|
LORAZEPAM 2 MG/ML ORAL CONCENTRATE [19224]
|
Facility
|
IP
|
$4.21
|
|
|
Service Code
|
NDC 0054353244
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.64 |
| Max. Negotiated Rate |
$4.21 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4.13
|
| Rate for Payer: Altius Auto/Workers Compensation |
$4.04
|
| Rate for Payer: Altius Commercial |
$4.04
|
| Rate for Payer: Beech Street Commercial |
$4.13
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3.46
|
| Rate for Payer: Cash Price |
$2.94
|
| Rate for Payer: ChoiceCare Network Commercial |
$4.08
|
| Rate for Payer: Cigna of WY Commercial |
$4.13
|
| Rate for Payer: Entrust Commercial |
$4.00
|
| Rate for Payer: First Choice Health Commercial |
$4.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2.78
|
| Rate for Payer: HealthUtah PPO |
$4.21
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4.08
|
| Rate for Payer: Multiplan Medicare/VA |
$2.64
|
| Rate for Payer: One Health Plan of WY PPO |
$4.13
|
| Rate for Payer: PacificSource Commercial |
$3.79
|
| Rate for Payer: PHCS PPO |
$4.13
|
| Rate for Payer: Three Rivers PPO |
$3.16
|
| Rate for Payer: TriWest Veterans Administration |
$2.78
|
| Rate for Payer: United Healthcare Commercial |
$3.66
|
| Rate for Payer: United Healthcare Medicare |
$2.78
|
| Rate for Payer: WINHealth Partners Commercial |
$4.00
|
| Rate for Payer: Wise Provider Network Commercial |
$4.00
|
|
|
LORAZEPAM 2 MG/ML ORAL CONCENTRATE [19224]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 0121077001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.10 |
| Max. Negotiated Rate |
$2.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.96
|
| Rate for Payer: Aetna of WY Medicare |
$1.32
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.92
|
| Rate for Payer: Altius Commercial |
$1.92
|
| Rate for Payer: Beech Street Commercial |
$1.96
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.64
|
| Rate for Payer: Cash Price |
$1.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.94
|
| Rate for Payer: Cigna of WY Commercial |
$1.96
|
| Rate for Payer: Entrust Commercial |
$1.90
|
| Rate for Payer: First Choice Health Commercial |
$1.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.16
|
| Rate for Payer: HealthUtah PPO |
$2.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.94
|
| Rate for Payer: Multiplan Medicare/VA |
$1.10
|
| Rate for Payer: One Health Plan of WY PPO |
$1.96
|
| Rate for Payer: PacificSource Commercial |
$1.80
|
| Rate for Payer: PHCS PPO |
$1.96
|
| Rate for Payer: Three Rivers PPO |
$1.50
|
| Rate for Payer: TriWest Veterans Administration |
$1.16
|
| Rate for Payer: United Healthcare Commercial |
$1.74
|
| Rate for Payer: United Healthcare Medicare |
$1.16
|
| Rate for Payer: WINHealth Partners Commercial |
$1.96
|
| Rate for Payer: Wise Provider Network Commercial |
$1.90
|
|
|
LORAZEPAM 2 MG/ML ORAL CONCENTRATE [19224]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 0121077001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.25 |
| Max. Negotiated Rate |
$2.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.96
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.92
|
| Rate for Payer: Altius Commercial |
$1.92
|
| Rate for Payer: Beech Street Commercial |
$1.96
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.64
|
| Rate for Payer: Cash Price |
$1.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.94
|
| Rate for Payer: Cigna of WY Commercial |
$1.96
|
| Rate for Payer: Entrust Commercial |
$1.90
|
| Rate for Payer: First Choice Health Commercial |
$1.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.32
|
| Rate for Payer: HealthUtah PPO |
$2.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.94
|
| Rate for Payer: Multiplan Medicare/VA |
$1.25
|
| Rate for Payer: One Health Plan of WY PPO |
$1.96
|
| Rate for Payer: PacificSource Commercial |
$1.80
|
| Rate for Payer: PHCS PPO |
$1.96
|
| Rate for Payer: Three Rivers PPO |
$1.50
|
| Rate for Payer: TriWest Veterans Administration |
$1.32
|
| Rate for Payer: United Healthcare Commercial |
$1.74
|
| Rate for Payer: United Healthcare Medicare |
$1.32
|
| Rate for Payer: WINHealth Partners Commercial |
$1.90
|
| Rate for Payer: Wise Provider Network Commercial |
$1.90
|
|
|
LORAZEPAM INJECTION
|
Professional
|
Both
|
$8.00
|
|
|
Service Code
|
HCPCS J2060
|
| Hospital Charge Code |
J2060
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$8.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$7.84
|
| Rate for Payer: Aetna of WY Medicare |
$0.96
|
| Rate for Payer: Beech Street Commercial |
$7.60
|
| Rate for Payer: Cash Price |
$5.60
|
| Rate for Payer: Cash Price |
$5.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$7.76
|
| Rate for Payer: Cigna of WY Commercial |
$7.84
|
| Rate for Payer: First Choice Health Commercial |
$7.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$7.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.96
|
| Rate for Payer: HealthUtah PPO |
$8.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$7.76
|
| Rate for Payer: Multiplan Medicare/VA |
$0.82
|
| Rate for Payer: One Health Plan of WY PPO |
$7.84
|
| Rate for Payer: PacificSource Commercial |
$7.20
|
| Rate for Payer: PHCS PPO |
$7.60
|
| Rate for Payer: Three Rivers PPO |
$6.00
|
| Rate for Payer: TriWest Veterans Administration |
$0.96
|
| Rate for Payer: United Healthcare Commercial |
$6.96
|
| Rate for Payer: United Healthcare Medicare |
$0.96
|
| Rate for Payer: WINHealth Partners Commercial |
$7.60
|
|
|
LOSARTAN 100 MG TABLET [18747]
|
Facility
|
IP
|
$2.77
|
|
|
Service Code
|
NDC 6808434811
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.74 |
| Max. Negotiated Rate |
$2.77 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.71
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.66
|
| Rate for Payer: Altius Commercial |
$2.66
|
| Rate for Payer: Beech Street Commercial |
$2.71
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.27
|
| Rate for Payer: Cash Price |
$1.94
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.69
|
| Rate for Payer: Cigna of WY Commercial |
$2.71
|
| Rate for Payer: Entrust Commercial |
$2.63
|
| Rate for Payer: First Choice Health Commercial |
$2.63
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.63
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.83
|
| Rate for Payer: HealthUtah PPO |
$2.77
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.69
|
| Rate for Payer: Multiplan Medicare/VA |
$1.74
|
| Rate for Payer: One Health Plan of WY PPO |
$2.71
|
| Rate for Payer: PacificSource Commercial |
$2.49
|
| Rate for Payer: PHCS PPO |
$2.71
|
| Rate for Payer: Three Rivers PPO |
$2.08
|
| Rate for Payer: TriWest Veterans Administration |
$1.83
|
| Rate for Payer: United Healthcare Commercial |
$2.41
|
| Rate for Payer: United Healthcare Medicare |
$1.83
|
| Rate for Payer: WINHealth Partners Commercial |
$2.63
|
| Rate for Payer: Wise Provider Network Commercial |
$2.63
|
|
|
LOSARTAN 100 MG TABLET [18747]
|
Facility
|
OP
|
$1.03
|
|
|
Service Code
|
NDC 3172270290
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$1.03 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.01
|
| Rate for Payer: Aetna of WY Medicare |
$0.68
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.99
|
| Rate for Payer: Altius Commercial |
$0.99
|
| Rate for Payer: Beech Street Commercial |
$1.01
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.85
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.00
|
| Rate for Payer: Cigna of WY Commercial |
$1.01
|
| Rate for Payer: Entrust Commercial |
$0.98
|
| Rate for Payer: First Choice Health Commercial |
$0.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.60
|
| Rate for Payer: HealthUtah PPO |
$1.03
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.00
|
| Rate for Payer: Multiplan Medicare/VA |
$0.57
|
| Rate for Payer: One Health Plan of WY PPO |
$1.01
|
| Rate for Payer: PacificSource Commercial |
$0.93
|
| Rate for Payer: PHCS PPO |
$1.01
|
| Rate for Payer: Three Rivers PPO |
$0.77
|
| Rate for Payer: TriWest Veterans Administration |
$0.60
|
| Rate for Payer: United Healthcare Commercial |
$0.90
|
| Rate for Payer: United Healthcare Medicare |
$0.60
|
| Rate for Payer: WINHealth Partners Commercial |
$1.01
|
| Rate for Payer: Wise Provider Network Commercial |
$0.98
|
|
|
LOSARTAN 100 MG TABLET [18747]
|
Facility
|
IP
|
$0.93
|
|
|
Service Code
|
NDC 4354736209
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.91
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.89
|
| Rate for Payer: Altius Commercial |
$0.89
|
| Rate for Payer: Beech Street Commercial |
$0.91
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.76
|
| Rate for Payer: Cash Price |
$0.65
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.90
|
| Rate for Payer: Cigna of WY Commercial |
$0.91
|
| Rate for Payer: Entrust Commercial |
$0.88
|
| Rate for Payer: First Choice Health Commercial |
$0.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.61
|
| Rate for Payer: HealthUtah PPO |
$0.93
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.90
|
| Rate for Payer: Multiplan Medicare/VA |
$0.58
|
| Rate for Payer: One Health Plan of WY PPO |
$0.91
|
| Rate for Payer: PacificSource Commercial |
$0.84
|
| Rate for Payer: PHCS PPO |
$0.91
|
| Rate for Payer: Three Rivers PPO |
$0.70
|
| Rate for Payer: TriWest Veterans Administration |
$0.61
|
| Rate for Payer: United Healthcare Commercial |
$0.81
|
| Rate for Payer: United Healthcare Medicare |
$0.61
|
| Rate for Payer: WINHealth Partners Commercial |
$0.88
|
| Rate for Payer: Wise Provider Network Commercial |
$0.88
|
|
|
LOSARTAN 100 MG TABLET [18747]
|
Facility
|
IP
|
$1.03
|
|
|
Service Code
|
NDC 3172270290
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$1.03 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.01
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.99
|
| Rate for Payer: Altius Commercial |
$0.99
|
| Rate for Payer: Beech Street Commercial |
$1.01
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.85
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.00
|
| Rate for Payer: Cigna of WY Commercial |
$1.01
|
| Rate for Payer: Entrust Commercial |
$0.98
|
| Rate for Payer: First Choice Health Commercial |
$0.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.68
|
| Rate for Payer: HealthUtah PPO |
$1.03
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.00
|
| Rate for Payer: Multiplan Medicare/VA |
$0.65
|
| Rate for Payer: One Health Plan of WY PPO |
$1.01
|
| Rate for Payer: PacificSource Commercial |
$0.93
|
| Rate for Payer: PHCS PPO |
$1.01
|
| Rate for Payer: Three Rivers PPO |
$0.77
|
| Rate for Payer: TriWest Veterans Administration |
$0.68
|
| Rate for Payer: United Healthcare Commercial |
$0.90
|
| Rate for Payer: United Healthcare Medicare |
$0.68
|
| Rate for Payer: WINHealth Partners Commercial |
$0.98
|
| Rate for Payer: Wise Provider Network Commercial |
$0.98
|
|
|
LOSARTAN 100 MG TABLET [18747]
|
Facility
|
OP
|
$2.77
|
|
|
Service Code
|
NDC 6808434811
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$2.77 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.71
|
| Rate for Payer: Aetna of WY Medicare |
$1.83
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.66
|
| Rate for Payer: Altius Commercial |
$2.66
|
| Rate for Payer: Beech Street Commercial |
$2.71
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.27
|
| Rate for Payer: Cash Price |
$1.94
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.69
|
| Rate for Payer: Cigna of WY Commercial |
$2.71
|
| Rate for Payer: Entrust Commercial |
$2.63
|
| Rate for Payer: First Choice Health Commercial |
$2.63
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.63
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.61
|
| Rate for Payer: HealthUtah PPO |
$2.77
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.69
|
| Rate for Payer: Multiplan Medicare/VA |
$1.53
|
| Rate for Payer: One Health Plan of WY PPO |
$2.71
|
| Rate for Payer: PacificSource Commercial |
$2.49
|
| Rate for Payer: PHCS PPO |
$2.71
|
| Rate for Payer: Three Rivers PPO |
$2.08
|
| Rate for Payer: TriWest Veterans Administration |
$1.61
|
| Rate for Payer: United Healthcare Commercial |
$2.41
|
| Rate for Payer: United Healthcare Medicare |
$1.61
|
| Rate for Payer: WINHealth Partners Commercial |
$2.71
|
| Rate for Payer: Wise Provider Network Commercial |
$2.63
|
|
|
LOSARTAN 100 MG TABLET [18747]
|
Facility
|
OP
|
$0.93
|
|
|
Service Code
|
NDC 4354736209
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.91
|
| Rate for Payer: Aetna of WY Medicare |
$0.61
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.89
|
| Rate for Payer: Altius Commercial |
$0.89
|
| Rate for Payer: Beech Street Commercial |
$0.91
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.76
|
| Rate for Payer: Cash Price |
$0.65
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.90
|
| Rate for Payer: Cigna of WY Commercial |
$0.91
|
| Rate for Payer: Entrust Commercial |
$0.88
|
| Rate for Payer: First Choice Health Commercial |
$0.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.54
|
| Rate for Payer: HealthUtah PPO |
$0.93
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.90
|
| Rate for Payer: Multiplan Medicare/VA |
$0.51
|
| Rate for Payer: One Health Plan of WY PPO |
$0.91
|
| Rate for Payer: PacificSource Commercial |
$0.84
|
| Rate for Payer: PHCS PPO |
$0.91
|
| Rate for Payer: Three Rivers PPO |
$0.70
|
| Rate for Payer: TriWest Veterans Administration |
$0.54
|
| Rate for Payer: United Healthcare Commercial |
$0.81
|
| Rate for Payer: United Healthcare Medicare |
$0.54
|
| Rate for Payer: WINHealth Partners Commercial |
$0.91
|
| Rate for Payer: Wise Provider Network Commercial |
$0.88
|
|
|
LOSARTAN 25 MG TABLET [13682]
|
Facility
|
OP
|
$2.05
|
|
|
Service Code
|
NDC 6808434601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.13 |
| Max. Negotiated Rate |
$2.05 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.01
|
| Rate for Payer: Aetna of WY Medicare |
$1.35
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.97
|
| Rate for Payer: Altius Commercial |
$1.97
|
| Rate for Payer: Beech Street Commercial |
$2.01
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.68
|
| Rate for Payer: Cash Price |
$1.44
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.99
|
| Rate for Payer: Cigna of WY Commercial |
$2.01
|
| Rate for Payer: Entrust Commercial |
$1.95
|
| Rate for Payer: First Choice Health Commercial |
$1.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.19
|
| Rate for Payer: HealthUtah PPO |
$2.05
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.99
|
| Rate for Payer: Multiplan Medicare/VA |
$1.13
|
| Rate for Payer: One Health Plan of WY PPO |
$2.01
|
| Rate for Payer: PacificSource Commercial |
$1.84
|
| Rate for Payer: PHCS PPO |
$2.01
|
| Rate for Payer: Three Rivers PPO |
$1.54
|
| Rate for Payer: TriWest Veterans Administration |
$1.19
|
| Rate for Payer: United Healthcare Commercial |
$1.78
|
| Rate for Payer: United Healthcare Medicare |
$1.19
|
| Rate for Payer: WINHealth Partners Commercial |
$2.01
|
| Rate for Payer: Wise Provider Network Commercial |
$1.95
|
|
|
LOSARTAN 25 MG TABLET [13682]
|
Facility
|
IP
|
$2.05
|
|
|
Service Code
|
NDC 6808434611
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.29 |
| Max. Negotiated Rate |
$2.05 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.01
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.97
|
| Rate for Payer: Altius Commercial |
$1.97
|
| Rate for Payer: Beech Street Commercial |
$2.01
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.68
|
| Rate for Payer: Cash Price |
$1.44
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.99
|
| Rate for Payer: Cigna of WY Commercial |
$2.01
|
| Rate for Payer: Entrust Commercial |
$1.95
|
| Rate for Payer: First Choice Health Commercial |
$1.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.35
|
| Rate for Payer: HealthUtah PPO |
$2.05
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.99
|
| Rate for Payer: Multiplan Medicare/VA |
$1.29
|
| Rate for Payer: One Health Plan of WY PPO |
$2.01
|
| Rate for Payer: PacificSource Commercial |
$1.84
|
| Rate for Payer: PHCS PPO |
$2.01
|
| Rate for Payer: Three Rivers PPO |
$1.54
|
| Rate for Payer: TriWest Veterans Administration |
$1.35
|
| Rate for Payer: United Healthcare Commercial |
$1.78
|
| Rate for Payer: United Healthcare Medicare |
$1.35
|
| Rate for Payer: WINHealth Partners Commercial |
$1.95
|
| Rate for Payer: Wise Provider Network Commercial |
$1.95
|
|
|
LOSARTAN 25 MG TABLET [13682]
|
Facility
|
OP
|
$2.05
|
|
|
Service Code
|
NDC 6808434611
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.13 |
| Max. Negotiated Rate |
$2.05 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.01
|
| Rate for Payer: Aetna of WY Medicare |
$1.35
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.97
|
| Rate for Payer: Altius Commercial |
$1.97
|
| Rate for Payer: Beech Street Commercial |
$2.01
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.68
|
| Rate for Payer: Cash Price |
$1.44
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.99
|
| Rate for Payer: Cigna of WY Commercial |
$2.01
|
| Rate for Payer: Entrust Commercial |
$1.95
|
| Rate for Payer: First Choice Health Commercial |
$1.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.19
|
| Rate for Payer: HealthUtah PPO |
$2.05
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.99
|
| Rate for Payer: Multiplan Medicare/VA |
$1.13
|
| Rate for Payer: One Health Plan of WY PPO |
$2.01
|
| Rate for Payer: PacificSource Commercial |
$1.84
|
| Rate for Payer: PHCS PPO |
$2.01
|
| Rate for Payer: Three Rivers PPO |
$1.54
|
| Rate for Payer: TriWest Veterans Administration |
$1.19
|
| Rate for Payer: United Healthcare Commercial |
$1.78
|
| Rate for Payer: United Healthcare Medicare |
$1.19
|
| Rate for Payer: WINHealth Partners Commercial |
$2.01
|
| Rate for Payer: Wise Provider Network Commercial |
$1.95
|
|
|
LOSARTAN 25 MG TABLET [13682]
|
Facility
|
IP
|
$2.05
|
|
|
Service Code
|
NDC 6808434601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.29 |
| Max. Negotiated Rate |
$2.05 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.01
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.97
|
| Rate for Payer: Altius Commercial |
$1.97
|
| Rate for Payer: Beech Street Commercial |
$2.01
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.68
|
| Rate for Payer: Cash Price |
$1.44
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.99
|
| Rate for Payer: Cigna of WY Commercial |
$2.01
|
| Rate for Payer: Entrust Commercial |
$1.95
|
| Rate for Payer: First Choice Health Commercial |
$1.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.35
|
| Rate for Payer: HealthUtah PPO |
$2.05
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.99
|
| Rate for Payer: Multiplan Medicare/VA |
$1.29
|
| Rate for Payer: One Health Plan of WY PPO |
$2.01
|
| Rate for Payer: PacificSource Commercial |
$1.84
|
| Rate for Payer: PHCS PPO |
$2.01
|
| Rate for Payer: Three Rivers PPO |
$1.54
|
| Rate for Payer: TriWest Veterans Administration |
$1.35
|
| Rate for Payer: United Healthcare Commercial |
$1.78
|
| Rate for Payer: United Healthcare Medicare |
$1.35
|
| Rate for Payer: WINHealth Partners Commercial |
$1.95
|
| Rate for Payer: Wise Provider Network Commercial |
$1.95
|
|
|
LOSARTAN 50 MG TABLET [103]
|
Facility
|
OP
|
$2.42
|
|
|
Service Code
|
NDC 6808434701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$2.42 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.37
|
| Rate for Payer: Aetna of WY Medicare |
$1.60
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.32
|
| Rate for Payer: Altius Commercial |
$2.32
|
| Rate for Payer: Beech Street Commercial |
$2.37
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.99
|
| Rate for Payer: Cash Price |
$1.69
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.35
|
| Rate for Payer: Cigna of WY Commercial |
$2.37
|
| Rate for Payer: Entrust Commercial |
$2.30
|
| Rate for Payer: First Choice Health Commercial |
$2.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.40
|
| Rate for Payer: HealthUtah PPO |
$2.42
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.35
|
| Rate for Payer: Multiplan Medicare/VA |
$1.33
|
| Rate for Payer: One Health Plan of WY PPO |
$2.37
|
| Rate for Payer: PacificSource Commercial |
$2.18
|
| Rate for Payer: PHCS PPO |
$2.37
|
| Rate for Payer: Three Rivers PPO |
$1.82
|
| Rate for Payer: TriWest Veterans Administration |
$1.40
|
| Rate for Payer: United Healthcare Commercial |
$2.11
|
| Rate for Payer: United Healthcare Medicare |
$1.40
|
| Rate for Payer: WINHealth Partners Commercial |
$2.37
|
| Rate for Payer: Wise Provider Network Commercial |
$2.30
|
|
|
LOSARTAN 50 MG TABLET [103]
|
Facility
|
OP
|
$2.42
|
|
|
Service Code
|
NDC 6808434711
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$2.42 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.37
|
| Rate for Payer: Aetna of WY Medicare |
$1.60
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.32
|
| Rate for Payer: Altius Commercial |
$2.32
|
| Rate for Payer: Beech Street Commercial |
$2.37
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.99
|
| Rate for Payer: Cash Price |
$1.69
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.35
|
| Rate for Payer: Cigna of WY Commercial |
$2.37
|
| Rate for Payer: Entrust Commercial |
$2.30
|
| Rate for Payer: First Choice Health Commercial |
$2.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.40
|
| Rate for Payer: HealthUtah PPO |
$2.42
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.35
|
| Rate for Payer: Multiplan Medicare/VA |
$1.33
|
| Rate for Payer: One Health Plan of WY PPO |
$2.37
|
| Rate for Payer: PacificSource Commercial |
$2.18
|
| Rate for Payer: PHCS PPO |
$2.37
|
| Rate for Payer: Three Rivers PPO |
$1.82
|
| Rate for Payer: TriWest Veterans Administration |
$1.40
|
| Rate for Payer: United Healthcare Commercial |
$2.11
|
| Rate for Payer: United Healthcare Medicare |
$1.40
|
| Rate for Payer: WINHealth Partners Commercial |
$2.37
|
| Rate for Payer: Wise Provider Network Commercial |
$2.30
|
|
|
LOSARTAN 50 MG TABLET [103]
|
Facility
|
IP
|
$2.42
|
|
|
Service Code
|
NDC 6808434711
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.52 |
| Max. Negotiated Rate |
$2.42 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.37
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.32
|
| Rate for Payer: Altius Commercial |
$2.32
|
| Rate for Payer: Beech Street Commercial |
$2.37
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.99
|
| Rate for Payer: Cash Price |
$1.69
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.35
|
| Rate for Payer: Cigna of WY Commercial |
$2.37
|
| Rate for Payer: Entrust Commercial |
$2.30
|
| Rate for Payer: First Choice Health Commercial |
$2.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.60
|
| Rate for Payer: HealthUtah PPO |
$2.42
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.35
|
| Rate for Payer: Multiplan Medicare/VA |
$1.52
|
| Rate for Payer: One Health Plan of WY PPO |
$2.37
|
| Rate for Payer: PacificSource Commercial |
$2.18
|
| Rate for Payer: PHCS PPO |
$2.37
|
| Rate for Payer: Three Rivers PPO |
$1.82
|
| Rate for Payer: TriWest Veterans Administration |
$1.60
|
| Rate for Payer: United Healthcare Commercial |
$2.11
|
| Rate for Payer: United Healthcare Medicare |
$1.60
|
| Rate for Payer: WINHealth Partners Commercial |
$2.30
|
| Rate for Payer: Wise Provider Network Commercial |
$2.30
|
|
|
LOSARTAN 50 MG TABLET [103]
|
Facility
|
IP
|
$2.42
|
|
|
Service Code
|
NDC 6808434701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.52 |
| Max. Negotiated Rate |
$2.42 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.37
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.32
|
| Rate for Payer: Altius Commercial |
$2.32
|
| Rate for Payer: Beech Street Commercial |
$2.37
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.99
|
| Rate for Payer: Cash Price |
$1.69
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.35
|
| Rate for Payer: Cigna of WY Commercial |
$2.37
|
| Rate for Payer: Entrust Commercial |
$2.30
|
| Rate for Payer: First Choice Health Commercial |
$2.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.60
|
| Rate for Payer: HealthUtah PPO |
$2.42
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.35
|
| Rate for Payer: Multiplan Medicare/VA |
$1.52
|
| Rate for Payer: One Health Plan of WY PPO |
$2.37
|
| Rate for Payer: PacificSource Commercial |
$2.18
|
| Rate for Payer: PHCS PPO |
$2.37
|
| Rate for Payer: Three Rivers PPO |
$1.82
|
| Rate for Payer: TriWest Veterans Administration |
$1.60
|
| Rate for Payer: United Healthcare Commercial |
$2.11
|
| Rate for Payer: United Healthcare Medicare |
$1.60
|
| Rate for Payer: WINHealth Partners Commercial |
$2.30
|
| Rate for Payer: Wise Provider Network Commercial |
$2.30
|
|
|
LOW COST SKIN SUBSTITUTE APP
|
Professional
|
Both
|
$815.00
|
|
|
Service Code
|
HCPCS C5271
|
| Hospital Charge Code |
C5271
|
| Min. Negotiated Rate |
$611.25 |
| Max. Negotiated Rate |
$815.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$798.70
|
| Rate for Payer: Beech Street Commercial |
$774.25
|
| Rate for Payer: Cash Price |
$570.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$790.55
|
| Rate for Payer: Cigna of WY Commercial |
$798.70
|
| Rate for Payer: First Choice Health Commercial |
$733.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$774.25
|
| Rate for Payer: HealthUtah PPO |
$815.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$790.55
|
| Rate for Payer: One Health Plan of WY PPO |
$798.70
|
| Rate for Payer: PacificSource Commercial |
$733.50
|
| Rate for Payer: PHCS PPO |
$774.25
|
| Rate for Payer: Three Rivers PPO |
$611.25
|
| Rate for Payer: United Healthcare Commercial |
$709.05
|
| Rate for Payer: WINHealth Partners Commercial |
$774.25
|
|
|
LSO SAG R AN/POS PNL PRE OTS
|
Professional
|
Both
|
$350.00
|
|
|
Service Code
|
HCPCS L0648
|
| Hospital Charge Code |
L0648
|
| Min. Negotiated Rate |
$262.50 |
| Max. Negotiated Rate |
$988.74 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$343.00
|
| Rate for Payer: Aetna of WY Medicare |
$988.74
|
| Rate for Payer: Beech Street Commercial |
$332.50
|
| Rate for Payer: Cash Price |
$245.00
|
| Rate for Payer: Cash Price |
$245.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$339.50
|
| Rate for Payer: Cigna of WY Commercial |
$343.00
|
| Rate for Payer: First Choice Health Commercial |
$315.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$332.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$988.74
|
| Rate for Payer: HealthUtah PPO |
$350.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$339.50
|
| Rate for Payer: Multiplan Medicare/VA |
$840.43
|
| Rate for Payer: One Health Plan of WY PPO |
$343.00
|
| Rate for Payer: PacificSource Commercial |
$315.00
|
| Rate for Payer: PHCS PPO |
$332.50
|
| Rate for Payer: Three Rivers PPO |
$262.50
|
| Rate for Payer: TriWest Veterans Administration |
$988.74
|
| Rate for Payer: United Healthcare Commercial |
$304.50
|
| Rate for Payer: United Healthcare Medicare |
$988.74
|
| Rate for Payer: WINHealth Partners Commercial |
$332.50
|
|
|
LUBRICANT/DIFFUS BECK PA700
|
Facility
|
IP
|
$60.01
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$37.63 |
| Max. Negotiated Rate |
$60.01 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$58.81
|
| Rate for Payer: Altius Auto/Workers Compensation |
$57.61
|
| Rate for Payer: Altius Commercial |
$57.61
|
| Rate for Payer: Beech Street Commercial |
$58.81
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$49.27
|
| Rate for Payer: Cash Price |
$42.01
|
| Rate for Payer: ChoiceCare Network Commercial |
$58.21
|
| Rate for Payer: Cigna of WY Commercial |
$58.81
|
| Rate for Payer: Entrust Commercial |
$57.01
|
| Rate for Payer: First Choice Health Commercial |
$57.01
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$57.01
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$39.61
|
| Rate for Payer: HealthUtah PPO |
$60.01
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$58.21
|
| Rate for Payer: Multiplan Medicare/VA |
$37.63
|
| Rate for Payer: One Health Plan of WY PPO |
$58.81
|
| Rate for Payer: PacificSource Commercial |
$54.01
|
| Rate for Payer: PHCS PPO |
$58.81
|
| Rate for Payer: Three Rivers PPO |
$45.01
|
| Rate for Payer: TriWest Veterans Administration |
$39.61
|
| Rate for Payer: United Healthcare Commercial |
$52.21
|
| Rate for Payer: United Healthcare Medicare |
$39.61
|
| Rate for Payer: WINHealth Partners Commercial |
$57.01
|
| Rate for Payer: Wise Provider Network Commercial |
$57.01
|
|
|
LUBRICANT/DIFFUS BECK PA700
|
Facility
|
OP
|
$60.01
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$33.07 |
| Max. Negotiated Rate |
$60.01 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$58.81
|
| Rate for Payer: Aetna of WY Medicare |
$39.61
|
| Rate for Payer: Altius Auto/Workers Compensation |
$57.61
|
| Rate for Payer: Altius Commercial |
$57.61
|
| Rate for Payer: Beech Street Commercial |
$58.81
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$49.27
|
| Rate for Payer: Cash Price |
$42.01
|
| Rate for Payer: ChoiceCare Network Commercial |
$58.21
|
| Rate for Payer: Cigna of WY Commercial |
$58.81
|
| Rate for Payer: Entrust Commercial |
$57.01
|
| Rate for Payer: First Choice Health Commercial |
$57.01
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$57.01
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$34.81
|
| Rate for Payer: HealthUtah PPO |
$60.01
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$58.21
|
| Rate for Payer: Multiplan Medicare/VA |
$33.07
|
| Rate for Payer: One Health Plan of WY PPO |
$58.81
|
| Rate for Payer: PacificSource Commercial |
$54.01
|
| Rate for Payer: PHCS PPO |
$58.81
|
| Rate for Payer: Three Rivers PPO |
$45.01
|
| Rate for Payer: TriWest Veterans Administration |
$34.81
|
| Rate for Payer: United Healthcare Commercial |
$52.21
|
| Rate for Payer: United Healthcare Medicare |
$34.81
|
| Rate for Payer: WINHealth Partners Commercial |
$58.81
|
| Rate for Payer: Wise Provider Network Commercial |
$57.01
|
|
|
LUBRICANTS TOPICAL GEL [2971]
|
Facility
|
OP
|
$0.24
|
|
|
Service Code
|
NDC 4141505575
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.24 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.24
|
| Rate for Payer: Aetna of WY Medicare |
$0.16
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.23
|
| Rate for Payer: Altius Commercial |
$0.23
|
| Rate for Payer: Beech Street Commercial |
$0.24
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.20
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.23
|
| Rate for Payer: Cigna of WY Commercial |
$0.24
|
| Rate for Payer: Entrust Commercial |
$0.23
|
| Rate for Payer: First Choice Health Commercial |
$0.23
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.23
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.14
|
| Rate for Payer: HealthUtah PPO |
$0.24
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.23
|
| Rate for Payer: Multiplan Medicare/VA |
$0.13
|
| Rate for Payer: One Health Plan of WY PPO |
$0.24
|
| Rate for Payer: PacificSource Commercial |
$0.22
|
| Rate for Payer: PHCS PPO |
$0.24
|
| Rate for Payer: Three Rivers PPO |
$0.18
|
| Rate for Payer: TriWest Veterans Administration |
$0.14
|
| Rate for Payer: United Healthcare Commercial |
$0.21
|
| Rate for Payer: United Healthcare Medicare |
$0.14
|
| Rate for Payer: WINHealth Partners Commercial |
$0.24
|
| Rate for Payer: Wise Provider Network Commercial |
$0.23
|
|
|
LUBRICANTS TOPICAL GEL [2971]
|
Facility
|
IP
|
$0.24
|
|
|
Service Code
|
NDC 4141505575
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.24 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.24
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.23
|
| Rate for Payer: Altius Commercial |
$0.23
|
| Rate for Payer: Beech Street Commercial |
$0.24
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.20
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.23
|
| Rate for Payer: Cigna of WY Commercial |
$0.24
|
| Rate for Payer: Entrust Commercial |
$0.23
|
| Rate for Payer: First Choice Health Commercial |
$0.23
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.23
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.16
|
| Rate for Payer: HealthUtah PPO |
$0.24
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.23
|
| Rate for Payer: Multiplan Medicare/VA |
$0.15
|
| Rate for Payer: One Health Plan of WY PPO |
$0.24
|
| Rate for Payer: PacificSource Commercial |
$0.22
|
| Rate for Payer: PHCS PPO |
$0.24
|
| Rate for Payer: Three Rivers PPO |
$0.18
|
| Rate for Payer: TriWest Veterans Administration |
$0.16
|
| Rate for Payer: United Healthcare Commercial |
$0.21
|
| Rate for Payer: United Healthcare Medicare |
$0.16
|
| Rate for Payer: WINHealth Partners Commercial |
$0.23
|
| Rate for Payer: Wise Provider Network Commercial |
$0.23
|
|
|
LYSIS/EXCISION PENILE POSTCIRCUMCISION ADHESIONS
|
Professional
|
Both
|
$1,003.00
|
|
|
Service Code
|
HCPCS 54162
|
| Hospital Charge Code |
54162
|
| Min. Negotiated Rate |
$164.64 |
| Max. Negotiated Rate |
$1,003.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$982.94
|
| Rate for Payer: Aetna of WY Medicare |
$193.70
|
| Rate for Payer: Beech Street Commercial |
$952.85
|
| Rate for Payer: Cash Price |
$702.10
|
| Rate for Payer: Cash Price |
$702.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$972.91
|
| Rate for Payer: Cigna of WY Commercial |
$982.94
|
| Rate for Payer: First Choice Health Commercial |
$902.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$952.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$193.70
|
| Rate for Payer: HealthUtah PPO |
$1,003.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$972.91
|
| Rate for Payer: Multiplan Medicare/VA |
$164.64
|
| Rate for Payer: One Health Plan of WY PPO |
$982.94
|
| Rate for Payer: PacificSource Commercial |
$902.70
|
| Rate for Payer: PHCS PPO |
$952.85
|
| Rate for Payer: Three Rivers PPO |
$752.25
|
| Rate for Payer: TriWest Veterans Administration |
$193.70
|
| Rate for Payer: United Healthcare Commercial |
$872.61
|
| Rate for Payer: United Healthcare Medicare |
$193.70
|
| Rate for Payer: WINHealth Partners Commercial |
$852.55
|
|
