|
ACETAMINOPHEN 500 MG TABLET [7875]
|
Facility
|
IP
|
$0.18
|
|
|
Service Code
|
NDC 0904673061
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.18
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.17
|
| Rate for Payer: Altius Commercial |
$0.17
|
| Rate for Payer: Beech Street Commercial |
$0.18
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.15
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.17
|
| Rate for Payer: Cigna of WY Commercial |
$0.18
|
| Rate for Payer: Entrust Commercial |
$0.17
|
| Rate for Payer: First Choice Health Commercial |
$0.17
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.17
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.12
|
| Rate for Payer: HealthUtah PPO |
$0.18
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.17
|
| Rate for Payer: Multiplan Medicare/VA |
$0.11
|
| Rate for Payer: One Health Plan of WY PPO |
$0.18
|
| Rate for Payer: PacificSource Commercial |
$0.16
|
| Rate for Payer: PHCS PPO |
$0.18
|
| Rate for Payer: Three Rivers PPO |
$0.14
|
| Rate for Payer: TriWest Veterans Administration |
$0.12
|
| Rate for Payer: United Healthcare Commercial |
$0.16
|
| Rate for Payer: United Healthcare Medicare |
$0.12
|
| Rate for Payer: WINHealth Partners Commercial |
$0.17
|
| Rate for Payer: Wise Provider Network Commercial |
$0.17
|
|
|
ACETAMINOPHEN 500 MG TABLET [7875]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 0904673061
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.18
|
| Rate for Payer: Aetna of WY Medicare |
$0.12
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.17
|
| Rate for Payer: Altius Commercial |
$0.17
|
| Rate for Payer: Beech Street Commercial |
$0.18
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.15
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.17
|
| Rate for Payer: Cigna of WY Commercial |
$0.18
|
| Rate for Payer: Entrust Commercial |
$0.17
|
| Rate for Payer: First Choice Health Commercial |
$0.17
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.17
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.10
|
| Rate for Payer: HealthUtah PPO |
$0.18
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.17
|
| Rate for Payer: Multiplan Medicare/VA |
$0.10
|
| Rate for Payer: One Health Plan of WY PPO |
$0.18
|
| Rate for Payer: PacificSource Commercial |
$0.16
|
| Rate for Payer: PHCS PPO |
$0.18
|
| Rate for Payer: Three Rivers PPO |
$0.14
|
| Rate for Payer: TriWest Veterans Administration |
$0.10
|
| Rate for Payer: United Healthcare Commercial |
$0.16
|
| Rate for Payer: United Healthcare Medicare |
$0.10
|
| Rate for Payer: WINHealth Partners Commercial |
$0.18
|
| Rate for Payer: Wise Provider Network Commercial |
$0.17
|
|
|
ACETAMINOPHEN 500 MG TABLET [7875]
|
Facility
|
IP
|
$0.07
|
|
|
Service Code
|
NDC 0904672040
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.07
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.07
|
| Rate for Payer: Altius Commercial |
$0.07
|
| Rate for Payer: Beech Street Commercial |
$0.07
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.07
|
| Rate for Payer: Cigna of WY Commercial |
$0.07
|
| Rate for Payer: Entrust Commercial |
$0.07
|
| Rate for Payer: First Choice Health Commercial |
$0.07
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.07
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.05
|
| Rate for Payer: HealthUtah PPO |
$0.07
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.07
|
| Rate for Payer: Multiplan Medicare/VA |
$0.04
|
| Rate for Payer: One Health Plan of WY PPO |
$0.07
|
| Rate for Payer: PacificSource Commercial |
$0.06
|
| Rate for Payer: PHCS PPO |
$0.07
|
| Rate for Payer: Three Rivers PPO |
$0.05
|
| Rate for Payer: TriWest Veterans Administration |
$0.05
|
| Rate for Payer: United Healthcare Commercial |
$0.06
|
| Rate for Payer: United Healthcare Medicare |
$0.05
|
| Rate for Payer: WINHealth Partners Commercial |
$0.07
|
| Rate for Payer: Wise Provider Network Commercial |
$0.07
|
|
|
ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY [1510]
|
Facility
|
IP
|
$1.42
|
|
|
Service Code
|
NDC 4580273030
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.89 |
| Max. Negotiated Rate |
$1.42 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.39
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.36
|
| Rate for Payer: Altius Commercial |
$1.36
|
| Rate for Payer: Beech Street Commercial |
$1.39
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.17
|
| Rate for Payer: Cash Price |
$0.99
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.38
|
| Rate for Payer: Cigna of WY Commercial |
$1.39
|
| Rate for Payer: Entrust Commercial |
$1.35
|
| Rate for Payer: First Choice Health Commercial |
$1.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.94
|
| Rate for Payer: HealthUtah PPO |
$1.42
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.38
|
| Rate for Payer: Multiplan Medicare/VA |
$0.89
|
| Rate for Payer: One Health Plan of WY PPO |
$1.39
|
| Rate for Payer: PacificSource Commercial |
$1.28
|
| Rate for Payer: PHCS PPO |
$1.39
|
| Rate for Payer: Three Rivers PPO |
$1.06
|
| Rate for Payer: TriWest Veterans Administration |
$0.94
|
| Rate for Payer: United Healthcare Commercial |
$1.24
|
| Rate for Payer: United Healthcare Medicare |
$0.94
|
| Rate for Payer: WINHealth Partners Commercial |
$1.35
|
| Rate for Payer: Wise Provider Network Commercial |
$1.35
|
|
|
ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY [1510]
|
Facility
|
OP
|
$1.42
|
|
|
Service Code
|
NDC 4580273030
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.78 |
| Max. Negotiated Rate |
$1.42 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.39
|
| Rate for Payer: Aetna of WY Medicare |
$0.94
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.36
|
| Rate for Payer: Altius Commercial |
$1.36
|
| Rate for Payer: Beech Street Commercial |
$1.39
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.17
|
| Rate for Payer: Cash Price |
$0.99
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.38
|
| Rate for Payer: Cigna of WY Commercial |
$1.39
|
| Rate for Payer: Entrust Commercial |
$1.35
|
| Rate for Payer: First Choice Health Commercial |
$1.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.82
|
| Rate for Payer: HealthUtah PPO |
$1.42
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.38
|
| Rate for Payer: Multiplan Medicare/VA |
$0.78
|
| Rate for Payer: One Health Plan of WY PPO |
$1.39
|
| Rate for Payer: PacificSource Commercial |
$1.28
|
| Rate for Payer: PHCS PPO |
$1.39
|
| Rate for Payer: Three Rivers PPO |
$1.06
|
| Rate for Payer: TriWest Veterans Administration |
$0.82
|
| Rate for Payer: United Healthcare Commercial |
$1.24
|
| Rate for Payer: United Healthcare Medicare |
$0.82
|
| Rate for Payer: WINHealth Partners Commercial |
$1.39
|
| Rate for Payer: Wise Provider Network Commercial |
$1.35
|
|
|
ACETAMINOPHEN ER 650 MG TABLET,EXTENDED RELEASE [8567]
|
Facility
|
IP
|
$0.22
|
|
|
Service Code
|
NDC 5166033301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.22
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.21
|
| Rate for Payer: Altius Commercial |
$0.21
|
| Rate for Payer: Beech Street Commercial |
$0.22
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.18
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.21
|
| Rate for Payer: Cigna of WY Commercial |
$0.22
|
| Rate for Payer: Entrust Commercial |
$0.21
|
| Rate for Payer: First Choice Health Commercial |
$0.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.15
|
| Rate for Payer: HealthUtah PPO |
$0.22
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.21
|
| Rate for Payer: Multiplan Medicare/VA |
$0.14
|
| Rate for Payer: One Health Plan of WY PPO |
$0.22
|
| Rate for Payer: PacificSource Commercial |
$0.20
|
| Rate for Payer: PHCS PPO |
$0.22
|
| Rate for Payer: Three Rivers PPO |
$0.17
|
| Rate for Payer: TriWest Veterans Administration |
$0.15
|
| Rate for Payer: United Healthcare Commercial |
$0.19
|
| Rate for Payer: United Healthcare Medicare |
$0.15
|
| Rate for Payer: WINHealth Partners Commercial |
$0.21
|
| Rate for Payer: Wise Provider Network Commercial |
$0.21
|
|
|
ACETAMINOPHEN ER 650 MG TABLET,EXTENDED RELEASE [8567]
|
Facility
|
OP
|
$0.22
|
|
|
Service Code
|
NDC 5166033301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.22
|
| Rate for Payer: Aetna of WY Medicare |
$0.15
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.21
|
| Rate for Payer: Altius Commercial |
$0.21
|
| Rate for Payer: Beech Street Commercial |
$0.22
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.18
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.21
|
| Rate for Payer: Cigna of WY Commercial |
$0.22
|
| Rate for Payer: Entrust Commercial |
$0.21
|
| Rate for Payer: First Choice Health Commercial |
$0.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.13
|
| Rate for Payer: HealthUtah PPO |
$0.22
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.21
|
| Rate for Payer: Multiplan Medicare/VA |
$0.12
|
| Rate for Payer: One Health Plan of WY PPO |
$0.22
|
| Rate for Payer: PacificSource Commercial |
$0.20
|
| Rate for Payer: PHCS PPO |
$0.22
|
| Rate for Payer: Three Rivers PPO |
$0.17
|
| Rate for Payer: TriWest Veterans Administration |
$0.13
|
| Rate for Payer: United Healthcare Commercial |
$0.19
|
| Rate for Payer: United Healthcare Medicare |
$0.13
|
| Rate for Payer: WINHealth Partners Commercial |
$0.22
|
| Rate for Payer: Wise Provider Network Commercial |
$0.21
|
|
|
ACETAZOLAMIDE 250 MG TABLET [5981]
|
Facility
|
OP
|
$1.40
|
|
|
Service Code
|
NDC 7075672111
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.77 |
| Max. Negotiated Rate |
$1.40 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.37
|
| Rate for Payer: Aetna of WY Medicare |
$0.92
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.34
|
| Rate for Payer: Altius Commercial |
$1.34
|
| Rate for Payer: Beech Street Commercial |
$1.37
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.15
|
| Rate for Payer: Cash Price |
$0.98
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.36
|
| Rate for Payer: Cigna of WY Commercial |
$1.37
|
| Rate for Payer: Entrust Commercial |
$1.33
|
| Rate for Payer: First Choice Health Commercial |
$1.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.81
|
| Rate for Payer: HealthUtah PPO |
$1.40
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.36
|
| Rate for Payer: Multiplan Medicare/VA |
$0.77
|
| Rate for Payer: One Health Plan of WY PPO |
$1.37
|
| Rate for Payer: PacificSource Commercial |
$1.26
|
| Rate for Payer: PHCS PPO |
$1.37
|
| Rate for Payer: Three Rivers PPO |
$1.05
|
| Rate for Payer: TriWest Veterans Administration |
$0.81
|
| Rate for Payer: United Healthcare Commercial |
$1.22
|
| Rate for Payer: United Healthcare Medicare |
$0.81
|
| Rate for Payer: WINHealth Partners Commercial |
$1.37
|
| Rate for Payer: Wise Provider Network Commercial |
$1.33
|
|
|
ACETAZOLAMIDE 250 MG TABLET [5981]
|
Facility
|
IP
|
$1.40
|
|
|
Service Code
|
NDC 7075672111
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$1.40 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.37
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.34
|
| Rate for Payer: Altius Commercial |
$1.34
|
| Rate for Payer: Beech Street Commercial |
$1.37
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.15
|
| Rate for Payer: Cash Price |
$0.98
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.36
|
| Rate for Payer: Cigna of WY Commercial |
$1.37
|
| Rate for Payer: Entrust Commercial |
$1.33
|
| Rate for Payer: First Choice Health Commercial |
$1.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.92
|
| Rate for Payer: HealthUtah PPO |
$1.40
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.36
|
| Rate for Payer: Multiplan Medicare/VA |
$0.88
|
| Rate for Payer: One Health Plan of WY PPO |
$1.37
|
| Rate for Payer: PacificSource Commercial |
$1.26
|
| Rate for Payer: PHCS PPO |
$1.37
|
| Rate for Payer: Three Rivers PPO |
$1.05
|
| Rate for Payer: TriWest Veterans Administration |
$0.92
|
| Rate for Payer: United Healthcare Commercial |
$1.22
|
| Rate for Payer: United Healthcare Medicare |
$0.92
|
| Rate for Payer: WINHealth Partners Commercial |
$1.33
|
| Rate for Payer: Wise Provider Network Commercial |
$1.33
|
|
|
ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION [35100]
|
Facility
|
OP
|
$28.75
|
|
|
Service Code
|
HCPCS J0132
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.84 |
| Max. Negotiated Rate |
$28.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$28.18
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$21.66
|
| Rate for Payer: Aetna of WY Medicare |
$18.98
|
| Rate for Payer: Aetna of WY Medicare |
$14.59
|
| Rate for Payer: Altius Auto/Workers Compensation |
$21.22
|
| Rate for Payer: Altius Auto/Workers Compensation |
$27.60
|
| Rate for Payer: Altius Commercial |
$27.60
|
| Rate for Payer: Altius Commercial |
$21.22
|
| Rate for Payer: Beech Street Commercial |
$21.66
|
| Rate for Payer: Beech Street Commercial |
$28.18
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$23.60
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$18.14
|
| Rate for Payer: Cash Price |
$15.47
|
| Rate for Payer: Cash Price |
$20.12
|
| Rate for Payer: ChoiceCare Network Commercial |
$27.89
|
| Rate for Payer: ChoiceCare Network Commercial |
$21.44
|
| Rate for Payer: Cigna of WY Commercial |
$21.66
|
| Rate for Payer: Cigna of WY Commercial |
$28.18
|
| Rate for Payer: Entrust Commercial |
$27.31
|
| Rate for Payer: Entrust Commercial |
$21.00
|
| Rate for Payer: First Choice Health Commercial |
$21.00
|
| Rate for Payer: First Choice Health Commercial |
$27.31
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$21.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$27.31
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$16.68
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$12.82
|
| Rate for Payer: HealthUtah PPO |
$22.10
|
| Rate for Payer: HealthUtah PPO |
$28.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$21.44
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$27.89
|
| Rate for Payer: Multiplan Medicare/VA |
$15.84
|
| Rate for Payer: Multiplan Medicare/VA |
$12.18
|
| Rate for Payer: One Health Plan of WY PPO |
$21.66
|
| Rate for Payer: One Health Plan of WY PPO |
$28.18
|
| Rate for Payer: PacificSource Commercial |
$25.88
|
| Rate for Payer: PacificSource Commercial |
$19.89
|
| Rate for Payer: PHCS PPO |
$21.66
|
| Rate for Payer: PHCS PPO |
$28.18
|
| Rate for Payer: Three Rivers PPO |
$16.58
|
| Rate for Payer: Three Rivers PPO |
$21.56
|
| Rate for Payer: TriWest Veterans Administration |
$16.68
|
| Rate for Payer: TriWest Veterans Administration |
$12.82
|
| Rate for Payer: United Healthcare Commercial |
$19.23
|
| Rate for Payer: United Healthcare Commercial |
$25.01
|
| Rate for Payer: United Healthcare Medicare |
$16.68
|
| Rate for Payer: United Healthcare Medicare |
$12.82
|
| Rate for Payer: WINHealth Partners Commercial |
$21.66
|
| Rate for Payer: WINHealth Partners Commercial |
$28.18
|
| Rate for Payer: Wise Provider Network Commercial |
$21.00
|
| Rate for Payer: Wise Provider Network Commercial |
$27.31
|
|
|
ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION [35100]
|
Facility
|
IP
|
$28.75
|
|
|
Service Code
|
HCPCS J0132
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.03 |
| Max. Negotiated Rate |
$28.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$28.18
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$21.66
|
| Rate for Payer: Altius Auto/Workers Compensation |
$21.22
|
| Rate for Payer: Altius Auto/Workers Compensation |
$27.60
|
| Rate for Payer: Altius Commercial |
$21.22
|
| Rate for Payer: Altius Commercial |
$27.60
|
| Rate for Payer: Beech Street Commercial |
$28.18
|
| Rate for Payer: Beech Street Commercial |
$21.66
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$23.60
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$18.14
|
| Rate for Payer: Cash Price |
$15.47
|
| Rate for Payer: Cash Price |
$20.12
|
| Rate for Payer: ChoiceCare Network Commercial |
$27.89
|
| Rate for Payer: ChoiceCare Network Commercial |
$21.44
|
| Rate for Payer: Cigna of WY Commercial |
$21.66
|
| Rate for Payer: Cigna of WY Commercial |
$28.18
|
| Rate for Payer: Entrust Commercial |
$21.00
|
| Rate for Payer: Entrust Commercial |
$27.31
|
| Rate for Payer: First Choice Health Commercial |
$27.31
|
| Rate for Payer: First Choice Health Commercial |
$21.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$21.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$27.31
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$18.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$14.59
|
| Rate for Payer: HealthUtah PPO |
$28.75
|
| Rate for Payer: HealthUtah PPO |
$22.10
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$27.89
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$21.44
|
| Rate for Payer: Multiplan Medicare/VA |
$18.03
|
| Rate for Payer: Multiplan Medicare/VA |
$13.86
|
| Rate for Payer: One Health Plan of WY PPO |
$21.66
|
| Rate for Payer: One Health Plan of WY PPO |
$28.18
|
| Rate for Payer: PacificSource Commercial |
$25.88
|
| Rate for Payer: PacificSource Commercial |
$19.89
|
| Rate for Payer: PHCS PPO |
$21.66
|
| Rate for Payer: PHCS PPO |
$28.18
|
| Rate for Payer: Three Rivers PPO |
$16.58
|
| Rate for Payer: Three Rivers PPO |
$21.56
|
| Rate for Payer: TriWest Veterans Administration |
$18.98
|
| Rate for Payer: TriWest Veterans Administration |
$14.59
|
| Rate for Payer: United Healthcare Commercial |
$25.01
|
| Rate for Payer: United Healthcare Commercial |
$19.23
|
| Rate for Payer: United Healthcare Medicare |
$14.59
|
| Rate for Payer: United Healthcare Medicare |
$18.98
|
| Rate for Payer: WINHealth Partners Commercial |
$21.00
|
| Rate for Payer: WINHealth Partners Commercial |
$27.31
|
| Rate for Payer: Wise Provider Network Commercial |
$27.31
|
| Rate for Payer: Wise Provider Network Commercial |
$21.00
|
|
|
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION [1047]
|
Facility
|
IP
|
$3.47
|
|
|
Service Code
|
HCPCS J7608
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.18 |
| Max. Negotiated Rate |
$3.47 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3.40
|
| Rate for Payer: Altius Auto/Workers Compensation |
$3.33
|
| Rate for Payer: Altius Commercial |
$3.33
|
| Rate for Payer: Beech Street Commercial |
$3.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.85
|
| Rate for Payer: Cash Price |
$2.43
|
| Rate for Payer: ChoiceCare Network Commercial |
$3.37
|
| Rate for Payer: Cigna of WY Commercial |
$3.40
|
| Rate for Payer: Entrust Commercial |
$3.30
|
| Rate for Payer: First Choice Health Commercial |
$3.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2.29
|
| Rate for Payer: HealthUtah PPO |
$3.47
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3.37
|
| Rate for Payer: Multiplan Medicare/VA |
$2.18
|
| Rate for Payer: One Health Plan of WY PPO |
$3.40
|
| Rate for Payer: PacificSource Commercial |
$3.12
|
| Rate for Payer: PHCS PPO |
$3.40
|
| Rate for Payer: Three Rivers PPO |
$2.60
|
| Rate for Payer: TriWest Veterans Administration |
$2.29
|
| Rate for Payer: United Healthcare Commercial |
$3.02
|
| Rate for Payer: United Healthcare Medicare |
$2.29
|
| Rate for Payer: WINHealth Partners Commercial |
$3.30
|
| Rate for Payer: Wise Provider Network Commercial |
$3.30
|
|
|
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION [1047]
|
Facility
|
OP
|
$3.47
|
|
|
Service Code
|
HCPCS J7608
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.91 |
| Max. Negotiated Rate |
$3.47 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3.40
|
| Rate for Payer: Aetna of WY Medicare |
$2.29
|
| Rate for Payer: Altius Auto/Workers Compensation |
$3.33
|
| Rate for Payer: Altius Commercial |
$3.33
|
| Rate for Payer: Beech Street Commercial |
$3.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.85
|
| Rate for Payer: Cash Price |
$2.43
|
| Rate for Payer: ChoiceCare Network Commercial |
$3.37
|
| Rate for Payer: Cigna of WY Commercial |
$3.40
|
| Rate for Payer: Entrust Commercial |
$3.30
|
| Rate for Payer: First Choice Health Commercial |
$3.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2.01
|
| Rate for Payer: HealthUtah PPO |
$3.47
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3.37
|
| Rate for Payer: Multiplan Medicare/VA |
$1.91
|
| Rate for Payer: One Health Plan of WY PPO |
$3.40
|
| Rate for Payer: PacificSource Commercial |
$3.12
|
| Rate for Payer: PHCS PPO |
$3.40
|
| Rate for Payer: Three Rivers PPO |
$2.60
|
| Rate for Payer: TriWest Veterans Administration |
$2.01
|
| Rate for Payer: United Healthcare Commercial |
$3.02
|
| Rate for Payer: United Healthcare Medicare |
$2.01
|
| Rate for Payer: WINHealth Partners Commercial |
$3.40
|
| Rate for Payer: Wise Provider Network Commercial |
$3.30
|
|
|
ACNE SURGERY
|
Professional
|
Both
|
$267.00
|
|
|
Service Code
|
HCPCS 10040
|
| Hospital Charge Code |
10040
|
| Min. Negotiated Rate |
$42.42 |
| Max. Negotiated Rate |
$267.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$261.66
|
| Rate for Payer: Aetna of WY Medicare |
$49.90
|
| Rate for Payer: Beech Street Commercial |
$253.65
|
| Rate for Payer: Cash Price |
$186.90
|
| Rate for Payer: Cash Price |
$186.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$258.99
|
| Rate for Payer: Cigna of WY Commercial |
$261.66
|
| Rate for Payer: First Choice Health Commercial |
$240.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$253.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$49.90
|
| Rate for Payer: HealthUtah PPO |
$267.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$258.99
|
| Rate for Payer: Multiplan Medicare/VA |
$42.42
|
| Rate for Payer: One Health Plan of WY PPO |
$261.66
|
| Rate for Payer: PacificSource Commercial |
$240.30
|
| Rate for Payer: PHCS PPO |
$253.65
|
| Rate for Payer: Three Rivers PPO |
$200.25
|
| Rate for Payer: TriWest Veterans Administration |
$49.90
|
| Rate for Payer: United Healthcare Commercial |
$232.29
|
| Rate for Payer: United Healthcare Medicare |
$49.90
|
| Rate for Payer: WINHealth Partners Commercial |
$226.95
|
|
|
ACROMIOPLASTY/ACROMIONECTOMY PRTL +-LIGAMENT RLS
|
Professional
|
Both
|
$3,143.00
|
|
|
Service Code
|
HCPCS 23130
|
| Hospital Charge Code |
23130
|
| Min. Negotiated Rate |
$514.21 |
| Max. Negotiated Rate |
$3,143.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,080.14
|
| Rate for Payer: Aetna of WY Medicare |
$604.95
|
| Rate for Payer: Beech Street Commercial |
$2,985.85
|
| Rate for Payer: Cash Price |
$2,200.10
|
| Rate for Payer: Cash Price |
$2,200.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,048.71
|
| Rate for Payer: Cigna of WY Commercial |
$3,080.14
|
| Rate for Payer: First Choice Health Commercial |
$2,828.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,985.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$604.95
|
| Rate for Payer: HealthUtah PPO |
$3,143.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,048.71
|
| Rate for Payer: Multiplan Medicare/VA |
$514.21
|
| Rate for Payer: One Health Plan of WY PPO |
$3,080.14
|
| Rate for Payer: PacificSource Commercial |
$2,828.70
|
| Rate for Payer: PHCS PPO |
$2,985.85
|
| Rate for Payer: Three Rivers PPO |
$2,357.25
|
| Rate for Payer: TriWest Veterans Administration |
$604.95
|
| Rate for Payer: United Healthcare Commercial |
$2,734.41
|
| Rate for Payer: United Healthcare Medicare |
$604.95
|
| Rate for Payer: WINHealth Partners Commercial |
$2,671.55
|
|
|
ACROMIOPLASTY/ACROMIONECTOMY PRTL +-LIGAMENT RLS
|
Professional
|
Both
|
$3,143.00
|
|
|
Service Code
|
HCPCS 23130 80
|
| Hospital Charge Code |
23130
|
| Min. Negotiated Rate |
$514.21 |
| Max. Negotiated Rate |
$3,143.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,080.14
|
| Rate for Payer: Aetna of WY Medicare |
$604.95
|
| Rate for Payer: Beech Street Commercial |
$2,985.85
|
| Rate for Payer: Cash Price |
$2,200.10
|
| Rate for Payer: Cash Price |
$2,200.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,048.71
|
| Rate for Payer: Cigna of WY Commercial |
$3,080.14
|
| Rate for Payer: First Choice Health Commercial |
$2,828.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,985.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$604.95
|
| Rate for Payer: HealthUtah PPO |
$3,143.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,048.71
|
| Rate for Payer: Multiplan Medicare/VA |
$514.21
|
| Rate for Payer: One Health Plan of WY PPO |
$3,080.14
|
| Rate for Payer: PacificSource Commercial |
$2,828.70
|
| Rate for Payer: PHCS PPO |
$2,985.85
|
| Rate for Payer: Three Rivers PPO |
$2,357.25
|
| Rate for Payer: TriWest Veterans Administration |
$604.95
|
| Rate for Payer: United Healthcare Commercial |
$2,734.41
|
| Rate for Payer: United Healthcare Medicare |
$604.95
|
| Rate for Payer: WINHealth Partners Commercial |
$2,671.55
|
|
|
ACROMIOPLASTY/ACROMIONECTOMY PRTL +-LIGAMENT RLS
|
Professional
|
Both
|
$3,143.00
|
|
|
Service Code
|
HCPCS 23130 AS
|
| Hospital Charge Code |
23130
|
| Min. Negotiated Rate |
$514.21 |
| Max. Negotiated Rate |
$3,143.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,080.14
|
| Rate for Payer: Aetna of WY Medicare |
$604.95
|
| Rate for Payer: Beech Street Commercial |
$2,985.85
|
| Rate for Payer: Cash Price |
$2,200.10
|
| Rate for Payer: Cash Price |
$2,200.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,048.71
|
| Rate for Payer: Cigna of WY Commercial |
$3,080.14
|
| Rate for Payer: First Choice Health Commercial |
$2,828.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,985.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$604.95
|
| Rate for Payer: HealthUtah PPO |
$3,143.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,048.71
|
| Rate for Payer: Multiplan Medicare/VA |
$514.21
|
| Rate for Payer: One Health Plan of WY PPO |
$3,080.14
|
| Rate for Payer: PacificSource Commercial |
$2,828.70
|
| Rate for Payer: PHCS PPO |
$2,985.85
|
| Rate for Payer: Three Rivers PPO |
$2,357.25
|
| Rate for Payer: TriWest Veterans Administration |
$604.95
|
| Rate for Payer: United Healthcare Commercial |
$2,734.41
|
| Rate for Payer: United Healthcare Medicare |
$604.95
|
| Rate for Payer: WINHealth Partners Commercial |
$2,671.55
|
|
|
ACTIVATED CHARCOAL 25 G/120 ML SUSPENSION (WRAPPED) [4000700]
|
Facility
|
IP
|
$0.45
|
|
|
Service Code
|
NDC 0574052174
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.44
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.43
|
| Rate for Payer: Altius Commercial |
$0.43
|
| Rate for Payer: Beech Street Commercial |
$0.44
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.37
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.44
|
| Rate for Payer: Cigna of WY Commercial |
$0.44
|
| Rate for Payer: Entrust Commercial |
$0.43
|
| Rate for Payer: First Choice Health Commercial |
$0.43
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.43
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.30
|
| Rate for Payer: HealthUtah PPO |
$0.45
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.44
|
| Rate for Payer: Multiplan Medicare/VA |
$0.28
|
| Rate for Payer: One Health Plan of WY PPO |
$0.44
|
| Rate for Payer: PacificSource Commercial |
$0.41
|
| Rate for Payer: PHCS PPO |
$0.44
|
| Rate for Payer: Three Rivers PPO |
$0.34
|
| Rate for Payer: TriWest Veterans Administration |
$0.30
|
| Rate for Payer: United Healthcare Commercial |
$0.39
|
| Rate for Payer: United Healthcare Medicare |
$0.30
|
| Rate for Payer: WINHealth Partners Commercial |
$0.43
|
| Rate for Payer: Wise Provider Network Commercial |
$0.43
|
|
|
ACTIVATED CHARCOAL 25 G/120 ML SUSPENSION (WRAPPED) [4000700]
|
Facility
|
IP
|
$0.81
|
|
|
Service Code
|
NDC 6668920204
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$0.81 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.79
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.78
|
| Rate for Payer: Altius Commercial |
$0.78
|
| Rate for Payer: Beech Street Commercial |
$0.79
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.67
|
| Rate for Payer: Cash Price |
$0.56
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.79
|
| Rate for Payer: Cigna of WY Commercial |
$0.79
|
| Rate for Payer: Entrust Commercial |
$0.77
|
| Rate for Payer: First Choice Health Commercial |
$0.77
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.77
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.53
|
| Rate for Payer: HealthUtah PPO |
$0.81
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.79
|
| Rate for Payer: Multiplan Medicare/VA |
$0.51
|
| Rate for Payer: One Health Plan of WY PPO |
$0.79
|
| Rate for Payer: PacificSource Commercial |
$0.73
|
| Rate for Payer: PHCS PPO |
$0.79
|
| Rate for Payer: Three Rivers PPO |
$0.61
|
| Rate for Payer: TriWest Veterans Administration |
$0.53
|
| Rate for Payer: United Healthcare Commercial |
$0.70
|
| Rate for Payer: United Healthcare Medicare |
$0.53
|
| Rate for Payer: WINHealth Partners Commercial |
$0.77
|
| Rate for Payer: Wise Provider Network Commercial |
$0.77
|
|
|
ACTIVATED CHARCOAL 25 G/120 ML SUSPENSION (WRAPPED) [4000700]
|
Facility
|
OP
|
$0.81
|
|
|
Service Code
|
NDC 6668920204
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$0.81 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.79
|
| Rate for Payer: Aetna of WY Medicare |
$0.53
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.78
|
| Rate for Payer: Altius Commercial |
$0.78
|
| Rate for Payer: Beech Street Commercial |
$0.79
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.67
|
| Rate for Payer: Cash Price |
$0.56
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.79
|
| Rate for Payer: Cigna of WY Commercial |
$0.79
|
| Rate for Payer: Entrust Commercial |
$0.77
|
| Rate for Payer: First Choice Health Commercial |
$0.77
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.77
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.47
|
| Rate for Payer: HealthUtah PPO |
$0.81
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.79
|
| Rate for Payer: Multiplan Medicare/VA |
$0.45
|
| Rate for Payer: One Health Plan of WY PPO |
$0.79
|
| Rate for Payer: PacificSource Commercial |
$0.73
|
| Rate for Payer: PHCS PPO |
$0.79
|
| Rate for Payer: Three Rivers PPO |
$0.61
|
| Rate for Payer: TriWest Veterans Administration |
$0.47
|
| Rate for Payer: United Healthcare Commercial |
$0.70
|
| Rate for Payer: United Healthcare Medicare |
$0.47
|
| Rate for Payer: WINHealth Partners Commercial |
$0.79
|
| Rate for Payer: Wise Provider Network Commercial |
$0.77
|
|
|
ACTIVATED CHARCOAL 25 G/120 ML SUSPENSION (WRAPPED) [4000700]
|
Facility
|
OP
|
$0.45
|
|
|
Service Code
|
NDC 0574052174
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.44
|
| Rate for Payer: Aetna of WY Medicare |
$0.30
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.43
|
| Rate for Payer: Altius Commercial |
$0.43
|
| Rate for Payer: Beech Street Commercial |
$0.44
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.37
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.44
|
| Rate for Payer: Cigna of WY Commercial |
$0.44
|
| Rate for Payer: Entrust Commercial |
$0.43
|
| Rate for Payer: First Choice Health Commercial |
$0.43
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.43
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.26
|
| Rate for Payer: HealthUtah PPO |
$0.45
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.44
|
| Rate for Payer: Multiplan Medicare/VA |
$0.25
|
| Rate for Payer: One Health Plan of WY PPO |
$0.44
|
| Rate for Payer: PacificSource Commercial |
$0.41
|
| Rate for Payer: PHCS PPO |
$0.44
|
| Rate for Payer: Three Rivers PPO |
$0.34
|
| Rate for Payer: TriWest Veterans Administration |
$0.26
|
| Rate for Payer: United Healthcare Commercial |
$0.39
|
| Rate for Payer: United Healthcare Medicare |
$0.26
|
| Rate for Payer: WINHealth Partners Commercial |
$0.44
|
| Rate for Payer: Wise Provider Network Commercial |
$0.43
|
|
|
ACTIVATED CHARCOAL-SORBITOL 25 GRAM/120 ML SUSPENSION (WRAPPED) [4000701]
|
Facility
|
OP
|
$0.45
|
|
|
Service Code
|
NDC 0574052074
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.44
|
| Rate for Payer: Aetna of WY Medicare |
$0.30
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.43
|
| Rate for Payer: Altius Commercial |
$0.43
|
| Rate for Payer: Beech Street Commercial |
$0.44
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.37
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.44
|
| Rate for Payer: Cigna of WY Commercial |
$0.44
|
| Rate for Payer: Entrust Commercial |
$0.43
|
| Rate for Payer: First Choice Health Commercial |
$0.43
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.43
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.26
|
| Rate for Payer: HealthUtah PPO |
$0.45
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.44
|
| Rate for Payer: Multiplan Medicare/VA |
$0.25
|
| Rate for Payer: One Health Plan of WY PPO |
$0.44
|
| Rate for Payer: PacificSource Commercial |
$0.41
|
| Rate for Payer: PHCS PPO |
$0.44
|
| Rate for Payer: Three Rivers PPO |
$0.34
|
| Rate for Payer: TriWest Veterans Administration |
$0.26
|
| Rate for Payer: United Healthcare Commercial |
$0.39
|
| Rate for Payer: United Healthcare Medicare |
$0.26
|
| Rate for Payer: WINHealth Partners Commercial |
$0.44
|
| Rate for Payer: Wise Provider Network Commercial |
$0.43
|
|
|
ACTIVATED CHARCOAL-SORBITOL 25 GRAM/120 ML SUSPENSION (WRAPPED) [4000701]
|
Facility
|
IP
|
$0.45
|
|
|
Service Code
|
NDC 0574052074
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$0.45 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.44
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.43
|
| Rate for Payer: Altius Commercial |
$0.43
|
| Rate for Payer: Beech Street Commercial |
$0.44
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.37
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.44
|
| Rate for Payer: Cigna of WY Commercial |
$0.44
|
| Rate for Payer: Entrust Commercial |
$0.43
|
| Rate for Payer: First Choice Health Commercial |
$0.43
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.43
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.30
|
| Rate for Payer: HealthUtah PPO |
$0.45
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.44
|
| Rate for Payer: Multiplan Medicare/VA |
$0.28
|
| Rate for Payer: One Health Plan of WY PPO |
$0.44
|
| Rate for Payer: PacificSource Commercial |
$0.41
|
| Rate for Payer: PHCS PPO |
$0.44
|
| Rate for Payer: Three Rivers PPO |
$0.34
|
| Rate for Payer: TriWest Veterans Administration |
$0.30
|
| Rate for Payer: United Healthcare Commercial |
$0.39
|
| Rate for Payer: United Healthcare Medicare |
$0.30
|
| Rate for Payer: WINHealth Partners Commercial |
$0.43
|
| Rate for Payer: Wise Provider Network Commercial |
$0.43
|
|
|
ACYCLOVIR 200 MG CAPSULE [16491]
|
Facility
|
IP
|
$0.60
|
|
|
Service Code
|
NDC 7257800201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.59
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.58
|
| Rate for Payer: Altius Commercial |
$0.58
|
| Rate for Payer: Beech Street Commercial |
$0.59
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.49
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.58
|
| Rate for Payer: Cigna of WY Commercial |
$0.59
|
| Rate for Payer: Entrust Commercial |
$0.57
|
| Rate for Payer: First Choice Health Commercial |
$0.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.40
|
| Rate for Payer: HealthUtah PPO |
$0.60
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.58
|
| Rate for Payer: Multiplan Medicare/VA |
$0.38
|
| Rate for Payer: One Health Plan of WY PPO |
$0.59
|
| Rate for Payer: PacificSource Commercial |
$0.54
|
| Rate for Payer: PHCS PPO |
$0.59
|
| Rate for Payer: Three Rivers PPO |
$0.45
|
| Rate for Payer: TriWest Veterans Administration |
$0.40
|
| Rate for Payer: United Healthcare Commercial |
$0.52
|
| Rate for Payer: United Healthcare Medicare |
$0.40
|
| Rate for Payer: WINHealth Partners Commercial |
$0.57
|
| Rate for Payer: Wise Provider Network Commercial |
$0.57
|
|
|
ACYCLOVIR 200 MG CAPSULE [16491]
|
Facility
|
OP
|
$0.60
|
|
|
Service Code
|
NDC 7257800201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.59
|
| Rate for Payer: Aetna of WY Medicare |
$0.40
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.58
|
| Rate for Payer: Altius Commercial |
$0.58
|
| Rate for Payer: Beech Street Commercial |
$0.59
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.49
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.58
|
| Rate for Payer: Cigna of WY Commercial |
$0.59
|
| Rate for Payer: Entrust Commercial |
$0.57
|
| Rate for Payer: First Choice Health Commercial |
$0.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.35
|
| Rate for Payer: HealthUtah PPO |
$0.60
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.58
|
| Rate for Payer: Multiplan Medicare/VA |
$0.33
|
| Rate for Payer: One Health Plan of WY PPO |
$0.59
|
| Rate for Payer: PacificSource Commercial |
$0.54
|
| Rate for Payer: PHCS PPO |
$0.59
|
| Rate for Payer: Three Rivers PPO |
$0.45
|
| Rate for Payer: TriWest Veterans Administration |
$0.35
|
| Rate for Payer: United Healthcare Commercial |
$0.52
|
| Rate for Payer: United Healthcare Medicare |
$0.35
|
| Rate for Payer: WINHealth Partners Commercial |
$0.59
|
| Rate for Payer: Wise Provider Network Commercial |
$0.57
|
|
