|
HYDROCORTISONE 2.5 % TOPICAL CREAM [15899]
|
Facility
|
IP
|
$0.41
|
|
|
Service Code
|
NDC 5167230032
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.40
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.39
|
| Rate for Payer: Altius Commercial |
$0.39
|
| Rate for Payer: Beech Street Commercial |
$0.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.34
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.40
|
| Rate for Payer: Cigna of WY Commercial |
$0.40
|
| Rate for Payer: Entrust Commercial |
$0.39
|
| Rate for Payer: First Choice Health Commercial |
$0.39
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.39
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.27
|
| Rate for Payer: HealthUtah PPO |
$0.41
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.40
|
| Rate for Payer: Multiplan Medicare/VA |
$0.26
|
| Rate for Payer: One Health Plan of WY PPO |
$0.40
|
| Rate for Payer: PacificSource Commercial |
$0.37
|
| Rate for Payer: PHCS PPO |
$0.40
|
| Rate for Payer: Three Rivers PPO |
$0.31
|
| Rate for Payer: TriWest Veterans Administration |
$0.27
|
| Rate for Payer: United Healthcare Commercial |
$0.36
|
| Rate for Payer: United Healthcare Medicare |
$0.27
|
| Rate for Payer: WINHealth Partners Commercial |
$0.39
|
| Rate for Payer: Wise Provider Network Commercial |
$0.39
|
|
|
HYDROCORTISONE 2.5 % TOPICAL CREAM [15899]
|
Facility
|
OP
|
$0.87
|
|
|
Service Code
|
NDC 0472033730
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$0.87 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.85
|
| Rate for Payer: Aetna of WY Medicare |
$0.57
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.84
|
| Rate for Payer: Altius Commercial |
$0.84
|
| Rate for Payer: Beech Street Commercial |
$0.85
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.71
|
| Rate for Payer: Cash Price |
$0.61
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.84
|
| Rate for Payer: Cigna of WY Commercial |
$0.85
|
| Rate for Payer: Entrust Commercial |
$0.83
|
| Rate for Payer: First Choice Health Commercial |
$0.83
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.83
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.50
|
| Rate for Payer: HealthUtah PPO |
$0.87
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.84
|
| Rate for Payer: Multiplan Medicare/VA |
$0.48
|
| Rate for Payer: One Health Plan of WY PPO |
$0.85
|
| Rate for Payer: PacificSource Commercial |
$0.78
|
| Rate for Payer: PHCS PPO |
$0.85
|
| Rate for Payer: Three Rivers PPO |
$0.65
|
| Rate for Payer: TriWest Veterans Administration |
$0.50
|
| Rate for Payer: United Healthcare Commercial |
$0.76
|
| Rate for Payer: United Healthcare Medicare |
$0.50
|
| Rate for Payer: WINHealth Partners Commercial |
$0.85
|
| Rate for Payer: Wise Provider Network Commercial |
$0.83
|
|
|
HYDROCORTISONE 2.5 % TOPICAL CREAM [15899]
|
Facility
|
OP
|
$0.41
|
|
|
Service Code
|
NDC 5167230032
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.40
|
| Rate for Payer: Aetna of WY Medicare |
$0.27
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.39
|
| Rate for Payer: Altius Commercial |
$0.39
|
| Rate for Payer: Beech Street Commercial |
$0.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.34
|
| Rate for Payer: Cash Price |
$0.29
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.40
|
| Rate for Payer: Cigna of WY Commercial |
$0.40
|
| Rate for Payer: Entrust Commercial |
$0.39
|
| Rate for Payer: First Choice Health Commercial |
$0.39
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.39
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.24
|
| Rate for Payer: HealthUtah PPO |
$0.41
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.40
|
| Rate for Payer: Multiplan Medicare/VA |
$0.23
|
| Rate for Payer: One Health Plan of WY PPO |
$0.40
|
| Rate for Payer: PacificSource Commercial |
$0.37
|
| Rate for Payer: PHCS PPO |
$0.40
|
| Rate for Payer: Three Rivers PPO |
$0.31
|
| Rate for Payer: TriWest Veterans Administration |
$0.24
|
| Rate for Payer: United Healthcare Commercial |
$0.36
|
| Rate for Payer: United Healthcare Medicare |
$0.24
|
| Rate for Payer: WINHealth Partners Commercial |
$0.40
|
| Rate for Payer: Wise Provider Network Commercial |
$0.39
|
|
|
HYDROCORTISONE 2.5 % TOPICAL CREAM [15899]
|
Facility
|
IP
|
$0.87
|
|
|
Service Code
|
NDC 0472033730
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$0.87 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.85
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.84
|
| Rate for Payer: Altius Commercial |
$0.84
|
| Rate for Payer: Beech Street Commercial |
$0.85
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.71
|
| Rate for Payer: Cash Price |
$0.61
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.84
|
| Rate for Payer: Cigna of WY Commercial |
$0.85
|
| Rate for Payer: Entrust Commercial |
$0.83
|
| Rate for Payer: First Choice Health Commercial |
$0.83
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.83
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.57
|
| Rate for Payer: HealthUtah PPO |
$0.87
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.84
|
| Rate for Payer: Multiplan Medicare/VA |
$0.55
|
| Rate for Payer: One Health Plan of WY PPO |
$0.85
|
| Rate for Payer: PacificSource Commercial |
$0.78
|
| Rate for Payer: PHCS PPO |
$0.85
|
| Rate for Payer: Three Rivers PPO |
$0.65
|
| Rate for Payer: TriWest Veterans Administration |
$0.57
|
| Rate for Payer: United Healthcare Commercial |
$0.76
|
| Rate for Payer: United Healthcare Medicare |
$0.57
|
| Rate for Payer: WINHealth Partners Commercial |
$0.83
|
| Rate for Payer: Wise Provider Network Commercial |
$0.83
|
|
|
HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY [8681]
|
Facility
|
OP
|
$16.84
|
|
|
Service Code
|
NDC 4249430112
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.28 |
| Max. Negotiated Rate |
$16.84 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.50
|
| Rate for Payer: Aetna of WY Medicare |
$11.11
|
| Rate for Payer: Altius Auto/Workers Compensation |
$16.17
|
| Rate for Payer: Altius Commercial |
$16.17
|
| Rate for Payer: Beech Street Commercial |
$16.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.83
|
| Rate for Payer: Cash Price |
$11.79
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.33
|
| Rate for Payer: Cigna of WY Commercial |
$16.50
|
| Rate for Payer: Entrust Commercial |
$16.00
|
| Rate for Payer: First Choice Health Commercial |
$16.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.77
|
| Rate for Payer: HealthUtah PPO |
$16.84
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.33
|
| Rate for Payer: Multiplan Medicare/VA |
$9.28
|
| Rate for Payer: One Health Plan of WY PPO |
$16.50
|
| Rate for Payer: PacificSource Commercial |
$15.16
|
| Rate for Payer: PHCS PPO |
$16.50
|
| Rate for Payer: Three Rivers PPO |
$12.63
|
| Rate for Payer: TriWest Veterans Administration |
$9.77
|
| Rate for Payer: United Healthcare Commercial |
$14.65
|
| Rate for Payer: United Healthcare Medicare |
$9.77
|
| Rate for Payer: WINHealth Partners Commercial |
$16.50
|
| Rate for Payer: Wise Provider Network Commercial |
$16.00
|
|
|
HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY [8681]
|
Facility
|
IP
|
$34.50
|
|
|
Service Code
|
NDC 0713050306
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.63 |
| Max. Negotiated Rate |
$34.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$33.81
|
| Rate for Payer: Altius Auto/Workers Compensation |
$33.12
|
| Rate for Payer: Altius Commercial |
$33.12
|
| Rate for Payer: Beech Street Commercial |
$33.81
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$28.32
|
| Rate for Payer: Cash Price |
$24.15
|
| Rate for Payer: ChoiceCare Network Commercial |
$33.46
|
| Rate for Payer: Cigna of WY Commercial |
$33.81
|
| Rate for Payer: Entrust Commercial |
$32.78
|
| Rate for Payer: First Choice Health Commercial |
$32.78
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$32.78
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$22.77
|
| Rate for Payer: HealthUtah PPO |
$34.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$33.46
|
| Rate for Payer: Multiplan Medicare/VA |
$21.63
|
| Rate for Payer: One Health Plan of WY PPO |
$33.81
|
| Rate for Payer: PacificSource Commercial |
$31.05
|
| Rate for Payer: PHCS PPO |
$33.81
|
| Rate for Payer: Three Rivers PPO |
$25.88
|
| Rate for Payer: TriWest Veterans Administration |
$22.77
|
| Rate for Payer: United Healthcare Commercial |
$30.02
|
| Rate for Payer: United Healthcare Medicare |
$22.77
|
| Rate for Payer: WINHealth Partners Commercial |
$32.78
|
| Rate for Payer: Wise Provider Network Commercial |
$32.78
|
|
|
HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY [8681]
|
Facility
|
IP
|
$16.84
|
|
|
Service Code
|
NDC 4249430112
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.56 |
| Max. Negotiated Rate |
$16.84 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.50
|
| Rate for Payer: Altius Auto/Workers Compensation |
$16.17
|
| Rate for Payer: Altius Commercial |
$16.17
|
| Rate for Payer: Beech Street Commercial |
$16.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.83
|
| Rate for Payer: Cash Price |
$11.79
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.33
|
| Rate for Payer: Cigna of WY Commercial |
$16.50
|
| Rate for Payer: Entrust Commercial |
$16.00
|
| Rate for Payer: First Choice Health Commercial |
$16.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.11
|
| Rate for Payer: HealthUtah PPO |
$16.84
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.33
|
| Rate for Payer: Multiplan Medicare/VA |
$10.56
|
| Rate for Payer: One Health Plan of WY PPO |
$16.50
|
| Rate for Payer: PacificSource Commercial |
$15.16
|
| Rate for Payer: PHCS PPO |
$16.50
|
| Rate for Payer: Three Rivers PPO |
$12.63
|
| Rate for Payer: TriWest Veterans Administration |
$11.11
|
| Rate for Payer: United Healthcare Commercial |
$14.65
|
| Rate for Payer: United Healthcare Medicare |
$11.11
|
| Rate for Payer: WINHealth Partners Commercial |
$16.00
|
| Rate for Payer: Wise Provider Network Commercial |
$16.00
|
|
|
HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY [8681]
|
Facility
|
OP
|
$34.50
|
|
|
Service Code
|
NDC 0713050306
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.01 |
| Max. Negotiated Rate |
$34.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$33.81
|
| Rate for Payer: Aetna of WY Medicare |
$22.77
|
| Rate for Payer: Altius Auto/Workers Compensation |
$33.12
|
| Rate for Payer: Altius Commercial |
$33.12
|
| Rate for Payer: Beech Street Commercial |
$33.81
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$28.32
|
| Rate for Payer: Cash Price |
$24.15
|
| Rate for Payer: ChoiceCare Network Commercial |
$33.46
|
| Rate for Payer: Cigna of WY Commercial |
$33.81
|
| Rate for Payer: Entrust Commercial |
$32.78
|
| Rate for Payer: First Choice Health Commercial |
$32.78
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$32.78
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$20.01
|
| Rate for Payer: HealthUtah PPO |
$34.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$33.46
|
| Rate for Payer: Multiplan Medicare/VA |
$19.01
|
| Rate for Payer: One Health Plan of WY PPO |
$33.81
|
| Rate for Payer: PacificSource Commercial |
$31.05
|
| Rate for Payer: PHCS PPO |
$33.81
|
| Rate for Payer: Three Rivers PPO |
$25.88
|
| Rate for Payer: TriWest Veterans Administration |
$20.01
|
| Rate for Payer: United Healthcare Commercial |
$30.02
|
| Rate for Payer: United Healthcare Medicare |
$20.01
|
| Rate for Payer: WINHealth Partners Commercial |
$33.81
|
| Rate for Payer: Wise Provider Network Commercial |
$32.78
|
|
|
HYDROCORTISONE-ALOE VERA 1 % TOPICAL CREAM [14735]
|
Facility
|
OP
|
$0.21
|
|
|
Service Code
|
NDC 0536127780
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.21
|
| Rate for Payer: Aetna of WY Medicare |
$0.14
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.20
|
| Rate for Payer: Altius Commercial |
$0.20
|
| Rate for Payer: Beech Street Commercial |
$0.21
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.17
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.20
|
| Rate for Payer: Cigna of WY Commercial |
$0.21
|
| Rate for Payer: Entrust Commercial |
$0.20
|
| Rate for Payer: First Choice Health Commercial |
$0.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.12
|
| Rate for Payer: HealthUtah PPO |
$0.21
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.20
|
| Rate for Payer: Multiplan Medicare/VA |
$0.12
|
| Rate for Payer: One Health Plan of WY PPO |
$0.21
|
| Rate for Payer: PacificSource Commercial |
$0.19
|
| Rate for Payer: PHCS PPO |
$0.21
|
| Rate for Payer: Three Rivers PPO |
$0.16
|
| Rate for Payer: TriWest Veterans Administration |
$0.12
|
| Rate for Payer: United Healthcare Commercial |
$0.18
|
| Rate for Payer: United Healthcare Medicare |
$0.12
|
| Rate for Payer: WINHealth Partners Commercial |
$0.21
|
| Rate for Payer: Wise Provider Network Commercial |
$0.20
|
|
|
HYDROCORTISONE-ALOE VERA 1 % TOPICAL CREAM [14735]
|
Facility
|
IP
|
$0.21
|
|
|
Service Code
|
NDC 0536127780
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.21
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.20
|
| Rate for Payer: Altius Commercial |
$0.20
|
| Rate for Payer: Beech Street Commercial |
$0.21
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.17
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.20
|
| Rate for Payer: Cigna of WY Commercial |
$0.21
|
| Rate for Payer: Entrust Commercial |
$0.20
|
| Rate for Payer: First Choice Health Commercial |
$0.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.14
|
| Rate for Payer: HealthUtah PPO |
$0.21
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.20
|
| Rate for Payer: Multiplan Medicare/VA |
$0.13
|
| Rate for Payer: One Health Plan of WY PPO |
$0.21
|
| Rate for Payer: PacificSource Commercial |
$0.19
|
| Rate for Payer: PHCS PPO |
$0.21
|
| Rate for Payer: Three Rivers PPO |
$0.16
|
| Rate for Payer: TriWest Veterans Administration |
$0.14
|
| Rate for Payer: United Healthcare Commercial |
$0.18
|
| Rate for Payer: United Healthcare Medicare |
$0.14
|
| Rate for Payer: WINHealth Partners Commercial |
$0.20
|
| Rate for Payer: Wise Provider Network Commercial |
$0.20
|
|
|
HYDROCORTISONE-PRAMOXINE 2.5 %-1 % RECTAL CREAM [2640]
|
Facility
|
OP
|
$9.47
|
|
|
Service Code
|
NDC 5281781701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.22 |
| Max. Negotiated Rate |
$9.47 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$9.28
|
| Rate for Payer: Aetna of WY Medicare |
$6.25
|
| Rate for Payer: Altius Auto/Workers Compensation |
$9.09
|
| Rate for Payer: Altius Commercial |
$9.09
|
| Rate for Payer: Beech Street Commercial |
$9.28
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$7.77
|
| Rate for Payer: Cash Price |
$6.63
|
| Rate for Payer: ChoiceCare Network Commercial |
$9.19
|
| Rate for Payer: Cigna of WY Commercial |
$9.28
|
| Rate for Payer: Entrust Commercial |
$9.00
|
| Rate for Payer: First Choice Health Commercial |
$9.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$9.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$5.49
|
| Rate for Payer: HealthUtah PPO |
$9.47
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$9.19
|
| Rate for Payer: Multiplan Medicare/VA |
$5.22
|
| Rate for Payer: One Health Plan of WY PPO |
$9.28
|
| Rate for Payer: PacificSource Commercial |
$8.52
|
| Rate for Payer: PHCS PPO |
$9.28
|
| Rate for Payer: Three Rivers PPO |
$7.10
|
| Rate for Payer: TriWest Veterans Administration |
$5.49
|
| Rate for Payer: United Healthcare Commercial |
$8.24
|
| Rate for Payer: United Healthcare Medicare |
$5.49
|
| Rate for Payer: WINHealth Partners Commercial |
$9.28
|
| Rate for Payer: Wise Provider Network Commercial |
$9.00
|
|
|
HYDROCORTISONE-PRAMOXINE 2.5 %-1 % RECTAL CREAM [2640]
|
Facility
|
IP
|
$9.47
|
|
|
Service Code
|
NDC 5281781701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.94 |
| Max. Negotiated Rate |
$9.47 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$9.28
|
| Rate for Payer: Altius Auto/Workers Compensation |
$9.09
|
| Rate for Payer: Altius Commercial |
$9.09
|
| Rate for Payer: Beech Street Commercial |
$9.28
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$7.77
|
| Rate for Payer: Cash Price |
$6.63
|
| Rate for Payer: ChoiceCare Network Commercial |
$9.19
|
| Rate for Payer: Cigna of WY Commercial |
$9.28
|
| Rate for Payer: Entrust Commercial |
$9.00
|
| Rate for Payer: First Choice Health Commercial |
$9.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$9.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$6.25
|
| Rate for Payer: HealthUtah PPO |
$9.47
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$9.19
|
| Rate for Payer: Multiplan Medicare/VA |
$5.94
|
| Rate for Payer: One Health Plan of WY PPO |
$9.28
|
| Rate for Payer: PacificSource Commercial |
$8.52
|
| Rate for Payer: PHCS PPO |
$9.28
|
| Rate for Payer: Three Rivers PPO |
$7.10
|
| Rate for Payer: TriWest Veterans Administration |
$6.25
|
| Rate for Payer: United Healthcare Commercial |
$8.24
|
| Rate for Payer: United Healthcare Medicare |
$6.25
|
| Rate for Payer: WINHealth Partners Commercial |
$9.00
|
| Rate for Payer: Wise Provider Network Commercial |
$9.00
|
|
|
HYDROCORTISONE SODIUM SUCC I
|
Professional
|
Both
|
$62.00
|
|
|
Service Code
|
HCPCS J1720
|
| Hospital Charge Code |
J1720
|
| Min. Negotiated Rate |
$15.69 |
| Max. Negotiated Rate |
$62.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$60.76
|
| Rate for Payer: Aetna of WY Medicare |
$18.46
|
| Rate for Payer: Beech Street Commercial |
$58.90
|
| Rate for Payer: Cash Price |
$43.40
|
| Rate for Payer: Cash Price |
$43.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$60.14
|
| Rate for Payer: Cigna of WY Commercial |
$60.76
|
| Rate for Payer: First Choice Health Commercial |
$55.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$58.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$18.46
|
| Rate for Payer: HealthUtah PPO |
$62.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$60.14
|
| Rate for Payer: Multiplan Medicare/VA |
$15.69
|
| Rate for Payer: One Health Plan of WY PPO |
$60.76
|
| Rate for Payer: PacificSource Commercial |
$55.80
|
| Rate for Payer: PHCS PPO |
$58.90
|
| Rate for Payer: Three Rivers PPO |
$46.50
|
| Rate for Payer: TriWest Veterans Administration |
$18.46
|
| Rate for Payer: United Healthcare Commercial |
$53.94
|
| Rate for Payer: United Healthcare Medicare |
$18.46
|
| Rate for Payer: WINHealth Partners Commercial |
$58.90
|
|
|
HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION [89557]
|
Facility
|
OP
|
$60.84
|
|
|
Service Code
|
HCPCS J1720
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.52 |
| Max. Negotiated Rate |
$60.84 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$59.62
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$58.80
|
| Rate for Payer: Aetna of WY Medicare |
$40.15
|
| Rate for Payer: Aetna of WY Medicare |
$39.60
|
| Rate for Payer: Altius Auto/Workers Compensation |
$57.60
|
| Rate for Payer: Altius Auto/Workers Compensation |
$58.41
|
| Rate for Payer: Altius Commercial |
$58.41
|
| Rate for Payer: Altius Commercial |
$57.60
|
| Rate for Payer: Beech Street Commercial |
$58.80
|
| Rate for Payer: Beech Street Commercial |
$59.62
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$49.95
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$49.26
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Cash Price |
$42.59
|
| Rate for Payer: ChoiceCare Network Commercial |
$59.01
|
| Rate for Payer: ChoiceCare Network Commercial |
$58.20
|
| Rate for Payer: Cigna of WY Commercial |
$58.80
|
| Rate for Payer: Cigna of WY Commercial |
$59.62
|
| Rate for Payer: Entrust Commercial |
$57.80
|
| Rate for Payer: Entrust Commercial |
$57.00
|
| Rate for Payer: First Choice Health Commercial |
$57.00
|
| Rate for Payer: First Choice Health Commercial |
$57.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$57.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$57.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$35.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$34.80
|
| Rate for Payer: HealthUtah PPO |
$60.00
|
| Rate for Payer: HealthUtah PPO |
$60.84
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$58.20
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$59.01
|
| Rate for Payer: Multiplan Medicare/VA |
$33.52
|
| Rate for Payer: Multiplan Medicare/VA |
$33.06
|
| Rate for Payer: One Health Plan of WY PPO |
$58.80
|
| Rate for Payer: One Health Plan of WY PPO |
$59.62
|
| Rate for Payer: PacificSource Commercial |
$54.76
|
| Rate for Payer: PacificSource Commercial |
$54.00
|
| Rate for Payer: PHCS PPO |
$58.80
|
| Rate for Payer: PHCS PPO |
$59.62
|
| Rate for Payer: Three Rivers PPO |
$45.00
|
| Rate for Payer: Three Rivers PPO |
$45.63
|
| Rate for Payer: TriWest Veterans Administration |
$35.29
|
| Rate for Payer: TriWest Veterans Administration |
$34.80
|
| Rate for Payer: United Healthcare Commercial |
$52.20
|
| Rate for Payer: United Healthcare Commercial |
$52.93
|
| Rate for Payer: United Healthcare Medicare |
$35.29
|
| Rate for Payer: United Healthcare Medicare |
$34.80
|
| Rate for Payer: WINHealth Partners Commercial |
$58.80
|
| Rate for Payer: WINHealth Partners Commercial |
$59.62
|
| Rate for Payer: Wise Provider Network Commercial |
$57.00
|
| Rate for Payer: Wise Provider Network Commercial |
$57.80
|
|
|
HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION [89557]
|
Facility
|
IP
|
$60.84
|
|
|
Service Code
|
HCPCS J1720
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$38.15 |
| Max. Negotiated Rate |
$60.84 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$59.62
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$58.80
|
| Rate for Payer: Altius Auto/Workers Compensation |
$58.41
|
| Rate for Payer: Altius Auto/Workers Compensation |
$57.60
|
| Rate for Payer: Altius Commercial |
$57.60
|
| Rate for Payer: Altius Commercial |
$58.41
|
| Rate for Payer: Beech Street Commercial |
$59.62
|
| Rate for Payer: Beech Street Commercial |
$58.80
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$49.26
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$49.95
|
| Rate for Payer: Cash Price |
$42.59
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$58.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$59.01
|
| Rate for Payer: Cigna of WY Commercial |
$59.62
|
| Rate for Payer: Cigna of WY Commercial |
$58.80
|
| Rate for Payer: Entrust Commercial |
$57.00
|
| Rate for Payer: Entrust Commercial |
$57.80
|
| Rate for Payer: First Choice Health Commercial |
$57.00
|
| Rate for Payer: First Choice Health Commercial |
$57.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$57.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$57.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$40.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$39.60
|
| Rate for Payer: HealthUtah PPO |
$60.84
|
| Rate for Payer: HealthUtah PPO |
$60.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$58.20
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$59.01
|
| Rate for Payer: Multiplan Medicare/VA |
$38.15
|
| Rate for Payer: Multiplan Medicare/VA |
$37.62
|
| Rate for Payer: One Health Plan of WY PPO |
$59.62
|
| Rate for Payer: One Health Plan of WY PPO |
$58.80
|
| Rate for Payer: PacificSource Commercial |
$54.76
|
| Rate for Payer: PacificSource Commercial |
$54.00
|
| Rate for Payer: PHCS PPO |
$58.80
|
| Rate for Payer: PHCS PPO |
$59.62
|
| Rate for Payer: Three Rivers PPO |
$45.00
|
| Rate for Payer: Three Rivers PPO |
$45.63
|
| Rate for Payer: TriWest Veterans Administration |
$40.15
|
| Rate for Payer: TriWest Veterans Administration |
$39.60
|
| Rate for Payer: United Healthcare Commercial |
$52.20
|
| Rate for Payer: United Healthcare Commercial |
$52.93
|
| Rate for Payer: United Healthcare Medicare |
$40.15
|
| Rate for Payer: United Healthcare Medicare |
$39.60
|
| Rate for Payer: WINHealth Partners Commercial |
$57.00
|
| Rate for Payer: WINHealth Partners Commercial |
$57.80
|
| Rate for Payer: Wise Provider Network Commercial |
$57.00
|
| Rate for Payer: Wise Provider Network Commercial |
$57.80
|
|
|
HYDROGEL DRSG GEL FILLER
|
Professional
|
Both
|
$19.00
|
|
|
Service Code
|
HCPCS A6248
|
| Hospital Charge Code |
A6248
|
| Min. Negotiated Rate |
$14.25 |
| Max. Negotiated Rate |
$22.17 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18.62
|
| Rate for Payer: Aetna of WY Medicare |
$22.17
|
| Rate for Payer: Beech Street Commercial |
$18.05
|
| Rate for Payer: Cash Price |
$13.30
|
| Rate for Payer: Cash Price |
$13.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$18.43
|
| Rate for Payer: Cigna of WY Commercial |
$18.62
|
| Rate for Payer: First Choice Health Commercial |
$17.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$18.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$22.17
|
| Rate for Payer: HealthUtah PPO |
$19.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$18.43
|
| Rate for Payer: Multiplan Medicare/VA |
$18.84
|
| Rate for Payer: One Health Plan of WY PPO |
$18.62
|
| Rate for Payer: PacificSource Commercial |
$17.10
|
| Rate for Payer: PHCS PPO |
$18.05
|
| Rate for Payer: Three Rivers PPO |
$14.25
|
| Rate for Payer: TriWest Veterans Administration |
$22.17
|
| Rate for Payer: United Healthcare Commercial |
$16.53
|
| Rate for Payer: United Healthcare Medicare |
$22.17
|
| Rate for Payer: WINHealth Partners Commercial |
$18.05
|
|
|
HYDROMORPHONE 0.25 MG/0.5 ML INJECTION SYRINGE [185370]
|
Facility
|
IP
|
$39.49
|
|
|
Service Code
|
HCPCS J1171
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.76 |
| Max. Negotiated Rate |
$39.49 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$38.70
|
| Rate for Payer: Altius Auto/Workers Compensation |
$37.91
|
| Rate for Payer: Altius Commercial |
$37.91
|
| Rate for Payer: Beech Street Commercial |
$38.70
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$32.42
|
| Rate for Payer: Cash Price |
$27.64
|
| Rate for Payer: ChoiceCare Network Commercial |
$38.31
|
| Rate for Payer: Cigna of WY Commercial |
$38.70
|
| Rate for Payer: Entrust Commercial |
$37.52
|
| Rate for Payer: First Choice Health Commercial |
$37.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$37.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$26.06
|
| Rate for Payer: HealthUtah PPO |
$39.49
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$38.31
|
| Rate for Payer: Multiplan Medicare/VA |
$24.76
|
| Rate for Payer: One Health Plan of WY PPO |
$38.70
|
| Rate for Payer: PacificSource Commercial |
$35.54
|
| Rate for Payer: PHCS PPO |
$38.70
|
| Rate for Payer: Three Rivers PPO |
$29.62
|
| Rate for Payer: TriWest Veterans Administration |
$26.06
|
| Rate for Payer: United Healthcare Commercial |
$34.36
|
| Rate for Payer: United Healthcare Medicare |
$26.06
|
| Rate for Payer: WINHealth Partners Commercial |
$37.52
|
| Rate for Payer: Wise Provider Network Commercial |
$37.52
|
|
|
HYDROMORPHONE 0.25 MG/0.5 ML INJECTION SYRINGE [185370]
|
Facility
|
OP
|
$39.49
|
|
|
Service Code
|
HCPCS J1171
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.76 |
| Max. Negotiated Rate |
$39.49 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$38.70
|
| Rate for Payer: Aetna of WY Medicare |
$26.06
|
| Rate for Payer: Altius Auto/Workers Compensation |
$37.91
|
| Rate for Payer: Altius Commercial |
$37.91
|
| Rate for Payer: Beech Street Commercial |
$38.70
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$32.42
|
| Rate for Payer: Cash Price |
$27.64
|
| Rate for Payer: ChoiceCare Network Commercial |
$38.31
|
| Rate for Payer: Cigna of WY Commercial |
$38.70
|
| Rate for Payer: Entrust Commercial |
$37.52
|
| Rate for Payer: First Choice Health Commercial |
$37.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$37.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$22.90
|
| Rate for Payer: HealthUtah PPO |
$39.49
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$38.31
|
| Rate for Payer: Multiplan Medicare/VA |
$21.76
|
| Rate for Payer: One Health Plan of WY PPO |
$38.70
|
| Rate for Payer: PacificSource Commercial |
$35.54
|
| Rate for Payer: PHCS PPO |
$38.70
|
| Rate for Payer: Three Rivers PPO |
$29.62
|
| Rate for Payer: TriWest Veterans Administration |
$22.90
|
| Rate for Payer: United Healthcare Commercial |
$34.36
|
| Rate for Payer: United Healthcare Medicare |
$22.90
|
| Rate for Payer: WINHealth Partners Commercial |
$38.70
|
| Rate for Payer: Wise Provider Network Commercial |
$37.52
|
|
|
HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SYRINGE [128354]
|
Facility
|
IP
|
$37.26
|
|
|
Service Code
|
HCPCS J1171
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.36 |
| Max. Negotiated Rate |
$37.26 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$36.51
|
| Rate for Payer: Altius Auto/Workers Compensation |
$35.77
|
| Rate for Payer: Altius Commercial |
$35.77
|
| Rate for Payer: Beech Street Commercial |
$36.51
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$30.59
|
| Rate for Payer: Cash Price |
$26.08
|
| Rate for Payer: ChoiceCare Network Commercial |
$36.14
|
| Rate for Payer: Cigna of WY Commercial |
$36.51
|
| Rate for Payer: Entrust Commercial |
$35.40
|
| Rate for Payer: First Choice Health Commercial |
$35.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$35.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$24.59
|
| Rate for Payer: HealthUtah PPO |
$37.26
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$36.14
|
| Rate for Payer: Multiplan Medicare/VA |
$23.36
|
| Rate for Payer: One Health Plan of WY PPO |
$36.51
|
| Rate for Payer: PacificSource Commercial |
$33.53
|
| Rate for Payer: PHCS PPO |
$36.51
|
| Rate for Payer: Three Rivers PPO |
$27.94
|
| Rate for Payer: TriWest Veterans Administration |
$24.59
|
| Rate for Payer: United Healthcare Commercial |
$32.42
|
| Rate for Payer: United Healthcare Medicare |
$24.59
|
| Rate for Payer: WINHealth Partners Commercial |
$35.40
|
| Rate for Payer: Wise Provider Network Commercial |
$35.40
|
|
|
HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SYRINGE [128354]
|
Facility
|
OP
|
$37.26
|
|
|
Service Code
|
HCPCS J1171
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.53 |
| Max. Negotiated Rate |
$37.26 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$36.51
|
| Rate for Payer: Aetna of WY Medicare |
$24.59
|
| Rate for Payer: Altius Auto/Workers Compensation |
$35.77
|
| Rate for Payer: Altius Commercial |
$35.77
|
| Rate for Payer: Beech Street Commercial |
$36.51
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$30.59
|
| Rate for Payer: Cash Price |
$26.08
|
| Rate for Payer: ChoiceCare Network Commercial |
$36.14
|
| Rate for Payer: Cigna of WY Commercial |
$36.51
|
| Rate for Payer: Entrust Commercial |
$35.40
|
| Rate for Payer: First Choice Health Commercial |
$35.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$35.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$21.61
|
| Rate for Payer: HealthUtah PPO |
$37.26
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$36.14
|
| Rate for Payer: Multiplan Medicare/VA |
$20.53
|
| Rate for Payer: One Health Plan of WY PPO |
$36.51
|
| Rate for Payer: PacificSource Commercial |
$33.53
|
| Rate for Payer: PHCS PPO |
$36.51
|
| Rate for Payer: Three Rivers PPO |
$27.94
|
| Rate for Payer: TriWest Veterans Administration |
$21.61
|
| Rate for Payer: United Healthcare Commercial |
$32.42
|
| Rate for Payer: United Healthcare Medicare |
$21.61
|
| Rate for Payer: WINHealth Partners Commercial |
$36.51
|
| Rate for Payer: Wise Provider Network Commercial |
$35.40
|
|
|
HYDROMORPHONE 2 MG/ML INJECTION SOLUTION [10716]
|
Facility
|
IP
|
$23.39
|
|
|
Service Code
|
HCPCS J1171
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.67 |
| Max. Negotiated Rate |
$23.39 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$22.92
|
| Rate for Payer: Altius Auto/Workers Compensation |
$22.45
|
| Rate for Payer: Altius Commercial |
$22.45
|
| Rate for Payer: Beech Street Commercial |
$22.92
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$19.20
|
| Rate for Payer: Cash Price |
$16.37
|
| Rate for Payer: ChoiceCare Network Commercial |
$22.69
|
| Rate for Payer: Cigna of WY Commercial |
$22.92
|
| Rate for Payer: Entrust Commercial |
$22.22
|
| Rate for Payer: First Choice Health Commercial |
$22.22
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$22.22
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$15.44
|
| Rate for Payer: HealthUtah PPO |
$23.39
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$22.69
|
| Rate for Payer: Multiplan Medicare/VA |
$14.67
|
| Rate for Payer: One Health Plan of WY PPO |
$22.92
|
| Rate for Payer: PacificSource Commercial |
$21.05
|
| Rate for Payer: PHCS PPO |
$22.92
|
| Rate for Payer: Three Rivers PPO |
$17.54
|
| Rate for Payer: TriWest Veterans Administration |
$15.44
|
| Rate for Payer: United Healthcare Commercial |
$20.35
|
| Rate for Payer: United Healthcare Medicare |
$15.44
|
| Rate for Payer: WINHealth Partners Commercial |
$22.22
|
| Rate for Payer: Wise Provider Network Commercial |
$22.22
|
|
|
HYDROMORPHONE 2 MG/ML INJECTION SOLUTION [10716]
|
Facility
|
OP
|
$23.39
|
|
|
Service Code
|
HCPCS J1171
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.89 |
| Max. Negotiated Rate |
$23.39 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$22.92
|
| Rate for Payer: Aetna of WY Medicare |
$15.44
|
| Rate for Payer: Altius Auto/Workers Compensation |
$22.45
|
| Rate for Payer: Altius Commercial |
$22.45
|
| Rate for Payer: Beech Street Commercial |
$22.92
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$19.20
|
| Rate for Payer: Cash Price |
$16.37
|
| Rate for Payer: ChoiceCare Network Commercial |
$22.69
|
| Rate for Payer: Cigna of WY Commercial |
$22.92
|
| Rate for Payer: Entrust Commercial |
$22.22
|
| Rate for Payer: First Choice Health Commercial |
$22.22
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$22.22
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$13.57
|
| Rate for Payer: HealthUtah PPO |
$23.39
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$22.69
|
| Rate for Payer: Multiplan Medicare/VA |
$12.89
|
| Rate for Payer: One Health Plan of WY PPO |
$22.92
|
| Rate for Payer: PacificSource Commercial |
$21.05
|
| Rate for Payer: PHCS PPO |
$22.92
|
| Rate for Payer: Three Rivers PPO |
$17.54
|
| Rate for Payer: TriWest Veterans Administration |
$13.57
|
| Rate for Payer: United Healthcare Commercial |
$20.35
|
| Rate for Payer: United Healthcare Medicare |
$13.57
|
| Rate for Payer: WINHealth Partners Commercial |
$22.92
|
| Rate for Payer: Wise Provider Network Commercial |
$22.22
|
|
|
HYDROMORPHONE 2 MG TABLET [10016]
|
Facility
|
OP
|
$1.43
|
|
|
Service Code
|
NDC 6068757911
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$1.43 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.40
|
| Rate for Payer: Aetna of WY Medicare |
$0.94
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.37
|
| Rate for Payer: Altius Commercial |
$1.37
|
| Rate for Payer: Beech Street Commercial |
$1.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.17
|
| Rate for Payer: Cash Price |
$1.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.39
|
| Rate for Payer: Cigna of WY Commercial |
$1.40
|
| Rate for Payer: Entrust Commercial |
$1.36
|
| Rate for Payer: First Choice Health Commercial |
$1.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.83
|
| Rate for Payer: HealthUtah PPO |
$1.43
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.39
|
| Rate for Payer: Multiplan Medicare/VA |
$0.79
|
| Rate for Payer: One Health Plan of WY PPO |
$1.40
|
| Rate for Payer: PacificSource Commercial |
$1.29
|
| Rate for Payer: PHCS PPO |
$1.40
|
| Rate for Payer: Three Rivers PPO |
$1.07
|
| Rate for Payer: TriWest Veterans Administration |
$0.83
|
| Rate for Payer: United Healthcare Commercial |
$1.24
|
| Rate for Payer: United Healthcare Medicare |
$0.83
|
| Rate for Payer: WINHealth Partners Commercial |
$1.40
|
| Rate for Payer: Wise Provider Network Commercial |
$1.36
|
|
|
HYDROMORPHONE 2 MG TABLET [10016]
|
Facility
|
IP
|
$1.43
|
|
|
Service Code
|
NDC 6068757911
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.90 |
| Max. Negotiated Rate |
$1.43 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.40
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.37
|
| Rate for Payer: Altius Commercial |
$1.37
|
| Rate for Payer: Beech Street Commercial |
$1.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.17
|
| Rate for Payer: Cash Price |
$1.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.39
|
| Rate for Payer: Cigna of WY Commercial |
$1.40
|
| Rate for Payer: Entrust Commercial |
$1.36
|
| Rate for Payer: First Choice Health Commercial |
$1.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.94
|
| Rate for Payer: HealthUtah PPO |
$1.43
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.39
|
| Rate for Payer: Multiplan Medicare/VA |
$0.90
|
| Rate for Payer: One Health Plan of WY PPO |
$1.40
|
| Rate for Payer: PacificSource Commercial |
$1.29
|
| Rate for Payer: PHCS PPO |
$1.40
|
| Rate for Payer: Three Rivers PPO |
$1.07
|
| 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 |
$1.36
|
| Rate for Payer: Wise Provider Network Commercial |
$1.36
|
|
|
HYDROMORPHONE INJECTION
|
Professional
|
Both
|
$2.00
|
|
|
Service Code
|
HCPCS J1170
|
| Hospital Charge Code |
J1170
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$4.76 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.96
|
| Rate for Payer: Aetna of WY Medicare |
$4.76
|
| Rate for Payer: Beech Street Commercial |
$1.90
|
| Rate for Payer: Cash Price |
$1.40
|
| Rate for Payer: Cash Price |
$1.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.94
|
| Rate for Payer: Cigna of WY Commercial |
$1.96
|
| Rate for Payer: First Choice Health Commercial |
$1.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$4.76
|
| Rate for Payer: HealthUtah PPO |
$2.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.94
|
| Rate for Payer: Multiplan Medicare/VA |
$4.04
|
| Rate for Payer: One Health Plan of WY PPO |
$1.96
|
| Rate for Payer: PacificSource Commercial |
$1.80
|
| Rate for Payer: PHCS PPO |
$1.90
|
| Rate for Payer: Three Rivers PPO |
$1.50
|
| Rate for Payer: TriWest Veterans Administration |
$4.76
|
| Rate for Payer: United Healthcare Commercial |
$1.74
|
| Rate for Payer: United Healthcare Medicare |
$4.76
|
| Rate for Payer: WINHealth Partners Commercial |
$1.90
|
|
