|
ASPIRIN 325 MG TABLET,DELAYED RELEASE [10909]
|
Facility
|
OP
|
$15.09
|
|
|
Service Code
|
NDC 0536123201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.17 |
| Max. Negotiated Rate |
$15.09 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.79
|
| Rate for Payer: Aetna of WY Medicare |
$9.96
|
| Rate for Payer: Altius Commercial |
$14.49
|
| Rate for Payer: Beech Street Commercial |
$14.79
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.64
|
| Rate for Payer: Cash Price |
$10.56
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.64
|
| Rate for Payer: Cigna of WY Commercial |
$14.79
|
| Rate for Payer: Entrust Commercial |
$14.34
|
| Rate for Payer: First Choice Health Commercial |
$14.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.60
|
| Rate for Payer: HealthUtah PPO |
$15.09
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.64
|
| Rate for Payer: Multiplan Medicare/VA |
$8.17
|
| Rate for Payer: One Health Plan of WY PPO |
$14.79
|
| Rate for Payer: PacificSource Commercial |
$13.58
|
| Rate for Payer: PHCS PPO |
$14.79
|
| Rate for Payer: Three Rivers PPO |
$11.32
|
| Rate for Payer: TriWest Veterans Administration |
$8.60
|
| Rate for Payer: United Healthcare Commercial |
$14.41
|
| Rate for Payer: United Healthcare Medicare |
$8.60
|
| Rate for Payer: WINHealth Partners Commercial |
$14.79
|
| Rate for Payer: Wise Provider Network Commercial |
$14.34
|
|
|
ASPIRIN 325 MG TABLET,DELAYED RELEASE [10909]
|
Facility
|
IP
|
$15.09
|
|
|
Service Code
|
NDC 0536123201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.74 |
| Max. Negotiated Rate |
$15.09 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.79
|
| Rate for Payer: Aetna of WY Medicare |
$9.66
|
| Rate for Payer: Altius Commercial |
$14.49
|
| Rate for Payer: Beech Street Commercial |
$14.79
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.64
|
| Rate for Payer: Cash Price |
$10.56
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.64
|
| Rate for Payer: Cigna of WY Commercial |
$14.79
|
| Rate for Payer: Entrust Commercial |
$14.34
|
| Rate for Payer: First Choice Health Commercial |
$14.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.20
|
| Rate for Payer: HealthUtah PPO |
$15.09
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.64
|
| Rate for Payer: Multiplan Medicare/VA |
$8.74
|
| Rate for Payer: One Health Plan of WY PPO |
$14.79
|
| Rate for Payer: PacificSource Commercial |
$13.58
|
| Rate for Payer: PHCS PPO |
$14.79
|
| Rate for Payer: Three Rivers PPO |
$11.32
|
| Rate for Payer: TriWest Veterans Administration |
$9.20
|
| Rate for Payer: United Healthcare Commercial |
$14.41
|
| Rate for Payer: United Healthcare Medicare |
$9.20
|
| Rate for Payer: WINHealth Partners Commercial |
$14.34
|
| Rate for Payer: Wise Provider Network Commercial |
$14.34
|
|
|
ASPIRIN 81 MG CHEWABLE TABLET [15387]
|
Facility
|
OP
|
$15.27
|
|
|
Service Code
|
NDC 6655300201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.27 |
| Max. Negotiated Rate |
$15.27 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.96
|
| Rate for Payer: Aetna of WY Medicare |
$10.08
|
| Rate for Payer: Altius Commercial |
$14.66
|
| Rate for Payer: Beech Street Commercial |
$14.96
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.81
|
| Rate for Payer: Cash Price |
$10.69
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.81
|
| Rate for Payer: Cigna of WY Commercial |
$14.96
|
| Rate for Payer: Entrust Commercial |
$14.51
|
| Rate for Payer: First Choice Health Commercial |
$14.51
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.51
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.70
|
| Rate for Payer: HealthUtah PPO |
$15.27
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.81
|
| Rate for Payer: Multiplan Medicare/VA |
$8.27
|
| Rate for Payer: One Health Plan of WY PPO |
$14.96
|
| Rate for Payer: PacificSource Commercial |
$13.74
|
| Rate for Payer: PHCS PPO |
$14.96
|
| Rate for Payer: Three Rivers PPO |
$11.45
|
| Rate for Payer: TriWest Veterans Administration |
$8.70
|
| Rate for Payer: United Healthcare Commercial |
$14.58
|
| Rate for Payer: United Healthcare Medicare |
$8.70
|
| Rate for Payer: WINHealth Partners Commercial |
$14.96
|
| Rate for Payer: Wise Provider Network Commercial |
$14.51
|
|
|
ASPIRIN 81 MG CHEWABLE TABLET [15387]
|
Facility
|
IP
|
$15.27
|
|
|
Service Code
|
NDC 6655300201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.85 |
| Max. Negotiated Rate |
$15.27 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.96
|
| Rate for Payer: Aetna of WY Medicare |
$9.77
|
| Rate for Payer: Altius Commercial |
$14.66
|
| Rate for Payer: Beech Street Commercial |
$14.96
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.81
|
| Rate for Payer: Cash Price |
$10.69
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.81
|
| Rate for Payer: Cigna of WY Commercial |
$14.96
|
| Rate for Payer: Entrust Commercial |
$14.51
|
| Rate for Payer: First Choice Health Commercial |
$14.51
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.51
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.31
|
| Rate for Payer: HealthUtah PPO |
$15.27
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.81
|
| Rate for Payer: Multiplan Medicare/VA |
$8.85
|
| Rate for Payer: One Health Plan of WY PPO |
$14.96
|
| Rate for Payer: PacificSource Commercial |
$13.74
|
| Rate for Payer: PHCS PPO |
$14.96
|
| Rate for Payer: Three Rivers PPO |
$11.45
|
| Rate for Payer: TriWest Veterans Administration |
$9.31
|
| Rate for Payer: United Healthcare Commercial |
$14.58
|
| Rate for Payer: United Healthcare Medicare |
$9.31
|
| Rate for Payer: WINHealth Partners Commercial |
$14.51
|
| Rate for Payer: Wise Provider Network Commercial |
$14.51
|
|
|
ASPIRIN 81 MG CHEWABLE TABLET [15387]
|
Facility
|
OP
|
$15.09
|
|
|
Service Code
|
NDC 0904404073
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.17 |
| Max. Negotiated Rate |
$15.09 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.79
|
| Rate for Payer: Aetna of WY Medicare |
$9.96
|
| Rate for Payer: Altius Commercial |
$14.49
|
| Rate for Payer: Beech Street Commercial |
$14.79
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.64
|
| Rate for Payer: Cash Price |
$10.56
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.64
|
| Rate for Payer: Cigna of WY Commercial |
$14.79
|
| Rate for Payer: Entrust Commercial |
$14.34
|
| Rate for Payer: First Choice Health Commercial |
$14.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.60
|
| Rate for Payer: HealthUtah PPO |
$15.09
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.64
|
| Rate for Payer: Multiplan Medicare/VA |
$8.17
|
| Rate for Payer: One Health Plan of WY PPO |
$14.79
|
| Rate for Payer: PacificSource Commercial |
$13.58
|
| Rate for Payer: PHCS PPO |
$14.79
|
| Rate for Payer: Three Rivers PPO |
$11.32
|
| Rate for Payer: TriWest Veterans Administration |
$8.60
|
| Rate for Payer: United Healthcare Commercial |
$14.41
|
| Rate for Payer: United Healthcare Medicare |
$8.60
|
| Rate for Payer: WINHealth Partners Commercial |
$14.79
|
| Rate for Payer: Wise Provider Network Commercial |
$14.34
|
|
|
ASPIRIN 81 MG CHEWABLE TABLET [15387]
|
Facility
|
OP
|
$15.20
|
|
|
Service Code
|
NDC 6373943402
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.23 |
| Max. Negotiated Rate |
$15.20 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.90
|
| Rate for Payer: Aetna of WY Medicare |
$10.03
|
| Rate for Payer: Altius Commercial |
$14.59
|
| Rate for Payer: Beech Street Commercial |
$14.90
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.74
|
| Rate for Payer: Cash Price |
$10.64
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.74
|
| Rate for Payer: Cigna of WY Commercial |
$14.90
|
| Rate for Payer: Entrust Commercial |
$14.44
|
| Rate for Payer: First Choice Health Commercial |
$14.44
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.44
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.66
|
| Rate for Payer: HealthUtah PPO |
$15.20
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.74
|
| Rate for Payer: Multiplan Medicare/VA |
$8.23
|
| Rate for Payer: One Health Plan of WY PPO |
$14.90
|
| Rate for Payer: PacificSource Commercial |
$13.68
|
| Rate for Payer: PHCS PPO |
$14.90
|
| Rate for Payer: Three Rivers PPO |
$11.40
|
| Rate for Payer: TriWest Veterans Administration |
$8.66
|
| Rate for Payer: United Healthcare Commercial |
$14.52
|
| Rate for Payer: United Healthcare Medicare |
$8.66
|
| Rate for Payer: WINHealth Partners Commercial |
$14.90
|
| Rate for Payer: Wise Provider Network Commercial |
$14.44
|
|
|
ASPIRIN 81 MG CHEWABLE TABLET [15387]
|
Facility
|
IP
|
$15.20
|
|
|
Service Code
|
NDC 6373943402
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.81 |
| Max. Negotiated Rate |
$15.20 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.90
|
| Rate for Payer: Aetna of WY Medicare |
$9.73
|
| Rate for Payer: Altius Commercial |
$14.59
|
| Rate for Payer: Beech Street Commercial |
$14.90
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.74
|
| Rate for Payer: Cash Price |
$10.64
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.74
|
| Rate for Payer: Cigna of WY Commercial |
$14.90
|
| Rate for Payer: Entrust Commercial |
$14.44
|
| Rate for Payer: First Choice Health Commercial |
$14.44
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.44
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.27
|
| Rate for Payer: HealthUtah PPO |
$15.20
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.74
|
| Rate for Payer: Multiplan Medicare/VA |
$8.81
|
| Rate for Payer: One Health Plan of WY PPO |
$14.90
|
| Rate for Payer: PacificSource Commercial |
$13.68
|
| Rate for Payer: PHCS PPO |
$14.90
|
| Rate for Payer: Three Rivers PPO |
$11.40
|
| Rate for Payer: TriWest Veterans Administration |
$9.27
|
| Rate for Payer: United Healthcare Commercial |
$14.52
|
| Rate for Payer: United Healthcare Medicare |
$9.27
|
| Rate for Payer: WINHealth Partners Commercial |
$14.44
|
| Rate for Payer: Wise Provider Network Commercial |
$14.44
|
|
|
ASPIRIN 81 MG CHEWABLE TABLET [15387]
|
Facility
|
IP
|
$15.09
|
|
|
Service Code
|
NDC 0904404073
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.74 |
| Max. Negotiated Rate |
$15.09 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.79
|
| Rate for Payer: Aetna of WY Medicare |
$9.66
|
| Rate for Payer: Altius Commercial |
$14.49
|
| Rate for Payer: Beech Street Commercial |
$14.79
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.64
|
| Rate for Payer: Cash Price |
$10.56
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.64
|
| Rate for Payer: Cigna of WY Commercial |
$14.79
|
| Rate for Payer: Entrust Commercial |
$14.34
|
| Rate for Payer: First Choice Health Commercial |
$14.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.20
|
| Rate for Payer: HealthUtah PPO |
$15.09
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.64
|
| Rate for Payer: Multiplan Medicare/VA |
$8.74
|
| Rate for Payer: One Health Plan of WY PPO |
$14.79
|
| Rate for Payer: PacificSource Commercial |
$13.58
|
| Rate for Payer: PHCS PPO |
$14.79
|
| Rate for Payer: Three Rivers PPO |
$11.32
|
| Rate for Payer: TriWest Veterans Administration |
$9.20
|
| Rate for Payer: United Healthcare Commercial |
$14.41
|
| Rate for Payer: United Healthcare Medicare |
$9.20
|
| Rate for Payer: WINHealth Partners Commercial |
$14.34
|
| Rate for Payer: Wise Provider Network Commercial |
$14.34
|
|
|
ASPIRIN 81 MG TABLET,DELAYED RELEASE [7719]
|
Facility
|
OP
|
$15.08
|
|
|
Service Code
|
NDC 0536123441
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.17 |
| Max. Negotiated Rate |
$15.08 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.78
|
| Rate for Payer: Aetna of WY Medicare |
$9.95
|
| Rate for Payer: Altius Commercial |
$14.48
|
| Rate for Payer: Beech Street Commercial |
$14.78
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.63
|
| Rate for Payer: Cash Price |
$10.56
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.63
|
| Rate for Payer: Cigna of WY Commercial |
$14.78
|
| Rate for Payer: Entrust Commercial |
$14.33
|
| Rate for Payer: First Choice Health Commercial |
$14.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.60
|
| Rate for Payer: HealthUtah PPO |
$15.08
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.63
|
| Rate for Payer: Multiplan Medicare/VA |
$8.17
|
| Rate for Payer: One Health Plan of WY PPO |
$14.78
|
| Rate for Payer: PacificSource Commercial |
$13.57
|
| Rate for Payer: PHCS PPO |
$14.78
|
| Rate for Payer: Three Rivers PPO |
$11.31
|
| Rate for Payer: TriWest Veterans Administration |
$8.60
|
| Rate for Payer: United Healthcare Commercial |
$14.40
|
| Rate for Payer: United Healthcare Medicare |
$8.60
|
| Rate for Payer: WINHealth Partners Commercial |
$14.78
|
| Rate for Payer: Wise Provider Network Commercial |
$14.33
|
|
|
ASPIRIN 81 MG TABLET,DELAYED RELEASE [7719]
|
Facility
|
IP
|
$15.08
|
|
|
Service Code
|
NDC 0536123441
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.74 |
| Max. Negotiated Rate |
$15.08 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.78
|
| Rate for Payer: Aetna of WY Medicare |
$9.65
|
| Rate for Payer: Altius Commercial |
$14.48
|
| Rate for Payer: Beech Street Commercial |
$14.78
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.63
|
| Rate for Payer: Cash Price |
$10.56
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.63
|
| Rate for Payer: Cigna of WY Commercial |
$14.78
|
| Rate for Payer: Entrust Commercial |
$14.33
|
| Rate for Payer: First Choice Health Commercial |
$14.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.20
|
| Rate for Payer: HealthUtah PPO |
$15.08
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.63
|
| Rate for Payer: Multiplan Medicare/VA |
$8.74
|
| Rate for Payer: One Health Plan of WY PPO |
$14.78
|
| Rate for Payer: PacificSource Commercial |
$13.57
|
| Rate for Payer: PHCS PPO |
$14.78
|
| Rate for Payer: Three Rivers PPO |
$11.31
|
| Rate for Payer: TriWest Veterans Administration |
$9.20
|
| Rate for Payer: United Healthcare Commercial |
$14.40
|
| Rate for Payer: United Healthcare Medicare |
$9.20
|
| Rate for Payer: WINHealth Partners Commercial |
$14.33
|
| Rate for Payer: Wise Provider Network Commercial |
$14.33
|
|
|
ASPIRIN 81 MG TABLET,DELAYED RELEASE [7719]
|
Facility
|
OP
|
$15.22
|
|
|
Service Code
|
NDC 6373921202
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.24 |
| Max. Negotiated Rate |
$15.22 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.92
|
| Rate for Payer: Aetna of WY Medicare |
$10.05
|
| Rate for Payer: Altius Commercial |
$14.61
|
| Rate for Payer: Beech Street Commercial |
$14.92
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.76
|
| Rate for Payer: Cash Price |
$10.65
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.76
|
| Rate for Payer: Cigna of WY Commercial |
$14.92
|
| Rate for Payer: Entrust Commercial |
$14.46
|
| Rate for Payer: First Choice Health Commercial |
$14.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.68
|
| Rate for Payer: HealthUtah PPO |
$15.22
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.76
|
| Rate for Payer: Multiplan Medicare/VA |
$8.24
|
| Rate for Payer: One Health Plan of WY PPO |
$14.92
|
| Rate for Payer: PacificSource Commercial |
$13.70
|
| Rate for Payer: PHCS PPO |
$14.92
|
| Rate for Payer: Three Rivers PPO |
$11.42
|
| Rate for Payer: TriWest Veterans Administration |
$8.68
|
| Rate for Payer: United Healthcare Commercial |
$14.54
|
| Rate for Payer: United Healthcare Medicare |
$8.68
|
| Rate for Payer: WINHealth Partners Commercial |
$14.92
|
| Rate for Payer: Wise Provider Network Commercial |
$14.46
|
|
|
ASPIRIN 81 MG TABLET,DELAYED RELEASE [7719]
|
Facility
|
OP
|
$15.09
|
|
|
Service Code
|
NDC 4612259848
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.17 |
| Max. Negotiated Rate |
$15.09 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.79
|
| Rate for Payer: Aetna of WY Medicare |
$9.96
|
| Rate for Payer: Altius Commercial |
$14.49
|
| Rate for Payer: Beech Street Commercial |
$14.79
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.64
|
| Rate for Payer: Cash Price |
$10.56
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.64
|
| Rate for Payer: Cigna of WY Commercial |
$14.79
|
| Rate for Payer: Entrust Commercial |
$14.34
|
| Rate for Payer: First Choice Health Commercial |
$14.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.60
|
| Rate for Payer: HealthUtah PPO |
$15.09
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.64
|
| Rate for Payer: Multiplan Medicare/VA |
$8.17
|
| Rate for Payer: One Health Plan of WY PPO |
$14.79
|
| Rate for Payer: PacificSource Commercial |
$13.58
|
| Rate for Payer: PHCS PPO |
$14.79
|
| Rate for Payer: Three Rivers PPO |
$11.32
|
| Rate for Payer: TriWest Veterans Administration |
$8.60
|
| Rate for Payer: United Healthcare Commercial |
$14.41
|
| Rate for Payer: United Healthcare Medicare |
$8.60
|
| Rate for Payer: WINHealth Partners Commercial |
$14.79
|
| Rate for Payer: Wise Provider Network Commercial |
$14.34
|
|
|
ASPIRIN 81 MG TABLET,DELAYED RELEASE [7719]
|
Facility
|
IP
|
$15.09
|
|
|
Service Code
|
NDC 4612259848
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.74 |
| Max. Negotiated Rate |
$15.09 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.79
|
| Rate for Payer: Aetna of WY Medicare |
$9.66
|
| Rate for Payer: Altius Commercial |
$14.49
|
| Rate for Payer: Beech Street Commercial |
$14.79
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.64
|
| Rate for Payer: Cash Price |
$10.56
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.64
|
| Rate for Payer: Cigna of WY Commercial |
$14.79
|
| Rate for Payer: Entrust Commercial |
$14.34
|
| Rate for Payer: First Choice Health Commercial |
$14.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.20
|
| Rate for Payer: HealthUtah PPO |
$15.09
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.64
|
| Rate for Payer: Multiplan Medicare/VA |
$8.74
|
| Rate for Payer: One Health Plan of WY PPO |
$14.79
|
| Rate for Payer: PacificSource Commercial |
$13.58
|
| Rate for Payer: PHCS PPO |
$14.79
|
| Rate for Payer: Three Rivers PPO |
$11.32
|
| Rate for Payer: TriWest Veterans Administration |
$9.20
|
| Rate for Payer: United Healthcare Commercial |
$14.41
|
| Rate for Payer: United Healthcare Medicare |
$9.20
|
| Rate for Payer: WINHealth Partners Commercial |
$14.34
|
| Rate for Payer: Wise Provider Network Commercial |
$14.34
|
|
|
ASPIRIN 81 MG TABLET,DELAYED RELEASE [7719]
|
Facility
|
IP
|
$15.22
|
|
|
Service Code
|
NDC 6373921202
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.82 |
| Max. Negotiated Rate |
$15.22 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.92
|
| Rate for Payer: Aetna of WY Medicare |
$9.74
|
| Rate for Payer: Altius Commercial |
$14.61
|
| Rate for Payer: Beech Street Commercial |
$14.92
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.76
|
| Rate for Payer: Cash Price |
$10.65
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.76
|
| Rate for Payer: Cigna of WY Commercial |
$14.92
|
| Rate for Payer: Entrust Commercial |
$14.46
|
| Rate for Payer: First Choice Health Commercial |
$14.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.28
|
| Rate for Payer: HealthUtah PPO |
$15.22
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.76
|
| Rate for Payer: Multiplan Medicare/VA |
$8.82
|
| Rate for Payer: One Health Plan of WY PPO |
$14.92
|
| Rate for Payer: PacificSource Commercial |
$13.70
|
| Rate for Payer: PHCS PPO |
$14.92
|
| Rate for Payer: Three Rivers PPO |
$11.42
|
| Rate for Payer: TriWest Veterans Administration |
$9.28
|
| Rate for Payer: United Healthcare Commercial |
$14.54
|
| Rate for Payer: United Healthcare Medicare |
$9.28
|
| Rate for Payer: WINHealth Partners Commercial |
$14.46
|
| Rate for Payer: Wise Provider Network Commercial |
$14.46
|
|
|
ASSAY OF PHENYLALANINE BLOOD
|
Professional
|
Both
|
$109.00
|
|
|
Service Code
|
HCPCS 84030
|
| Min. Negotiated Rate |
$4.68 |
| Max. Negotiated Rate |
$109.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$106.82
|
| Rate for Payer: Aetna of WY Medicare |
$5.50
|
| Rate for Payer: Beech Street Commercial |
$103.55
|
| Rate for Payer: Cash Price |
$76.30
|
| Rate for Payer: Cash Price |
$76.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$105.73
|
| Rate for Payer: Cigna of WY Commercial |
$106.82
|
| Rate for Payer: First Choice Health Commercial |
$98.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$103.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$5.50
|
| Rate for Payer: HealthUtah PPO |
$109.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$105.73
|
| Rate for Payer: Multiplan Medicare/VA |
$4.68
|
| Rate for Payer: One Health Plan of WY PPO |
$106.82
|
| Rate for Payer: PacificSource Commercial |
$98.10
|
| Rate for Payer: PHCS PPO |
$103.55
|
| Rate for Payer: Three Rivers PPO |
$81.75
|
| Rate for Payer: TriWest Veterans Administration |
$5.50
|
| Rate for Payer: United Healthcare Commercial |
$103.55
|
| Rate for Payer: WINHealth Partners Commercial |
$103.55
|
|
|
ASSAY OF PROSTATE SPECIFIC ANTIGEN TOTAL
|
Professional
|
Both
|
$91.00
|
|
|
Service Code
|
HCPCS 84153
|
| Min. Negotiated Rate |
$15.63 |
| Max. Negotiated Rate |
$91.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$89.18
|
| Rate for Payer: Aetna of WY Medicare |
$18.39
|
| Rate for Payer: Beech Street Commercial |
$86.45
|
| Rate for Payer: Cash Price |
$63.70
|
| Rate for Payer: Cash Price |
$63.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$88.27
|
| Rate for Payer: Cigna of WY Commercial |
$89.18
|
| Rate for Payer: First Choice Health Commercial |
$81.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$86.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$18.39
|
| Rate for Payer: HealthUtah PPO |
$91.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$88.27
|
| Rate for Payer: Multiplan Medicare/VA |
$15.63
|
| Rate for Payer: One Health Plan of WY PPO |
$89.18
|
| Rate for Payer: PacificSource Commercial |
$81.90
|
| Rate for Payer: PHCS PPO |
$86.45
|
| Rate for Payer: Three Rivers PPO |
$68.25
|
| Rate for Payer: TriWest Veterans Administration |
$18.39
|
| Rate for Payer: United Healthcare Commercial |
$86.45
|
| Rate for Payer: WINHealth Partners Commercial |
$86.45
|
|
|
ASSAY OF THYROID STIMULATING HORMONE TSH
|
Professional
|
Both
|
$94.00
|
|
|
Service Code
|
HCPCS 84443
|
| Min. Negotiated Rate |
$14.28 |
| Max. Negotiated Rate |
$94.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$92.12
|
| Rate for Payer: Aetna of WY Medicare |
$16.80
|
| Rate for Payer: Beech Street Commercial |
$89.30
|
| Rate for Payer: Cash Price |
$65.80
|
| Rate for Payer: Cash Price |
$65.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$91.18
|
| Rate for Payer: Cigna of WY Commercial |
$92.12
|
| Rate for Payer: First Choice Health Commercial |
$84.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$89.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$16.80
|
| Rate for Payer: HealthUtah PPO |
$94.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$91.18
|
| Rate for Payer: Multiplan Medicare/VA |
$14.28
|
| Rate for Payer: One Health Plan of WY PPO |
$92.12
|
| Rate for Payer: PacificSource Commercial |
$84.60
|
| Rate for Payer: PHCS PPO |
$89.30
|
| Rate for Payer: Three Rivers PPO |
$70.50
|
| Rate for Payer: TriWest Veterans Administration |
$16.80
|
| Rate for Payer: United Healthcare Commercial |
$89.30
|
| Rate for Payer: WINHealth Partners Commercial |
$89.30
|
|
|
ASSAY OF TROPONIN QUANTITATIVE
|
Professional
|
Both
|
$87.00
|
|
|
Service Code
|
HCPCS 84484
|
| Min. Negotiated Rate |
$10.60 |
| Max. Negotiated Rate |
$87.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$85.26
|
| Rate for Payer: Aetna of WY Medicare |
$12.47
|
| Rate for Payer: Beech Street Commercial |
$82.65
|
| Rate for Payer: Cash Price |
$60.90
|
| Rate for Payer: Cash Price |
$60.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$84.39
|
| Rate for Payer: Cigna of WY Commercial |
$85.26
|
| Rate for Payer: First Choice Health Commercial |
$78.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$82.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$12.47
|
| Rate for Payer: HealthUtah PPO |
$87.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$84.39
|
| Rate for Payer: Multiplan Medicare/VA |
$10.60
|
| Rate for Payer: One Health Plan of WY PPO |
$85.26
|
| Rate for Payer: PacificSource Commercial |
$78.30
|
| Rate for Payer: PHCS PPO |
$82.65
|
| Rate for Payer: Three Rivers PPO |
$65.25
|
| Rate for Payer: TriWest Veterans Administration |
$12.47
|
| Rate for Payer: United Healthcare Commercial |
$82.65
|
| Rate for Payer: WINHealth Partners Commercial |
$82.65
|
|
|
ASSMT & CARE PLANNING PT W/COGNITIVE IMPAIRMENT
|
Professional
|
Both
|
$543.00
|
|
|
Service Code
|
HCPCS 99483
|
| Min. Negotiated Rate |
$157.87 |
| Max. Negotiated Rate |
$543.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$532.14
|
| Rate for Payer: Aetna of WY Medicare |
$185.73
|
| Rate for Payer: Beech Street Commercial |
$515.85
|
| Rate for Payer: Cash Price |
$380.10
|
| Rate for Payer: Cash Price |
$380.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$526.71
|
| Rate for Payer: Cigna of WY Commercial |
$532.14
|
| Rate for Payer: First Choice Health Commercial |
$488.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$515.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$185.73
|
| Rate for Payer: HealthUtah PPO |
$543.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$526.71
|
| Rate for Payer: Multiplan Medicare/VA |
$157.87
|
| Rate for Payer: One Health Plan of WY PPO |
$532.14
|
| Rate for Payer: PacificSource Commercial |
$488.70
|
| Rate for Payer: PHCS PPO |
$515.85
|
| Rate for Payer: Three Rivers PPO |
$407.25
|
| Rate for Payer: TriWest Veterans Administration |
$185.73
|
| Rate for Payer: United Healthcare Commercial |
$515.85
|
| Rate for Payer: WINHealth Partners Commercial |
$515.85
|
|
|
ATENOLOL 25 MG TABLET [5852]
|
Facility
|
OP
|
$16.04
|
|
|
Service Code
|
NDC 6068760501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.69 |
| Max. Negotiated Rate |
$16.04 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.72
|
| Rate for Payer: Aetna of WY Medicare |
$10.59
|
| Rate for Payer: Altius Commercial |
$15.40
|
| Rate for Payer: Beech Street Commercial |
$15.72
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.56
|
| Rate for Payer: Cash Price |
$11.23
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.56
|
| Rate for Payer: Cigna of WY Commercial |
$15.72
|
| Rate for Payer: Entrust Commercial |
$15.24
|
| Rate for Payer: First Choice Health Commercial |
$15.24
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.24
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.14
|
| Rate for Payer: HealthUtah PPO |
$16.04
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.56
|
| Rate for Payer: Multiplan Medicare/VA |
$8.69
|
| Rate for Payer: One Health Plan of WY PPO |
$15.72
|
| Rate for Payer: PacificSource Commercial |
$14.44
|
| Rate for Payer: PHCS PPO |
$15.72
|
| Rate for Payer: Three Rivers PPO |
$12.03
|
| Rate for Payer: TriWest Veterans Administration |
$9.14
|
| Rate for Payer: United Healthcare Commercial |
$15.32
|
| Rate for Payer: United Healthcare Medicare |
$9.14
|
| Rate for Payer: WINHealth Partners Commercial |
$15.72
|
| Rate for Payer: Wise Provider Network Commercial |
$15.24
|
|
|
ATENOLOL 25 MG TABLET [5852]
|
Facility
|
OP
|
$16.04
|
|
|
Service Code
|
NDC 6068760511
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.69 |
| Max. Negotiated Rate |
$16.04 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.72
|
| Rate for Payer: Aetna of WY Medicare |
$10.59
|
| Rate for Payer: Altius Commercial |
$15.40
|
| Rate for Payer: Beech Street Commercial |
$15.72
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.56
|
| Rate for Payer: Cash Price |
$11.23
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.56
|
| Rate for Payer: Cigna of WY Commercial |
$15.72
|
| Rate for Payer: Entrust Commercial |
$15.24
|
| Rate for Payer: First Choice Health Commercial |
$15.24
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.24
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.14
|
| Rate for Payer: HealthUtah PPO |
$16.04
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.56
|
| Rate for Payer: Multiplan Medicare/VA |
$8.69
|
| Rate for Payer: One Health Plan of WY PPO |
$15.72
|
| Rate for Payer: PacificSource Commercial |
$14.44
|
| Rate for Payer: PHCS PPO |
$15.72
|
| Rate for Payer: Three Rivers PPO |
$12.03
|
| Rate for Payer: TriWest Veterans Administration |
$9.14
|
| Rate for Payer: United Healthcare Commercial |
$15.32
|
| Rate for Payer: United Healthcare Medicare |
$9.14
|
| Rate for Payer: WINHealth Partners Commercial |
$15.72
|
| Rate for Payer: Wise Provider Network Commercial |
$15.24
|
|
|
ATENOLOL 25 MG TABLET [5852]
|
Facility
|
IP
|
$16.04
|
|
|
Service Code
|
NDC 6068760511
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.30 |
| Max. Negotiated Rate |
$16.04 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.72
|
| Rate for Payer: Aetna of WY Medicare |
$10.27
|
| Rate for Payer: Altius Commercial |
$15.40
|
| Rate for Payer: Beech Street Commercial |
$15.72
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.56
|
| Rate for Payer: Cash Price |
$11.23
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.56
|
| Rate for Payer: Cigna of WY Commercial |
$15.72
|
| Rate for Payer: Entrust Commercial |
$15.24
|
| Rate for Payer: First Choice Health Commercial |
$15.24
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.24
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.78
|
| Rate for Payer: HealthUtah PPO |
$16.04
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.56
|
| Rate for Payer: Multiplan Medicare/VA |
$9.30
|
| Rate for Payer: One Health Plan of WY PPO |
$15.72
|
| Rate for Payer: PacificSource Commercial |
$14.44
|
| Rate for Payer: PHCS PPO |
$15.72
|
| Rate for Payer: Three Rivers PPO |
$12.03
|
| Rate for Payer: TriWest Veterans Administration |
$9.78
|
| Rate for Payer: United Healthcare Commercial |
$15.32
|
| Rate for Payer: United Healthcare Medicare |
$9.78
|
| Rate for Payer: WINHealth Partners Commercial |
$15.24
|
| Rate for Payer: Wise Provider Network Commercial |
$15.24
|
|
|
ATENOLOL 25 MG TABLET [5852]
|
Facility
|
IP
|
$16.04
|
|
|
Service Code
|
NDC 6068760501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.30 |
| Max. Negotiated Rate |
$16.04 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.72
|
| Rate for Payer: Aetna of WY Medicare |
$10.27
|
| Rate for Payer: Altius Commercial |
$15.40
|
| Rate for Payer: Beech Street Commercial |
$15.72
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.56
|
| Rate for Payer: Cash Price |
$11.23
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.56
|
| Rate for Payer: Cigna of WY Commercial |
$15.72
|
| Rate for Payer: Entrust Commercial |
$15.24
|
| Rate for Payer: First Choice Health Commercial |
$15.24
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.24
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.78
|
| Rate for Payer: HealthUtah PPO |
$16.04
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.56
|
| Rate for Payer: Multiplan Medicare/VA |
$9.30
|
| Rate for Payer: One Health Plan of WY PPO |
$15.72
|
| Rate for Payer: PacificSource Commercial |
$14.44
|
| Rate for Payer: PHCS PPO |
$15.72
|
| Rate for Payer: Three Rivers PPO |
$12.03
|
| Rate for Payer: TriWest Veterans Administration |
$9.78
|
| Rate for Payer: United Healthcare Commercial |
$15.32
|
| Rate for Payer: United Healthcare Medicare |
$9.78
|
| Rate for Payer: WINHealth Partners Commercial |
$15.24
|
| Rate for Payer: Wise Provider Network Commercial |
$15.24
|
|
|
ATHLETIC SUPP LG ADLT
|
Facility
|
IP
|
$11.94
|
|
| Hospital Charge Code |
3000249
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$6.92 |
| Max. Negotiated Rate |
$11.94 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$11.70
|
| Rate for Payer: Aetna of WY Medicare |
$7.64
|
| Rate for Payer: Altius Commercial |
$11.46
|
| Rate for Payer: Beech Street Commercial |
$11.70
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$11.58
|
| Rate for Payer: Cash Price |
$8.35
|
| Rate for Payer: ChoiceCare Network Commercial |
$11.58
|
| Rate for Payer: Cigna of WY Commercial |
$11.70
|
| Rate for Payer: Entrust Commercial |
$11.34
|
| Rate for Payer: First Choice Health Commercial |
$11.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$11.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$7.28
|
| Rate for Payer: HealthUtah PPO |
$11.94
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$11.58
|
| Rate for Payer: Multiplan Medicare/VA |
$6.92
|
| Rate for Payer: One Health Plan of WY PPO |
$11.70
|
| Rate for Payer: PacificSource Commercial |
$10.75
|
| Rate for Payer: PHCS PPO |
$11.70
|
| Rate for Payer: Three Rivers PPO |
$8.96
|
| Rate for Payer: TriWest Veterans Administration |
$7.28
|
| Rate for Payer: United Healthcare Commercial |
$11.40
|
| Rate for Payer: United Healthcare Medicare |
$7.28
|
| Rate for Payer: WINHealth Partners Commercial |
$11.34
|
| Rate for Payer: Wise Provider Network Commercial |
$11.34
|
|
|
ATHLETIC SUPP LG ADLT
|
Facility
|
OP
|
$11.94
|
|
| Hospital Charge Code |
3000249
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$6.47 |
| Max. Negotiated Rate |
$11.94 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$11.70
|
| Rate for Payer: Aetna of WY Medicare |
$7.88
|
| Rate for Payer: Altius Commercial |
$11.46
|
| Rate for Payer: Beech Street Commercial |
$11.70
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$11.58
|
| Rate for Payer: Cash Price |
$8.35
|
| Rate for Payer: ChoiceCare Network Commercial |
$11.58
|
| Rate for Payer: Cigna of WY Commercial |
$11.70
|
| Rate for Payer: Entrust Commercial |
$11.34
|
| Rate for Payer: First Choice Health Commercial |
$11.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$11.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$6.81
|
| Rate for Payer: HealthUtah PPO |
$11.94
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$11.58
|
| Rate for Payer: Multiplan Medicare/VA |
$6.47
|
| Rate for Payer: One Health Plan of WY PPO |
$11.70
|
| Rate for Payer: PacificSource Commercial |
$10.75
|
| Rate for Payer: PHCS PPO |
$11.70
|
| Rate for Payer: Three Rivers PPO |
$8.96
|
| Rate for Payer: TriWest Veterans Administration |
$6.81
|
| Rate for Payer: United Healthcare Commercial |
$11.40
|
| Rate for Payer: United Healthcare Medicare |
$6.81
|
| Rate for Payer: WINHealth Partners Commercial |
$11.70
|
| Rate for Payer: Wise Provider Network Commercial |
$11.34
|
|
