|
LEVETIRACETAM 250 MG TABLET [11009]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 6808485911
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$1.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.98
|
| 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 |
$0.66
|
| Rate for Payer: HealthUtah PPO |
$1.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.97
|
| Rate for Payer: Multiplan Medicare/VA |
$0.63
|
| 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 |
$0.66
|
| Rate for Payer: United Healthcare Commercial |
$0.87
|
| Rate for Payer: United Healthcare Medicare |
$0.66
|
| Rate for Payer: WINHealth Partners Commercial |
$0.95
|
| Rate for Payer: Wise Provider Network Commercial |
$0.95
|
|
|
LEVETIRACETAM 250 MG TABLET [11009]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 6808485901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$1.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.98
|
| 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 |
$0.66
|
| Rate for Payer: HealthUtah PPO |
$1.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.97
|
| Rate for Payer: Multiplan Medicare/VA |
$0.63
|
| 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 |
$0.66
|
| Rate for Payer: United Healthcare Commercial |
$0.87
|
| Rate for Payer: United Healthcare Medicare |
$0.66
|
| Rate for Payer: WINHealth Partners Commercial |
$0.95
|
| Rate for Payer: Wise Provider Network Commercial |
$0.95
|
|
|
LEVETIRACETAM 250 MG TABLET [11009]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 6808485901
|
|
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
|
|
|
LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION [41894]
|
Facility
|
OP
|
$18.11
|
|
|
Service Code
|
HCPCS J1953
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.98 |
| Max. Negotiated Rate |
$18.11 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$17.75
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$17.05
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$22.93
|
| Rate for Payer: Aetna of WY Medicare |
$11.95
|
| Rate for Payer: Aetna of WY Medicare |
$15.44
|
| Rate for Payer: Aetna of WY Medicare |
$11.48
|
| Rate for Payer: Altius Auto/Workers Compensation |
$17.39
|
| Rate for Payer: Altius Auto/Workers Compensation |
$16.70
|
| Rate for Payer: Altius Auto/Workers Compensation |
$22.46
|
| Rate for Payer: Altius Commercial |
$17.39
|
| Rate for Payer: Altius Commercial |
$22.46
|
| Rate for Payer: Altius Commercial |
$16.70
|
| Rate for Payer: Beech Street Commercial |
$17.75
|
| Rate for Payer: Beech Street Commercial |
$22.93
|
| Rate for Payer: Beech Street Commercial |
$17.05
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.87
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.29
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$19.21
|
| Rate for Payer: Cash Price |
$12.68
|
| Rate for Payer: Cash Price |
$12.18
|
| Rate for Payer: Cash Price |
$16.38
|
| Rate for Payer: ChoiceCare Network Commercial |
$17.57
|
| Rate for Payer: ChoiceCare Network Commercial |
$22.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.88
|
| Rate for Payer: Cigna of WY Commercial |
$22.93
|
| Rate for Payer: Cigna of WY Commercial |
$17.05
|
| Rate for Payer: Cigna of WY Commercial |
$17.75
|
| Rate for Payer: Entrust Commercial |
$22.23
|
| Rate for Payer: Entrust Commercial |
$17.20
|
| Rate for Payer: Entrust Commercial |
$16.53
|
| Rate for Payer: First Choice Health Commercial |
$17.20
|
| Rate for Payer: First Choice Health Commercial |
$16.53
|
| Rate for Payer: First Choice Health Commercial |
$22.23
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.53
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$22.23
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.09
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$13.57
|
| Rate for Payer: HealthUtah PPO |
$17.40
|
| Rate for Payer: HealthUtah PPO |
$23.40
|
| Rate for Payer: HealthUtah PPO |
$18.11
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$22.70
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.88
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.57
|
| Rate for Payer: Multiplan Medicare/VA |
$9.59
|
| Rate for Payer: Multiplan Medicare/VA |
$9.98
|
| Rate for Payer: Multiplan Medicare/VA |
$12.89
|
| Rate for Payer: One Health Plan of WY PPO |
$17.05
|
| Rate for Payer: One Health Plan of WY PPO |
$22.93
|
| Rate for Payer: One Health Plan of WY PPO |
$17.75
|
| Rate for Payer: PacificSource Commercial |
$21.06
|
| Rate for Payer: PacificSource Commercial |
$16.30
|
| Rate for Payer: PacificSource Commercial |
$15.66
|
| Rate for Payer: PHCS PPO |
$17.75
|
| Rate for Payer: PHCS PPO |
$17.05
|
| Rate for Payer: PHCS PPO |
$22.93
|
| Rate for Payer: Three Rivers PPO |
$13.58
|
| Rate for Payer: Three Rivers PPO |
$13.05
|
| Rate for Payer: Three Rivers PPO |
$17.55
|
| Rate for Payer: TriWest Veterans Administration |
$13.57
|
| Rate for Payer: TriWest Veterans Administration |
$10.50
|
| Rate for Payer: TriWest Veterans Administration |
$10.09
|
| Rate for Payer: United Healthcare Commercial |
$15.14
|
| Rate for Payer: United Healthcare Commercial |
$15.76
|
| Rate for Payer: United Healthcare Commercial |
$20.36
|
| Rate for Payer: United Healthcare Medicare |
$13.57
|
| Rate for Payer: United Healthcare Medicare |
$10.09
|
| Rate for Payer: United Healthcare Medicare |
$10.50
|
| Rate for Payer: WINHealth Partners Commercial |
$22.93
|
| Rate for Payer: WINHealth Partners Commercial |
$17.05
|
| Rate for Payer: WINHealth Partners Commercial |
$17.75
|
| Rate for Payer: Wise Provider Network Commercial |
$16.53
|
| Rate for Payer: Wise Provider Network Commercial |
$22.23
|
| Rate for Payer: Wise Provider Network Commercial |
$17.20
|
|
|
LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION [41894]
|
Facility
|
IP
|
$17.40
|
|
|
Service Code
|
HCPCS J1953
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.91 |
| Max. Negotiated Rate |
$17.40 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$17.05
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$17.75
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$22.93
|
| Rate for Payer: Altius Auto/Workers Compensation |
$16.70
|
| Rate for Payer: Altius Auto/Workers Compensation |
$17.39
|
| Rate for Payer: Altius Auto/Workers Compensation |
$22.46
|
| Rate for Payer: Altius Commercial |
$17.39
|
| Rate for Payer: Altius Commercial |
$16.70
|
| Rate for Payer: Altius Commercial |
$22.46
|
| Rate for Payer: Beech Street Commercial |
$22.93
|
| Rate for Payer: Beech Street Commercial |
$17.75
|
| Rate for Payer: Beech Street Commercial |
$17.05
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.29
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$19.21
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.87
|
| Rate for Payer: Cash Price |
$12.68
|
| Rate for Payer: Cash Price |
$12.18
|
| Rate for Payer: Cash Price |
$16.38
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.88
|
| Rate for Payer: ChoiceCare Network Commercial |
$22.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$17.57
|
| Rate for Payer: Cigna of WY Commercial |
$17.75
|
| Rate for Payer: Cigna of WY Commercial |
$22.93
|
| Rate for Payer: Cigna of WY Commercial |
$17.05
|
| Rate for Payer: Entrust Commercial |
$22.23
|
| Rate for Payer: Entrust Commercial |
$16.53
|
| Rate for Payer: Entrust Commercial |
$17.20
|
| Rate for Payer: First Choice Health Commercial |
$17.20
|
| Rate for Payer: First Choice Health Commercial |
$22.23
|
| Rate for Payer: First Choice Health Commercial |
$16.53
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.53
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$22.23
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.48
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$15.44
|
| Rate for Payer: HealthUtah PPO |
$17.40
|
| Rate for Payer: HealthUtah PPO |
$18.11
|
| Rate for Payer: HealthUtah PPO |
$23.40
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$22.70
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.57
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.88
|
| Rate for Payer: Multiplan Medicare/VA |
$14.67
|
| Rate for Payer: Multiplan Medicare/VA |
$10.91
|
| Rate for Payer: Multiplan Medicare/VA |
$11.35
|
| Rate for Payer: One Health Plan of WY PPO |
$17.05
|
| Rate for Payer: One Health Plan of WY PPO |
$17.75
|
| Rate for Payer: One Health Plan of WY PPO |
$22.93
|
| Rate for Payer: PacificSource Commercial |
$21.06
|
| Rate for Payer: PacificSource Commercial |
$15.66
|
| Rate for Payer: PacificSource Commercial |
$16.30
|
| Rate for Payer: PHCS PPO |
$17.75
|
| Rate for Payer: PHCS PPO |
$17.05
|
| Rate for Payer: PHCS PPO |
$22.93
|
| Rate for Payer: Three Rivers PPO |
$13.58
|
| Rate for Payer: Three Rivers PPO |
$13.05
|
| Rate for Payer: Three Rivers PPO |
$17.55
|
| Rate for Payer: TriWest Veterans Administration |
$11.95
|
| Rate for Payer: TriWest Veterans Administration |
$11.48
|
| Rate for Payer: TriWest Veterans Administration |
$15.44
|
| Rate for Payer: United Healthcare Commercial |
$15.14
|
| Rate for Payer: United Healthcare Commercial |
$20.36
|
| Rate for Payer: United Healthcare Commercial |
$15.76
|
| Rate for Payer: United Healthcare Medicare |
$11.48
|
| Rate for Payer: United Healthcare Medicare |
$15.44
|
| Rate for Payer: United Healthcare Medicare |
$11.95
|
| Rate for Payer: WINHealth Partners Commercial |
$17.20
|
| Rate for Payer: WINHealth Partners Commercial |
$16.53
|
| Rate for Payer: WINHealth Partners Commercial |
$22.23
|
| Rate for Payer: Wise Provider Network Commercial |
$22.23
|
| Rate for Payer: Wise Provider Network Commercial |
$16.53
|
| Rate for Payer: Wise Provider Network Commercial |
$17.20
|
|
|
LEVETIRACETAM 500 MG TABLET [3633]
|
Facility
|
OP
|
$1.08
|
|
|
Service Code
|
NDC 6068765711
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$1.08 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.06
|
| Rate for Payer: Aetna of WY Medicare |
$0.71
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.04
|
| Rate for Payer: Altius Commercial |
$1.04
|
| Rate for Payer: Beech Street Commercial |
$1.06
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.89
|
| Rate for Payer: Cash Price |
$0.76
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.05
|
| Rate for Payer: Cigna of WY Commercial |
$1.06
|
| Rate for Payer: Entrust Commercial |
$1.03
|
| Rate for Payer: First Choice Health Commercial |
$1.03
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.03
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.63
|
| Rate for Payer: HealthUtah PPO |
$1.08
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.05
|
| Rate for Payer: Multiplan Medicare/VA |
$0.60
|
| Rate for Payer: One Health Plan of WY PPO |
$1.06
|
| Rate for Payer: PacificSource Commercial |
$0.97
|
| Rate for Payer: PHCS PPO |
$1.06
|
| Rate for Payer: Three Rivers PPO |
$0.81
|
| Rate for Payer: TriWest Veterans Administration |
$0.63
|
| Rate for Payer: United Healthcare Commercial |
$0.94
|
| Rate for Payer: United Healthcare Medicare |
$0.63
|
| Rate for Payer: WINHealth Partners Commercial |
$1.06
|
| Rate for Payer: Wise Provider Network Commercial |
$1.03
|
|
|
LEVETIRACETAM 500 MG TABLET [3633]
|
Facility
|
IP
|
$1.08
|
|
|
Service Code
|
NDC 6808487011
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.68 |
| Max. Negotiated Rate |
$1.08 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.06
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.04
|
| Rate for Payer: Altius Commercial |
$1.04
|
| Rate for Payer: Beech Street Commercial |
$1.06
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.89
|
| Rate for Payer: Cash Price |
$0.76
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.05
|
| Rate for Payer: Cigna of WY Commercial |
$1.06
|
| Rate for Payer: Entrust Commercial |
$1.03
|
| Rate for Payer: First Choice Health Commercial |
$1.03
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.03
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.71
|
| Rate for Payer: HealthUtah PPO |
$1.08
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.05
|
| Rate for Payer: Multiplan Medicare/VA |
$0.68
|
| Rate for Payer: One Health Plan of WY PPO |
$1.06
|
| Rate for Payer: PacificSource Commercial |
$0.97
|
| Rate for Payer: PHCS PPO |
$1.06
|
| Rate for Payer: Three Rivers PPO |
$0.81
|
| Rate for Payer: TriWest Veterans Administration |
$0.71
|
| Rate for Payer: United Healthcare Commercial |
$0.94
|
| Rate for Payer: United Healthcare Medicare |
$0.71
|
| Rate for Payer: WINHealth Partners Commercial |
$1.03
|
| Rate for Payer: Wise Provider Network Commercial |
$1.03
|
|
|
LEVETIRACETAM 500 MG TABLET [3633]
|
Facility
|
IP
|
$1.08
|
|
|
Service Code
|
NDC 6068765711
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.68 |
| Max. Negotiated Rate |
$1.08 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.06
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.04
|
| Rate for Payer: Altius Commercial |
$1.04
|
| Rate for Payer: Beech Street Commercial |
$1.06
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.89
|
| Rate for Payer: Cash Price |
$0.76
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.05
|
| Rate for Payer: Cigna of WY Commercial |
$1.06
|
| Rate for Payer: Entrust Commercial |
$1.03
|
| Rate for Payer: First Choice Health Commercial |
$1.03
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.03
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.71
|
| Rate for Payer: HealthUtah PPO |
$1.08
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.05
|
| Rate for Payer: Multiplan Medicare/VA |
$0.68
|
| Rate for Payer: One Health Plan of WY PPO |
$1.06
|
| Rate for Payer: PacificSource Commercial |
$0.97
|
| Rate for Payer: PHCS PPO |
$1.06
|
| Rate for Payer: Three Rivers PPO |
$0.81
|
| Rate for Payer: TriWest Veterans Administration |
$0.71
|
| Rate for Payer: United Healthcare Commercial |
$0.94
|
| Rate for Payer: United Healthcare Medicare |
$0.71
|
| Rate for Payer: WINHealth Partners Commercial |
$1.03
|
| Rate for Payer: Wise Provider Network Commercial |
$1.03
|
|
|
LEVETIRACETAM 500 MG TABLET [3633]
|
Facility
|
OP
|
$1.08
|
|
|
Service Code
|
NDC 6808487001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$1.08 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.06
|
| Rate for Payer: Aetna of WY Medicare |
$0.71
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.04
|
| Rate for Payer: Altius Commercial |
$1.04
|
| Rate for Payer: Beech Street Commercial |
$1.06
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.89
|
| Rate for Payer: Cash Price |
$0.76
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.05
|
| Rate for Payer: Cigna of WY Commercial |
$1.06
|
| Rate for Payer: Entrust Commercial |
$1.03
|
| Rate for Payer: First Choice Health Commercial |
$1.03
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.03
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.63
|
| Rate for Payer: HealthUtah PPO |
$1.08
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.05
|
| Rate for Payer: Multiplan Medicare/VA |
$0.60
|
| Rate for Payer: One Health Plan of WY PPO |
$1.06
|
| Rate for Payer: PacificSource Commercial |
$0.97
|
| Rate for Payer: PHCS PPO |
$1.06
|
| Rate for Payer: Three Rivers PPO |
$0.81
|
| Rate for Payer: TriWest Veterans Administration |
$0.63
|
| Rate for Payer: United Healthcare Commercial |
$0.94
|
| Rate for Payer: United Healthcare Medicare |
$0.63
|
| Rate for Payer: WINHealth Partners Commercial |
$1.06
|
| Rate for Payer: Wise Provider Network Commercial |
$1.03
|
|
|
LEVETIRACETAM 500 MG TABLET [3633]
|
Facility
|
IP
|
$1.08
|
|
|
Service Code
|
NDC 6808487001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.68 |
| Max. Negotiated Rate |
$1.08 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.06
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.04
|
| Rate for Payer: Altius Commercial |
$1.04
|
| Rate for Payer: Beech Street Commercial |
$1.06
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.89
|
| Rate for Payer: Cash Price |
$0.76
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.05
|
| Rate for Payer: Cigna of WY Commercial |
$1.06
|
| Rate for Payer: Entrust Commercial |
$1.03
|
| Rate for Payer: First Choice Health Commercial |
$1.03
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.03
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.71
|
| Rate for Payer: HealthUtah PPO |
$1.08
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.05
|
| Rate for Payer: Multiplan Medicare/VA |
$0.68
|
| Rate for Payer: One Health Plan of WY PPO |
$1.06
|
| Rate for Payer: PacificSource Commercial |
$0.97
|
| Rate for Payer: PHCS PPO |
$1.06
|
| Rate for Payer: Three Rivers PPO |
$0.81
|
| Rate for Payer: TriWest Veterans Administration |
$0.71
|
| Rate for Payer: United Healthcare Commercial |
$0.94
|
| Rate for Payer: United Healthcare Medicare |
$0.71
|
| Rate for Payer: WINHealth Partners Commercial |
$1.03
|
| Rate for Payer: Wise Provider Network Commercial |
$1.03
|
|
|
LEVETIRACETAM 500 MG TABLET [3633]
|
Facility
|
OP
|
$1.08
|
|
|
Service Code
|
NDC 6808487011
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$1.08 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.06
|
| Rate for Payer: Aetna of WY Medicare |
$0.71
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.04
|
| Rate for Payer: Altius Commercial |
$1.04
|
| Rate for Payer: Beech Street Commercial |
$1.06
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.89
|
| Rate for Payer: Cash Price |
$0.76
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.05
|
| Rate for Payer: Cigna of WY Commercial |
$1.06
|
| Rate for Payer: Entrust Commercial |
$1.03
|
| Rate for Payer: First Choice Health Commercial |
$1.03
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.03
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.63
|
| Rate for Payer: HealthUtah PPO |
$1.08
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.05
|
| Rate for Payer: Multiplan Medicare/VA |
$0.60
|
| Rate for Payer: One Health Plan of WY PPO |
$1.06
|
| Rate for Payer: PacificSource Commercial |
$0.97
|
| Rate for Payer: PHCS PPO |
$1.06
|
| Rate for Payer: Three Rivers PPO |
$0.81
|
| Rate for Payer: TriWest Veterans Administration |
$0.63
|
| Rate for Payer: United Healthcare Commercial |
$0.94
|
| Rate for Payer: United Healthcare Medicare |
$0.63
|
| Rate for Payer: WINHealth Partners Commercial |
$1.06
|
| Rate for Payer: Wise Provider Network Commercial |
$1.03
|
|
|
LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [28387]
|
Facility
|
IP
|
$15.24
|
|
|
Service Code
|
HCPCS J1956
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$15.24 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.94
|
| Rate for Payer: Altius Auto/Workers Compensation |
$14.63
|
| Rate for Payer: Altius Commercial |
$14.63
|
| Rate for Payer: Beech Street Commercial |
$14.94
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.51
|
| Rate for Payer: Cash Price |
$10.67
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.78
|
| Rate for Payer: Cigna of WY Commercial |
$14.94
|
| Rate for Payer: Entrust Commercial |
$14.48
|
| Rate for Payer: First Choice Health Commercial |
$14.48
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.48
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.06
|
| Rate for Payer: HealthUtah PPO |
$15.24
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.78
|
| Rate for Payer: Multiplan Medicare/VA |
$9.56
|
| Rate for Payer: One Health Plan of WY PPO |
$14.94
|
| Rate for Payer: PacificSource Commercial |
$13.72
|
| Rate for Payer: PHCS PPO |
$14.94
|
| Rate for Payer: Three Rivers PPO |
$11.43
|
| Rate for Payer: TriWest Veterans Administration |
$10.06
|
| Rate for Payer: United Healthcare Commercial |
$13.26
|
| Rate for Payer: United Healthcare Medicare |
$10.06
|
| Rate for Payer: WINHealth Partners Commercial |
$14.48
|
| Rate for Payer: Wise Provider Network Commercial |
$14.48
|
|
|
LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [28387]
|
Facility
|
OP
|
$15.24
|
|
|
Service Code
|
HCPCS J1956
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.40 |
| Max. Negotiated Rate |
$15.24 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.94
|
| Rate for Payer: Aetna of WY Medicare |
$10.06
|
| Rate for Payer: Altius Auto/Workers Compensation |
$14.63
|
| Rate for Payer: Altius Commercial |
$14.63
|
| Rate for Payer: Beech Street Commercial |
$14.94
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.51
|
| Rate for Payer: Cash Price |
$10.67
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.78
|
| Rate for Payer: Cigna of WY Commercial |
$14.94
|
| Rate for Payer: Entrust Commercial |
$14.48
|
| Rate for Payer: First Choice Health Commercial |
$14.48
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.48
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.84
|
| Rate for Payer: HealthUtah PPO |
$15.24
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.78
|
| Rate for Payer: Multiplan Medicare/VA |
$8.40
|
| Rate for Payer: One Health Plan of WY PPO |
$14.94
|
| Rate for Payer: PacificSource Commercial |
$13.72
|
| Rate for Payer: PHCS PPO |
$14.94
|
| Rate for Payer: Three Rivers PPO |
$11.43
|
| Rate for Payer: TriWest Veterans Administration |
$8.84
|
| Rate for Payer: United Healthcare Commercial |
$13.26
|
| Rate for Payer: United Healthcare Medicare |
$8.84
|
| Rate for Payer: WINHealth Partners Commercial |
$14.94
|
| Rate for Payer: Wise Provider Network Commercial |
$14.48
|
|
|
LEVOFLOXACIN 500 MG TABLET [17601]
|
Facility
|
OP
|
$0.97
|
|
|
Service Code
|
NDC 0904635261
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.95
|
| Rate for Payer: Aetna of WY Medicare |
$0.64
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.93
|
| Rate for Payer: Altius Commercial |
$0.93
|
| Rate for Payer: Beech Street Commercial |
$0.95
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.80
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.94
|
| Rate for Payer: Cigna of WY Commercial |
$0.95
|
| Rate for Payer: Entrust Commercial |
$0.92
|
| Rate for Payer: First Choice Health Commercial |
$0.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.56
|
| Rate for Payer: HealthUtah PPO |
$0.97
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.94
|
| Rate for Payer: Multiplan Medicare/VA |
$0.53
|
| Rate for Payer: One Health Plan of WY PPO |
$0.95
|
| Rate for Payer: PacificSource Commercial |
$0.87
|
| Rate for Payer: PHCS PPO |
$0.95
|
| Rate for Payer: Three Rivers PPO |
$0.73
|
| Rate for Payer: TriWest Veterans Administration |
$0.56
|
| Rate for Payer: United Healthcare Commercial |
$0.84
|
| Rate for Payer: United Healthcare Medicare |
$0.56
|
| Rate for Payer: WINHealth Partners Commercial |
$0.95
|
| Rate for Payer: Wise Provider Network Commercial |
$0.92
|
|
|
LEVOFLOXACIN 500 MG TABLET [17601]
|
Facility
|
IP
|
$0.97
|
|
|
Service Code
|
NDC 0904635261
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.95
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.93
|
| Rate for Payer: Altius Commercial |
$0.93
|
| Rate for Payer: Beech Street Commercial |
$0.95
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.80
|
| Rate for Payer: Cash Price |
$0.68
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.94
|
| Rate for Payer: Cigna of WY Commercial |
$0.95
|
| Rate for Payer: Entrust Commercial |
$0.92
|
| Rate for Payer: First Choice Health Commercial |
$0.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.64
|
| Rate for Payer: HealthUtah PPO |
$0.97
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.94
|
| Rate for Payer: Multiplan Medicare/VA |
$0.61
|
| Rate for Payer: One Health Plan of WY PPO |
$0.95
|
| Rate for Payer: PacificSource Commercial |
$0.87
|
| Rate for Payer: PHCS PPO |
$0.95
|
| Rate for Payer: Three Rivers PPO |
$0.73
|
| Rate for Payer: TriWest Veterans Administration |
$0.64
|
| Rate for Payer: United Healthcare Commercial |
$0.84
|
| Rate for Payer: United Healthcare Medicare |
$0.64
|
| Rate for Payer: WINHealth Partners Commercial |
$0.92
|
| Rate for Payer: Wise Provider Network Commercial |
$0.92
|
|
|
LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [28388]
|
Facility
|
OP
|
$15.17
|
|
|
Service Code
|
HCPCS J1956
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.36 |
| Max. Negotiated Rate |
$15.17 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.87
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.80
|
| Rate for Payer: Aetna of WY Medicare |
$10.01
|
| Rate for Payer: Aetna of WY Medicare |
$9.97
|
| Rate for Payer: Altius Auto/Workers Compensation |
$14.50
|
| Rate for Payer: Altius Auto/Workers Compensation |
$14.56
|
| Rate for Payer: Altius Commercial |
$14.56
|
| Rate for Payer: Altius Commercial |
$14.50
|
| Rate for Payer: Beech Street Commercial |
$14.80
|
| Rate for Payer: Beech Street Commercial |
$14.87
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.45
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.40
|
| Rate for Payer: Cash Price |
$10.57
|
| Rate for Payer: Cash Price |
$10.62
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.71
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.65
|
| Rate for Payer: Cigna of WY Commercial |
$14.80
|
| Rate for Payer: Cigna of WY Commercial |
$14.87
|
| Rate for Payer: Entrust Commercial |
$14.41
|
| Rate for Payer: Entrust Commercial |
$14.34
|
| Rate for Payer: First Choice Health Commercial |
$14.34
|
| Rate for Payer: First Choice Health Commercial |
$14.41
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.41
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.76
|
| Rate for Payer: HealthUtah PPO |
$15.10
|
| Rate for Payer: HealthUtah PPO |
$15.17
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.65
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.71
|
| Rate for Payer: Multiplan Medicare/VA |
$8.36
|
| Rate for Payer: Multiplan Medicare/VA |
$8.32
|
| Rate for Payer: One Health Plan of WY PPO |
$14.80
|
| Rate for Payer: One Health Plan of WY PPO |
$14.87
|
| Rate for Payer: PacificSource Commercial |
$13.65
|
| Rate for Payer: PacificSource Commercial |
$13.59
|
| Rate for Payer: PHCS PPO |
$14.80
|
| Rate for Payer: PHCS PPO |
$14.87
|
| Rate for Payer: Three Rivers PPO |
$11.32
|
| Rate for Payer: Three Rivers PPO |
$11.38
|
| Rate for Payer: TriWest Veterans Administration |
$8.80
|
| Rate for Payer: TriWest Veterans Administration |
$8.76
|
| Rate for Payer: United Healthcare Commercial |
$13.14
|
| Rate for Payer: United Healthcare Commercial |
$13.20
|
| Rate for Payer: United Healthcare Medicare |
$8.80
|
| Rate for Payer: United Healthcare Medicare |
$8.76
|
| Rate for Payer: WINHealth Partners Commercial |
$14.80
|
| Rate for Payer: WINHealth Partners Commercial |
$14.87
|
| Rate for Payer: Wise Provider Network Commercial |
$14.34
|
| Rate for Payer: Wise Provider Network Commercial |
$14.41
|
|
|
LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [28388]
|
Facility
|
IP
|
$15.17
|
|
|
Service Code
|
HCPCS J1956
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.51 |
| Max. Negotiated Rate |
$15.17 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.87
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.80
|
| Rate for Payer: Altius Auto/Workers Compensation |
$14.56
|
| Rate for Payer: Altius Auto/Workers Compensation |
$14.50
|
| Rate for Payer: Altius Commercial |
$14.50
|
| Rate for Payer: Altius Commercial |
$14.56
|
| Rate for Payer: Beech Street Commercial |
$14.87
|
| Rate for Payer: Beech Street Commercial |
$14.80
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.45
|
| Rate for Payer: Cash Price |
$10.62
|
| Rate for Payer: Cash Price |
$10.57
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.65
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.71
|
| Rate for Payer: Cigna of WY Commercial |
$14.87
|
| Rate for Payer: Cigna of WY Commercial |
$14.80
|
| Rate for Payer: Entrust Commercial |
$14.34
|
| Rate for Payer: Entrust Commercial |
$14.41
|
| Rate for Payer: First Choice Health Commercial |
$14.34
|
| Rate for Payer: First Choice Health Commercial |
$14.41
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.41
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.01
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.97
|
| Rate for Payer: HealthUtah PPO |
$15.17
|
| Rate for Payer: HealthUtah PPO |
$15.10
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.65
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.71
|
| Rate for Payer: Multiplan Medicare/VA |
$9.51
|
| Rate for Payer: Multiplan Medicare/VA |
$9.47
|
| Rate for Payer: One Health Plan of WY PPO |
$14.87
|
| Rate for Payer: One Health Plan of WY PPO |
$14.80
|
| Rate for Payer: PacificSource Commercial |
$13.65
|
| Rate for Payer: PacificSource Commercial |
$13.59
|
| Rate for Payer: PHCS PPO |
$14.80
|
| Rate for Payer: PHCS PPO |
$14.87
|
| Rate for Payer: Three Rivers PPO |
$11.32
|
| Rate for Payer: Three Rivers PPO |
$11.38
|
| Rate for Payer: TriWest Veterans Administration |
$10.01
|
| Rate for Payer: TriWest Veterans Administration |
$9.97
|
| Rate for Payer: United Healthcare Commercial |
$13.14
|
| Rate for Payer: United Healthcare Commercial |
$13.20
|
| Rate for Payer: United Healthcare Medicare |
$10.01
|
| Rate for Payer: United Healthcare Medicare |
$9.97
|
| Rate for Payer: WINHealth Partners Commercial |
$14.34
|
| Rate for Payer: WINHealth Partners Commercial |
$14.41
|
| Rate for Payer: Wise Provider Network Commercial |
$14.34
|
| Rate for Payer: Wise Provider Network Commercial |
$14.41
|
|
|
LEVOFLOXACIN 750 MG TABLET [17727]
|
Facility
|
OP
|
$2.82
|
|
|
Service Code
|
NDC 7257810092
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.55 |
| Max. Negotiated Rate |
$2.82 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.76
|
| Rate for Payer: Aetna of WY Medicare |
$1.86
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.71
|
| Rate for Payer: Altius Commercial |
$2.71
|
| Rate for Payer: Beech Street Commercial |
$2.76
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.32
|
| Rate for Payer: Cash Price |
$1.98
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.74
|
| Rate for Payer: Cigna of WY Commercial |
$2.76
|
| Rate for Payer: Entrust Commercial |
$2.68
|
| Rate for Payer: First Choice Health Commercial |
$2.68
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.68
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.64
|
| Rate for Payer: HealthUtah PPO |
$2.82
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.74
|
| Rate for Payer: Multiplan Medicare/VA |
$1.55
|
| Rate for Payer: One Health Plan of WY PPO |
$2.76
|
| Rate for Payer: PacificSource Commercial |
$2.54
|
| Rate for Payer: PHCS PPO |
$2.76
|
| Rate for Payer: Three Rivers PPO |
$2.12
|
| Rate for Payer: TriWest Veterans Administration |
$1.64
|
| Rate for Payer: United Healthcare Commercial |
$2.45
|
| Rate for Payer: United Healthcare Medicare |
$1.64
|
| Rate for Payer: WINHealth Partners Commercial |
$2.76
|
| Rate for Payer: Wise Provider Network Commercial |
$2.68
|
|
|
LEVOFLOXACIN 750 MG TABLET [17727]
|
Facility
|
IP
|
$2.82
|
|
|
Service Code
|
NDC 7257810092
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.77 |
| Max. Negotiated Rate |
$2.82 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.76
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.71
|
| Rate for Payer: Altius Commercial |
$2.71
|
| Rate for Payer: Beech Street Commercial |
$2.76
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.32
|
| Rate for Payer: Cash Price |
$1.98
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.74
|
| Rate for Payer: Cigna of WY Commercial |
$2.76
|
| Rate for Payer: Entrust Commercial |
$2.68
|
| Rate for Payer: First Choice Health Commercial |
$2.68
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.68
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.86
|
| Rate for Payer: HealthUtah PPO |
$2.82
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.74
|
| Rate for Payer: Multiplan Medicare/VA |
$1.77
|
| Rate for Payer: One Health Plan of WY PPO |
$2.76
|
| Rate for Payer: PacificSource Commercial |
$2.54
|
| Rate for Payer: PHCS PPO |
$2.76
|
| Rate for Payer: Three Rivers PPO |
$2.12
|
| Rate for Payer: TriWest Veterans Administration |
$1.86
|
| Rate for Payer: United Healthcare Commercial |
$2.45
|
| Rate for Payer: United Healthcare Medicare |
$1.86
|
| Rate for Payer: WINHealth Partners Commercial |
$2.68
|
| Rate for Payer: Wise Provider Network Commercial |
$2.68
|
|
|
LEVONORGESTREL 1.5 MG TABLET [87479]
|
Facility
|
IP
|
$37.12
|
|
|
Service Code
|
NDC 6818085211
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.27 |
| Max. Negotiated Rate |
$37.12 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$36.38
|
| Rate for Payer: Altius Auto/Workers Compensation |
$35.64
|
| Rate for Payer: Altius Commercial |
$35.64
|
| Rate for Payer: Beech Street Commercial |
$36.38
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$30.48
|
| Rate for Payer: Cash Price |
$25.99
|
| Rate for Payer: ChoiceCare Network Commercial |
$36.01
|
| Rate for Payer: Cigna of WY Commercial |
$36.38
|
| Rate for Payer: Entrust Commercial |
$35.26
|
| Rate for Payer: First Choice Health Commercial |
$35.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$35.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$24.50
|
| Rate for Payer: HealthUtah PPO |
$37.12
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$36.01
|
| Rate for Payer: Multiplan Medicare/VA |
$23.27
|
| Rate for Payer: One Health Plan of WY PPO |
$36.38
|
| Rate for Payer: PacificSource Commercial |
$33.41
|
| Rate for Payer: PHCS PPO |
$36.38
|
| Rate for Payer: Three Rivers PPO |
$27.84
|
| Rate for Payer: TriWest Veterans Administration |
$24.50
|
| Rate for Payer: United Healthcare Commercial |
$32.29
|
| Rate for Payer: United Healthcare Medicare |
$24.50
|
| Rate for Payer: WINHealth Partners Commercial |
$35.26
|
| Rate for Payer: Wise Provider Network Commercial |
$35.26
|
|
|
LEVONORGESTREL 1.5 MG TABLET [87479]
|
Facility
|
OP
|
$37.12
|
|
|
Service Code
|
NDC 6818085211
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.45 |
| Max. Negotiated Rate |
$37.12 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$36.38
|
| Rate for Payer: Aetna of WY Medicare |
$24.50
|
| Rate for Payer: Altius Auto/Workers Compensation |
$35.64
|
| Rate for Payer: Altius Commercial |
$35.64
|
| Rate for Payer: Beech Street Commercial |
$36.38
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$30.48
|
| Rate for Payer: Cash Price |
$25.99
|
| Rate for Payer: ChoiceCare Network Commercial |
$36.01
|
| Rate for Payer: Cigna of WY Commercial |
$36.38
|
| Rate for Payer: Entrust Commercial |
$35.26
|
| Rate for Payer: First Choice Health Commercial |
$35.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$35.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$21.53
|
| Rate for Payer: HealthUtah PPO |
$37.12
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$36.01
|
| Rate for Payer: Multiplan Medicare/VA |
$20.45
|
| Rate for Payer: One Health Plan of WY PPO |
$36.38
|
| Rate for Payer: PacificSource Commercial |
$33.41
|
| Rate for Payer: PHCS PPO |
$36.38
|
| Rate for Payer: Three Rivers PPO |
$27.84
|
| Rate for Payer: TriWest Veterans Administration |
$21.53
|
| Rate for Payer: United Healthcare Commercial |
$32.29
|
| Rate for Payer: United Healthcare Medicare |
$21.53
|
| Rate for Payer: WINHealth Partners Commercial |
$36.38
|
| Rate for Payer: Wise Provider Network Commercial |
$35.26
|
|
|
LEVONORGESTREL 1.5 MG TABLET [87479]
|
Facility
|
IP
|
$45.00
|
|
|
Service Code
|
NDC 6275672060
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.22 |
| Max. Negotiated Rate |
$45.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$44.10
|
| Rate for Payer: Altius Auto/Workers Compensation |
$43.20
|
| Rate for Payer: Altius Commercial |
$43.20
|
| Rate for Payer: Beech Street Commercial |
$44.10
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$36.94
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$43.65
|
| Rate for Payer: Cigna of WY Commercial |
$44.10
|
| Rate for Payer: Entrust Commercial |
$42.75
|
| Rate for Payer: First Choice Health Commercial |
$42.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$42.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$29.70
|
| Rate for Payer: HealthUtah PPO |
$45.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$43.65
|
| Rate for Payer: Multiplan Medicare/VA |
$28.22
|
| Rate for Payer: One Health Plan of WY PPO |
$44.10
|
| Rate for Payer: PacificSource Commercial |
$40.50
|
| Rate for Payer: PHCS PPO |
$44.10
|
| Rate for Payer: Three Rivers PPO |
$33.75
|
| Rate for Payer: TriWest Veterans Administration |
$29.70
|
| Rate for Payer: United Healthcare Commercial |
$39.15
|
| Rate for Payer: United Healthcare Medicare |
$29.70
|
| Rate for Payer: WINHealth Partners Commercial |
$42.75
|
| Rate for Payer: Wise Provider Network Commercial |
$42.75
|
|
|
LEVONORGESTREL 1.5 MG TABLET [87479]
|
Facility
|
OP
|
$45.00
|
|
|
Service Code
|
NDC 6275672060
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.80 |
| Max. Negotiated Rate |
$45.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$44.10
|
| Rate for Payer: Aetna of WY Medicare |
$29.70
|
| Rate for Payer: Altius Auto/Workers Compensation |
$43.20
|
| Rate for Payer: Altius Commercial |
$43.20
|
| Rate for Payer: Beech Street Commercial |
$44.10
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$36.94
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$43.65
|
| Rate for Payer: Cigna of WY Commercial |
$44.10
|
| Rate for Payer: Entrust Commercial |
$42.75
|
| Rate for Payer: First Choice Health Commercial |
$42.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$42.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$26.10
|
| Rate for Payer: HealthUtah PPO |
$45.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$43.65
|
| Rate for Payer: Multiplan Medicare/VA |
$24.80
|
| Rate for Payer: One Health Plan of WY PPO |
$44.10
|
| Rate for Payer: PacificSource Commercial |
$40.50
|
| Rate for Payer: PHCS PPO |
$44.10
|
| Rate for Payer: Three Rivers PPO |
$33.75
|
| Rate for Payer: TriWest Veterans Administration |
$26.10
|
| Rate for Payer: United Healthcare Commercial |
$39.15
|
| Rate for Payer: United Healthcare Medicare |
$26.10
|
| Rate for Payer: WINHealth Partners Commercial |
$44.10
|
| Rate for Payer: Wise Provider Network Commercial |
$42.75
|
|
|
LEVONORGESTREL 17.5 MCG/24 HR (UP TO 5 YRS) 19.5MG INTRAUTERINE DEVICE [146832]
|
Facility
|
IP
|
$1,214.63
|
|
|
Service Code
|
HCPCS J7296
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$761.57 |
| Max. Negotiated Rate |
$1,214.63 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,190.34
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,166.04
|
| Rate for Payer: Altius Commercial |
$1,166.04
|
| Rate for Payer: Beech Street Commercial |
$1,190.34
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$997.21
|
| Rate for Payer: Cash Price |
$850.24
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,178.19
|
| Rate for Payer: Cigna of WY Commercial |
$1,190.34
|
| Rate for Payer: Entrust Commercial |
$1,153.90
|
| Rate for Payer: First Choice Health Commercial |
$1,153.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,153.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$801.66
|
| Rate for Payer: HealthUtah PPO |
$1,214.63
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,178.19
|
| Rate for Payer: Multiplan Medicare/VA |
$761.57
|
| Rate for Payer: One Health Plan of WY PPO |
$1,190.34
|
| Rate for Payer: PacificSource Commercial |
$1,093.17
|
| Rate for Payer: PHCS PPO |
$1,190.34
|
| Rate for Payer: Three Rivers PPO |
$910.97
|
| Rate for Payer: TriWest Veterans Administration |
$801.66
|
| Rate for Payer: United Healthcare Commercial |
$1,056.73
|
| Rate for Payer: United Healthcare Medicare |
$801.66
|
| Rate for Payer: WINHealth Partners Commercial |
$1,153.90
|
| Rate for Payer: Wise Provider Network Commercial |
$1,153.90
|
|
|
LEVONORGESTREL 17.5 MCG/24 HR (UP TO 5 YRS) 19.5MG INTRAUTERINE DEVICE [146832]
|
Facility
|
OP
|
$1,214.63
|
|
|
Service Code
|
HCPCS J7296
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$669.26 |
| Max. Negotiated Rate |
$1,214.63 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,190.34
|
| Rate for Payer: Aetna of WY Medicare |
$801.66
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,166.04
|
| Rate for Payer: Altius Commercial |
$1,166.04
|
| Rate for Payer: Beech Street Commercial |
$1,190.34
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$997.21
|
| Rate for Payer: Cash Price |
$850.24
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,178.19
|
| Rate for Payer: Cigna of WY Commercial |
$1,190.34
|
| Rate for Payer: Entrust Commercial |
$1,153.90
|
| Rate for Payer: First Choice Health Commercial |
$1,153.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,153.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$704.49
|
| Rate for Payer: HealthUtah PPO |
$1,214.63
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,178.19
|
| Rate for Payer: Multiplan Medicare/VA |
$669.26
|
| Rate for Payer: One Health Plan of WY PPO |
$1,190.34
|
| Rate for Payer: PacificSource Commercial |
$1,093.17
|
| Rate for Payer: PHCS PPO |
$1,190.34
|
| Rate for Payer: Three Rivers PPO |
$910.97
|
| Rate for Payer: TriWest Veterans Administration |
$704.49
|
| Rate for Payer: United Healthcare Commercial |
$1,056.73
|
| Rate for Payer: United Healthcare Medicare |
$704.49
|
| Rate for Payer: WINHealth Partners Commercial |
$1,190.34
|
| Rate for Payer: Wise Provider Network Commercial |
$1,153.90
|
|
