|
FLUOROURACIL 50 MG/ML INTRAVENOUS SOLUTION (WRAPPED) [4000719]
|
Facility
|
OP
|
$17.40
|
|
|
Service Code
|
HCPCS J9190
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.42 |
| Max. Negotiated Rate |
$17.40 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$17.05
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.72
|
| Rate for Payer: Aetna of WY Medicare |
$11.48
|
| Rate for Payer: Aetna of WY Medicare |
$11.26
|
| Rate for Payer: Altius Commercial |
$16.38
|
| Rate for Payer: Altius Commercial |
$16.70
|
| Rate for Payer: Beech Street Commercial |
$16.72
|
| Rate for Payer: Beech Street Commercial |
$17.05
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.55
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.88
|
| Rate for Payer: Cash Price |
$11.94
|
| Rate for Payer: Cash Price |
$12.18
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.88
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.55
|
| Rate for Payer: Cigna of WY Commercial |
$17.05
|
| Rate for Payer: Cigna of WY Commercial |
$16.72
|
| Rate for Payer: Entrust Commercial |
$16.21
|
| Rate for Payer: Entrust Commercial |
$16.53
|
| Rate for Payer: First Choice Health Commercial |
$16.21
|
| Rate for Payer: First Choice Health Commercial |
$16.53
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.53
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.72
|
| Rate for Payer: HealthUtah PPO |
$17.06
|
| Rate for Payer: HealthUtah PPO |
$17.40
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.55
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.88
|
| Rate for Payer: Multiplan Medicare/VA |
$9.42
|
| Rate for Payer: Multiplan Medicare/VA |
$9.24
|
| Rate for Payer: One Health Plan of WY PPO |
$16.72
|
| Rate for Payer: One Health Plan of WY PPO |
$17.05
|
| Rate for Payer: PacificSource Commercial |
$15.66
|
| Rate for Payer: PacificSource Commercial |
$15.35
|
| Rate for Payer: PHCS PPO |
$16.72
|
| Rate for Payer: PHCS PPO |
$17.05
|
| Rate for Payer: Three Rivers PPO |
$13.05
|
| Rate for Payer: Three Rivers PPO |
$12.80
|
| Rate for Payer: TriWest Veterans Administration |
$9.92
|
| Rate for Payer: TriWest Veterans Administration |
$9.72
|
| Rate for Payer: United Healthcare Commercial |
$16.29
|
| Rate for Payer: United Healthcare Commercial |
$16.62
|
| Rate for Payer: United Healthcare Medicare |
$9.92
|
| Rate for Payer: United Healthcare Medicare |
$9.72
|
| Rate for Payer: WINHealth Partners Commercial |
$16.72
|
| Rate for Payer: WINHealth Partners Commercial |
$17.05
|
| Rate for Payer: Wise Provider Network Commercial |
$16.21
|
| Rate for Payer: Wise Provider Network Commercial |
$16.53
|
|
|
FLUOXETINE 10 MG CAPSULE [14508]
|
Facility
|
OP
|
$15.35
|
|
|
Service Code
|
NDC 0904578461
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.31 |
| Max. Negotiated Rate |
$15.35 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.04
|
| Rate for Payer: Aetna of WY Medicare |
$10.13
|
| Rate for Payer: Altius Commercial |
$14.74
|
| Rate for Payer: Beech Street Commercial |
$15.04
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.89
|
| Rate for Payer: Cash Price |
$10.74
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.89
|
| Rate for Payer: Cigna of WY Commercial |
$15.04
|
| Rate for Payer: Entrust Commercial |
$14.58
|
| Rate for Payer: First Choice Health Commercial |
$14.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.75
|
| Rate for Payer: HealthUtah PPO |
$15.35
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.89
|
| Rate for Payer: Multiplan Medicare/VA |
$8.31
|
| Rate for Payer: One Health Plan of WY PPO |
$15.04
|
| Rate for Payer: PacificSource Commercial |
$13.82
|
| Rate for Payer: PHCS PPO |
$15.04
|
| Rate for Payer: Three Rivers PPO |
$11.51
|
| Rate for Payer: TriWest Veterans Administration |
$8.75
|
| Rate for Payer: United Healthcare Commercial |
$14.66
|
| Rate for Payer: United Healthcare Medicare |
$8.75
|
| Rate for Payer: WINHealth Partners Commercial |
$15.04
|
| Rate for Payer: Wise Provider Network Commercial |
$14.58
|
|
|
FLUOXETINE 10 MG CAPSULE [14508]
|
Facility
|
IP
|
$15.35
|
|
|
Service Code
|
NDC 0904578461
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.90 |
| Max. Negotiated Rate |
$15.35 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.04
|
| Rate for Payer: Aetna of WY Medicare |
$9.82
|
| Rate for Payer: Altius Commercial |
$14.74
|
| Rate for Payer: Beech Street Commercial |
$15.04
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.89
|
| Rate for Payer: Cash Price |
$10.74
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.89
|
| Rate for Payer: Cigna of WY Commercial |
$15.04
|
| Rate for Payer: Entrust Commercial |
$14.58
|
| Rate for Payer: First Choice Health Commercial |
$14.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.36
|
| Rate for Payer: HealthUtah PPO |
$15.35
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.89
|
| Rate for Payer: Multiplan Medicare/VA |
$8.90
|
| Rate for Payer: One Health Plan of WY PPO |
$15.04
|
| Rate for Payer: PacificSource Commercial |
$13.82
|
| Rate for Payer: PHCS PPO |
$15.04
|
| Rate for Payer: Three Rivers PPO |
$11.51
|
| Rate for Payer: TriWest Veterans Administration |
$9.36
|
| Rate for Payer: United Healthcare Commercial |
$14.66
|
| Rate for Payer: United Healthcare Medicare |
$9.36
|
| Rate for Payer: WINHealth Partners Commercial |
$14.58
|
| Rate for Payer: Wise Provider Network Commercial |
$14.58
|
|
|
FLUOXETINE 20 MG CAPSULE [18922]
|
Facility
|
OP
|
$15.38
|
|
|
Service Code
|
NDC 0904578561
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.33 |
| Max. Negotiated Rate |
$15.38 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.07
|
| Rate for Payer: Aetna of WY Medicare |
$10.15
|
| Rate for Payer: Altius Commercial |
$14.76
|
| Rate for Payer: Beech Street Commercial |
$15.07
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.92
|
| Rate for Payer: Cash Price |
$10.77
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.92
|
| Rate for Payer: Cigna of WY Commercial |
$15.07
|
| Rate for Payer: Entrust Commercial |
$14.61
|
| Rate for Payer: First Choice Health Commercial |
$14.61
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.61
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.77
|
| Rate for Payer: HealthUtah PPO |
$15.38
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.92
|
| Rate for Payer: Multiplan Medicare/VA |
$8.33
|
| Rate for Payer: One Health Plan of WY PPO |
$15.07
|
| Rate for Payer: PacificSource Commercial |
$13.84
|
| Rate for Payer: PHCS PPO |
$15.07
|
| Rate for Payer: Three Rivers PPO |
$11.54
|
| Rate for Payer: TriWest Veterans Administration |
$8.77
|
| Rate for Payer: United Healthcare Commercial |
$14.69
|
| Rate for Payer: United Healthcare Medicare |
$8.77
|
| Rate for Payer: WINHealth Partners Commercial |
$15.07
|
| Rate for Payer: Wise Provider Network Commercial |
$14.61
|
|
|
FLUOXETINE 20 MG CAPSULE [18922]
|
Facility
|
IP
|
$15.38
|
|
|
Service Code
|
NDC 0904578561
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.91 |
| Max. Negotiated Rate |
$15.38 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.07
|
| Rate for Payer: Aetna of WY Medicare |
$9.84
|
| Rate for Payer: Altius Commercial |
$14.76
|
| Rate for Payer: Beech Street Commercial |
$15.07
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.92
|
| Rate for Payer: Cash Price |
$10.77
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.92
|
| Rate for Payer: Cigna of WY Commercial |
$15.07
|
| Rate for Payer: Entrust Commercial |
$14.61
|
| Rate for Payer: First Choice Health Commercial |
$14.61
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.61
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.38
|
| Rate for Payer: HealthUtah PPO |
$15.38
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.92
|
| Rate for Payer: Multiplan Medicare/VA |
$8.91
|
| Rate for Payer: One Health Plan of WY PPO |
$15.07
|
| Rate for Payer: PacificSource Commercial |
$13.84
|
| Rate for Payer: PHCS PPO |
$15.07
|
| Rate for Payer: Three Rivers PPO |
$11.54
|
| Rate for Payer: TriWest Veterans Administration |
$9.38
|
| Rate for Payer: United Healthcare Commercial |
$14.69
|
| Rate for Payer: United Healthcare Medicare |
$9.38
|
| Rate for Payer: WINHealth Partners Commercial |
$14.61
|
| Rate for Payer: Wise Provider Network Commercial |
$14.61
|
|
|
FLUOXETINE 40 MG CAPSULE [256]
|
Facility
|
IP
|
$18.01
|
|
|
Service Code
|
NDC 6068765911
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.44 |
| Max. Negotiated Rate |
$18.01 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$17.65
|
| Rate for Payer: Aetna of WY Medicare |
$11.53
|
| Rate for Payer: Altius Commercial |
$17.29
|
| Rate for Payer: Beech Street Commercial |
$17.65
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$17.47
|
| Rate for Payer: Cash Price |
$12.61
|
| Rate for Payer: ChoiceCare Network Commercial |
$17.47
|
| Rate for Payer: Cigna of WY Commercial |
$17.65
|
| Rate for Payer: Entrust Commercial |
$17.11
|
| Rate for Payer: First Choice Health Commercial |
$17.11
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.11
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.99
|
| Rate for Payer: HealthUtah PPO |
$18.01
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.47
|
| Rate for Payer: Multiplan Medicare/VA |
$10.44
|
| Rate for Payer: One Health Plan of WY PPO |
$17.65
|
| Rate for Payer: PacificSource Commercial |
$16.21
|
| Rate for Payer: PHCS PPO |
$17.65
|
| Rate for Payer: Three Rivers PPO |
$13.51
|
| Rate for Payer: TriWest Veterans Administration |
$10.99
|
| Rate for Payer: United Healthcare Commercial |
$17.20
|
| Rate for Payer: United Healthcare Medicare |
$10.99
|
| Rate for Payer: WINHealth Partners Commercial |
$17.11
|
| Rate for Payer: Wise Provider Network Commercial |
$17.11
|
|
|
FLUOXETINE 40 MG CAPSULE [256]
|
Facility
|
OP
|
$17.32
|
|
|
Service Code
|
NDC 5022811505
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.38 |
| Max. Negotiated Rate |
$17.32 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.97
|
| Rate for Payer: Aetna of WY Medicare |
$11.43
|
| Rate for Payer: Altius Commercial |
$16.63
|
| Rate for Payer: Beech Street Commercial |
$16.97
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.80
|
| Rate for Payer: Cash Price |
$12.12
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.80
|
| Rate for Payer: Cigna of WY Commercial |
$16.97
|
| Rate for Payer: Entrust Commercial |
$16.45
|
| Rate for Payer: First Choice Health Commercial |
$16.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.87
|
| Rate for Payer: HealthUtah PPO |
$17.32
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.80
|
| Rate for Payer: Multiplan Medicare/VA |
$9.38
|
| Rate for Payer: One Health Plan of WY PPO |
$16.97
|
| Rate for Payer: PacificSource Commercial |
$15.59
|
| Rate for Payer: PHCS PPO |
$16.97
|
| Rate for Payer: Three Rivers PPO |
$12.99
|
| Rate for Payer: TriWest Veterans Administration |
$9.87
|
| Rate for Payer: United Healthcare Commercial |
$16.54
|
| Rate for Payer: United Healthcare Medicare |
$9.87
|
| Rate for Payer: WINHealth Partners Commercial |
$16.97
|
| Rate for Payer: Wise Provider Network Commercial |
$16.45
|
|
|
FLUOXETINE 40 MG CAPSULE [256]
|
Facility
|
OP
|
$18.01
|
|
|
Service Code
|
NDC 6068765911
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.75 |
| Max. Negotiated Rate |
$18.01 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$17.65
|
| Rate for Payer: Aetna of WY Medicare |
$11.89
|
| Rate for Payer: Altius Commercial |
$17.29
|
| Rate for Payer: Beech Street Commercial |
$17.65
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$17.47
|
| Rate for Payer: Cash Price |
$12.61
|
| Rate for Payer: ChoiceCare Network Commercial |
$17.47
|
| Rate for Payer: Cigna of WY Commercial |
$17.65
|
| Rate for Payer: Entrust Commercial |
$17.11
|
| Rate for Payer: First Choice Health Commercial |
$17.11
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.11
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.27
|
| Rate for Payer: HealthUtah PPO |
$18.01
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.47
|
| Rate for Payer: Multiplan Medicare/VA |
$9.75
|
| Rate for Payer: One Health Plan of WY PPO |
$17.65
|
| Rate for Payer: PacificSource Commercial |
$16.21
|
| Rate for Payer: PHCS PPO |
$17.65
|
| Rate for Payer: Three Rivers PPO |
$13.51
|
| Rate for Payer: TriWest Veterans Administration |
$10.27
|
| Rate for Payer: United Healthcare Commercial |
$17.20
|
| Rate for Payer: United Healthcare Medicare |
$10.27
|
| Rate for Payer: WINHealth Partners Commercial |
$17.65
|
| Rate for Payer: Wise Provider Network Commercial |
$17.11
|
|
|
FLUOXETINE 40 MG CAPSULE [256]
|
Facility
|
IP
|
$17.32
|
|
|
Service Code
|
NDC 5022811505
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.04 |
| Max. Negotiated Rate |
$17.32 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.97
|
| Rate for Payer: Aetna of WY Medicare |
$11.08
|
| Rate for Payer: Altius Commercial |
$16.63
|
| Rate for Payer: Beech Street Commercial |
$16.97
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.80
|
| Rate for Payer: Cash Price |
$12.12
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.80
|
| Rate for Payer: Cigna of WY Commercial |
$16.97
|
| Rate for Payer: Entrust Commercial |
$16.45
|
| Rate for Payer: First Choice Health Commercial |
$16.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.57
|
| Rate for Payer: HealthUtah PPO |
$17.32
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.80
|
| Rate for Payer: Multiplan Medicare/VA |
$10.04
|
| Rate for Payer: One Health Plan of WY PPO |
$16.97
|
| Rate for Payer: PacificSource Commercial |
$15.59
|
| Rate for Payer: PHCS PPO |
$16.97
|
| Rate for Payer: Three Rivers PPO |
$12.99
|
| Rate for Payer: TriWest Veterans Administration |
$10.57
|
| Rate for Payer: United Healthcare Commercial |
$16.54
|
| Rate for Payer: United Healthcare Medicare |
$10.57
|
| Rate for Payer: WINHealth Partners Commercial |
$16.45
|
| Rate for Payer: Wise Provider Network Commercial |
$16.45
|
|
|
FLUTICASONE FUR. 100 MCG-UMECLID 62.5 MCG-VILANT 25 MCG INHALAT.POWDER [150586]
|
Facility
|
OP
|
$47.84
|
|
|
Service Code
|
NDC 0173088714
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.91 |
| Max. Negotiated Rate |
$47.84 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$46.88
|
| Rate for Payer: Aetna of WY Medicare |
$31.57
|
| Rate for Payer: Altius Commercial |
$45.93
|
| Rate for Payer: Beech Street Commercial |
$46.88
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$46.40
|
| Rate for Payer: Cash Price |
$33.49
|
| Rate for Payer: ChoiceCare Network Commercial |
$46.40
|
| Rate for Payer: Cigna of WY Commercial |
$46.88
|
| Rate for Payer: Entrust Commercial |
$45.45
|
| Rate for Payer: First Choice Health Commercial |
$45.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$45.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$27.27
|
| Rate for Payer: HealthUtah PPO |
$47.84
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$46.40
|
| Rate for Payer: Multiplan Medicare/VA |
$25.91
|
| Rate for Payer: One Health Plan of WY PPO |
$46.88
|
| Rate for Payer: PacificSource Commercial |
$43.06
|
| Rate for Payer: PHCS PPO |
$46.88
|
| Rate for Payer: Three Rivers PPO |
$35.88
|
| Rate for Payer: TriWest Veterans Administration |
$27.27
|
| Rate for Payer: United Healthcare Commercial |
$45.69
|
| Rate for Payer: United Healthcare Medicare |
$27.27
|
| Rate for Payer: WINHealth Partners Commercial |
$46.88
|
| Rate for Payer: Wise Provider Network Commercial |
$45.45
|
|
|
FLUTICASONE FUR. 100 MCG-UMECLID 62.5 MCG-VILANT 25 MCG INHALAT.POWDER [150586]
|
Facility
|
IP
|
$47.84
|
|
|
Service Code
|
NDC 0173088714
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.72 |
| Max. Negotiated Rate |
$47.84 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$46.88
|
| Rate for Payer: Aetna of WY Medicare |
$30.62
|
| Rate for Payer: Altius Commercial |
$45.93
|
| Rate for Payer: Beech Street Commercial |
$46.88
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$46.40
|
| Rate for Payer: Cash Price |
$33.49
|
| Rate for Payer: ChoiceCare Network Commercial |
$46.40
|
| Rate for Payer: Cigna of WY Commercial |
$46.88
|
| Rate for Payer: Entrust Commercial |
$45.45
|
| Rate for Payer: First Choice Health Commercial |
$45.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$45.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$29.18
|
| Rate for Payer: HealthUtah PPO |
$47.84
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$46.40
|
| Rate for Payer: Multiplan Medicare/VA |
$27.72
|
| Rate for Payer: One Health Plan of WY PPO |
$46.88
|
| Rate for Payer: PacificSource Commercial |
$43.06
|
| Rate for Payer: PHCS PPO |
$46.88
|
| Rate for Payer: Three Rivers PPO |
$35.88
|
| Rate for Payer: TriWest Veterans Administration |
$29.18
|
| Rate for Payer: United Healthcare Commercial |
$45.69
|
| Rate for Payer: United Healthcare Medicare |
$29.18
|
| Rate for Payer: WINHealth Partners Commercial |
$45.45
|
| Rate for Payer: Wise Provider Network Commercial |
$45.45
|
|
|
FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER [19837]
|
Facility
|
OP
|
$55.79
|
|
|
Service Code
|
NDC 6699307996
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$30.21 |
| Max. Negotiated Rate |
$55.79 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$54.67
|
| Rate for Payer: Aetna of WY Medicare |
$36.82
|
| Rate for Payer: Altius Commercial |
$53.56
|
| Rate for Payer: Beech Street Commercial |
$54.67
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$54.12
|
| Rate for Payer: Cash Price |
$39.05
|
| Rate for Payer: ChoiceCare Network Commercial |
$54.12
|
| Rate for Payer: Cigna of WY Commercial |
$54.67
|
| Rate for Payer: Entrust Commercial |
$53.00
|
| Rate for Payer: First Choice Health Commercial |
$53.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$53.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$31.80
|
| Rate for Payer: HealthUtah PPO |
$55.79
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$54.12
|
| Rate for Payer: Multiplan Medicare/VA |
$30.21
|
| Rate for Payer: One Health Plan of WY PPO |
$54.67
|
| Rate for Payer: PacificSource Commercial |
$50.21
|
| Rate for Payer: PHCS PPO |
$54.67
|
| Rate for Payer: Three Rivers PPO |
$41.84
|
| Rate for Payer: TriWest Veterans Administration |
$31.80
|
| Rate for Payer: United Healthcare Commercial |
$53.28
|
| Rate for Payer: United Healthcare Medicare |
$31.80
|
| Rate for Payer: WINHealth Partners Commercial |
$54.67
|
| Rate for Payer: Wise Provider Network Commercial |
$53.00
|
|
|
FLUTICASONE PROPIONATE 110 MCG/ACTUATION HFA AEROSOL INHALER [19837]
|
Facility
|
IP
|
$55.79
|
|
|
Service Code
|
NDC 6699307996
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.33 |
| Max. Negotiated Rate |
$55.79 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$54.67
|
| Rate for Payer: Aetna of WY Medicare |
$35.71
|
| Rate for Payer: Altius Commercial |
$53.56
|
| Rate for Payer: Beech Street Commercial |
$54.67
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$54.12
|
| Rate for Payer: Cash Price |
$39.05
|
| Rate for Payer: ChoiceCare Network Commercial |
$54.12
|
| Rate for Payer: Cigna of WY Commercial |
$54.67
|
| Rate for Payer: Entrust Commercial |
$53.00
|
| Rate for Payer: First Choice Health Commercial |
$53.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$53.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$34.03
|
| Rate for Payer: HealthUtah PPO |
$55.79
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$54.12
|
| Rate for Payer: Multiplan Medicare/VA |
$32.33
|
| Rate for Payer: One Health Plan of WY PPO |
$54.67
|
| Rate for Payer: PacificSource Commercial |
$50.21
|
| Rate for Payer: PHCS PPO |
$54.67
|
| Rate for Payer: Three Rivers PPO |
$41.84
|
| Rate for Payer: TriWest Veterans Administration |
$34.03
|
| Rate for Payer: United Healthcare Commercial |
$53.28
|
| Rate for Payer: United Healthcare Medicare |
$34.03
|
| Rate for Payer: WINHealth Partners Commercial |
$53.00
|
| Rate for Payer: Wise Provider Network Commercial |
$53.00
|
|
|
FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION [18925]
|
Facility
|
OP
|
$33.65
|
|
|
Service Code
|
NDC 6050508291
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.22 |
| Max. Negotiated Rate |
$33.65 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$32.98
|
| Rate for Payer: Aetna of WY Medicare |
$22.21
|
| Rate for Payer: Altius Commercial |
$32.30
|
| Rate for Payer: Beech Street Commercial |
$32.98
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$32.64
|
| Rate for Payer: Cash Price |
$23.56
|
| Rate for Payer: ChoiceCare Network Commercial |
$32.64
|
| Rate for Payer: Cigna of WY Commercial |
$32.98
|
| Rate for Payer: Entrust Commercial |
$31.97
|
| Rate for Payer: First Choice Health Commercial |
$31.97
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$31.97
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$19.18
|
| Rate for Payer: HealthUtah PPO |
$33.65
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$32.64
|
| Rate for Payer: Multiplan Medicare/VA |
$18.22
|
| Rate for Payer: One Health Plan of WY PPO |
$32.98
|
| Rate for Payer: PacificSource Commercial |
$30.28
|
| Rate for Payer: PHCS PPO |
$32.98
|
| Rate for Payer: Three Rivers PPO |
$25.24
|
| Rate for Payer: TriWest Veterans Administration |
$19.18
|
| Rate for Payer: United Healthcare Commercial |
$32.14
|
| Rate for Payer: United Healthcare Medicare |
$19.18
|
| Rate for Payer: WINHealth Partners Commercial |
$32.98
|
| Rate for Payer: Wise Provider Network Commercial |
$31.97
|
|
|
FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION [18925]
|
Facility
|
IP
|
$33.65
|
|
|
Service Code
|
NDC 6050508291
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.50 |
| Max. Negotiated Rate |
$33.65 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$32.98
|
| Rate for Payer: Aetna of WY Medicare |
$21.54
|
| Rate for Payer: Altius Commercial |
$32.30
|
| Rate for Payer: Beech Street Commercial |
$32.98
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$32.64
|
| Rate for Payer: Cash Price |
$23.56
|
| Rate for Payer: ChoiceCare Network Commercial |
$32.64
|
| Rate for Payer: Cigna of WY Commercial |
$32.98
|
| Rate for Payer: Entrust Commercial |
$31.97
|
| Rate for Payer: First Choice Health Commercial |
$31.97
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$31.97
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$20.53
|
| Rate for Payer: HealthUtah PPO |
$33.65
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$32.64
|
| Rate for Payer: Multiplan Medicare/VA |
$19.50
|
| Rate for Payer: One Health Plan of WY PPO |
$32.98
|
| Rate for Payer: PacificSource Commercial |
$30.28
|
| Rate for Payer: PHCS PPO |
$32.98
|
| Rate for Payer: Three Rivers PPO |
$25.24
|
| Rate for Payer: TriWest Veterans Administration |
$20.53
|
| Rate for Payer: United Healthcare Commercial |
$32.14
|
| Rate for Payer: United Healthcare Medicare |
$20.53
|
| Rate for Payer: WINHealth Partners Commercial |
$31.97
|
| Rate for Payer: Wise Provider Network Commercial |
$31.97
|
|
|
FLU VACC 2023-24(65YR UP)-MF59C(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE [181430]
|
Facility
|
OP
|
$216.70
|
|
|
Service Code
|
NDC 7046112303
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$117.34 |
| Max. Negotiated Rate |
$216.70 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$212.37
|
| Rate for Payer: Aetna of WY Medicare |
$143.02
|
| Rate for Payer: Altius Commercial |
$208.03
|
| Rate for Payer: Beech Street Commercial |
$212.37
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$210.20
|
| Rate for Payer: Cash Price |
$151.69
|
| Rate for Payer: ChoiceCare Network Commercial |
$210.20
|
| Rate for Payer: Cigna of WY Commercial |
$212.37
|
| Rate for Payer: Entrust Commercial |
$205.86
|
| Rate for Payer: First Choice Health Commercial |
$205.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$205.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$123.52
|
| Rate for Payer: HealthUtah PPO |
$216.70
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$210.20
|
| Rate for Payer: Multiplan Medicare/VA |
$117.34
|
| Rate for Payer: One Health Plan of WY PPO |
$212.37
|
| Rate for Payer: PacificSource Commercial |
$195.03
|
| Rate for Payer: PHCS PPO |
$212.37
|
| Rate for Payer: Three Rivers PPO |
$162.52
|
| Rate for Payer: TriWest Veterans Administration |
$123.52
|
| Rate for Payer: United Healthcare Commercial |
$206.95
|
| Rate for Payer: United Healthcare Medicare |
$123.52
|
| Rate for Payer: WINHealth Partners Commercial |
$212.37
|
| Rate for Payer: Wise Provider Network Commercial |
$205.86
|
|
|
FLU VACC 2023-24(65YR UP)-MF59C(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE [181430]
|
Facility
|
OP
|
$216.70
|
|
|
Service Code
|
NDC 7046112304
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$117.34 |
| Max. Negotiated Rate |
$216.70 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$212.37
|
| Rate for Payer: Aetna of WY Medicare |
$143.02
|
| Rate for Payer: Altius Commercial |
$208.03
|
| Rate for Payer: Beech Street Commercial |
$212.37
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$210.20
|
| Rate for Payer: Cash Price |
$151.69
|
| Rate for Payer: ChoiceCare Network Commercial |
$210.20
|
| Rate for Payer: Cigna of WY Commercial |
$212.37
|
| Rate for Payer: Entrust Commercial |
$205.86
|
| Rate for Payer: First Choice Health Commercial |
$205.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$205.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$123.52
|
| Rate for Payer: HealthUtah PPO |
$216.70
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$210.20
|
| Rate for Payer: Multiplan Medicare/VA |
$117.34
|
| Rate for Payer: One Health Plan of WY PPO |
$212.37
|
| Rate for Payer: PacificSource Commercial |
$195.03
|
| Rate for Payer: PHCS PPO |
$212.37
|
| Rate for Payer: Three Rivers PPO |
$162.52
|
| Rate for Payer: TriWest Veterans Administration |
$123.52
|
| Rate for Payer: United Healthcare Commercial |
$206.95
|
| Rate for Payer: United Healthcare Medicare |
$123.52
|
| Rate for Payer: WINHealth Partners Commercial |
$212.37
|
| Rate for Payer: Wise Provider Network Commercial |
$205.86
|
|
|
FLU VACC 2023-24(65YR UP)-MF59C(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE [181430]
|
Facility
|
IP
|
$216.70
|
|
|
Service Code
|
NDC 7046112304
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$125.58 |
| Max. Negotiated Rate |
$216.70 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$212.37
|
| Rate for Payer: Aetna of WY Medicare |
$138.69
|
| Rate for Payer: Altius Commercial |
$208.03
|
| Rate for Payer: Beech Street Commercial |
$212.37
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$210.20
|
| Rate for Payer: Cash Price |
$151.69
|
| Rate for Payer: ChoiceCare Network Commercial |
$210.20
|
| Rate for Payer: Cigna of WY Commercial |
$212.37
|
| Rate for Payer: Entrust Commercial |
$205.86
|
| Rate for Payer: First Choice Health Commercial |
$205.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$205.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$132.19
|
| Rate for Payer: HealthUtah PPO |
$216.70
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$210.20
|
| Rate for Payer: Multiplan Medicare/VA |
$125.58
|
| Rate for Payer: One Health Plan of WY PPO |
$212.37
|
| Rate for Payer: PacificSource Commercial |
$195.03
|
| Rate for Payer: PHCS PPO |
$212.37
|
| Rate for Payer: Three Rivers PPO |
$162.52
|
| Rate for Payer: TriWest Veterans Administration |
$132.19
|
| Rate for Payer: United Healthcare Commercial |
$206.95
|
| Rate for Payer: United Healthcare Medicare |
$132.19
|
| Rate for Payer: WINHealth Partners Commercial |
$205.86
|
| Rate for Payer: Wise Provider Network Commercial |
$205.86
|
|
|
FLU VACC 2023-24(65YR UP)-MF59C(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE [181430]
|
Facility
|
IP
|
$216.70
|
|
|
Service Code
|
NDC 7046112303
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$125.58 |
| Max. Negotiated Rate |
$216.70 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$212.37
|
| Rate for Payer: Aetna of WY Medicare |
$138.69
|
| Rate for Payer: Altius Commercial |
$208.03
|
| Rate for Payer: Beech Street Commercial |
$212.37
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$210.20
|
| Rate for Payer: Cash Price |
$151.69
|
| Rate for Payer: ChoiceCare Network Commercial |
$210.20
|
| Rate for Payer: Cigna of WY Commercial |
$212.37
|
| Rate for Payer: Entrust Commercial |
$205.86
|
| Rate for Payer: First Choice Health Commercial |
$205.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$205.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$132.19
|
| Rate for Payer: HealthUtah PPO |
$216.70
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$210.20
|
| Rate for Payer: Multiplan Medicare/VA |
$125.58
|
| Rate for Payer: One Health Plan of WY PPO |
$212.37
|
| Rate for Payer: PacificSource Commercial |
$195.03
|
| Rate for Payer: PHCS PPO |
$212.37
|
| Rate for Payer: Three Rivers PPO |
$162.52
|
| Rate for Payer: TriWest Veterans Administration |
$132.19
|
| Rate for Payer: United Healthcare Commercial |
$206.95
|
| Rate for Payer: United Healthcare Medicare |
$132.19
|
| Rate for Payer: WINHealth Partners Commercial |
$205.86
|
| Rate for Payer: Wise Provider Network Commercial |
$205.86
|
|
|
FLU VACCINE QS2023-24(65YR UP)(PF)240 MCG/0.7 ML INTRAMUSCULAR SYRINGE [181835]
|
Facility
|
OP
|
$174.41
|
|
|
Service Code
|
NDC 4928112388
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$94.44 |
| Max. Negotiated Rate |
$174.41 |
| Rate for Payer: United Healthcare Commercial |
$166.56
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$170.92
|
| Rate for Payer: Aetna of WY Medicare |
$115.11
|
| Rate for Payer: Altius Commercial |
$167.43
|
| Rate for Payer: Beech Street Commercial |
$170.92
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$169.18
|
| Rate for Payer: Cash Price |
$122.09
|
| Rate for Payer: ChoiceCare Network Commercial |
$169.18
|
| Rate for Payer: Cigna of WY Commercial |
$170.92
|
| Rate for Payer: Entrust Commercial |
$165.69
|
| Rate for Payer: First Choice Health Commercial |
$165.69
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$165.69
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$99.41
|
| Rate for Payer: HealthUtah PPO |
$174.41
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$169.18
|
| Rate for Payer: Multiplan Medicare/VA |
$94.44
|
| Rate for Payer: One Health Plan of WY PPO |
$170.92
|
| Rate for Payer: PacificSource Commercial |
$156.97
|
| Rate for Payer: PHCS PPO |
$170.92
|
| Rate for Payer: Three Rivers PPO |
$130.81
|
| Rate for Payer: TriWest Veterans Administration |
$99.41
|
| Rate for Payer: United Healthcare Medicare |
$99.41
|
| Rate for Payer: WINHealth Partners Commercial |
$170.92
|
| Rate for Payer: Wise Provider Network Commercial |
$165.69
|
|
|
FLU VACCINE QS2023-24(65YR UP)(PF)240 MCG/0.7 ML INTRAMUSCULAR SYRINGE [181835]
|
Facility
|
IP
|
$174.40
|
|
|
Service Code
|
NDC 4928112365
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$101.06 |
| Max. Negotiated Rate |
$174.40 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$170.91
|
| Rate for Payer: Aetna of WY Medicare |
$111.62
|
| Rate for Payer: Altius Commercial |
$167.42
|
| Rate for Payer: Beech Street Commercial |
$170.91
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$169.17
|
| Rate for Payer: Cash Price |
$122.08
|
| Rate for Payer: ChoiceCare Network Commercial |
$169.17
|
| Rate for Payer: Cigna of WY Commercial |
$170.91
|
| Rate for Payer: Entrust Commercial |
$165.68
|
| Rate for Payer: First Choice Health Commercial |
$165.68
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$165.68
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$106.38
|
| Rate for Payer: HealthUtah PPO |
$174.40
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$169.17
|
| Rate for Payer: Multiplan Medicare/VA |
$101.06
|
| Rate for Payer: One Health Plan of WY PPO |
$170.91
|
| Rate for Payer: PacificSource Commercial |
$156.96
|
| Rate for Payer: PHCS PPO |
$170.91
|
| Rate for Payer: Three Rivers PPO |
$130.80
|
| Rate for Payer: TriWest Veterans Administration |
$106.38
|
| Rate for Payer: United Healthcare Commercial |
$166.55
|
| Rate for Payer: United Healthcare Medicare |
$106.38
|
| Rate for Payer: WINHealth Partners Commercial |
$165.68
|
| Rate for Payer: Wise Provider Network Commercial |
$165.68
|
|
|
FLU VACCINE QS2023-24(65YR UP)(PF)240 MCG/0.7 ML INTRAMUSCULAR SYRINGE [181835]
|
Facility
|
OP
|
$174.40
|
|
|
Service Code
|
NDC 4928112365
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$94.44 |
| Max. Negotiated Rate |
$174.40 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$170.91
|
| Rate for Payer: Aetna of WY Medicare |
$115.10
|
| Rate for Payer: Altius Commercial |
$167.42
|
| Rate for Payer: Beech Street Commercial |
$170.91
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$169.17
|
| Rate for Payer: Cash Price |
$122.08
|
| Rate for Payer: ChoiceCare Network Commercial |
$169.17
|
| Rate for Payer: Cigna of WY Commercial |
$170.91
|
| Rate for Payer: Entrust Commercial |
$165.68
|
| Rate for Payer: First Choice Health Commercial |
$165.68
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$165.68
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$99.41
|
| Rate for Payer: HealthUtah PPO |
$174.40
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$169.17
|
| Rate for Payer: Multiplan Medicare/VA |
$94.44
|
| Rate for Payer: One Health Plan of WY PPO |
$170.91
|
| Rate for Payer: PacificSource Commercial |
$156.96
|
| Rate for Payer: PHCS PPO |
$170.91
|
| Rate for Payer: Three Rivers PPO |
$130.80
|
| Rate for Payer: TriWest Veterans Administration |
$99.41
|
| Rate for Payer: United Healthcare Commercial |
$166.55
|
| Rate for Payer: United Healthcare Medicare |
$99.41
|
| Rate for Payer: WINHealth Partners Commercial |
$170.91
|
| Rate for Payer: Wise Provider Network Commercial |
$165.68
|
|
|
FLU VACCINE QS2023-24(65YR UP)(PF)240 MCG/0.7 ML INTRAMUSCULAR SYRINGE [181835]
|
Facility
|
IP
|
$174.41
|
|
|
Service Code
|
NDC 4928112388
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$101.07 |
| Max. Negotiated Rate |
$174.41 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$170.92
|
| Rate for Payer: Aetna of WY Medicare |
$111.62
|
| Rate for Payer: Altius Commercial |
$167.43
|
| Rate for Payer: Beech Street Commercial |
$170.92
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$169.18
|
| Rate for Payer: Cash Price |
$122.09
|
| Rate for Payer: ChoiceCare Network Commercial |
$169.18
|
| Rate for Payer: Cigna of WY Commercial |
$170.92
|
| Rate for Payer: Entrust Commercial |
$165.69
|
| Rate for Payer: First Choice Health Commercial |
$165.69
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$165.69
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$106.39
|
| Rate for Payer: HealthUtah PPO |
$174.41
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$169.18
|
| Rate for Payer: Multiplan Medicare/VA |
$101.07
|
| Rate for Payer: One Health Plan of WY PPO |
$170.92
|
| Rate for Payer: PacificSource Commercial |
$156.97
|
| Rate for Payer: PHCS PPO |
$170.92
|
| Rate for Payer: Three Rivers PPO |
$130.81
|
| Rate for Payer: TriWest Veterans Administration |
$106.39
|
| Rate for Payer: United Healthcare Commercial |
$166.56
|
| Rate for Payer: United Healthcare Medicare |
$106.39
|
| Rate for Payer: WINHealth Partners Commercial |
$165.69
|
| Rate for Payer: Wise Provider Network Commercial |
$165.69
|
|
|
FLU VACCINE QS 2023-24(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE [181815]
|
Facility
|
OP
|
$91.04
|
|
|
Service Code
|
NDC 4928142388
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$49.30 |
| Max. Negotiated Rate |
$91.04 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$89.22
|
| Rate for Payer: Aetna of WY Medicare |
$60.09
|
| Rate for Payer: Altius Commercial |
$87.40
|
| Rate for Payer: Beech Street Commercial |
$89.22
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$88.31
|
| Rate for Payer: Cash Price |
$63.73
|
| Rate for Payer: ChoiceCare Network Commercial |
$88.31
|
| Rate for Payer: Cigna of WY Commercial |
$89.22
|
| Rate for Payer: Entrust Commercial |
$86.49
|
| Rate for Payer: First Choice Health Commercial |
$86.49
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$86.49
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$51.89
|
| Rate for Payer: HealthUtah PPO |
$91.04
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$88.31
|
| Rate for Payer: Multiplan Medicare/VA |
$49.30
|
| Rate for Payer: One Health Plan of WY PPO |
$89.22
|
| Rate for Payer: PacificSource Commercial |
$81.94
|
| Rate for Payer: PHCS PPO |
$89.22
|
| Rate for Payer: Three Rivers PPO |
$68.28
|
| Rate for Payer: TriWest Veterans Administration |
$51.89
|
| Rate for Payer: United Healthcare Commercial |
$86.94
|
| Rate for Payer: United Healthcare Medicare |
$51.89
|
| Rate for Payer: WINHealth Partners Commercial |
$89.22
|
| Rate for Payer: Wise Provider Network Commercial |
$86.49
|
|
|
FLU VACCINE QS 2023-24(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE [181815]
|
Facility
|
IP
|
$91.02
|
|
|
Service Code
|
NDC 4928142350
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$52.75 |
| Max. Negotiated Rate |
$91.02 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$89.20
|
| Rate for Payer: Aetna of WY Medicare |
$58.25
|
| Rate for Payer: Altius Commercial |
$87.38
|
| Rate for Payer: Beech Street Commercial |
$89.20
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$88.29
|
| Rate for Payer: Cash Price |
$63.72
|
| Rate for Payer: ChoiceCare Network Commercial |
$88.29
|
| Rate for Payer: Cigna of WY Commercial |
$89.20
|
| Rate for Payer: Entrust Commercial |
$86.47
|
| Rate for Payer: First Choice Health Commercial |
$86.47
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$86.47
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$55.52
|
| Rate for Payer: HealthUtah PPO |
$91.02
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$88.29
|
| Rate for Payer: Multiplan Medicare/VA |
$52.75
|
| Rate for Payer: One Health Plan of WY PPO |
$89.20
|
| Rate for Payer: PacificSource Commercial |
$81.92
|
| Rate for Payer: PHCS PPO |
$89.20
|
| Rate for Payer: Three Rivers PPO |
$68.26
|
| Rate for Payer: TriWest Veterans Administration |
$55.52
|
| Rate for Payer: United Healthcare Commercial |
$86.92
|
| Rate for Payer: United Healthcare Medicare |
$55.52
|
| Rate for Payer: WINHealth Partners Commercial |
$86.47
|
| Rate for Payer: Wise Provider Network Commercial |
$86.47
|
|
