|
LYSIS INTRANASAL SYNECHIA
|
Professional
|
Both
|
$1,126.00
|
|
|
Service Code
|
HCPCS 30560
|
| Hospital Charge Code |
30560
|
| Min. Negotiated Rate |
$126.02 |
| Max. Negotiated Rate |
$1,126.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,103.48
|
| Rate for Payer: Aetna of WY Medicare |
$148.26
|
| Rate for Payer: Beech Street Commercial |
$1,069.70
|
| Rate for Payer: Cash Price |
$788.20
|
| Rate for Payer: Cash Price |
$788.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,092.22
|
| Rate for Payer: Cigna of WY Commercial |
$1,103.48
|
| Rate for Payer: First Choice Health Commercial |
$1,013.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,069.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$148.26
|
| Rate for Payer: HealthUtah PPO |
$1,126.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,092.22
|
| Rate for Payer: Multiplan Medicare/VA |
$126.02
|
| Rate for Payer: One Health Plan of WY PPO |
$1,103.48
|
| Rate for Payer: PacificSource Commercial |
$1,013.40
|
| Rate for Payer: PHCS PPO |
$1,069.70
|
| Rate for Payer: Three Rivers PPO |
$844.50
|
| Rate for Payer: TriWest Veterans Administration |
$148.26
|
| Rate for Payer: United Healthcare Commercial |
$979.62
|
| Rate for Payer: United Healthcare Medicare |
$148.26
|
| Rate for Payer: WINHealth Partners Commercial |
$957.10
|
|
|
LYSIS OF ADHESIONS SALPINX/OVARY
|
Professional
|
Both
|
$3,730.00
|
|
|
Service Code
|
HCPCS 58740
|
| Hospital Charge Code |
58740
|
| Min. Negotiated Rate |
$737.07 |
| Max. Negotiated Rate |
$3,730.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,655.40
|
| Rate for Payer: Aetna of WY Medicare |
$867.14
|
| Rate for Payer: Beech Street Commercial |
$3,543.50
|
| Rate for Payer: Cash Price |
$2,611.00
|
| Rate for Payer: Cash Price |
$2,611.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,618.10
|
| Rate for Payer: Cigna of WY Commercial |
$3,655.40
|
| Rate for Payer: First Choice Health Commercial |
$3,357.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,543.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$867.14
|
| Rate for Payer: HealthUtah PPO |
$3,730.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,618.10
|
| Rate for Payer: Multiplan Medicare/VA |
$737.07
|
| Rate for Payer: One Health Plan of WY PPO |
$3,655.40
|
| Rate for Payer: PacificSource Commercial |
$3,357.00
|
| Rate for Payer: PHCS PPO |
$3,543.50
|
| Rate for Payer: Three Rivers PPO |
$2,797.50
|
| Rate for Payer: TriWest Veterans Administration |
$867.14
|
| Rate for Payer: United Healthcare Commercial |
$3,245.10
|
| Rate for Payer: United Healthcare Medicare |
$867.14
|
| Rate for Payer: WINHealth Partners Commercial |
$3,170.50
|
|
|
LYSIS OF ADHESIONS SALPINX/OVARY
|
Professional
|
Both
|
$3,730.00
|
|
|
Service Code
|
HCPCS 58740 AS
|
| Hospital Charge Code |
58740
|
| Min. Negotiated Rate |
$737.07 |
| Max. Negotiated Rate |
$3,730.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,655.40
|
| Rate for Payer: Aetna of WY Medicare |
$867.14
|
| Rate for Payer: Beech Street Commercial |
$3,543.50
|
| Rate for Payer: Cash Price |
$2,611.00
|
| Rate for Payer: Cash Price |
$2,611.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,618.10
|
| Rate for Payer: Cigna of WY Commercial |
$3,655.40
|
| Rate for Payer: First Choice Health Commercial |
$3,357.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,543.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$867.14
|
| Rate for Payer: HealthUtah PPO |
$3,730.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,618.10
|
| Rate for Payer: Multiplan Medicare/VA |
$737.07
|
| Rate for Payer: One Health Plan of WY PPO |
$3,655.40
|
| Rate for Payer: PacificSource Commercial |
$3,357.00
|
| Rate for Payer: PHCS PPO |
$3,543.50
|
| Rate for Payer: Three Rivers PPO |
$2,797.50
|
| Rate for Payer: TriWest Veterans Administration |
$867.14
|
| Rate for Payer: United Healthcare Commercial |
$3,245.10
|
| Rate for Payer: United Healthcare Medicare |
$867.14
|
| Rate for Payer: WINHealth Partners Commercial |
$3,170.50
|
|
|
LYSIS OF ADHESIONS SALPINX/OVARY
|
Professional
|
Both
|
$3,730.00
|
|
|
Service Code
|
HCPCS 58740 80
|
| Hospital Charge Code |
58740
|
| Min. Negotiated Rate |
$737.07 |
| Max. Negotiated Rate |
$3,730.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,655.40
|
| Rate for Payer: Aetna of WY Medicare |
$867.14
|
| Rate for Payer: Beech Street Commercial |
$3,543.50
|
| Rate for Payer: Cash Price |
$2,611.00
|
| Rate for Payer: Cash Price |
$2,611.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,618.10
|
| Rate for Payer: Cigna of WY Commercial |
$3,655.40
|
| Rate for Payer: First Choice Health Commercial |
$3,357.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,543.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$867.14
|
| Rate for Payer: HealthUtah PPO |
$3,730.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,618.10
|
| Rate for Payer: Multiplan Medicare/VA |
$737.07
|
| Rate for Payer: One Health Plan of WY PPO |
$3,655.40
|
| Rate for Payer: PacificSource Commercial |
$3,357.00
|
| Rate for Payer: PHCS PPO |
$3,543.50
|
| Rate for Payer: Three Rivers PPO |
$2,797.50
|
| Rate for Payer: TriWest Veterans Administration |
$867.14
|
| Rate for Payer: United Healthcare Commercial |
$3,245.10
|
| Rate for Payer: United Healthcare Medicare |
$867.14
|
| Rate for Payer: WINHealth Partners Commercial |
$3,170.50
|
|
|
MAFENIDE 50 GRAM TOPICAL PACKET [19381]
|
Facility
|
OP
|
$165.00
|
|
|
Service Code
|
NDC 5074231050
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$90.92 |
| Max. Negotiated Rate |
$165.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$161.70
|
| Rate for Payer: Aetna of WY Medicare |
$108.90
|
| Rate for Payer: Altius Auto/Workers Compensation |
$158.40
|
| Rate for Payer: Altius Commercial |
$158.40
|
| Rate for Payer: Beech Street Commercial |
$161.70
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$135.46
|
| Rate for Payer: Cash Price |
$115.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$160.05
|
| Rate for Payer: Cigna of WY Commercial |
$161.70
|
| Rate for Payer: Entrust Commercial |
$156.75
|
| Rate for Payer: First Choice Health Commercial |
$156.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$156.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$95.70
|
| Rate for Payer: HealthUtah PPO |
$165.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$160.05
|
| Rate for Payer: Multiplan Medicare/VA |
$90.92
|
| Rate for Payer: One Health Plan of WY PPO |
$161.70
|
| Rate for Payer: PacificSource Commercial |
$148.50
|
| Rate for Payer: PHCS PPO |
$161.70
|
| Rate for Payer: Three Rivers PPO |
$123.75
|
| Rate for Payer: TriWest Veterans Administration |
$95.70
|
| Rate for Payer: United Healthcare Commercial |
$143.55
|
| Rate for Payer: United Healthcare Medicare |
$95.70
|
| Rate for Payer: WINHealth Partners Commercial |
$161.70
|
| Rate for Payer: Wise Provider Network Commercial |
$156.75
|
|
|
MAFENIDE 50 GRAM TOPICAL PACKET [19381]
|
Facility
|
IP
|
$165.00
|
|
|
Service Code
|
NDC 5074231025
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$103.46 |
| Max. Negotiated Rate |
$165.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$161.70
|
| Rate for Payer: Altius Auto/Workers Compensation |
$158.40
|
| Rate for Payer: Altius Commercial |
$158.40
|
| Rate for Payer: Beech Street Commercial |
$161.70
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$135.46
|
| Rate for Payer: Cash Price |
$115.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$160.05
|
| Rate for Payer: Cigna of WY Commercial |
$161.70
|
| Rate for Payer: Entrust Commercial |
$156.75
|
| Rate for Payer: First Choice Health Commercial |
$156.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$156.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$108.90
|
| Rate for Payer: HealthUtah PPO |
$165.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$160.05
|
| Rate for Payer: Multiplan Medicare/VA |
$103.46
|
| Rate for Payer: One Health Plan of WY PPO |
$161.70
|
| Rate for Payer: PacificSource Commercial |
$148.50
|
| Rate for Payer: PHCS PPO |
$161.70
|
| Rate for Payer: Three Rivers PPO |
$123.75
|
| Rate for Payer: TriWest Veterans Administration |
$108.90
|
| Rate for Payer: United Healthcare Commercial |
$143.55
|
| Rate for Payer: United Healthcare Medicare |
$108.90
|
| Rate for Payer: WINHealth Partners Commercial |
$156.75
|
| Rate for Payer: Wise Provider Network Commercial |
$156.75
|
|
|
MAFENIDE 50 GRAM TOPICAL PACKET [19381]
|
Facility
|
OP
|
$165.00
|
|
|
Service Code
|
NDC 5074231025
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$90.92 |
| Max. Negotiated Rate |
$165.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$161.70
|
| Rate for Payer: Aetna of WY Medicare |
$108.90
|
| Rate for Payer: Altius Auto/Workers Compensation |
$158.40
|
| Rate for Payer: Altius Commercial |
$158.40
|
| Rate for Payer: Beech Street Commercial |
$161.70
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$135.46
|
| Rate for Payer: Cash Price |
$115.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$160.05
|
| Rate for Payer: Cigna of WY Commercial |
$161.70
|
| Rate for Payer: Entrust Commercial |
$156.75
|
| Rate for Payer: First Choice Health Commercial |
$156.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$156.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$95.70
|
| Rate for Payer: HealthUtah PPO |
$165.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$160.05
|
| Rate for Payer: Multiplan Medicare/VA |
$90.92
|
| Rate for Payer: One Health Plan of WY PPO |
$161.70
|
| Rate for Payer: PacificSource Commercial |
$148.50
|
| Rate for Payer: PHCS PPO |
$161.70
|
| Rate for Payer: Three Rivers PPO |
$123.75
|
| Rate for Payer: TriWest Veterans Administration |
$95.70
|
| Rate for Payer: United Healthcare Commercial |
$143.55
|
| Rate for Payer: United Healthcare Medicare |
$95.70
|
| Rate for Payer: WINHealth Partners Commercial |
$161.70
|
| Rate for Payer: Wise Provider Network Commercial |
$156.75
|
|
|
MAFENIDE 50 GRAM TOPICAL PACKET [19381]
|
Facility
|
IP
|
$165.00
|
|
|
Service Code
|
NDC 5074231050
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$103.46 |
| Max. Negotiated Rate |
$165.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$161.70
|
| Rate for Payer: Altius Auto/Workers Compensation |
$158.40
|
| Rate for Payer: Altius Commercial |
$158.40
|
| Rate for Payer: Beech Street Commercial |
$161.70
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$135.46
|
| Rate for Payer: Cash Price |
$115.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$160.05
|
| Rate for Payer: Cigna of WY Commercial |
$161.70
|
| Rate for Payer: Entrust Commercial |
$156.75
|
| Rate for Payer: First Choice Health Commercial |
$156.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$156.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$108.90
|
| Rate for Payer: HealthUtah PPO |
$165.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$160.05
|
| Rate for Payer: Multiplan Medicare/VA |
$103.46
|
| Rate for Payer: One Health Plan of WY PPO |
$161.70
|
| Rate for Payer: PacificSource Commercial |
$148.50
|
| Rate for Payer: PHCS PPO |
$161.70
|
| Rate for Payer: Three Rivers PPO |
$123.75
|
| Rate for Payer: TriWest Veterans Administration |
$108.90
|
| Rate for Payer: United Healthcare Commercial |
$143.55
|
| Rate for Payer: United Healthcare Medicare |
$108.90
|
| Rate for Payer: WINHealth Partners Commercial |
$156.75
|
| Rate for Payer: Wise Provider Network Commercial |
$156.75
|
|
|
MAFENIDE 85 MG/G TOPICAL CREAM [8060]
|
Facility
|
IP
|
$5.11
|
|
|
Service Code
|
NDC 1657172360
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.20 |
| Max. Negotiated Rate |
$5.11 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5.01
|
| Rate for Payer: Altius Auto/Workers Compensation |
$4.91
|
| Rate for Payer: Altius Commercial |
$4.91
|
| Rate for Payer: Beech Street Commercial |
$5.01
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$4.20
|
| Rate for Payer: Cash Price |
$3.58
|
| Rate for Payer: ChoiceCare Network Commercial |
$4.96
|
| Rate for Payer: Cigna of WY Commercial |
$5.01
|
| Rate for Payer: Entrust Commercial |
$4.85
|
| Rate for Payer: First Choice Health Commercial |
$4.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3.37
|
| Rate for Payer: HealthUtah PPO |
$5.11
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4.96
|
| Rate for Payer: Multiplan Medicare/VA |
$3.20
|
| Rate for Payer: One Health Plan of WY PPO |
$5.01
|
| Rate for Payer: PacificSource Commercial |
$4.60
|
| Rate for Payer: PHCS PPO |
$5.01
|
| Rate for Payer: Three Rivers PPO |
$3.83
|
| Rate for Payer: TriWest Veterans Administration |
$3.37
|
| Rate for Payer: United Healthcare Commercial |
$4.45
|
| Rate for Payer: United Healthcare Medicare |
$3.37
|
| Rate for Payer: WINHealth Partners Commercial |
$4.85
|
| Rate for Payer: Wise Provider Network Commercial |
$4.85
|
|
|
MAFENIDE 85 MG/G TOPICAL CREAM [8060]
|
Facility
|
OP
|
$5.11
|
|
|
Service Code
|
NDC 1657172360
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.82 |
| Max. Negotiated Rate |
$5.11 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5.01
|
| Rate for Payer: Aetna of WY Medicare |
$3.37
|
| Rate for Payer: Altius Auto/Workers Compensation |
$4.91
|
| Rate for Payer: Altius Commercial |
$4.91
|
| Rate for Payer: Beech Street Commercial |
$5.01
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$4.20
|
| Rate for Payer: Cash Price |
$3.58
|
| Rate for Payer: ChoiceCare Network Commercial |
$4.96
|
| Rate for Payer: Cigna of WY Commercial |
$5.01
|
| Rate for Payer: Entrust Commercial |
$4.85
|
| Rate for Payer: First Choice Health Commercial |
$4.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2.96
|
| Rate for Payer: HealthUtah PPO |
$5.11
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4.96
|
| Rate for Payer: Multiplan Medicare/VA |
$2.82
|
| Rate for Payer: One Health Plan of WY PPO |
$5.01
|
| Rate for Payer: PacificSource Commercial |
$4.60
|
| Rate for Payer: PHCS PPO |
$5.01
|
| Rate for Payer: Three Rivers PPO |
$3.83
|
| Rate for Payer: TriWest Veterans Administration |
$2.96
|
| Rate for Payer: United Healthcare Commercial |
$4.45
|
| Rate for Payer: United Healthcare Medicare |
$2.96
|
| Rate for Payer: WINHealth Partners Commercial |
$5.01
|
| Rate for Payer: Wise Provider Network Commercial |
$4.85
|
|
|
MAGIC MOUTHWASH ORAL SUSPENSION (1:1:1) [400477]
|
Facility
|
OP
|
$0.65
|
|
|
Service Code
|
NDC 9994004771
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$0.65 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.64
|
| Rate for Payer: Aetna of WY Medicare |
$0.43
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.62
|
| Rate for Payer: Altius Commercial |
$0.62
|
| Rate for Payer: Beech Street Commercial |
$0.64
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.53
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.63
|
| Rate for Payer: Cigna of WY Commercial |
$0.64
|
| Rate for Payer: Entrust Commercial |
$0.62
|
| Rate for Payer: First Choice Health Commercial |
$0.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.38
|
| Rate for Payer: HealthUtah PPO |
$0.65
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.63
|
| Rate for Payer: Multiplan Medicare/VA |
$0.36
|
| Rate for Payer: One Health Plan of WY PPO |
$0.64
|
| Rate for Payer: PacificSource Commercial |
$0.59
|
| Rate for Payer: PHCS PPO |
$0.64
|
| Rate for Payer: Three Rivers PPO |
$0.49
|
| Rate for Payer: TriWest Veterans Administration |
$0.38
|
| Rate for Payer: United Healthcare Commercial |
$0.57
|
| Rate for Payer: United Healthcare Medicare |
$0.38
|
| Rate for Payer: WINHealth Partners Commercial |
$0.64
|
| Rate for Payer: Wise Provider Network Commercial |
$0.62
|
|
|
MAGIC MOUTHWASH ORAL SUSPENSION (1:1:1) [400477]
|
Facility
|
IP
|
$0.65
|
|
|
Service Code
|
NDC 9994004771
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$0.65 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.64
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.62
|
| Rate for Payer: Altius Commercial |
$0.62
|
| Rate for Payer: Beech Street Commercial |
$0.64
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.53
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.63
|
| Rate for Payer: Cigna of WY Commercial |
$0.64
|
| Rate for Payer: Entrust Commercial |
$0.62
|
| Rate for Payer: First Choice Health Commercial |
$0.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.43
|
| Rate for Payer: HealthUtah PPO |
$0.65
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.63
|
| Rate for Payer: Multiplan Medicare/VA |
$0.41
|
| Rate for Payer: One Health Plan of WY PPO |
$0.64
|
| Rate for Payer: PacificSource Commercial |
$0.59
|
| Rate for Payer: PHCS PPO |
$0.64
|
| Rate for Payer: Three Rivers PPO |
$0.49
|
| Rate for Payer: TriWest Veterans Administration |
$0.43
|
| Rate for Payer: United Healthcare Commercial |
$0.57
|
| Rate for Payer: United Healthcare Medicare |
$0.43
|
| Rate for Payer: WINHealth Partners Commercial |
$0.62
|
| Rate for Payer: Wise Provider Network Commercial |
$0.62
|
|
|
MAGNESIUM CITRATE ORAL SOLUTION [15238]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 6945238998
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.03
|
| Rate for Payer: Aetna of WY Medicare |
$0.02
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.03
|
| Rate for Payer: Altius Commercial |
$0.03
|
| Rate for Payer: Beech Street Commercial |
$0.03
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.03
|
| Rate for Payer: Cigna of WY Commercial |
$0.03
|
| Rate for Payer: Entrust Commercial |
$0.03
|
| Rate for Payer: First Choice Health Commercial |
$0.03
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.03
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.02
|
| Rate for Payer: HealthUtah PPO |
$0.03
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.03
|
| Rate for Payer: Multiplan Medicare/VA |
$0.02
|
| Rate for Payer: One Health Plan of WY PPO |
$0.03
|
| Rate for Payer: PacificSource Commercial |
$0.03
|
| Rate for Payer: PHCS PPO |
$0.03
|
| Rate for Payer: Three Rivers PPO |
$0.02
|
| Rate for Payer: TriWest Veterans Administration |
$0.02
|
| Rate for Payer: United Healthcare Commercial |
$0.03
|
| Rate for Payer: United Healthcare Medicare |
$0.02
|
| Rate for Payer: WINHealth Partners Commercial |
$0.03
|
| Rate for Payer: Wise Provider Network Commercial |
$0.03
|
|
|
MAGNESIUM CITRATE ORAL SOLUTION [15238]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 6945238998
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.03
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.03
|
| Rate for Payer: Altius Commercial |
$0.03
|
| Rate for Payer: Beech Street Commercial |
$0.03
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.03
|
| Rate for Payer: Cigna of WY Commercial |
$0.03
|
| Rate for Payer: Entrust Commercial |
$0.03
|
| Rate for Payer: First Choice Health Commercial |
$0.03
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.03
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.02
|
| Rate for Payer: HealthUtah PPO |
$0.03
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.03
|
| Rate for Payer: Multiplan Medicare/VA |
$0.02
|
| Rate for Payer: One Health Plan of WY PPO |
$0.03
|
| Rate for Payer: PacificSource Commercial |
$0.03
|
| Rate for Payer: PHCS PPO |
$0.03
|
| Rate for Payer: Three Rivers PPO |
$0.02
|
| Rate for Payer: TriWest Veterans Administration |
$0.02
|
| Rate for Payer: United Healthcare Commercial |
$0.03
|
| Rate for Payer: United Healthcare Medicare |
$0.02
|
| Rate for Payer: WINHealth Partners Commercial |
$0.03
|
| Rate for Payer: Wise Provider Network Commercial |
$0.03
|
|
|
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION [10511]
|
Facility
|
IP
|
$0.27
|
|
|
Service Code
|
NDC 6068742945
|
|
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
|
|
|
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION [10511]
|
Facility
|
IP
|
$0.26
|
|
|
Service Code
|
NDC 0121043130
|
|
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
|
|
|
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION [10511]
|
Facility
|
OP
|
$0.27
|
|
|
Service Code
|
NDC 6068742945
|
|
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
|
|
|
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION [10511]
|
Facility
|
OP
|
$0.26
|
|
|
Service Code
|
NDC 0121043130
|
|
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
|
|
|
MAGNESIUM L-LACTATE ER 84 MG TABLET,EXTENDED RELEASE [35233]
|
Facility
|
IP
|
$0.83
|
|
|
Service Code
|
NDC 7132180010
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.52 |
| Max. Negotiated Rate |
$0.83 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.81
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.80
|
| Rate for Payer: Altius Commercial |
$0.80
|
| Rate for Payer: Beech Street Commercial |
$0.81
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.68
|
| Rate for Payer: Cash Price |
$0.58
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.81
|
| Rate for Payer: Cigna of WY Commercial |
$0.81
|
| Rate for Payer: Entrust Commercial |
$0.79
|
| Rate for Payer: First Choice Health Commercial |
$0.79
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.79
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.55
|
| Rate for Payer: HealthUtah PPO |
$0.83
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.81
|
| Rate for Payer: Multiplan Medicare/VA |
$0.52
|
| Rate for Payer: One Health Plan of WY PPO |
$0.81
|
| Rate for Payer: PacificSource Commercial |
$0.75
|
| Rate for Payer: PHCS PPO |
$0.81
|
| Rate for Payer: Three Rivers PPO |
$0.62
|
| Rate for Payer: TriWest Veterans Administration |
$0.55
|
| Rate for Payer: United Healthcare Commercial |
$0.72
|
| Rate for Payer: United Healthcare Medicare |
$0.55
|
| Rate for Payer: WINHealth Partners Commercial |
$0.79
|
| Rate for Payer: Wise Provider Network Commercial |
$0.79
|
|
|
MAGNESIUM L-LACTATE ER 84 MG TABLET,EXTENDED RELEASE [35233]
|
Facility
|
OP
|
$0.83
|
|
|
Service Code
|
NDC 7132180010
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$0.83 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.81
|
| Rate for Payer: Aetna of WY Medicare |
$0.55
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.80
|
| Rate for Payer: Altius Commercial |
$0.80
|
| Rate for Payer: Beech Street Commercial |
$0.81
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.68
|
| Rate for Payer: Cash Price |
$0.58
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.81
|
| Rate for Payer: Cigna of WY Commercial |
$0.81
|
| Rate for Payer: Entrust Commercial |
$0.79
|
| Rate for Payer: First Choice Health Commercial |
$0.79
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.79
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.48
|
| Rate for Payer: HealthUtah PPO |
$0.83
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.81
|
| Rate for Payer: Multiplan Medicare/VA |
$0.46
|
| Rate for Payer: One Health Plan of WY PPO |
$0.81
|
| Rate for Payer: PacificSource Commercial |
$0.75
|
| Rate for Payer: PHCS PPO |
$0.81
|
| Rate for Payer: Three Rivers PPO |
$0.62
|
| Rate for Payer: TriWest Veterans Administration |
$0.48
|
| Rate for Payer: United Healthcare Commercial |
$0.72
|
| Rate for Payer: United Healthcare Medicare |
$0.48
|
| Rate for Payer: WINHealth Partners Commercial |
$0.81
|
| Rate for Payer: Wise Provider Network Commercial |
$0.79
|
|
|
MAGNESIUM L-LACTATE ER 84 MG TABLET,EXTENDED RELEASE [35233]
|
Facility
|
OP
|
$1.33
|
|
|
Service Code
|
NDC 5901642016
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.73 |
| Max. Negotiated Rate |
$1.33 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.30
|
| Rate for Payer: Aetna of WY Medicare |
$0.88
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.28
|
| Rate for Payer: Altius Commercial |
$1.28
|
| Rate for Payer: Beech Street Commercial |
$1.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.09
|
| Rate for Payer: Cash Price |
$0.93
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.29
|
| Rate for Payer: Cigna of WY Commercial |
$1.30
|
| Rate for Payer: Entrust Commercial |
$1.26
|
| Rate for Payer: First Choice Health Commercial |
$1.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.77
|
| Rate for Payer: HealthUtah PPO |
$1.33
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.29
|
| Rate for Payer: Multiplan Medicare/VA |
$0.73
|
| Rate for Payer: One Health Plan of WY PPO |
$1.30
|
| Rate for Payer: PacificSource Commercial |
$1.20
|
| Rate for Payer: PHCS PPO |
$1.30
|
| Rate for Payer: Three Rivers PPO |
$1.00
|
| Rate for Payer: TriWest Veterans Administration |
$0.77
|
| Rate for Payer: United Healthcare Commercial |
$1.16
|
| Rate for Payer: United Healthcare Medicare |
$0.77
|
| Rate for Payer: WINHealth Partners Commercial |
$1.30
|
| Rate for Payer: Wise Provider Network Commercial |
$1.26
|
|
|
MAGNESIUM L-LACTATE ER 84 MG TABLET,EXTENDED RELEASE [35233]
|
Facility
|
IP
|
$1.48
|
|
|
Service Code
|
NDC 3676542016
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$1.48 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.45
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.42
|
| Rate for Payer: Altius Commercial |
$1.42
|
| Rate for Payer: Beech Street Commercial |
$1.45
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.22
|
| Rate for Payer: Cash Price |
$1.04
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.44
|
| Rate for Payer: Cigna of WY Commercial |
$1.45
|
| Rate for Payer: Entrust Commercial |
$1.41
|
| Rate for Payer: First Choice Health Commercial |
$1.41
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.41
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.98
|
| Rate for Payer: HealthUtah PPO |
$1.48
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.44
|
| Rate for Payer: Multiplan Medicare/VA |
$0.93
|
| Rate for Payer: One Health Plan of WY PPO |
$1.45
|
| Rate for Payer: PacificSource Commercial |
$1.33
|
| Rate for Payer: PHCS PPO |
$1.45
|
| Rate for Payer: Three Rivers PPO |
$1.11
|
| Rate for Payer: TriWest Veterans Administration |
$0.98
|
| Rate for Payer: United Healthcare Commercial |
$1.29
|
| Rate for Payer: United Healthcare Medicare |
$0.98
|
| Rate for Payer: WINHealth Partners Commercial |
$1.41
|
| Rate for Payer: Wise Provider Network Commercial |
$1.41
|
|
|
MAGNESIUM L-LACTATE ER 84 MG TABLET,EXTENDED RELEASE [35233]
|
Facility
|
OP
|
$1.48
|
|
|
Service Code
|
NDC 3676542016
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$1.48 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.45
|
| Rate for Payer: Aetna of WY Medicare |
$0.98
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.42
|
| Rate for Payer: Altius Commercial |
$1.42
|
| Rate for Payer: Beech Street Commercial |
$1.45
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.22
|
| Rate for Payer: Cash Price |
$1.04
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.44
|
| Rate for Payer: Cigna of WY Commercial |
$1.45
|
| Rate for Payer: Entrust Commercial |
$1.41
|
| Rate for Payer: First Choice Health Commercial |
$1.41
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.41
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.86
|
| Rate for Payer: HealthUtah PPO |
$1.48
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.44
|
| Rate for Payer: Multiplan Medicare/VA |
$0.82
|
| Rate for Payer: One Health Plan of WY PPO |
$1.45
|
| Rate for Payer: PacificSource Commercial |
$1.33
|
| Rate for Payer: PHCS PPO |
$1.45
|
| Rate for Payer: Three Rivers PPO |
$1.11
|
| Rate for Payer: TriWest Veterans Administration |
$0.86
|
| Rate for Payer: United Healthcare Commercial |
$1.29
|
| Rate for Payer: United Healthcare Medicare |
$0.86
|
| Rate for Payer: WINHealth Partners Commercial |
$1.45
|
| Rate for Payer: Wise Provider Network Commercial |
$1.41
|
|
|
MAGNESIUM L-LACTATE ER 84 MG TABLET,EXTENDED RELEASE [35233]
|
Facility
|
IP
|
$1.33
|
|
|
Service Code
|
NDC 5901642016
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.83 |
| Max. Negotiated Rate |
$1.33 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.30
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.28
|
| Rate for Payer: Altius Commercial |
$1.28
|
| Rate for Payer: Beech Street Commercial |
$1.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.09
|
| Rate for Payer: Cash Price |
$0.93
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.29
|
| Rate for Payer: Cigna of WY Commercial |
$1.30
|
| Rate for Payer: Entrust Commercial |
$1.26
|
| Rate for Payer: First Choice Health Commercial |
$1.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.88
|
| Rate for Payer: HealthUtah PPO |
$1.33
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.29
|
| Rate for Payer: Multiplan Medicare/VA |
$0.83
|
| Rate for Payer: One Health Plan of WY PPO |
$1.30
|
| Rate for Payer: PacificSource Commercial |
$1.20
|
| Rate for Payer: PHCS PPO |
$1.30
|
| Rate for Payer: Three Rivers PPO |
$1.00
|
| Rate for Payer: TriWest Veterans Administration |
$0.88
|
| Rate for Payer: United Healthcare Commercial |
$1.16
|
| Rate for Payer: United Healthcare Medicare |
$0.88
|
| Rate for Payer: WINHealth Partners Commercial |
$1.26
|
| Rate for Payer: Wise Provider Network Commercial |
$1.26
|
|
|
MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET [10269]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 5789663412
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.10
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.10
|
| Rate for Payer: Altius Commercial |
$0.10
|
| Rate for Payer: Beech Street Commercial |
$0.10
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.08
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.10
|
| Rate for Payer: Cigna of WY Commercial |
$0.10
|
| Rate for Payer: Entrust Commercial |
$0.10
|
| Rate for Payer: First Choice Health Commercial |
$0.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.07
|
| Rate for Payer: HealthUtah PPO |
$0.10
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.10
|
| Rate for Payer: Multiplan Medicare/VA |
$0.06
|
| Rate for Payer: One Health Plan of WY PPO |
$0.10
|
| Rate for Payer: PacificSource Commercial |
$0.09
|
| Rate for Payer: PHCS PPO |
$0.10
|
| Rate for Payer: Three Rivers PPO |
$0.08
|
| Rate for Payer: TriWest Veterans Administration |
$0.07
|
| Rate for Payer: United Healthcare Commercial |
$0.09
|
| Rate for Payer: United Healthcare Medicare |
$0.07
|
| Rate for Payer: WINHealth Partners Commercial |
$0.10
|
| Rate for Payer: Wise Provider Network Commercial |
$0.10
|
|
