|
LEG BAG URINE COMB PK LG
|
Facility
|
IP
|
$24.00
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$15.05 |
| Max. Negotiated Rate |
$24.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$23.52
|
| Rate for Payer: Altius Auto/Workers Compensation |
$23.04
|
| Rate for Payer: Altius Commercial |
$23.04
|
| Rate for Payer: Beech Street Commercial |
$23.52
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$19.70
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$23.28
|
| Rate for Payer: Cigna of WY Commercial |
$23.52
|
| Rate for Payer: Entrust Commercial |
$22.80
|
| Rate for Payer: First Choice Health Commercial |
$22.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$22.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$15.84
|
| Rate for Payer: HealthUtah PPO |
$24.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$23.28
|
| Rate for Payer: Multiplan Medicare/VA |
$15.05
|
| Rate for Payer: One Health Plan of WY PPO |
$23.52
|
| Rate for Payer: PacificSource Commercial |
$21.60
|
| Rate for Payer: PHCS PPO |
$23.52
|
| Rate for Payer: Three Rivers PPO |
$18.00
|
| Rate for Payer: TriWest Veterans Administration |
$15.84
|
| Rate for Payer: United Healthcare Commercial |
$20.88
|
| Rate for Payer: United Healthcare Medicare |
$15.84
|
| Rate for Payer: WINHealth Partners Commercial |
$22.80
|
| Rate for Payer: Wise Provider Network Commercial |
$22.80
|
|
|
LENGTHENING TENDON EXTENSOR HAND/FINGER EACH
|
Professional
|
Both
|
$1,390.00
|
|
|
Service Code
|
HCPCS 26476
|
| Hospital Charge Code |
26476
|
| Min. Negotiated Rate |
$538.22 |
| Max. Negotiated Rate |
$1,390.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,362.20
|
| Rate for Payer: Aetna of WY Medicare |
$633.20
|
| Rate for Payer: Beech Street Commercial |
$1,320.50
|
| Rate for Payer: Cash Price |
$973.00
|
| Rate for Payer: Cash Price |
$973.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,348.30
|
| Rate for Payer: Cigna of WY Commercial |
$1,362.20
|
| Rate for Payer: First Choice Health Commercial |
$1,251.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,320.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$633.20
|
| Rate for Payer: HealthUtah PPO |
$1,390.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,348.30
|
| Rate for Payer: Multiplan Medicare/VA |
$538.22
|
| Rate for Payer: One Health Plan of WY PPO |
$1,362.20
|
| Rate for Payer: PacificSource Commercial |
$1,251.00
|
| Rate for Payer: PHCS PPO |
$1,320.50
|
| Rate for Payer: Three Rivers PPO |
$1,042.50
|
| Rate for Payer: TriWest Veterans Administration |
$633.20
|
| Rate for Payer: United Healthcare Commercial |
$1,209.30
|
| Rate for Payer: United Healthcare Medicare |
$633.20
|
| Rate for Payer: WINHealth Partners Commercial |
$1,181.50
|
|
|
LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION [10225]
|
Facility
|
IP
|
$55.00
|
|
|
Service Code
|
HCPCS J0640
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.48 |
| Max. Negotiated Rate |
$55.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$53.90
|
| Rate for Payer: Altius Auto/Workers Compensation |
$52.80
|
| Rate for Payer: Altius Commercial |
$52.80
|
| Rate for Payer: Beech Street Commercial |
$53.90
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$45.16
|
| Rate for Payer: Cash Price |
$38.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$53.35
|
| Rate for Payer: Cigna of WY Commercial |
$53.90
|
| Rate for Payer: Entrust Commercial |
$52.25
|
| Rate for Payer: First Choice Health Commercial |
$52.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$52.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$36.30
|
| Rate for Payer: HealthUtah PPO |
$55.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$53.35
|
| Rate for Payer: Multiplan Medicare/VA |
$34.48
|
| Rate for Payer: One Health Plan of WY PPO |
$53.90
|
| Rate for Payer: PacificSource Commercial |
$49.50
|
| Rate for Payer: PHCS PPO |
$53.90
|
| Rate for Payer: Three Rivers PPO |
$41.25
|
| Rate for Payer: TriWest Veterans Administration |
$36.30
|
| Rate for Payer: United Healthcare Commercial |
$47.85
|
| Rate for Payer: United Healthcare Medicare |
$36.30
|
| Rate for Payer: WINHealth Partners Commercial |
$52.25
|
| Rate for Payer: Wise Provider Network Commercial |
$52.25
|
|
|
LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION [10225]
|
Facility
|
OP
|
$55.00
|
|
|
Service Code
|
HCPCS J0640
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.30 |
| Max. Negotiated Rate |
$55.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$53.90
|
| Rate for Payer: Aetna of WY Medicare |
$36.30
|
| Rate for Payer: Altius Auto/Workers Compensation |
$52.80
|
| Rate for Payer: Altius Commercial |
$52.80
|
| Rate for Payer: Beech Street Commercial |
$53.90
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$45.16
|
| Rate for Payer: Cash Price |
$38.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$53.35
|
| Rate for Payer: Cigna of WY Commercial |
$53.90
|
| Rate for Payer: Entrust Commercial |
$52.25
|
| Rate for Payer: First Choice Health Commercial |
$52.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$52.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$31.90
|
| Rate for Payer: HealthUtah PPO |
$55.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$53.35
|
| Rate for Payer: Multiplan Medicare/VA |
$30.30
|
| Rate for Payer: One Health Plan of WY PPO |
$53.90
|
| Rate for Payer: PacificSource Commercial |
$49.50
|
| Rate for Payer: PHCS PPO |
$53.90
|
| Rate for Payer: Three Rivers PPO |
$41.25
|
| Rate for Payer: TriWest Veterans Administration |
$31.90
|
| Rate for Payer: United Healthcare Commercial |
$47.85
|
| Rate for Payer: United Healthcare Medicare |
$31.90
|
| Rate for Payer: WINHealth Partners Commercial |
$53.90
|
| Rate for Payer: Wise Provider Network Commercial |
$52.25
|
|
|
LEUCOVORIN CALCIUM 10 MG/ML INJECTION SOLUTION [16291]
|
Facility
|
IP
|
$24.46
|
|
|
Service Code
|
HCPCS J0640
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.34 |
| Max. Negotiated Rate |
$24.46 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$23.97
|
| Rate for Payer: Altius Auto/Workers Compensation |
$23.48
|
| Rate for Payer: Altius Commercial |
$23.48
|
| Rate for Payer: Beech Street Commercial |
$23.97
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$20.08
|
| Rate for Payer: Cash Price |
$17.12
|
| Rate for Payer: ChoiceCare Network Commercial |
$23.73
|
| Rate for Payer: Cigna of WY Commercial |
$23.97
|
| Rate for Payer: Entrust Commercial |
$23.24
|
| Rate for Payer: First Choice Health Commercial |
$23.24
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$23.24
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$16.14
|
| Rate for Payer: HealthUtah PPO |
$24.46
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$23.73
|
| Rate for Payer: Multiplan Medicare/VA |
$15.34
|
| Rate for Payer: One Health Plan of WY PPO |
$23.97
|
| Rate for Payer: PacificSource Commercial |
$22.01
|
| Rate for Payer: PHCS PPO |
$23.97
|
| Rate for Payer: Three Rivers PPO |
$18.34
|
| Rate for Payer: TriWest Veterans Administration |
$16.14
|
| Rate for Payer: United Healthcare Commercial |
$21.28
|
| Rate for Payer: United Healthcare Medicare |
$16.14
|
| Rate for Payer: WINHealth Partners Commercial |
$23.24
|
| Rate for Payer: Wise Provider Network Commercial |
$23.24
|
|
|
LEUCOVORIN CALCIUM 10 MG/ML INJECTION SOLUTION [16291]
|
Facility
|
OP
|
$24.46
|
|
|
Service Code
|
HCPCS J0640
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.48 |
| Max. Negotiated Rate |
$24.46 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$23.97
|
| Rate for Payer: Aetna of WY Medicare |
$16.14
|
| Rate for Payer: Altius Auto/Workers Compensation |
$23.48
|
| Rate for Payer: Altius Commercial |
$23.48
|
| Rate for Payer: Beech Street Commercial |
$23.97
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$20.08
|
| Rate for Payer: Cash Price |
$17.12
|
| Rate for Payer: ChoiceCare Network Commercial |
$23.73
|
| Rate for Payer: Cigna of WY Commercial |
$23.97
|
| Rate for Payer: Entrust Commercial |
$23.24
|
| Rate for Payer: First Choice Health Commercial |
$23.24
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$23.24
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$14.19
|
| Rate for Payer: HealthUtah PPO |
$24.46
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$23.73
|
| Rate for Payer: Multiplan Medicare/VA |
$13.48
|
| Rate for Payer: One Health Plan of WY PPO |
$23.97
|
| Rate for Payer: PacificSource Commercial |
$22.01
|
| Rate for Payer: PHCS PPO |
$23.97
|
| Rate for Payer: Three Rivers PPO |
$18.34
|
| Rate for Payer: TriWest Veterans Administration |
$14.19
|
| Rate for Payer: United Healthcare Commercial |
$21.28
|
| Rate for Payer: United Healthcare Medicare |
$14.19
|
| Rate for Payer: WINHealth Partners Commercial |
$23.97
|
| Rate for Payer: Wise Provider Network Commercial |
$23.24
|
|
|
LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION [6154]
|
Facility
|
OP
|
$137.50
|
|
|
Service Code
|
HCPCS J0640
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$75.76 |
| Max. Negotiated Rate |
$137.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$134.75
|
| Rate for Payer: Aetna of WY Medicare |
$90.75
|
| Rate for Payer: Altius Auto/Workers Compensation |
$132.00
|
| Rate for Payer: Altius Commercial |
$132.00
|
| Rate for Payer: Beech Street Commercial |
$134.75
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$112.89
|
| Rate for Payer: Cash Price |
$96.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$133.38
|
| Rate for Payer: Cigna of WY Commercial |
$134.75
|
| Rate for Payer: Entrust Commercial |
$130.62
|
| Rate for Payer: First Choice Health Commercial |
$130.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$130.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$79.75
|
| Rate for Payer: HealthUtah PPO |
$137.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$133.38
|
| Rate for Payer: Multiplan Medicare/VA |
$75.76
|
| Rate for Payer: One Health Plan of WY PPO |
$134.75
|
| Rate for Payer: PacificSource Commercial |
$123.75
|
| Rate for Payer: PHCS PPO |
$134.75
|
| Rate for Payer: Three Rivers PPO |
$103.12
|
| Rate for Payer: TriWest Veterans Administration |
$79.75
|
| Rate for Payer: United Healthcare Commercial |
$119.62
|
| Rate for Payer: United Healthcare Medicare |
$79.75
|
| Rate for Payer: WINHealth Partners Commercial |
$134.75
|
| Rate for Payer: Wise Provider Network Commercial |
$130.62
|
|
|
LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION [6154]
|
Facility
|
IP
|
$137.50
|
|
|
Service Code
|
HCPCS J0640
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$86.21 |
| Max. Negotiated Rate |
$137.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$134.75
|
| Rate for Payer: Altius Auto/Workers Compensation |
$132.00
|
| Rate for Payer: Altius Commercial |
$132.00
|
| Rate for Payer: Beech Street Commercial |
$134.75
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$112.89
|
| Rate for Payer: Cash Price |
$96.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$133.38
|
| Rate for Payer: Cigna of WY Commercial |
$134.75
|
| Rate for Payer: Entrust Commercial |
$130.62
|
| Rate for Payer: First Choice Health Commercial |
$130.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$130.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$90.75
|
| Rate for Payer: HealthUtah PPO |
$137.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$133.38
|
| Rate for Payer: Multiplan Medicare/VA |
$86.21
|
| Rate for Payer: One Health Plan of WY PPO |
$134.75
|
| Rate for Payer: PacificSource Commercial |
$123.75
|
| Rate for Payer: PHCS PPO |
$134.75
|
| Rate for Payer: Three Rivers PPO |
$103.12
|
| Rate for Payer: TriWest Veterans Administration |
$90.75
|
| Rate for Payer: United Healthcare Commercial |
$119.62
|
| Rate for Payer: United Healthcare Medicare |
$90.75
|
| Rate for Payer: WINHealth Partners Commercial |
$130.62
|
| Rate for Payer: Wise Provider Network Commercial |
$130.62
|
|
|
LEUPROLIDE 22.5 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT [12561]
|
Facility
|
OP
|
$9,673.32
|
|
|
Service Code
|
HCPCS J9217
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,330.00 |
| Max. Negotiated Rate |
$9,673.32 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$9,479.85
|
| Rate for Payer: Aetna of WY Medicare |
$6,384.39
|
| Rate for Payer: Altius Auto/Workers Compensation |
$9,286.39
|
| Rate for Payer: Altius Commercial |
$9,286.39
|
| Rate for Payer: Beech Street Commercial |
$9,479.85
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$7,941.80
|
| Rate for Payer: Cash Price |
$6,771.32
|
| Rate for Payer: ChoiceCare Network Commercial |
$9,383.12
|
| Rate for Payer: Cigna of WY Commercial |
$9,479.85
|
| Rate for Payer: Entrust Commercial |
$9,189.65
|
| Rate for Payer: First Choice Health Commercial |
$9,189.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$9,189.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$5,610.53
|
| Rate for Payer: HealthUtah PPO |
$9,673.32
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$9,383.12
|
| Rate for Payer: Multiplan Medicare/VA |
$5,330.00
|
| Rate for Payer: One Health Plan of WY PPO |
$9,479.85
|
| Rate for Payer: PacificSource Commercial |
$8,705.99
|
| Rate for Payer: PHCS PPO |
$9,479.85
|
| Rate for Payer: Three Rivers PPO |
$7,254.99
|
| Rate for Payer: TriWest Veterans Administration |
$5,610.53
|
| Rate for Payer: United Healthcare Commercial |
$8,415.79
|
| Rate for Payer: United Healthcare Medicare |
$5,610.53
|
| Rate for Payer: WINHealth Partners Commercial |
$9,479.85
|
| Rate for Payer: Wise Provider Network Commercial |
$9,189.65
|
|
|
LEUPROLIDE 22.5 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT [12561]
|
Facility
|
IP
|
$9,673.32
|
|
|
Service Code
|
HCPCS J9217
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6,065.17 |
| Max. Negotiated Rate |
$9,673.32 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$9,479.85
|
| Rate for Payer: Altius Auto/Workers Compensation |
$9,286.39
|
| Rate for Payer: Altius Commercial |
$9,286.39
|
| Rate for Payer: Beech Street Commercial |
$9,479.85
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$7,941.80
|
| Rate for Payer: Cash Price |
$6,771.32
|
| Rate for Payer: ChoiceCare Network Commercial |
$9,383.12
|
| Rate for Payer: Cigna of WY Commercial |
$9,479.85
|
| Rate for Payer: Entrust Commercial |
$9,189.65
|
| Rate for Payer: First Choice Health Commercial |
$9,189.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$9,189.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$6,384.39
|
| Rate for Payer: HealthUtah PPO |
$9,673.32
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$9,383.12
|
| Rate for Payer: Multiplan Medicare/VA |
$6,065.17
|
| Rate for Payer: One Health Plan of WY PPO |
$9,479.85
|
| Rate for Payer: PacificSource Commercial |
$8,705.99
|
| Rate for Payer: PHCS PPO |
$9,479.85
|
| Rate for Payer: Three Rivers PPO |
$7,254.99
|
| Rate for Payer: TriWest Veterans Administration |
$6,384.39
|
| Rate for Payer: United Healthcare Commercial |
$8,415.79
|
| Rate for Payer: United Healthcare Medicare |
$6,384.39
|
| Rate for Payer: WINHealth Partners Commercial |
$9,189.65
|
| Rate for Payer: Wise Provider Network Commercial |
$9,189.65
|
|
|
LEUPROLIDE 22.5 MG (3 MONTH) SUBCUTANEOUS SYRINGE [26102]
|
Facility
|
OP
|
$1,370.07
|
|
|
Service Code
|
HCPCS J9217
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$754.91 |
| Max. Negotiated Rate |
$1,370.07 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,342.67
|
| Rate for Payer: Aetna of WY Medicare |
$904.25
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,315.27
|
| Rate for Payer: Altius Commercial |
$1,315.27
|
| Rate for Payer: Beech Street Commercial |
$1,342.67
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,124.83
|
| Rate for Payer: Cash Price |
$959.05
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,328.97
|
| Rate for Payer: Cigna of WY Commercial |
$1,342.67
|
| Rate for Payer: Entrust Commercial |
$1,301.57
|
| Rate for Payer: First Choice Health Commercial |
$1,301.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,301.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$794.64
|
| Rate for Payer: HealthUtah PPO |
$1,370.07
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,328.97
|
| Rate for Payer: Multiplan Medicare/VA |
$754.91
|
| Rate for Payer: One Health Plan of WY PPO |
$1,342.67
|
| Rate for Payer: PacificSource Commercial |
$1,233.06
|
| Rate for Payer: PHCS PPO |
$1,342.67
|
| Rate for Payer: Three Rivers PPO |
$1,027.55
|
| Rate for Payer: TriWest Veterans Administration |
$794.64
|
| Rate for Payer: United Healthcare Commercial |
$1,191.96
|
| Rate for Payer: United Healthcare Medicare |
$794.64
|
| Rate for Payer: WINHealth Partners Commercial |
$1,342.67
|
| Rate for Payer: Wise Provider Network Commercial |
$1,301.57
|
|
|
LEUPROLIDE 22.5 MG (3 MONTH) SUBCUTANEOUS SYRINGE [26102]
|
Facility
|
IP
|
$1,370.07
|
|
|
Service Code
|
HCPCS J9217
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$859.03 |
| Max. Negotiated Rate |
$1,370.07 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,342.67
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,315.27
|
| Rate for Payer: Altius Commercial |
$1,315.27
|
| Rate for Payer: Beech Street Commercial |
$1,342.67
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,124.83
|
| Rate for Payer: Cash Price |
$959.05
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,328.97
|
| Rate for Payer: Cigna of WY Commercial |
$1,342.67
|
| Rate for Payer: Entrust Commercial |
$1,301.57
|
| Rate for Payer: First Choice Health Commercial |
$1,301.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,301.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$904.25
|
| Rate for Payer: HealthUtah PPO |
$1,370.07
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,328.97
|
| Rate for Payer: Multiplan Medicare/VA |
$859.03
|
| Rate for Payer: One Health Plan of WY PPO |
$1,342.67
|
| Rate for Payer: PacificSource Commercial |
$1,233.06
|
| Rate for Payer: PHCS PPO |
$1,342.67
|
| Rate for Payer: Three Rivers PPO |
$1,027.55
|
| Rate for Payer: TriWest Veterans Administration |
$904.25
|
| Rate for Payer: United Healthcare Commercial |
$1,191.96
|
| Rate for Payer: United Healthcare Medicare |
$904.25
|
| Rate for Payer: WINHealth Partners Commercial |
$1,301.57
|
| Rate for Payer: Wise Provider Network Commercial |
$1,301.57
|
|
|
LEUPROLIDE 30 MG (4 MONTH) INTRAMUSCULAR SYRINGE KIT [14782]
|
Facility
|
OP
|
$12,892.80
|
|
|
Service Code
|
HCPCS J9217
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7,103.93 |
| Max. Negotiated Rate |
$12,892.80 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$12,634.94
|
| Rate for Payer: Aetna of WY Medicare |
$8,509.25
|
| Rate for Payer: Altius Auto/Workers Compensation |
$12,377.09
|
| Rate for Payer: Altius Commercial |
$12,377.09
|
| Rate for Payer: Beech Street Commercial |
$12,634.94
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$10,584.99
|
| Rate for Payer: Cash Price |
$9,024.96
|
| Rate for Payer: ChoiceCare Network Commercial |
$12,506.02
|
| Rate for Payer: Cigna of WY Commercial |
$12,634.94
|
| Rate for Payer: Entrust Commercial |
$12,248.16
|
| Rate for Payer: First Choice Health Commercial |
$12,248.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$12,248.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$7,477.82
|
| Rate for Payer: HealthUtah PPO |
$12,892.80
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$12,506.02
|
| Rate for Payer: Multiplan Medicare/VA |
$7,103.93
|
| Rate for Payer: One Health Plan of WY PPO |
$12,634.94
|
| Rate for Payer: PacificSource Commercial |
$11,603.52
|
| Rate for Payer: PHCS PPO |
$12,634.94
|
| Rate for Payer: Three Rivers PPO |
$9,669.60
|
| Rate for Payer: TriWest Veterans Administration |
$7,477.82
|
| Rate for Payer: United Healthcare Commercial |
$11,216.74
|
| Rate for Payer: United Healthcare Medicare |
$7,477.82
|
| Rate for Payer: WINHealth Partners Commercial |
$12,634.94
|
| Rate for Payer: Wise Provider Network Commercial |
$12,248.16
|
|
|
LEUPROLIDE 30 MG (4 MONTH) INTRAMUSCULAR SYRINGE KIT [14782]
|
Facility
|
IP
|
$12,892.80
|
|
|
Service Code
|
HCPCS J9217
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8,083.79 |
| Max. Negotiated Rate |
$12,892.80 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$12,634.94
|
| Rate for Payer: Altius Auto/Workers Compensation |
$12,377.09
|
| Rate for Payer: Altius Commercial |
$12,377.09
|
| Rate for Payer: Beech Street Commercial |
$12,634.94
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$10,584.99
|
| Rate for Payer: Cash Price |
$9,024.96
|
| Rate for Payer: ChoiceCare Network Commercial |
$12,506.02
|
| Rate for Payer: Cigna of WY Commercial |
$12,634.94
|
| Rate for Payer: Entrust Commercial |
$12,248.16
|
| Rate for Payer: First Choice Health Commercial |
$12,248.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$12,248.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8,509.25
|
| Rate for Payer: HealthUtah PPO |
$12,892.80
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$12,506.02
|
| Rate for Payer: Multiplan Medicare/VA |
$8,083.79
|
| Rate for Payer: One Health Plan of WY PPO |
$12,634.94
|
| Rate for Payer: PacificSource Commercial |
$11,603.52
|
| Rate for Payer: PHCS PPO |
$12,634.94
|
| Rate for Payer: Three Rivers PPO |
$9,669.60
|
| Rate for Payer: TriWest Veterans Administration |
$8,509.25
|
| Rate for Payer: United Healthcare Commercial |
$11,216.74
|
| Rate for Payer: United Healthcare Medicare |
$8,509.25
|
| Rate for Payer: WINHealth Partners Commercial |
$12,248.16
|
| Rate for Payer: Wise Provider Network Commercial |
$12,248.16
|
|
|
LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT [1982]
|
Facility
|
IP
|
$1,816.11
|
|
|
Service Code
|
HCPCS J1950
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,138.70 |
| Max. Negotiated Rate |
$1,816.11 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,779.79
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,743.47
|
| Rate for Payer: Altius Commercial |
$1,743.47
|
| Rate for Payer: Beech Street Commercial |
$1,779.79
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,491.03
|
| Rate for Payer: Cash Price |
$1,271.28
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,761.63
|
| Rate for Payer: Cigna of WY Commercial |
$1,779.79
|
| Rate for Payer: Entrust Commercial |
$1,725.30
|
| Rate for Payer: First Choice Health Commercial |
$1,725.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,725.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,198.63
|
| Rate for Payer: HealthUtah PPO |
$1,816.11
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,761.63
|
| Rate for Payer: Multiplan Medicare/VA |
$1,138.70
|
| Rate for Payer: One Health Plan of WY PPO |
$1,779.79
|
| Rate for Payer: PacificSource Commercial |
$1,634.50
|
| Rate for Payer: PHCS PPO |
$1,779.79
|
| Rate for Payer: Three Rivers PPO |
$1,362.08
|
| Rate for Payer: TriWest Veterans Administration |
$1,198.63
|
| Rate for Payer: United Healthcare Commercial |
$1,580.02
|
| Rate for Payer: United Healthcare Medicare |
$1,198.63
|
| Rate for Payer: WINHealth Partners Commercial |
$1,725.30
|
| Rate for Payer: Wise Provider Network Commercial |
$1,725.30
|
|
|
LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT [1982]
|
Facility
|
OP
|
$1,816.11
|
|
|
Service Code
|
HCPCS J1950
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,000.68 |
| Max. Negotiated Rate |
$1,816.11 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,779.79
|
| Rate for Payer: Aetna of WY Medicare |
$1,198.63
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,743.47
|
| Rate for Payer: Altius Commercial |
$1,743.47
|
| Rate for Payer: Beech Street Commercial |
$1,779.79
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,491.03
|
| Rate for Payer: Cash Price |
$1,271.28
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,761.63
|
| Rate for Payer: Cigna of WY Commercial |
$1,779.79
|
| Rate for Payer: Entrust Commercial |
$1,725.30
|
| Rate for Payer: First Choice Health Commercial |
$1,725.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,725.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,053.34
|
| Rate for Payer: HealthUtah PPO |
$1,816.11
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,761.63
|
| Rate for Payer: Multiplan Medicare/VA |
$1,000.68
|
| Rate for Payer: One Health Plan of WY PPO |
$1,779.79
|
| Rate for Payer: PacificSource Commercial |
$1,634.50
|
| Rate for Payer: PHCS PPO |
$1,779.79
|
| Rate for Payer: Three Rivers PPO |
$1,362.08
|
| Rate for Payer: TriWest Veterans Administration |
$1,053.34
|
| Rate for Payer: United Healthcare Commercial |
$1,580.02
|
| Rate for Payer: United Healthcare Medicare |
$1,053.34
|
| Rate for Payer: WINHealth Partners Commercial |
$1,779.79
|
| Rate for Payer: Wise Provider Network Commercial |
$1,725.30
|
|
|
LEUPROLIDE ACETATE 45 MG (6 MONTH) SUBCUTANEOUS SYRINGE [37957]
|
Facility
|
OP
|
$2,725.13
|
|
|
Service Code
|
HCPCS J9217
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,501.55 |
| Max. Negotiated Rate |
$2,725.13 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,670.63
|
| Rate for Payer: Aetna of WY Medicare |
$1,798.59
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2,616.12
|
| Rate for Payer: Altius Commercial |
$2,616.12
|
| Rate for Payer: Beech Street Commercial |
$2,670.63
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,237.33
|
| Rate for Payer: Cash Price |
$1,907.59
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,643.38
|
| Rate for Payer: Cigna of WY Commercial |
$2,670.63
|
| Rate for Payer: Entrust Commercial |
$2,588.87
|
| Rate for Payer: First Choice Health Commercial |
$2,588.87
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,588.87
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,580.58
|
| Rate for Payer: HealthUtah PPO |
$2,725.13
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,643.38
|
| Rate for Payer: Multiplan Medicare/VA |
$1,501.55
|
| Rate for Payer: One Health Plan of WY PPO |
$2,670.63
|
| Rate for Payer: PacificSource Commercial |
$2,452.62
|
| Rate for Payer: PHCS PPO |
$2,670.63
|
| Rate for Payer: Three Rivers PPO |
$2,043.85
|
| Rate for Payer: TriWest Veterans Administration |
$1,580.58
|
| Rate for Payer: United Healthcare Commercial |
$2,370.86
|
| Rate for Payer: United Healthcare Medicare |
$1,580.58
|
| Rate for Payer: WINHealth Partners Commercial |
$2,670.63
|
| Rate for Payer: Wise Provider Network Commercial |
$2,588.87
|
|
|
LEUPROLIDE ACETATE 45 MG (6 MONTH) SUBCUTANEOUS SYRINGE [37957]
|
Facility
|
IP
|
$2,725.13
|
|
|
Service Code
|
HCPCS J9217
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,708.66 |
| Max. Negotiated Rate |
$2,725.13 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,670.63
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2,616.12
|
| Rate for Payer: Altius Commercial |
$2,616.12
|
| Rate for Payer: Beech Street Commercial |
$2,670.63
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,237.33
|
| Rate for Payer: Cash Price |
$1,907.59
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,643.38
|
| Rate for Payer: Cigna of WY Commercial |
$2,670.63
|
| Rate for Payer: Entrust Commercial |
$2,588.87
|
| Rate for Payer: First Choice Health Commercial |
$2,588.87
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,588.87
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,798.59
|
| Rate for Payer: HealthUtah PPO |
$2,725.13
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,643.38
|
| Rate for Payer: Multiplan Medicare/VA |
$1,708.66
|
| Rate for Payer: One Health Plan of WY PPO |
$2,670.63
|
| Rate for Payer: PacificSource Commercial |
$2,452.62
|
| Rate for Payer: PHCS PPO |
$2,670.63
|
| Rate for Payer: Three Rivers PPO |
$2,043.85
|
| Rate for Payer: TriWest Veterans Administration |
$1,798.59
|
| Rate for Payer: United Healthcare Commercial |
$2,370.86
|
| Rate for Payer: United Healthcare Medicare |
$1,798.59
|
| Rate for Payer: WINHealth Partners Commercial |
$2,588.87
|
| Rate for Payer: Wise Provider Network Commercial |
$2,588.87
|
|
|
LEUPROLIDE ACETATE (6 MONTH) 45 MG INTRAMUSCULAR SYRINGE KIT [92704]
|
Facility
|
IP
|
$19,331.98
|
|
|
Service Code
|
HCPCS J9217
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12,121.15 |
| Max. Negotiated Rate |
$19,331.98 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18,945.34
|
| Rate for Payer: Altius Auto/Workers Compensation |
$18,558.70
|
| Rate for Payer: Altius Commercial |
$18,558.70
|
| Rate for Payer: Beech Street Commercial |
$18,945.34
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15,871.56
|
| Rate for Payer: Cash Price |
$13,532.39
|
| Rate for Payer: ChoiceCare Network Commercial |
$18,752.02
|
| Rate for Payer: Cigna of WY Commercial |
$18,945.34
|
| Rate for Payer: Entrust Commercial |
$18,365.38
|
| Rate for Payer: First Choice Health Commercial |
$18,365.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$18,365.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$12,759.11
|
| Rate for Payer: HealthUtah PPO |
$19,331.98
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$18,752.02
|
| Rate for Payer: Multiplan Medicare/VA |
$12,121.15
|
| Rate for Payer: One Health Plan of WY PPO |
$18,945.34
|
| Rate for Payer: PacificSource Commercial |
$17,398.78
|
| Rate for Payer: PHCS PPO |
$18,945.34
|
| Rate for Payer: Three Rivers PPO |
$14,498.98
|
| Rate for Payer: TriWest Veterans Administration |
$12,759.11
|
| Rate for Payer: United Healthcare Commercial |
$16,818.82
|
| Rate for Payer: United Healthcare Medicare |
$12,759.11
|
| Rate for Payer: WINHealth Partners Commercial |
$18,365.38
|
| Rate for Payer: Wise Provider Network Commercial |
$18,365.38
|
|
|
LEUPROLIDE ACETATE (6 MONTH) 45 MG INTRAMUSCULAR SYRINGE KIT [92704]
|
Facility
|
OP
|
$19,331.98
|
|
|
Service Code
|
HCPCS J9217
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10,651.92 |
| Max. Negotiated Rate |
$19,331.98 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18,945.34
|
| Rate for Payer: Aetna of WY Medicare |
$12,759.11
|
| Rate for Payer: Altius Auto/Workers Compensation |
$18,558.70
|
| Rate for Payer: Altius Commercial |
$18,558.70
|
| Rate for Payer: Beech Street Commercial |
$18,945.34
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15,871.56
|
| Rate for Payer: Cash Price |
$13,532.39
|
| Rate for Payer: ChoiceCare Network Commercial |
$18,752.02
|
| Rate for Payer: Cigna of WY Commercial |
$18,945.34
|
| Rate for Payer: Entrust Commercial |
$18,365.38
|
| Rate for Payer: First Choice Health Commercial |
$18,365.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$18,365.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11,212.55
|
| Rate for Payer: HealthUtah PPO |
$19,331.98
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$18,752.02
|
| Rate for Payer: Multiplan Medicare/VA |
$10,651.92
|
| Rate for Payer: One Health Plan of WY PPO |
$18,945.34
|
| Rate for Payer: PacificSource Commercial |
$17,398.78
|
| Rate for Payer: PHCS PPO |
$18,945.34
|
| Rate for Payer: Three Rivers PPO |
$14,498.98
|
| Rate for Payer: TriWest Veterans Administration |
$11,212.55
|
| Rate for Payer: United Healthcare Commercial |
$16,818.82
|
| Rate for Payer: United Healthcare Medicare |
$11,212.55
|
| Rate for Payer: WINHealth Partners Commercial |
$18,945.34
|
| Rate for Payer: Wise Provider Network Commercial |
$18,365.38
|
|
|
LEVALBUTEROL 1.25 MG/3 ML SOLUTION FOR NEBULIZATION [17050]
|
Facility
|
IP
|
$2.13
|
|
|
Service Code
|
HCPCS J7614
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.34 |
| Max. Negotiated Rate |
$2.13 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.09
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.04
|
| Rate for Payer: Altius Commercial |
$2.04
|
| Rate for Payer: Beech Street Commercial |
$2.09
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.75
|
| Rate for Payer: Cash Price |
$1.49
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.07
|
| Rate for Payer: Cigna of WY Commercial |
$2.09
|
| Rate for Payer: Entrust Commercial |
$2.02
|
| Rate for Payer: First Choice Health Commercial |
$2.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.41
|
| Rate for Payer: HealthUtah PPO |
$2.13
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.07
|
| Rate for Payer: Multiplan Medicare/VA |
$1.34
|
| Rate for Payer: One Health Plan of WY PPO |
$2.09
|
| Rate for Payer: PacificSource Commercial |
$1.92
|
| Rate for Payer: PHCS PPO |
$2.09
|
| Rate for Payer: Three Rivers PPO |
$1.60
|
| Rate for Payer: TriWest Veterans Administration |
$1.41
|
| Rate for Payer: United Healthcare Commercial |
$1.85
|
| Rate for Payer: United Healthcare Medicare |
$1.41
|
| Rate for Payer: WINHealth Partners Commercial |
$2.02
|
| Rate for Payer: Wise Provider Network Commercial |
$2.02
|
|
|
LEVALBUTEROL 1.25 MG/3 ML SOLUTION FOR NEBULIZATION [17050]
|
Facility
|
OP
|
$2.13
|
|
|
Service Code
|
HCPCS J7614
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.17 |
| Max. Negotiated Rate |
$2.13 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.09
|
| Rate for Payer: Aetna of WY Medicare |
$1.41
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.04
|
| Rate for Payer: Altius Commercial |
$2.04
|
| Rate for Payer: Beech Street Commercial |
$2.09
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.75
|
| Rate for Payer: Cash Price |
$1.49
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.07
|
| Rate for Payer: Cigna of WY Commercial |
$2.09
|
| Rate for Payer: Entrust Commercial |
$2.02
|
| Rate for Payer: First Choice Health Commercial |
$2.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.24
|
| Rate for Payer: HealthUtah PPO |
$2.13
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.07
|
| Rate for Payer: Multiplan Medicare/VA |
$1.17
|
| Rate for Payer: One Health Plan of WY PPO |
$2.09
|
| Rate for Payer: PacificSource Commercial |
$1.92
|
| Rate for Payer: PHCS PPO |
$2.09
|
| Rate for Payer: Three Rivers PPO |
$1.60
|
| Rate for Payer: TriWest Veterans Administration |
$1.24
|
| Rate for Payer: United Healthcare Commercial |
$1.85
|
| Rate for Payer: United Healthcare Medicare |
$1.24
|
| Rate for Payer: WINHealth Partners Commercial |
$2.09
|
| Rate for Payer: Wise Provider Network Commercial |
$2.02
|
|
|
LEVETIRACETAM 100 MG/ML ORAL SOLUTION [29720]
|
Facility
|
IP
|
$0.25
|
|
|
Service Code
|
NDC 3172257447
|
|
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
|
|
|
LEVETIRACETAM 100 MG/ML ORAL SOLUTION [29720]
|
Facility
|
OP
|
$0.25
|
|
|
Service Code
|
NDC 3172257447
|
|
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
|
|
|
LEVETIRACETAM 250 MG TABLET [11009]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 6808485911
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$1.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.98
|
| Rate for Payer: Aetna of WY Medicare |
$0.66
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.96
|
| Rate for Payer: Altius Commercial |
$0.96
|
| Rate for Payer: Beech Street Commercial |
$0.98
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.82
|
| Rate for Payer: Cash Price |
$0.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.97
|
| Rate for Payer: Cigna of WY Commercial |
$0.98
|
| Rate for Payer: Entrust Commercial |
$0.95
|
| Rate for Payer: First Choice Health Commercial |
$0.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.58
|
| Rate for Payer: HealthUtah PPO |
$1.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.97
|
| Rate for Payer: Multiplan Medicare/VA |
$0.55
|
| Rate for Payer: One Health Plan of WY PPO |
$0.98
|
| Rate for Payer: PacificSource Commercial |
$0.90
|
| Rate for Payer: PHCS PPO |
$0.98
|
| Rate for Payer: Three Rivers PPO |
$0.75
|
| Rate for Payer: TriWest Veterans Administration |
$0.58
|
| Rate for Payer: United Healthcare Commercial |
$0.87
|
| Rate for Payer: United Healthcare Medicare |
$0.58
|
| Rate for Payer: WINHealth Partners Commercial |
$0.98
|
| Rate for Payer: Wise Provider Network Commercial |
$0.95
|
|
