|
MELOXICAM 7.5 MG TABLET [9270]
|
Facility
|
IP
|
$0.66
|
|
|
Service Code
|
NDC 5026852515
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$0.66 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.65
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.63
|
| Rate for Payer: Altius Commercial |
$0.63
|
| Rate for Payer: Beech Street Commercial |
$0.65
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.54
|
| Rate for Payer: Cash Price |
$0.46
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.64
|
| Rate for Payer: Cigna of WY Commercial |
$0.65
|
| Rate for Payer: Entrust Commercial |
$0.63
|
| Rate for Payer: First Choice Health Commercial |
$0.63
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.63
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.44
|
| Rate for Payer: HealthUtah PPO |
$0.66
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.64
|
| Rate for Payer: Multiplan Medicare/VA |
$0.41
|
| Rate for Payer: One Health Plan of WY PPO |
$0.65
|
| Rate for Payer: PacificSource Commercial |
$0.59
|
| Rate for Payer: PHCS PPO |
$0.65
|
| Rate for Payer: Three Rivers PPO |
$0.50
|
| Rate for Payer: TriWest Veterans Administration |
$0.44
|
| Rate for Payer: United Healthcare Commercial |
$0.57
|
| Rate for Payer: United Healthcare Medicare |
$0.44
|
| Rate for Payer: WINHealth Partners Commercial |
$0.63
|
| Rate for Payer: Wise Provider Network Commercial |
$0.63
|
|
|
MELOXICAM 7.5 MG TABLET [9270]
|
Facility
|
OP
|
$0.66
|
|
|
Service Code
|
NDC 5026852515
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$0.66 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.65
|
| Rate for Payer: Aetna of WY Medicare |
$0.44
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.63
|
| Rate for Payer: Altius Commercial |
$0.63
|
| Rate for Payer: Beech Street Commercial |
$0.65
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.54
|
| Rate for Payer: Cash Price |
$0.46
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.64
|
| Rate for Payer: Cigna of WY Commercial |
$0.65
|
| Rate for Payer: Entrust Commercial |
$0.63
|
| Rate for Payer: First Choice Health Commercial |
$0.63
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.63
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.38
|
| Rate for Payer: HealthUtah PPO |
$0.66
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.64
|
| Rate for Payer: Multiplan Medicare/VA |
$0.36
|
| Rate for Payer: One Health Plan of WY PPO |
$0.65
|
| Rate for Payer: PacificSource Commercial |
$0.59
|
| Rate for Payer: PHCS PPO |
$0.65
|
| Rate for Payer: Three Rivers PPO |
$0.50
|
| 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 |
$0.65
|
| Rate for Payer: Wise Provider Network Commercial |
$0.63
|
|
|
MELOXICAM 7.5 MG TABLET [9270]
|
Facility
|
IP
|
$0.66
|
|
|
Service Code
|
NDC 5026852511
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$0.66 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.65
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.63
|
| Rate for Payer: Altius Commercial |
$0.63
|
| Rate for Payer: Beech Street Commercial |
$0.65
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.54
|
| Rate for Payer: Cash Price |
$0.46
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.64
|
| Rate for Payer: Cigna of WY Commercial |
$0.65
|
| Rate for Payer: Entrust Commercial |
$0.63
|
| Rate for Payer: First Choice Health Commercial |
$0.63
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.63
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.44
|
| Rate for Payer: HealthUtah PPO |
$0.66
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.64
|
| Rate for Payer: Multiplan Medicare/VA |
$0.41
|
| Rate for Payer: One Health Plan of WY PPO |
$0.65
|
| Rate for Payer: PacificSource Commercial |
$0.59
|
| Rate for Payer: PHCS PPO |
$0.65
|
| Rate for Payer: Three Rivers PPO |
$0.50
|
| Rate for Payer: TriWest Veterans Administration |
$0.44
|
| Rate for Payer: United Healthcare Commercial |
$0.57
|
| Rate for Payer: United Healthcare Medicare |
$0.44
|
| Rate for Payer: WINHealth Partners Commercial |
$0.63
|
| Rate for Payer: Wise Provider Network Commercial |
$0.63
|
|
|
MELOXICAM 7.5 MG TABLET [9270]
|
Facility
|
OP
|
$0.66
|
|
|
Service Code
|
NDC 5026852511
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$0.66 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.65
|
| Rate for Payer: Aetna of WY Medicare |
$0.44
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.63
|
| Rate for Payer: Altius Commercial |
$0.63
|
| Rate for Payer: Beech Street Commercial |
$0.65
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.54
|
| Rate for Payer: Cash Price |
$0.46
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.64
|
| Rate for Payer: Cigna of WY Commercial |
$0.65
|
| Rate for Payer: Entrust Commercial |
$0.63
|
| Rate for Payer: First Choice Health Commercial |
$0.63
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.63
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.38
|
| Rate for Payer: HealthUtah PPO |
$0.66
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.64
|
| Rate for Payer: Multiplan Medicare/VA |
$0.36
|
| Rate for Payer: One Health Plan of WY PPO |
$0.65
|
| Rate for Payer: PacificSource Commercial |
$0.59
|
| Rate for Payer: PHCS PPO |
$0.65
|
| Rate for Payer: Three Rivers PPO |
$0.50
|
| 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 |
$0.65
|
| Rate for Payer: Wise Provider Network Commercial |
$0.63
|
|
|
MEMANTINE 10 MG TABLET [31159]
|
Facility
|
OP
|
$2.67
|
|
|
Service Code
|
NDC 6068718411
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.47 |
| Max. Negotiated Rate |
$2.67 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.62
|
| Rate for Payer: Aetna of WY Medicare |
$1.76
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.56
|
| Rate for Payer: Altius Commercial |
$2.56
|
| Rate for Payer: Beech Street Commercial |
$2.62
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.19
|
| Rate for Payer: Cash Price |
$1.87
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.59
|
| Rate for Payer: Cigna of WY Commercial |
$2.62
|
| Rate for Payer: Entrust Commercial |
$2.54
|
| Rate for Payer: First Choice Health Commercial |
$2.54
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.54
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.55
|
| Rate for Payer: HealthUtah PPO |
$2.67
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.59
|
| Rate for Payer: Multiplan Medicare/VA |
$1.47
|
| Rate for Payer: One Health Plan of WY PPO |
$2.62
|
| Rate for Payer: PacificSource Commercial |
$2.40
|
| Rate for Payer: PHCS PPO |
$2.62
|
| Rate for Payer: Three Rivers PPO |
$2.00
|
| Rate for Payer: TriWest Veterans Administration |
$1.55
|
| Rate for Payer: United Healthcare Commercial |
$2.32
|
| Rate for Payer: United Healthcare Medicare |
$1.55
|
| Rate for Payer: WINHealth Partners Commercial |
$2.62
|
| Rate for Payer: Wise Provider Network Commercial |
$2.54
|
|
|
MEMANTINE 10 MG TABLET [31159]
|
Facility
|
OP
|
$2.67
|
|
|
Service Code
|
NDC 6068718457
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.47 |
| Max. Negotiated Rate |
$2.67 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.62
|
| Rate for Payer: Aetna of WY Medicare |
$1.76
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.56
|
| Rate for Payer: Altius Commercial |
$2.56
|
| Rate for Payer: Beech Street Commercial |
$2.62
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.19
|
| Rate for Payer: Cash Price |
$1.87
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.59
|
| Rate for Payer: Cigna of WY Commercial |
$2.62
|
| Rate for Payer: Entrust Commercial |
$2.54
|
| Rate for Payer: First Choice Health Commercial |
$2.54
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.54
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.55
|
| Rate for Payer: HealthUtah PPO |
$2.67
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.59
|
| Rate for Payer: Multiplan Medicare/VA |
$1.47
|
| Rate for Payer: One Health Plan of WY PPO |
$2.62
|
| Rate for Payer: PacificSource Commercial |
$2.40
|
| Rate for Payer: PHCS PPO |
$2.62
|
| Rate for Payer: Three Rivers PPO |
$2.00
|
| Rate for Payer: TriWest Veterans Administration |
$1.55
|
| Rate for Payer: United Healthcare Commercial |
$2.32
|
| Rate for Payer: United Healthcare Medicare |
$1.55
|
| Rate for Payer: WINHealth Partners Commercial |
$2.62
|
| Rate for Payer: Wise Provider Network Commercial |
$2.54
|
|
|
MEMANTINE 10 MG TABLET [31159]
|
Facility
|
IP
|
$2.67
|
|
|
Service Code
|
NDC 6068718457
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.67 |
| Max. Negotiated Rate |
$2.67 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.62
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.56
|
| Rate for Payer: Altius Commercial |
$2.56
|
| Rate for Payer: Beech Street Commercial |
$2.62
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.19
|
| Rate for Payer: Cash Price |
$1.87
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.59
|
| Rate for Payer: Cigna of WY Commercial |
$2.62
|
| Rate for Payer: Entrust Commercial |
$2.54
|
| Rate for Payer: First Choice Health Commercial |
$2.54
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.54
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.76
|
| Rate for Payer: HealthUtah PPO |
$2.67
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.59
|
| Rate for Payer: Multiplan Medicare/VA |
$1.67
|
| Rate for Payer: One Health Plan of WY PPO |
$2.62
|
| Rate for Payer: PacificSource Commercial |
$2.40
|
| Rate for Payer: PHCS PPO |
$2.62
|
| Rate for Payer: Three Rivers PPO |
$2.00
|
| Rate for Payer: TriWest Veterans Administration |
$1.76
|
| Rate for Payer: United Healthcare Commercial |
$2.32
|
| Rate for Payer: United Healthcare Medicare |
$1.76
|
| Rate for Payer: WINHealth Partners Commercial |
$2.54
|
| Rate for Payer: Wise Provider Network Commercial |
$2.54
|
|
|
MEMANTINE 10 MG TABLET [31159]
|
Facility
|
IP
|
$2.67
|
|
|
Service Code
|
NDC 6068718411
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.67 |
| Max. Negotiated Rate |
$2.67 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.62
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.56
|
| Rate for Payer: Altius Commercial |
$2.56
|
| Rate for Payer: Beech Street Commercial |
$2.62
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.19
|
| Rate for Payer: Cash Price |
$1.87
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.59
|
| Rate for Payer: Cigna of WY Commercial |
$2.62
|
| Rate for Payer: Entrust Commercial |
$2.54
|
| Rate for Payer: First Choice Health Commercial |
$2.54
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.54
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.76
|
| Rate for Payer: HealthUtah PPO |
$2.67
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.59
|
| Rate for Payer: Multiplan Medicare/VA |
$1.67
|
| Rate for Payer: One Health Plan of WY PPO |
$2.62
|
| Rate for Payer: PacificSource Commercial |
$2.40
|
| Rate for Payer: PHCS PPO |
$2.62
|
| Rate for Payer: Three Rivers PPO |
$2.00
|
| Rate for Payer: TriWest Veterans Administration |
$1.76
|
| Rate for Payer: United Healthcare Commercial |
$2.32
|
| Rate for Payer: United Healthcare Medicare |
$1.76
|
| Rate for Payer: WINHealth Partners Commercial |
$2.54
|
| Rate for Payer: Wise Provider Network Commercial |
$2.54
|
|
|
MEMANTINE 28 MG CAPSULE SPRINKLE,EXTENDED RELEASE 24HR [127756]
|
Facility
|
IP
|
$5.33
|
|
|
Service Code
|
NDC 5965140790
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.34 |
| Max. Negotiated Rate |
$5.33 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5.22
|
| Rate for Payer: Altius Auto/Workers Compensation |
$5.12
|
| Rate for Payer: Altius Commercial |
$5.12
|
| Rate for Payer: Beech Street Commercial |
$5.22
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$4.38
|
| Rate for Payer: Cash Price |
$3.73
|
| Rate for Payer: ChoiceCare Network Commercial |
$5.17
|
| Rate for Payer: Cigna of WY Commercial |
$5.22
|
| Rate for Payer: Entrust Commercial |
$5.06
|
| Rate for Payer: First Choice Health Commercial |
$5.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3.52
|
| Rate for Payer: HealthUtah PPO |
$5.33
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5.17
|
| Rate for Payer: Multiplan Medicare/VA |
$3.34
|
| Rate for Payer: One Health Plan of WY PPO |
$5.22
|
| Rate for Payer: PacificSource Commercial |
$4.80
|
| Rate for Payer: PHCS PPO |
$5.22
|
| Rate for Payer: Three Rivers PPO |
$4.00
|
| Rate for Payer: TriWest Veterans Administration |
$3.52
|
| Rate for Payer: United Healthcare Commercial |
$4.64
|
| Rate for Payer: United Healthcare Medicare |
$3.52
|
| Rate for Payer: WINHealth Partners Commercial |
$5.06
|
| Rate for Payer: Wise Provider Network Commercial |
$5.06
|
|
|
MEMANTINE 28 MG CAPSULE SPRINKLE,EXTENDED RELEASE 24HR [127756]
|
Facility
|
OP
|
$5.33
|
|
|
Service Code
|
NDC 5965140790
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.94 |
| Max. Negotiated Rate |
$5.33 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5.22
|
| Rate for Payer: Aetna of WY Medicare |
$3.52
|
| Rate for Payer: Altius Auto/Workers Compensation |
$5.12
|
| Rate for Payer: Altius Commercial |
$5.12
|
| Rate for Payer: Beech Street Commercial |
$5.22
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$4.38
|
| Rate for Payer: Cash Price |
$3.73
|
| Rate for Payer: ChoiceCare Network Commercial |
$5.17
|
| Rate for Payer: Cigna of WY Commercial |
$5.22
|
| Rate for Payer: Entrust Commercial |
$5.06
|
| Rate for Payer: First Choice Health Commercial |
$5.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3.09
|
| Rate for Payer: HealthUtah PPO |
$5.33
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5.17
|
| Rate for Payer: Multiplan Medicare/VA |
$2.94
|
| Rate for Payer: One Health Plan of WY PPO |
$5.22
|
| Rate for Payer: PacificSource Commercial |
$4.80
|
| Rate for Payer: PHCS PPO |
$5.22
|
| Rate for Payer: Three Rivers PPO |
$4.00
|
| Rate for Payer: TriWest Veterans Administration |
$3.09
|
| Rate for Payer: United Healthcare Commercial |
$4.64
|
| Rate for Payer: United Healthcare Medicare |
$3.09
|
| Rate for Payer: WINHealth Partners Commercial |
$5.22
|
| Rate for Payer: Wise Provider Network Commercial |
$5.06
|
|
|
MEMANTINE 28 MG CAPSULE SPRINKLE,EXTENDED RELEASE 24HR [127756]
|
Facility
|
OP
|
$5.33
|
|
|
Service Code
|
NDC 5965140730
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.94 |
| Max. Negotiated Rate |
$5.33 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5.22
|
| Rate for Payer: Aetna of WY Medicare |
$3.52
|
| Rate for Payer: Altius Auto/Workers Compensation |
$5.12
|
| Rate for Payer: Altius Commercial |
$5.12
|
| Rate for Payer: Beech Street Commercial |
$5.22
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$4.38
|
| Rate for Payer: Cash Price |
$3.73
|
| Rate for Payer: ChoiceCare Network Commercial |
$5.17
|
| Rate for Payer: Cigna of WY Commercial |
$5.22
|
| Rate for Payer: Entrust Commercial |
$5.06
|
| Rate for Payer: First Choice Health Commercial |
$5.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3.09
|
| Rate for Payer: HealthUtah PPO |
$5.33
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5.17
|
| Rate for Payer: Multiplan Medicare/VA |
$2.94
|
| Rate for Payer: One Health Plan of WY PPO |
$5.22
|
| Rate for Payer: PacificSource Commercial |
$4.80
|
| Rate for Payer: PHCS PPO |
$5.22
|
| Rate for Payer: Three Rivers PPO |
$4.00
|
| Rate for Payer: TriWest Veterans Administration |
$3.09
|
| Rate for Payer: United Healthcare Commercial |
$4.64
|
| Rate for Payer: United Healthcare Medicare |
$3.09
|
| Rate for Payer: WINHealth Partners Commercial |
$5.22
|
| Rate for Payer: Wise Provider Network Commercial |
$5.06
|
|
|
MEMANTINE 28 MG CAPSULE SPRINKLE,EXTENDED RELEASE 24HR [127756]
|
Facility
|
IP
|
$5.33
|
|
|
Service Code
|
NDC 5965140730
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.34 |
| Max. Negotiated Rate |
$5.33 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5.22
|
| Rate for Payer: Altius Auto/Workers Compensation |
$5.12
|
| Rate for Payer: Altius Commercial |
$5.12
|
| Rate for Payer: Beech Street Commercial |
$5.22
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$4.38
|
| Rate for Payer: Cash Price |
$3.73
|
| Rate for Payer: ChoiceCare Network Commercial |
$5.17
|
| Rate for Payer: Cigna of WY Commercial |
$5.22
|
| Rate for Payer: Entrust Commercial |
$5.06
|
| Rate for Payer: First Choice Health Commercial |
$5.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3.52
|
| Rate for Payer: HealthUtah PPO |
$5.33
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5.17
|
| Rate for Payer: Multiplan Medicare/VA |
$3.34
|
| Rate for Payer: One Health Plan of WY PPO |
$5.22
|
| Rate for Payer: PacificSource Commercial |
$4.80
|
| Rate for Payer: PHCS PPO |
$5.22
|
| Rate for Payer: Three Rivers PPO |
$4.00
|
| Rate for Payer: TriWest Veterans Administration |
$3.52
|
| Rate for Payer: United Healthcare Commercial |
$4.64
|
| Rate for Payer: United Healthcare Medicare |
$3.52
|
| Rate for Payer: WINHealth Partners Commercial |
$5.06
|
| Rate for Payer: Wise Provider Network Commercial |
$5.06
|
|
|
MEMANTINE 5 MG TABLET [31163]
|
Facility
|
IP
|
$1.93
|
|
|
Service Code
|
NDC 6068717311
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.21 |
| Max. Negotiated Rate |
$1.93 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.89
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.85
|
| Rate for Payer: Altius Commercial |
$1.85
|
| Rate for Payer: Beech Street Commercial |
$1.89
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.58
|
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.87
|
| Rate for Payer: Cigna of WY Commercial |
$1.89
|
| Rate for Payer: Entrust Commercial |
$1.83
|
| Rate for Payer: First Choice Health Commercial |
$1.83
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.83
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.27
|
| Rate for Payer: HealthUtah PPO |
$1.93
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.87
|
| Rate for Payer: Multiplan Medicare/VA |
$1.21
|
| Rate for Payer: One Health Plan of WY PPO |
$1.89
|
| Rate for Payer: PacificSource Commercial |
$1.74
|
| Rate for Payer: PHCS PPO |
$1.89
|
| Rate for Payer: Three Rivers PPO |
$1.45
|
| Rate for Payer: TriWest Veterans Administration |
$1.27
|
| Rate for Payer: United Healthcare Commercial |
$1.68
|
| Rate for Payer: United Healthcare Medicare |
$1.27
|
| Rate for Payer: WINHealth Partners Commercial |
$1.83
|
| Rate for Payer: Wise Provider Network Commercial |
$1.83
|
|
|
MEMANTINE 5 MG TABLET [31163]
|
Facility
|
OP
|
$1.93
|
|
|
Service Code
|
NDC 6068717357
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.06 |
| Max. Negotiated Rate |
$1.93 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.89
|
| Rate for Payer: Aetna of WY Medicare |
$1.27
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.85
|
| Rate for Payer: Altius Commercial |
$1.85
|
| Rate for Payer: Beech Street Commercial |
$1.89
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.58
|
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.87
|
| Rate for Payer: Cigna of WY Commercial |
$1.89
|
| Rate for Payer: Entrust Commercial |
$1.83
|
| Rate for Payer: First Choice Health Commercial |
$1.83
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.83
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.12
|
| Rate for Payer: HealthUtah PPO |
$1.93
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.87
|
| Rate for Payer: Multiplan Medicare/VA |
$1.06
|
| Rate for Payer: One Health Plan of WY PPO |
$1.89
|
| Rate for Payer: PacificSource Commercial |
$1.74
|
| Rate for Payer: PHCS PPO |
$1.89
|
| Rate for Payer: Three Rivers PPO |
$1.45
|
| Rate for Payer: TriWest Veterans Administration |
$1.12
|
| Rate for Payer: United Healthcare Commercial |
$1.68
|
| Rate for Payer: United Healthcare Medicare |
$1.12
|
| Rate for Payer: WINHealth Partners Commercial |
$1.89
|
| Rate for Payer: Wise Provider Network Commercial |
$1.83
|
|
|
MEMANTINE 5 MG TABLET [31163]
|
Facility
|
IP
|
$1.63
|
|
|
Service Code
|
NDC 0904650506
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$1.63 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.60
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.56
|
| Rate for Payer: Altius Commercial |
$1.56
|
| Rate for Payer: Beech Street Commercial |
$1.60
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.34
|
| Rate for Payer: Cash Price |
$1.14
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.58
|
| Rate for Payer: Cigna of WY Commercial |
$1.60
|
| Rate for Payer: Entrust Commercial |
$1.55
|
| Rate for Payer: First Choice Health Commercial |
$1.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.08
|
| Rate for Payer: HealthUtah PPO |
$1.63
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.58
|
| Rate for Payer: Multiplan Medicare/VA |
$1.02
|
| Rate for Payer: One Health Plan of WY PPO |
$1.60
|
| Rate for Payer: PacificSource Commercial |
$1.47
|
| Rate for Payer: PHCS PPO |
$1.60
|
| Rate for Payer: Three Rivers PPO |
$1.22
|
| Rate for Payer: TriWest Veterans Administration |
$1.08
|
| Rate for Payer: United Healthcare Commercial |
$1.42
|
| Rate for Payer: United Healthcare Medicare |
$1.08
|
| Rate for Payer: WINHealth Partners Commercial |
$1.55
|
| Rate for Payer: Wise Provider Network Commercial |
$1.55
|
|
|
MEMANTINE 5 MG TABLET [31163]
|
Facility
|
IP
|
$1.93
|
|
|
Service Code
|
NDC 6068717357
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.21 |
| Max. Negotiated Rate |
$1.93 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.89
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.85
|
| Rate for Payer: Altius Commercial |
$1.85
|
| Rate for Payer: Beech Street Commercial |
$1.89
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.58
|
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.87
|
| Rate for Payer: Cigna of WY Commercial |
$1.89
|
| Rate for Payer: Entrust Commercial |
$1.83
|
| Rate for Payer: First Choice Health Commercial |
$1.83
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.83
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.27
|
| Rate for Payer: HealthUtah PPO |
$1.93
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.87
|
| Rate for Payer: Multiplan Medicare/VA |
$1.21
|
| Rate for Payer: One Health Plan of WY PPO |
$1.89
|
| Rate for Payer: PacificSource Commercial |
$1.74
|
| Rate for Payer: PHCS PPO |
$1.89
|
| Rate for Payer: Three Rivers PPO |
$1.45
|
| Rate for Payer: TriWest Veterans Administration |
$1.27
|
| Rate for Payer: United Healthcare Commercial |
$1.68
|
| Rate for Payer: United Healthcare Medicare |
$1.27
|
| Rate for Payer: WINHealth Partners Commercial |
$1.83
|
| Rate for Payer: Wise Provider Network Commercial |
$1.83
|
|
|
MEMANTINE 5 MG TABLET [31163]
|
Facility
|
OP
|
$1.63
|
|
|
Service Code
|
NDC 0904650506
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.90 |
| Max. Negotiated Rate |
$1.63 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.60
|
| Rate for Payer: Aetna of WY Medicare |
$1.08
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.56
|
| Rate for Payer: Altius Commercial |
$1.56
|
| Rate for Payer: Beech Street Commercial |
$1.60
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.34
|
| Rate for Payer: Cash Price |
$1.14
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.58
|
| Rate for Payer: Cigna of WY Commercial |
$1.60
|
| Rate for Payer: Entrust Commercial |
$1.55
|
| Rate for Payer: First Choice Health Commercial |
$1.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.95
|
| Rate for Payer: HealthUtah PPO |
$1.63
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.58
|
| Rate for Payer: Multiplan Medicare/VA |
$0.90
|
| Rate for Payer: One Health Plan of WY PPO |
$1.60
|
| Rate for Payer: PacificSource Commercial |
$1.47
|
| Rate for Payer: PHCS PPO |
$1.60
|
| Rate for Payer: Three Rivers PPO |
$1.22
|
| Rate for Payer: TriWest Veterans Administration |
$0.95
|
| Rate for Payer: United Healthcare Commercial |
$1.42
|
| Rate for Payer: United Healthcare Medicare |
$0.95
|
| Rate for Payer: WINHealth Partners Commercial |
$1.60
|
| Rate for Payer: Wise Provider Network Commercial |
$1.55
|
|
|
MEMANTINE 5 MG TABLET [31163]
|
Facility
|
OP
|
$1.93
|
|
|
Service Code
|
NDC 6068717311
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.06 |
| Max. Negotiated Rate |
$1.93 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.89
|
| Rate for Payer: Aetna of WY Medicare |
$1.27
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.85
|
| Rate for Payer: Altius Commercial |
$1.85
|
| Rate for Payer: Beech Street Commercial |
$1.89
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.58
|
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.87
|
| Rate for Payer: Cigna of WY Commercial |
$1.89
|
| Rate for Payer: Entrust Commercial |
$1.83
|
| Rate for Payer: First Choice Health Commercial |
$1.83
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.83
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.12
|
| Rate for Payer: HealthUtah PPO |
$1.93
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.87
|
| Rate for Payer: Multiplan Medicare/VA |
$1.06
|
| Rate for Payer: One Health Plan of WY PPO |
$1.89
|
| Rate for Payer: PacificSource Commercial |
$1.74
|
| Rate for Payer: PHCS PPO |
$1.89
|
| Rate for Payer: Three Rivers PPO |
$1.45
|
| Rate for Payer: TriWest Veterans Administration |
$1.12
|
| Rate for Payer: United Healthcare Commercial |
$1.68
|
| Rate for Payer: United Healthcare Medicare |
$1.12
|
| Rate for Payer: WINHealth Partners Commercial |
$1.89
|
| Rate for Payer: Wise Provider Network Commercial |
$1.83
|
|
|
MENACWYD/MENACWY-CRM CONJ VACC GRPS ACWY IM USE
|
Professional
|
Both
|
$410.00
|
|
|
Service Code
|
HCPCS 90734
|
| Hospital Charge Code |
90734
|
| Min. Negotiated Rate |
$307.50 |
| Max. Negotiated Rate |
$410.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$401.80
|
| Rate for Payer: Beech Street Commercial |
$389.50
|
| Rate for Payer: Cash Price |
$287.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$397.70
|
| Rate for Payer: Cigna of WY Commercial |
$401.80
|
| Rate for Payer: First Choice Health Commercial |
$369.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$389.50
|
| Rate for Payer: HealthUtah PPO |
$410.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$397.70
|
| Rate for Payer: One Health Plan of WY PPO |
$401.80
|
| Rate for Payer: PacificSource Commercial |
$369.00
|
| Rate for Payer: PHCS PPO |
$389.50
|
| Rate for Payer: Three Rivers PPO |
$307.50
|
| Rate for Payer: United Healthcare Commercial |
$356.70
|
| Rate for Payer: WINHealth Partners Commercial |
$410.00
|
|
|
MENACWY-TT CONJ VACC SEROGROUPS ACWY FOR IM USE
|
Professional
|
Both
|
$380.00
|
|
|
Service Code
|
HCPCS 90619
|
| Hospital Charge Code |
90619
|
| Min. Negotiated Rate |
$285.00 |
| Max. Negotiated Rate |
$380.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$372.40
|
| Rate for Payer: Beech Street Commercial |
$361.00
|
| Rate for Payer: Cash Price |
$266.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$368.60
|
| Rate for Payer: Cigna of WY Commercial |
$372.40
|
| Rate for Payer: First Choice Health Commercial |
$342.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$361.00
|
| Rate for Payer: HealthUtah PPO |
$380.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$368.60
|
| Rate for Payer: One Health Plan of WY PPO |
$372.40
|
| Rate for Payer: PacificSource Commercial |
$342.00
|
| Rate for Payer: PHCS PPO |
$361.00
|
| Rate for Payer: Three Rivers PPO |
$285.00
|
| Rate for Payer: United Healthcare Commercial |
$330.60
|
| Rate for Payer: WINHealth Partners Commercial |
$380.00
|
|
|
MENB-4C RECOMBNT PROT & OUTER MEMB VESIC VACC IM
|
Professional
|
Both
|
$448.00
|
|
|
Service Code
|
HCPCS 90620
|
| Hospital Charge Code |
90620
|
| Min. Negotiated Rate |
$336.00 |
| Max. Negotiated Rate |
$448.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$439.04
|
| Rate for Payer: Beech Street Commercial |
$425.60
|
| Rate for Payer: Cash Price |
$313.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$434.56
|
| Rate for Payer: Cigna of WY Commercial |
$439.04
|
| Rate for Payer: First Choice Health Commercial |
$403.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$425.60
|
| Rate for Payer: HealthUtah PPO |
$448.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$434.56
|
| Rate for Payer: One Health Plan of WY PPO |
$439.04
|
| Rate for Payer: PacificSource Commercial |
$403.20
|
| Rate for Payer: PHCS PPO |
$425.60
|
| Rate for Payer: Three Rivers PPO |
$336.00
|
| Rate for Payer: United Healthcare Commercial |
$389.76
|
| Rate for Payer: WINHealth Partners Commercial |
$448.00
|
|
|
MENINGOCOCCAL A CONJ VACC 2 OF 2(PF) 10 MCG/0.5 ML (FINAL) IM SOLUTION [140206]
|
Facility
|
OP
|
$249.00
|
|
|
Service Code
|
NDC 5816095801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$137.20 |
| Max. Negotiated Rate |
$249.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$244.02
|
| Rate for Payer: Aetna of WY Medicare |
$164.34
|
| Rate for Payer: Altius Auto/Workers Compensation |
$239.04
|
| Rate for Payer: Altius Commercial |
$239.04
|
| Rate for Payer: Beech Street Commercial |
$244.02
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$204.43
|
| Rate for Payer: Cash Price |
$174.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$241.53
|
| Rate for Payer: Cigna of WY Commercial |
$244.02
|
| Rate for Payer: Entrust Commercial |
$236.55
|
| Rate for Payer: First Choice Health Commercial |
$236.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$236.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$144.42
|
| Rate for Payer: HealthUtah PPO |
$249.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$241.53
|
| Rate for Payer: Multiplan Medicare/VA |
$137.20
|
| Rate for Payer: One Health Plan of WY PPO |
$244.02
|
| Rate for Payer: PacificSource Commercial |
$224.10
|
| Rate for Payer: PHCS PPO |
$244.02
|
| Rate for Payer: Three Rivers PPO |
$186.75
|
| Rate for Payer: TriWest Veterans Administration |
$144.42
|
| Rate for Payer: United Healthcare Commercial |
$216.63
|
| Rate for Payer: United Healthcare Medicare |
$144.42
|
| Rate for Payer: WINHealth Partners Commercial |
$244.02
|
| Rate for Payer: Wise Provider Network Commercial |
$236.55
|
|
|
MENINGOCOCCAL A CONJ VACC 2 OF 2(PF) 10 MCG/0.5 ML (FINAL) IM SOLUTION [140206]
|
Facility
|
IP
|
$249.00
|
|
|
Service Code
|
NDC 5816095801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$156.12 |
| Max. Negotiated Rate |
$249.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$244.02
|
| Rate for Payer: Altius Auto/Workers Compensation |
$239.04
|
| Rate for Payer: Altius Commercial |
$239.04
|
| Rate for Payer: Beech Street Commercial |
$244.02
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$204.43
|
| Rate for Payer: Cash Price |
$174.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$241.53
|
| Rate for Payer: Cigna of WY Commercial |
$244.02
|
| Rate for Payer: Entrust Commercial |
$236.55
|
| Rate for Payer: First Choice Health Commercial |
$236.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$236.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$164.34
|
| Rate for Payer: HealthUtah PPO |
$249.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$241.53
|
| Rate for Payer: Multiplan Medicare/VA |
$156.12
|
| Rate for Payer: One Health Plan of WY PPO |
$244.02
|
| Rate for Payer: PacificSource Commercial |
$224.10
|
| Rate for Payer: PHCS PPO |
$244.02
|
| Rate for Payer: Three Rivers PPO |
$186.75
|
| Rate for Payer: TriWest Veterans Administration |
$164.34
|
| Rate for Payer: United Healthcare Commercial |
$216.63
|
| Rate for Payer: United Healthcare Medicare |
$164.34
|
| Rate for Payer: WINHealth Partners Commercial |
$236.55
|
| Rate for Payer: Wise Provider Network Commercial |
$236.55
|
|
|
MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE [139170]
|
Facility
|
IP
|
$487.75
|
|
|
Service Code
|
NDC 5816097602
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$305.82 |
| Max. Negotiated Rate |
$487.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$478.00
|
| Rate for Payer: Altius Auto/Workers Compensation |
$468.24
|
| Rate for Payer: Altius Commercial |
$468.24
|
| Rate for Payer: Beech Street Commercial |
$478.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$400.44
|
| Rate for Payer: Cash Price |
$341.43
|
| Rate for Payer: ChoiceCare Network Commercial |
$473.12
|
| Rate for Payer: Cigna of WY Commercial |
$478.00
|
| Rate for Payer: Entrust Commercial |
$463.36
|
| Rate for Payer: First Choice Health Commercial |
$463.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$463.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$321.92
|
| Rate for Payer: HealthUtah PPO |
$487.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$473.12
|
| Rate for Payer: Multiplan Medicare/VA |
$305.82
|
| Rate for Payer: One Health Plan of WY PPO |
$478.00
|
| Rate for Payer: PacificSource Commercial |
$438.98
|
| Rate for Payer: PHCS PPO |
$478.00
|
| Rate for Payer: Three Rivers PPO |
$365.81
|
| Rate for Payer: TriWest Veterans Administration |
$321.92
|
| Rate for Payer: United Healthcare Commercial |
$424.34
|
| Rate for Payer: United Healthcare Medicare |
$321.92
|
| Rate for Payer: WINHealth Partners Commercial |
$463.36
|
| Rate for Payer: Wise Provider Network Commercial |
$463.36
|
|
|
MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE [139170]
|
Facility
|
OP
|
$487.75
|
|
|
Service Code
|
NDC 5816097620
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$268.75 |
| Max. Negotiated Rate |
$487.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$478.00
|
| Rate for Payer: Aetna of WY Medicare |
$321.92
|
| Rate for Payer: Altius Auto/Workers Compensation |
$468.24
|
| Rate for Payer: Altius Commercial |
$468.24
|
| Rate for Payer: Beech Street Commercial |
$478.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$400.44
|
| Rate for Payer: Cash Price |
$341.43
|
| Rate for Payer: ChoiceCare Network Commercial |
$473.12
|
| Rate for Payer: Cigna of WY Commercial |
$478.00
|
| Rate for Payer: Entrust Commercial |
$463.36
|
| Rate for Payer: First Choice Health Commercial |
$463.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$463.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$282.90
|
| Rate for Payer: HealthUtah PPO |
$487.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$473.12
|
| Rate for Payer: Multiplan Medicare/VA |
$268.75
|
| Rate for Payer: One Health Plan of WY PPO |
$478.00
|
| Rate for Payer: PacificSource Commercial |
$438.98
|
| Rate for Payer: PHCS PPO |
$478.00
|
| Rate for Payer: Three Rivers PPO |
$365.81
|
| Rate for Payer: TriWest Veterans Administration |
$282.90
|
| Rate for Payer: United Healthcare Commercial |
$424.34
|
| Rate for Payer: United Healthcare Medicare |
$282.90
|
| Rate for Payer: WINHealth Partners Commercial |
$478.00
|
| Rate for Payer: Wise Provider Network Commercial |
$463.36
|
|
