|
LIOTHYRONINE 5 MCG TABLET [7694]
|
Facility
|
OP
|
$2.72
|
|
|
Service Code
|
NDC 4279401812
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.72 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.67
|
| Rate for Payer: Aetna of WY Medicare |
$1.80
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.61
|
| Rate for Payer: Altius Commercial |
$2.61
|
| Rate for Payer: Beech Street Commercial |
$2.67
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.23
|
| Rate for Payer: Cash Price |
$1.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.64
|
| Rate for Payer: Cigna of WY Commercial |
$2.67
|
| Rate for Payer: Entrust Commercial |
$2.58
|
| Rate for Payer: First Choice Health Commercial |
$2.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.58
|
| Rate for Payer: HealthUtah PPO |
$2.72
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.64
|
| Rate for Payer: Multiplan Medicare/VA |
$1.50
|
| Rate for Payer: One Health Plan of WY PPO |
$2.67
|
| Rate for Payer: PacificSource Commercial |
$2.45
|
| Rate for Payer: PHCS PPO |
$2.67
|
| Rate for Payer: Three Rivers PPO |
$2.04
|
| Rate for Payer: TriWest Veterans Administration |
$1.58
|
| Rate for Payer: United Healthcare Commercial |
$2.37
|
| Rate for Payer: United Healthcare Medicare |
$1.58
|
| Rate for Payer: WINHealth Partners Commercial |
$2.67
|
| Rate for Payer: Wise Provider Network Commercial |
$2.58
|
|
|
LIPID PANEL
|
Professional
|
Both
|
$99.00
|
|
|
Service Code
|
HCPCS 80061
|
| Hospital Charge Code |
80061
|
| Min. Negotiated Rate |
$11.38 |
| Max. Negotiated Rate |
$99.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$97.02
|
| Rate for Payer: Aetna of WY Medicare |
$13.39
|
| Rate for Payer: Beech Street Commercial |
$94.05
|
| Rate for Payer: Cash Price |
$69.30
|
| Rate for Payer: Cash Price |
$69.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$96.03
|
| Rate for Payer: Cigna of WY Commercial |
$97.02
|
| Rate for Payer: First Choice Health Commercial |
$89.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$94.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$13.39
|
| Rate for Payer: HealthUtah PPO |
$99.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$96.03
|
| Rate for Payer: Multiplan Medicare/VA |
$11.38
|
| Rate for Payer: One Health Plan of WY PPO |
$97.02
|
| Rate for Payer: PacificSource Commercial |
$89.10
|
| Rate for Payer: PHCS PPO |
$94.05
|
| Rate for Payer: Three Rivers PPO |
$74.25
|
| Rate for Payer: TriWest Veterans Administration |
$13.39
|
| Rate for Payer: United Healthcare Commercial |
$86.13
|
| Rate for Payer: United Healthcare Medicare |
$13.39
|
| Rate for Payer: WINHealth Partners Commercial |
$94.05
|
|
|
LISINOPRIL 10 MG TABLET [13088]
|
Facility
|
IP
|
$0.26
|
|
|
Service Code
|
NDC 0904679861
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.25
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.25
|
| Rate for Payer: Altius Commercial |
$0.25
|
| Rate for Payer: Beech Street Commercial |
$0.25
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.21
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.25
|
| Rate for Payer: Cigna of WY Commercial |
$0.25
|
| Rate for Payer: Entrust Commercial |
$0.25
|
| Rate for Payer: First Choice Health Commercial |
$0.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.17
|
| Rate for Payer: HealthUtah PPO |
$0.26
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.25
|
| Rate for Payer: Multiplan Medicare/VA |
$0.16
|
| Rate for Payer: One Health Plan of WY PPO |
$0.25
|
| Rate for Payer: PacificSource Commercial |
$0.23
|
| Rate for Payer: PHCS PPO |
$0.25
|
| Rate for Payer: Three Rivers PPO |
$0.20
|
| Rate for Payer: TriWest Veterans Administration |
$0.17
|
| Rate for Payer: United Healthcare Commercial |
$0.23
|
| Rate for Payer: United Healthcare Medicare |
$0.17
|
| Rate for Payer: WINHealth Partners Commercial |
$0.25
|
| Rate for Payer: Wise Provider Network Commercial |
$0.25
|
|
|
LISINOPRIL 10 MG TABLET [13088]
|
Facility
|
OP
|
$0.26
|
|
|
Service Code
|
NDC 0904679861
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.25
|
| Rate for Payer: Aetna of WY Medicare |
$0.17
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.25
|
| Rate for Payer: Altius Commercial |
$0.25
|
| Rate for Payer: Beech Street Commercial |
$0.25
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.21
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.25
|
| Rate for Payer: Cigna of WY Commercial |
$0.25
|
| Rate for Payer: Entrust Commercial |
$0.25
|
| Rate for Payer: First Choice Health Commercial |
$0.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.15
|
| Rate for Payer: HealthUtah PPO |
$0.26
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.25
|
| Rate for Payer: Multiplan Medicare/VA |
$0.14
|
| Rate for Payer: One Health Plan of WY PPO |
$0.25
|
| Rate for Payer: PacificSource Commercial |
$0.23
|
| Rate for Payer: PHCS PPO |
$0.25
|
| Rate for Payer: Three Rivers PPO |
$0.20
|
| Rate for Payer: TriWest Veterans Administration |
$0.15
|
| Rate for Payer: United Healthcare Commercial |
$0.23
|
| Rate for Payer: United Healthcare Medicare |
$0.15
|
| Rate for Payer: WINHealth Partners Commercial |
$0.25
|
| Rate for Payer: Wise Provider Network Commercial |
$0.25
|
|
|
LISINOPRIL 20 MG TABLET [4659]
|
Facility
|
OP
|
$0.27
|
|
|
Service Code
|
NDC 0904679961
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.26
|
| Rate for Payer: Aetna of WY Medicare |
$0.18
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.26
|
| Rate for Payer: Altius Commercial |
$0.26
|
| Rate for Payer: Beech Street Commercial |
$0.26
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.22
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.26
|
| Rate for Payer: Cigna of WY Commercial |
$0.26
|
| Rate for Payer: Entrust Commercial |
$0.26
|
| Rate for Payer: First Choice Health Commercial |
$0.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.16
|
| Rate for Payer: HealthUtah PPO |
$0.27
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.26
|
| Rate for Payer: Multiplan Medicare/VA |
$0.15
|
| Rate for Payer: One Health Plan of WY PPO |
$0.26
|
| Rate for Payer: PacificSource Commercial |
$0.24
|
| Rate for Payer: PHCS PPO |
$0.26
|
| Rate for Payer: Three Rivers PPO |
$0.20
|
| Rate for Payer: TriWest Veterans Administration |
$0.16
|
| Rate for Payer: United Healthcare Commercial |
$0.23
|
| Rate for Payer: United Healthcare Medicare |
$0.16
|
| Rate for Payer: WINHealth Partners Commercial |
$0.26
|
| Rate for Payer: Wise Provider Network Commercial |
$0.26
|
|
|
LISINOPRIL 20 MG TABLET [4659]
|
Facility
|
IP
|
$0.27
|
|
|
Service Code
|
NDC 0904679961
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.26
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.26
|
| Rate for Payer: Altius Commercial |
$0.26
|
| Rate for Payer: Beech Street Commercial |
$0.26
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.22
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.26
|
| Rate for Payer: Cigna of WY Commercial |
$0.26
|
| Rate for Payer: Entrust Commercial |
$0.26
|
| Rate for Payer: First Choice Health Commercial |
$0.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.18
|
| Rate for Payer: HealthUtah PPO |
$0.27
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.26
|
| Rate for Payer: Multiplan Medicare/VA |
$0.17
|
| Rate for Payer: One Health Plan of WY PPO |
$0.26
|
| Rate for Payer: PacificSource Commercial |
$0.24
|
| Rate for Payer: PHCS PPO |
$0.26
|
| Rate for Payer: Three Rivers PPO |
$0.20
|
| Rate for Payer: TriWest Veterans Administration |
$0.18
|
| Rate for Payer: United Healthcare Commercial |
$0.23
|
| Rate for Payer: United Healthcare Medicare |
$0.18
|
| Rate for Payer: WINHealth Partners Commercial |
$0.26
|
| Rate for Payer: Wise Provider Network Commercial |
$0.26
|
|
|
LISINOPRIL 2.5 MG TABLET [19095]
|
Facility
|
OP
|
$2.21
|
|
|
Service Code
|
NDC 6068765621
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.22 |
| Max. Negotiated Rate |
$2.21 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.17
|
| Rate for Payer: Aetna of WY Medicare |
$1.46
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.12
|
| Rate for Payer: Altius Commercial |
$2.12
|
| Rate for Payer: Beech Street Commercial |
$2.17
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.81
|
| Rate for Payer: Cash Price |
$1.55
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.14
|
| Rate for Payer: Cigna of WY Commercial |
$2.17
|
| Rate for Payer: Entrust Commercial |
$2.10
|
| Rate for Payer: First Choice Health Commercial |
$2.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.28
|
| Rate for Payer: HealthUtah PPO |
$2.21
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.14
|
| Rate for Payer: Multiplan Medicare/VA |
$1.22
|
| Rate for Payer: One Health Plan of WY PPO |
$2.17
|
| Rate for Payer: PacificSource Commercial |
$1.99
|
| Rate for Payer: PHCS PPO |
$2.17
|
| Rate for Payer: Three Rivers PPO |
$1.66
|
| Rate for Payer: TriWest Veterans Administration |
$1.28
|
| Rate for Payer: United Healthcare Commercial |
$1.92
|
| Rate for Payer: United Healthcare Medicare |
$1.28
|
| Rate for Payer: WINHealth Partners Commercial |
$2.17
|
| Rate for Payer: Wise Provider Network Commercial |
$2.10
|
|
|
LISINOPRIL 2.5 MG TABLET [19095]
|
Facility
|
IP
|
$2.21
|
|
|
Service Code
|
NDC 6068765621
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.39 |
| Max. Negotiated Rate |
$2.21 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.17
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.12
|
| Rate for Payer: Altius Commercial |
$2.12
|
| Rate for Payer: Beech Street Commercial |
$2.17
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.81
|
| Rate for Payer: Cash Price |
$1.55
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.14
|
| Rate for Payer: Cigna of WY Commercial |
$2.17
|
| Rate for Payer: Entrust Commercial |
$2.10
|
| Rate for Payer: First Choice Health Commercial |
$2.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.46
|
| Rate for Payer: HealthUtah PPO |
$2.21
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.14
|
| Rate for Payer: Multiplan Medicare/VA |
$1.39
|
| Rate for Payer: One Health Plan of WY PPO |
$2.17
|
| Rate for Payer: PacificSource Commercial |
$1.99
|
| Rate for Payer: PHCS PPO |
$2.17
|
| Rate for Payer: Three Rivers PPO |
$1.66
|
| Rate for Payer: TriWest Veterans Administration |
$1.46
|
| Rate for Payer: United Healthcare Commercial |
$1.92
|
| Rate for Payer: United Healthcare Medicare |
$1.46
|
| Rate for Payer: WINHealth Partners Commercial |
$2.10
|
| Rate for Payer: Wise Provider Network Commercial |
$2.10
|
|
|
LISINOPRIL 2.5 MG TABLET [19095]
|
Facility
|
IP
|
$2.21
|
|
|
Service Code
|
NDC 6068765611
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.39 |
| Max. Negotiated Rate |
$2.21 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.17
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.12
|
| Rate for Payer: Altius Commercial |
$2.12
|
| Rate for Payer: Beech Street Commercial |
$2.17
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.81
|
| Rate for Payer: Cash Price |
$1.55
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.14
|
| Rate for Payer: Cigna of WY Commercial |
$2.17
|
| Rate for Payer: Entrust Commercial |
$2.10
|
| Rate for Payer: First Choice Health Commercial |
$2.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.46
|
| Rate for Payer: HealthUtah PPO |
$2.21
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.14
|
| Rate for Payer: Multiplan Medicare/VA |
$1.39
|
| Rate for Payer: One Health Plan of WY PPO |
$2.17
|
| Rate for Payer: PacificSource Commercial |
$1.99
|
| Rate for Payer: PHCS PPO |
$2.17
|
| Rate for Payer: Three Rivers PPO |
$1.66
|
| Rate for Payer: TriWest Veterans Administration |
$1.46
|
| Rate for Payer: United Healthcare Commercial |
$1.92
|
| Rate for Payer: United Healthcare Medicare |
$1.46
|
| Rate for Payer: WINHealth Partners Commercial |
$2.10
|
| Rate for Payer: Wise Provider Network Commercial |
$2.10
|
|
|
LISINOPRIL 2.5 MG TABLET [19095]
|
Facility
|
OP
|
$2.21
|
|
|
Service Code
|
NDC 6068765611
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.22 |
| Max. Negotiated Rate |
$2.21 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.17
|
| Rate for Payer: Aetna of WY Medicare |
$1.46
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.12
|
| Rate for Payer: Altius Commercial |
$2.12
|
| Rate for Payer: Beech Street Commercial |
$2.17
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.81
|
| Rate for Payer: Cash Price |
$1.55
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.14
|
| Rate for Payer: Cigna of WY Commercial |
$2.17
|
| Rate for Payer: Entrust Commercial |
$2.10
|
| Rate for Payer: First Choice Health Commercial |
$2.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.28
|
| Rate for Payer: HealthUtah PPO |
$2.21
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.14
|
| Rate for Payer: Multiplan Medicare/VA |
$1.22
|
| Rate for Payer: One Health Plan of WY PPO |
$2.17
|
| Rate for Payer: PacificSource Commercial |
$1.99
|
| Rate for Payer: PHCS PPO |
$2.17
|
| Rate for Payer: Three Rivers PPO |
$1.66
|
| Rate for Payer: TriWest Veterans Administration |
$1.28
|
| Rate for Payer: United Healthcare Commercial |
$1.92
|
| Rate for Payer: United Healthcare Medicare |
$1.28
|
| Rate for Payer: WINHealth Partners Commercial |
$2.17
|
| Rate for Payer: Wise Provider Network Commercial |
$2.10
|
|
|
LISINOPRIL 40 MG TABLET [18629]
|
Facility
|
IP
|
$0.56
|
|
|
Service Code
|
NDC 0904720061
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.55
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.54
|
| Rate for Payer: Altius Commercial |
$0.54
|
| Rate for Payer: Beech Street Commercial |
$0.55
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.46
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.54
|
| Rate for Payer: Cigna of WY Commercial |
$0.55
|
| Rate for Payer: Entrust Commercial |
$0.53
|
| Rate for Payer: First Choice Health Commercial |
$0.53
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.53
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.37
|
| Rate for Payer: HealthUtah PPO |
$0.56
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.54
|
| Rate for Payer: Multiplan Medicare/VA |
$0.35
|
| Rate for Payer: One Health Plan of WY PPO |
$0.55
|
| Rate for Payer: PacificSource Commercial |
$0.50
|
| Rate for Payer: PHCS PPO |
$0.55
|
| Rate for Payer: Three Rivers PPO |
$0.42
|
| Rate for Payer: TriWest Veterans Administration |
$0.37
|
| Rate for Payer: United Healthcare Commercial |
$0.49
|
| Rate for Payer: United Healthcare Medicare |
$0.37
|
| Rate for Payer: WINHealth Partners Commercial |
$0.53
|
| Rate for Payer: Wise Provider Network Commercial |
$0.53
|
|
|
LISINOPRIL 40 MG TABLET [18629]
|
Facility
|
OP
|
$0.56
|
|
|
Service Code
|
NDC 0904720061
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.56 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.55
|
| Rate for Payer: Aetna of WY Medicare |
$0.37
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.54
|
| Rate for Payer: Altius Commercial |
$0.54
|
| Rate for Payer: Beech Street Commercial |
$0.55
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.46
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.54
|
| Rate for Payer: Cigna of WY Commercial |
$0.55
|
| Rate for Payer: Entrust Commercial |
$0.53
|
| Rate for Payer: First Choice Health Commercial |
$0.53
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.53
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.32
|
| Rate for Payer: HealthUtah PPO |
$0.56
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.54
|
| Rate for Payer: Multiplan Medicare/VA |
$0.31
|
| Rate for Payer: One Health Plan of WY PPO |
$0.55
|
| Rate for Payer: PacificSource Commercial |
$0.50
|
| Rate for Payer: PHCS PPO |
$0.55
|
| Rate for Payer: Three Rivers PPO |
$0.42
|
| Rate for Payer: TriWest Veterans Administration |
$0.32
|
| Rate for Payer: United Healthcare Commercial |
$0.49
|
| Rate for Payer: United Healthcare Medicare |
$0.32
|
| Rate for Payer: WINHealth Partners Commercial |
$0.55
|
| Rate for Payer: Wise Provider Network Commercial |
$0.53
|
|
|
LISINOPRIL 5 MG TABLET [16436]
|
Facility
|
OP
|
$0.68
|
|
|
Service Code
|
NDC 6808419611
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$0.68 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.67
|
| Rate for Payer: Aetna of WY Medicare |
$0.45
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.65
|
| Rate for Payer: Altius Commercial |
$0.65
|
| Rate for Payer: Beech Street Commercial |
$0.67
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.56
|
| Rate for Payer: Cash Price |
$0.48
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.66
|
| Rate for Payer: Cigna of WY Commercial |
$0.67
|
| Rate for Payer: Entrust Commercial |
$0.65
|
| Rate for Payer: First Choice Health Commercial |
$0.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.39
|
| Rate for Payer: HealthUtah PPO |
$0.68
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.66
|
| Rate for Payer: Multiplan Medicare/VA |
$0.37
|
| Rate for Payer: One Health Plan of WY PPO |
$0.67
|
| Rate for Payer: PacificSource Commercial |
$0.61
|
| Rate for Payer: PHCS PPO |
$0.67
|
| Rate for Payer: Three Rivers PPO |
$0.51
|
| Rate for Payer: TriWest Veterans Administration |
$0.39
|
| Rate for Payer: United Healthcare Commercial |
$0.59
|
| Rate for Payer: United Healthcare Medicare |
$0.39
|
| Rate for Payer: WINHealth Partners Commercial |
$0.67
|
| Rate for Payer: Wise Provider Network Commercial |
$0.65
|
|
|
LISINOPRIL 5 MG TABLET [16436]
|
Facility
|
IP
|
$0.68
|
|
|
Service Code
|
NDC 6808419611
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$0.68 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.67
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.65
|
| Rate for Payer: Altius Commercial |
$0.65
|
| Rate for Payer: Beech Street Commercial |
$0.67
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.56
|
| Rate for Payer: Cash Price |
$0.48
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.66
|
| Rate for Payer: Cigna of WY Commercial |
$0.67
|
| Rate for Payer: Entrust Commercial |
$0.65
|
| Rate for Payer: First Choice Health Commercial |
$0.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.45
|
| Rate for Payer: HealthUtah PPO |
$0.68
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.66
|
| Rate for Payer: Multiplan Medicare/VA |
$0.43
|
| Rate for Payer: One Health Plan of WY PPO |
$0.67
|
| Rate for Payer: PacificSource Commercial |
$0.61
|
| Rate for Payer: PHCS PPO |
$0.67
|
| Rate for Payer: Three Rivers PPO |
$0.51
|
| Rate for Payer: TriWest Veterans Administration |
$0.45
|
| Rate for Payer: United Healthcare Commercial |
$0.59
|
| Rate for Payer: United Healthcare Medicare |
$0.45
|
| Rate for Payer: WINHealth Partners Commercial |
$0.65
|
| Rate for Payer: Wise Provider Network Commercial |
$0.65
|
|
|
LISINOPRIL 5 MG TABLET [16436]
|
Facility
|
OP
|
$0.26
|
|
|
Service Code
|
NDC 0904679761
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.25
|
| Rate for Payer: Aetna of WY Medicare |
$0.17
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.25
|
| Rate for Payer: Altius Commercial |
$0.25
|
| Rate for Payer: Beech Street Commercial |
$0.25
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.21
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.25
|
| Rate for Payer: Cigna of WY Commercial |
$0.25
|
| Rate for Payer: Entrust Commercial |
$0.25
|
| Rate for Payer: First Choice Health Commercial |
$0.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.15
|
| Rate for Payer: HealthUtah PPO |
$0.26
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.25
|
| Rate for Payer: Multiplan Medicare/VA |
$0.14
|
| Rate for Payer: One Health Plan of WY PPO |
$0.25
|
| Rate for Payer: PacificSource Commercial |
$0.23
|
| Rate for Payer: PHCS PPO |
$0.25
|
| Rate for Payer: Three Rivers PPO |
$0.20
|
| Rate for Payer: TriWest Veterans Administration |
$0.15
|
| Rate for Payer: United Healthcare Commercial |
$0.23
|
| Rate for Payer: United Healthcare Medicare |
$0.15
|
| Rate for Payer: WINHealth Partners Commercial |
$0.25
|
| Rate for Payer: Wise Provider Network Commercial |
$0.25
|
|
|
LISINOPRIL 5 MG TABLET [16436]
|
Facility
|
IP
|
$0.26
|
|
|
Service Code
|
NDC 0904679761
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.25
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.25
|
| Rate for Payer: Altius Commercial |
$0.25
|
| Rate for Payer: Beech Street Commercial |
$0.25
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.21
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.25
|
| Rate for Payer: Cigna of WY Commercial |
$0.25
|
| Rate for Payer: Entrust Commercial |
$0.25
|
| Rate for Payer: First Choice Health Commercial |
$0.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.17
|
| Rate for Payer: HealthUtah PPO |
$0.26
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.25
|
| Rate for Payer: Multiplan Medicare/VA |
$0.16
|
| Rate for Payer: One Health Plan of WY PPO |
$0.25
|
| Rate for Payer: PacificSource Commercial |
$0.23
|
| Rate for Payer: PHCS PPO |
$0.25
|
| Rate for Payer: Three Rivers PPO |
$0.20
|
| Rate for Payer: TriWest Veterans Administration |
$0.17
|
| Rate for Payer: United Healthcare Commercial |
$0.23
|
| Rate for Payer: United Healthcare Medicare |
$0.17
|
| Rate for Payer: WINHealth Partners Commercial |
$0.25
|
| Rate for Payer: Wise Provider Network Commercial |
$0.25
|
|
|
LITHIUM CARBONATE 150 MG CAPSULE [6776]
|
Facility
|
OP
|
$0.60
|
|
|
Service Code
|
NDC 0054852625
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.59
|
| Rate for Payer: Aetna of WY Medicare |
$0.40
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.58
|
| Rate for Payer: Altius Commercial |
$0.58
|
| Rate for Payer: Beech Street Commercial |
$0.59
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.49
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.58
|
| Rate for Payer: Cigna of WY Commercial |
$0.59
|
| Rate for Payer: Entrust Commercial |
$0.57
|
| Rate for Payer: First Choice Health Commercial |
$0.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.35
|
| Rate for Payer: HealthUtah PPO |
$0.60
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.58
|
| Rate for Payer: Multiplan Medicare/VA |
$0.33
|
| Rate for Payer: One Health Plan of WY PPO |
$0.59
|
| Rate for Payer: PacificSource Commercial |
$0.54
|
| Rate for Payer: PHCS PPO |
$0.59
|
| Rate for Payer: Three Rivers PPO |
$0.45
|
| Rate for Payer: TriWest Veterans Administration |
$0.35
|
| Rate for Payer: United Healthcare Commercial |
$0.52
|
| Rate for Payer: United Healthcare Medicare |
$0.35
|
| Rate for Payer: WINHealth Partners Commercial |
$0.59
|
| Rate for Payer: Wise Provider Network Commercial |
$0.57
|
|
|
LITHIUM CARBONATE 150 MG CAPSULE [6776]
|
Facility
|
IP
|
$0.60
|
|
|
Service Code
|
NDC 0054852625
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.59
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.58
|
| Rate for Payer: Altius Commercial |
$0.58
|
| Rate for Payer: Beech Street Commercial |
$0.59
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.49
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.58
|
| Rate for Payer: Cigna of WY Commercial |
$0.59
|
| Rate for Payer: Entrust Commercial |
$0.57
|
| Rate for Payer: First Choice Health Commercial |
$0.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.40
|
| Rate for Payer: HealthUtah PPO |
$0.60
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.58
|
| Rate for Payer: Multiplan Medicare/VA |
$0.38
|
| Rate for Payer: One Health Plan of WY PPO |
$0.59
|
| Rate for Payer: PacificSource Commercial |
$0.54
|
| Rate for Payer: PHCS PPO |
$0.59
|
| Rate for Payer: Three Rivers PPO |
$0.45
|
| Rate for Payer: TriWest Veterans Administration |
$0.40
|
| Rate for Payer: United Healthcare Commercial |
$0.52
|
| Rate for Payer: United Healthcare Medicare |
$0.40
|
| Rate for Payer: WINHealth Partners Commercial |
$0.57
|
| Rate for Payer: Wise Provider Network Commercial |
$0.57
|
|
|
LMA MADGIC ATOMIZER MAD700
|
Facility
|
IP
|
$33.23
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$20.84 |
| Max. Negotiated Rate |
$33.23 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$32.57
|
| Rate for Payer: Altius Auto/Workers Compensation |
$31.90
|
| Rate for Payer: Altius Commercial |
$31.90
|
| Rate for Payer: Beech Street Commercial |
$32.57
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$27.28
|
| Rate for Payer: Cash Price |
$23.26
|
| Rate for Payer: ChoiceCare Network Commercial |
$32.23
|
| Rate for Payer: Cigna of WY Commercial |
$32.57
|
| Rate for Payer: Entrust Commercial |
$31.57
|
| Rate for Payer: First Choice Health Commercial |
$31.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$31.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$21.93
|
| Rate for Payer: HealthUtah PPO |
$33.23
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$32.23
|
| Rate for Payer: Multiplan Medicare/VA |
$20.84
|
| Rate for Payer: One Health Plan of WY PPO |
$32.57
|
| Rate for Payer: PacificSource Commercial |
$29.91
|
| Rate for Payer: PHCS PPO |
$32.57
|
| Rate for Payer: Three Rivers PPO |
$24.92
|
| Rate for Payer: TriWest Veterans Administration |
$21.93
|
| Rate for Payer: United Healthcare Commercial |
$28.91
|
| Rate for Payer: United Healthcare Medicare |
$21.93
|
| Rate for Payer: WINHealth Partners Commercial |
$31.57
|
| Rate for Payer: Wise Provider Network Commercial |
$31.57
|
|
|
LMA MADGIC ATOMIZER MAD700
|
Facility
|
OP
|
$33.23
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$18.31 |
| Max. Negotiated Rate |
$33.23 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$32.57
|
| Rate for Payer: Aetna of WY Medicare |
$21.93
|
| Rate for Payer: Altius Auto/Workers Compensation |
$31.90
|
| Rate for Payer: Altius Commercial |
$31.90
|
| Rate for Payer: Beech Street Commercial |
$32.57
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$27.28
|
| Rate for Payer: Cash Price |
$23.26
|
| Rate for Payer: ChoiceCare Network Commercial |
$32.23
|
| Rate for Payer: Cigna of WY Commercial |
$32.57
|
| Rate for Payer: Entrust Commercial |
$31.57
|
| Rate for Payer: First Choice Health Commercial |
$31.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$31.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$19.27
|
| Rate for Payer: HealthUtah PPO |
$33.23
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$32.23
|
| Rate for Payer: Multiplan Medicare/VA |
$18.31
|
| Rate for Payer: One Health Plan of WY PPO |
$32.57
|
| Rate for Payer: PacificSource Commercial |
$29.91
|
| Rate for Payer: PHCS PPO |
$32.57
|
| Rate for Payer: Three Rivers PPO |
$24.92
|
| Rate for Payer: TriWest Veterans Administration |
$19.27
|
| Rate for Payer: United Healthcare Commercial |
$28.91
|
| Rate for Payer: United Healthcare Medicare |
$19.27
|
| Rate for Payer: WINHealth Partners Commercial |
$32.57
|
| Rate for Payer: Wise Provider Network Commercial |
$31.57
|
|
|
LMA SZ 1.5 UNIQUE 105300000015
|
Facility
|
IP
|
$18.38
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$11.52 |
| Max. Negotiated Rate |
$18.38 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18.01
|
| Rate for Payer: Altius Auto/Workers Compensation |
$17.64
|
| Rate for Payer: Altius Commercial |
$17.64
|
| Rate for Payer: Beech Street Commercial |
$18.01
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.09
|
| Rate for Payer: Cash Price |
$12.86
|
| Rate for Payer: ChoiceCare Network Commercial |
$17.83
|
| Rate for Payer: Cigna of WY Commercial |
$18.01
|
| Rate for Payer: Entrust Commercial |
$17.46
|
| Rate for Payer: First Choice Health Commercial |
$17.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$12.13
|
| Rate for Payer: HealthUtah PPO |
$18.38
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.83
|
| Rate for Payer: Multiplan Medicare/VA |
$11.52
|
| Rate for Payer: One Health Plan of WY PPO |
$18.01
|
| Rate for Payer: PacificSource Commercial |
$16.54
|
| Rate for Payer: PHCS PPO |
$18.01
|
| Rate for Payer: Three Rivers PPO |
$13.78
|
| Rate for Payer: TriWest Veterans Administration |
$12.13
|
| Rate for Payer: United Healthcare Commercial |
$15.99
|
| Rate for Payer: United Healthcare Medicare |
$12.13
|
| Rate for Payer: WINHealth Partners Commercial |
$17.46
|
| Rate for Payer: Wise Provider Network Commercial |
$17.46
|
|
|
LMA SZ 1.5 UNIQUE 105300000015
|
Facility
|
OP
|
$18.38
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$10.13 |
| Max. Negotiated Rate |
$18.38 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18.01
|
| Rate for Payer: Aetna of WY Medicare |
$12.13
|
| Rate for Payer: Altius Auto/Workers Compensation |
$17.64
|
| Rate for Payer: Altius Commercial |
$17.64
|
| Rate for Payer: Beech Street Commercial |
$18.01
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.09
|
| Rate for Payer: Cash Price |
$12.86
|
| Rate for Payer: ChoiceCare Network Commercial |
$17.83
|
| Rate for Payer: Cigna of WY Commercial |
$18.01
|
| Rate for Payer: Entrust Commercial |
$17.46
|
| Rate for Payer: First Choice Health Commercial |
$17.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.66
|
| Rate for Payer: HealthUtah PPO |
$18.38
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.83
|
| Rate for Payer: Multiplan Medicare/VA |
$10.13
|
| Rate for Payer: One Health Plan of WY PPO |
$18.01
|
| Rate for Payer: PacificSource Commercial |
$16.54
|
| Rate for Payer: PHCS PPO |
$18.01
|
| Rate for Payer: Three Rivers PPO |
$13.78
|
| Rate for Payer: TriWest Veterans Administration |
$10.66
|
| Rate for Payer: United Healthcare Commercial |
$15.99
|
| Rate for Payer: United Healthcare Medicare |
$10.66
|
| Rate for Payer: WINHealth Partners Commercial |
$18.01
|
| Rate for Payer: Wise Provider Network Commercial |
$17.46
|
|
|
LMA SZ 1 UNIQUE 105300-000010
|
Facility
|
OP
|
$18.38
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$10.13 |
| Max. Negotiated Rate |
$18.38 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18.01
|
| Rate for Payer: Aetna of WY Medicare |
$12.13
|
| Rate for Payer: Altius Auto/Workers Compensation |
$17.64
|
| Rate for Payer: Altius Commercial |
$17.64
|
| Rate for Payer: Beech Street Commercial |
$18.01
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.09
|
| Rate for Payer: Cash Price |
$12.86
|
| Rate for Payer: ChoiceCare Network Commercial |
$17.83
|
| Rate for Payer: Cigna of WY Commercial |
$18.01
|
| Rate for Payer: Entrust Commercial |
$17.46
|
| Rate for Payer: First Choice Health Commercial |
$17.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.66
|
| Rate for Payer: HealthUtah PPO |
$18.38
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.83
|
| Rate for Payer: Multiplan Medicare/VA |
$10.13
|
| Rate for Payer: One Health Plan of WY PPO |
$18.01
|
| Rate for Payer: PacificSource Commercial |
$16.54
|
| Rate for Payer: PHCS PPO |
$18.01
|
| Rate for Payer: Three Rivers PPO |
$13.78
|
| Rate for Payer: TriWest Veterans Administration |
$10.66
|
| Rate for Payer: United Healthcare Commercial |
$15.99
|
| Rate for Payer: United Healthcare Medicare |
$10.66
|
| Rate for Payer: WINHealth Partners Commercial |
$18.01
|
| Rate for Payer: Wise Provider Network Commercial |
$17.46
|
|
|
LMA SZ 1 UNIQUE 105300-000010
|
Facility
|
IP
|
$18.38
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$11.52 |
| Max. Negotiated Rate |
$18.38 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18.01
|
| Rate for Payer: Altius Auto/Workers Compensation |
$17.64
|
| Rate for Payer: Altius Commercial |
$17.64
|
| Rate for Payer: Beech Street Commercial |
$18.01
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.09
|
| Rate for Payer: Cash Price |
$12.86
|
| Rate for Payer: ChoiceCare Network Commercial |
$17.83
|
| Rate for Payer: Cigna of WY Commercial |
$18.01
|
| Rate for Payer: Entrust Commercial |
$17.46
|
| Rate for Payer: First Choice Health Commercial |
$17.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$12.13
|
| Rate for Payer: HealthUtah PPO |
$18.38
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.83
|
| Rate for Payer: Multiplan Medicare/VA |
$11.52
|
| Rate for Payer: One Health Plan of WY PPO |
$18.01
|
| Rate for Payer: PacificSource Commercial |
$16.54
|
| Rate for Payer: PHCS PPO |
$18.01
|
| Rate for Payer: Three Rivers PPO |
$13.78
|
| Rate for Payer: TriWest Veterans Administration |
$12.13
|
| Rate for Payer: United Healthcare Commercial |
$15.99
|
| Rate for Payer: United Healthcare Medicare |
$12.13
|
| Rate for Payer: WINHealth Partners Commercial |
$17.46
|
| Rate for Payer: Wise Provider Network Commercial |
$17.46
|
|
|
LMA SZ 2.5 UNIQUE 105300000025
|
Facility
|
IP
|
$18.38
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$11.52 |
| Max. Negotiated Rate |
$18.38 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18.01
|
| Rate for Payer: Altius Auto/Workers Compensation |
$17.64
|
| Rate for Payer: Altius Commercial |
$17.64
|
| Rate for Payer: Beech Street Commercial |
$18.01
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.09
|
| Rate for Payer: Cash Price |
$12.86
|
| Rate for Payer: ChoiceCare Network Commercial |
$17.83
|
| Rate for Payer: Cigna of WY Commercial |
$18.01
|
| Rate for Payer: Entrust Commercial |
$17.46
|
| Rate for Payer: First Choice Health Commercial |
$17.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$12.13
|
| Rate for Payer: HealthUtah PPO |
$18.38
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.83
|
| Rate for Payer: Multiplan Medicare/VA |
$11.52
|
| Rate for Payer: One Health Plan of WY PPO |
$18.01
|
| Rate for Payer: PacificSource Commercial |
$16.54
|
| Rate for Payer: PHCS PPO |
$18.01
|
| Rate for Payer: Three Rivers PPO |
$13.78
|
| Rate for Payer: TriWest Veterans Administration |
$12.13
|
| Rate for Payer: United Healthcare Commercial |
$15.99
|
| Rate for Payer: United Healthcare Medicare |
$12.13
|
| Rate for Payer: WINHealth Partners Commercial |
$17.46
|
| Rate for Payer: Wise Provider Network Commercial |
$17.46
|
|
