|
AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION [16449]
|
Facility
|
IP
|
$15.26
|
|
|
Service Code
|
NDC 0093416173
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.84 |
| Max. Negotiated Rate |
$15.26 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.95
|
| Rate for Payer: Aetna of WY Medicare |
$9.77
|
| Rate for Payer: Altius Commercial |
$14.65
|
| Rate for Payer: Beech Street Commercial |
$14.95
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.80
|
| Rate for Payer: Cash Price |
$10.68
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.80
|
| Rate for Payer: Cigna of WY Commercial |
$14.95
|
| Rate for Payer: Entrust Commercial |
$14.50
|
| Rate for Payer: First Choice Health Commercial |
$14.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.31
|
| Rate for Payer: HealthUtah PPO |
$15.26
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.80
|
| Rate for Payer: Multiplan Medicare/VA |
$8.84
|
| Rate for Payer: One Health Plan of WY PPO |
$14.95
|
| Rate for Payer: PacificSource Commercial |
$13.73
|
| Rate for Payer: PHCS PPO |
$14.95
|
| Rate for Payer: Three Rivers PPO |
$11.44
|
| Rate for Payer: TriWest Veterans Administration |
$9.31
|
| Rate for Payer: United Healthcare Commercial |
$14.57
|
| Rate for Payer: United Healthcare Medicare |
$9.31
|
| Rate for Payer: WINHealth Partners Commercial |
$14.50
|
| Rate for Payer: Wise Provider Network Commercial |
$14.50
|
|
|
AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION [16449]
|
Facility
|
IP
|
$15.26
|
|
|
Service Code
|
NDC 0143988701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.84 |
| Max. Negotiated Rate |
$15.26 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.95
|
| Rate for Payer: Aetna of WY Medicare |
$9.77
|
| Rate for Payer: Altius Commercial |
$14.65
|
| Rate for Payer: Beech Street Commercial |
$14.95
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.80
|
| Rate for Payer: Cash Price |
$10.68
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.80
|
| Rate for Payer: Cigna of WY Commercial |
$14.95
|
| Rate for Payer: Entrust Commercial |
$14.50
|
| Rate for Payer: First Choice Health Commercial |
$14.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.31
|
| Rate for Payer: HealthUtah PPO |
$15.26
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.80
|
| Rate for Payer: Multiplan Medicare/VA |
$8.84
|
| Rate for Payer: One Health Plan of WY PPO |
$14.95
|
| Rate for Payer: PacificSource Commercial |
$13.73
|
| Rate for Payer: PHCS PPO |
$14.95
|
| Rate for Payer: Three Rivers PPO |
$11.44
|
| Rate for Payer: TriWest Veterans Administration |
$9.31
|
| Rate for Payer: United Healthcare Commercial |
$14.57
|
| Rate for Payer: United Healthcare Medicare |
$9.31
|
| Rate for Payer: WINHealth Partners Commercial |
$14.50
|
| Rate for Payer: Wise Provider Network Commercial |
$14.50
|
|
|
AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION [16449]
|
Facility
|
IP
|
$15.31
|
|
|
Service Code
|
NDC 6586207101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.87 |
| Max. Negotiated Rate |
$15.31 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.00
|
| Rate for Payer: Aetna of WY Medicare |
$9.80
|
| Rate for Payer: Altius Commercial |
$14.70
|
| Rate for Payer: Beech Street Commercial |
$15.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.85
|
| Rate for Payer: Cash Price |
$10.72
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.85
|
| Rate for Payer: Cigna of WY Commercial |
$15.00
|
| Rate for Payer: Entrust Commercial |
$14.54
|
| Rate for Payer: First Choice Health Commercial |
$14.54
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.54
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.34
|
| Rate for Payer: HealthUtah PPO |
$15.31
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.85
|
| Rate for Payer: Multiplan Medicare/VA |
$8.87
|
| Rate for Payer: One Health Plan of WY PPO |
$15.00
|
| Rate for Payer: PacificSource Commercial |
$13.78
|
| Rate for Payer: PHCS PPO |
$15.00
|
| Rate for Payer: Three Rivers PPO |
$11.48
|
| Rate for Payer: TriWest Veterans Administration |
$9.34
|
| Rate for Payer: United Healthcare Commercial |
$14.62
|
| Rate for Payer: United Healthcare Medicare |
$9.34
|
| Rate for Payer: WINHealth Partners Commercial |
$14.54
|
| Rate for Payer: Wise Provider Network Commercial |
$14.54
|
|
|
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION [8974]
|
Facility
|
OP
|
$15.58
|
|
|
Service Code
|
NDC 6586253401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.44 |
| Max. Negotiated Rate |
$15.58 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.27
|
| Rate for Payer: Aetna of WY Medicare |
$10.28
|
| Rate for Payer: Altius Commercial |
$14.96
|
| Rate for Payer: Beech Street Commercial |
$15.27
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.11
|
| Rate for Payer: Cash Price |
$10.91
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.11
|
| Rate for Payer: Cigna of WY Commercial |
$15.27
|
| Rate for Payer: Entrust Commercial |
$14.80
|
| Rate for Payer: First Choice Health Commercial |
$14.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.88
|
| Rate for Payer: HealthUtah PPO |
$15.58
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.11
|
| Rate for Payer: Multiplan Medicare/VA |
$8.44
|
| Rate for Payer: One Health Plan of WY PPO |
$15.27
|
| Rate for Payer: PacificSource Commercial |
$14.02
|
| Rate for Payer: PHCS PPO |
$15.27
|
| Rate for Payer: Three Rivers PPO |
$11.68
|
| Rate for Payer: TriWest Veterans Administration |
$8.88
|
| Rate for Payer: United Healthcare Commercial |
$14.88
|
| Rate for Payer: United Healthcare Medicare |
$8.88
|
| Rate for Payer: WINHealth Partners Commercial |
$15.27
|
| Rate for Payer: Wise Provider Network Commercial |
$14.80
|
|
|
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION [8974]
|
Facility
|
IP
|
$15.58
|
|
|
Service Code
|
NDC 6586253401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.03 |
| Max. Negotiated Rate |
$15.58 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.27
|
| Rate for Payer: Aetna of WY Medicare |
$9.97
|
| Rate for Payer: Altius Commercial |
$14.96
|
| Rate for Payer: Beech Street Commercial |
$15.27
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.11
|
| Rate for Payer: Cash Price |
$10.91
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.11
|
| Rate for Payer: Cigna of WY Commercial |
$15.27
|
| Rate for Payer: Entrust Commercial |
$14.80
|
| Rate for Payer: First Choice Health Commercial |
$14.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.50
|
| Rate for Payer: HealthUtah PPO |
$15.58
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.11
|
| Rate for Payer: Multiplan Medicare/VA |
$9.03
|
| Rate for Payer: One Health Plan of WY PPO |
$15.27
|
| Rate for Payer: PacificSource Commercial |
$14.02
|
| Rate for Payer: PHCS PPO |
$15.27
|
| Rate for Payer: Three Rivers PPO |
$11.68
|
| Rate for Payer: TriWest Veterans Administration |
$9.50
|
| Rate for Payer: United Healthcare Commercial |
$14.88
|
| Rate for Payer: United Healthcare Medicare |
$9.50
|
| Rate for Payer: WINHealth Partners Commercial |
$14.80
|
| Rate for Payer: Wise Provider Network Commercial |
$14.80
|
|
|
AMOXICILLIN 500 MG CAPSULE [389]
|
Facility
|
IP
|
$15.71
|
|
|
Service Code
|
NDC 6586201701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.10 |
| Max. Negotiated Rate |
$15.71 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.40
|
| Rate for Payer: Aetna of WY Medicare |
$10.05
|
| Rate for Payer: Altius Commercial |
$15.08
|
| Rate for Payer: Beech Street Commercial |
$15.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.24
|
| Rate for Payer: Cash Price |
$11.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.24
|
| Rate for Payer: Cigna of WY Commercial |
$15.40
|
| Rate for Payer: Entrust Commercial |
$14.92
|
| Rate for Payer: First Choice Health Commercial |
$14.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.58
|
| Rate for Payer: HealthUtah PPO |
$15.71
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.24
|
| Rate for Payer: Multiplan Medicare/VA |
$9.10
|
| Rate for Payer: One Health Plan of WY PPO |
$15.40
|
| Rate for Payer: PacificSource Commercial |
$14.14
|
| Rate for Payer: PHCS PPO |
$15.40
|
| Rate for Payer: Three Rivers PPO |
$11.78
|
| Rate for Payer: TriWest Veterans Administration |
$9.58
|
| Rate for Payer: United Healthcare Commercial |
$15.00
|
| Rate for Payer: United Healthcare Medicare |
$9.58
|
| Rate for Payer: WINHealth Partners Commercial |
$14.92
|
| Rate for Payer: Wise Provider Network Commercial |
$14.92
|
|
|
AMOXICILLIN 500 MG CAPSULE [389]
|
Facility
|
OP
|
$15.36
|
|
|
Service Code
|
NDC 0781261301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.32 |
| Max. Negotiated Rate |
$15.36 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.05
|
| Rate for Payer: Aetna of WY Medicare |
$10.14
|
| Rate for Payer: Altius Commercial |
$14.75
|
| Rate for Payer: Beech Street Commercial |
$15.05
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.90
|
| Rate for Payer: Cash Price |
$10.75
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.90
|
| Rate for Payer: Cigna of WY Commercial |
$15.05
|
| Rate for Payer: Entrust Commercial |
$14.59
|
| Rate for Payer: First Choice Health Commercial |
$14.59
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.59
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.76
|
| Rate for Payer: HealthUtah PPO |
$15.36
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.90
|
| Rate for Payer: Multiplan Medicare/VA |
$8.32
|
| Rate for Payer: One Health Plan of WY PPO |
$15.05
|
| Rate for Payer: PacificSource Commercial |
$13.82
|
| Rate for Payer: PHCS PPO |
$15.05
|
| Rate for Payer: Three Rivers PPO |
$11.52
|
| Rate for Payer: TriWest Veterans Administration |
$8.76
|
| Rate for Payer: United Healthcare Commercial |
$14.67
|
| Rate for Payer: United Healthcare Medicare |
$8.76
|
| Rate for Payer: WINHealth Partners Commercial |
$15.05
|
| Rate for Payer: Wise Provider Network Commercial |
$14.59
|
|
|
AMOXICILLIN 500 MG CAPSULE [389]
|
Facility
|
IP
|
$15.36
|
|
|
Service Code
|
NDC 0781261301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.90 |
| Max. Negotiated Rate |
$15.36 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.05
|
| Rate for Payer: Aetna of WY Medicare |
$9.83
|
| Rate for Payer: Altius Commercial |
$14.75
|
| Rate for Payer: Beech Street Commercial |
$15.05
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.90
|
| Rate for Payer: Cash Price |
$10.75
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.90
|
| Rate for Payer: Cigna of WY Commercial |
$15.05
|
| Rate for Payer: Entrust Commercial |
$14.59
|
| Rate for Payer: First Choice Health Commercial |
$14.59
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.59
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.37
|
| Rate for Payer: HealthUtah PPO |
$15.36
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.90
|
| Rate for Payer: Multiplan Medicare/VA |
$8.90
|
| Rate for Payer: One Health Plan of WY PPO |
$15.05
|
| Rate for Payer: PacificSource Commercial |
$13.82
|
| Rate for Payer: PHCS PPO |
$15.05
|
| Rate for Payer: Three Rivers PPO |
$11.52
|
| Rate for Payer: TriWest Veterans Administration |
$9.37
|
| Rate for Payer: United Healthcare Commercial |
$14.67
|
| Rate for Payer: United Healthcare Medicare |
$9.37
|
| Rate for Payer: WINHealth Partners Commercial |
$14.59
|
| Rate for Payer: Wise Provider Network Commercial |
$14.59
|
|
|
AMOXICILLIN 500 MG CAPSULE [389]
|
Facility
|
OP
|
$15.71
|
|
|
Service Code
|
NDC 6586201701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.51 |
| Max. Negotiated Rate |
$15.71 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.40
|
| Rate for Payer: Aetna of WY Medicare |
$10.37
|
| Rate for Payer: Altius Commercial |
$15.08
|
| Rate for Payer: Beech Street Commercial |
$15.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.24
|
| Rate for Payer: Cash Price |
$11.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.24
|
| Rate for Payer: Cigna of WY Commercial |
$15.40
|
| Rate for Payer: Entrust Commercial |
$14.92
|
| Rate for Payer: First Choice Health Commercial |
$14.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.95
|
| Rate for Payer: HealthUtah PPO |
$15.71
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.24
|
| Rate for Payer: Multiplan Medicare/VA |
$8.51
|
| Rate for Payer: One Health Plan of WY PPO |
$15.40
|
| Rate for Payer: PacificSource Commercial |
$14.14
|
| Rate for Payer: PHCS PPO |
$15.40
|
| Rate for Payer: Three Rivers PPO |
$11.78
|
| Rate for Payer: TriWest Veterans Administration |
$8.95
|
| Rate for Payer: United Healthcare Commercial |
$15.00
|
| Rate for Payer: United Healthcare Medicare |
$8.95
|
| Rate for Payer: WINHealth Partners Commercial |
$15.40
|
| Rate for Payer: Wise Provider Network Commercial |
$14.92
|
|
|
AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET [20367]
|
Facility
|
OP
|
$16.76
|
|
|
Service Code
|
NDC 6586250220
|
|
Hospital Revenue Code
|
250
|
| 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 |
$11.73
|
| 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
|
|
|
AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET [20367]
|
Facility
|
IP
|
$16.76
|
|
|
Service Code
|
NDC 6586250220
|
|
Hospital Revenue Code
|
250
|
| 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 |
$11.73
|
| 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
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET [20218]
|
Facility
|
OP
|
$16.45
|
|
|
Service Code
|
NDC 6586250320
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.91 |
| Max. Negotiated Rate |
$16.45 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.12
|
| Rate for Payer: Aetna of WY Medicare |
$10.86
|
| Rate for Payer: Altius Commercial |
$15.79
|
| Rate for Payer: Beech Street Commercial |
$16.12
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.96
|
| Rate for Payer: Cash Price |
$11.51
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.96
|
| Rate for Payer: Cigna of WY Commercial |
$16.12
|
| Rate for Payer: Entrust Commercial |
$15.63
|
| Rate for Payer: First Choice Health Commercial |
$15.63
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.63
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.38
|
| Rate for Payer: HealthUtah PPO |
$16.45
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.96
|
| Rate for Payer: Multiplan Medicare/VA |
$8.91
|
| Rate for Payer: One Health Plan of WY PPO |
$16.12
|
| Rate for Payer: PacificSource Commercial |
$14.80
|
| Rate for Payer: PHCS PPO |
$16.12
|
| Rate for Payer: Three Rivers PPO |
$12.34
|
| Rate for Payer: TriWest Veterans Administration |
$9.38
|
| Rate for Payer: United Healthcare Commercial |
$15.71
|
| Rate for Payer: United Healthcare Medicare |
$9.38
|
| Rate for Payer: WINHealth Partners Commercial |
$16.12
|
| Rate for Payer: Wise Provider Network Commercial |
$15.63
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET [20218]
|
Facility
|
IP
|
$16.45
|
|
|
Service Code
|
NDC 6586250320
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.53 |
| Max. Negotiated Rate |
$16.45 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.12
|
| Rate for Payer: Aetna of WY Medicare |
$10.53
|
| Rate for Payer: Altius Commercial |
$15.79
|
| Rate for Payer: Beech Street Commercial |
$16.12
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.96
|
| Rate for Payer: Cash Price |
$11.51
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.96
|
| Rate for Payer: Cigna of WY Commercial |
$16.12
|
| Rate for Payer: Entrust Commercial |
$15.63
|
| Rate for Payer: First Choice Health Commercial |
$15.63
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.63
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.03
|
| Rate for Payer: HealthUtah PPO |
$16.45
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.96
|
| Rate for Payer: Multiplan Medicare/VA |
$9.53
|
| Rate for Payer: One Health Plan of WY PPO |
$16.12
|
| Rate for Payer: PacificSource Commercial |
$14.80
|
| Rate for Payer: PHCS PPO |
$16.12
|
| Rate for Payer: Three Rivers PPO |
$12.34
|
| Rate for Payer: TriWest Veterans Administration |
$10.03
|
| Rate for Payer: United Healthcare Commercial |
$15.71
|
| Rate for Payer: United Healthcare Medicare |
$10.03
|
| Rate for Payer: WINHealth Partners Commercial |
$15.63
|
| Rate for Payer: Wise Provider Network Commercial |
$15.63
|
|
|
AMP F/TH 1/2 JT/PHALANX W/NEURECT LOCAL FLAP
|
Professional
|
Both
|
$5,849.00
|
|
|
Service Code
|
HCPCS 26952
|
| Min. Negotiated Rate |
$569.98 |
| Max. Negotiated Rate |
$5,849.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5,732.02
|
| Rate for Payer: Aetna of WY Medicare |
$670.57
|
| Rate for Payer: Beech Street Commercial |
$5,556.55
|
| Rate for Payer: Cash Price |
$4,094.30
|
| Rate for Payer: Cash Price |
$4,094.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$5,673.53
|
| Rate for Payer: Cigna of WY Commercial |
$5,732.02
|
| Rate for Payer: First Choice Health Commercial |
$5,264.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5,556.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$670.57
|
| Rate for Payer: HealthUtah PPO |
$5,849.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5,673.53
|
| Rate for Payer: Multiplan Medicare/VA |
$569.98
|
| Rate for Payer: One Health Plan of WY PPO |
$5,732.02
|
| Rate for Payer: PacificSource Commercial |
$5,264.10
|
| Rate for Payer: PHCS PPO |
$5,556.55
|
| Rate for Payer: Three Rivers PPO |
$4,386.75
|
| Rate for Payer: TriWest Veterans Administration |
$670.57
|
| Rate for Payer: United Healthcare Commercial |
$5,556.55
|
| Rate for Payer: WINHealth Partners Commercial |
$4,971.65
|
|
|
AMP F/TH 1/2 JT/PHALANX W/NEURECT LOCAL FLAP
|
Professional
|
Both
|
$1,171.00
|
|
|
Service Code
|
HCPCS 26952 80
|
| Min. Negotiated Rate |
$878.25 |
| Max. Negotiated Rate |
$1,171.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,147.58
|
| Rate for Payer: Beech Street Commercial |
$1,112.45
|
| Rate for Payer: Cash Price |
$819.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,135.87
|
| Rate for Payer: Cigna of WY Commercial |
$1,147.58
|
| Rate for Payer: First Choice Health Commercial |
$1,053.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,112.45
|
| Rate for Payer: HealthUtah PPO |
$1,171.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,135.87
|
| Rate for Payer: One Health Plan of WY PPO |
$1,147.58
|
| Rate for Payer: PacificSource Commercial |
$1,053.90
|
| Rate for Payer: PHCS PPO |
$1,112.45
|
| Rate for Payer: Three Rivers PPO |
$878.25
|
| Rate for Payer: United Healthcare Commercial |
$1,112.45
|
| Rate for Payer: WINHealth Partners Commercial |
$995.35
|
|
|
AMP F/TH 1/2 JT/PHALANX W/NEURECT W/DIR CLSR
|
Professional
|
Both
|
$2,002.00
|
|
|
Service Code
|
HCPCS 26951
|
| Min. Negotiated Rate |
$586.90 |
| Max. Negotiated Rate |
$2,002.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,961.96
|
| Rate for Payer: Aetna of WY Medicare |
$690.47
|
| Rate for Payer: Beech Street Commercial |
$1,901.90
|
| Rate for Payer: Cash Price |
$1,401.40
|
| Rate for Payer: Cash Price |
$1,401.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,941.94
|
| Rate for Payer: Cigna of WY Commercial |
$1,961.96
|
| Rate for Payer: First Choice Health Commercial |
$1,801.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,901.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$690.47
|
| Rate for Payer: HealthUtah PPO |
$2,002.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,941.94
|
| Rate for Payer: Multiplan Medicare/VA |
$586.90
|
| Rate for Payer: One Health Plan of WY PPO |
$1,961.96
|
| Rate for Payer: PacificSource Commercial |
$1,801.80
|
| Rate for Payer: PHCS PPO |
$1,901.90
|
| Rate for Payer: Three Rivers PPO |
$1,501.50
|
| Rate for Payer: TriWest Veterans Administration |
$690.47
|
| Rate for Payer: United Healthcare Commercial |
$1,901.90
|
| Rate for Payer: WINHealth Partners Commercial |
$1,701.70
|
|
|
AMP F/TH 1/2 JT/PHALANX W/NEURECT W/DIR CLSR
|
Professional
|
Both
|
$910.00
|
|
|
Service Code
|
HCPCS 26951 80
|
| Min. Negotiated Rate |
$682.50 |
| Max. Negotiated Rate |
$910.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$891.80
|
| Rate for Payer: Beech Street Commercial |
$864.50
|
| Rate for Payer: Cash Price |
$637.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$882.70
|
| Rate for Payer: Cigna of WY Commercial |
$891.80
|
| Rate for Payer: First Choice Health Commercial |
$819.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$864.50
|
| Rate for Payer: HealthUtah PPO |
$910.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$882.70
|
| Rate for Payer: One Health Plan of WY PPO |
$891.80
|
| Rate for Payer: PacificSource Commercial |
$819.00
|
| Rate for Payer: PHCS PPO |
$864.50
|
| Rate for Payer: Three Rivers PPO |
$682.50
|
| Rate for Payer: United Healthcare Commercial |
$864.50
|
| Rate for Payer: WINHealth Partners Commercial |
$773.50
|
|
|
AMPICILLIN 1 GRAM SOLUTION FOR INJECTION [16206]
|
Facility
|
OP
|
$33.38
|
|
|
Service Code
|
HCPCS J0290
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.08 |
| Max. Negotiated Rate |
$33.38 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$32.71
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$32.53
|
| Rate for Payer: Aetna of WY Medicare |
$21.91
|
| Rate for Payer: Aetna of WY Medicare |
$22.03
|
| Rate for Payer: Altius Commercial |
$32.04
|
| Rate for Payer: Altius Commercial |
$31.86
|
| Rate for Payer: Beech Street Commercial |
$32.53
|
| Rate for Payer: Beech Street Commercial |
$32.71
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$32.19
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$32.38
|
| Rate for Payer: Cash Price |
$23.23
|
| Rate for Payer: Cash Price |
$23.36
|
| Rate for Payer: ChoiceCare Network Commercial |
$32.19
|
| Rate for Payer: ChoiceCare Network Commercial |
$32.38
|
| Rate for Payer: Cigna of WY Commercial |
$32.71
|
| Rate for Payer: Cigna of WY Commercial |
$32.53
|
| Rate for Payer: Entrust Commercial |
$31.53
|
| Rate for Payer: Entrust Commercial |
$31.71
|
| Rate for Payer: First Choice Health Commercial |
$31.53
|
| Rate for Payer: First Choice Health Commercial |
$31.71
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$31.71
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$31.53
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$19.03
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$18.92
|
| Rate for Payer: HealthUtah PPO |
$33.19
|
| Rate for Payer: HealthUtah PPO |
$33.38
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$32.19
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$32.38
|
| Rate for Payer: Multiplan Medicare/VA |
$18.08
|
| Rate for Payer: Multiplan Medicare/VA |
$17.97
|
| Rate for Payer: One Health Plan of WY PPO |
$32.53
|
| Rate for Payer: One Health Plan of WY PPO |
$32.71
|
| Rate for Payer: PacificSource Commercial |
$30.04
|
| Rate for Payer: PacificSource Commercial |
$29.87
|
| Rate for Payer: PHCS PPO |
$32.71
|
| Rate for Payer: PHCS PPO |
$32.53
|
| Rate for Payer: Three Rivers PPO |
$24.89
|
| Rate for Payer: Three Rivers PPO |
$25.04
|
| Rate for Payer: TriWest Veterans Administration |
$19.03
|
| Rate for Payer: TriWest Veterans Administration |
$18.92
|
| Rate for Payer: United Healthcare Commercial |
$31.70
|
| Rate for Payer: United Healthcare Commercial |
$31.88
|
| Rate for Payer: United Healthcare Medicare |
$19.03
|
| Rate for Payer: United Healthcare Medicare |
$18.92
|
| Rate for Payer: WINHealth Partners Commercial |
$32.53
|
| Rate for Payer: WINHealth Partners Commercial |
$32.71
|
| Rate for Payer: Wise Provider Network Commercial |
$31.71
|
| Rate for Payer: Wise Provider Network Commercial |
$31.53
|
|
|
AMPICILLIN 1 GRAM SOLUTION FOR INJECTION [16206]
|
Facility
|
IP
|
$33.19
|
|
|
Service Code
|
HCPCS J0290
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.23 |
| Max. Negotiated Rate |
$33.19 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$32.53
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$32.71
|
| Rate for Payer: Aetna of WY Medicare |
$21.24
|
| Rate for Payer: Aetna of WY Medicare |
$21.36
|
| Rate for Payer: Altius Commercial |
$32.04
|
| Rate for Payer: Altius Commercial |
$31.86
|
| Rate for Payer: Beech Street Commercial |
$32.71
|
| Rate for Payer: Beech Street Commercial |
$32.53
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$32.38
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$32.19
|
| Rate for Payer: Cash Price |
$23.36
|
| Rate for Payer: Cash Price |
$23.23
|
| Rate for Payer: ChoiceCare Network Commercial |
$32.38
|
| Rate for Payer: ChoiceCare Network Commercial |
$32.19
|
| Rate for Payer: Cigna of WY Commercial |
$32.71
|
| Rate for Payer: Cigna of WY Commercial |
$32.53
|
| Rate for Payer: Entrust Commercial |
$31.71
|
| Rate for Payer: Entrust Commercial |
$31.53
|
| Rate for Payer: First Choice Health Commercial |
$31.71
|
| Rate for Payer: First Choice Health Commercial |
$31.53
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$31.53
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$31.71
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$20.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$20.36
|
| Rate for Payer: HealthUtah PPO |
$33.38
|
| Rate for Payer: HealthUtah PPO |
$33.19
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$32.38
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$32.19
|
| Rate for Payer: Multiplan Medicare/VA |
$19.34
|
| Rate for Payer: Multiplan Medicare/VA |
$19.23
|
| Rate for Payer: One Health Plan of WY PPO |
$32.71
|
| Rate for Payer: One Health Plan of WY PPO |
$32.53
|
| Rate for Payer: PacificSource Commercial |
$30.04
|
| Rate for Payer: PacificSource Commercial |
$29.87
|
| Rate for Payer: PHCS PPO |
$32.53
|
| Rate for Payer: PHCS PPO |
$32.71
|
| Rate for Payer: Three Rivers PPO |
$24.89
|
| Rate for Payer: Three Rivers PPO |
$25.04
|
| Rate for Payer: TriWest Veterans Administration |
$20.36
|
| Rate for Payer: TriWest Veterans Administration |
$20.25
|
| Rate for Payer: United Healthcare Commercial |
$31.70
|
| Rate for Payer: United Healthcare Commercial |
$31.88
|
| Rate for Payer: United Healthcare Medicare |
$20.25
|
| Rate for Payer: United Healthcare Medicare |
$20.36
|
| Rate for Payer: WINHealth Partners Commercial |
$31.71
|
| Rate for Payer: WINHealth Partners Commercial |
$31.53
|
| Rate for Payer: Wise Provider Network Commercial |
$31.53
|
| Rate for Payer: Wise Provider Network Commercial |
$31.71
|
|
|
AMPICILLIN 2 GRAM SOLUTION FOR INJECTION [14724]
|
Facility
|
IP
|
$39.88
|
|
|
Service Code
|
HCPCS J0290
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.11 |
| Max. Negotiated Rate |
$39.88 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$39.08
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$39.07
|
| Rate for Payer: Aetna of WY Medicare |
$25.52
|
| Rate for Payer: Aetna of WY Medicare |
$25.52
|
| Rate for Payer: Altius Commercial |
$38.28
|
| Rate for Payer: Altius Commercial |
$38.28
|
| Rate for Payer: Beech Street Commercial |
$39.08
|
| Rate for Payer: Beech Street Commercial |
$39.07
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$38.68
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$38.67
|
| Rate for Payer: Cash Price |
$27.92
|
| Rate for Payer: Cash Price |
$27.91
|
| Rate for Payer: ChoiceCare Network Commercial |
$38.68
|
| Rate for Payer: ChoiceCare Network Commercial |
$38.67
|
| Rate for Payer: Cigna of WY Commercial |
$39.07
|
| Rate for Payer: Cigna of WY Commercial |
$39.08
|
| Rate for Payer: Entrust Commercial |
$37.89
|
| Rate for Payer: Entrust Commercial |
$37.88
|
| Rate for Payer: First Choice Health Commercial |
$37.89
|
| Rate for Payer: First Choice Health Commercial |
$37.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$37.89
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$37.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$24.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$24.33
|
| Rate for Payer: HealthUtah PPO |
$39.88
|
| Rate for Payer: HealthUtah PPO |
$39.87
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$38.67
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$38.68
|
| Rate for Payer: Multiplan Medicare/VA |
$23.11
|
| Rate for Payer: Multiplan Medicare/VA |
$23.10
|
| Rate for Payer: One Health Plan of WY PPO |
$39.08
|
| Rate for Payer: One Health Plan of WY PPO |
$39.07
|
| Rate for Payer: PacificSource Commercial |
$35.88
|
| Rate for Payer: PacificSource Commercial |
$35.89
|
| Rate for Payer: PHCS PPO |
$39.07
|
| Rate for Payer: PHCS PPO |
$39.08
|
| Rate for Payer: Three Rivers PPO |
$29.90
|
| Rate for Payer: Three Rivers PPO |
$29.91
|
| Rate for Payer: TriWest Veterans Administration |
$24.33
|
| Rate for Payer: TriWest Veterans Administration |
$24.32
|
| Rate for Payer: United Healthcare Commercial |
$38.08
|
| Rate for Payer: United Healthcare Commercial |
$38.09
|
| Rate for Payer: United Healthcare Medicare |
$24.32
|
| Rate for Payer: United Healthcare Medicare |
$24.33
|
| Rate for Payer: WINHealth Partners Commercial |
$37.88
|
| Rate for Payer: WINHealth Partners Commercial |
$37.89
|
| Rate for Payer: Wise Provider Network Commercial |
$37.88
|
| Rate for Payer: Wise Provider Network Commercial |
$37.89
|
|
|
AMPICILLIN 2 GRAM SOLUTION FOR INJECTION [14724]
|
Facility
|
OP
|
$39.87
|
|
|
Service Code
|
HCPCS J0290
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.59 |
| Max. Negotiated Rate |
$39.87 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$39.07
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$39.08
|
| Rate for Payer: Aetna of WY Medicare |
$26.32
|
| Rate for Payer: Aetna of WY Medicare |
$26.31
|
| Rate for Payer: Altius Commercial |
$38.28
|
| Rate for Payer: Altius Commercial |
$38.28
|
| Rate for Payer: Beech Street Commercial |
$39.07
|
| Rate for Payer: Beech Street Commercial |
$39.08
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$38.67
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$38.68
|
| Rate for Payer: Cash Price |
$27.91
|
| Rate for Payer: Cash Price |
$27.92
|
| Rate for Payer: ChoiceCare Network Commercial |
$38.68
|
| Rate for Payer: ChoiceCare Network Commercial |
$38.67
|
| Rate for Payer: Cigna of WY Commercial |
$39.08
|
| Rate for Payer: Cigna of WY Commercial |
$39.07
|
| Rate for Payer: Entrust Commercial |
$37.89
|
| Rate for Payer: Entrust Commercial |
$37.88
|
| Rate for Payer: First Choice Health Commercial |
$37.88
|
| Rate for Payer: First Choice Health Commercial |
$37.89
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$37.89
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$37.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$22.73
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$22.73
|
| Rate for Payer: HealthUtah PPO |
$39.87
|
| Rate for Payer: HealthUtah PPO |
$39.88
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$38.68
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$38.67
|
| Rate for Payer: Multiplan Medicare/VA |
$21.60
|
| Rate for Payer: Multiplan Medicare/VA |
$21.59
|
| Rate for Payer: One Health Plan of WY PPO |
$39.08
|
| Rate for Payer: One Health Plan of WY PPO |
$39.07
|
| Rate for Payer: PacificSource Commercial |
$35.88
|
| Rate for Payer: PacificSource Commercial |
$35.89
|
| Rate for Payer: PHCS PPO |
$39.07
|
| Rate for Payer: PHCS PPO |
$39.08
|
| Rate for Payer: Three Rivers PPO |
$29.90
|
| Rate for Payer: Three Rivers PPO |
$29.91
|
| Rate for Payer: TriWest Veterans Administration |
$22.73
|
| Rate for Payer: TriWest Veterans Administration |
$22.73
|
| Rate for Payer: United Healthcare Commercial |
$38.08
|
| Rate for Payer: United Healthcare Commercial |
$38.09
|
| Rate for Payer: United Healthcare Medicare |
$22.73
|
| Rate for Payer: United Healthcare Medicare |
$22.73
|
| Rate for Payer: WINHealth Partners Commercial |
$39.07
|
| Rate for Payer: WINHealth Partners Commercial |
$39.08
|
| Rate for Payer: Wise Provider Network Commercial |
$37.89
|
| Rate for Payer: Wise Provider Network Commercial |
$37.88
|
|
|
AMPICILLIN 500 MG INJ
|
Professional
|
Both
|
$2.00
|
|
|
Service Code
|
HCPCS J0290
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$2.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.96
|
| Rate for Payer: Aetna of WY Medicare |
$1.00
|
| Rate for Payer: Beech Street Commercial |
$1.90
|
| Rate for Payer: Cash Price |
$1.40
|
| Rate for Payer: Cash Price |
$1.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.94
|
| Rate for Payer: Cigna of WY Commercial |
$1.96
|
| Rate for Payer: First Choice Health Commercial |
$1.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.00
|
| Rate for Payer: HealthUtah PPO |
$2.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.94
|
| Rate for Payer: Multiplan Medicare/VA |
$0.85
|
| Rate for Payer: One Health Plan of WY PPO |
$1.96
|
| Rate for Payer: PacificSource Commercial |
$1.80
|
| Rate for Payer: PHCS PPO |
$1.90
|
| Rate for Payer: Three Rivers PPO |
$1.50
|
| Rate for Payer: TriWest Veterans Administration |
$1.00
|
| Rate for Payer: United Healthcare Commercial |
$1.90
|
| Rate for Payer: WINHealth Partners Commercial |
$1.90
|
|
|
AMPICILLIN 500 MG SOLUTION FOR INJECTION [13513]
|
Facility
|
OP
|
$24.34
|
|
|
Service Code
|
HCPCS J0290
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.18 |
| Max. Negotiated Rate |
$24.34 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$23.85
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$25.06
|
| Rate for Payer: Aetna of WY Medicare |
$16.88
|
| Rate for Payer: Aetna of WY Medicare |
$16.06
|
| Rate for Payer: Altius Commercial |
$23.37
|
| Rate for Payer: Altius Commercial |
$24.55
|
| Rate for Payer: Beech Street Commercial |
$23.85
|
| Rate for Payer: Beech Street Commercial |
$25.06
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$23.61
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$24.80
|
| Rate for Payer: Cash Price |
$17.04
|
| Rate for Payer: Cash Price |
$17.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$23.61
|
| Rate for Payer: ChoiceCare Network Commercial |
$24.80
|
| Rate for Payer: Cigna of WY Commercial |
$25.06
|
| Rate for Payer: Cigna of WY Commercial |
$23.85
|
| Rate for Payer: Entrust Commercial |
$23.12
|
| Rate for Payer: Entrust Commercial |
$24.29
|
| Rate for Payer: First Choice Health Commercial |
$23.12
|
| Rate for Payer: First Choice Health Commercial |
$24.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$24.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$23.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$13.87
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$14.57
|
| Rate for Payer: HealthUtah PPO |
$25.57
|
| Rate for Payer: HealthUtah PPO |
$24.34
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$23.61
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.80
|
| Rate for Payer: Multiplan Medicare/VA |
$13.85
|
| Rate for Payer: Multiplan Medicare/VA |
$13.18
|
| Rate for Payer: One Health Plan of WY PPO |
$23.85
|
| Rate for Payer: One Health Plan of WY PPO |
$25.06
|
| Rate for Payer: PacificSource Commercial |
$23.01
|
| Rate for Payer: PacificSource Commercial |
$21.91
|
| Rate for Payer: PHCS PPO |
$23.85
|
| Rate for Payer: PHCS PPO |
$25.06
|
| Rate for Payer: Three Rivers PPO |
$18.26
|
| Rate for Payer: Three Rivers PPO |
$19.18
|
| Rate for Payer: TriWest Veterans Administration |
$14.57
|
| Rate for Payer: TriWest Veterans Administration |
$13.87
|
| Rate for Payer: United Healthcare Commercial |
$23.24
|
| Rate for Payer: United Healthcare Commercial |
$24.42
|
| Rate for Payer: United Healthcare Medicare |
$14.57
|
| Rate for Payer: United Healthcare Medicare |
$13.87
|
| Rate for Payer: WINHealth Partners Commercial |
$23.85
|
| Rate for Payer: WINHealth Partners Commercial |
$25.06
|
| Rate for Payer: Wise Provider Network Commercial |
$24.29
|
| Rate for Payer: Wise Provider Network Commercial |
$23.12
|
|
|
AMPICILLIN 500 MG SOLUTION FOR INJECTION [13513]
|
Facility
|
IP
|
$24.34
|
|
|
Service Code
|
HCPCS J0290
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.11 |
| Max. Negotiated Rate |
$24.34 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$23.85
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$25.06
|
| Rate for Payer: Aetna of WY Medicare |
$16.36
|
| Rate for Payer: Aetna of WY Medicare |
$15.58
|
| Rate for Payer: Altius Commercial |
$23.37
|
| Rate for Payer: Altius Commercial |
$24.55
|
| Rate for Payer: Beech Street Commercial |
$23.85
|
| Rate for Payer: Beech Street Commercial |
$25.06
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$23.61
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$24.80
|
| Rate for Payer: Cash Price |
$17.04
|
| Rate for Payer: Cash Price |
$17.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$24.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$23.61
|
| Rate for Payer: Cigna of WY Commercial |
$25.06
|
| Rate for Payer: Cigna of WY Commercial |
$23.85
|
| Rate for Payer: Entrust Commercial |
$24.29
|
| Rate for Payer: Entrust Commercial |
$23.12
|
| Rate for Payer: First Choice Health Commercial |
$23.12
|
| Rate for Payer: First Choice Health Commercial |
$24.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$24.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$23.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$14.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$15.60
|
| Rate for Payer: HealthUtah PPO |
$25.57
|
| Rate for Payer: HealthUtah PPO |
$24.34
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$23.61
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.80
|
| Rate for Payer: Multiplan Medicare/VA |
$14.82
|
| Rate for Payer: Multiplan Medicare/VA |
$14.11
|
| Rate for Payer: One Health Plan of WY PPO |
$23.85
|
| Rate for Payer: One Health Plan of WY PPO |
$25.06
|
| Rate for Payer: PacificSource Commercial |
$23.01
|
| Rate for Payer: PacificSource Commercial |
$21.91
|
| Rate for Payer: PHCS PPO |
$25.06
|
| Rate for Payer: PHCS PPO |
$23.85
|
| Rate for Payer: Three Rivers PPO |
$18.26
|
| Rate for Payer: Three Rivers PPO |
$19.18
|
| Rate for Payer: TriWest Veterans Administration |
$14.85
|
| Rate for Payer: TriWest Veterans Administration |
$15.60
|
| Rate for Payer: United Healthcare Commercial |
$24.42
|
| Rate for Payer: United Healthcare Commercial |
$23.24
|
| Rate for Payer: United Healthcare Medicare |
$15.60
|
| Rate for Payer: United Healthcare Medicare |
$14.85
|
| Rate for Payer: WINHealth Partners Commercial |
$23.12
|
| Rate for Payer: WINHealth Partners Commercial |
$24.29
|
| Rate for Payer: Wise Provider Network Commercial |
$23.12
|
| Rate for Payer: Wise Provider Network Commercial |
$24.29
|
|
|
AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION [14372]
|
Facility
|
OP
|
$40.84
|
|
|
Service Code
|
HCPCS J0295
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.11 |
| Max. Negotiated Rate |
$40.84 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$40.02
|
| Rate for Payer: Aetna of WY Medicare |
$26.95
|
| Rate for Payer: Altius Commercial |
$39.21
|
| Rate for Payer: Beech Street Commercial |
$40.02
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$39.61
|
| Rate for Payer: Cash Price |
$28.59
|
| Rate for Payer: ChoiceCare Network Commercial |
$39.61
|
| Rate for Payer: Cigna of WY Commercial |
$40.02
|
| Rate for Payer: Entrust Commercial |
$38.80
|
| Rate for Payer: First Choice Health Commercial |
$38.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$38.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$23.28
|
| Rate for Payer: HealthUtah PPO |
$40.84
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$39.61
|
| Rate for Payer: Multiplan Medicare/VA |
$22.11
|
| Rate for Payer: One Health Plan of WY PPO |
$40.02
|
| Rate for Payer: PacificSource Commercial |
$36.76
|
| Rate for Payer: PHCS PPO |
$40.02
|
| Rate for Payer: Three Rivers PPO |
$30.63
|
| Rate for Payer: TriWest Veterans Administration |
$23.28
|
| Rate for Payer: United Healthcare Commercial |
$39.00
|
| Rate for Payer: United Healthcare Medicare |
$23.28
|
| Rate for Payer: WINHealth Partners Commercial |
$40.02
|
| Rate for Payer: Wise Provider Network Commercial |
$38.80
|
|
