|
EPIMED 14G X 4" CURVED NEEDLE
|
Facility
|
IP
|
$3.50
|
|
| Hospital Charge Code |
2800293
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2.03 |
| Max. Negotiated Rate |
$3.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3.43
|
| Rate for Payer: Aetna of WY Medicare |
$2.24
|
| Rate for Payer: Altius Commercial |
$3.36
|
| Rate for Payer: Beech Street Commercial |
$3.43
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3.40
|
| Rate for Payer: Cash Price |
$2.45
|
| Rate for Payer: ChoiceCare Network Commercial |
$3.40
|
| Rate for Payer: Cigna of WY Commercial |
$3.43
|
| Rate for Payer: Entrust Commercial |
$3.32
|
| Rate for Payer: First Choice Health Commercial |
$3.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2.14
|
| Rate for Payer: HealthUtah PPO |
$3.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3.40
|
| Rate for Payer: Multiplan Medicare/VA |
$2.03
|
| Rate for Payer: One Health Plan of WY PPO |
$3.43
|
| Rate for Payer: PacificSource Commercial |
$3.15
|
| Rate for Payer: PHCS PPO |
$3.43
|
| Rate for Payer: Three Rivers PPO |
$2.62
|
| Rate for Payer: TriWest Veterans Administration |
$2.14
|
| Rate for Payer: United Healthcare Commercial |
$3.34
|
| Rate for Payer: United Healthcare Medicare |
$2.14
|
| Rate for Payer: WINHealth Partners Commercial |
$3.32
|
| Rate for Payer: Wise Provider Network Commercial |
$3.32
|
|
|
EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE [13791]
|
Facility
|
IP
|
$18.37
|
|
|
Service Code
|
HCPCS J0171
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.65 |
| Max. Negotiated Rate |
$18.37 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18.00
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18.56
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$19.60
|
| Rate for Payer: Aetna of WY Medicare |
$11.76
|
| Rate for Payer: Aetna of WY Medicare |
$12.80
|
| Rate for Payer: Aetna of WY Medicare |
$12.12
|
| Rate for Payer: Altius Commercial |
$18.18
|
| Rate for Payer: Altius Commercial |
$19.20
|
| Rate for Payer: Altius Commercial |
$17.64
|
| Rate for Payer: Beech Street Commercial |
$19.60
|
| Rate for Payer: Beech Street Commercial |
$18.56
|
| Rate for Payer: Beech Street Commercial |
$18.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$18.37
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$19.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$17.82
|
| Rate for Payer: Cash Price |
$12.86
|
| Rate for Payer: Cash Price |
$14.00
|
| Rate for Payer: Cash Price |
$13.26
|
| Rate for Payer: ChoiceCare Network Commercial |
$19.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$18.37
|
| Rate for Payer: ChoiceCare Network Commercial |
$17.82
|
| Rate for Payer: Cigna of WY Commercial |
$18.56
|
| Rate for Payer: Cigna of WY Commercial |
$18.00
|
| Rate for Payer: Cigna of WY Commercial |
$19.60
|
| Rate for Payer: Entrust Commercial |
$17.45
|
| Rate for Payer: Entrust Commercial |
$19.00
|
| Rate for Payer: Entrust Commercial |
$17.99
|
| Rate for Payer: First Choice Health Commercial |
$19.00
|
| Rate for Payer: First Choice Health Commercial |
$17.45
|
| Rate for Payer: First Choice Health Commercial |
$17.99
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.99
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$19.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$12.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.21
|
| Rate for Payer: HealthUtah PPO |
$20.00
|
| Rate for Payer: HealthUtah PPO |
$18.94
|
| Rate for Payer: HealthUtah PPO |
$18.37
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.82
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$18.37
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$19.40
|
| Rate for Payer: Multiplan Medicare/VA |
$11.59
|
| Rate for Payer: Multiplan Medicare/VA |
$10.98
|
| Rate for Payer: Multiplan Medicare/VA |
$10.65
|
| Rate for Payer: One Health Plan of WY PPO |
$19.60
|
| Rate for Payer: One Health Plan of WY PPO |
$18.56
|
| Rate for Payer: One Health Plan of WY PPO |
$18.00
|
| Rate for Payer: PacificSource Commercial |
$17.05
|
| Rate for Payer: PacificSource Commercial |
$16.53
|
| Rate for Payer: PacificSource Commercial |
$18.00
|
| Rate for Payer: PHCS PPO |
$18.56
|
| Rate for Payer: PHCS PPO |
$19.60
|
| Rate for Payer: PHCS PPO |
$18.00
|
| Rate for Payer: Three Rivers PPO |
$14.20
|
| Rate for Payer: Three Rivers PPO |
$15.00
|
| Rate for Payer: Three Rivers PPO |
$13.78
|
| Rate for Payer: TriWest Veterans Administration |
$11.55
|
| Rate for Payer: TriWest Veterans Administration |
$11.21
|
| Rate for Payer: TriWest Veterans Administration |
$12.20
|
| Rate for Payer: United Healthcare Commercial |
$19.10
|
| Rate for Payer: United Healthcare Commercial |
$17.54
|
| Rate for Payer: United Healthcare Commercial |
$18.09
|
| Rate for Payer: United Healthcare Medicare |
$11.21
|
| Rate for Payer: United Healthcare Medicare |
$11.55
|
| Rate for Payer: United Healthcare Medicare |
$12.20
|
| Rate for Payer: WINHealth Partners Commercial |
$17.99
|
| Rate for Payer: WINHealth Partners Commercial |
$17.45
|
| Rate for Payer: WINHealth Partners Commercial |
$19.00
|
| Rate for Payer: Wise Provider Network Commercial |
$17.99
|
| Rate for Payer: Wise Provider Network Commercial |
$19.00
|
| Rate for Payer: Wise Provider Network Commercial |
$17.45
|
|
|
EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE [13791]
|
Facility
|
OP
|
$20.00
|
|
|
Service Code
|
HCPCS J0171
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.83 |
| Max. Negotiated Rate |
$20.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$19.60
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18.00
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18.56
|
| Rate for Payer: Aetna of WY Medicare |
$13.20
|
| Rate for Payer: Aetna of WY Medicare |
$12.50
|
| Rate for Payer: Aetna of WY Medicare |
$12.12
|
| Rate for Payer: Altius Commercial |
$18.18
|
| Rate for Payer: Altius Commercial |
$19.20
|
| Rate for Payer: Altius Commercial |
$17.64
|
| Rate for Payer: Beech Street Commercial |
$19.60
|
| Rate for Payer: Beech Street Commercial |
$18.56
|
| Rate for Payer: Beech Street Commercial |
$18.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$17.82
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$19.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$18.37
|
| Rate for Payer: Cash Price |
$13.26
|
| Rate for Payer: Cash Price |
$12.86
|
| Rate for Payer: Cash Price |
$14.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$19.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$17.82
|
| Rate for Payer: ChoiceCare Network Commercial |
$18.37
|
| Rate for Payer: Cigna of WY Commercial |
$19.60
|
| Rate for Payer: Cigna of WY Commercial |
$18.00
|
| Rate for Payer: Cigna of WY Commercial |
$18.56
|
| Rate for Payer: Entrust Commercial |
$17.45
|
| Rate for Payer: Entrust Commercial |
$17.99
|
| Rate for Payer: Entrust Commercial |
$19.00
|
| Rate for Payer: First Choice Health Commercial |
$17.45
|
| Rate for Payer: First Choice Health Commercial |
$17.99
|
| Rate for Payer: First Choice Health Commercial |
$19.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$19.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.99
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.47
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.80
|
| Rate for Payer: HealthUtah PPO |
$20.00
|
| Rate for Payer: HealthUtah PPO |
$18.94
|
| Rate for Payer: HealthUtah PPO |
$18.37
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.82
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$18.37
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$19.40
|
| Rate for Payer: Multiplan Medicare/VA |
$9.95
|
| Rate for Payer: Multiplan Medicare/VA |
$10.83
|
| Rate for Payer: Multiplan Medicare/VA |
$10.26
|
| Rate for Payer: One Health Plan of WY PPO |
$18.56
|
| Rate for Payer: One Health Plan of WY PPO |
$18.00
|
| Rate for Payer: One Health Plan of WY PPO |
$19.60
|
| Rate for Payer: PacificSource Commercial |
$16.53
|
| Rate for Payer: PacificSource Commercial |
$17.05
|
| Rate for Payer: PacificSource Commercial |
$18.00
|
| Rate for Payer: PHCS PPO |
$18.56
|
| Rate for Payer: PHCS PPO |
$18.00
|
| Rate for Payer: PHCS PPO |
$19.60
|
| Rate for Payer: Three Rivers PPO |
$15.00
|
| Rate for Payer: Three Rivers PPO |
$13.78
|
| Rate for Payer: Three Rivers PPO |
$14.20
|
| Rate for Payer: TriWest Veterans Administration |
$10.47
|
| Rate for Payer: TriWest Veterans Administration |
$10.80
|
| Rate for Payer: TriWest Veterans Administration |
$11.40
|
| Rate for Payer: United Healthcare Commercial |
$19.10
|
| Rate for Payer: United Healthcare Commercial |
$17.54
|
| Rate for Payer: United Healthcare Commercial |
$18.09
|
| Rate for Payer: United Healthcare Medicare |
$11.40
|
| Rate for Payer: United Healthcare Medicare |
$10.80
|
| Rate for Payer: United Healthcare Medicare |
$10.47
|
| Rate for Payer: WINHealth Partners Commercial |
$18.00
|
| Rate for Payer: WINHealth Partners Commercial |
$18.56
|
| Rate for Payer: WINHealth Partners Commercial |
$19.60
|
| Rate for Payer: Wise Provider Network Commercial |
$17.99
|
| Rate for Payer: Wise Provider Network Commercial |
$17.45
|
| Rate for Payer: Wise Provider Network Commercial |
$19.00
|
|
|
EPINEPHRINE 1 MG/ML INJECTION SOLUTION [29544]
|
Facility
|
OP
|
$41.25
|
|
|
Service Code
|
HCPCS J0171
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.34 |
| Max. Negotiated Rate |
$41.25 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$40.42
|
| Rate for Payer: Aetna of WY Medicare |
$27.22
|
| Rate for Payer: Altius Commercial |
$39.60
|
| Rate for Payer: Beech Street Commercial |
$40.42
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$40.01
|
| Rate for Payer: Cash Price |
$28.87
|
| Rate for Payer: ChoiceCare Network Commercial |
$40.01
|
| Rate for Payer: Cigna of WY Commercial |
$40.42
|
| Rate for Payer: Entrust Commercial |
$39.19
|
| Rate for Payer: First Choice Health Commercial |
$39.19
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$39.19
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$23.51
|
| Rate for Payer: HealthUtah PPO |
$41.25
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$40.01
|
| Rate for Payer: Multiplan Medicare/VA |
$22.34
|
| Rate for Payer: One Health Plan of WY PPO |
$40.42
|
| Rate for Payer: PacificSource Commercial |
$37.12
|
| Rate for Payer: PHCS PPO |
$40.42
|
| Rate for Payer: Three Rivers PPO |
$30.94
|
| Rate for Payer: TriWest Veterans Administration |
$23.51
|
| Rate for Payer: United Healthcare Commercial |
$39.39
|
| Rate for Payer: United Healthcare Medicare |
$23.51
|
| Rate for Payer: WINHealth Partners Commercial |
$40.42
|
| Rate for Payer: Wise Provider Network Commercial |
$39.19
|
|
|
EPINEPHRINE 1 MG/ML INJECTION SOLUTION [29544]
|
Facility
|
IP
|
$41.25
|
|
|
Service Code
|
HCPCS J0171
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.90 |
| Max. Negotiated Rate |
$41.25 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$40.42
|
| Rate for Payer: Aetna of WY Medicare |
$26.40
|
| Rate for Payer: Altius Commercial |
$39.60
|
| Rate for Payer: Beech Street Commercial |
$40.42
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$40.01
|
| Rate for Payer: Cash Price |
$28.87
|
| Rate for Payer: ChoiceCare Network Commercial |
$40.01
|
| Rate for Payer: Cigna of WY Commercial |
$40.42
|
| Rate for Payer: Entrust Commercial |
$39.19
|
| Rate for Payer: First Choice Health Commercial |
$39.19
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$39.19
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$25.16
|
| Rate for Payer: HealthUtah PPO |
$41.25
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$40.01
|
| Rate for Payer: Multiplan Medicare/VA |
$23.90
|
| Rate for Payer: One Health Plan of WY PPO |
$40.42
|
| Rate for Payer: PacificSource Commercial |
$37.12
|
| Rate for Payer: PHCS PPO |
$40.42
|
| Rate for Payer: Three Rivers PPO |
$30.94
|
| Rate for Payer: TriWest Veterans Administration |
$25.16
|
| Rate for Payer: United Healthcare Commercial |
$39.39
|
| Rate for Payer: United Healthcare Medicare |
$25.16
|
| Rate for Payer: WINHealth Partners Commercial |
$39.19
|
| Rate for Payer: Wise Provider Network Commercial |
$39.19
|
|
|
EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION [42727]
|
Facility
|
OP
|
$48.00
|
|
|
Service Code
|
HCPCS J0171
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.99 |
| Max. Negotiated Rate |
$48.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$47.04
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$55.02
|
| Rate for Payer: Aetna of WY Medicare |
$37.05
|
| Rate for Payer: Aetna of WY Medicare |
$31.68
|
| Rate for Payer: Altius Commercial |
$53.89
|
| Rate for Payer: Altius Commercial |
$46.08
|
| Rate for Payer: Beech Street Commercial |
$47.04
|
| Rate for Payer: Beech Street Commercial |
$55.02
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$46.56
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$54.46
|
| Rate for Payer: Cash Price |
$39.30
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$46.56
|
| Rate for Payer: ChoiceCare Network Commercial |
$54.46
|
| Rate for Payer: Cigna of WY Commercial |
$47.04
|
| Rate for Payer: Cigna of WY Commercial |
$55.02
|
| Rate for Payer: Entrust Commercial |
$45.60
|
| Rate for Payer: Entrust Commercial |
$53.33
|
| Rate for Payer: First Choice Health Commercial |
$53.33
|
| Rate for Payer: First Choice Health Commercial |
$45.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$53.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$45.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$27.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$32.00
|
| Rate for Payer: HealthUtah PPO |
$48.00
|
| Rate for Payer: HealthUtah PPO |
$56.14
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$46.56
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$54.46
|
| Rate for Payer: Multiplan Medicare/VA |
$30.40
|
| Rate for Payer: Multiplan Medicare/VA |
$25.99
|
| Rate for Payer: One Health Plan of WY PPO |
$47.04
|
| Rate for Payer: One Health Plan of WY PPO |
$55.02
|
| Rate for Payer: PacificSource Commercial |
$50.53
|
| Rate for Payer: PacificSource Commercial |
$43.20
|
| Rate for Payer: PHCS PPO |
$55.02
|
| Rate for Payer: PHCS PPO |
$47.04
|
| Rate for Payer: Three Rivers PPO |
$36.00
|
| Rate for Payer: Three Rivers PPO |
$42.10
|
| Rate for Payer: TriWest Veterans Administration |
$27.36
|
| Rate for Payer: TriWest Veterans Administration |
$32.00
|
| Rate for Payer: United Healthcare Commercial |
$45.84
|
| Rate for Payer: United Healthcare Commercial |
$53.61
|
| Rate for Payer: United Healthcare Medicare |
$32.00
|
| Rate for Payer: United Healthcare Medicare |
$27.36
|
| Rate for Payer: WINHealth Partners Commercial |
$47.04
|
| Rate for Payer: WINHealth Partners Commercial |
$55.02
|
| Rate for Payer: Wise Provider Network Commercial |
$45.60
|
| Rate for Payer: Wise Provider Network Commercial |
$53.33
|
|
|
EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION [42727]
|
Facility
|
IP
|
$48.00
|
|
|
Service Code
|
HCPCS J0171
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.82 |
| Max. Negotiated Rate |
$48.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$47.04
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$55.02
|
| Rate for Payer: Aetna of WY Medicare |
$35.93
|
| Rate for Payer: Aetna of WY Medicare |
$30.72
|
| Rate for Payer: Altius Commercial |
$46.08
|
| Rate for Payer: Altius Commercial |
$53.89
|
| Rate for Payer: Beech Street Commercial |
$55.02
|
| Rate for Payer: Beech Street Commercial |
$47.04
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$46.56
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$54.46
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Cash Price |
$39.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$54.46
|
| Rate for Payer: ChoiceCare Network Commercial |
$46.56
|
| Rate for Payer: Cigna of WY Commercial |
$55.02
|
| Rate for Payer: Cigna of WY Commercial |
$47.04
|
| Rate for Payer: Entrust Commercial |
$53.33
|
| Rate for Payer: Entrust Commercial |
$45.60
|
| Rate for Payer: First Choice Health Commercial |
$45.60
|
| Rate for Payer: First Choice Health Commercial |
$53.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$45.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$53.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$34.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$29.28
|
| Rate for Payer: HealthUtah PPO |
$56.14
|
| Rate for Payer: HealthUtah PPO |
$48.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$46.56
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$54.46
|
| Rate for Payer: Multiplan Medicare/VA |
$32.53
|
| Rate for Payer: Multiplan Medicare/VA |
$27.82
|
| Rate for Payer: One Health Plan of WY PPO |
$55.02
|
| Rate for Payer: One Health Plan of WY PPO |
$47.04
|
| Rate for Payer: PacificSource Commercial |
$43.20
|
| Rate for Payer: PacificSource Commercial |
$50.53
|
| Rate for Payer: PHCS PPO |
$55.02
|
| Rate for Payer: PHCS PPO |
$47.04
|
| Rate for Payer: Three Rivers PPO |
$42.10
|
| Rate for Payer: Three Rivers PPO |
$36.00
|
| Rate for Payer: TriWest Veterans Administration |
$29.28
|
| Rate for Payer: TriWest Veterans Administration |
$34.25
|
| Rate for Payer: United Healthcare Commercial |
$45.84
|
| Rate for Payer: United Healthcare Commercial |
$53.61
|
| Rate for Payer: United Healthcare Medicare |
$34.25
|
| Rate for Payer: United Healthcare Medicare |
$29.28
|
| Rate for Payer: WINHealth Partners Commercial |
$45.60
|
| Rate for Payer: WINHealth Partners Commercial |
$53.33
|
| Rate for Payer: Wise Provider Network Commercial |
$45.60
|
| Rate for Payer: Wise Provider Network Commercial |
$53.33
|
|
|
EPISIOTOMY/VAG RPR OTH/THN ATTENDING
|
Professional
|
Both
|
$376.00
|
|
|
Service Code
|
HCPCS 59300
|
| Min. Negotiated Rate |
$118.48 |
| Max. Negotiated Rate |
$376.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$368.48
|
| Rate for Payer: Aetna of WY Medicare |
$139.39
|
| Rate for Payer: Beech Street Commercial |
$357.20
|
| Rate for Payer: Cash Price |
$263.20
|
| Rate for Payer: Cash Price |
$263.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$364.72
|
| Rate for Payer: Cigna of WY Commercial |
$368.48
|
| Rate for Payer: First Choice Health Commercial |
$338.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$357.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$139.39
|
| Rate for Payer: HealthUtah PPO |
$376.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$364.72
|
| Rate for Payer: Multiplan Medicare/VA |
$118.48
|
| Rate for Payer: One Health Plan of WY PPO |
$368.48
|
| Rate for Payer: PacificSource Commercial |
$338.40
|
| Rate for Payer: PHCS PPO |
$357.20
|
| Rate for Payer: Three Rivers PPO |
$282.00
|
| Rate for Payer: TriWest Veterans Administration |
$139.39
|
| Rate for Payer: United Healthcare Commercial |
$357.20
|
| Rate for Payer: WINHealth Partners Commercial |
$319.60
|
|
|
EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION [152607]
|
Facility
|
IP
|
$16.76
|
|
|
Service Code
|
HCPCS Q5106
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.71 |
| Max. Negotiated Rate |
$16.76 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.42
|
| Rate for Payer: Aetna of WY Medicare |
$10.73
|
| Rate for Payer: Altius Commercial |
$16.09
|
| Rate for Payer: Beech Street Commercial |
$16.42
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.26
|
| Rate for Payer: Cash Price |
$11.74
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.26
|
| Rate for Payer: Cigna of WY Commercial |
$16.42
|
| Rate for Payer: Entrust Commercial |
$15.92
|
| Rate for Payer: First Choice Health Commercial |
$15.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.22
|
| Rate for Payer: HealthUtah PPO |
$16.76
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.26
|
| Rate for Payer: Multiplan Medicare/VA |
$9.71
|
| Rate for Payer: One Health Plan of WY PPO |
$16.42
|
| Rate for Payer: PacificSource Commercial |
$15.08
|
| Rate for Payer: PHCS PPO |
$16.42
|
| Rate for Payer: Three Rivers PPO |
$12.57
|
| Rate for Payer: TriWest Veterans Administration |
$10.22
|
| Rate for Payer: United Healthcare Commercial |
$16.01
|
| Rate for Payer: United Healthcare Medicare |
$10.22
|
| Rate for Payer: WINHealth Partners Commercial |
$15.92
|
| Rate for Payer: Wise Provider Network Commercial |
$15.92
|
|
|
EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION [152607]
|
Facility
|
OP
|
$16.76
|
|
|
Service Code
|
HCPCS Q5106
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.08 |
| Max. Negotiated Rate |
$16.76 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.42
|
| Rate for Payer: Aetna of WY Medicare |
$11.06
|
| Rate for Payer: Altius Commercial |
$16.09
|
| Rate for Payer: Beech Street Commercial |
$16.42
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.26
|
| Rate for Payer: Cash Price |
$11.74
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.26
|
| Rate for Payer: Cigna of WY Commercial |
$16.42
|
| Rate for Payer: Entrust Commercial |
$15.92
|
| Rate for Payer: First Choice Health Commercial |
$15.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.55
|
| Rate for Payer: HealthUtah PPO |
$16.76
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.26
|
| Rate for Payer: Multiplan Medicare/VA |
$9.08
|
| Rate for Payer: One Health Plan of WY PPO |
$16.42
|
| Rate for Payer: PacificSource Commercial |
$15.08
|
| Rate for Payer: PHCS PPO |
$16.42
|
| Rate for Payer: Three Rivers PPO |
$12.57
|
| Rate for Payer: TriWest Veterans Administration |
$9.55
|
| Rate for Payer: United Healthcare Commercial |
$16.01
|
| Rate for Payer: United Healthcare Medicare |
$9.55
|
| Rate for Payer: WINHealth Partners Commercial |
$16.42
|
| Rate for Payer: Wise Provider Network Commercial |
$15.92
|
|
|
EPOETIN ALFA, NON-ESRD
|
Professional
|
Both
|
$21.00
|
|
|
Service Code
|
HCPCS J0885
|
| Min. Negotiated Rate |
$7.03 |
| Max. Negotiated Rate |
$21.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$20.58
|
| Rate for Payer: Aetna of WY Medicare |
$8.27
|
| Rate for Payer: Beech Street Commercial |
$19.95
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$20.37
|
| Rate for Payer: Cigna of WY Commercial |
$20.58
|
| Rate for Payer: First Choice Health Commercial |
$18.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$19.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.27
|
| Rate for Payer: HealthUtah PPO |
$21.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$20.37
|
| Rate for Payer: Multiplan Medicare/VA |
$7.03
|
| Rate for Payer: One Health Plan of WY PPO |
$20.58
|
| Rate for Payer: PacificSource Commercial |
$18.90
|
| Rate for Payer: PHCS PPO |
$19.95
|
| Rate for Payer: Three Rivers PPO |
$15.75
|
| Rate for Payer: TriWest Veterans Administration |
$8.27
|
| Rate for Payer: United Healthcare Commercial |
$19.95
|
| Rate for Payer: WINHealth Partners Commercial |
$19.95
|
|
|
ERTAPENEM 1 GRAM SOLUTION FOR INJECTION [20796]
|
Facility
|
IP
|
$190.60
|
|
|
Service Code
|
HCPCS J1335
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$110.45 |
| Max. Negotiated Rate |
$190.60 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$186.79
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$107.80
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$218.74
|
| Rate for Payer: Aetna of WY Medicare |
$142.85
|
| Rate for Payer: Aetna of WY Medicare |
$121.98
|
| Rate for Payer: Aetna of WY Medicare |
$70.40
|
| Rate for Payer: Altius Commercial |
$214.27
|
| Rate for Payer: Altius Commercial |
$105.60
|
| Rate for Payer: Altius Commercial |
$182.98
|
| Rate for Payer: Beech Street Commercial |
$186.79
|
| Rate for Payer: Beech Street Commercial |
$218.74
|
| Rate for Payer: Beech Street Commercial |
$107.80
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$216.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$184.88
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$106.70
|
| Rate for Payer: Cash Price |
$156.24
|
| Rate for Payer: Cash Price |
$77.00
|
| Rate for Payer: Cash Price |
$133.42
|
| Rate for Payer: ChoiceCare Network Commercial |
$184.88
|
| Rate for Payer: ChoiceCare Network Commercial |
$216.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$106.70
|
| Rate for Payer: Cigna of WY Commercial |
$107.80
|
| Rate for Payer: Cigna of WY Commercial |
$186.79
|
| Rate for Payer: Cigna of WY Commercial |
$218.74
|
| Rate for Payer: Entrust Commercial |
$104.50
|
| Rate for Payer: Entrust Commercial |
$212.04
|
| Rate for Payer: Entrust Commercial |
$181.07
|
| Rate for Payer: First Choice Health Commercial |
$104.50
|
| Rate for Payer: First Choice Health Commercial |
$212.04
|
| Rate for Payer: First Choice Health Commercial |
$181.07
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$181.07
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$212.04
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$104.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$67.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$116.27
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$136.15
|
| Rate for Payer: HealthUtah PPO |
$223.20
|
| Rate for Payer: HealthUtah PPO |
$190.60
|
| Rate for Payer: HealthUtah PPO |
$110.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$216.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$184.88
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$106.70
|
| Rate for Payer: Multiplan Medicare/VA |
$63.74
|
| Rate for Payer: Multiplan Medicare/VA |
$110.45
|
| Rate for Payer: Multiplan Medicare/VA |
$129.34
|
| Rate for Payer: One Health Plan of WY PPO |
$186.79
|
| Rate for Payer: One Health Plan of WY PPO |
$218.74
|
| Rate for Payer: One Health Plan of WY PPO |
$107.80
|
| Rate for Payer: PacificSource Commercial |
$200.88
|
| Rate for Payer: PacificSource Commercial |
$171.54
|
| Rate for Payer: PacificSource Commercial |
$99.00
|
| Rate for Payer: PHCS PPO |
$107.80
|
| Rate for Payer: PHCS PPO |
$218.74
|
| Rate for Payer: PHCS PPO |
$186.79
|
| Rate for Payer: Three Rivers PPO |
$142.95
|
| Rate for Payer: Three Rivers PPO |
$82.50
|
| Rate for Payer: Three Rivers PPO |
$167.40
|
| Rate for Payer: TriWest Veterans Administration |
$67.10
|
| Rate for Payer: TriWest Veterans Administration |
$116.27
|
| Rate for Payer: TriWest Veterans Administration |
$136.15
|
| Rate for Payer: United Healthcare Commercial |
$182.02
|
| Rate for Payer: United Healthcare Commercial |
$213.16
|
| Rate for Payer: United Healthcare Commercial |
$105.05
|
| Rate for Payer: United Healthcare Medicare |
$67.10
|
| Rate for Payer: United Healthcare Medicare |
$136.15
|
| Rate for Payer: United Healthcare Medicare |
$116.27
|
| Rate for Payer: WINHealth Partners Commercial |
$181.07
|
| Rate for Payer: WINHealth Partners Commercial |
$104.50
|
| Rate for Payer: WINHealth Partners Commercial |
$212.04
|
| Rate for Payer: Wise Provider Network Commercial |
$104.50
|
| Rate for Payer: Wise Provider Network Commercial |
$181.07
|
| Rate for Payer: Wise Provider Network Commercial |
$212.04
|
|
|
ERTAPENEM 1 GRAM SOLUTION FOR INJECTION [20796]
|
Facility
|
OP
|
$110.00
|
|
|
Service Code
|
HCPCS J1335
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$59.56 |
| Max. Negotiated Rate |
$110.00 |
| Rate for Payer: PacificSource Commercial |
$99.00
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$107.80
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$218.74
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$186.79
|
| Rate for Payer: Aetna of WY Medicare |
$125.80
|
| Rate for Payer: Aetna of WY Medicare |
$147.31
|
| Rate for Payer: Aetna of WY Medicare |
$72.60
|
| Rate for Payer: Altius Commercial |
$214.27
|
| Rate for Payer: Altius Commercial |
$105.60
|
| Rate for Payer: Altius Commercial |
$182.98
|
| Rate for Payer: Beech Street Commercial |
$186.79
|
| Rate for Payer: Beech Street Commercial |
$107.80
|
| Rate for Payer: Beech Street Commercial |
$218.74
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$106.70
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$184.88
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$216.50
|
| Rate for Payer: Cash Price |
$133.42
|
| Rate for Payer: Cash Price |
$77.00
|
| Rate for Payer: Cash Price |
$156.24
|
| Rate for Payer: ChoiceCare Network Commercial |
$106.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$184.88
|
| Rate for Payer: ChoiceCare Network Commercial |
$216.50
|
| Rate for Payer: Cigna of WY Commercial |
$107.80
|
| Rate for Payer: Cigna of WY Commercial |
$218.74
|
| Rate for Payer: Cigna of WY Commercial |
$186.79
|
| Rate for Payer: Entrust Commercial |
$212.04
|
| Rate for Payer: Entrust Commercial |
$104.50
|
| Rate for Payer: Entrust Commercial |
$181.07
|
| Rate for Payer: First Choice Health Commercial |
$104.50
|
| Rate for Payer: First Choice Health Commercial |
$212.04
|
| Rate for Payer: First Choice Health Commercial |
$181.07
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$212.04
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$104.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$181.07
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$127.22
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$108.64
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$62.70
|
| Rate for Payer: HealthUtah PPO |
$223.20
|
| Rate for Payer: HealthUtah PPO |
$110.00
|
| Rate for Payer: HealthUtah PPO |
$190.60
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$184.88
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$106.70
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$216.50
|
| Rate for Payer: Multiplan Medicare/VA |
$120.86
|
| Rate for Payer: Multiplan Medicare/VA |
$103.21
|
| Rate for Payer: Multiplan Medicare/VA |
$59.56
|
| Rate for Payer: One Health Plan of WY PPO |
$107.80
|
| Rate for Payer: One Health Plan of WY PPO |
$186.79
|
| Rate for Payer: One Health Plan of WY PPO |
$218.74
|
| Rate for Payer: PacificSource Commercial |
$200.88
|
| Rate for Payer: PacificSource Commercial |
$171.54
|
| Rate for Payer: PHCS PPO |
$186.79
|
| Rate for Payer: PHCS PPO |
$107.80
|
| Rate for Payer: PHCS PPO |
$218.74
|
| Rate for Payer: Three Rivers PPO |
$82.50
|
| Rate for Payer: Three Rivers PPO |
$142.95
|
| Rate for Payer: Three Rivers PPO |
$167.40
|
| Rate for Payer: TriWest Veterans Administration |
$127.22
|
| Rate for Payer: TriWest Veterans Administration |
$62.70
|
| Rate for Payer: TriWest Veterans Administration |
$108.64
|
| Rate for Payer: United Healthcare Commercial |
$182.02
|
| Rate for Payer: United Healthcare Commercial |
$213.16
|
| Rate for Payer: United Healthcare Commercial |
$105.05
|
| Rate for Payer: United Healthcare Medicare |
$62.70
|
| Rate for Payer: United Healthcare Medicare |
$108.64
|
| Rate for Payer: United Healthcare Medicare |
$127.22
|
| Rate for Payer: WINHealth Partners Commercial |
$107.80
|
| Rate for Payer: WINHealth Partners Commercial |
$186.79
|
| Rate for Payer: WINHealth Partners Commercial |
$218.74
|
| Rate for Payer: Wise Provider Network Commercial |
$181.07
|
| Rate for Payer: Wise Provider Network Commercial |
$104.50
|
| Rate for Payer: Wise Provider Network Commercial |
$212.04
|
|
|
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [12186]
|
Facility
|
OP
|
$41.56
|
|
|
Service Code
|
NDC 1747807031
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.50 |
| Max. Negotiated Rate |
$41.56 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$40.73
|
| Rate for Payer: Aetna of WY Medicare |
$27.43
|
| Rate for Payer: Altius Commercial |
$39.90
|
| Rate for Payer: Beech Street Commercial |
$40.73
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$40.31
|
| Rate for Payer: Cash Price |
$29.09
|
| Rate for Payer: ChoiceCare Network Commercial |
$40.31
|
| Rate for Payer: Cigna of WY Commercial |
$40.73
|
| Rate for Payer: Entrust Commercial |
$39.48
|
| Rate for Payer: First Choice Health Commercial |
$39.48
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$39.48
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$23.69
|
| Rate for Payer: HealthUtah PPO |
$41.56
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$40.31
|
| Rate for Payer: Multiplan Medicare/VA |
$22.50
|
| Rate for Payer: One Health Plan of WY PPO |
$40.73
|
| Rate for Payer: PacificSource Commercial |
$37.40
|
| Rate for Payer: PHCS PPO |
$40.73
|
| Rate for Payer: Three Rivers PPO |
$31.17
|
| Rate for Payer: TriWest Veterans Administration |
$23.69
|
| Rate for Payer: United Healthcare Commercial |
$39.69
|
| Rate for Payer: United Healthcare Medicare |
$23.69
|
| Rate for Payer: WINHealth Partners Commercial |
$40.73
|
| Rate for Payer: Wise Provider Network Commercial |
$39.48
|
|
|
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [12186]
|
Facility
|
IP
|
$41.56
|
|
|
Service Code
|
NDC 1747807031
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.08 |
| Max. Negotiated Rate |
$41.56 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$40.73
|
| Rate for Payer: Aetna of WY Medicare |
$26.60
|
| Rate for Payer: Altius Commercial |
$39.90
|
| Rate for Payer: Beech Street Commercial |
$40.73
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$40.31
|
| Rate for Payer: Cash Price |
$29.09
|
| Rate for Payer: ChoiceCare Network Commercial |
$40.31
|
| Rate for Payer: Cigna of WY Commercial |
$40.73
|
| Rate for Payer: Entrust Commercial |
$39.48
|
| Rate for Payer: First Choice Health Commercial |
$39.48
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$39.48
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$25.35
|
| Rate for Payer: HealthUtah PPO |
$41.56
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$40.31
|
| Rate for Payer: Multiplan Medicare/VA |
$24.08
|
| Rate for Payer: One Health Plan of WY PPO |
$40.73
|
| Rate for Payer: PacificSource Commercial |
$37.40
|
| Rate for Payer: PHCS PPO |
$40.73
|
| Rate for Payer: Three Rivers PPO |
$31.17
|
| Rate for Payer: TriWest Veterans Administration |
$25.35
|
| Rate for Payer: United Healthcare Commercial |
$39.69
|
| Rate for Payer: United Healthcare Medicare |
$25.35
|
| Rate for Payer: WINHealth Partners Commercial |
$39.48
|
| Rate for Payer: Wise Provider Network Commercial |
$39.48
|
|
|
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [12186]
|
Facility
|
IP
|
$47.28
|
|
|
Service Code
|
NDC 2420891019
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.40 |
| Max. Negotiated Rate |
$47.28 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$46.33
|
| Rate for Payer: Aetna of WY Medicare |
$30.26
|
| Rate for Payer: Altius Commercial |
$45.39
|
| Rate for Payer: Beech Street Commercial |
$46.33
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$45.86
|
| Rate for Payer: Cash Price |
$33.09
|
| Rate for Payer: ChoiceCare Network Commercial |
$45.86
|
| Rate for Payer: Cigna of WY Commercial |
$46.33
|
| Rate for Payer: Entrust Commercial |
$44.92
|
| Rate for Payer: First Choice Health Commercial |
$44.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$44.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$28.84
|
| Rate for Payer: HealthUtah PPO |
$47.28
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$45.86
|
| Rate for Payer: Multiplan Medicare/VA |
$27.40
|
| Rate for Payer: One Health Plan of WY PPO |
$46.33
|
| Rate for Payer: PacificSource Commercial |
$42.55
|
| Rate for Payer: PHCS PPO |
$46.33
|
| Rate for Payer: Three Rivers PPO |
$35.46
|
| Rate for Payer: TriWest Veterans Administration |
$28.84
|
| Rate for Payer: United Healthcare Commercial |
$45.15
|
| Rate for Payer: United Healthcare Medicare |
$28.84
|
| Rate for Payer: WINHealth Partners Commercial |
$44.92
|
| Rate for Payer: Wise Provider Network Commercial |
$44.92
|
|
|
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [12186]
|
Facility
|
IP
|
$40.36
|
|
|
Service Code
|
NDC 0574402450
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.39 |
| Max. Negotiated Rate |
$40.36 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$39.55
|
| Rate for Payer: Aetna of WY Medicare |
$25.83
|
| Rate for Payer: Altius Commercial |
$38.75
|
| Rate for Payer: Beech Street Commercial |
$39.55
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$39.15
|
| Rate for Payer: Cash Price |
$28.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$39.15
|
| Rate for Payer: Cigna of WY Commercial |
$39.55
|
| Rate for Payer: Entrust Commercial |
$38.34
|
| Rate for Payer: First Choice Health Commercial |
$38.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$38.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$24.62
|
| Rate for Payer: HealthUtah PPO |
$40.36
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$39.15
|
| Rate for Payer: Multiplan Medicare/VA |
$23.39
|
| Rate for Payer: One Health Plan of WY PPO |
$39.55
|
| Rate for Payer: PacificSource Commercial |
$36.32
|
| Rate for Payer: PHCS PPO |
$39.55
|
| Rate for Payer: Three Rivers PPO |
$30.27
|
| Rate for Payer: TriWest Veterans Administration |
$24.62
|
| Rate for Payer: United Healthcare Commercial |
$38.54
|
| Rate for Payer: United Healthcare Medicare |
$24.62
|
| Rate for Payer: WINHealth Partners Commercial |
$38.34
|
| Rate for Payer: Wise Provider Network Commercial |
$38.34
|
|
|
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [12186]
|
Facility
|
OP
|
$40.36
|
|
|
Service Code
|
NDC 0574402411
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.85 |
| Max. Negotiated Rate |
$40.36 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$39.55
|
| Rate for Payer: Aetna of WY Medicare |
$26.64
|
| Rate for Payer: Altius Commercial |
$38.75
|
| Rate for Payer: Beech Street Commercial |
$39.55
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$39.15
|
| Rate for Payer: Cash Price |
$28.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$39.15
|
| Rate for Payer: Cigna of WY Commercial |
$39.55
|
| Rate for Payer: Entrust Commercial |
$38.34
|
| Rate for Payer: First Choice Health Commercial |
$38.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$38.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$23.01
|
| Rate for Payer: HealthUtah PPO |
$40.36
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$39.15
|
| Rate for Payer: Multiplan Medicare/VA |
$21.85
|
| Rate for Payer: One Health Plan of WY PPO |
$39.55
|
| Rate for Payer: PacificSource Commercial |
$36.32
|
| Rate for Payer: PHCS PPO |
$39.55
|
| Rate for Payer: Three Rivers PPO |
$30.27
|
| Rate for Payer: TriWest Veterans Administration |
$23.01
|
| Rate for Payer: United Healthcare Commercial |
$38.54
|
| Rate for Payer: United Healthcare Medicare |
$23.01
|
| Rate for Payer: WINHealth Partners Commercial |
$39.55
|
| Rate for Payer: Wise Provider Network Commercial |
$38.34
|
|
|
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [12186]
|
Facility
|
IP
|
$40.36
|
|
|
Service Code
|
NDC 0574402411
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.39 |
| Max. Negotiated Rate |
$40.36 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$39.55
|
| Rate for Payer: Aetna of WY Medicare |
$25.83
|
| Rate for Payer: Altius Commercial |
$38.75
|
| Rate for Payer: Beech Street Commercial |
$39.55
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$39.15
|
| Rate for Payer: Cash Price |
$28.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$39.15
|
| Rate for Payer: Cigna of WY Commercial |
$39.55
|
| Rate for Payer: Entrust Commercial |
$38.34
|
| Rate for Payer: First Choice Health Commercial |
$38.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$38.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$24.62
|
| Rate for Payer: HealthUtah PPO |
$40.36
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$39.15
|
| Rate for Payer: Multiplan Medicare/VA |
$23.39
|
| Rate for Payer: One Health Plan of WY PPO |
$39.55
|
| Rate for Payer: PacificSource Commercial |
$36.32
|
| Rate for Payer: PHCS PPO |
$39.55
|
| Rate for Payer: Three Rivers PPO |
$30.27
|
| Rate for Payer: TriWest Veterans Administration |
$24.62
|
| Rate for Payer: United Healthcare Commercial |
$38.54
|
| Rate for Payer: United Healthcare Medicare |
$24.62
|
| Rate for Payer: WINHealth Partners Commercial |
$38.34
|
| Rate for Payer: Wise Provider Network Commercial |
$38.34
|
|
|
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [12186]
|
Facility
|
OP
|
$47.28
|
|
|
Service Code
|
NDC 2420891019
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.60 |
| Max. Negotiated Rate |
$47.28 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$46.33
|
| Rate for Payer: Aetna of WY Medicare |
$31.20
|
| Rate for Payer: Altius Commercial |
$45.39
|
| Rate for Payer: Beech Street Commercial |
$46.33
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$45.86
|
| Rate for Payer: Cash Price |
$33.09
|
| Rate for Payer: ChoiceCare Network Commercial |
$45.86
|
| Rate for Payer: Cigna of WY Commercial |
$46.33
|
| Rate for Payer: Entrust Commercial |
$44.92
|
| Rate for Payer: First Choice Health Commercial |
$44.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$44.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$26.95
|
| Rate for Payer: HealthUtah PPO |
$47.28
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$45.86
|
| Rate for Payer: Multiplan Medicare/VA |
$25.60
|
| Rate for Payer: One Health Plan of WY PPO |
$46.33
|
| Rate for Payer: PacificSource Commercial |
$42.55
|
| Rate for Payer: PHCS PPO |
$46.33
|
| Rate for Payer: Three Rivers PPO |
$35.46
|
| Rate for Payer: TriWest Veterans Administration |
$26.95
|
| Rate for Payer: United Healthcare Commercial |
$45.15
|
| Rate for Payer: United Healthcare Medicare |
$26.95
|
| Rate for Payer: WINHealth Partners Commercial |
$46.33
|
| Rate for Payer: Wise Provider Network Commercial |
$44.92
|
|
|
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [12186]
|
Facility
|
OP
|
$40.36
|
|
|
Service Code
|
NDC 0574402450
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.85 |
| Max. Negotiated Rate |
$40.36 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$39.55
|
| Rate for Payer: Aetna of WY Medicare |
$26.64
|
| Rate for Payer: Altius Commercial |
$38.75
|
| Rate for Payer: Beech Street Commercial |
$39.55
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$39.15
|
| Rate for Payer: Cash Price |
$28.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$39.15
|
| Rate for Payer: Cigna of WY Commercial |
$39.55
|
| Rate for Payer: Entrust Commercial |
$38.34
|
| Rate for Payer: First Choice Health Commercial |
$38.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$38.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$23.01
|
| Rate for Payer: HealthUtah PPO |
$40.36
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$39.15
|
| Rate for Payer: Multiplan Medicare/VA |
$21.85
|
| Rate for Payer: One Health Plan of WY PPO |
$39.55
|
| Rate for Payer: PacificSource Commercial |
$36.32
|
| Rate for Payer: PHCS PPO |
$39.55
|
| Rate for Payer: Three Rivers PPO |
$30.27
|
| Rate for Payer: TriWest Veterans Administration |
$23.01
|
| Rate for Payer: United Healthcare Commercial |
$38.54
|
| Rate for Payer: United Healthcare Medicare |
$23.01
|
| Rate for Payer: WINHealth Partners Commercial |
$39.55
|
| Rate for Payer: Wise Provider Network Commercial |
$38.34
|
|
|
ESCITALOPRAM 10 MG TABLET [25995]
|
Facility
|
OP
|
$15.96
|
|
|
Service Code
|
NDC 6808461711
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.64 |
| Max. Negotiated Rate |
$15.96 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.64
|
| Rate for Payer: Aetna of WY Medicare |
$10.53
|
| Rate for Payer: Altius Commercial |
$15.32
|
| Rate for Payer: Beech Street Commercial |
$15.64
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.48
|
| Rate for Payer: Cash Price |
$11.17
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.48
|
| Rate for Payer: Cigna of WY Commercial |
$15.64
|
| Rate for Payer: Entrust Commercial |
$15.16
|
| Rate for Payer: First Choice Health Commercial |
$15.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.10
|
| Rate for Payer: HealthUtah PPO |
$15.96
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.48
|
| Rate for Payer: Multiplan Medicare/VA |
$8.64
|
| Rate for Payer: One Health Plan of WY PPO |
$15.64
|
| Rate for Payer: PacificSource Commercial |
$14.36
|
| Rate for Payer: PHCS PPO |
$15.64
|
| Rate for Payer: Three Rivers PPO |
$11.97
|
| Rate for Payer: TriWest Veterans Administration |
$9.10
|
| Rate for Payer: United Healthcare Commercial |
$15.24
|
| Rate for Payer: United Healthcare Medicare |
$9.10
|
| Rate for Payer: WINHealth Partners Commercial |
$15.64
|
| Rate for Payer: Wise Provider Network Commercial |
$15.16
|
|
|
ESCITALOPRAM 10 MG TABLET [25995]
|
Facility
|
IP
|
$15.96
|
|
|
Service Code
|
NDC 6808461711
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.25 |
| Max. Negotiated Rate |
$15.96 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.64
|
| Rate for Payer: Aetna of WY Medicare |
$10.21
|
| Rate for Payer: Altius Commercial |
$15.32
|
| Rate for Payer: Beech Street Commercial |
$15.64
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.48
|
| Rate for Payer: Cash Price |
$11.17
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.48
|
| Rate for Payer: Cigna of WY Commercial |
$15.64
|
| Rate for Payer: Entrust Commercial |
$15.16
|
| Rate for Payer: First Choice Health Commercial |
$15.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.74
|
| Rate for Payer: HealthUtah PPO |
$15.96
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.48
|
| Rate for Payer: Multiplan Medicare/VA |
$9.25
|
| Rate for Payer: One Health Plan of WY PPO |
$15.64
|
| Rate for Payer: PacificSource Commercial |
$14.36
|
| Rate for Payer: PHCS PPO |
$15.64
|
| Rate for Payer: Three Rivers PPO |
$11.97
|
| Rate for Payer: TriWest Veterans Administration |
$9.74
|
| Rate for Payer: United Healthcare Commercial |
$15.24
|
| Rate for Payer: United Healthcare Medicare |
$9.74
|
| Rate for Payer: WINHealth Partners Commercial |
$15.16
|
| Rate for Payer: Wise Provider Network Commercial |
$15.16
|
|
|
ESCITALOPRAM 10 MG TABLET [25995]
|
Facility
|
IP
|
$15.96
|
|
|
Service Code
|
NDC 6808461701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.25 |
| Max. Negotiated Rate |
$15.96 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.64
|
| Rate for Payer: Aetna of WY Medicare |
$10.21
|
| Rate for Payer: Altius Commercial |
$15.32
|
| Rate for Payer: Beech Street Commercial |
$15.64
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.48
|
| Rate for Payer: Cash Price |
$11.17
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.48
|
| Rate for Payer: Cigna of WY Commercial |
$15.64
|
| Rate for Payer: Entrust Commercial |
$15.16
|
| Rate for Payer: First Choice Health Commercial |
$15.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.74
|
| Rate for Payer: HealthUtah PPO |
$15.96
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.48
|
| Rate for Payer: Multiplan Medicare/VA |
$9.25
|
| Rate for Payer: One Health Plan of WY PPO |
$15.64
|
| Rate for Payer: PacificSource Commercial |
$14.36
|
| Rate for Payer: PHCS PPO |
$15.64
|
| Rate for Payer: Three Rivers PPO |
$11.97
|
| Rate for Payer: TriWest Veterans Administration |
$9.74
|
| Rate for Payer: United Healthcare Commercial |
$15.24
|
| Rate for Payer: United Healthcare Medicare |
$9.74
|
| Rate for Payer: WINHealth Partners Commercial |
$15.16
|
| Rate for Payer: Wise Provider Network Commercial |
$15.16
|
|
|
ESCITALOPRAM 10 MG TABLET [25995]
|
Facility
|
OP
|
$15.96
|
|
|
Service Code
|
NDC 6808461701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.64 |
| Max. Negotiated Rate |
$15.96 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.64
|
| Rate for Payer: Aetna of WY Medicare |
$10.53
|
| Rate for Payer: Altius Commercial |
$15.32
|
| Rate for Payer: Beech Street Commercial |
$15.64
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.48
|
| Rate for Payer: Cash Price |
$11.17
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.48
|
| Rate for Payer: Cigna of WY Commercial |
$15.64
|
| Rate for Payer: Entrust Commercial |
$15.16
|
| Rate for Payer: First Choice Health Commercial |
$15.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.10
|
| Rate for Payer: HealthUtah PPO |
$15.96
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.48
|
| Rate for Payer: Multiplan Medicare/VA |
$8.64
|
| Rate for Payer: One Health Plan of WY PPO |
$15.64
|
| Rate for Payer: PacificSource Commercial |
$14.36
|
| Rate for Payer: PHCS PPO |
$15.64
|
| Rate for Payer: Three Rivers PPO |
$11.97
|
| Rate for Payer: TriWest Veterans Administration |
$9.10
|
| Rate for Payer: United Healthcare Commercial |
$15.24
|
| Rate for Payer: United Healthcare Medicare |
$9.10
|
| Rate for Payer: WINHealth Partners Commercial |
$15.64
|
| Rate for Payer: Wise Provider Network Commercial |
$15.16
|
|
