|
METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION [20449]
|
Facility
|
OP
|
$16.04
|
|
|
Service Code
|
NDC 3600003310
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.84 |
| Max. Negotiated Rate |
$16.04 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.72
|
| Rate for Payer: Aetna of WY Medicare |
$10.59
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.40
|
| Rate for Payer: Altius Commercial |
$15.40
|
| Rate for Payer: Beech Street Commercial |
$15.72
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.17
|
| Rate for Payer: Cash Price |
$11.23
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.56
|
| Rate for Payer: Cigna of WY Commercial |
$15.72
|
| Rate for Payer: Entrust Commercial |
$15.24
|
| Rate for Payer: First Choice Health Commercial |
$15.24
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.24
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.30
|
| Rate for Payer: HealthUtah PPO |
$16.04
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.56
|
| Rate for Payer: Multiplan Medicare/VA |
$8.84
|
| Rate for Payer: One Health Plan of WY PPO |
$15.72
|
| Rate for Payer: PacificSource Commercial |
$14.44
|
| Rate for Payer: PHCS PPO |
$15.72
|
| Rate for Payer: Three Rivers PPO |
$12.03
|
| Rate for Payer: TriWest Veterans Administration |
$9.30
|
| Rate for Payer: United Healthcare Commercial |
$13.95
|
| Rate for Payer: United Healthcare Medicare |
$9.30
|
| Rate for Payer: WINHealth Partners Commercial |
$15.72
|
| Rate for Payer: Wise Provider Network Commercial |
$15.24
|
|
|
METRONIDAZOLE 1 % TOPICAL GEL [38846]
|
Facility
|
OP
|
$9.70
|
|
|
Service Code
|
NDC 5167242153
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.34 |
| Max. Negotiated Rate |
$9.70 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$9.51
|
| Rate for Payer: Aetna of WY Medicare |
$6.40
|
| Rate for Payer: Altius Auto/Workers Compensation |
$9.31
|
| Rate for Payer: Altius Commercial |
$9.31
|
| Rate for Payer: Beech Street Commercial |
$9.51
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$7.96
|
| Rate for Payer: Cash Price |
$6.79
|
| Rate for Payer: ChoiceCare Network Commercial |
$9.41
|
| Rate for Payer: Cigna of WY Commercial |
$9.51
|
| Rate for Payer: Entrust Commercial |
$9.22
|
| Rate for Payer: First Choice Health Commercial |
$9.22
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$9.22
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$5.63
|
| Rate for Payer: HealthUtah PPO |
$9.70
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$9.41
|
| Rate for Payer: Multiplan Medicare/VA |
$5.34
|
| Rate for Payer: One Health Plan of WY PPO |
$9.51
|
| Rate for Payer: PacificSource Commercial |
$8.73
|
| Rate for Payer: PHCS PPO |
$9.51
|
| Rate for Payer: Three Rivers PPO |
$7.28
|
| Rate for Payer: TriWest Veterans Administration |
$5.63
|
| Rate for Payer: United Healthcare Commercial |
$8.44
|
| Rate for Payer: United Healthcare Medicare |
$5.63
|
| Rate for Payer: WINHealth Partners Commercial |
$9.51
|
| Rate for Payer: Wise Provider Network Commercial |
$9.22
|
|
|
METRONIDAZOLE 1 % TOPICAL GEL [38846]
|
Facility
|
IP
|
$9.70
|
|
|
Service Code
|
NDC 5167242153
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.08 |
| Max. Negotiated Rate |
$9.70 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$9.51
|
| Rate for Payer: Altius Auto/Workers Compensation |
$9.31
|
| Rate for Payer: Altius Commercial |
$9.31
|
| Rate for Payer: Beech Street Commercial |
$9.51
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$7.96
|
| Rate for Payer: Cash Price |
$6.79
|
| Rate for Payer: ChoiceCare Network Commercial |
$9.41
|
| Rate for Payer: Cigna of WY Commercial |
$9.51
|
| Rate for Payer: Entrust Commercial |
$9.22
|
| Rate for Payer: First Choice Health Commercial |
$9.22
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$9.22
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$6.40
|
| Rate for Payer: HealthUtah PPO |
$9.70
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$9.41
|
| Rate for Payer: Multiplan Medicare/VA |
$6.08
|
| Rate for Payer: One Health Plan of WY PPO |
$9.51
|
| Rate for Payer: PacificSource Commercial |
$8.73
|
| Rate for Payer: PHCS PPO |
$9.51
|
| Rate for Payer: Three Rivers PPO |
$7.28
|
| Rate for Payer: TriWest Veterans Administration |
$6.40
|
| Rate for Payer: United Healthcare Commercial |
$8.44
|
| Rate for Payer: United Healthcare Medicare |
$6.40
|
| Rate for Payer: WINHealth Partners Commercial |
$9.22
|
| Rate for Payer: Wise Provider Network Commercial |
$9.22
|
|
|
METRONIDAZOLE 1 % TOPICAL GEL WITH PUMP [99737]
|
Facility
|
OP
|
$10.59
|
|
|
Service Code
|
NDC 5167242159
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.84 |
| Max. Negotiated Rate |
$10.59 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$10.38
|
| Rate for Payer: Aetna of WY Medicare |
$6.99
|
| Rate for Payer: Altius Auto/Workers Compensation |
$10.17
|
| Rate for Payer: Altius Commercial |
$10.17
|
| Rate for Payer: Beech Street Commercial |
$10.38
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$8.69
|
| Rate for Payer: Cash Price |
$7.41
|
| Rate for Payer: ChoiceCare Network Commercial |
$10.27
|
| Rate for Payer: Cigna of WY Commercial |
$10.38
|
| Rate for Payer: Entrust Commercial |
$10.06
|
| Rate for Payer: First Choice Health Commercial |
$10.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$10.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$6.14
|
| Rate for Payer: HealthUtah PPO |
$10.59
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$10.27
|
| Rate for Payer: Multiplan Medicare/VA |
$5.84
|
| Rate for Payer: One Health Plan of WY PPO |
$10.38
|
| Rate for Payer: PacificSource Commercial |
$9.53
|
| Rate for Payer: PHCS PPO |
$10.38
|
| Rate for Payer: Three Rivers PPO |
$7.94
|
| Rate for Payer: TriWest Veterans Administration |
$6.14
|
| Rate for Payer: United Healthcare Commercial |
$9.21
|
| Rate for Payer: United Healthcare Medicare |
$6.14
|
| Rate for Payer: WINHealth Partners Commercial |
$10.38
|
| Rate for Payer: Wise Provider Network Commercial |
$10.06
|
|
|
METRONIDAZOLE 1 % TOPICAL GEL WITH PUMP [99737]
|
Facility
|
IP
|
$10.59
|
|
|
Service Code
|
NDC 5167242159
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.64 |
| Max. Negotiated Rate |
$10.59 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$10.38
|
| Rate for Payer: Altius Auto/Workers Compensation |
$10.17
|
| Rate for Payer: Altius Commercial |
$10.17
|
| Rate for Payer: Beech Street Commercial |
$10.38
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$8.69
|
| Rate for Payer: Cash Price |
$7.41
|
| Rate for Payer: ChoiceCare Network Commercial |
$10.27
|
| Rate for Payer: Cigna of WY Commercial |
$10.38
|
| Rate for Payer: Entrust Commercial |
$10.06
|
| Rate for Payer: First Choice Health Commercial |
$10.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$10.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$6.99
|
| Rate for Payer: HealthUtah PPO |
$10.59
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$10.27
|
| Rate for Payer: Multiplan Medicare/VA |
$6.64
|
| Rate for Payer: One Health Plan of WY PPO |
$10.38
|
| Rate for Payer: PacificSource Commercial |
$9.53
|
| Rate for Payer: PHCS PPO |
$10.38
|
| Rate for Payer: Three Rivers PPO |
$7.94
|
| Rate for Payer: TriWest Veterans Administration |
$6.99
|
| Rate for Payer: United Healthcare Commercial |
$9.21
|
| Rate for Payer: United Healthcare Medicare |
$6.99
|
| Rate for Payer: WINHealth Partners Commercial |
$10.06
|
| Rate for Payer: Wise Provider Network Commercial |
$10.06
|
|
|
METRONIDAZOLE 500 MG/100 ML IN SODIUM CHLOR(ISO) INTRAVENOUS PIGGYBACK [6283]
|
Facility
|
OP
|
$15.11
|
|
|
Service Code
|
HCPCS J1836
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.33 |
| Max. Negotiated Rate |
$15.11 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.81
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.78
|
| Rate for Payer: Aetna of WY Medicare |
$9.97
|
| Rate for Payer: Aetna of WY Medicare |
$9.95
|
| Rate for Payer: Altius Auto/Workers Compensation |
$14.48
|
| Rate for Payer: Altius Auto/Workers Compensation |
$14.51
|
| Rate for Payer: Altius Commercial |
$14.51
|
| Rate for Payer: Altius Commercial |
$14.48
|
| Rate for Payer: Beech Street Commercial |
$14.78
|
| Rate for Payer: Beech Street Commercial |
$14.81
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.41
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.38
|
| Rate for Payer: Cash Price |
$10.56
|
| Rate for Payer: Cash Price |
$10.57
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.66
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.63
|
| Rate for Payer: Cigna of WY Commercial |
$14.78
|
| Rate for Payer: Cigna of WY Commercial |
$14.81
|
| Rate for Payer: Entrust Commercial |
$14.35
|
| Rate for Payer: Entrust Commercial |
$14.33
|
| Rate for Payer: First Choice Health Commercial |
$14.33
|
| Rate for Payer: First Choice Health Commercial |
$14.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.76
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.75
|
| Rate for Payer: HealthUtah PPO |
$15.08
|
| Rate for Payer: HealthUtah PPO |
$15.11
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.63
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.66
|
| Rate for Payer: Multiplan Medicare/VA |
$8.33
|
| Rate for Payer: Multiplan Medicare/VA |
$8.31
|
| Rate for Payer: One Health Plan of WY PPO |
$14.78
|
| Rate for Payer: One Health Plan of WY PPO |
$14.81
|
| Rate for Payer: PacificSource Commercial |
$13.60
|
| Rate for Payer: PacificSource Commercial |
$13.57
|
| Rate for Payer: PHCS PPO |
$14.78
|
| Rate for Payer: PHCS PPO |
$14.81
|
| Rate for Payer: Three Rivers PPO |
$11.31
|
| Rate for Payer: Three Rivers PPO |
$11.33
|
| Rate for Payer: TriWest Veterans Administration |
$8.76
|
| Rate for Payer: TriWest Veterans Administration |
$8.75
|
| Rate for Payer: United Healthcare Commercial |
$13.12
|
| Rate for Payer: United Healthcare Commercial |
$13.15
|
| Rate for Payer: United Healthcare Medicare |
$8.76
|
| Rate for Payer: United Healthcare Medicare |
$8.75
|
| Rate for Payer: WINHealth Partners Commercial |
$14.78
|
| Rate for Payer: WINHealth Partners Commercial |
$14.81
|
| Rate for Payer: Wise Provider Network Commercial |
$14.33
|
| Rate for Payer: Wise Provider Network Commercial |
$14.35
|
|
|
METRONIDAZOLE 500 MG/100 ML IN SODIUM CHLOR(ISO) INTRAVENOUS PIGGYBACK [6283]
|
Facility
|
IP
|
$15.11
|
|
|
Service Code
|
HCPCS J1836
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.47 |
| Max. Negotiated Rate |
$15.11 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.81
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.78
|
| Rate for Payer: Altius Auto/Workers Compensation |
$14.51
|
| Rate for Payer: Altius Auto/Workers Compensation |
$14.48
|
| Rate for Payer: Altius Commercial |
$14.48
|
| Rate for Payer: Altius Commercial |
$14.51
|
| Rate for Payer: Beech Street Commercial |
$14.81
|
| Rate for Payer: Beech Street Commercial |
$14.78
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.38
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.41
|
| Rate for Payer: Cash Price |
$10.57
|
| Rate for Payer: Cash Price |
$10.56
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.63
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.66
|
| Rate for Payer: Cigna of WY Commercial |
$14.81
|
| Rate for Payer: Cigna of WY Commercial |
$14.78
|
| Rate for Payer: Entrust Commercial |
$14.33
|
| Rate for Payer: Entrust Commercial |
$14.35
|
| Rate for Payer: First Choice Health Commercial |
$14.33
|
| Rate for Payer: First Choice Health Commercial |
$14.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.97
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.95
|
| Rate for Payer: HealthUtah PPO |
$15.11
|
| Rate for Payer: HealthUtah PPO |
$15.08
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.63
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.66
|
| Rate for Payer: Multiplan Medicare/VA |
$9.47
|
| Rate for Payer: Multiplan Medicare/VA |
$9.46
|
| Rate for Payer: One Health Plan of WY PPO |
$14.81
|
| Rate for Payer: One Health Plan of WY PPO |
$14.78
|
| Rate for Payer: PacificSource Commercial |
$13.60
|
| Rate for Payer: PacificSource Commercial |
$13.57
|
| Rate for Payer: PHCS PPO |
$14.78
|
| Rate for Payer: PHCS PPO |
$14.81
|
| Rate for Payer: Three Rivers PPO |
$11.31
|
| Rate for Payer: Three Rivers PPO |
$11.33
|
| Rate for Payer: TriWest Veterans Administration |
$9.97
|
| Rate for Payer: TriWest Veterans Administration |
$9.95
|
| Rate for Payer: United Healthcare Commercial |
$13.12
|
| Rate for Payer: United Healthcare Commercial |
$13.15
|
| Rate for Payer: United Healthcare Medicare |
$9.97
|
| Rate for Payer: United Healthcare Medicare |
$9.95
|
| Rate for Payer: WINHealth Partners Commercial |
$14.33
|
| Rate for Payer: WINHealth Partners Commercial |
$14.35
|
| Rate for Payer: Wise Provider Network Commercial |
$14.33
|
| Rate for Payer: Wise Provider Network Commercial |
$14.35
|
|
|
METRONIDAZOLE 500 MG TABLET [6857]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 6068755001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.65 |
| Max. Negotiated Rate |
$3.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.94
|
| Rate for Payer: Aetna of WY Medicare |
$1.98
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.88
|
| Rate for Payer: Altius Commercial |
$2.88
|
| Rate for Payer: Beech Street Commercial |
$2.94
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.46
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.91
|
| Rate for Payer: Cigna of WY Commercial |
$2.94
|
| Rate for Payer: Entrust Commercial |
$2.85
|
| Rate for Payer: First Choice Health Commercial |
$2.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.74
|
| Rate for Payer: HealthUtah PPO |
$3.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.91
|
| Rate for Payer: Multiplan Medicare/VA |
$1.65
|
| Rate for Payer: One Health Plan of WY PPO |
$2.94
|
| Rate for Payer: PacificSource Commercial |
$2.70
|
| Rate for Payer: PHCS PPO |
$2.94
|
| Rate for Payer: Three Rivers PPO |
$2.25
|
| Rate for Payer: TriWest Veterans Administration |
$1.74
|
| Rate for Payer: United Healthcare Commercial |
$2.61
|
| Rate for Payer: United Healthcare Medicare |
$1.74
|
| Rate for Payer: WINHealth Partners Commercial |
$2.94
|
| Rate for Payer: Wise Provider Network Commercial |
$2.85
|
|
|
METRONIDAZOLE 500 MG TABLET [6857]
|
Facility
|
OP
|
$2.52
|
|
|
Service Code
|
NDC 5026853511
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.39 |
| Max. Negotiated Rate |
$2.52 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.47
|
| Rate for Payer: Aetna of WY Medicare |
$1.66
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.42
|
| Rate for Payer: Altius Commercial |
$2.42
|
| Rate for Payer: Beech Street Commercial |
$2.47
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.07
|
| Rate for Payer: Cash Price |
$1.76
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.44
|
| Rate for Payer: Cigna of WY Commercial |
$2.47
|
| Rate for Payer: Entrust Commercial |
$2.39
|
| Rate for Payer: First Choice Health Commercial |
$2.39
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.39
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.46
|
| Rate for Payer: HealthUtah PPO |
$2.52
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.44
|
| Rate for Payer: Multiplan Medicare/VA |
$1.39
|
| Rate for Payer: One Health Plan of WY PPO |
$2.47
|
| Rate for Payer: PacificSource Commercial |
$2.27
|
| Rate for Payer: PHCS PPO |
$2.47
|
| Rate for Payer: Three Rivers PPO |
$1.89
|
| Rate for Payer: TriWest Veterans Administration |
$1.46
|
| Rate for Payer: United Healthcare Commercial |
$2.19
|
| Rate for Payer: United Healthcare Medicare |
$1.46
|
| Rate for Payer: WINHealth Partners Commercial |
$2.47
|
| Rate for Payer: Wise Provider Network Commercial |
$2.39
|
|
|
METRONIDAZOLE 500 MG TABLET [6857]
|
Facility
|
IP
|
$2.52
|
|
|
Service Code
|
NDC 5026853511
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.58 |
| Max. Negotiated Rate |
$2.52 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.47
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.42
|
| Rate for Payer: Altius Commercial |
$2.42
|
| Rate for Payer: Beech Street Commercial |
$2.47
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.07
|
| Rate for Payer: Cash Price |
$1.76
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.44
|
| Rate for Payer: Cigna of WY Commercial |
$2.47
|
| Rate for Payer: Entrust Commercial |
$2.39
|
| Rate for Payer: First Choice Health Commercial |
$2.39
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.39
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.66
|
| Rate for Payer: HealthUtah PPO |
$2.52
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.44
|
| Rate for Payer: Multiplan Medicare/VA |
$1.58
|
| Rate for Payer: One Health Plan of WY PPO |
$2.47
|
| Rate for Payer: PacificSource Commercial |
$2.27
|
| Rate for Payer: PHCS PPO |
$2.47
|
| Rate for Payer: Three Rivers PPO |
$1.89
|
| Rate for Payer: TriWest Veterans Administration |
$1.66
|
| Rate for Payer: United Healthcare Commercial |
$2.19
|
| Rate for Payer: United Healthcare Medicare |
$1.66
|
| Rate for Payer: WINHealth Partners Commercial |
$2.39
|
| Rate for Payer: Wise Provider Network Commercial |
$2.39
|
|
|
METRONIDAZOLE 500 MG TABLET [6857]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 6068755011
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.88 |
| Max. Negotiated Rate |
$3.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.94
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.88
|
| Rate for Payer: Altius Commercial |
$2.88
|
| Rate for Payer: Beech Street Commercial |
$2.94
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.46
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.91
|
| Rate for Payer: Cigna of WY Commercial |
$2.94
|
| Rate for Payer: Entrust Commercial |
$2.85
|
| Rate for Payer: First Choice Health Commercial |
$2.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.98
|
| Rate for Payer: HealthUtah PPO |
$3.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.91
|
| Rate for Payer: Multiplan Medicare/VA |
$1.88
|
| Rate for Payer: One Health Plan of WY PPO |
$2.94
|
| Rate for Payer: PacificSource Commercial |
$2.70
|
| Rate for Payer: PHCS PPO |
$2.94
|
| Rate for Payer: Three Rivers PPO |
$2.25
|
| Rate for Payer: TriWest Veterans Administration |
$1.98
|
| Rate for Payer: United Healthcare Commercial |
$2.61
|
| Rate for Payer: United Healthcare Medicare |
$1.98
|
| Rate for Payer: WINHealth Partners Commercial |
$2.85
|
| Rate for Payer: Wise Provider Network Commercial |
$2.85
|
|
|
METRONIDAZOLE 500 MG TABLET [6857]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 6068755011
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.65 |
| Max. Negotiated Rate |
$3.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.94
|
| Rate for Payer: Aetna of WY Medicare |
$1.98
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.88
|
| Rate for Payer: Altius Commercial |
$2.88
|
| Rate for Payer: Beech Street Commercial |
$2.94
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.46
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.91
|
| Rate for Payer: Cigna of WY Commercial |
$2.94
|
| Rate for Payer: Entrust Commercial |
$2.85
|
| Rate for Payer: First Choice Health Commercial |
$2.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.74
|
| Rate for Payer: HealthUtah PPO |
$3.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.91
|
| Rate for Payer: Multiplan Medicare/VA |
$1.65
|
| Rate for Payer: One Health Plan of WY PPO |
$2.94
|
| Rate for Payer: PacificSource Commercial |
$2.70
|
| Rate for Payer: PHCS PPO |
$2.94
|
| Rate for Payer: Three Rivers PPO |
$2.25
|
| Rate for Payer: TriWest Veterans Administration |
$1.74
|
| Rate for Payer: United Healthcare Commercial |
$2.61
|
| Rate for Payer: United Healthcare Medicare |
$1.74
|
| Rate for Payer: WINHealth Partners Commercial |
$2.94
|
| Rate for Payer: Wise Provider Network Commercial |
$2.85
|
|
|
METRONIDAZOLE 500 MG TABLET [6857]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 6068755001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.88 |
| Max. Negotiated Rate |
$3.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.94
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.88
|
| Rate for Payer: Altius Commercial |
$2.88
|
| Rate for Payer: Beech Street Commercial |
$2.94
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.46
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.91
|
| Rate for Payer: Cigna of WY Commercial |
$2.94
|
| Rate for Payer: Entrust Commercial |
$2.85
|
| Rate for Payer: First Choice Health Commercial |
$2.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.98
|
| Rate for Payer: HealthUtah PPO |
$3.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.91
|
| Rate for Payer: Multiplan Medicare/VA |
$1.88
|
| Rate for Payer: One Health Plan of WY PPO |
$2.94
|
| Rate for Payer: PacificSource Commercial |
$2.70
|
| Rate for Payer: PHCS PPO |
$2.94
|
| Rate for Payer: Three Rivers PPO |
$2.25
|
| Rate for Payer: TriWest Veterans Administration |
$1.98
|
| Rate for Payer: United Healthcare Commercial |
$2.61
|
| Rate for Payer: United Healthcare Medicare |
$1.98
|
| Rate for Payer: WINHealth Partners Commercial |
$2.85
|
| Rate for Payer: Wise Provider Network Commercial |
$2.85
|
|
|
MICAFUNGIN 100 MG INTRAVENOUS SOLUTION [42329]
|
Facility
|
IP
|
$295.50
|
|
|
Service Code
|
HCPCS J2247
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$185.28 |
| Max. Negotiated Rate |
$295.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$289.59
|
| Rate for Payer: Altius Auto/Workers Compensation |
$283.68
|
| Rate for Payer: Altius Commercial |
$283.68
|
| Rate for Payer: Beech Street Commercial |
$289.59
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$242.61
|
| Rate for Payer: Cash Price |
$206.85
|
| Rate for Payer: ChoiceCare Network Commercial |
$286.64
|
| Rate for Payer: Cigna of WY Commercial |
$289.59
|
| Rate for Payer: Entrust Commercial |
$280.72
|
| Rate for Payer: First Choice Health Commercial |
$280.72
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$280.72
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$195.03
|
| Rate for Payer: HealthUtah PPO |
$295.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$286.64
|
| Rate for Payer: Multiplan Medicare/VA |
$185.28
|
| Rate for Payer: One Health Plan of WY PPO |
$289.59
|
| Rate for Payer: PacificSource Commercial |
$265.95
|
| Rate for Payer: PHCS PPO |
$289.59
|
| Rate for Payer: Three Rivers PPO |
$221.62
|
| Rate for Payer: TriWest Veterans Administration |
$195.03
|
| Rate for Payer: United Healthcare Commercial |
$257.08
|
| Rate for Payer: United Healthcare Medicare |
$195.03
|
| Rate for Payer: WINHealth Partners Commercial |
$280.72
|
| Rate for Payer: Wise Provider Network Commercial |
$280.72
|
|
|
MICAFUNGIN 100 MG INTRAVENOUS SOLUTION [42329]
|
Facility
|
OP
|
$295.50
|
|
|
Service Code
|
HCPCS J2247
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$162.82 |
| Max. Negotiated Rate |
$295.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$289.59
|
| Rate for Payer: Aetna of WY Medicare |
$195.03
|
| Rate for Payer: Altius Auto/Workers Compensation |
$283.68
|
| Rate for Payer: Altius Commercial |
$283.68
|
| Rate for Payer: Beech Street Commercial |
$289.59
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$242.61
|
| Rate for Payer: Cash Price |
$206.85
|
| Rate for Payer: ChoiceCare Network Commercial |
$286.64
|
| Rate for Payer: Cigna of WY Commercial |
$289.59
|
| Rate for Payer: Entrust Commercial |
$280.72
|
| Rate for Payer: First Choice Health Commercial |
$280.72
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$280.72
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$171.39
|
| Rate for Payer: HealthUtah PPO |
$295.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$286.64
|
| Rate for Payer: Multiplan Medicare/VA |
$162.82
|
| Rate for Payer: One Health Plan of WY PPO |
$289.59
|
| Rate for Payer: PacificSource Commercial |
$265.95
|
| Rate for Payer: PHCS PPO |
$289.59
|
| Rate for Payer: Three Rivers PPO |
$221.62
|
| Rate for Payer: TriWest Veterans Administration |
$171.39
|
| Rate for Payer: United Healthcare Commercial |
$257.08
|
| Rate for Payer: United Healthcare Medicare |
$171.39
|
| Rate for Payer: WINHealth Partners Commercial |
$289.59
|
| Rate for Payer: Wise Provider Network Commercial |
$280.72
|
|
|
MICONAZOLE NITRATE 2 % TOPICAL CREAM [3292]
|
Facility
|
OP
|
$0.28
|
|
|
Service Code
|
NDC 1170104514
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.28 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.27
|
| Rate for Payer: Aetna of WY Medicare |
$0.18
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.27
|
| Rate for Payer: Altius Commercial |
$0.27
|
| Rate for Payer: Beech Street Commercial |
$0.27
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.23
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.27
|
| Rate for Payer: Cigna of WY Commercial |
$0.27
|
| Rate for Payer: Entrust Commercial |
$0.27
|
| Rate for Payer: First Choice Health Commercial |
$0.27
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.27
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.16
|
| Rate for Payer: HealthUtah PPO |
$0.28
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.27
|
| Rate for Payer: Multiplan Medicare/VA |
$0.15
|
| Rate for Payer: One Health Plan of WY PPO |
$0.27
|
| Rate for Payer: PacificSource Commercial |
$0.25
|
| Rate for Payer: PHCS PPO |
$0.27
|
| Rate for Payer: Three Rivers PPO |
$0.21
|
| Rate for Payer: TriWest Veterans Administration |
$0.16
|
| Rate for Payer: United Healthcare Commercial |
$0.24
|
| Rate for Payer: United Healthcare Medicare |
$0.16
|
| Rate for Payer: WINHealth Partners Commercial |
$0.27
|
| Rate for Payer: Wise Provider Network Commercial |
$0.27
|
|
|
MICONAZOLE NITRATE 2 % TOPICAL CREAM [3292]
|
Facility
|
IP
|
$0.28
|
|
|
Service Code
|
NDC 1170104514
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.28 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.27
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.27
|
| Rate for Payer: Altius Commercial |
$0.27
|
| Rate for Payer: Beech Street Commercial |
$0.27
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.23
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.27
|
| Rate for Payer: Cigna of WY Commercial |
$0.27
|
| Rate for Payer: Entrust Commercial |
$0.27
|
| Rate for Payer: First Choice Health Commercial |
$0.27
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.27
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.18
|
| Rate for Payer: HealthUtah PPO |
$0.28
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.27
|
| Rate for Payer: Multiplan Medicare/VA |
$0.18
|
| Rate for Payer: One Health Plan of WY PPO |
$0.27
|
| Rate for Payer: PacificSource Commercial |
$0.25
|
| Rate for Payer: PHCS PPO |
$0.27
|
| Rate for Payer: Three Rivers PPO |
$0.21
|
| Rate for Payer: TriWest Veterans Administration |
$0.18
|
| Rate for Payer: United Healthcare Commercial |
$0.24
|
| Rate for Payer: United Healthcare Medicare |
$0.18
|
| Rate for Payer: WINHealth Partners Commercial |
$0.27
|
| Rate for Payer: Wise Provider Network Commercial |
$0.27
|
|
|
MICONAZOLE NITRATE 2 % TOPICAL CREAM [3292]
|
Facility
|
IP
|
$0.59
|
|
|
Service Code
|
NDC 0536137575
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$0.59 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.58
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.57
|
| Rate for Payer: Altius Commercial |
$0.57
|
| Rate for Payer: Beech Street Commercial |
$0.58
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.48
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.57
|
| Rate for Payer: Cigna of WY Commercial |
$0.58
|
| Rate for Payer: Entrust Commercial |
$0.56
|
| Rate for Payer: First Choice Health Commercial |
$0.56
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.56
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.39
|
| Rate for Payer: HealthUtah PPO |
$0.59
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.57
|
| Rate for Payer: Multiplan Medicare/VA |
$0.37
|
| Rate for Payer: One Health Plan of WY PPO |
$0.58
|
| Rate for Payer: PacificSource Commercial |
$0.53
|
| Rate for Payer: PHCS PPO |
$0.58
|
| Rate for Payer: Three Rivers PPO |
$0.44
|
| Rate for Payer: TriWest Veterans Administration |
$0.39
|
| Rate for Payer: United Healthcare Commercial |
$0.51
|
| Rate for Payer: United Healthcare Medicare |
$0.39
|
| Rate for Payer: WINHealth Partners Commercial |
$0.56
|
| Rate for Payer: Wise Provider Network Commercial |
$0.56
|
|
|
MICONAZOLE NITRATE 2 % TOPICAL CREAM [3292]
|
Facility
|
OP
|
$0.59
|
|
|
Service Code
|
NDC 0536137575
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$0.59 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.58
|
| Rate for Payer: Aetna of WY Medicare |
$0.39
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.57
|
| Rate for Payer: Altius Commercial |
$0.57
|
| Rate for Payer: Beech Street Commercial |
$0.58
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.48
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.57
|
| Rate for Payer: Cigna of WY Commercial |
$0.58
|
| Rate for Payer: Entrust Commercial |
$0.56
|
| Rate for Payer: First Choice Health Commercial |
$0.56
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.56
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.34
|
| Rate for Payer: HealthUtah PPO |
$0.59
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.57
|
| Rate for Payer: Multiplan Medicare/VA |
$0.33
|
| Rate for Payer: One Health Plan of WY PPO |
$0.58
|
| Rate for Payer: PacificSource Commercial |
$0.53
|
| Rate for Payer: PHCS PPO |
$0.58
|
| Rate for Payer: Three Rivers PPO |
$0.44
|
| Rate for Payer: TriWest Veterans Administration |
$0.34
|
| Rate for Payer: United Healthcare Commercial |
$0.51
|
| Rate for Payer: United Healthcare Medicare |
$0.34
|
| Rate for Payer: WINHealth Partners Commercial |
$0.58
|
| Rate for Payer: Wise Provider Network Commercial |
$0.56
|
|
|
MICONAZOLE NITRATE 2 % VAGINAL CREAM [5477]
|
Facility
|
IP
|
$0.67
|
|
|
Service Code
|
NDC 8770179251
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$0.67 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.66
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.64
|
| Rate for Payer: Altius Commercial |
$0.64
|
| Rate for Payer: Beech Street Commercial |
$0.66
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.55
|
| Rate for Payer: Cash Price |
$0.47
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.65
|
| Rate for Payer: Cigna of WY Commercial |
$0.66
|
| Rate for Payer: Entrust Commercial |
$0.64
|
| Rate for Payer: First Choice Health Commercial |
$0.64
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.64
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.44
|
| Rate for Payer: HealthUtah PPO |
$0.67
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.65
|
| Rate for Payer: Multiplan Medicare/VA |
$0.42
|
| Rate for Payer: One Health Plan of WY PPO |
$0.66
|
| Rate for Payer: PacificSource Commercial |
$0.60
|
| Rate for Payer: PHCS PPO |
$0.66
|
| Rate for Payer: Three Rivers PPO |
$0.50
|
| Rate for Payer: TriWest Veterans Administration |
$0.44
|
| Rate for Payer: United Healthcare Commercial |
$0.58
|
| Rate for Payer: United Healthcare Medicare |
$0.44
|
| Rate for Payer: WINHealth Partners Commercial |
$0.64
|
| Rate for Payer: Wise Provider Network Commercial |
$0.64
|
|
|
MICONAZOLE NITRATE 2 % VAGINAL CREAM [5477]
|
Facility
|
OP
|
$0.67
|
|
|
Service Code
|
NDC 2438559029
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$0.67 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.66
|
| Rate for Payer: Aetna of WY Medicare |
$0.44
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.64
|
| Rate for Payer: Altius Commercial |
$0.64
|
| Rate for Payer: Beech Street Commercial |
$0.66
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.55
|
| Rate for Payer: Cash Price |
$0.47
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.65
|
| Rate for Payer: Cigna of WY Commercial |
$0.66
|
| Rate for Payer: Entrust Commercial |
$0.64
|
| Rate for Payer: First Choice Health Commercial |
$0.64
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.64
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.39
|
| Rate for Payer: HealthUtah PPO |
$0.67
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.65
|
| Rate for Payer: Multiplan Medicare/VA |
$0.37
|
| Rate for Payer: One Health Plan of WY PPO |
$0.66
|
| Rate for Payer: PacificSource Commercial |
$0.60
|
| Rate for Payer: PHCS PPO |
$0.66
|
| Rate for Payer: Three Rivers PPO |
$0.50
|
| Rate for Payer: TriWest Veterans Administration |
$0.39
|
| Rate for Payer: United Healthcare Commercial |
$0.58
|
| Rate for Payer: United Healthcare Medicare |
$0.39
|
| Rate for Payer: WINHealth Partners Commercial |
$0.66
|
| Rate for Payer: Wise Provider Network Commercial |
$0.64
|
|
|
MICONAZOLE NITRATE 2 % VAGINAL CREAM [5477]
|
Facility
|
IP
|
$0.67
|
|
|
Service Code
|
NDC 2438559029
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$0.67 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.66
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.64
|
| Rate for Payer: Altius Commercial |
$0.64
|
| Rate for Payer: Beech Street Commercial |
$0.66
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.55
|
| Rate for Payer: Cash Price |
$0.47
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.65
|
| Rate for Payer: Cigna of WY Commercial |
$0.66
|
| Rate for Payer: Entrust Commercial |
$0.64
|
| Rate for Payer: First Choice Health Commercial |
$0.64
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.64
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.44
|
| Rate for Payer: HealthUtah PPO |
$0.67
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.65
|
| Rate for Payer: Multiplan Medicare/VA |
$0.42
|
| Rate for Payer: One Health Plan of WY PPO |
$0.66
|
| Rate for Payer: PacificSource Commercial |
$0.60
|
| Rate for Payer: PHCS PPO |
$0.66
|
| Rate for Payer: Three Rivers PPO |
$0.50
|
| Rate for Payer: TriWest Veterans Administration |
$0.44
|
| Rate for Payer: United Healthcare Commercial |
$0.58
|
| Rate for Payer: United Healthcare Medicare |
$0.44
|
| Rate for Payer: WINHealth Partners Commercial |
$0.64
|
| Rate for Payer: Wise Provider Network Commercial |
$0.64
|
|
|
MICONAZOLE NITRATE 2 % VAGINAL CREAM [5477]
|
Facility
|
OP
|
$0.67
|
|
|
Service Code
|
NDC 8770179251
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$0.67 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.66
|
| Rate for Payer: Aetna of WY Medicare |
$0.44
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.64
|
| Rate for Payer: Altius Commercial |
$0.64
|
| Rate for Payer: Beech Street Commercial |
$0.66
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.55
|
| Rate for Payer: Cash Price |
$0.47
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.65
|
| Rate for Payer: Cigna of WY Commercial |
$0.66
|
| Rate for Payer: Entrust Commercial |
$0.64
|
| Rate for Payer: First Choice Health Commercial |
$0.64
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.64
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.39
|
| Rate for Payer: HealthUtah PPO |
$0.67
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.65
|
| Rate for Payer: Multiplan Medicare/VA |
$0.37
|
| Rate for Payer: One Health Plan of WY PPO |
$0.66
|
| Rate for Payer: PacificSource Commercial |
$0.60
|
| Rate for Payer: PHCS PPO |
$0.66
|
| Rate for Payer: Three Rivers PPO |
$0.50
|
| Rate for Payer: TriWest Veterans Administration |
$0.39
|
| Rate for Payer: United Healthcare Commercial |
$0.58
|
| Rate for Payer: United Healthcare Medicare |
$0.39
|
| Rate for Payer: WINHealth Partners Commercial |
$0.66
|
| Rate for Payer: Wise Provider Network Commercial |
$0.64
|
|
|
MICRO GRASPER 3622
|
Facility
|
OP
|
$178.50
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$98.35 |
| Max. Negotiated Rate |
$178.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$174.93
|
| Rate for Payer: Aetna of WY Medicare |
$117.81
|
| Rate for Payer: Altius Auto/Workers Compensation |
$171.36
|
| Rate for Payer: Altius Commercial |
$171.36
|
| Rate for Payer: Beech Street Commercial |
$174.93
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$146.55
|
| Rate for Payer: Cash Price |
$124.95
|
| Rate for Payer: ChoiceCare Network Commercial |
$173.14
|
| Rate for Payer: Cigna of WY Commercial |
$174.93
|
| Rate for Payer: Entrust Commercial |
$169.58
|
| Rate for Payer: First Choice Health Commercial |
$169.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$169.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$103.53
|
| Rate for Payer: HealthUtah PPO |
$178.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$173.14
|
| Rate for Payer: Multiplan Medicare/VA |
$98.35
|
| Rate for Payer: One Health Plan of WY PPO |
$174.93
|
| Rate for Payer: PacificSource Commercial |
$160.65
|
| Rate for Payer: PHCS PPO |
$174.93
|
| Rate for Payer: Three Rivers PPO |
$133.88
|
| Rate for Payer: TriWest Veterans Administration |
$103.53
|
| Rate for Payer: United Healthcare Commercial |
$155.30
|
| Rate for Payer: United Healthcare Medicare |
$103.53
|
| Rate for Payer: WINHealth Partners Commercial |
$174.93
|
| Rate for Payer: Wise Provider Network Commercial |
$169.58
|
|
|
MICRO GRASPER 3622
|
Facility
|
IP
|
$178.50
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$111.92 |
| Max. Negotiated Rate |
$178.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$174.93
|
| Rate for Payer: Altius Auto/Workers Compensation |
$171.36
|
| Rate for Payer: Altius Commercial |
$171.36
|
| Rate for Payer: Beech Street Commercial |
$174.93
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$146.55
|
| Rate for Payer: Cash Price |
$124.95
|
| Rate for Payer: ChoiceCare Network Commercial |
$173.14
|
| Rate for Payer: Cigna of WY Commercial |
$174.93
|
| Rate for Payer: Entrust Commercial |
$169.58
|
| Rate for Payer: First Choice Health Commercial |
$169.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$169.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$117.81
|
| Rate for Payer: HealthUtah PPO |
$178.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$173.14
|
| Rate for Payer: Multiplan Medicare/VA |
$111.92
|
| Rate for Payer: One Health Plan of WY PPO |
$174.93
|
| Rate for Payer: PacificSource Commercial |
$160.65
|
| Rate for Payer: PHCS PPO |
$174.93
|
| Rate for Payer: Three Rivers PPO |
$133.88
|
| Rate for Payer: TriWest Veterans Administration |
$117.81
|
| Rate for Payer: United Healthcare Commercial |
$155.30
|
| Rate for Payer: United Healthcare Medicare |
$117.81
|
| Rate for Payer: WINHealth Partners Commercial |
$169.58
|
| Rate for Payer: Wise Provider Network Commercial |
$169.58
|
|
