|
LEVONORGESTREL 21 MCG/24 HR (UP TO 8 YEARS) 52 MG INTRAUTERINE DEVICE [1252]
|
Facility
|
OP
|
$1,214.63
|
|
|
Service Code
|
HCPCS J7298
|
|
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
|
|
|
LEVONORGESTREL 21 MCG/24 HR (UP TO 8 YEARS) 52 MG INTRAUTERINE DEVICE [1252]
|
Facility
|
IP
|
$1,214.63
|
|
|
Service Code
|
HCPCS J7298
|
|
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 IMPLANT SYS
|
Professional
|
Both
|
$875.00
|
|
|
Service Code
|
HCPCS J7306
|
| Hospital Charge Code |
J7306
|
| Min. Negotiated Rate |
$656.25 |
| Max. Negotiated Rate |
$875.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$857.50
|
| Rate for Payer: Beech Street Commercial |
$831.25
|
| Rate for Payer: Cash Price |
$612.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$848.75
|
| Rate for Payer: Cigna of WY Commercial |
$857.50
|
| Rate for Payer: First Choice Health Commercial |
$787.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$831.25
|
| Rate for Payer: HealthUtah PPO |
$875.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$848.75
|
| Rate for Payer: One Health Plan of WY PPO |
$857.50
|
| Rate for Payer: PacificSource Commercial |
$787.50
|
| Rate for Payer: PHCS PPO |
$831.25
|
| Rate for Payer: Three Rivers PPO |
$656.25
|
| Rate for Payer: United Healthcare Commercial |
$761.25
|
| Rate for Payer: WINHealth Partners Commercial |
$831.25
|
|
|
LEVONORGESTREL IU 52 MG
|
Professional
|
Both
|
$1,171.00
|
|
|
Service Code
|
HCPCS J7302
|
| Hospital Charge Code |
J7302
|
| Min. Negotiated Rate |
$878.25 |
| Max. Negotiated Rate |
$1,171.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,147.58
|
| Rate for Payer: Beech Street Commercial |
$1,112.45
|
| Rate for Payer: Cash Price |
$819.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,135.87
|
| Rate for Payer: Cigna of WY Commercial |
$1,147.58
|
| Rate for Payer: First Choice Health Commercial |
$1,053.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,112.45
|
| Rate for Payer: HealthUtah PPO |
$1,171.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,135.87
|
| Rate for Payer: One Health Plan of WY PPO |
$1,147.58
|
| Rate for Payer: PacificSource Commercial |
$1,053.90
|
| Rate for Payer: PHCS PPO |
$1,112.45
|
| Rate for Payer: Three Rivers PPO |
$878.25
|
| Rate for Payer: United Healthcare Commercial |
$1,018.77
|
| Rate for Payer: WINHealth Partners Commercial |
$1,112.45
|
|
|
LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION [94771]
|
Facility
|
OP
|
$180.38
|
|
|
Service Code
|
HCPCS J0650
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$99.39 |
| Max. Negotiated Rate |
$180.38 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$176.77
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$169.90
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$191.63
|
| Rate for Payer: Aetna of WY Medicare |
$119.05
|
| Rate for Payer: Aetna of WY Medicare |
$129.06
|
| Rate for Payer: Aetna of WY Medicare |
$114.42
|
| Rate for Payer: Altius Auto/Workers Compensation |
$173.16
|
| Rate for Payer: Altius Auto/Workers Compensation |
$166.44
|
| Rate for Payer: Altius Auto/Workers Compensation |
$187.72
|
| Rate for Payer: Altius Commercial |
$173.16
|
| Rate for Payer: Altius Commercial |
$187.72
|
| Rate for Payer: Altius Commercial |
$166.44
|
| Rate for Payer: Beech Street Commercial |
$176.77
|
| Rate for Payer: Beech Street Commercial |
$191.63
|
| Rate for Payer: Beech Street Commercial |
$169.90
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$148.09
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$142.34
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$160.54
|
| Rate for Payer: Cash Price |
$126.26
|
| Rate for Payer: Cash Price |
$121.36
|
| Rate for Payer: Cash Price |
$136.88
|
| Rate for Payer: ChoiceCare Network Commercial |
$174.97
|
| Rate for Payer: ChoiceCare Network Commercial |
$189.67
|
| Rate for Payer: ChoiceCare Network Commercial |
$168.17
|
| Rate for Payer: Cigna of WY Commercial |
$191.63
|
| Rate for Payer: Cigna of WY Commercial |
$169.90
|
| Rate for Payer: Cigna of WY Commercial |
$176.77
|
| Rate for Payer: Entrust Commercial |
$185.76
|
| Rate for Payer: Entrust Commercial |
$171.36
|
| Rate for Payer: Entrust Commercial |
$164.70
|
| Rate for Payer: First Choice Health Commercial |
$171.36
|
| Rate for Payer: First Choice Health Commercial |
$164.70
|
| Rate for Payer: First Choice Health Commercial |
$185.76
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$164.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$185.76
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$171.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$104.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$100.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$113.41
|
| Rate for Payer: HealthUtah PPO |
$173.37
|
| Rate for Payer: HealthUtah PPO |
$195.54
|
| Rate for Payer: HealthUtah PPO |
$180.38
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$189.67
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$168.17
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$174.97
|
| Rate for Payer: Multiplan Medicare/VA |
$95.53
|
| Rate for Payer: Multiplan Medicare/VA |
$99.39
|
| Rate for Payer: Multiplan Medicare/VA |
$107.74
|
| Rate for Payer: One Health Plan of WY PPO |
$169.90
|
| Rate for Payer: One Health Plan of WY PPO |
$191.63
|
| Rate for Payer: One Health Plan of WY PPO |
$176.77
|
| Rate for Payer: PacificSource Commercial |
$175.99
|
| Rate for Payer: PacificSource Commercial |
$162.34
|
| Rate for Payer: PacificSource Commercial |
$156.03
|
| Rate for Payer: PHCS PPO |
$176.77
|
| Rate for Payer: PHCS PPO |
$169.90
|
| Rate for Payer: PHCS PPO |
$191.63
|
| Rate for Payer: Three Rivers PPO |
$135.28
|
| Rate for Payer: Three Rivers PPO |
$130.03
|
| Rate for Payer: Three Rivers PPO |
$146.66
|
| Rate for Payer: TriWest Veterans Administration |
$113.41
|
| Rate for Payer: TriWest Veterans Administration |
$104.62
|
| Rate for Payer: TriWest Veterans Administration |
$100.55
|
| Rate for Payer: United Healthcare Commercial |
$150.83
|
| Rate for Payer: United Healthcare Commercial |
$156.93
|
| Rate for Payer: United Healthcare Commercial |
$170.12
|
| Rate for Payer: United Healthcare Medicare |
$113.41
|
| Rate for Payer: United Healthcare Medicare |
$100.55
|
| Rate for Payer: United Healthcare Medicare |
$104.62
|
| Rate for Payer: WINHealth Partners Commercial |
$191.63
|
| Rate for Payer: WINHealth Partners Commercial |
$169.90
|
| Rate for Payer: WINHealth Partners Commercial |
$176.77
|
| Rate for Payer: Wise Provider Network Commercial |
$164.70
|
| Rate for Payer: Wise Provider Network Commercial |
$185.76
|
| Rate for Payer: Wise Provider Network Commercial |
$171.36
|
|
|
LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION [94771]
|
Facility
|
IP
|
$173.37
|
|
|
Service Code
|
HCPCS J0650
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$108.70 |
| Max. Negotiated Rate |
$173.37 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$169.90
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$176.77
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$191.63
|
| Rate for Payer: Altius Auto/Workers Compensation |
$166.44
|
| Rate for Payer: Altius Auto/Workers Compensation |
$173.16
|
| Rate for Payer: Altius Auto/Workers Compensation |
$187.72
|
| Rate for Payer: Altius Commercial |
$173.16
|
| Rate for Payer: Altius Commercial |
$166.44
|
| Rate for Payer: Altius Commercial |
$187.72
|
| Rate for Payer: Beech Street Commercial |
$191.63
|
| Rate for Payer: Beech Street Commercial |
$176.77
|
| Rate for Payer: Beech Street Commercial |
$169.90
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$142.34
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$160.54
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$148.09
|
| Rate for Payer: Cash Price |
$126.26
|
| Rate for Payer: Cash Price |
$121.36
|
| Rate for Payer: Cash Price |
$136.88
|
| Rate for Payer: ChoiceCare Network Commercial |
$168.17
|
| Rate for Payer: ChoiceCare Network Commercial |
$189.67
|
| Rate for Payer: ChoiceCare Network Commercial |
$174.97
|
| Rate for Payer: Cigna of WY Commercial |
$176.77
|
| Rate for Payer: Cigna of WY Commercial |
$191.63
|
| Rate for Payer: Cigna of WY Commercial |
$169.90
|
| Rate for Payer: Entrust Commercial |
$185.76
|
| Rate for Payer: Entrust Commercial |
$164.70
|
| Rate for Payer: Entrust Commercial |
$171.36
|
| Rate for Payer: First Choice Health Commercial |
$171.36
|
| Rate for Payer: First Choice Health Commercial |
$185.76
|
| Rate for Payer: First Choice Health Commercial |
$164.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$164.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$185.76
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$171.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$114.42
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$119.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$129.06
|
| Rate for Payer: HealthUtah PPO |
$173.37
|
| Rate for Payer: HealthUtah PPO |
$180.38
|
| Rate for Payer: HealthUtah PPO |
$195.54
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$189.67
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$174.97
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$168.17
|
| Rate for Payer: Multiplan Medicare/VA |
$122.60
|
| Rate for Payer: Multiplan Medicare/VA |
$108.70
|
| Rate for Payer: Multiplan Medicare/VA |
$113.10
|
| Rate for Payer: One Health Plan of WY PPO |
$169.90
|
| Rate for Payer: One Health Plan of WY PPO |
$176.77
|
| Rate for Payer: One Health Plan of WY PPO |
$191.63
|
| Rate for Payer: PacificSource Commercial |
$175.99
|
| Rate for Payer: PacificSource Commercial |
$156.03
|
| Rate for Payer: PacificSource Commercial |
$162.34
|
| Rate for Payer: PHCS PPO |
$176.77
|
| Rate for Payer: PHCS PPO |
$169.90
|
| Rate for Payer: PHCS PPO |
$191.63
|
| Rate for Payer: Three Rivers PPO |
$135.28
|
| Rate for Payer: Three Rivers PPO |
$130.03
|
| Rate for Payer: Three Rivers PPO |
$146.66
|
| Rate for Payer: TriWest Veterans Administration |
$119.05
|
| Rate for Payer: TriWest Veterans Administration |
$114.42
|
| Rate for Payer: TriWest Veterans Administration |
$129.06
|
| Rate for Payer: United Healthcare Commercial |
$150.83
|
| Rate for Payer: United Healthcare Commercial |
$170.12
|
| Rate for Payer: United Healthcare Commercial |
$156.93
|
| Rate for Payer: United Healthcare Medicare |
$114.42
|
| Rate for Payer: United Healthcare Medicare |
$129.06
|
| Rate for Payer: United Healthcare Medicare |
$119.05
|
| Rate for Payer: WINHealth Partners Commercial |
$171.36
|
| Rate for Payer: WINHealth Partners Commercial |
$164.70
|
| Rate for Payer: WINHealth Partners Commercial |
$185.76
|
| Rate for Payer: Wise Provider Network Commercial |
$185.76
|
| Rate for Payer: Wise Provider Network Commercial |
$164.70
|
| Rate for Payer: Wise Provider Network Commercial |
$171.36
|
|
|
LEVOTHYROXINE 100 MCG TABLET [9290]
|
Facility
|
IP
|
$6.62
|
|
|
Service Code
|
NDC 0074662490
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.15 |
| Max. Negotiated Rate |
$6.62 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$6.49
|
| Rate for Payer: Altius Auto/Workers Compensation |
$6.36
|
| Rate for Payer: Altius Commercial |
$6.36
|
| Rate for Payer: Beech Street Commercial |
$6.49
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$5.44
|
| Rate for Payer: Cash Price |
$4.64
|
| Rate for Payer: ChoiceCare Network Commercial |
$6.42
|
| Rate for Payer: Cigna of WY Commercial |
$6.49
|
| Rate for Payer: Entrust Commercial |
$6.29
|
| Rate for Payer: First Choice Health Commercial |
$6.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$6.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$4.37
|
| Rate for Payer: HealthUtah PPO |
$6.62
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$6.42
|
| Rate for Payer: Multiplan Medicare/VA |
$4.15
|
| Rate for Payer: One Health Plan of WY PPO |
$6.49
|
| Rate for Payer: PacificSource Commercial |
$5.96
|
| Rate for Payer: PHCS PPO |
$6.49
|
| Rate for Payer: Three Rivers PPO |
$4.96
|
| Rate for Payer: TriWest Veterans Administration |
$4.37
|
| Rate for Payer: United Healthcare Commercial |
$5.76
|
| Rate for Payer: United Healthcare Medicare |
$4.37
|
| Rate for Payer: WINHealth Partners Commercial |
$6.29
|
| Rate for Payer: Wise Provider Network Commercial |
$6.29
|
|
|
LEVOTHYROXINE 100 MCG TABLET [9290]
|
Facility
|
OP
|
$2.41
|
|
|
Service Code
|
NDC 6068749701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$2.41 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.36
|
| Rate for Payer: Aetna of WY Medicare |
$1.59
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.31
|
| Rate for Payer: Altius Commercial |
$2.31
|
| Rate for Payer: Beech Street Commercial |
$2.36
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.98
|
| Rate for Payer: Cash Price |
$1.69
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.34
|
| Rate for Payer: Cigna of WY Commercial |
$2.36
|
| Rate for Payer: Entrust Commercial |
$2.29
|
| Rate for Payer: First Choice Health Commercial |
$2.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.40
|
| Rate for Payer: HealthUtah PPO |
$2.41
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.34
|
| Rate for Payer: Multiplan Medicare/VA |
$1.33
|
| Rate for Payer: One Health Plan of WY PPO |
$2.36
|
| Rate for Payer: PacificSource Commercial |
$2.17
|
| Rate for Payer: PHCS PPO |
$2.36
|
| Rate for Payer: Three Rivers PPO |
$1.81
|
| Rate for Payer: TriWest Veterans Administration |
$1.40
|
| Rate for Payer: United Healthcare Commercial |
$2.10
|
| Rate for Payer: United Healthcare Medicare |
$1.40
|
| Rate for Payer: WINHealth Partners Commercial |
$2.36
|
| Rate for Payer: Wise Provider Network Commercial |
$2.29
|
|
|
LEVOTHYROXINE 100 MCG TABLET [9290]
|
Facility
|
OP
|
$6.62
|
|
|
Service Code
|
NDC 0074662490
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.65 |
| Max. Negotiated Rate |
$6.62 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$6.49
|
| Rate for Payer: Aetna of WY Medicare |
$4.37
|
| Rate for Payer: Altius Auto/Workers Compensation |
$6.36
|
| Rate for Payer: Altius Commercial |
$6.36
|
| Rate for Payer: Beech Street Commercial |
$6.49
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$5.44
|
| Rate for Payer: Cash Price |
$4.64
|
| Rate for Payer: ChoiceCare Network Commercial |
$6.42
|
| Rate for Payer: Cigna of WY Commercial |
$6.49
|
| Rate for Payer: Entrust Commercial |
$6.29
|
| Rate for Payer: First Choice Health Commercial |
$6.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$6.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3.84
|
| Rate for Payer: HealthUtah PPO |
$6.62
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$6.42
|
| Rate for Payer: Multiplan Medicare/VA |
$3.65
|
| Rate for Payer: One Health Plan of WY PPO |
$6.49
|
| Rate for Payer: PacificSource Commercial |
$5.96
|
| Rate for Payer: PHCS PPO |
$6.49
|
| Rate for Payer: Three Rivers PPO |
$4.96
|
| Rate for Payer: TriWest Veterans Administration |
$3.84
|
| Rate for Payer: United Healthcare Commercial |
$5.76
|
| Rate for Payer: United Healthcare Medicare |
$3.84
|
| Rate for Payer: WINHealth Partners Commercial |
$6.49
|
| Rate for Payer: Wise Provider Network Commercial |
$6.29
|
|
|
LEVOTHYROXINE 100 MCG TABLET [9290]
|
Facility
|
IP
|
$2.41
|
|
|
Service Code
|
NDC 6068749701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.51 |
| Max. Negotiated Rate |
$2.41 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.36
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.31
|
| Rate for Payer: Altius Commercial |
$2.31
|
| Rate for Payer: Beech Street Commercial |
$2.36
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.98
|
| Rate for Payer: Cash Price |
$1.69
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.34
|
| Rate for Payer: Cigna of WY Commercial |
$2.36
|
| Rate for Payer: Entrust Commercial |
$2.29
|
| Rate for Payer: First Choice Health Commercial |
$2.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.59
|
| Rate for Payer: HealthUtah PPO |
$2.41
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.34
|
| Rate for Payer: Multiplan Medicare/VA |
$1.51
|
| Rate for Payer: One Health Plan of WY PPO |
$2.36
|
| Rate for Payer: PacificSource Commercial |
$2.17
|
| Rate for Payer: PHCS PPO |
$2.36
|
| Rate for Payer: Three Rivers PPO |
$1.81
|
| Rate for Payer: TriWest Veterans Administration |
$1.59
|
| Rate for Payer: United Healthcare Commercial |
$2.10
|
| Rate for Payer: United Healthcare Medicare |
$1.59
|
| Rate for Payer: WINHealth Partners Commercial |
$2.29
|
| Rate for Payer: Wise Provider Network Commercial |
$2.29
|
|
|
LEVOTHYROXINE 100 MCG TABLET [9290]
|
Facility
|
IP
|
$2.41
|
|
|
Service Code
|
NDC 6068749711
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.51 |
| Max. Negotiated Rate |
$2.41 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.36
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.31
|
| Rate for Payer: Altius Commercial |
$2.31
|
| Rate for Payer: Beech Street Commercial |
$2.36
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.98
|
| Rate for Payer: Cash Price |
$1.69
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.34
|
| Rate for Payer: Cigna of WY Commercial |
$2.36
|
| Rate for Payer: Entrust Commercial |
$2.29
|
| Rate for Payer: First Choice Health Commercial |
$2.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.59
|
| Rate for Payer: HealthUtah PPO |
$2.41
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.34
|
| Rate for Payer: Multiplan Medicare/VA |
$1.51
|
| Rate for Payer: One Health Plan of WY PPO |
$2.36
|
| Rate for Payer: PacificSource Commercial |
$2.17
|
| Rate for Payer: PHCS PPO |
$2.36
|
| Rate for Payer: Three Rivers PPO |
$1.81
|
| Rate for Payer: TriWest Veterans Administration |
$1.59
|
| Rate for Payer: United Healthcare Commercial |
$2.10
|
| Rate for Payer: United Healthcare Medicare |
$1.59
|
| Rate for Payer: WINHealth Partners Commercial |
$2.29
|
| Rate for Payer: Wise Provider Network Commercial |
$2.29
|
|
|
LEVOTHYROXINE 100 MCG TABLET [9290]
|
Facility
|
OP
|
$2.41
|
|
|
Service Code
|
NDC 6068749711
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$2.41 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.36
|
| Rate for Payer: Aetna of WY Medicare |
$1.59
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.31
|
| Rate for Payer: Altius Commercial |
$2.31
|
| Rate for Payer: Beech Street Commercial |
$2.36
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.98
|
| Rate for Payer: Cash Price |
$1.69
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.34
|
| Rate for Payer: Cigna of WY Commercial |
$2.36
|
| Rate for Payer: Entrust Commercial |
$2.29
|
| Rate for Payer: First Choice Health Commercial |
$2.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.40
|
| Rate for Payer: HealthUtah PPO |
$2.41
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.34
|
| Rate for Payer: Multiplan Medicare/VA |
$1.33
|
| Rate for Payer: One Health Plan of WY PPO |
$2.36
|
| Rate for Payer: PacificSource Commercial |
$2.17
|
| Rate for Payer: PHCS PPO |
$2.36
|
| Rate for Payer: Three Rivers PPO |
$1.81
|
| Rate for Payer: TriWest Veterans Administration |
$1.40
|
| Rate for Payer: United Healthcare Commercial |
$2.10
|
| Rate for Payer: United Healthcare Medicare |
$1.40
|
| Rate for Payer: WINHealth Partners Commercial |
$2.36
|
| Rate for Payer: Wise Provider Network Commercial |
$2.29
|
|
|
LEVOTHYROXINE 125 MCG TABLET [12640]
|
Facility
|
IP
|
$2.84
|
|
|
Service Code
|
NDC 6068751901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.78 |
| Max. Negotiated Rate |
$2.84 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.78
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.73
|
| Rate for Payer: Altius Commercial |
$2.73
|
| Rate for Payer: Beech Street Commercial |
$2.78
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.33
|
| Rate for Payer: Cash Price |
$1.99
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.75
|
| Rate for Payer: Cigna of WY Commercial |
$2.78
|
| Rate for Payer: Entrust Commercial |
$2.70
|
| Rate for Payer: First Choice Health Commercial |
$2.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.87
|
| Rate for Payer: HealthUtah PPO |
$2.84
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.75
|
| Rate for Payer: Multiplan Medicare/VA |
$1.78
|
| Rate for Payer: One Health Plan of WY PPO |
$2.78
|
| Rate for Payer: PacificSource Commercial |
$2.56
|
| Rate for Payer: PHCS PPO |
$2.78
|
| Rate for Payer: Three Rivers PPO |
$2.13
|
| Rate for Payer: TriWest Veterans Administration |
$1.87
|
| Rate for Payer: United Healthcare Commercial |
$2.47
|
| Rate for Payer: United Healthcare Medicare |
$1.87
|
| Rate for Payer: WINHealth Partners Commercial |
$2.70
|
| Rate for Payer: Wise Provider Network Commercial |
$2.70
|
|
|
LEVOTHYROXINE 125 MCG TABLET [12640]
|
Facility
|
IP
|
$2.84
|
|
|
Service Code
|
NDC 6068751911
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.78 |
| Max. Negotiated Rate |
$2.84 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.78
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.73
|
| Rate for Payer: Altius Commercial |
$2.73
|
| Rate for Payer: Beech Street Commercial |
$2.78
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.33
|
| Rate for Payer: Cash Price |
$1.99
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.75
|
| Rate for Payer: Cigna of WY Commercial |
$2.78
|
| Rate for Payer: Entrust Commercial |
$2.70
|
| Rate for Payer: First Choice Health Commercial |
$2.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.87
|
| Rate for Payer: HealthUtah PPO |
$2.84
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.75
|
| Rate for Payer: Multiplan Medicare/VA |
$1.78
|
| Rate for Payer: One Health Plan of WY PPO |
$2.78
|
| Rate for Payer: PacificSource Commercial |
$2.56
|
| Rate for Payer: PHCS PPO |
$2.78
|
| Rate for Payer: Three Rivers PPO |
$2.13
|
| Rate for Payer: TriWest Veterans Administration |
$1.87
|
| Rate for Payer: United Healthcare Commercial |
$2.47
|
| Rate for Payer: United Healthcare Medicare |
$1.87
|
| Rate for Payer: WINHealth Partners Commercial |
$2.70
|
| Rate for Payer: Wise Provider Network Commercial |
$2.70
|
|
|
LEVOTHYROXINE 125 MCG TABLET [12640]
|
Facility
|
OP
|
$2.84
|
|
|
Service Code
|
NDC 6068751901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.56 |
| Max. Negotiated Rate |
$2.84 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.78
|
| Rate for Payer: Aetna of WY Medicare |
$1.87
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.73
|
| Rate for Payer: Altius Commercial |
$2.73
|
| Rate for Payer: Beech Street Commercial |
$2.78
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.33
|
| Rate for Payer: Cash Price |
$1.99
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.75
|
| Rate for Payer: Cigna of WY Commercial |
$2.78
|
| Rate for Payer: Entrust Commercial |
$2.70
|
| Rate for Payer: First Choice Health Commercial |
$2.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.65
|
| Rate for Payer: HealthUtah PPO |
$2.84
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.75
|
| Rate for Payer: Multiplan Medicare/VA |
$1.56
|
| Rate for Payer: One Health Plan of WY PPO |
$2.78
|
| Rate for Payer: PacificSource Commercial |
$2.56
|
| Rate for Payer: PHCS PPO |
$2.78
|
| Rate for Payer: Three Rivers PPO |
$2.13
|
| Rate for Payer: TriWest Veterans Administration |
$1.65
|
| Rate for Payer: United Healthcare Commercial |
$2.47
|
| Rate for Payer: United Healthcare Medicare |
$1.65
|
| Rate for Payer: WINHealth Partners Commercial |
$2.78
|
| Rate for Payer: Wise Provider Network Commercial |
$2.70
|
|
|
LEVOTHYROXINE 125 MCG TABLET [12640]
|
Facility
|
OP
|
$2.84
|
|
|
Service Code
|
NDC 6068751911
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.56 |
| Max. Negotiated Rate |
$2.84 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.78
|
| Rate for Payer: Aetna of WY Medicare |
$1.87
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.73
|
| Rate for Payer: Altius Commercial |
$2.73
|
| Rate for Payer: Beech Street Commercial |
$2.78
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.33
|
| Rate for Payer: Cash Price |
$1.99
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.75
|
| Rate for Payer: Cigna of WY Commercial |
$2.78
|
| Rate for Payer: Entrust Commercial |
$2.70
|
| Rate for Payer: First Choice Health Commercial |
$2.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.65
|
| Rate for Payer: HealthUtah PPO |
$2.84
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.75
|
| Rate for Payer: Multiplan Medicare/VA |
$1.56
|
| Rate for Payer: One Health Plan of WY PPO |
$2.78
|
| Rate for Payer: PacificSource Commercial |
$2.56
|
| Rate for Payer: PHCS PPO |
$2.78
|
| Rate for Payer: Three Rivers PPO |
$2.13
|
| Rate for Payer: TriWest Veterans Administration |
$1.65
|
| Rate for Payer: United Healthcare Commercial |
$2.47
|
| Rate for Payer: United Healthcare Medicare |
$1.65
|
| Rate for Payer: WINHealth Partners Commercial |
$2.78
|
| Rate for Payer: Wise Provider Network Commercial |
$2.70
|
|
|
LEVOTHYROXINE 25 MCG TABLET [8451]
|
Facility
|
IP
|
$1.75
|
|
|
Service Code
|
NDC 5107944401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.10 |
| Max. Negotiated Rate |
$1.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.72
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.68
|
| Rate for Payer: Altius Commercial |
$1.68
|
| Rate for Payer: Beech Street Commercial |
$1.72
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.44
|
| Rate for Payer: Cash Price |
$1.23
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.70
|
| Rate for Payer: Cigna of WY Commercial |
$1.72
|
| Rate for Payer: Entrust Commercial |
$1.66
|
| Rate for Payer: First Choice Health Commercial |
$1.66
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.66
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.16
|
| Rate for Payer: HealthUtah PPO |
$1.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.70
|
| Rate for Payer: Multiplan Medicare/VA |
$1.10
|
| Rate for Payer: One Health Plan of WY PPO |
$1.72
|
| Rate for Payer: PacificSource Commercial |
$1.58
|
| Rate for Payer: PHCS PPO |
$1.72
|
| Rate for Payer: Three Rivers PPO |
$1.31
|
| Rate for Payer: TriWest Veterans Administration |
$1.16
|
| Rate for Payer: United Healthcare Commercial |
$1.52
|
| Rate for Payer: United Healthcare Medicare |
$1.16
|
| Rate for Payer: WINHealth Partners Commercial |
$1.66
|
| Rate for Payer: Wise Provider Network Commercial |
$1.66
|
|
|
LEVOTHYROXINE 25 MCG TABLET [8451]
|
Facility
|
OP
|
$1.86
|
|
|
Service Code
|
NDC 6068745311
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$1.86 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.82
|
| Rate for Payer: Aetna of WY Medicare |
$1.23
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.79
|
| Rate for Payer: Altius Commercial |
$1.79
|
| Rate for Payer: Beech Street Commercial |
$1.82
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.53
|
| Rate for Payer: Cash Price |
$1.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.80
|
| Rate for Payer: Cigna of WY Commercial |
$1.82
|
| Rate for Payer: Entrust Commercial |
$1.77
|
| Rate for Payer: First Choice Health Commercial |
$1.77
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.77
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.08
|
| Rate for Payer: HealthUtah PPO |
$1.86
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.80
|
| Rate for Payer: Multiplan Medicare/VA |
$1.02
|
| Rate for Payer: One Health Plan of WY PPO |
$1.82
|
| Rate for Payer: PacificSource Commercial |
$1.67
|
| Rate for Payer: PHCS PPO |
$1.82
|
| Rate for Payer: Three Rivers PPO |
$1.40
|
| Rate for Payer: TriWest Veterans Administration |
$1.08
|
| Rate for Payer: United Healthcare Commercial |
$1.62
|
| Rate for Payer: United Healthcare Medicare |
$1.08
|
| Rate for Payer: WINHealth Partners Commercial |
$1.82
|
| Rate for Payer: Wise Provider Network Commercial |
$1.77
|
|
|
LEVOTHYROXINE 25 MCG TABLET [8451]
|
Facility
|
OP
|
$1.86
|
|
|
Service Code
|
NDC 6068745301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$1.86 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.82
|
| Rate for Payer: Aetna of WY Medicare |
$1.23
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.79
|
| Rate for Payer: Altius Commercial |
$1.79
|
| Rate for Payer: Beech Street Commercial |
$1.82
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.53
|
| Rate for Payer: Cash Price |
$1.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.80
|
| Rate for Payer: Cigna of WY Commercial |
$1.82
|
| Rate for Payer: Entrust Commercial |
$1.77
|
| Rate for Payer: First Choice Health Commercial |
$1.77
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.77
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.08
|
| Rate for Payer: HealthUtah PPO |
$1.86
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.80
|
| Rate for Payer: Multiplan Medicare/VA |
$1.02
|
| Rate for Payer: One Health Plan of WY PPO |
$1.82
|
| Rate for Payer: PacificSource Commercial |
$1.67
|
| Rate for Payer: PHCS PPO |
$1.82
|
| Rate for Payer: Three Rivers PPO |
$1.40
|
| Rate for Payer: TriWest Veterans Administration |
$1.08
|
| Rate for Payer: United Healthcare Commercial |
$1.62
|
| Rate for Payer: United Healthcare Medicare |
$1.08
|
| Rate for Payer: WINHealth Partners Commercial |
$1.82
|
| Rate for Payer: Wise Provider Network Commercial |
$1.77
|
|
|
LEVOTHYROXINE 25 MCG TABLET [8451]
|
Facility
|
IP
|
$1.86
|
|
|
Service Code
|
NDC 6068745301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.17 |
| Max. Negotiated Rate |
$1.86 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.82
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.79
|
| Rate for Payer: Altius Commercial |
$1.79
|
| Rate for Payer: Beech Street Commercial |
$1.82
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.53
|
| Rate for Payer: Cash Price |
$1.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.80
|
| Rate for Payer: Cigna of WY Commercial |
$1.82
|
| Rate for Payer: Entrust Commercial |
$1.77
|
| Rate for Payer: First Choice Health Commercial |
$1.77
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.77
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.23
|
| Rate for Payer: HealthUtah PPO |
$1.86
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.80
|
| Rate for Payer: Multiplan Medicare/VA |
$1.17
|
| Rate for Payer: One Health Plan of WY PPO |
$1.82
|
| Rate for Payer: PacificSource Commercial |
$1.67
|
| Rate for Payer: PHCS PPO |
$1.82
|
| Rate for Payer: Three Rivers PPO |
$1.40
|
| Rate for Payer: TriWest Veterans Administration |
$1.23
|
| Rate for Payer: United Healthcare Commercial |
$1.62
|
| Rate for Payer: United Healthcare Medicare |
$1.23
|
| Rate for Payer: WINHealth Partners Commercial |
$1.77
|
| Rate for Payer: Wise Provider Network Commercial |
$1.77
|
|
|
LEVOTHYROXINE 25 MCG TABLET [8451]
|
Facility
|
OP
|
$1.75
|
|
|
Service Code
|
NDC 5107944420
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$1.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.72
|
| Rate for Payer: Aetna of WY Medicare |
$1.16
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.68
|
| Rate for Payer: Altius Commercial |
$1.68
|
| Rate for Payer: Beech Street Commercial |
$1.72
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.44
|
| Rate for Payer: Cash Price |
$1.23
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.70
|
| Rate for Payer: Cigna of WY Commercial |
$1.72
|
| Rate for Payer: Entrust Commercial |
$1.66
|
| Rate for Payer: First Choice Health Commercial |
$1.66
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.66
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.02
|
| Rate for Payer: HealthUtah PPO |
$1.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.70
|
| Rate for Payer: Multiplan Medicare/VA |
$0.96
|
| Rate for Payer: One Health Plan of WY PPO |
$1.72
|
| Rate for Payer: PacificSource Commercial |
$1.58
|
| Rate for Payer: PHCS PPO |
$1.72
|
| Rate for Payer: Three Rivers PPO |
$1.31
|
| Rate for Payer: TriWest Veterans Administration |
$1.02
|
| Rate for Payer: United Healthcare Commercial |
$1.52
|
| Rate for Payer: United Healthcare Medicare |
$1.02
|
| Rate for Payer: WINHealth Partners Commercial |
$1.72
|
| Rate for Payer: Wise Provider Network Commercial |
$1.66
|
|
|
LEVOTHYROXINE 25 MCG TABLET [8451]
|
Facility
|
IP
|
$1.75
|
|
|
Service Code
|
NDC 5107944420
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.10 |
| Max. Negotiated Rate |
$1.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.72
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.68
|
| Rate for Payer: Altius Commercial |
$1.68
|
| Rate for Payer: Beech Street Commercial |
$1.72
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.44
|
| Rate for Payer: Cash Price |
$1.23
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.70
|
| Rate for Payer: Cigna of WY Commercial |
$1.72
|
| Rate for Payer: Entrust Commercial |
$1.66
|
| Rate for Payer: First Choice Health Commercial |
$1.66
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.66
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.16
|
| Rate for Payer: HealthUtah PPO |
$1.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.70
|
| Rate for Payer: Multiplan Medicare/VA |
$1.10
|
| Rate for Payer: One Health Plan of WY PPO |
$1.72
|
| Rate for Payer: PacificSource Commercial |
$1.58
|
| Rate for Payer: PHCS PPO |
$1.72
|
| Rate for Payer: Three Rivers PPO |
$1.31
|
| Rate for Payer: TriWest Veterans Administration |
$1.16
|
| Rate for Payer: United Healthcare Commercial |
$1.52
|
| Rate for Payer: United Healthcare Medicare |
$1.16
|
| Rate for Payer: WINHealth Partners Commercial |
$1.66
|
| Rate for Payer: Wise Provider Network Commercial |
$1.66
|
|
|
LEVOTHYROXINE 25 MCG TABLET [8451]
|
Facility
|
OP
|
$1.75
|
|
|
Service Code
|
NDC 5107944401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$1.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.72
|
| Rate for Payer: Aetna of WY Medicare |
$1.16
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.68
|
| Rate for Payer: Altius Commercial |
$1.68
|
| Rate for Payer: Beech Street Commercial |
$1.72
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.44
|
| Rate for Payer: Cash Price |
$1.23
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.70
|
| Rate for Payer: Cigna of WY Commercial |
$1.72
|
| Rate for Payer: Entrust Commercial |
$1.66
|
| Rate for Payer: First Choice Health Commercial |
$1.66
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.66
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.02
|
| Rate for Payer: HealthUtah PPO |
$1.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.70
|
| Rate for Payer: Multiplan Medicare/VA |
$0.96
|
| Rate for Payer: One Health Plan of WY PPO |
$1.72
|
| Rate for Payer: PacificSource Commercial |
$1.58
|
| Rate for Payer: PHCS PPO |
$1.72
|
| Rate for Payer: Three Rivers PPO |
$1.31
|
| Rate for Payer: TriWest Veterans Administration |
$1.02
|
| Rate for Payer: United Healthcare Commercial |
$1.52
|
| Rate for Payer: United Healthcare Medicare |
$1.02
|
| Rate for Payer: WINHealth Partners Commercial |
$1.72
|
| Rate for Payer: Wise Provider Network Commercial |
$1.66
|
|
|
LEVOTHYROXINE 25 MCG TABLET [8451]
|
Facility
|
IP
|
$1.86
|
|
|
Service Code
|
NDC 6068745311
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.17 |
| Max. Negotiated Rate |
$1.86 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.82
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.79
|
| Rate for Payer: Altius Commercial |
$1.79
|
| Rate for Payer: Beech Street Commercial |
$1.82
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.53
|
| Rate for Payer: Cash Price |
$1.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.80
|
| Rate for Payer: Cigna of WY Commercial |
$1.82
|
| Rate for Payer: Entrust Commercial |
$1.77
|
| Rate for Payer: First Choice Health Commercial |
$1.77
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.77
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.23
|
| Rate for Payer: HealthUtah PPO |
$1.86
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.80
|
| Rate for Payer: Multiplan Medicare/VA |
$1.17
|
| Rate for Payer: One Health Plan of WY PPO |
$1.82
|
| Rate for Payer: PacificSource Commercial |
$1.67
|
| Rate for Payer: PHCS PPO |
$1.82
|
| Rate for Payer: Three Rivers PPO |
$1.40
|
| Rate for Payer: TriWest Veterans Administration |
$1.23
|
| Rate for Payer: United Healthcare Commercial |
$1.62
|
| Rate for Payer: United Healthcare Medicare |
$1.23
|
| Rate for Payer: WINHealth Partners Commercial |
$1.77
|
| Rate for Payer: Wise Provider Network Commercial |
$1.77
|
|
|
LEVOTHYROXINE 50 MCG TABLET [12043]
|
Facility
|
IP
|
$1.88
|
|
|
Service Code
|
NDC 6068746401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.18 |
| Max. Negotiated Rate |
$1.88 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.84
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.80
|
| Rate for Payer: Altius Commercial |
$1.80
|
| Rate for Payer: Beech Street Commercial |
$1.84
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.54
|
| Rate for Payer: Cash Price |
$1.32
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.82
|
| Rate for Payer: Cigna of WY Commercial |
$1.84
|
| Rate for Payer: Entrust Commercial |
$1.79
|
| Rate for Payer: First Choice Health Commercial |
$1.79
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.79
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.24
|
| Rate for Payer: HealthUtah PPO |
$1.88
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.82
|
| Rate for Payer: Multiplan Medicare/VA |
$1.18
|
| Rate for Payer: One Health Plan of WY PPO |
$1.84
|
| Rate for Payer: PacificSource Commercial |
$1.69
|
| Rate for Payer: PHCS PPO |
$1.84
|
| Rate for Payer: Three Rivers PPO |
$1.41
|
| Rate for Payer: TriWest Veterans Administration |
$1.24
|
| Rate for Payer: United Healthcare Commercial |
$1.64
|
| Rate for Payer: United Healthcare Medicare |
$1.24
|
| Rate for Payer: WINHealth Partners Commercial |
$1.79
|
| Rate for Payer: Wise Provider Network Commercial |
$1.79
|
|
