |
$1.19
|
| Rate for Payer: One Health Plan of WY PPO |
$2.12
|
| Rate for Payer: PacificSource Commercial |
$1.94
|
| Rate for Payer: PHCS PPO |
$2.12
|
| Rate for Payer: Three Rivers PPO |
$1.62
|
| Rate for Payer: TriWest Veterans Administration |
$1.25
|
| Rate for Payer: United Healthcare Commercial |
$1.88
|
| Rate for Payer: United Healthcare Medicare |
$1.25
|
| Rate for Payer: WINHealth Partners Commercial |
$2.12
|
| Rate for Payer: Wise Provider Network Commercial |
$2.05
|
|
|
GLIMEPIRIDE 2 MG TABLET [8242]
|
Facility
|
IP
|
$2.16
|
|
|
Service Code
|
NDC 6808432611
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.35 |
| Max. Negotiated Rate |
$2.16 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.12
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.07
|
| Rate for Payer: Altius Commercial |
$2.07
|
| Rate for Payer: Beech Street Commercial |
$2.12
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.77
|
| Rate for Payer: Cash Price |
$1.52
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.10
|
| Rate for Payer: Cigna of WY Commercial |
$2.12
|
| Rate for Payer: Entrust Commercial |
$2.05
|
| Rate for Payer: First Choice Health Commercial |
$2.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.43
|
| Rate for Payer: HealthUtah PPO |
$2.16
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.10
|
| Rate for Payer: Multiplan Medicare/VA |
$1.35
|
| Rate for Payer: One Health Plan of WY PPO |
$2.12
|
| Rate for Payer: PacificSource Commercial |
$1.94
|
| Rate for Payer: PHCS PPO |
$2.12
|
| Rate for Payer: Three Rivers PPO |
$1.62
|
| Rate for Payer: TriWest Veterans Administration |
$1.43
|
| Rate for Payer: United Healthcare Commercial |
$1.88
|
| Rate for Payer: United Healthcare Medicare |
$1.43
|
| Rate for Payer: WINHealth Partners Commercial |
$2.05
|
| Rate for Payer: Wise Provider Network Commercial |
$2.05
|
|
|
GLIMEPIRIDE 2 MG TABLET [8242]
|
Facility
|
OP
|
$2.16
|
|
|
Service Code
|
NDC 6808432611
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.19 |
| Max. Negotiated Rate |
$2.16 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.12
|
| Rate for Payer: Aetna of WY Medicare |
$1.43
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.07
|
| Rate for Payer: Altius Commercial |
$2.07
|
| Rate for Payer: Beech Street Commercial |
$2.12
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.77
|
| Rate for Payer: Cash Price |
$1.52
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.10
|
| Rate for Payer: Cigna of WY Commercial |
$2.12
|
| Rate for Payer: Entrust Commercial |
$2.05
|
| Rate for Payer: First Choice Health Commercial |
$2.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.25
|
| Rate for Payer: HealthUtah PPO |
$2.16
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.10
|
| Rate for Payer: Multiplan Medicare/VA |
$1.19
|
| Rate for Payer: One Health Plan of WY PPO |
$2.12
|
| Rate for Payer: PacificSource Commercial |
$1.94
|
| Rate for Payer: PHCS PPO |
$2.12
|
| Rate for Payer: Three Rivers PPO |
$1.62
|
| Rate for Payer: TriWest Veterans Administration |
$1.25
|
| Rate for Payer: United Healthcare Commercial |
$1.88
|
| Rate for Payer: United Healthcare Medicare |
$1.25
|
| Rate for Payer: WINHealth Partners Commercial |
$2.12
|
| Rate for Payer: Wise Provider Network Commercial |
$2.05
|
|
|
GLIMEPIRIDE 2 MG TABLET [8242]
|
Facility
|
IP
|
$2.16
|
|
|
Service Code
|
NDC 6808432601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.35 |
| Max. Negotiated Rate |
$2.16 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.12
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.07
|
| Rate for Payer: Altius Commercial |
$2.07
|
| Rate for Payer: Beech Street Commercial |
$2.12
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.77
|
| Rate for Payer: Cash Price |
$1.52
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.10
|
| Rate for Payer: Cigna of WY Commercial |
$2.12
|
| Rate for Payer: Entrust Commercial |
$2.05
|
| Rate for Payer: First Choice Health Commercial |
$2.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.43
|
| Rate for Payer: HealthUtah PPO |
$2.16
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.10
|
| Rate for Payer: Multiplan Medicare/VA |
$1.35
|
| Rate for Payer: One Health Plan of WY PPO |
$2.12
|
| Rate for Payer: PacificSource Commercial |
$1.94
|
| Rate for Payer: PHCS PPO |
$2.12
|
| Rate for Payer: Three Rivers PPO |
$1.62
|
| Rate for Payer: TriWest Veterans Administration |
$1.43
|
| Rate for Payer: United Healthcare Commercial |
$1.88
|
| Rate for Payer: United Healthcare Medicare |
$1.43
|
| Rate for Payer: WINHealth Partners Commercial |
$2.05
|
| Rate for Payer: Wise Provider Network Commercial |
$2.05
|
|
|
GLIPIZIDE 5 MG TABLET [19751]
|
Facility
|
OP
|
$0.20
|
|
|
Service Code
|
NDC 6050501410
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.20
|
| Rate for Payer: Aetna of WY Medicare |
$0.13
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.19
|
| Rate for Payer: Altius Commercial |
$0.19
|
| Rate for Payer: Beech Street Commercial |
$0.20
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.16
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.19
|
| Rate for Payer: Cigna of WY Commercial |
$0.20
|
| Rate for Payer: Entrust Commercial |
$0.19
|
| Rate for Payer: First Choice Health Commercial |
$0.19
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.19
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.12
|
| Rate for Payer: HealthUtah PPO |
$0.20
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.19
|
| Rate for Payer: Multiplan Medicare/VA |
$0.11
|
| Rate for Payer: One Health Plan of WY PPO |
$0.20
|
| Rate for Payer: PacificSource Commercial |
$0.18
|
| Rate for Payer: PHCS PPO |
$0.20
|
| Rate for Payer: Three Rivers PPO |
$0.15
|
| Rate for Payer: TriWest Veterans Administration |
$0.12
|
| Rate for Payer: United Healthcare Commercial |
$0.17
|
| Rate for Payer: United Healthcare Medicare |
$0.12
|
| Rate for Payer: WINHealth Partners Commercial |
$0.20
|
| Rate for Payer: Wise Provider Network Commercial |
$0.19
|
|
|
GLIPIZIDE 5 MG TABLET [19751]
|
Facility
|
IP
|
$0.20
|
|
|
Service Code
|
NDC 6050501410
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.20
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.19
|
| Rate for Payer: Altius Commercial |
$0.19
|
| Rate for Payer: Beech Street Commercial |
$0.20
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.16
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.19
|
| Rate for Payer: Cigna of WY Commercial |
$0.20
|
| Rate for Payer: Entrust Commercial |
$0.19
|
| Rate for Payer: First Choice Health Commercial |
$0.19
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.19
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.13
|
| Rate for Payer: HealthUtah PPO |
$0.20
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.19
|
| Rate for Payer: Multiplan Medicare/VA |
$0.13
|
| Rate for Payer: One Health Plan of WY PPO |
$0.20
|
| Rate for Payer: PacificSource Commercial |
$0.18
|
| Rate for Payer: PHCS PPO |
$0.20
|
| Rate for Payer: Three Rivers PPO |
$0.15
|
| Rate for Payer: TriWest Veterans Administration |
$0.13
|
| Rate for Payer: United Healthcare Commercial |
$0.17
|
| Rate for Payer: United Healthcare Medicare |
$0.13
|
| Rate for Payer: WINHealth Partners Commercial |
$0.19
|
| Rate for Payer: Wise Provider Network Commercial |
$0.19
|
|
|
GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR [4430]
|
Facility
|
IP
|
$1.01
|
|
|
Service Code
|
NDC 6498028101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$1.01 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.99
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.97
|
| Rate for Payer: Altius Commercial |
$0.97
|
| Rate for Payer: Beech Street Commercial |
$0.99
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.83
|
| Rate for Payer: Cash Price |
$0.71
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.98
|
| Rate for Payer: Cigna of WY Commercial |
$0.99
|
| Rate for Payer: Entrust Commercial |
$0.96
|
| Rate for Payer: First Choice Health Commercial |
$0.96
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.96
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.67
|
| Rate for Payer: HealthUtah PPO |
$1.01
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.98
|
| Rate for Payer: Multiplan Medicare/VA |
$0.63
|
| Rate for Payer: One Health Plan of WY PPO |
$0.99
|
| Rate for Payer: PacificSource Commercial |
$0.91
|
| Rate for Payer: PHCS PPO |
$0.99
|
| Rate for Payer: Three Rivers PPO |
$0.76
|
| Rate for Payer: TriWest Veterans Administration |
$0.67
|
| Rate for Payer: United Healthcare Commercial |
$0.88
|
| Rate for Payer: United Healthcare Medicare |
$0.67
|
| Rate for Payer: WINHealth Partners Commercial |
$0.96
|
| Rate for Payer: Wise Provider Network Commercial |
$0.96
|
|
|
GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR [4430]
|
Facility
|
OP
|
$1.01
|
|
|
Service Code
|
NDC 6498028101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$1.01 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.99
|
| Rate for Payer: Aetna of WY Medicare |
$0.67
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.97
|
| Rate for Payer: Altius Commercial |
$0.97
|
| Rate for Payer: Beech Street Commercial |
$0.99
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.83
|
| Rate for Payer: Cash Price |
$0.71
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.98
|
| Rate for Payer: Cigna of WY Commercial |
$0.99
|
| Rate for Payer: Entrust Commercial |
$0.96
|
| Rate for Payer: First Choice Health Commercial |
$0.96
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.96
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.59
|
| Rate for Payer: HealthUtah PPO |
$1.01
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.98
|
| Rate for Payer: Multiplan Medicare/VA |
$0.56
|
| Rate for Payer: One Health Plan of WY PPO |
$0.99
|
| Rate for Payer: PacificSource Commercial |
$0.91
|
| Rate for Payer: PHCS PPO |
$0.99
|
| Rate for Payer: Three Rivers PPO |
$0.76
|
| Rate for Payer: TriWest Veterans Administration |
$0.59
|
| Rate for Payer: United Healthcare Commercial |
$0.88
|
| Rate for Payer: United Healthcare Medicare |
$0.59
|
| Rate for Payer: WINHealth Partners Commercial |
$0.99
|
| Rate for Payer: Wise Provider Network Commercial |
$0.96
|
|
|
GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR [5714]
|
Facility
|
IP
|
$0.53
|
|
|
Service Code
|
NDC 6498028001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.52
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.51
|
| Rate for Payer: Altius Commercial |
$0.51
|
| Rate for Payer: Beech Street Commercial |
$0.52
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.44
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.51
|
| Rate for Payer: Cigna of WY Commercial |
$0.52
|
| Rate for Payer: Entrust Commercial |
$0.50
|
| Rate for Payer: First Choice Health Commercial |
$0.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.35
|
| Rate for Payer: HealthUtah PPO |
$0.53
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.51
|
| Rate for Payer: Multiplan Medicare/VA |
$0.33
|
| Rate for Payer: One Health Plan of WY PPO |
$0.52
|
| Rate for Payer: PacificSource Commercial |
$0.48
|
| Rate for Payer: PHCS PPO |
$0.52
|
| Rate for Payer: Three Rivers PPO |
$0.40
|
| Rate for Payer: TriWest Veterans Administration |
$0.35
|
| Rate for Payer: United Healthcare Commercial |
$0.46
|
| Rate for Payer: United Healthcare Medicare |
$0.35
|
| Rate for Payer: WINHealth Partners Commercial |
$0.50
|
| Rate for Payer: Wise Provider Network Commercial |
$0.50
|
|
|
GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR [5714]
|
Facility
|
OP
|
$0.53
|
|
|
Service Code
|
NDC 6498028001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.52
|
| Rate for Payer: Aetna of WY Medicare |
$0.35
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.51
|
| Rate for Payer: Altius Commercial |
$0.51
|
| Rate for Payer: Beech Street Commercial |
$0.52
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.44
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.51
|
| Rate for Payer: Cigna of WY Commercial |
$0.52
|
| Rate for Payer: Entrust Commercial |
$0.50
|
| Rate for Payer: First Choice Health Commercial |
$0.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.31
|
| Rate for Payer: HealthUtah PPO |
$0.53
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.51
|
| Rate for Payer: Multiplan Medicare/VA |
$0.29
|
| Rate for Payer: One Health Plan of WY PPO |
$0.52
|
| Rate for Payer: PacificSource Commercial |
$0.48
|
| Rate for Payer: PHCS PPO |
$0.52
|
| Rate for Payer: Three Rivers PPO |
$0.40
|
| Rate for Payer: TriWest Veterans Administration |
$0.31
|
| Rate for Payer: United Healthcare Commercial |
$0.46
|
| Rate for Payer: United Healthcare Medicare |
$0.31
|
| Rate for Payer: WINHealth Partners Commercial |
$0.52
|
| Rate for Payer: Wise Provider Network Commercial |
$0.50
|
|
|
GLOSSECTOMY <ONE-HALF TONGUE
|
Professional
|
Both
|
$5,466.00
|
|
|
Service Code
|
HCPCS 41120
|
| Hospital Charge Code |
41120
|
| Min. Negotiated Rate |
$870.45 |
| Max. Negotiated Rate |
$5,466.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5,356.68
|
| Rate for Payer: Aetna of WY Medicare |
$1,024.06
|
| Rate for Payer: Beech Street Commercial |
$5,192.70
|
| Rate for Payer: Cash Price |
$3,826.20
|
| Rate for Payer: Cash Price |
$3,826.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$5,302.02
|
| Rate for Payer: Cigna of WY Commercial |
$5,356.68
|
| Rate for Payer: First Choice Health Commercial |
$4,919.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5,192.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,024.06
|
| Rate for Payer: HealthUtah PPO |
$5,466.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5,302.02
|
| Rate for Payer: Multiplan Medicare/VA |
$870.45
|
| Rate for Payer: One Health Plan of WY PPO |
$5,356.68
|
| Rate for Payer: PacificSource Commercial |
$4,919.40
|
| Rate for Payer: PHCS PPO |
$5,192.70
|
| Rate for Payer: Three Rivers PPO |
$4,099.50
|
| Rate for Payer: TriWest Veterans Administration |
$1,024.06
|
| Rate for Payer: United Healthcare Commercial |
$4,755.42
|
| Rate for Payer: United Healthcare Medicare |
$1,024.06
|
| Rate for Payer: WINHealth Partners Commercial |
$4,646.10
|
|
|
GLUCAGON 1 MG SOLUTION FOR INJECTION [17275]
|
Facility
|
IP
|
$365.00
|
|
|
Service Code
|
HCPCS J1610
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$228.86 |
| Max. Negotiated Rate |
$365.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$357.70
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$316.25
|
| Rate for Payer: Altius Auto/Workers Compensation |
$350.40
|
| Rate for Payer: Altius Auto/Workers Compensation |
$309.79
|
| Rate for Payer: Altius Commercial |
$309.79
|
| Rate for Payer: Altius Commercial |
$350.40
|
| Rate for Payer: Beech Street Commercial |
$357.70
|
| Rate for Payer: Beech Street Commercial |
$316.25
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$264.94
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$299.66
|
| Rate for Payer: Cash Price |
$255.50
|
| Rate for Payer: Cash Price |
$225.89
|
| Rate for Payer: ChoiceCare Network Commercial |
$313.02
|
| Rate for Payer: ChoiceCare Network Commercial |
$354.05
|
| Rate for Payer: Cigna of WY Commercial |
$357.70
|
| Rate for Payer: Cigna of WY Commercial |
$316.25
|
| Rate for Payer: Entrust Commercial |
$306.56
|
| Rate for Payer: Entrust Commercial |
$346.75
|
| Rate for Payer: First Choice Health Commercial |
$306.56
|
| Rate for Payer: First Choice Health Commercial |
$346.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$306.56
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$346.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$240.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$212.98
|
| Rate for Payer: HealthUtah PPO |
$365.00
|
| Rate for Payer: HealthUtah PPO |
$322.70
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$313.02
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$354.05
|
| Rate for Payer: Multiplan Medicare/VA |
$228.86
|
| Rate for Payer: Multiplan Medicare/VA |
$202.33
|
| Rate for Payer: One Health Plan of WY PPO |
$357.70
|
| Rate for Payer: One Health Plan of WY PPO |
$316.25
|
| Rate for Payer: PacificSource Commercial |
$328.50
|
| Rate for Payer: PacificSource Commercial |
$290.43
|
| Rate for Payer: PHCS PPO |
$316.25
|
| Rate for Payer: PHCS PPO |
$357.70
|
| Rate for Payer: Three Rivers PPO |
$242.02
|
| Rate for Payer: Three Rivers PPO |
$273.75
|
| Rate for Payer: TriWest Veterans Administration |
$240.90
|
| Rate for Payer: TriWest Veterans Administration |
$212.98
|
| Rate for Payer: United Healthcare Commercial |
$280.75
|
| Rate for Payer: United Healthcare Commercial |
$317.55
|
| Rate for Payer: United Healthcare Medicare |
$240.90
|
| Rate for Payer: United Healthcare Medicare |
$212.98
|
| Rate for Payer: WINHealth Partners Commercial |
$306.56
|
| Rate for Payer: WINHealth Partners Commercial |
$346.75
|
| Rate for Payer: Wise Provider Network Commercial |
$306.56
|
| Rate for Payer: Wise Provider Network Commercial |
$346.75
|
|
|
GLUCAGON 1 MG SOLUTION FOR INJECTION [17275]
|
Facility
|
OP
|
$365.00
|
|
|
Service Code
|
HCPCS J1610
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$201.12 |
| Max. Negotiated Rate |
$365.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$357.70
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$316.25
|
| Rate for Payer: Aetna of WY Medicare |
$240.90
|
| Rate for Payer: Aetna of WY Medicare |
$212.98
|
| Rate for Payer: Altius Auto/Workers Compensation |
$309.79
|
| Rate for Payer: Altius Auto/Workers Compensation |
$350.40
|
| Rate for Payer: Altius Commercial |
$350.40
|
| Rate for Payer: Altius Commercial |
$309.79
|
| Rate for Payer: Beech Street Commercial |
$316.25
|
| Rate for Payer: Beech Street Commercial |
$357.70
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$299.66
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$264.94
|
| Rate for Payer: Cash Price |
$225.89
|
| Rate for Payer: Cash Price |
$255.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$354.05
|
| Rate for Payer: ChoiceCare Network Commercial |
$313.02
|
| Rate for Payer: Cigna of WY Commercial |
$316.25
|
| Rate for Payer: Cigna of WY Commercial |
$357.70
|
| Rate for Payer: Entrust Commercial |
$346.75
|
| Rate for Payer: Entrust Commercial |
$306.56
|
| Rate for Payer: First Choice Health Commercial |
$306.56
|
| Rate for Payer: First Choice Health Commercial |
$346.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$306.56
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$346.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$211.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$187.17
|
| Rate for Payer: HealthUtah PPO |
$322.70
|
| Rate for Payer: HealthUtah PPO |
$365.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$313.02
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$354.05
|
| Rate for Payer: Multiplan Medicare/VA |
$201.12
|
| Rate for Payer: Multiplan Medicare/VA |
$177.81
|
| Rate for Payer: One Health Plan of WY PPO |
$316.25
|
| Rate for Payer: One Health Plan of WY PPO |
$357.70
|
| Rate for Payer: PacificSource Commercial |
$328.50
|
| Rate for Payer: PacificSource Commercial |
$290.43
|
| Rate for Payer: PHCS PPO |
$316.25
|
| Rate for Payer: PHCS PPO |
$357.70
|
| Rate for Payer: Three Rivers PPO |
$242.02
|
| Rate for Payer: Three Rivers PPO |
$273.75
|
| Rate for Payer: TriWest Veterans Administration |
$211.70
|
| Rate for Payer: TriWest Veterans Administration |
$187.17
|
| Rate for Payer: United Healthcare Commercial |
$280.75
|
| Rate for Payer: United Healthcare Commercial |
$317.55
|
| Rate for Payer: United Healthcare Medicare |
$211.70
|
| Rate for Payer: United Healthcare Medicare |
$187.17
|
| Rate for Payer: WINHealth Partners Commercial |
$316.25
|
| Rate for Payer: WINHealth Partners Commercial |
$357.70
|
| Rate for Payer: Wise Provider Network Commercial |
$306.56
|
| Rate for Payer: Wise Provider Network Commercial |
$346.75
|
|
|
GLUCAGON HYDROCHLORIDE/1 MG
|
Professional
|
Both
|
$92.00
|
|
|
Service Code
|
HCPCS J1610
|
| Hospital Charge Code |
J1610
|
| Min. Negotiated Rate |
$69.00 |
| Max. Negotiated Rate |
$191.52 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$90.16
|
| Rate for Payer: Aetna of WY Medicare |
$191.52
|
| Rate for Payer: Beech Street Commercial |
$87.40
|
| Rate for Payer: Cash Price |
$64.40
|
| Rate for Payer: Cash Price |
$64.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$89.24
|
| Rate for Payer: Cigna of WY Commercial |
$90.16
|
| Rate for Payer: First Choice Health Commercial |
$82.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$87.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$191.52
|
| Rate for Payer: HealthUtah PPO |
$92.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$89.24
|
| Rate for Payer: Multiplan Medicare/VA |
$162.79
|
| Rate for Payer: One Health Plan of WY PPO |
$90.16
|
| Rate for Payer: PacificSource Commercial |
$82.80
|
| Rate for Payer: PHCS PPO |
$87.40
|
| Rate for Payer: Three Rivers PPO |
$69.00
|
| Rate for Payer: TriWest Veterans Administration |
$191.52
|
| Rate for Payer: United Healthcare Commercial |
$80.04
|
| Rate for Payer: United Healthcare Medicare |
$191.52
|
| Rate for Payer: WINHealth Partners Commercial |
$87.40
|
|
|
GLUC BLD GLUC MNTR DEV CLEARED FDA SPEC HOME USE
|
Professional
|
Both
|
$12.00
|
|
|
Service Code
|
HCPCS 82962
|
| Hospital Charge Code |
82962
|
| Min. Negotiated Rate |
$2.79 |
| Max. Negotiated Rate |
$12.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$11.76
|
| Rate for Payer: Aetna of WY Medicare |
$3.28
|
| Rate for Payer: Beech Street Commercial |
$11.40
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$11.64
|
| Rate for Payer: Cigna of WY Commercial |
$11.76
|
| Rate for Payer: First Choice Health Commercial |
$10.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$11.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3.28
|
| Rate for Payer: HealthUtah PPO |
$12.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$11.64
|
| Rate for Payer: Multiplan Medicare/VA |
$2.79
|
| Rate for Payer: One Health Plan of WY PPO |
$11.76
|
| Rate for Payer: PacificSource Commercial |
$10.80
|
| Rate for Payer: PHCS PPO |
$11.40
|
| Rate for Payer: Three Rivers PPO |
$9.00
|
| Rate for Payer: TriWest Veterans Administration |
$3.28
|
| Rate for Payer: United Healthcare Commercial |
$10.44
|
| Rate for Payer: United Healthcare Medicare |
$3.28
|
| Rate for Payer: WINHealth Partners Commercial |
$11.40
|
|
|
GLUCOSAMINE-CHONDROITIN 500 MG-400 MG TABLET [19525]
|
Facility
|
OP
|
$0.45
|
|
|
Service Code
|
NDC 4329256003
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.44
|
| Rate for Payer: Aetna of WY Medicare |
$0.30
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.43
|
| Rate for Payer: Altius Commercial |
$0.43
|
| Rate for Payer: Beech Street Commercial |
$0.44
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.37
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.44
|
| Rate for Payer: Cigna of WY Commercial |
$0.44
|
| Rate for Payer: Entrust Commercial |
$0.43
|
| Rate for Payer: First Choice Health Commercial |
$0.43
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.43
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.26
|
| Rate for Payer: HealthUtah PPO |
$0.45
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.44
|
| Rate for Payer: Multiplan Medicare/VA |
$0.25
|
| Rate for Payer: One Health Plan of WY PPO |
$0.44
|
| Rate for Payer: PacificSource Commercial |
$0.41
|
| Rate for Payer: PHCS PPO |
$0.44
|
| Rate for Payer: Three Rivers PPO |
$0.34
|
| Rate for Payer: TriWest Veterans Administration |
$0.26
|
| Rate for Payer: United Healthcare Commercial |
$0.39
|
| Rate for Payer: United Healthcare Medicare |
$0.26
|
| Rate for Payer: WINHealth Partners Commercial |
$0.44
|
| Rate for Payer: Wise Provider Network Commercial |
$0.43
|
|
|
GLUCOSAMINE-CHONDROITIN 500 MG-400 MG TABLET [19525]
|
Facility
|
IP
|
$0.45
|
|
|
Service Code
|
NDC 4329256003
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.44
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.43
|
| Rate for Payer: Altius Commercial |
$0.43
|
| Rate for Payer: Beech Street Commercial |
$0.44
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.37
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.44
|
| Rate for Payer: Cigna of WY Commercial |
$0.44
|
| Rate for Payer: Entrust Commercial |
$0.43
|
| Rate for Payer: First Choice Health Commercial |
$0.43
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.43
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.30
|
| Rate for Payer: HealthUtah PPO |
$0.45
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.44
|
| Rate for Payer: Multiplan Medicare/VA |
$0.28
|
| Rate for Payer: One Health Plan of WY PPO |
$0.44
|
| Rate for Payer: PacificSource Commercial |
$0.41
|
| Rate for Payer: PHCS PPO |
$0.44
|
| Rate for Payer: Three Rivers PPO |
$0.34
|
| Rate for Payer: TriWest Veterans Administration |
$0.30
|
| Rate for Payer: United Healthcare Commercial |
$0.39
|
| Rate for Payer: United Healthcare Medicare |
$0.30
|
| Rate for Payer: WINHealth Partners Commercial |
$0.43
|
| Rate for Payer: Wise Provider Network Commercial |
$0.43
|
|
|
GLUCOSE AMB
|
Facility
|
OP
|
$18.42
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$10.15 |
| Max. Negotiated Rate |
$18.42 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18.05
|
| Rate for Payer: Aetna of WY Medicare |
$12.16
|
| Rate for Payer: Altius Auto/Workers Compensation |
$17.68
|
| Rate for Payer: Altius Commercial |
$17.68
|
| Rate for Payer: Beech Street Commercial |
$18.05
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.12
|
| Rate for Payer: Cash Price |
$12.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$17.87
|
| Rate for Payer: Cigna of WY Commercial |
$18.05
|
| Rate for Payer: Entrust Commercial |
$17.50
|
| Rate for Payer: First Choice Health Commercial |
$17.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.68
|
| Rate for Payer: HealthUtah PPO |
$18.42
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.87
|
| Rate for Payer: Multiplan Medicare/VA |
$10.15
|
| Rate for Payer: One Health Plan of WY PPO |
$18.05
|
| Rate for Payer: PacificSource Commercial |
$16.58
|
| Rate for Payer: PHCS PPO |
$18.05
|
| Rate for Payer: Three Rivers PPO |
$13.82
|
| Rate for Payer: TriWest Veterans Administration |
$10.68
|
| Rate for Payer: United Healthcare Commercial |
$16.03
|
| Rate for Payer: United Healthcare Medicare |
$10.68
|
| Rate for Payer: WINHealth Partners Commercial |
$18.05
|
| Rate for Payer: Wise Provider Network Commercial |
$17.50
|
|
|
GLUCOSE AMB
|
Facility
|
IP
|
$18.42
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$11.55 |
| Max. Negotiated Rate |
$18.42 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18.05
|
| Rate for Payer: Altius Auto/Workers Compensation |
$17.68
|
| Rate for Payer: Altius Commercial |
$17.68
|
| Rate for Payer: Beech Street Commercial |
$18.05
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.12
|
| Rate for Payer: Cash Price |
$12.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$17.87
|
| Rate for Payer: Cigna of WY Commercial |
$18.05
|
| Rate for Payer: Entrust Commercial |
$17.50
|
| Rate for Payer: First Choice Health Commercial |
$17.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$12.16
|
| Rate for Payer: HealthUtah PPO |
$18.42
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.87
|
| Rate for Payer: Multiplan Medicare/VA |
$11.55
|
| Rate for Payer: One Health Plan of WY PPO |
$18.05
|
| Rate for Payer: PacificSource Commercial |
$16.58
|
| Rate for Payer: PHCS PPO |
$18.05
|
| Rate for Payer: Three Rivers PPO |
$13.82
|
| Rate for Payer: TriWest Veterans Administration |
$12.16
|
| Rate for Payer: United Healthcare Commercial |
$16.03
|
| Rate for Payer: United Healthcare Medicare |
$12.16
|
| Rate for Payer: WINHealth Partners Commercial |
$17.50
|
| Rate for Payer: Wise Provider Network Commercial |
$17.50
|
|
|
GLUCOSE BLOOD REAGENT STRIP
|
Professional
|
Both
|
$35.00
|
|
|
Service Code
|
HCPCS 82948
|
| Hospital Charge Code |
82948
|
| Min. Negotiated Rate |
$4.28 |
| Max. Negotiated Rate |
$35.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$34.30
|
| Rate for Payer: Aetna of WY Medicare |
$5.04
|
| Rate for Payer: Beech Street Commercial |
$33.25
|
| Rate for Payer: Cash Price |
$24.50
|
| Rate for Payer: Cash Price |
$24.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$33.95
|
| Rate for Payer: Cigna of WY Commercial |
$34.30
|
| Rate for Payer: First Choice Health Commercial |
$31.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$33.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$5.04
|
| Rate for Payer: HealthUtah PPO |
$35.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$33.95
|
| Rate for Payer: Multiplan Medicare/VA |
$4.28
|
| Rate for Payer: One Health Plan of WY PPO |
$34.30
|
| Rate for Payer: PacificSource Commercial |
$31.50
|
| Rate for Payer: PHCS PPO |
$33.25
|
| Rate for Payer: Three Rivers PPO |
$26.25
|
| Rate for Payer: TriWest Veterans Administration |
$5.04
|
| Rate for Payer: United Healthcare Commercial |
$30.45
|
| Rate for Payer: United Healthcare Medicare |
$5.04
|
| Rate for Payer: WINHealth Partners Commercial |
$33.25
|
|
|
GLUCOSE QUANTITATIVE BLOOD XCPT REAGENT STRIP
|
Professional
|
Both
|
$35.00
|
|
|
Service Code
|
HCPCS 82947
|
| Hospital Charge Code |
82947
|
| Min. Negotiated Rate |
$3.34 |
| Max. Negotiated Rate |
$35.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$34.30
|
| Rate for Payer: Aetna of WY Medicare |
$3.93
|
| Rate for Payer: Beech Street Commercial |
$33.25
|
| Rate for Payer: Cash Price |
$24.50
|
| Rate for Payer: Cash Price |
$24.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$33.95
|
| Rate for Payer: Cigna of WY Commercial |
$34.30
|
| Rate for Payer: First Choice Health Commercial |
$31.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$33.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3.93
|
| Rate for Payer: HealthUtah PPO |
$35.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$33.95
|
| Rate for Payer: Multiplan Medicare/VA |
$3.34
|
| Rate for Payer: One Health Plan of WY PPO |
$34.30
|
| Rate for Payer: PacificSource Commercial |
$31.50
|
| Rate for Payer: PHCS PPO |
$33.25
|
| Rate for Payer: Three Rivers PPO |
$26.25
|
| Rate for Payer: TriWest Veterans Administration |
$3.93
|
| Rate for Payer: United Healthcare Commercial |
$30.45
|
| Rate for Payer: United Healthcare Medicare |
$3.93
|
| Rate for Payer: WINHealth Partners Commercial |
$33.25
|
|
|
GLYCERIN 0.5 % EYE DROPS [183741]
|
Facility
|
OP
|
$3.90
|
|
|
Service Code
|
NDC 1011902278
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.15 |
| Max. Negotiated Rate |
$3.90 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3.82
|
| Rate for Payer: Aetna of WY Medicare |
$2.57
|
| Rate for Payer: Altius Auto/Workers Compensation |
$3.74
|
| Rate for Payer: Altius Commercial |
$3.74
|
| Rate for Payer: Beech Street Commercial |
$3.82
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3.20
|
| Rate for Payer: Cash Price |
$2.73
|
| Rate for Payer: ChoiceCare Network Commercial |
$3.78
|
| Rate for Payer: Cigna of WY Commercial |
$3.82
|
| Rate for Payer: Entrust Commercial |
$3.70
|
| Rate for Payer: First Choice Health Commercial |
$3.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2.26
|
| Rate for Payer: HealthUtah PPO |
$3.90
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3.78
|
| Rate for Payer: Multiplan Medicare/VA |
$2.15
|
| Rate for Payer: One Health Plan of WY PPO |
$3.82
|
| Rate for Payer: PacificSource Commercial |
$3.51
|
| Rate for Payer: PHCS PPO |
$3.82
|
| Rate for Payer: Three Rivers PPO |
$2.92
|
| Rate for Payer: TriWest Veterans Administration |
$2.26
|
| Rate for Payer: United Healthcare Commercial |
$3.39
|
| Rate for Payer: United Healthcare Medicare |
$2.26
|
| Rate for Payer: WINHealth Partners Commercial |
$3.82
|
| Rate for Payer: Wise Provider Network Commercial |
$3.70
|
|
|
GLYCERIN 0.5 % EYE DROPS [183741]
|
Facility
|
IP
|
$3.90
|
|
|
Service Code
|
NDC 1011902278
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.45 |
| Max. Negotiated Rate |
$3.90 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3.82
|
| Rate for Payer: Altius Auto/Workers Compensation |
$3.74
|
| Rate for Payer: Altius Commercial |
$3.74
|
| Rate for Payer: Beech Street Commercial |
$3.82
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3.20
|
| Rate for Payer: Cash Price |
$2.73
|
| Rate for Payer: ChoiceCare Network Commercial |
$3.78
|
| Rate for Payer: Cigna of WY Commercial |
$3.82
|
| Rate for Payer: Entrust Commercial |
$3.70
|
| Rate for Payer: First Choice Health Commercial |
$3.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2.57
|
| Rate for Payer: HealthUtah PPO |
$3.90
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3.78
|
| Rate for Payer: Multiplan Medicare/VA |
$2.45
|
| Rate for Payer: One Health Plan of WY PPO |
$3.82
|
| Rate for Payer: PacificSource Commercial |
$3.51
|
| Rate for Payer: PHCS PPO |
$3.82
|
| Rate for Payer: Three Rivers PPO |
$2.92
|
| Rate for Payer: TriWest Veterans Administration |
$2.57
|
| Rate for Payer: United Healthcare Commercial |
$3.39
|
| Rate for Payer: United Healthcare Medicare |
$2.57
|
| Rate for Payer: WINHealth Partners Commercial |
$3.70
|
| Rate for Payer: Wise Provider Network Commercial |
$3.70
|
|
