|
AVOX-4 CO OXIMETER CTRL LEVEL
|
Facility
|
IP
|
$68.64
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$43.04 |
| Max. Negotiated Rate |
$68.64 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$67.27
|
| Rate for Payer: Altius Auto/Workers Compensation |
$65.89
|
| Rate for Payer: Altius Commercial |
$65.89
|
| Rate for Payer: Beech Street Commercial |
$67.27
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$56.35
|
| Rate for Payer: Cash Price |
$48.04
|
| Rate for Payer: ChoiceCare Network Commercial |
$66.58
|
| Rate for Payer: Cigna of WY Commercial |
$67.27
|
| Rate for Payer: Entrust Commercial |
$65.21
|
| Rate for Payer: First Choice Health Commercial |
$65.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$65.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$45.30
|
| Rate for Payer: HealthUtah PPO |
$68.64
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$66.58
|
| Rate for Payer: Multiplan Medicare/VA |
$43.04
|
| Rate for Payer: One Health Plan of WY PPO |
$67.27
|
| Rate for Payer: PacificSource Commercial |
$61.78
|
| Rate for Payer: PHCS PPO |
$67.27
|
| Rate for Payer: Three Rivers PPO |
$51.48
|
| Rate for Payer: TriWest Veterans Administration |
$45.30
|
| Rate for Payer: United Healthcare Commercial |
$59.72
|
| Rate for Payer: United Healthcare Medicare |
$45.30
|
| Rate for Payer: WINHealth Partners Commercial |
$65.21
|
| Rate for Payer: Wise Provider Network Commercial |
$65.21
|
|
|
AVULSION NAIL PLATE PARTIAL/COMPLETE SIMPLE 1
|
Professional
|
Both
|
$275.00
|
|
|
Service Code
|
HCPCS 11730
|
| Hospital Charge Code |
11730
|
| Min. Negotiated Rate |
$43.88 |
| Max. Negotiated Rate |
$275.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$269.50
|
| Rate for Payer: Aetna of WY Medicare |
$51.62
|
| Rate for Payer: Beech Street Commercial |
$261.25
|
| Rate for Payer: Cash Price |
$192.50
|
| Rate for Payer: Cash Price |
$192.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$266.75
|
| Rate for Payer: Cigna of WY Commercial |
$269.50
|
| Rate for Payer: First Choice Health Commercial |
$247.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$261.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$51.62
|
| Rate for Payer: HealthUtah PPO |
$275.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$266.75
|
| Rate for Payer: Multiplan Medicare/VA |
$43.88
|
| Rate for Payer: One Health Plan of WY PPO |
$269.50
|
| Rate for Payer: PacificSource Commercial |
$247.50
|
| Rate for Payer: PHCS PPO |
$261.25
|
| Rate for Payer: Three Rivers PPO |
$206.25
|
| Rate for Payer: TriWest Veterans Administration |
$51.62
|
| Rate for Payer: United Healthcare Commercial |
$239.25
|
| Rate for Payer: United Healthcare Medicare |
$51.62
|
| Rate for Payer: WINHealth Partners Commercial |
$233.75
|
|
|
AVULSION NAIL PLATE PARTIAL/COMP SIMPLE EA ADDL
|
Professional
|
Both
|
$89.00
|
|
|
Service Code
|
HCPCS 11732
|
| Hospital Charge Code |
11732
|
| Min. Negotiated Rate |
$13.70 |
| Max. Negotiated Rate |
$89.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$87.22
|
| Rate for Payer: Aetna of WY Medicare |
$16.12
|
| Rate for Payer: Beech Street Commercial |
$84.55
|
| Rate for Payer: Cash Price |
$62.30
|
| Rate for Payer: Cash Price |
$62.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$86.33
|
| Rate for Payer: Cigna of WY Commercial |
$87.22
|
| Rate for Payer: First Choice Health Commercial |
$80.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$84.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$16.12
|
| Rate for Payer: HealthUtah PPO |
$89.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$86.33
|
| Rate for Payer: Multiplan Medicare/VA |
$13.70
|
| Rate for Payer: One Health Plan of WY PPO |
$87.22
|
| Rate for Payer: PacificSource Commercial |
$80.10
|
| Rate for Payer: PHCS PPO |
$84.55
|
| Rate for Payer: Three Rivers PPO |
$66.75
|
| Rate for Payer: TriWest Veterans Administration |
$16.12
|
| Rate for Payer: United Healthcare Commercial |
$77.43
|
| Rate for Payer: United Healthcare Medicare |
$16.12
|
| Rate for Payer: WINHealth Partners Commercial |
$75.65
|
|
|
AZACITIDINE 100 MG SOLUTION FOR INJECTION [35686]
|
Facility
|
OP
|
$105.00
|
|
|
Service Code
|
HCPCS J9025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$57.86 |
| Max. Negotiated Rate |
$105.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$102.90
|
| Rate for Payer: Aetna of WY Medicare |
$69.30
|
| Rate for Payer: Altius Auto/Workers Compensation |
$100.80
|
| Rate for Payer: Altius Commercial |
$100.80
|
| Rate for Payer: Beech Street Commercial |
$102.90
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$86.20
|
| Rate for Payer: Cash Price |
$73.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$101.85
|
| Rate for Payer: Cigna of WY Commercial |
$102.90
|
| Rate for Payer: Entrust Commercial |
$99.75
|
| Rate for Payer: First Choice Health Commercial |
$99.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$99.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$60.90
|
| Rate for Payer: HealthUtah PPO |
$105.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$101.85
|
| Rate for Payer: Multiplan Medicare/VA |
$57.86
|
| Rate for Payer: One Health Plan of WY PPO |
$102.90
|
| Rate for Payer: PacificSource Commercial |
$94.50
|
| Rate for Payer: PHCS PPO |
$102.90
|
| Rate for Payer: Three Rivers PPO |
$78.75
|
| Rate for Payer: TriWest Veterans Administration |
$60.90
|
| Rate for Payer: United Healthcare Commercial |
$91.35
|
| Rate for Payer: United Healthcare Medicare |
$60.90
|
| Rate for Payer: WINHealth Partners Commercial |
$102.90
|
| Rate for Payer: Wise Provider Network Commercial |
$99.75
|
|
|
AZACITIDINE 100 MG SOLUTION FOR INJECTION [35686]
|
Facility
|
IP
|
$105.00
|
|
|
Service Code
|
HCPCS J9025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$65.84 |
| Max. Negotiated Rate |
$105.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$102.90
|
| Rate for Payer: Altius Auto/Workers Compensation |
$100.80
|
| Rate for Payer: Altius Commercial |
$100.80
|
| Rate for Payer: Beech Street Commercial |
$102.90
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$86.20
|
| Rate for Payer: Cash Price |
$73.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$101.85
|
| Rate for Payer: Cigna of WY Commercial |
$102.90
|
| Rate for Payer: Entrust Commercial |
$99.75
|
| Rate for Payer: First Choice Health Commercial |
$99.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$99.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$69.30
|
| Rate for Payer: HealthUtah PPO |
$105.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$101.85
|
| Rate for Payer: Multiplan Medicare/VA |
$65.84
|
| Rate for Payer: One Health Plan of WY PPO |
$102.90
|
| Rate for Payer: PacificSource Commercial |
$94.50
|
| Rate for Payer: PHCS PPO |
$102.90
|
| Rate for Payer: Three Rivers PPO |
$78.75
|
| Rate for Payer: TriWest Veterans Administration |
$69.30
|
| Rate for Payer: United Healthcare Commercial |
$91.35
|
| Rate for Payer: United Healthcare Medicare |
$69.30
|
| Rate for Payer: WINHealth Partners Commercial |
$99.75
|
| Rate for Payer: Wise Provider Network Commercial |
$99.75
|
|
|
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION [17517]
|
Facility
|
OP
|
$1.88
|
|
|
Service Code
|
NDC 7071014602
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.04 |
| Max. Negotiated Rate |
$1.88 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.84
|
| Rate for Payer: Aetna of WY Medicare |
$1.24
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.80
|
| Rate for Payer: Altius Commercial |
$1.80
|
| Rate for Payer: Beech Street Commercial |
$1.84
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.54
|
| Rate for Payer: Cash Price |
$1.32
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.82
|
| Rate for Payer: Cigna of WY Commercial |
$1.84
|
| Rate for Payer: Entrust Commercial |
$1.79
|
| Rate for Payer: First Choice Health Commercial |
$1.79
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.79
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.09
|
| Rate for Payer: HealthUtah PPO |
$1.88
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.82
|
| Rate for Payer: Multiplan Medicare/VA |
$1.04
|
| Rate for Payer: One Health Plan of WY PPO |
$1.84
|
| Rate for Payer: PacificSource Commercial |
$1.69
|
| Rate for Payer: PHCS PPO |
$1.84
|
| Rate for Payer: Three Rivers PPO |
$1.41
|
| Rate for Payer: TriWest Veterans Administration |
$1.09
|
| Rate for Payer: United Healthcare Commercial |
$1.64
|
| Rate for Payer: United Healthcare Medicare |
$1.09
|
| Rate for Payer: WINHealth Partners Commercial |
$1.84
|
| Rate for Payer: Wise Provider Network Commercial |
$1.79
|
|
|
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION [17517]
|
Facility
|
IP
|
$1.88
|
|
|
Service Code
|
NDC 7071014602
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.18 |
| Max. Negotiated Rate |
$1.88 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.84
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.80
|
| Rate for Payer: Altius Commercial |
$1.80
|
| Rate for Payer: Beech Street Commercial |
$1.84
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.54
|
| Rate for Payer: Cash Price |
$1.32
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.82
|
| Rate for Payer: Cigna of WY Commercial |
$1.84
|
| Rate for Payer: Entrust Commercial |
$1.79
|
| Rate for Payer: First Choice Health Commercial |
$1.79
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.79
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.24
|
| Rate for Payer: HealthUtah PPO |
$1.88
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.82
|
| Rate for Payer: Multiplan Medicare/VA |
$1.18
|
| Rate for Payer: One Health Plan of WY PPO |
$1.84
|
| Rate for Payer: PacificSource Commercial |
$1.69
|
| Rate for Payer: PHCS PPO |
$1.84
|
| Rate for Payer: Three Rivers PPO |
$1.41
|
| Rate for Payer: TriWest Veterans Administration |
$1.24
|
| Rate for Payer: United Healthcare Commercial |
$1.64
|
| Rate for Payer: United Healthcare Medicare |
$1.24
|
| Rate for Payer: WINHealth Partners Commercial |
$1.79
|
| Rate for Payer: Wise Provider Network Commercial |
$1.79
|
|
|
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION [17517]
|
Facility
|
OP
|
$2.67
|
|
|
Service Code
|
NDC 5976231401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.47 |
| Max. Negotiated Rate |
$2.67 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.62
|
| Rate for Payer: Aetna of WY Medicare |
$1.76
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.56
|
| Rate for Payer: Altius Commercial |
$2.56
|
| Rate for Payer: Beech Street Commercial |
$2.62
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.19
|
| Rate for Payer: Cash Price |
$1.87
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.59
|
| Rate for Payer: Cigna of WY Commercial |
$2.62
|
| Rate for Payer: Entrust Commercial |
$2.54
|
| Rate for Payer: First Choice Health Commercial |
$2.54
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.54
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.55
|
| Rate for Payer: HealthUtah PPO |
$2.67
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.59
|
| Rate for Payer: Multiplan Medicare/VA |
$1.47
|
| Rate for Payer: One Health Plan of WY PPO |
$2.62
|
| Rate for Payer: PacificSource Commercial |
$2.40
|
| Rate for Payer: PHCS PPO |
$2.62
|
| Rate for Payer: Three Rivers PPO |
$2.00
|
| Rate for Payer: TriWest Veterans Administration |
$1.55
|
| Rate for Payer: United Healthcare Commercial |
$2.32
|
| Rate for Payer: United Healthcare Medicare |
$1.55
|
| Rate for Payer: WINHealth Partners Commercial |
$2.62
|
| Rate for Payer: Wise Provider Network Commercial |
$2.54
|
|
|
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION [17517]
|
Facility
|
IP
|
$2.67
|
|
|
Service Code
|
NDC 5976231401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.67 |
| Max. Negotiated Rate |
$2.67 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.62
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.56
|
| Rate for Payer: Altius Commercial |
$2.56
|
| Rate for Payer: Beech Street Commercial |
$2.62
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.19
|
| Rate for Payer: Cash Price |
$1.87
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.59
|
| Rate for Payer: Cigna of WY Commercial |
$2.62
|
| Rate for Payer: Entrust Commercial |
$2.54
|
| Rate for Payer: First Choice Health Commercial |
$2.54
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.54
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.76
|
| Rate for Payer: HealthUtah PPO |
$2.67
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.59
|
| Rate for Payer: Multiplan Medicare/VA |
$1.67
|
| Rate for Payer: One Health Plan of WY PPO |
$2.62
|
| Rate for Payer: PacificSource Commercial |
$2.40
|
| Rate for Payer: PHCS PPO |
$2.62
|
| Rate for Payer: Three Rivers PPO |
$2.00
|
| Rate for Payer: TriWest Veterans Administration |
$1.76
|
| Rate for Payer: United Healthcare Commercial |
$2.32
|
| Rate for Payer: United Healthcare Medicare |
$1.76
|
| Rate for Payer: WINHealth Partners Commercial |
$2.54
|
| Rate for Payer: Wise Provider Network Commercial |
$2.54
|
|
|
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION [17517]
|
Facility
|
OP
|
$3.49
|
|
|
Service Code
|
NDC 0093202631
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.92 |
| Max. Negotiated Rate |
$3.49 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3.42
|
| Rate for Payer: Aetna of WY Medicare |
$2.30
|
| Rate for Payer: Altius Auto/Workers Compensation |
$3.35
|
| Rate for Payer: Altius Commercial |
$3.35
|
| Rate for Payer: Beech Street Commercial |
$3.42
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.87
|
| Rate for Payer: Cash Price |
$2.44
|
| Rate for Payer: ChoiceCare Network Commercial |
$3.39
|
| Rate for Payer: Cigna of WY Commercial |
$3.42
|
| 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 |
$2.02
|
| Rate for Payer: HealthUtah PPO |
$3.49
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3.39
|
| Rate for Payer: Multiplan Medicare/VA |
$1.92
|
| Rate for Payer: One Health Plan of WY PPO |
$3.42
|
| Rate for Payer: PacificSource Commercial |
$3.14
|
| Rate for Payer: PHCS PPO |
$3.42
|
| Rate for Payer: Three Rivers PPO |
$2.62
|
| Rate for Payer: TriWest Veterans Administration |
$2.02
|
| Rate for Payer: United Healthcare Commercial |
$3.04
|
| Rate for Payer: United Healthcare Medicare |
$2.02
|
| Rate for Payer: WINHealth Partners Commercial |
$3.42
|
| Rate for Payer: Wise Provider Network Commercial |
$3.32
|
|
|
AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION [17517]
|
Facility
|
IP
|
$3.49
|
|
|
Service Code
|
NDC 0093202631
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.19 |
| Max. Negotiated Rate |
$3.49 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3.42
|
| Rate for Payer: Altius Auto/Workers Compensation |
$3.35
|
| Rate for Payer: Altius Commercial |
$3.35
|
| Rate for Payer: Beech Street Commercial |
$3.42
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.87
|
| Rate for Payer: Cash Price |
$2.44
|
| Rate for Payer: ChoiceCare Network Commercial |
$3.39
|
| Rate for Payer: Cigna of WY Commercial |
$3.42
|
| 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 |
$2.30
|
| Rate for Payer: HealthUtah PPO |
$3.49
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3.39
|
| Rate for Payer: Multiplan Medicare/VA |
$2.19
|
| Rate for Payer: One Health Plan of WY PPO |
$3.42
|
| Rate for Payer: PacificSource Commercial |
$3.14
|
| Rate for Payer: PHCS PPO |
$3.42
|
| Rate for Payer: Three Rivers PPO |
$2.62
|
| Rate for Payer: TriWest Veterans Administration |
$2.30
|
| Rate for Payer: United Healthcare Commercial |
$3.04
|
| Rate for Payer: United Healthcare Medicare |
$2.30
|
| Rate for Payer: WINHealth Partners Commercial |
$3.32
|
| Rate for Payer: Wise Provider Network Commercial |
$3.32
|
|
|
AZITHROMYCIN 250 MG TABLET [3126]
|
Facility
|
OP
|
$10.00
|
|
|
Service Code
|
NDC 5011178751
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.51 |
| Max. Negotiated Rate |
$10.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$9.80
|
| Rate for Payer: Aetna of WY Medicare |
$6.60
|
| Rate for Payer: Altius Auto/Workers Compensation |
$9.60
|
| Rate for Payer: Altius Commercial |
$9.60
|
| Rate for Payer: Beech Street Commercial |
$9.80
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$8.21
|
| Rate for Payer: Cash Price |
$7.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$9.70
|
| Rate for Payer: Cigna of WY Commercial |
$9.80
|
| Rate for Payer: Entrust Commercial |
$9.50
|
| Rate for Payer: First Choice Health Commercial |
$9.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$9.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$5.80
|
| Rate for Payer: HealthUtah PPO |
$10.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$9.70
|
| Rate for Payer: Multiplan Medicare/VA |
$5.51
|
| Rate for Payer: One Health Plan of WY PPO |
$9.80
|
| Rate for Payer: PacificSource Commercial |
$9.00
|
| Rate for Payer: PHCS PPO |
$9.80
|
| Rate for Payer: Three Rivers PPO |
$7.50
|
| Rate for Payer: TriWest Veterans Administration |
$5.80
|
| Rate for Payer: United Healthcare Commercial |
$8.70
|
| Rate for Payer: United Healthcare Medicare |
$5.80
|
| Rate for Payer: WINHealth Partners Commercial |
$9.80
|
| Rate for Payer: Wise Provider Network Commercial |
$9.50
|
|
|
AZITHROMYCIN 250 MG TABLET [3126]
|
Facility
|
IP
|
$2.39
|
|
|
Service Code
|
NDC 6809490006
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.39 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.34
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.29
|
| Rate for Payer: Altius Commercial |
$2.29
|
| Rate for Payer: Beech Street Commercial |
$2.34
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.96
|
| Rate for Payer: Cash Price |
$1.67
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.32
|
| Rate for Payer: Cigna of WY Commercial |
$2.34
|
| Rate for Payer: Entrust Commercial |
$2.27
|
| Rate for Payer: First Choice Health Commercial |
$2.27
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.27
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.58
|
| Rate for Payer: HealthUtah PPO |
$2.39
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.32
|
| Rate for Payer: Multiplan Medicare/VA |
$1.50
|
| Rate for Payer: One Health Plan of WY PPO |
$2.34
|
| Rate for Payer: PacificSource Commercial |
$2.15
|
| Rate for Payer: PHCS PPO |
$2.34
|
| Rate for Payer: Three Rivers PPO |
$1.79
|
| Rate for Payer: TriWest Veterans Administration |
$1.58
|
| Rate for Payer: United Healthcare Commercial |
$2.08
|
| Rate for Payer: United Healthcare Medicare |
$1.58
|
| Rate for Payer: WINHealth Partners Commercial |
$2.27
|
| Rate for Payer: Wise Provider Network Commercial |
$2.27
|
|
|
AZITHROMYCIN 250 MG TABLET [3126]
|
Facility
|
OP
|
$2.94
|
|
|
Service Code
|
NDC 6586264169
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.62 |
| Max. Negotiated Rate |
$2.94 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.88
|
| Rate for Payer: Aetna of WY Medicare |
$1.94
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.82
|
| Rate for Payer: Altius Commercial |
$2.82
|
| Rate for Payer: Beech Street Commercial |
$2.88
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.41
|
| Rate for Payer: Cash Price |
$2.06
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.85
|
| Rate for Payer: Cigna of WY Commercial |
$2.88
|
| Rate for Payer: Entrust Commercial |
$2.79
|
| Rate for Payer: First Choice Health Commercial |
$2.79
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.79
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.71
|
| Rate for Payer: HealthUtah PPO |
$2.94
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.85
|
| Rate for Payer: Multiplan Medicare/VA |
$1.62
|
| Rate for Payer: One Health Plan of WY PPO |
$2.88
|
| Rate for Payer: PacificSource Commercial |
$2.65
|
| Rate for Payer: PHCS PPO |
$2.88
|
| Rate for Payer: Three Rivers PPO |
$2.20
|
| Rate for Payer: TriWest Veterans Administration |
$1.71
|
| Rate for Payer: United Healthcare Commercial |
$2.56
|
| Rate for Payer: United Healthcare Medicare |
$1.71
|
| Rate for Payer: WINHealth Partners Commercial |
$2.88
|
| Rate for Payer: Wise Provider Network Commercial |
$2.79
|
|
|
AZITHROMYCIN 250 MG TABLET [3126]
|
Facility
|
IP
|
$10.00
|
|
|
Service Code
|
NDC 5011178751
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.27 |
| Max. Negotiated Rate |
$10.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$9.80
|
| Rate for Payer: Altius Auto/Workers Compensation |
$9.60
|
| Rate for Payer: Altius Commercial |
$9.60
|
| Rate for Payer: Beech Street Commercial |
$9.80
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$8.21
|
| Rate for Payer: Cash Price |
$7.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$9.70
|
| Rate for Payer: Cigna of WY Commercial |
$9.80
|
| Rate for Payer: Entrust Commercial |
$9.50
|
| Rate for Payer: First Choice Health Commercial |
$9.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$9.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$6.60
|
| Rate for Payer: HealthUtah PPO |
$10.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$9.70
|
| Rate for Payer: Multiplan Medicare/VA |
$6.27
|
| Rate for Payer: One Health Plan of WY PPO |
$9.80
|
| Rate for Payer: PacificSource Commercial |
$9.00
|
| Rate for Payer: PHCS PPO |
$9.80
|
| Rate for Payer: Three Rivers PPO |
$7.50
|
| Rate for Payer: TriWest Veterans Administration |
$6.60
|
| Rate for Payer: United Healthcare Commercial |
$8.70
|
| Rate for Payer: United Healthcare Medicare |
$6.60
|
| Rate for Payer: WINHealth Partners Commercial |
$9.50
|
| Rate for Payer: Wise Provider Network Commercial |
$9.50
|
|
|
AZITHROMYCIN 250 MG TABLET [3126]
|
Facility
|
IP
|
$2.94
|
|
|
Service Code
|
NDC 6586264169
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.84 |
| Max. Negotiated Rate |
$2.94 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.88
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.82
|
| Rate for Payer: Altius Commercial |
$2.82
|
| Rate for Payer: Beech Street Commercial |
$2.88
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.41
|
| Rate for Payer: Cash Price |
$2.06
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.85
|
| Rate for Payer: Cigna of WY Commercial |
$2.88
|
| Rate for Payer: Entrust Commercial |
$2.79
|
| Rate for Payer: First Choice Health Commercial |
$2.79
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.79
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.94
|
| Rate for Payer: HealthUtah PPO |
$2.94
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.85
|
| Rate for Payer: Multiplan Medicare/VA |
$1.84
|
| Rate for Payer: One Health Plan of WY PPO |
$2.88
|
| Rate for Payer: PacificSource Commercial |
$2.65
|
| Rate for Payer: PHCS PPO |
$2.88
|
| Rate for Payer: Three Rivers PPO |
$2.20
|
| Rate for Payer: TriWest Veterans Administration |
$1.94
|
| Rate for Payer: United Healthcare Commercial |
$2.56
|
| Rate for Payer: United Healthcare Medicare |
$1.94
|
| Rate for Payer: WINHealth Partners Commercial |
$2.79
|
| Rate for Payer: Wise Provider Network Commercial |
$2.79
|
|
|
AZITHROMYCIN 250 MG TABLET [3126]
|
Facility
|
OP
|
$2.39
|
|
|
Service Code
|
NDC 6809490006
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$2.39 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.34
|
| Rate for Payer: Aetna of WY Medicare |
$1.58
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.29
|
| Rate for Payer: Altius Commercial |
$2.29
|
| Rate for Payer: Beech Street Commercial |
$2.34
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.96
|
| Rate for Payer: Cash Price |
$1.67
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.32
|
| Rate for Payer: Cigna of WY Commercial |
$2.34
|
| Rate for Payer: Entrust Commercial |
$2.27
|
| Rate for Payer: First Choice Health Commercial |
$2.27
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.27
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.39
|
| Rate for Payer: HealthUtah PPO |
$2.39
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.32
|
| Rate for Payer: Multiplan Medicare/VA |
$1.32
|
| Rate for Payer: One Health Plan of WY PPO |
$2.34
|
| Rate for Payer: PacificSource Commercial |
$2.15
|
| Rate for Payer: PHCS PPO |
$2.34
|
| Rate for Payer: Three Rivers PPO |
$1.79
|
| Rate for Payer: TriWest Veterans Administration |
$1.39
|
| Rate for Payer: United Healthcare Commercial |
$2.08
|
| Rate for Payer: United Healthcare Medicare |
$1.39
|
| Rate for Payer: WINHealth Partners Commercial |
$2.34
|
| Rate for Payer: Wise Provider Network Commercial |
$2.27
|
|
|
AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION [14310]
|
Facility
|
IP
|
$32.62
|
|
|
Service Code
|
HCPCS J0456
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.45 |
| Max. Negotiated Rate |
$32.62 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$31.97
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$35.97
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$33.08
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$27.56
|
| Rate for Payer: Altius Auto/Workers Compensation |
$31.32
|
| Rate for Payer: Altius Auto/Workers Compensation |
$32.40
|
| Rate for Payer: Altius Auto/Workers Compensation |
$35.23
|
| Rate for Payer: Altius Auto/Workers Compensation |
$27.00
|
| Rate for Payer: Altius Commercial |
$31.32
|
| Rate for Payer: Altius Commercial |
$35.23
|
| Rate for Payer: Altius Commercial |
$27.00
|
| Rate for Payer: Altius Commercial |
$32.40
|
| Rate for Payer: Beech Street Commercial |
$35.97
|
| Rate for Payer: Beech Street Commercial |
$33.08
|
| Rate for Payer: Beech Street Commercial |
$31.97
|
| Rate for Payer: Beech Street Commercial |
$27.56
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$23.09
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$26.78
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$27.71
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$30.13
|
| Rate for Payer: Cash Price |
$19.69
|
| Rate for Payer: Cash Price |
$23.62
|
| Rate for Payer: Cash Price |
$22.84
|
| Rate for Payer: Cash Price |
$25.69
|
| Rate for Payer: ChoiceCare Network Commercial |
$31.64
|
| Rate for Payer: ChoiceCare Network Commercial |
$27.28
|
| Rate for Payer: ChoiceCare Network Commercial |
$32.74
|
| Rate for Payer: ChoiceCare Network Commercial |
$35.60
|
| Rate for Payer: Cigna of WY Commercial |
$35.97
|
| Rate for Payer: Cigna of WY Commercial |
$27.56
|
| Rate for Payer: Cigna of WY Commercial |
$33.08
|
| Rate for Payer: Cigna of WY Commercial |
$31.97
|
| Rate for Payer: Entrust Commercial |
$32.06
|
| Rate for Payer: Entrust Commercial |
$34.86
|
| Rate for Payer: Entrust Commercial |
$26.71
|
| Rate for Payer: Entrust Commercial |
$30.99
|
| Rate for Payer: First Choice Health Commercial |
$30.99
|
| Rate for Payer: First Choice Health Commercial |
$26.71
|
| Rate for Payer: First Choice Health Commercial |
$34.86
|
| Rate for Payer: First Choice Health Commercial |
$32.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$30.99
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$26.71
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$32.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$34.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$18.56
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$21.53
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$22.28
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$24.22
|
| Rate for Payer: HealthUtah PPO |
$28.12
|
| Rate for Payer: HealthUtah PPO |
$32.62
|
| Rate for Payer: HealthUtah PPO |
$36.70
|
| Rate for Payer: HealthUtah PPO |
$33.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$35.60
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$27.28
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$31.64
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$32.74
|
| Rate for Payer: Multiplan Medicare/VA |
$17.63
|
| Rate for Payer: Multiplan Medicare/VA |
$21.16
|
| Rate for Payer: Multiplan Medicare/VA |
$23.01
|
| Rate for Payer: Multiplan Medicare/VA |
$20.45
|
| Rate for Payer: One Health Plan of WY PPO |
$33.08
|
| Rate for Payer: One Health Plan of WY PPO |
$31.97
|
| Rate for Payer: One Health Plan of WY PPO |
$27.56
|
| Rate for Payer: One Health Plan of WY PPO |
$35.97
|
| Rate for Payer: PacificSource Commercial |
$30.38
|
| Rate for Payer: PacificSource Commercial |
$25.31
|
| Rate for Payer: PacificSource Commercial |
$29.36
|
| Rate for Payer: PacificSource Commercial |
$33.03
|
| Rate for Payer: PHCS PPO |
$35.97
|
| Rate for Payer: PHCS PPO |
$33.08
|
| Rate for Payer: PHCS PPO |
$27.56
|
| Rate for Payer: PHCS PPO |
$31.97
|
| Rate for Payer: Three Rivers PPO |
$24.46
|
| Rate for Payer: Three Rivers PPO |
$27.52
|
| Rate for Payer: Three Rivers PPO |
$25.31
|
| Rate for Payer: Three Rivers PPO |
$21.09
|
| Rate for Payer: TriWest Veterans Administration |
$22.28
|
| Rate for Payer: TriWest Veterans Administration |
$18.56
|
| Rate for Payer: TriWest Veterans Administration |
$21.53
|
| Rate for Payer: TriWest Veterans Administration |
$24.22
|
| Rate for Payer: United Healthcare Commercial |
$31.93
|
| Rate for Payer: United Healthcare Commercial |
$29.36
|
| Rate for Payer: United Healthcare Commercial |
$28.38
|
| Rate for Payer: United Healthcare Commercial |
$24.46
|
| Rate for Payer: United Healthcare Medicare |
$18.56
|
| Rate for Payer: United Healthcare Medicare |
$24.22
|
| Rate for Payer: United Healthcare Medicare |
$22.28
|
| Rate for Payer: United Healthcare Medicare |
$21.53
|
| Rate for Payer: WINHealth Partners Commercial |
$30.99
|
| Rate for Payer: WINHealth Partners Commercial |
$26.71
|
| Rate for Payer: WINHealth Partners Commercial |
$34.86
|
| Rate for Payer: WINHealth Partners Commercial |
$32.06
|
| Rate for Payer: Wise Provider Network Commercial |
$32.06
|
| Rate for Payer: Wise Provider Network Commercial |
$30.99
|
| Rate for Payer: Wise Provider Network Commercial |
$26.71
|
| Rate for Payer: Wise Provider Network Commercial |
$34.86
|
|
|
AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION [14310]
|
Facility
|
OP
|
$33.75
|
|
|
Service Code
|
HCPCS J0456
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.60 |
| Max. Negotiated Rate |
$33.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$33.08
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$31.97
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$27.56
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$35.97
|
| Rate for Payer: Aetna of WY Medicare |
$21.53
|
| Rate for Payer: Aetna of WY Medicare |
$22.28
|
| Rate for Payer: Aetna of WY Medicare |
$18.56
|
| Rate for Payer: Aetna of WY Medicare |
$24.22
|
| Rate for Payer: Altius Auto/Workers Compensation |
$32.40
|
| Rate for Payer: Altius Auto/Workers Compensation |
$35.23
|
| Rate for Payer: Altius Auto/Workers Compensation |
$31.32
|
| Rate for Payer: Altius Auto/Workers Compensation |
$27.00
|
| Rate for Payer: Altius Commercial |
$32.40
|
| Rate for Payer: Altius Commercial |
$31.32
|
| Rate for Payer: Altius Commercial |
$35.23
|
| Rate for Payer: Altius Commercial |
$27.00
|
| Rate for Payer: Beech Street Commercial |
$31.97
|
| Rate for Payer: Beech Street Commercial |
$33.08
|
| Rate for Payer: Beech Street Commercial |
$27.56
|
| Rate for Payer: Beech Street Commercial |
$35.97
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$23.09
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$27.71
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$26.78
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$30.13
|
| Rate for Payer: Cash Price |
$23.62
|
| Rate for Payer: Cash Price |
$22.84
|
| Rate for Payer: Cash Price |
$25.69
|
| Rate for Payer: Cash Price |
$19.69
|
| Rate for Payer: ChoiceCare Network Commercial |
$27.28
|
| Rate for Payer: ChoiceCare Network Commercial |
$32.74
|
| Rate for Payer: ChoiceCare Network Commercial |
$31.64
|
| Rate for Payer: ChoiceCare Network Commercial |
$35.60
|
| Rate for Payer: Cigna of WY Commercial |
$33.08
|
| Rate for Payer: Cigna of WY Commercial |
$27.56
|
| Rate for Payer: Cigna of WY Commercial |
$31.97
|
| Rate for Payer: Cigna of WY Commercial |
$35.97
|
| Rate for Payer: Entrust Commercial |
$30.99
|
| Rate for Payer: Entrust Commercial |
$26.71
|
| Rate for Payer: Entrust Commercial |
$34.86
|
| Rate for Payer: Entrust Commercial |
$32.06
|
| Rate for Payer: First Choice Health Commercial |
$32.06
|
| Rate for Payer: First Choice Health Commercial |
$26.71
|
| Rate for Payer: First Choice Health Commercial |
$30.99
|
| Rate for Payer: First Choice Health Commercial |
$34.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$30.99
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$26.71
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$34.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$32.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$21.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$16.31
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$18.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$19.58
|
| Rate for Payer: HealthUtah PPO |
$28.12
|
| Rate for Payer: HealthUtah PPO |
$36.70
|
| Rate for Payer: HealthUtah PPO |
$33.75
|
| Rate for Payer: HealthUtah PPO |
$32.62
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$31.64
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$35.60
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$32.74
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$27.28
|
| Rate for Payer: Multiplan Medicare/VA |
$18.60
|
| Rate for Payer: Multiplan Medicare/VA |
$15.49
|
| Rate for Payer: Multiplan Medicare/VA |
$20.22
|
| Rate for Payer: Multiplan Medicare/VA |
$17.97
|
| Rate for Payer: One Health Plan of WY PPO |
$27.56
|
| Rate for Payer: One Health Plan of WY PPO |
$35.97
|
| Rate for Payer: One Health Plan of WY PPO |
$33.08
|
| Rate for Payer: One Health Plan of WY PPO |
$31.97
|
| Rate for Payer: PacificSource Commercial |
$33.03
|
| Rate for Payer: PacificSource Commercial |
$25.31
|
| Rate for Payer: PacificSource Commercial |
$29.36
|
| Rate for Payer: PacificSource Commercial |
$30.38
|
| Rate for Payer: PHCS PPO |
$35.97
|
| Rate for Payer: PHCS PPO |
$33.08
|
| Rate for Payer: PHCS PPO |
$31.97
|
| Rate for Payer: PHCS PPO |
$27.56
|
| Rate for Payer: Three Rivers PPO |
$24.46
|
| Rate for Payer: Three Rivers PPO |
$27.52
|
| Rate for Payer: Three Rivers PPO |
$25.31
|
| Rate for Payer: Three Rivers PPO |
$21.09
|
| Rate for Payer: TriWest Veterans Administration |
$18.92
|
| Rate for Payer: TriWest Veterans Administration |
$21.29
|
| Rate for Payer: TriWest Veterans Administration |
$16.31
|
| Rate for Payer: TriWest Veterans Administration |
$19.58
|
| Rate for Payer: United Healthcare Commercial |
$29.36
|
| Rate for Payer: United Healthcare Commercial |
$28.38
|
| Rate for Payer: United Healthcare Commercial |
$24.46
|
| Rate for Payer: United Healthcare Commercial |
$31.93
|
| Rate for Payer: United Healthcare Medicare |
$19.58
|
| Rate for Payer: United Healthcare Medicare |
$16.31
|
| Rate for Payer: United Healthcare Medicare |
$18.92
|
| Rate for Payer: United Healthcare Medicare |
$21.29
|
| Rate for Payer: WINHealth Partners Commercial |
$35.97
|
| Rate for Payer: WINHealth Partners Commercial |
$31.97
|
| Rate for Payer: WINHealth Partners Commercial |
$27.56
|
| Rate for Payer: WINHealth Partners Commercial |
$33.08
|
| Rate for Payer: Wise Provider Network Commercial |
$30.99
|
| Rate for Payer: Wise Provider Network Commercial |
$26.71
|
| Rate for Payer: Wise Provider Network Commercial |
$32.06
|
| Rate for Payer: Wise Provider Network Commercial |
$34.86
|
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT [6246]
|
Facility
|
IP
|
$0.48
|
|
|
Service Code
|
NDC 6800147746
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.47
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.46
|
| Rate for Payer: Altius Commercial |
$0.46
|
| Rate for Payer: Beech Street Commercial |
$0.47
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.39
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.47
|
| Rate for Payer: Cigna of WY Commercial |
$0.47
|
| Rate for Payer: Entrust Commercial |
$0.46
|
| Rate for Payer: First Choice Health Commercial |
$0.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.32
|
| Rate for Payer: HealthUtah PPO |
$0.48
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.47
|
| Rate for Payer: Multiplan Medicare/VA |
$0.30
|
| Rate for Payer: One Health Plan of WY PPO |
$0.47
|
| Rate for Payer: PacificSource Commercial |
$0.43
|
| Rate for Payer: PHCS PPO |
$0.47
|
| Rate for Payer: Three Rivers PPO |
$0.36
|
| Rate for Payer: TriWest Veterans Administration |
$0.32
|
| Rate for Payer: United Healthcare Commercial |
$0.42
|
| Rate for Payer: United Healthcare Medicare |
$0.32
|
| Rate for Payer: WINHealth Partners Commercial |
$0.46
|
| Rate for Payer: Wise Provider Network Commercial |
$0.46
|
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT [6246]
|
Facility
|
OP
|
$0.48
|
|
|
Service Code
|
NDC 6800147746
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.47
|
| Rate for Payer: Aetna of WY Medicare |
$0.32
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.46
|
| Rate for Payer: Altius Commercial |
$0.46
|
| Rate for Payer: Beech Street Commercial |
$0.47
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.39
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.47
|
| Rate for Payer: Cigna of WY Commercial |
$0.47
|
| Rate for Payer: Entrust Commercial |
$0.46
|
| Rate for Payer: First Choice Health Commercial |
$0.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.28
|
| Rate for Payer: HealthUtah PPO |
$0.48
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.47
|
| Rate for Payer: Multiplan Medicare/VA |
$0.26
|
| Rate for Payer: One Health Plan of WY PPO |
$0.47
|
| Rate for Payer: PacificSource Commercial |
$0.43
|
| Rate for Payer: PHCS PPO |
$0.47
|
| Rate for Payer: Three Rivers PPO |
$0.36
|
| Rate for Payer: TriWest Veterans Administration |
$0.28
|
| Rate for Payer: United Healthcare Commercial |
$0.42
|
| Rate for Payer: United Healthcare Medicare |
$0.28
|
| Rate for Payer: WINHealth Partners Commercial |
$0.47
|
| Rate for Payer: Wise Provider Network Commercial |
$0.46
|
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET [28964]
|
Facility
|
IP
|
$0.53
|
|
|
Service Code
|
NDC 4580206000
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.52
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.51
|
| Rate for Payer: Altius Commercial |
$0.51
|
| Rate for Payer: Beech Street Commercial |
$0.52
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.44
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.51
|
| Rate for Payer: Cigna of WY Commercial |
$0.52
|
| Rate for Payer: Entrust Commercial |
$0.50
|
| Rate for Payer: First Choice Health Commercial |
$0.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.35
|
| Rate for Payer: HealthUtah PPO |
$0.53
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.51
|
| Rate for Payer: Multiplan Medicare/VA |
$0.33
|
| Rate for Payer: One Health Plan of WY PPO |
$0.52
|
| Rate for Payer: PacificSource Commercial |
$0.48
|
| Rate for Payer: PHCS PPO |
$0.52
|
| Rate for Payer: Three Rivers PPO |
$0.40
|
| Rate for Payer: TriWest Veterans Administration |
$0.35
|
| Rate for Payer: United Healthcare Commercial |
$0.46
|
| Rate for Payer: United Healthcare Medicare |
$0.35
|
| Rate for Payer: WINHealth Partners Commercial |
$0.50
|
| Rate for Payer: Wise Provider Network Commercial |
$0.50
|
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET [28964]
|
Facility
|
IP
|
$0.53
|
|
|
Service Code
|
NDC 6800147745
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.52
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.51
|
| Rate for Payer: Altius Commercial |
$0.51
|
| Rate for Payer: Beech Street Commercial |
$0.52
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.44
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.51
|
| Rate for Payer: Cigna of WY Commercial |
$0.52
|
| Rate for Payer: Entrust Commercial |
$0.50
|
| Rate for Payer: First Choice Health Commercial |
$0.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.35
|
| Rate for Payer: HealthUtah PPO |
$0.53
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.51
|
| Rate for Payer: Multiplan Medicare/VA |
$0.33
|
| Rate for Payer: One Health Plan of WY PPO |
$0.52
|
| Rate for Payer: PacificSource Commercial |
$0.48
|
| Rate for Payer: PHCS PPO |
$0.52
|
| Rate for Payer: Three Rivers PPO |
$0.40
|
| Rate for Payer: TriWest Veterans Administration |
$0.35
|
| Rate for Payer: United Healthcare Commercial |
$0.46
|
| Rate for Payer: United Healthcare Medicare |
$0.35
|
| Rate for Payer: WINHealth Partners Commercial |
$0.50
|
| Rate for Payer: Wise Provider Network Commercial |
$0.50
|
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET [28964]
|
Facility
|
OP
|
$0.53
|
|
|
Service Code
|
NDC 4580206000
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.52
|
| Rate for Payer: Aetna of WY Medicare |
$0.35
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.51
|
| Rate for Payer: Altius Commercial |
$0.51
|
| Rate for Payer: Beech Street Commercial |
$0.52
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.44
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.51
|
| Rate for Payer: Cigna of WY Commercial |
$0.52
|
| Rate for Payer: Entrust Commercial |
$0.50
|
| Rate for Payer: First Choice Health Commercial |
$0.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.31
|
| Rate for Payer: HealthUtah PPO |
$0.53
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.51
|
| Rate for Payer: Multiplan Medicare/VA |
$0.29
|
| Rate for Payer: One Health Plan of WY PPO |
$0.52
|
| Rate for Payer: PacificSource Commercial |
$0.48
|
| Rate for Payer: PHCS PPO |
$0.52
|
| Rate for Payer: Three Rivers PPO |
$0.40
|
| Rate for Payer: TriWest Veterans Administration |
$0.31
|
| Rate for Payer: United Healthcare Commercial |
$0.46
|
| Rate for Payer: United Healthcare Medicare |
$0.31
|
| Rate for Payer: WINHealth Partners Commercial |
$0.52
|
| Rate for Payer: Wise Provider Network Commercial |
$0.50
|
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET [28964]
|
Facility
|
IP
|
$0.53
|
|
|
Service Code
|
NDC 4580206070
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.52
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.51
|
| Rate for Payer: Altius Commercial |
$0.51
|
| Rate for Payer: Beech Street Commercial |
$0.52
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.44
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.51
|
| Rate for Payer: Cigna of WY Commercial |
$0.52
|
| Rate for Payer: Entrust Commercial |
$0.50
|
| Rate for Payer: First Choice Health Commercial |
$0.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.35
|
| Rate for Payer: HealthUtah PPO |
$0.53
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.51
|
| Rate for Payer: Multiplan Medicare/VA |
$0.33
|
| Rate for Payer: One Health Plan of WY PPO |
$0.52
|
| Rate for Payer: PacificSource Commercial |
$0.48
|
| Rate for Payer: PHCS PPO |
$0.52
|
| Rate for Payer: Three Rivers PPO |
$0.40
|
| Rate for Payer: TriWest Veterans Administration |
$0.35
|
| Rate for Payer: United Healthcare Commercial |
$0.46
|
| Rate for Payer: United Healthcare Medicare |
$0.35
|
| Rate for Payer: WINHealth Partners Commercial |
$0.50
|
| Rate for Payer: Wise Provider Network Commercial |
$0.50
|
|
