|
HYALURONATE SODIUM, STABILIZED 88 MG/4 ML INTRA-ARTICULAR SYRINGE [135747]
|
Facility
|
IP
|
$390.00
|
|
|
Service Code
|
HCPCS J7327
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$244.53 |
| Max. Negotiated Rate |
$390.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$382.20
|
| Rate for Payer: Altius Auto/Workers Compensation |
$374.40
|
| Rate for Payer: Altius Commercial |
$374.40
|
| Rate for Payer: Beech Street Commercial |
$382.20
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$320.19
|
| Rate for Payer: Cash Price |
$273.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$378.30
|
| Rate for Payer: Cigna of WY Commercial |
$382.20
|
| Rate for Payer: Entrust Commercial |
$370.50
|
| Rate for Payer: First Choice Health Commercial |
$370.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$370.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$257.40
|
| Rate for Payer: HealthUtah PPO |
$390.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$378.30
|
| Rate for Payer: Multiplan Medicare/VA |
$244.53
|
| Rate for Payer: One Health Plan of WY PPO |
$382.20
|
| Rate for Payer: PacificSource Commercial |
$351.00
|
| Rate for Payer: PHCS PPO |
$382.20
|
| Rate for Payer: Three Rivers PPO |
$292.50
|
| Rate for Payer: TriWest Veterans Administration |
$257.40
|
| Rate for Payer: United Healthcare Commercial |
$339.30
|
| Rate for Payer: United Healthcare Medicare |
$257.40
|
| Rate for Payer: WINHealth Partners Commercial |
$370.50
|
| Rate for Payer: Wise Provider Network Commercial |
$370.50
|
|
|
HYALURONATE SODIUM, STABILIZED 88 MG/4 ML INTRA-ARTICULAR SYRINGE [135747]
|
Facility
|
OP
|
$390.00
|
|
|
Service Code
|
HCPCS J7327
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$214.89 |
| Max. Negotiated Rate |
$390.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$382.20
|
| Rate for Payer: Aetna of WY Medicare |
$257.40
|
| Rate for Payer: Altius Auto/Workers Compensation |
$374.40
|
| Rate for Payer: Altius Commercial |
$374.40
|
| Rate for Payer: Beech Street Commercial |
$382.20
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$320.19
|
| Rate for Payer: Cash Price |
$273.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$378.30
|
| Rate for Payer: Cigna of WY Commercial |
$382.20
|
| Rate for Payer: Entrust Commercial |
$370.50
|
| Rate for Payer: First Choice Health Commercial |
$370.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$370.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$226.20
|
| Rate for Payer: HealthUtah PPO |
$390.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$378.30
|
| Rate for Payer: Multiplan Medicare/VA |
$214.89
|
| Rate for Payer: One Health Plan of WY PPO |
$382.20
|
| Rate for Payer: PacificSource Commercial |
$351.00
|
| Rate for Payer: PHCS PPO |
$382.20
|
| Rate for Payer: Three Rivers PPO |
$292.50
|
| Rate for Payer: TriWest Veterans Administration |
$226.20
|
| Rate for Payer: United Healthcare Commercial |
$339.30
|
| Rate for Payer: United Healthcare Medicare |
$226.20
|
| Rate for Payer: WINHealth Partners Commercial |
$382.20
|
| Rate for Payer: Wise Provider Network Commercial |
$370.50
|
|
|
HYALURONIDASE, HUMAN RECOMBINANT 150 UNIT/ML INJECTION SOLUTION [40745]
|
Facility
|
OP
|
$112.65
|
|
|
Service Code
|
HCPCS J3473
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$62.07 |
| Max. Negotiated Rate |
$112.65 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$110.40
|
| Rate for Payer: Aetna of WY Medicare |
$74.35
|
| Rate for Payer: Altius Auto/Workers Compensation |
$108.14
|
| Rate for Payer: Altius Commercial |
$108.14
|
| Rate for Payer: Beech Street Commercial |
$110.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$92.49
|
| Rate for Payer: Cash Price |
$78.86
|
| Rate for Payer: ChoiceCare Network Commercial |
$109.27
|
| Rate for Payer: Cigna of WY Commercial |
$110.40
|
| Rate for Payer: Entrust Commercial |
$107.02
|
| Rate for Payer: First Choice Health Commercial |
$107.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$107.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$65.34
|
| Rate for Payer: HealthUtah PPO |
$112.65
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$109.27
|
| Rate for Payer: Multiplan Medicare/VA |
$62.07
|
| Rate for Payer: One Health Plan of WY PPO |
$110.40
|
| Rate for Payer: PacificSource Commercial |
$101.38
|
| Rate for Payer: PHCS PPO |
$110.40
|
| Rate for Payer: Three Rivers PPO |
$84.49
|
| Rate for Payer: TriWest Veterans Administration |
$65.34
|
| Rate for Payer: United Healthcare Commercial |
$98.01
|
| Rate for Payer: United Healthcare Medicare |
$65.34
|
| Rate for Payer: WINHealth Partners Commercial |
$110.40
|
| Rate for Payer: Wise Provider Network Commercial |
$107.02
|
|
|
HYALURONIDASE, HUMAN RECOMBINANT 150 UNIT/ML INJECTION SOLUTION [40745]
|
Facility
|
IP
|
$112.65
|
|
|
Service Code
|
HCPCS J3473
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$70.63 |
| Max. Negotiated Rate |
$112.65 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$110.40
|
| Rate for Payer: Altius Auto/Workers Compensation |
$108.14
|
| Rate for Payer: Altius Commercial |
$108.14
|
| Rate for Payer: Beech Street Commercial |
$110.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$92.49
|
| Rate for Payer: Cash Price |
$78.86
|
| Rate for Payer: ChoiceCare Network Commercial |
$109.27
|
| Rate for Payer: Cigna of WY Commercial |
$110.40
|
| Rate for Payer: Entrust Commercial |
$107.02
|
| Rate for Payer: First Choice Health Commercial |
$107.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$107.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$74.35
|
| Rate for Payer: HealthUtah PPO |
$112.65
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$109.27
|
| Rate for Payer: Multiplan Medicare/VA |
$70.63
|
| Rate for Payer: One Health Plan of WY PPO |
$110.40
|
| Rate for Payer: PacificSource Commercial |
$101.38
|
| Rate for Payer: PHCS PPO |
$110.40
|
| Rate for Payer: Three Rivers PPO |
$84.49
|
| Rate for Payer: TriWest Veterans Administration |
$74.35
|
| Rate for Payer: United Healthcare Commercial |
$98.01
|
| Rate for Payer: United Healthcare Medicare |
$74.35
|
| Rate for Payer: WINHealth Partners Commercial |
$107.02
|
| Rate for Payer: Wise Provider Network Commercial |
$107.02
|
|
|
HYDRALAZINE 10 MG TABLET [893]
|
Facility
|
OP
|
$0.78
|
|
|
Service Code
|
NDC 6808444701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$0.78 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.76
|
| Rate for Payer: Aetna of WY Medicare |
$0.51
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.75
|
| Rate for Payer: Altius Commercial |
$0.75
|
| Rate for Payer: Beech Street Commercial |
$0.76
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.64
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.76
|
| Rate for Payer: Cigna of WY Commercial |
$0.76
|
| Rate for Payer: Entrust Commercial |
$0.74
|
| Rate for Payer: First Choice Health Commercial |
$0.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.45
|
| Rate for Payer: HealthUtah PPO |
$0.78
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.76
|
| Rate for Payer: Multiplan Medicare/VA |
$0.43
|
| Rate for Payer: One Health Plan of WY PPO |
$0.76
|
| Rate for Payer: PacificSource Commercial |
$0.70
|
| Rate for Payer: PHCS PPO |
$0.76
|
| Rate for Payer: Three Rivers PPO |
$0.59
|
| Rate for Payer: TriWest Veterans Administration |
$0.45
|
| Rate for Payer: United Healthcare Commercial |
$0.68
|
| Rate for Payer: United Healthcare Medicare |
$0.45
|
| Rate for Payer: WINHealth Partners Commercial |
$0.76
|
| Rate for Payer: Wise Provider Network Commercial |
$0.74
|
|
|
HYDRALAZINE 10 MG TABLET [893]
|
Facility
|
IP
|
$0.78
|
|
|
Service Code
|
NDC 6808444701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$0.78 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.76
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.75
|
| Rate for Payer: Altius Commercial |
$0.75
|
| Rate for Payer: Beech Street Commercial |
$0.76
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.64
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.76
|
| Rate for Payer: Cigna of WY Commercial |
$0.76
|
| Rate for Payer: Entrust Commercial |
$0.74
|
| Rate for Payer: First Choice Health Commercial |
$0.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.51
|
| Rate for Payer: HealthUtah PPO |
$0.78
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.76
|
| Rate for Payer: Multiplan Medicare/VA |
$0.49
|
| Rate for Payer: One Health Plan of WY PPO |
$0.76
|
| Rate for Payer: PacificSource Commercial |
$0.70
|
| Rate for Payer: PHCS PPO |
$0.76
|
| Rate for Payer: Three Rivers PPO |
$0.59
|
| Rate for Payer: TriWest Veterans Administration |
$0.51
|
| Rate for Payer: United Healthcare Commercial |
$0.68
|
| Rate for Payer: United Healthcare Medicare |
$0.51
|
| Rate for Payer: WINHealth Partners Commercial |
$0.74
|
| Rate for Payer: Wise Provider Network Commercial |
$0.74
|
|
|
HYDRALAZINE 10 MG TABLET [893]
|
Facility
|
IP
|
$0.78
|
|
|
Service Code
|
NDC 6808444711
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$0.78 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.76
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.75
|
| Rate for Payer: Altius Commercial |
$0.75
|
| Rate for Payer: Beech Street Commercial |
$0.76
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.64
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.76
|
| Rate for Payer: Cigna of WY Commercial |
$0.76
|
| Rate for Payer: Entrust Commercial |
$0.74
|
| Rate for Payer: First Choice Health Commercial |
$0.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.51
|
| Rate for Payer: HealthUtah PPO |
$0.78
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.76
|
| Rate for Payer: Multiplan Medicare/VA |
$0.49
|
| Rate for Payer: One Health Plan of WY PPO |
$0.76
|
| Rate for Payer: PacificSource Commercial |
$0.70
|
| Rate for Payer: PHCS PPO |
$0.76
|
| Rate for Payer: Three Rivers PPO |
$0.59
|
| Rate for Payer: TriWest Veterans Administration |
$0.51
|
| Rate for Payer: United Healthcare Commercial |
$0.68
|
| Rate for Payer: United Healthcare Medicare |
$0.51
|
| Rate for Payer: WINHealth Partners Commercial |
$0.74
|
| Rate for Payer: Wise Provider Network Commercial |
$0.74
|
|
|
HYDRALAZINE 10 MG TABLET [893]
|
Facility
|
OP
|
$0.78
|
|
|
Service Code
|
NDC 6808444711
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$0.78 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.76
|
| Rate for Payer: Aetna of WY Medicare |
$0.51
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.75
|
| Rate for Payer: Altius Commercial |
$0.75
|
| Rate for Payer: Beech Street Commercial |
$0.76
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.64
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.76
|
| Rate for Payer: Cigna of WY Commercial |
$0.76
|
| Rate for Payer: Entrust Commercial |
$0.74
|
| Rate for Payer: First Choice Health Commercial |
$0.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.45
|
| Rate for Payer: HealthUtah PPO |
$0.78
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.76
|
| Rate for Payer: Multiplan Medicare/VA |
$0.43
|
| Rate for Payer: One Health Plan of WY PPO |
$0.76
|
| Rate for Payer: PacificSource Commercial |
$0.70
|
| Rate for Payer: PHCS PPO |
$0.76
|
| Rate for Payer: Three Rivers PPO |
$0.59
|
| Rate for Payer: TriWest Veterans Administration |
$0.45
|
| Rate for Payer: United Healthcare Commercial |
$0.68
|
| Rate for Payer: United Healthcare Medicare |
$0.45
|
| Rate for Payer: WINHealth Partners Commercial |
$0.76
|
| Rate for Payer: Wise Provider Network Commercial |
$0.74
|
|
|
HYDRALAZINE 20 MG/ML INJECTION SOLUTION [8131]
|
Facility
|
OP
|
$56.25
|
|
|
Service Code
|
HCPCS J0360
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.99 |
| Max. Negotiated Rate |
$56.25 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$55.12
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$53.29
|
| Rate for Payer: Aetna of WY Medicare |
$37.12
|
| Rate for Payer: Aetna of WY Medicare |
$35.89
|
| Rate for Payer: Altius Auto/Workers Compensation |
$52.20
|
| Rate for Payer: Altius Auto/Workers Compensation |
$54.00
|
| Rate for Payer: Altius Commercial |
$54.00
|
| Rate for Payer: Altius Commercial |
$52.20
|
| Rate for Payer: Beech Street Commercial |
$53.29
|
| Rate for Payer: Beech Street Commercial |
$55.12
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$46.18
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$44.65
|
| Rate for Payer: Cash Price |
$38.07
|
| Rate for Payer: Cash Price |
$39.38
|
| Rate for Payer: ChoiceCare Network Commercial |
$54.56
|
| Rate for Payer: ChoiceCare Network Commercial |
$52.75
|
| Rate for Payer: Cigna of WY Commercial |
$53.29
|
| Rate for Payer: Cigna of WY Commercial |
$55.12
|
| Rate for Payer: Entrust Commercial |
$53.44
|
| Rate for Payer: Entrust Commercial |
$51.66
|
| Rate for Payer: First Choice Health Commercial |
$51.66
|
| Rate for Payer: First Choice Health Commercial |
$53.44
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$51.66
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$53.44
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$32.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$31.54
|
| Rate for Payer: HealthUtah PPO |
$54.38
|
| Rate for Payer: HealthUtah PPO |
$56.25
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$52.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$54.56
|
| Rate for Payer: Multiplan Medicare/VA |
$30.99
|
| Rate for Payer: Multiplan Medicare/VA |
$29.96
|
| Rate for Payer: One Health Plan of WY PPO |
$53.29
|
| Rate for Payer: One Health Plan of WY PPO |
$55.12
|
| Rate for Payer: PacificSource Commercial |
$50.62
|
| Rate for Payer: PacificSource Commercial |
$48.94
|
| Rate for Payer: PHCS PPO |
$53.29
|
| Rate for Payer: PHCS PPO |
$55.12
|
| Rate for Payer: Three Rivers PPO |
$40.78
|
| Rate for Payer: Three Rivers PPO |
$42.19
|
| Rate for Payer: TriWest Veterans Administration |
$32.62
|
| Rate for Payer: TriWest Veterans Administration |
$31.54
|
| Rate for Payer: United Healthcare Commercial |
$47.31
|
| Rate for Payer: United Healthcare Commercial |
$48.94
|
| Rate for Payer: United Healthcare Medicare |
$32.62
|
| Rate for Payer: United Healthcare Medicare |
$31.54
|
| Rate for Payer: WINHealth Partners Commercial |
$53.29
|
| Rate for Payer: WINHealth Partners Commercial |
$55.12
|
| Rate for Payer: Wise Provider Network Commercial |
$51.66
|
| Rate for Payer: Wise Provider Network Commercial |
$53.44
|
|
|
HYDRALAZINE 20 MG/ML INJECTION SOLUTION [8131]
|
Facility
|
IP
|
$56.25
|
|
|
Service Code
|
HCPCS J0360
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.27 |
| Max. Negotiated Rate |
$56.25 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$55.12
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$53.29
|
| Rate for Payer: Altius Auto/Workers Compensation |
$54.00
|
| Rate for Payer: Altius Auto/Workers Compensation |
$52.20
|
| Rate for Payer: Altius Commercial |
$52.20
|
| Rate for Payer: Altius Commercial |
$54.00
|
| Rate for Payer: Beech Street Commercial |
$55.12
|
| Rate for Payer: Beech Street Commercial |
$53.29
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$44.65
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$46.18
|
| Rate for Payer: Cash Price |
$39.38
|
| Rate for Payer: Cash Price |
$38.07
|
| Rate for Payer: ChoiceCare Network Commercial |
$52.75
|
| Rate for Payer: ChoiceCare Network Commercial |
$54.56
|
| Rate for Payer: Cigna of WY Commercial |
$55.12
|
| Rate for Payer: Cigna of WY Commercial |
$53.29
|
| Rate for Payer: Entrust Commercial |
$51.66
|
| Rate for Payer: Entrust Commercial |
$53.44
|
| Rate for Payer: First Choice Health Commercial |
$51.66
|
| Rate for Payer: First Choice Health Commercial |
$53.44
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$51.66
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$53.44
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$37.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$35.89
|
| Rate for Payer: HealthUtah PPO |
$56.25
|
| Rate for Payer: HealthUtah PPO |
$54.38
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$52.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$54.56
|
| Rate for Payer: Multiplan Medicare/VA |
$35.27
|
| Rate for Payer: Multiplan Medicare/VA |
$34.10
|
| Rate for Payer: One Health Plan of WY PPO |
$55.12
|
| Rate for Payer: One Health Plan of WY PPO |
$53.29
|
| Rate for Payer: PacificSource Commercial |
$50.62
|
| Rate for Payer: PacificSource Commercial |
$48.94
|
| Rate for Payer: PHCS PPO |
$53.29
|
| Rate for Payer: PHCS PPO |
$55.12
|
| Rate for Payer: Three Rivers PPO |
$40.78
|
| Rate for Payer: Three Rivers PPO |
$42.19
|
| Rate for Payer: TriWest Veterans Administration |
$37.12
|
| Rate for Payer: TriWest Veterans Administration |
$35.89
|
| Rate for Payer: United Healthcare Commercial |
$47.31
|
| Rate for Payer: United Healthcare Commercial |
$48.94
|
| Rate for Payer: United Healthcare Medicare |
$37.12
|
| Rate for Payer: United Healthcare Medicare |
$35.89
|
| Rate for Payer: WINHealth Partners Commercial |
$51.66
|
| Rate for Payer: WINHealth Partners Commercial |
$53.44
|
| Rate for Payer: Wise Provider Network Commercial |
$51.66
|
| Rate for Payer: Wise Provider Network Commercial |
$53.44
|
|
|
HYDROCHLOROTHIAZIDE 12.5 MG TABLET [42895]
|
Facility
|
IP
|
$0.11
|
|
|
Service Code
|
NDC 5140733001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.11
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.11
|
| Rate for Payer: Altius Commercial |
$0.11
|
| Rate for Payer: Beech Street Commercial |
$0.11
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.09
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.11
|
| Rate for Payer: Cigna of WY Commercial |
$0.11
|
| Rate for Payer: Entrust Commercial |
$0.10
|
| Rate for Payer: First Choice Health Commercial |
$0.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.07
|
| Rate for Payer: HealthUtah PPO |
$0.11
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.11
|
| Rate for Payer: Multiplan Medicare/VA |
$0.07
|
| Rate for Payer: One Health Plan of WY PPO |
$0.11
|
| Rate for Payer: PacificSource Commercial |
$0.10
|
| Rate for Payer: PHCS PPO |
$0.11
|
| Rate for Payer: Three Rivers PPO |
$0.08
|
| Rate for Payer: TriWest Veterans Administration |
$0.07
|
| Rate for Payer: United Healthcare Commercial |
$0.10
|
| Rate for Payer: United Healthcare Medicare |
$0.07
|
| Rate for Payer: WINHealth Partners Commercial |
$0.10
|
| Rate for Payer: Wise Provider Network Commercial |
$0.10
|
|
|
HYDROCHLOROTHIAZIDE 12.5 MG TABLET [42895]
|
Facility
|
OP
|
$0.11
|
|
|
Service Code
|
NDC 5140733001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.11
|
| Rate for Payer: Aetna of WY Medicare |
$0.07
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.11
|
| Rate for Payer: Altius Commercial |
$0.11
|
| Rate for Payer: Beech Street Commercial |
$0.11
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.09
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.11
|
| Rate for Payer: Cigna of WY Commercial |
$0.11
|
| Rate for Payer: Entrust Commercial |
$0.10
|
| Rate for Payer: First Choice Health Commercial |
$0.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.06
|
| Rate for Payer: HealthUtah PPO |
$0.11
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.11
|
| Rate for Payer: Multiplan Medicare/VA |
$0.06
|
| Rate for Payer: One Health Plan of WY PPO |
$0.11
|
| Rate for Payer: PacificSource Commercial |
$0.10
|
| Rate for Payer: PHCS PPO |
$0.11
|
| Rate for Payer: Three Rivers PPO |
$0.08
|
| Rate for Payer: TriWest Veterans Administration |
$0.06
|
| Rate for Payer: United Healthcare Commercial |
$0.10
|
| Rate for Payer: United Healthcare Medicare |
$0.06
|
| Rate for Payer: WINHealth Partners Commercial |
$0.11
|
| Rate for Payer: Wise Provider Network Commercial |
$0.10
|
|
|
HYDROCHLOROTHIAZIDE 25 MG TABLET [16492]
|
Facility
|
OP
|
$0.84
|
|
|
Service Code
|
NDC 6068759301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$0.84 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.82
|
| Rate for Payer: Aetna of WY Medicare |
$0.55
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.81
|
| Rate for Payer: Altius Commercial |
$0.81
|
| Rate for Payer: Beech Street Commercial |
$0.82
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.69
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.81
|
| Rate for Payer: Cigna of WY Commercial |
$0.82
|
| Rate for Payer: Entrust Commercial |
$0.80
|
| Rate for Payer: First Choice Health Commercial |
$0.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.49
|
| Rate for Payer: HealthUtah PPO |
$0.84
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.81
|
| Rate for Payer: Multiplan Medicare/VA |
$0.46
|
| Rate for Payer: One Health Plan of WY PPO |
$0.82
|
| Rate for Payer: PacificSource Commercial |
$0.76
|
| Rate for Payer: PHCS PPO |
$0.82
|
| Rate for Payer: Three Rivers PPO |
$0.63
|
| Rate for Payer: TriWest Veterans Administration |
$0.49
|
| Rate for Payer: United Healthcare Commercial |
$0.73
|
| Rate for Payer: United Healthcare Medicare |
$0.49
|
| Rate for Payer: WINHealth Partners Commercial |
$0.82
|
| Rate for Payer: Wise Provider Network Commercial |
$0.80
|
|
|
HYDROCHLOROTHIAZIDE 25 MG TABLET [16492]
|
Facility
|
IP
|
$0.84
|
|
|
Service Code
|
NDC 6068759301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$0.84 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.82
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.81
|
| Rate for Payer: Altius Commercial |
$0.81
|
| Rate for Payer: Beech Street Commercial |
$0.82
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.69
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.81
|
| Rate for Payer: Cigna of WY Commercial |
$0.82
|
| Rate for Payer: Entrust Commercial |
$0.80
|
| Rate for Payer: First Choice Health Commercial |
$0.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.55
|
| Rate for Payer: HealthUtah PPO |
$0.84
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.81
|
| Rate for Payer: Multiplan Medicare/VA |
$0.53
|
| Rate for Payer: One Health Plan of WY PPO |
$0.82
|
| Rate for Payer: PacificSource Commercial |
$0.76
|
| Rate for Payer: PHCS PPO |
$0.82
|
| Rate for Payer: Three Rivers PPO |
$0.63
|
| Rate for Payer: TriWest Veterans Administration |
$0.55
|
| Rate for Payer: United Healthcare Commercial |
$0.73
|
| Rate for Payer: United Healthcare Medicare |
$0.55
|
| Rate for Payer: WINHealth Partners Commercial |
$0.80
|
| Rate for Payer: Wise Provider Network Commercial |
$0.80
|
|
|
HYDROCHLOROTHIAZIDE 25 MG TABLET [16492]
|
Facility
|
IP
|
$0.84
|
|
|
Service Code
|
NDC 6068759311
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$0.84 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.82
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.81
|
| Rate for Payer: Altius Commercial |
$0.81
|
| Rate for Payer: Beech Street Commercial |
$0.82
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.69
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.81
|
| Rate for Payer: Cigna of WY Commercial |
$0.82
|
| Rate for Payer: Entrust Commercial |
$0.80
|
| Rate for Payer: First Choice Health Commercial |
$0.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.55
|
| Rate for Payer: HealthUtah PPO |
$0.84
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.81
|
| Rate for Payer: Multiplan Medicare/VA |
$0.53
|
| Rate for Payer: One Health Plan of WY PPO |
$0.82
|
| Rate for Payer: PacificSource Commercial |
$0.76
|
| Rate for Payer: PHCS PPO |
$0.82
|
| Rate for Payer: Three Rivers PPO |
$0.63
|
| Rate for Payer: TriWest Veterans Administration |
$0.55
|
| Rate for Payer: United Healthcare Commercial |
$0.73
|
| Rate for Payer: United Healthcare Medicare |
$0.55
|
| Rate for Payer: WINHealth Partners Commercial |
$0.80
|
| Rate for Payer: Wise Provider Network Commercial |
$0.80
|
|
|
HYDROCHLOROTHIAZIDE 25 MG TABLET [16492]
|
Facility
|
OP
|
$0.84
|
|
|
Service Code
|
NDC 6068759311
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$0.84 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.82
|
| Rate for Payer: Aetna of WY Medicare |
$0.55
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.81
|
| Rate for Payer: Altius Commercial |
$0.81
|
| Rate for Payer: Beech Street Commercial |
$0.82
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.69
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.81
|
| Rate for Payer: Cigna of WY Commercial |
$0.82
|
| Rate for Payer: Entrust Commercial |
$0.80
|
| Rate for Payer: First Choice Health Commercial |
$0.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.49
|
| Rate for Payer: HealthUtah PPO |
$0.84
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.81
|
| Rate for Payer: Multiplan Medicare/VA |
$0.46
|
| Rate for Payer: One Health Plan of WY PPO |
$0.82
|
| Rate for Payer: PacificSource Commercial |
$0.76
|
| Rate for Payer: PHCS PPO |
$0.82
|
| Rate for Payer: Three Rivers PPO |
$0.63
|
| Rate for Payer: TriWest Veterans Administration |
$0.49
|
| Rate for Payer: United Healthcare Commercial |
$0.73
|
| Rate for Payer: United Healthcare Medicare |
$0.49
|
| Rate for Payer: WINHealth Partners Commercial |
$0.82
|
| Rate for Payer: Wise Provider Network Commercial |
$0.80
|
|
|
HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET [7611]
|
Facility
|
OP
|
$2.40
|
|
|
Service Code
|
NDC 6068741811
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$2.40 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.35
|
| Rate for Payer: Aetna of WY Medicare |
$1.58
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.30
|
| Rate for Payer: Altius Commercial |
$2.30
|
| Rate for Payer: Beech Street Commercial |
$2.35
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.97
|
| Rate for Payer: Cash Price |
$1.68
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.33
|
| Rate for Payer: Cigna of WY Commercial |
$2.35
|
| Rate for Payer: Entrust Commercial |
$2.28
|
| Rate for Payer: First Choice Health Commercial |
$2.28
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.28
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.39
|
| Rate for Payer: HealthUtah PPO |
$2.40
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.33
|
| Rate for Payer: Multiplan Medicare/VA |
$1.32
|
| Rate for Payer: One Health Plan of WY PPO |
$2.35
|
| Rate for Payer: PacificSource Commercial |
$2.16
|
| Rate for Payer: PHCS PPO |
$2.35
|
| Rate for Payer: Three Rivers PPO |
$1.80
|
| Rate for Payer: TriWest Veterans Administration |
$1.39
|
| Rate for Payer: United Healthcare Commercial |
$2.09
|
| Rate for Payer: United Healthcare Medicare |
$1.39
|
| Rate for Payer: WINHealth Partners Commercial |
$2.35
|
| Rate for Payer: Wise Provider Network Commercial |
$2.28
|
|
|
HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET [7611]
|
Facility
|
IP
|
$1.79
|
|
|
Service Code
|
NDC 5026840211
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.12 |
| Max. Negotiated Rate |
$1.79 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.75
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.72
|
| Rate for Payer: Altius Commercial |
$1.72
|
| Rate for Payer: Beech Street Commercial |
$1.75
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.47
|
| Rate for Payer: Cash Price |
$1.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.74
|
| Rate for Payer: Cigna of WY Commercial |
$1.75
|
| Rate for Payer: Entrust Commercial |
$1.70
|
| Rate for Payer: First Choice Health Commercial |
$1.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.18
|
| Rate for Payer: HealthUtah PPO |
$1.79
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.74
|
| Rate for Payer: Multiplan Medicare/VA |
$1.12
|
| Rate for Payer: One Health Plan of WY PPO |
$1.75
|
| Rate for Payer: PacificSource Commercial |
$1.61
|
| Rate for Payer: PHCS PPO |
$1.75
|
| Rate for Payer: Three Rivers PPO |
$1.34
|
| Rate for Payer: TriWest Veterans Administration |
$1.18
|
| Rate for Payer: United Healthcare Commercial |
$1.56
|
| Rate for Payer: United Healthcare Medicare |
$1.18
|
| Rate for Payer: WINHealth Partners Commercial |
$1.70
|
| Rate for Payer: Wise Provider Network Commercial |
$1.70
|
|
|
HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET [7611]
|
Facility
|
OP
|
$1.79
|
|
|
Service Code
|
NDC 5026840211
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.99 |
| Max. Negotiated Rate |
$1.79 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.75
|
| Rate for Payer: Aetna of WY Medicare |
$1.18
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.72
|
| Rate for Payer: Altius Commercial |
$1.72
|
| Rate for Payer: Beech Street Commercial |
$1.75
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.47
|
| Rate for Payer: Cash Price |
$1.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.74
|
| Rate for Payer: Cigna of WY Commercial |
$1.75
|
| Rate for Payer: Entrust Commercial |
$1.70
|
| Rate for Payer: First Choice Health Commercial |
$1.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.04
|
| Rate for Payer: HealthUtah PPO |
$1.79
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.74
|
| Rate for Payer: Multiplan Medicare/VA |
$0.99
|
| Rate for Payer: One Health Plan of WY PPO |
$1.75
|
| Rate for Payer: PacificSource Commercial |
$1.61
|
| Rate for Payer: PHCS PPO |
$1.75
|
| Rate for Payer: Three Rivers PPO |
$1.34
|
| Rate for Payer: TriWest Veterans Administration |
$1.04
|
| Rate for Payer: United Healthcare Commercial |
$1.56
|
| Rate for Payer: United Healthcare Medicare |
$1.04
|
| Rate for Payer: WINHealth Partners Commercial |
$1.75
|
| Rate for Payer: Wise Provider Network Commercial |
$1.70
|
|
|
HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET [7611]
|
Facility
|
OP
|
$1.98
|
|
|
Service Code
|
NDC 0406012523
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$1.98 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.94
|
| Rate for Payer: Aetna of WY Medicare |
$1.31
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.90
|
| Rate for Payer: Altius Commercial |
$1.90
|
| Rate for Payer: Beech Street Commercial |
$1.94
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.63
|
| Rate for Payer: Cash Price |
$1.38
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.92
|
| Rate for Payer: Cigna of WY Commercial |
$1.94
|
| Rate for Payer: Entrust Commercial |
$1.88
|
| Rate for Payer: First Choice Health Commercial |
$1.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.15
|
| Rate for Payer: HealthUtah PPO |
$1.98
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.92
|
| Rate for Payer: Multiplan Medicare/VA |
$1.09
|
| Rate for Payer: One Health Plan of WY PPO |
$1.94
|
| Rate for Payer: PacificSource Commercial |
$1.78
|
| Rate for Payer: PHCS PPO |
$1.94
|
| Rate for Payer: Three Rivers PPO |
$1.48
|
| Rate for Payer: TriWest Veterans Administration |
$1.15
|
| Rate for Payer: United Healthcare Commercial |
$1.72
|
| Rate for Payer: United Healthcare Medicare |
$1.15
|
| Rate for Payer: WINHealth Partners Commercial |
$1.94
|
| Rate for Payer: Wise Provider Network Commercial |
$1.88
|
|
|
HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET [7611]
|
Facility
|
IP
|
$1.98
|
|
|
Service Code
|
NDC 0406012523
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$1.98 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.94
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.90
|
| Rate for Payer: Altius Commercial |
$1.90
|
| Rate for Payer: Beech Street Commercial |
$1.94
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.63
|
| Rate for Payer: Cash Price |
$1.38
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.92
|
| Rate for Payer: Cigna of WY Commercial |
$1.94
|
| Rate for Payer: Entrust Commercial |
$1.88
|
| Rate for Payer: First Choice Health Commercial |
$1.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.31
|
| Rate for Payer: HealthUtah PPO |
$1.98
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.92
|
| Rate for Payer: Multiplan Medicare/VA |
$1.24
|
| Rate for Payer: One Health Plan of WY PPO |
$1.94
|
| Rate for Payer: PacificSource Commercial |
$1.78
|
| Rate for Payer: PHCS PPO |
$1.94
|
| Rate for Payer: Three Rivers PPO |
$1.48
|
| Rate for Payer: TriWest Veterans Administration |
$1.31
|
| Rate for Payer: United Healthcare Commercial |
$1.72
|
| Rate for Payer: United Healthcare Medicare |
$1.31
|
| Rate for Payer: WINHealth Partners Commercial |
$1.88
|
| Rate for Payer: Wise Provider Network Commercial |
$1.88
|
|
|
HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET [7611]
|
Facility
|
OP
|
$0.88
|
|
|
Service Code
|
NDC 0406012505
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$0.88 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.86
|
| Rate for Payer: Aetna of WY Medicare |
$0.58
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.84
|
| Rate for Payer: Altius Commercial |
$0.84
|
| Rate for Payer: Beech Street Commercial |
$0.86
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.72
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.85
|
| Rate for Payer: Cigna of WY Commercial |
$0.86
|
| Rate for Payer: Entrust Commercial |
$0.84
|
| Rate for Payer: First Choice Health Commercial |
$0.84
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.84
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.51
|
| Rate for Payer: HealthUtah PPO |
$0.88
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.85
|
| Rate for Payer: Multiplan Medicare/VA |
$0.48
|
| Rate for Payer: One Health Plan of WY PPO |
$0.86
|
| Rate for Payer: PacificSource Commercial |
$0.79
|
| Rate for Payer: PHCS PPO |
$0.86
|
| Rate for Payer: Three Rivers PPO |
$0.66
|
| Rate for Payer: TriWest Veterans Administration |
$0.51
|
| Rate for Payer: United Healthcare Commercial |
$0.77
|
| Rate for Payer: United Healthcare Medicare |
$0.51
|
| Rate for Payer: WINHealth Partners Commercial |
$0.86
|
| Rate for Payer: Wise Provider Network Commercial |
$0.84
|
|
|
HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET [7611]
|
Facility
|
IP
|
$2.40
|
|
|
Service Code
|
NDC 6068741811
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.40 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.35
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.30
|
| Rate for Payer: Altius Commercial |
$2.30
|
| Rate for Payer: Beech Street Commercial |
$2.35
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.97
|
| Rate for Payer: Cash Price |
$1.68
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.33
|
| Rate for Payer: Cigna of WY Commercial |
$2.35
|
| Rate for Payer: Entrust Commercial |
$2.28
|
| Rate for Payer: First Choice Health Commercial |
$2.28
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.28
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.58
|
| Rate for Payer: HealthUtah PPO |
$2.40
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.33
|
| Rate for Payer: Multiplan Medicare/VA |
$1.50
|
| Rate for Payer: One Health Plan of WY PPO |
$2.35
|
| Rate for Payer: PacificSource Commercial |
$2.16
|
| Rate for Payer: PHCS PPO |
$2.35
|
| Rate for Payer: Three Rivers PPO |
$1.80
|
| Rate for Payer: TriWest Veterans Administration |
$1.58
|
| Rate for Payer: United Healthcare Commercial |
$2.09
|
| Rate for Payer: United Healthcare Medicare |
$1.58
|
| Rate for Payer: WINHealth Partners Commercial |
$2.28
|
| Rate for Payer: Wise Provider Network Commercial |
$2.28
|
|
|
HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET [7611]
|
Facility
|
IP
|
$0.88
|
|
|
Service Code
|
NDC 0406012505
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$0.88 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.86
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.84
|
| Rate for Payer: Altius Commercial |
$0.84
|
| Rate for Payer: Beech Street Commercial |
$0.86
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.72
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.85
|
| Rate for Payer: Cigna of WY Commercial |
$0.86
|
| Rate for Payer: Entrust Commercial |
$0.84
|
| Rate for Payer: First Choice Health Commercial |
$0.84
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.84
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.58
|
| Rate for Payer: HealthUtah PPO |
$0.88
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.85
|
| Rate for Payer: Multiplan Medicare/VA |
$0.55
|
| Rate for Payer: One Health Plan of WY PPO |
$0.86
|
| Rate for Payer: PacificSource Commercial |
$0.79
|
| Rate for Payer: PHCS PPO |
$0.86
|
| Rate for Payer: Three Rivers PPO |
$0.66
|
| Rate for Payer: TriWest Veterans Administration |
$0.58
|
| Rate for Payer: United Healthcare Commercial |
$0.77
|
| Rate for Payer: United Healthcare Medicare |
$0.58
|
| Rate for Payer: WINHealth Partners Commercial |
$0.84
|
| Rate for Payer: Wise Provider Network Commercial |
$0.84
|
|
|
HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET [7611]
|
Facility
|
OP
|
$2.40
|
|
|
Service Code
|
NDC 6068741801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$2.40 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.35
|
| Rate for Payer: Aetna of WY Medicare |
$1.58
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.30
|
| Rate for Payer: Altius Commercial |
$2.30
|
| Rate for Payer: Beech Street Commercial |
$2.35
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.97
|
| Rate for Payer: Cash Price |
$1.68
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.33
|
| Rate for Payer: Cigna of WY Commercial |
$2.35
|
| Rate for Payer: Entrust Commercial |
$2.28
|
| Rate for Payer: First Choice Health Commercial |
$2.28
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.28
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.39
|
| Rate for Payer: HealthUtah PPO |
$2.40
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.33
|
| Rate for Payer: Multiplan Medicare/VA |
$1.32
|
| Rate for Payer: One Health Plan of WY PPO |
$2.35
|
| Rate for Payer: PacificSource Commercial |
$2.16
|
| Rate for Payer: PHCS PPO |
$2.35
|
| Rate for Payer: Three Rivers PPO |
$1.80
|
| Rate for Payer: TriWest Veterans Administration |
$1.39
|
| Rate for Payer: United Healthcare Commercial |
$2.09
|
| Rate for Payer: United Healthcare Medicare |
$1.39
|
| Rate for Payer: WINHealth Partners Commercial |
$2.35
|
| Rate for Payer: Wise Provider Network Commercial |
$2.28
|
|
