|
HYSTEROSCOPY LYSIS INTRAUTERINE ADHESIONS
|
Professional
|
Both
|
$1,198.00
|
|
|
Service Code
|
HCPCS 58559
|
| Hospital Charge Code |
58559
|
| Min. Negotiated Rate |
$229.91 |
| Max. Negotiated Rate |
$1,198.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,174.04
|
| Rate for Payer: Aetna of WY Medicare |
$270.48
|
| Rate for Payer: Beech Street Commercial |
$1,138.10
|
| Rate for Payer: Cash Price |
$838.60
|
| Rate for Payer: Cash Price |
$838.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,162.06
|
| Rate for Payer: Cigna of WY Commercial |
$1,174.04
|
| Rate for Payer: First Choice Health Commercial |
$1,078.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,138.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$270.48
|
| Rate for Payer: HealthUtah PPO |
$1,198.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,162.06
|
| Rate for Payer: Multiplan Medicare/VA |
$229.91
|
| Rate for Payer: One Health Plan of WY PPO |
$1,174.04
|
| Rate for Payer: PacificSource Commercial |
$1,078.20
|
| Rate for Payer: PHCS PPO |
$1,138.10
|
| Rate for Payer: Three Rivers PPO |
$898.50
|
| Rate for Payer: TriWest Veterans Administration |
$270.48
|
| Rate for Payer: United Healthcare Commercial |
$1,042.26
|
| Rate for Payer: United Healthcare Medicare |
$270.48
|
| Rate for Payer: WINHealth Partners Commercial |
$1,018.30
|
|
|
HYSTEROSCOPY REMOVAL IMPACTED FOREIGN BODY
|
Professional
|
Both
|
$1,156.00
|
|
|
Service Code
|
HCPCS 58562
|
| Hospital Charge Code |
58562
|
| Min. Negotiated Rate |
$179.59 |
| Max. Negotiated Rate |
$1,156.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,132.88
|
| Rate for Payer: Aetna of WY Medicare |
$211.28
|
| Rate for Payer: Beech Street Commercial |
$1,098.20
|
| Rate for Payer: Cash Price |
$809.20
|
| Rate for Payer: Cash Price |
$809.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,121.32
|
| Rate for Payer: Cigna of WY Commercial |
$1,132.88
|
| Rate for Payer: First Choice Health Commercial |
$1,040.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,098.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$211.28
|
| Rate for Payer: HealthUtah PPO |
$1,156.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,121.32
|
| Rate for Payer: Multiplan Medicare/VA |
$179.59
|
| Rate for Payer: One Health Plan of WY PPO |
$1,132.88
|
| Rate for Payer: PacificSource Commercial |
$1,040.40
|
| Rate for Payer: PHCS PPO |
$1,098.20
|
| Rate for Payer: Three Rivers PPO |
$867.00
|
| Rate for Payer: TriWest Veterans Administration |
$211.28
|
| Rate for Payer: United Healthcare Commercial |
$1,005.72
|
| Rate for Payer: United Healthcare Medicare |
$211.28
|
| Rate for Payer: WINHealth Partners Commercial |
$982.60
|
|
|
HYSTEROSCOPY REMOVAL LEIOMYOMATA
|
Professional
|
Both
|
$1,506.00
|
|
|
Service Code
|
HCPCS 58561
|
| Hospital Charge Code |
58561
|
| Min. Negotiated Rate |
$289.60 |
| Max. Negotiated Rate |
$1,506.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,475.88
|
| Rate for Payer: Aetna of WY Medicare |
$340.71
|
| Rate for Payer: Beech Street Commercial |
$1,430.70
|
| Rate for Payer: Cash Price |
$1,054.20
|
| Rate for Payer: Cash Price |
$1,054.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,460.82
|
| Rate for Payer: Cigna of WY Commercial |
$1,475.88
|
| Rate for Payer: First Choice Health Commercial |
$1,355.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,430.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$340.71
|
| Rate for Payer: HealthUtah PPO |
$1,506.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,460.82
|
| Rate for Payer: Multiplan Medicare/VA |
$289.60
|
| Rate for Payer: One Health Plan of WY PPO |
$1,475.88
|
| Rate for Payer: PacificSource Commercial |
$1,355.40
|
| Rate for Payer: PHCS PPO |
$1,430.70
|
| Rate for Payer: Three Rivers PPO |
$1,129.50
|
| Rate for Payer: TriWest Veterans Administration |
$340.71
|
| Rate for Payer: United Healthcare Commercial |
$1,310.22
|
| Rate for Payer: United Healthcare Medicare |
$340.71
|
| Rate for Payer: WINHealth Partners Commercial |
$1,280.10
|
|
|
HZV ZOSTER VACC RECOMBINANT ADJUVANTED IM USE
|
Professional
|
Both
|
$222.00
|
|
|
Service Code
|
HCPCS 90750
|
| Hospital Charge Code |
90750
|
| Min. Negotiated Rate |
$166.50 |
| Max. Negotiated Rate |
$222.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$217.56
|
| Rate for Payer: Beech Street Commercial |
$210.90
|
| Rate for Payer: Cash Price |
$155.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$215.34
|
| Rate for Payer: Cigna of WY Commercial |
$217.56
|
| Rate for Payer: First Choice Health Commercial |
$199.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$210.90
|
| Rate for Payer: HealthUtah PPO |
$222.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$215.34
|
| Rate for Payer: One Health Plan of WY PPO |
$217.56
|
| Rate for Payer: PacificSource Commercial |
$199.80
|
| Rate for Payer: PHCS PPO |
$210.90
|
| Rate for Payer: Three Rivers PPO |
$166.50
|
| Rate for Payer: United Healthcare Commercial |
$193.14
|
| Rate for Payer: WINHealth Partners Commercial |
$210.90
|
|
|
IAADIADOO INFLUENZA
|
Professional
|
Both
|
$83.00
|
|
|
Service Code
|
HCPCS 87804
|
| Hospital Charge Code |
87804
|
| Min. Negotiated Rate |
$14.07 |
| Max. Negotiated Rate |
$83.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$81.34
|
| Rate for Payer: Aetna of WY Medicare |
$16.55
|
| Rate for Payer: Beech Street Commercial |
$78.85
|
| Rate for Payer: Cash Price |
$58.10
|
| Rate for Payer: Cash Price |
$58.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$80.51
|
| Rate for Payer: Cigna of WY Commercial |
$81.34
|
| Rate for Payer: First Choice Health Commercial |
$74.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$78.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$16.55
|
| Rate for Payer: HealthUtah PPO |
$83.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$80.51
|
| Rate for Payer: Multiplan Medicare/VA |
$14.07
|
| Rate for Payer: One Health Plan of WY PPO |
$81.34
|
| Rate for Payer: PacificSource Commercial |
$74.70
|
| Rate for Payer: PHCS PPO |
$78.85
|
| Rate for Payer: Three Rivers PPO |
$62.25
|
| Rate for Payer: TriWest Veterans Administration |
$16.55
|
| Rate for Payer: United Healthcare Commercial |
$72.21
|
| Rate for Payer: United Healthcare Medicare |
$16.55
|
| Rate for Payer: WINHealth Partners Commercial |
$78.85
|
|
|
IAADIADOO RESPIRATORY SYNCTIAL VIRUS
|
Professional
|
Both
|
$207.00
|
|
|
Service Code
|
HCPCS 87807
|
| Hospital Charge Code |
87807
|
| Min. Negotiated Rate |
$11.14 |
| Max. Negotiated Rate |
$207.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$202.86
|
| Rate for Payer: Aetna of WY Medicare |
$13.10
|
| Rate for Payer: Beech Street Commercial |
$196.65
|
| Rate for Payer: Cash Price |
$144.90
|
| Rate for Payer: Cash Price |
$144.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$200.79
|
| Rate for Payer: Cigna of WY Commercial |
$202.86
|
| Rate for Payer: First Choice Health Commercial |
$186.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$196.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$13.10
|
| Rate for Payer: HealthUtah PPO |
$207.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$200.79
|
| Rate for Payer: Multiplan Medicare/VA |
$11.14
|
| Rate for Payer: One Health Plan of WY PPO |
$202.86
|
| Rate for Payer: PacificSource Commercial |
$186.30
|
| Rate for Payer: PHCS PPO |
$196.65
|
| Rate for Payer: Three Rivers PPO |
$155.25
|
| Rate for Payer: TriWest Veterans Administration |
$13.10
|
| Rate for Payer: United Healthcare Commercial |
$180.09
|
| Rate for Payer: United Healthcare Medicare |
$13.10
|
| Rate for Payer: WINHealth Partners Commercial |
$196.65
|
|
|
IAADIADOO SEVERE AQT RESPIR SYND CORONAVIRUS
|
Professional
|
Both
|
$202.00
|
|
|
Service Code
|
HCPCS 87811
|
| Hospital Charge Code |
87811
|
| Min. Negotiated Rate |
$35.17 |
| Max. Negotiated Rate |
$202.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$197.96
|
| Rate for Payer: Aetna of WY Medicare |
$41.38
|
| Rate for Payer: Beech Street Commercial |
$191.90
|
| Rate for Payer: Cash Price |
$141.40
|
| Rate for Payer: Cash Price |
$141.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$195.94
|
| Rate for Payer: Cigna of WY Commercial |
$197.96
|
| Rate for Payer: First Choice Health Commercial |
$181.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$191.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$41.38
|
| Rate for Payer: HealthUtah PPO |
$202.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$195.94
|
| Rate for Payer: Multiplan Medicare/VA |
$35.17
|
| Rate for Payer: One Health Plan of WY PPO |
$197.96
|
| Rate for Payer: PacificSource Commercial |
$181.80
|
| Rate for Payer: PHCS PPO |
$191.90
|
| Rate for Payer: Three Rivers PPO |
$151.50
|
| Rate for Payer: TriWest Veterans Administration |
$41.38
|
| Rate for Payer: United Healthcare Commercial |
$175.74
|
| Rate for Payer: United Healthcare Medicare |
$41.38
|
| Rate for Payer: WINHealth Partners Commercial |
$191.90
|
|
|
IAADIADOO STREPTOCOCCUS GROUP A
|
Professional
|
Both
|
$63.00
|
|
|
Service Code
|
HCPCS 87880
|
| Hospital Charge Code |
87880
|
| Min. Negotiated Rate |
$14.05 |
| Max. Negotiated Rate |
$63.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$61.74
|
| Rate for Payer: Aetna of WY Medicare |
$16.53
|
| Rate for Payer: Beech Street Commercial |
$59.85
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$61.11
|
| Rate for Payer: Cigna of WY Commercial |
$61.74
|
| Rate for Payer: First Choice Health Commercial |
$56.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$59.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$16.53
|
| Rate for Payer: HealthUtah PPO |
$63.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$61.11
|
| Rate for Payer: Multiplan Medicare/VA |
$14.05
|
| Rate for Payer: One Health Plan of WY PPO |
$61.74
|
| Rate for Payer: PacificSource Commercial |
$56.70
|
| Rate for Payer: PHCS PPO |
$59.85
|
| Rate for Payer: Three Rivers PPO |
$47.25
|
| Rate for Payer: TriWest Veterans Administration |
$16.53
|
| Rate for Payer: United Healthcare Commercial |
$54.81
|
| Rate for Payer: United Healthcare Medicare |
$16.53
|
| Rate for Payer: WINHealth Partners Commercial |
$59.85
|
|
|
IAAD IA SEVERE AQT RESPIR SYND CORONAVIRUS
|
Professional
|
Both
|
$202.00
|
|
|
Service Code
|
HCPCS 87426
|
| Hospital Charge Code |
87426
|
| Min. Negotiated Rate |
$30.03 |
| Max. Negotiated Rate |
$202.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$197.96
|
| Rate for Payer: Aetna of WY Medicare |
$35.33
|
| Rate for Payer: Beech Street Commercial |
$191.90
|
| Rate for Payer: Cash Price |
$141.40
|
| Rate for Payer: Cash Price |
$141.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$195.94
|
| Rate for Payer: Cigna of WY Commercial |
$197.96
|
| Rate for Payer: First Choice Health Commercial |
$181.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$191.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$35.33
|
| Rate for Payer: HealthUtah PPO |
$202.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$195.94
|
| Rate for Payer: Multiplan Medicare/VA |
$30.03
|
| Rate for Payer: One Health Plan of WY PPO |
$197.96
|
| Rate for Payer: PacificSource Commercial |
$181.80
|
| Rate for Payer: PHCS PPO |
$191.90
|
| Rate for Payer: Three Rivers PPO |
$151.50
|
| Rate for Payer: TriWest Veterans Administration |
$35.33
|
| Rate for Payer: United Healthcare Commercial |
$175.74
|
| Rate for Payer: United Healthcare Medicare |
$35.33
|
| Rate for Payer: WINHealth Partners Commercial |
$191.90
|
|
|
IADNA RESPIRATRY PROBE & REV TRNSCR 3-5 TARGETS
|
Professional
|
Both
|
$406.00
|
|
|
Service Code
|
HCPCS 87631
|
| Hospital Charge Code |
87631
|
| Min. Negotiated Rate |
$121.24 |
| Max. Negotiated Rate |
$406.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$397.88
|
| Rate for Payer: Aetna of WY Medicare |
$142.63
|
| Rate for Payer: Beech Street Commercial |
$385.70
|
| Rate for Payer: Cash Price |
$284.20
|
| Rate for Payer: Cash Price |
$284.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$393.82
|
| Rate for Payer: Cigna of WY Commercial |
$397.88
|
| Rate for Payer: First Choice Health Commercial |
$365.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$385.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$142.63
|
| Rate for Payer: HealthUtah PPO |
$406.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$393.82
|
| Rate for Payer: Multiplan Medicare/VA |
$121.24
|
| Rate for Payer: One Health Plan of WY PPO |
$397.88
|
| Rate for Payer: PacificSource Commercial |
$365.40
|
| Rate for Payer: PHCS PPO |
$385.70
|
| Rate for Payer: Three Rivers PPO |
$304.50
|
| Rate for Payer: TriWest Veterans Administration |
$142.63
|
| Rate for Payer: United Healthcare Commercial |
$353.22
|
| Rate for Payer: United Healthcare Medicare |
$142.63
|
| Rate for Payer: WINHealth Partners Commercial |
$385.70
|
|
|
IADNA SARS-COV-2 COVID-19 AMPLIFIED PROBE TQ
|
Professional
|
Both
|
$340.00
|
|
|
Service Code
|
HCPCS 87635
|
| Hospital Charge Code |
87635
|
| Min. Negotiated Rate |
$43.61 |
| Max. Negotiated Rate |
$340.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$333.20
|
| Rate for Payer: Aetna of WY Medicare |
$51.31
|
| Rate for Payer: Beech Street Commercial |
$323.00
|
| Rate for Payer: Cash Price |
$238.00
|
| Rate for Payer: Cash Price |
$238.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$329.80
|
| Rate for Payer: Cigna of WY Commercial |
$333.20
|
| Rate for Payer: First Choice Health Commercial |
$306.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$323.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$51.31
|
| Rate for Payer: HealthUtah PPO |
$340.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$329.80
|
| Rate for Payer: Multiplan Medicare/VA |
$43.61
|
| Rate for Payer: One Health Plan of WY PPO |
$333.20
|
| Rate for Payer: PacificSource Commercial |
$306.00
|
| Rate for Payer: PHCS PPO |
$323.00
|
| Rate for Payer: Three Rivers PPO |
$255.00
|
| Rate for Payer: TriWest Veterans Administration |
$51.31
|
| Rate for Payer: United Healthcare Commercial |
$295.80
|
| Rate for Payer: United Healthcare Medicare |
$51.31
|
| Rate for Payer: WINHealth Partners Commercial |
$323.00
|
|
|
IADNA SARSCOV2& INF A&B MULT AMPLIFIED PROBE TQ
|
Professional
|
Both
|
$260.00
|
|
|
Service Code
|
HCPCS 87636
|
| Hospital Charge Code |
87636
|
| Min. Negotiated Rate |
$121.24 |
| Max. Negotiated Rate |
$260.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$254.80
|
| Rate for Payer: Aetna of WY Medicare |
$142.63
|
| Rate for Payer: Beech Street Commercial |
$247.00
|
| Rate for Payer: Cash Price |
$182.00
|
| Rate for Payer: Cash Price |
$182.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$252.20
|
| Rate for Payer: Cigna of WY Commercial |
$254.80
|
| Rate for Payer: First Choice Health Commercial |
$234.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$247.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$142.63
|
| Rate for Payer: HealthUtah PPO |
$260.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$252.20
|
| Rate for Payer: Multiplan Medicare/VA |
$121.24
|
| Rate for Payer: One Health Plan of WY PPO |
$254.80
|
| Rate for Payer: PacificSource Commercial |
$234.00
|
| Rate for Payer: PHCS PPO |
$247.00
|
| Rate for Payer: Three Rivers PPO |
$195.00
|
| Rate for Payer: TriWest Veterans Administration |
$142.63
|
| Rate for Payer: United Healthcare Commercial |
$226.20
|
| Rate for Payer: United Healthcare Medicare |
$142.63
|
| Rate for Payer: WINHealth Partners Commercial |
$247.00
|
|
|
IADNA STREPTOCOCCUS GROUP A AMPLIFIED PROBE TQ
|
Professional
|
Both
|
$101.00
|
|
|
Service Code
|
HCPCS 87651
|
| Hospital Charge Code |
87651
|
| Min. Negotiated Rate |
$29.83 |
| Max. Negotiated Rate |
$101.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$98.98
|
| Rate for Payer: Aetna of WY Medicare |
$35.09
|
| Rate for Payer: Beech Street Commercial |
$95.95
|
| Rate for Payer: Cash Price |
$70.70
|
| Rate for Payer: Cash Price |
$70.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$97.97
|
| Rate for Payer: Cigna of WY Commercial |
$98.98
|
| Rate for Payer: First Choice Health Commercial |
$90.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$95.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$35.09
|
| Rate for Payer: HealthUtah PPO |
$101.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$97.97
|
| Rate for Payer: Multiplan Medicare/VA |
$29.83
|
| Rate for Payer: One Health Plan of WY PPO |
$98.98
|
| Rate for Payer: PacificSource Commercial |
$90.90
|
| Rate for Payer: PHCS PPO |
$95.95
|
| Rate for Payer: Three Rivers PPO |
$75.75
|
| Rate for Payer: TriWest Veterans Administration |
$35.09
|
| Rate for Payer: United Healthcare Commercial |
$87.87
|
| Rate for Payer: United Healthcare Medicare |
$35.09
|
| Rate for Payer: WINHealth Partners Commercial |
$95.95
|
|
|
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION [17795]
|
Facility
|
OP
|
$0.62
|
|
|
Service Code
|
NDC 6809449459
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$0.62 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.61
|
| Rate for Payer: Aetna of WY Medicare |
$0.41
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.60
|
| Rate for Payer: Altius Commercial |
$0.60
|
| Rate for Payer: Beech Street Commercial |
$0.61
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.51
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.60
|
| Rate for Payer: Cigna of WY Commercial |
$0.61
|
| Rate for Payer: Entrust Commercial |
$0.59
|
| Rate for Payer: First Choice Health Commercial |
$0.59
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.59
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.36
|
| Rate for Payer: HealthUtah PPO |
$0.62
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.60
|
| Rate for Payer: Multiplan Medicare/VA |
$0.34
|
| Rate for Payer: One Health Plan of WY PPO |
$0.61
|
| Rate for Payer: PacificSource Commercial |
$0.56
|
| Rate for Payer: PHCS PPO |
$0.61
|
| Rate for Payer: Three Rivers PPO |
$0.47
|
| Rate for Payer: TriWest Veterans Administration |
$0.36
|
| Rate for Payer: United Healthcare Commercial |
$0.54
|
| Rate for Payer: United Healthcare Medicare |
$0.36
|
| Rate for Payer: WINHealth Partners Commercial |
$0.61
|
| Rate for Payer: Wise Provider Network Commercial |
$0.59
|
|
|
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION [17795]
|
Facility
|
IP
|
$0.25
|
|
|
Service Code
|
NDC 6800152192
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.25
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.24
|
| Rate for Payer: Altius Commercial |
$0.24
|
| Rate for Payer: Beech Street Commercial |
$0.25
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.21
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.24
|
| Rate for Payer: Cigna of WY Commercial |
$0.25
|
| Rate for Payer: Entrust Commercial |
$0.24
|
| Rate for Payer: First Choice Health Commercial |
$0.24
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.24
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.17
|
| Rate for Payer: HealthUtah PPO |
$0.25
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.24
|
| Rate for Payer: Multiplan Medicare/VA |
$0.16
|
| Rate for Payer: One Health Plan of WY PPO |
$0.25
|
| Rate for Payer: PacificSource Commercial |
$0.23
|
| Rate for Payer: PHCS PPO |
$0.25
|
| Rate for Payer: Three Rivers PPO |
$0.19
|
| Rate for Payer: TriWest Veterans Administration |
$0.17
|
| Rate for Payer: United Healthcare Commercial |
$0.22
|
| Rate for Payer: United Healthcare Medicare |
$0.17
|
| Rate for Payer: WINHealth Partners Commercial |
$0.24
|
| Rate for Payer: Wise Provider Network Commercial |
$0.24
|
|
|
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION [17795]
|
Facility
|
OP
|
$0.68
|
|
|
Service Code
|
NDC 6809460059
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$0.68 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.67
|
| Rate for Payer: Aetna of WY Medicare |
$0.45
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.65
|
| Rate for Payer: Altius Commercial |
$0.65
|
| Rate for Payer: Beech Street Commercial |
$0.67
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.56
|
| Rate for Payer: Cash Price |
$0.48
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.66
|
| Rate for Payer: Cigna of WY Commercial |
$0.67
|
| Rate for Payer: Entrust Commercial |
$0.65
|
| Rate for Payer: First Choice Health Commercial |
$0.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.39
|
| Rate for Payer: HealthUtah PPO |
$0.68
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.66
|
| Rate for Payer: Multiplan Medicare/VA |
$0.37
|
| Rate for Payer: One Health Plan of WY PPO |
$0.67
|
| Rate for Payer: PacificSource Commercial |
$0.61
|
| Rate for Payer: PHCS PPO |
$0.67
|
| Rate for Payer: Three Rivers PPO |
$0.51
|
| Rate for Payer: TriWest Veterans Administration |
$0.39
|
| Rate for Payer: United Healthcare Commercial |
$0.59
|
| Rate for Payer: United Healthcare Medicare |
$0.39
|
| Rate for Payer: WINHealth Partners Commercial |
$0.67
|
| Rate for Payer: Wise Provider Network Commercial |
$0.65
|
|
|
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION [17795]
|
Facility
|
IP
|
$0.62
|
|
|
Service Code
|
NDC 6809449459
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$0.62 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.61
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.60
|
| Rate for Payer: Altius Commercial |
$0.60
|
| Rate for Payer: Beech Street Commercial |
$0.61
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.51
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.60
|
| Rate for Payer: Cigna of WY Commercial |
$0.61
|
| Rate for Payer: Entrust Commercial |
$0.59
|
| Rate for Payer: First Choice Health Commercial |
$0.59
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.59
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.41
|
| Rate for Payer: HealthUtah PPO |
$0.62
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.60
|
| Rate for Payer: Multiplan Medicare/VA |
$0.39
|
| Rate for Payer: One Health Plan of WY PPO |
$0.61
|
| Rate for Payer: PacificSource Commercial |
$0.56
|
| Rate for Payer: PHCS PPO |
$0.61
|
| Rate for Payer: Three Rivers PPO |
$0.47
|
| Rate for Payer: TriWest Veterans Administration |
$0.41
|
| Rate for Payer: United Healthcare Commercial |
$0.54
|
| Rate for Payer: United Healthcare Medicare |
$0.41
|
| Rate for Payer: WINHealth Partners Commercial |
$0.59
|
| Rate for Payer: Wise Provider Network Commercial |
$0.59
|
|
|
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION [17795]
|
Facility
|
OP
|
$0.25
|
|
|
Service Code
|
NDC 6800152192
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.25
|
| Rate for Payer: Aetna of WY Medicare |
$0.17
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.24
|
| Rate for Payer: Altius Commercial |
$0.24
|
| Rate for Payer: Beech Street Commercial |
$0.25
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.21
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.24
|
| Rate for Payer: Cigna of WY Commercial |
$0.25
|
| Rate for Payer: Entrust Commercial |
$0.24
|
| Rate for Payer: First Choice Health Commercial |
$0.24
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.24
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.15
|
| Rate for Payer: HealthUtah PPO |
$0.25
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.24
|
| Rate for Payer: Multiplan Medicare/VA |
$0.14
|
| Rate for Payer: One Health Plan of WY PPO |
$0.25
|
| Rate for Payer: PacificSource Commercial |
$0.23
|
| Rate for Payer: PHCS PPO |
$0.25
|
| Rate for Payer: Three Rivers PPO |
$0.19
|
| Rate for Payer: TriWest Veterans Administration |
$0.15
|
| Rate for Payer: United Healthcare Commercial |
$0.22
|
| Rate for Payer: United Healthcare Medicare |
$0.15
|
| Rate for Payer: WINHealth Partners Commercial |
$0.25
|
| Rate for Payer: Wise Provider Network Commercial |
$0.24
|
|
|
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION [17795]
|
Facility
|
IP
|
$0.68
|
|
|
Service Code
|
NDC 6809460059
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$0.68 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.67
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.65
|
| Rate for Payer: Altius Commercial |
$0.65
|
| Rate for Payer: Beech Street Commercial |
$0.67
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.56
|
| Rate for Payer: Cash Price |
$0.48
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.66
|
| Rate for Payer: Cigna of WY Commercial |
$0.67
|
| Rate for Payer: Entrust Commercial |
$0.65
|
| Rate for Payer: First Choice Health Commercial |
$0.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.45
|
| Rate for Payer: HealthUtah PPO |
$0.68
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.66
|
| Rate for Payer: Multiplan Medicare/VA |
$0.43
|
| Rate for Payer: One Health Plan of WY PPO |
$0.67
|
| Rate for Payer: PacificSource Commercial |
$0.61
|
| Rate for Payer: PHCS PPO |
$0.67
|
| Rate for Payer: Three Rivers PPO |
$0.51
|
| Rate for Payer: TriWest Veterans Administration |
$0.45
|
| Rate for Payer: United Healthcare Commercial |
$0.59
|
| Rate for Payer: United Healthcare Medicare |
$0.45
|
| Rate for Payer: WINHealth Partners Commercial |
$0.65
|
| Rate for Payer: Wise Provider Network Commercial |
$0.65
|
|
|
IBUPROFEN 200 MG CAPSULE [4514]
|
Facility
|
OP
|
$0.57
|
|
|
Service Code
|
NDC 0573016940
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.57 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.56
|
| Rate for Payer: Aetna of WY Medicare |
$0.38
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.55
|
| Rate for Payer: Altius Commercial |
$0.55
|
| Rate for Payer: Beech Street Commercial |
$0.56
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.47
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.55
|
| Rate for Payer: Cigna of WY Commercial |
$0.56
|
| Rate for Payer: Entrust Commercial |
$0.54
|
| Rate for Payer: First Choice Health Commercial |
$0.54
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.54
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.33
|
| Rate for Payer: HealthUtah PPO |
$0.57
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.55
|
| Rate for Payer: Multiplan Medicare/VA |
$0.31
|
| Rate for Payer: One Health Plan of WY PPO |
$0.56
|
| Rate for Payer: PacificSource Commercial |
$0.51
|
| Rate for Payer: PHCS PPO |
$0.56
|
| Rate for Payer: Three Rivers PPO |
$0.43
|
| Rate for Payer: TriWest Veterans Administration |
$0.33
|
| Rate for Payer: United Healthcare Commercial |
$0.50
|
| Rate for Payer: United Healthcare Medicare |
$0.33
|
| Rate for Payer: WINHealth Partners Commercial |
$0.56
|
| Rate for Payer: Wise Provider Network Commercial |
$0.54
|
|
|
IBUPROFEN 200 MG CAPSULE [4514]
|
Facility
|
IP
|
$0.57
|
|
|
Service Code
|
NDC 0573016940
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$0.57 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.56
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.55
|
| Rate for Payer: Altius Commercial |
$0.55
|
| Rate for Payer: Beech Street Commercial |
$0.56
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.47
|
| Rate for Payer: Cash Price |
$0.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.55
|
| Rate for Payer: Cigna of WY Commercial |
$0.56
|
| Rate for Payer: Entrust Commercial |
$0.54
|
| Rate for Payer: First Choice Health Commercial |
$0.54
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.54
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.38
|
| Rate for Payer: HealthUtah PPO |
$0.57
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.55
|
| Rate for Payer: Multiplan Medicare/VA |
$0.36
|
| Rate for Payer: One Health Plan of WY PPO |
$0.56
|
| Rate for Payer: PacificSource Commercial |
$0.51
|
| Rate for Payer: PHCS PPO |
$0.56
|
| Rate for Payer: Three Rivers PPO |
$0.43
|
| Rate for Payer: TriWest Veterans Administration |
$0.38
|
| Rate for Payer: United Healthcare Commercial |
$0.50
|
| Rate for Payer: United Healthcare Medicare |
$0.38
|
| Rate for Payer: WINHealth Partners Commercial |
$0.54
|
| Rate for Payer: Wise Provider Network Commercial |
$0.54
|
|
|
IBUPROFEN 200 MG TABLET [14626]
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 0904674740
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.06
|
| Rate for Payer: Aetna of WY Medicare |
$0.04
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.06
|
| Rate for Payer: Altius Commercial |
$0.06
|
| Rate for Payer: Beech Street Commercial |
$0.06
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.06
|
| Rate for Payer: Cigna of WY Commercial |
$0.06
|
| Rate for Payer: Entrust Commercial |
$0.06
|
| Rate for Payer: First Choice Health Commercial |
$0.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.03
|
| Rate for Payer: HealthUtah PPO |
$0.06
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.06
|
| Rate for Payer: Multiplan Medicare/VA |
$0.03
|
| Rate for Payer: One Health Plan of WY PPO |
$0.06
|
| Rate for Payer: PacificSource Commercial |
$0.05
|
| Rate for Payer: PHCS PPO |
$0.06
|
| Rate for Payer: Three Rivers PPO |
$0.05
|
| Rate for Payer: TriWest Veterans Administration |
$0.03
|
| Rate for Payer: United Healthcare Commercial |
$0.05
|
| Rate for Payer: United Healthcare Medicare |
$0.03
|
| Rate for Payer: WINHealth Partners Commercial |
$0.06
|
| Rate for Payer: Wise Provider Network Commercial |
$0.06
|
|
|
IBUPROFEN 200 MG TABLET [14626]
|
Facility
|
OP
|
$0.27
|
|
|
Service Code
|
NDC 0904791461
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.26
|
| Rate for Payer: Aetna of WY Medicare |
$0.18
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.26
|
| Rate for Payer: Altius Commercial |
$0.26
|
| Rate for Payer: Beech Street Commercial |
$0.26
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.22
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.26
|
| Rate for Payer: Cigna of WY Commercial |
$0.26
|
| Rate for Payer: Entrust Commercial |
$0.26
|
| Rate for Payer: First Choice Health Commercial |
$0.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.16
|
| Rate for Payer: HealthUtah PPO |
$0.27
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.26
|
| Rate for Payer: Multiplan Medicare/VA |
$0.15
|
| Rate for Payer: One Health Plan of WY PPO |
$0.26
|
| Rate for Payer: PacificSource Commercial |
$0.24
|
| Rate for Payer: PHCS PPO |
$0.26
|
| Rate for Payer: Three Rivers PPO |
$0.20
|
| Rate for Payer: TriWest Veterans Administration |
$0.16
|
| Rate for Payer: United Healthcare Commercial |
$0.23
|
| Rate for Payer: United Healthcare Medicare |
$0.16
|
| Rate for Payer: WINHealth Partners Commercial |
$0.26
|
| Rate for Payer: Wise Provider Network Commercial |
$0.26
|
|
|
IBUPROFEN 200 MG TABLET [14626]
|
Facility
|
IP
|
$0.06
|
|
|
Service Code
|
NDC 0904674740
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.06
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.06
|
| Rate for Payer: Altius Commercial |
$0.06
|
| Rate for Payer: Beech Street Commercial |
$0.06
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.06
|
| Rate for Payer: Cigna of WY Commercial |
$0.06
|
| Rate for Payer: Entrust Commercial |
$0.06
|
| Rate for Payer: First Choice Health Commercial |
$0.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.04
|
| Rate for Payer: HealthUtah PPO |
$0.06
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.06
|
| Rate for Payer: Multiplan Medicare/VA |
$0.04
|
| Rate for Payer: One Health Plan of WY PPO |
$0.06
|
| Rate for Payer: PacificSource Commercial |
$0.05
|
| Rate for Payer: PHCS PPO |
$0.06
|
| Rate for Payer: Three Rivers PPO |
$0.05
|
| Rate for Payer: TriWest Veterans Administration |
$0.04
|
| Rate for Payer: United Healthcare Commercial |
$0.05
|
| Rate for Payer: United Healthcare Medicare |
$0.04
|
| Rate for Payer: WINHealth Partners Commercial |
$0.06
|
| Rate for Payer: Wise Provider Network Commercial |
$0.06
|
|
|
IBUPROFEN 200 MG TABLET [14626]
|
Facility
|
IP
|
$0.27
|
|
|
Service Code
|
NDC 0904791461
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.26
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.26
|
| Rate for Payer: Altius Commercial |
$0.26
|
| Rate for Payer: Beech Street Commercial |
$0.26
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.22
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.26
|
| Rate for Payer: Cigna of WY Commercial |
$0.26
|
| Rate for Payer: Entrust Commercial |
$0.26
|
| Rate for Payer: First Choice Health Commercial |
$0.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.18
|
| Rate for Payer: HealthUtah PPO |
$0.27
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.26
|
| Rate for Payer: Multiplan Medicare/VA |
$0.17
|
| Rate for Payer: One Health Plan of WY PPO |
$0.26
|
| Rate for Payer: PacificSource Commercial |
$0.24
|
| Rate for Payer: PHCS PPO |
$0.26
|
| Rate for Payer: Three Rivers PPO |
$0.20
|
| Rate for Payer: TriWest Veterans Administration |
$0.18
|
| Rate for Payer: United Healthcare Commercial |
$0.23
|
| Rate for Payer: United Healthcare Medicare |
$0.18
|
| Rate for Payer: WINHealth Partners Commercial |
$0.26
|
| Rate for Payer: Wise Provider Network Commercial |
$0.26
|
|
