|
MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET [86783]
|
Facility
|
IP
|
$0.18
|
|
|
Service Code
|
NDC 8770143233
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.18
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.17
|
| Rate for Payer: Altius Commercial |
$0.17
|
| Rate for Payer: Beech Street Commercial |
$0.18
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.15
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.17
|
| Rate for Payer: Cigna of WY Commercial |
$0.18
|
| Rate for Payer: Entrust Commercial |
$0.17
|
| Rate for Payer: First Choice Health Commercial |
$0.17
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.17
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.12
|
| Rate for Payer: HealthUtah PPO |
$0.18
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.17
|
| Rate for Payer: Multiplan Medicare/VA |
$0.11
|
| Rate for Payer: One Health Plan of WY PPO |
$0.18
|
| Rate for Payer: PacificSource Commercial |
$0.16
|
| Rate for Payer: PHCS PPO |
$0.18
|
| Rate for Payer: Three Rivers PPO |
$0.14
|
| Rate for Payer: TriWest Veterans Administration |
$0.12
|
| Rate for Payer: United Healthcare Commercial |
$0.16
|
| Rate for Payer: United Healthcare Medicare |
$0.12
|
| Rate for Payer: WINHealth Partners Commercial |
$0.17
|
| Rate for Payer: Wise Provider Network Commercial |
$0.17
|
|
|
MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET [86783]
|
Facility
|
IP
|
$0.43
|
|
|
Service Code
|
NDC 0904549261
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.42
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.41
|
| Rate for Payer: Altius Commercial |
$0.41
|
| Rate for Payer: Beech Street Commercial |
$0.42
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.35
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.42
|
| Rate for Payer: Cigna of WY Commercial |
$0.42
|
| Rate for Payer: Entrust Commercial |
$0.41
|
| Rate for Payer: First Choice Health Commercial |
$0.41
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.41
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.28
|
| Rate for Payer: HealthUtah PPO |
$0.43
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.42
|
| Rate for Payer: Multiplan Medicare/VA |
$0.27
|
| Rate for Payer: One Health Plan of WY PPO |
$0.42
|
| Rate for Payer: PacificSource Commercial |
$0.39
|
| Rate for Payer: PHCS PPO |
$0.42
|
| Rate for Payer: Three Rivers PPO |
$0.32
|
| Rate for Payer: TriWest Veterans Administration |
$0.28
|
| Rate for Payer: United Healthcare Commercial |
$0.37
|
| Rate for Payer: United Healthcare Medicare |
$0.28
|
| Rate for Payer: WINHealth Partners Commercial |
$0.41
|
| Rate for Payer: Wise Provider Network Commercial |
$0.41
|
|
|
MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET [86783]
|
Facility
|
OP
|
$0.43
|
|
|
Service Code
|
NDC 0904549261
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.42
|
| Rate for Payer: Aetna of WY Medicare |
$0.28
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.41
|
| Rate for Payer: Altius Commercial |
$0.41
|
| Rate for Payer: Beech Street Commercial |
$0.42
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.35
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.42
|
| Rate for Payer: Cigna of WY Commercial |
$0.42
|
| Rate for Payer: Entrust Commercial |
$0.41
|
| Rate for Payer: First Choice Health Commercial |
$0.41
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.41
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.25
|
| Rate for Payer: HealthUtah PPO |
$0.43
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.42
|
| Rate for Payer: Multiplan Medicare/VA |
$0.24
|
| Rate for Payer: One Health Plan of WY PPO |
$0.42
|
| Rate for Payer: PacificSource Commercial |
$0.39
|
| Rate for Payer: PHCS PPO |
$0.42
|
| Rate for Payer: Three Rivers PPO |
$0.32
|
| Rate for Payer: TriWest Veterans Administration |
$0.25
|
| Rate for Payer: United Healthcare Commercial |
$0.37
|
| Rate for Payer: United Healthcare Medicare |
$0.25
|
| Rate for Payer: WINHealth Partners Commercial |
$0.42
|
| Rate for Payer: Wise Provider Network Commercial |
$0.41
|
|
|
MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET [86783]
|
Facility
|
IP
|
$0.17
|
|
|
Service Code
|
NDC 4098522368
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.17
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.16
|
| Rate for Payer: Altius Commercial |
$0.16
|
| Rate for Payer: Beech Street Commercial |
$0.17
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.14
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.16
|
| Rate for Payer: Cigna of WY Commercial |
$0.17
|
| Rate for Payer: Entrust Commercial |
$0.16
|
| Rate for Payer: First Choice Health Commercial |
$0.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.11
|
| Rate for Payer: HealthUtah PPO |
$0.17
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.16
|
| Rate for Payer: Multiplan Medicare/VA |
$0.11
|
| Rate for Payer: One Health Plan of WY PPO |
$0.17
|
| Rate for Payer: PacificSource Commercial |
$0.15
|
| Rate for Payer: PHCS PPO |
$0.17
|
| Rate for Payer: Three Rivers PPO |
$0.13
|
| Rate for Payer: TriWest Veterans Administration |
$0.11
|
| Rate for Payer: United Healthcare Commercial |
$0.15
|
| Rate for Payer: United Healthcare Medicare |
$0.11
|
| Rate for Payer: WINHealth Partners Commercial |
$0.16
|
| Rate for Payer: Wise Provider Network Commercial |
$0.16
|
|
|
MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET [86783]
|
Facility
|
OP
|
$0.90
|
|
|
Service Code
|
NDC 7733386125
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.88
|
| Rate for Payer: Aetna of WY Medicare |
$0.59
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.86
|
| Rate for Payer: Altius Commercial |
$0.86
|
| Rate for Payer: Beech Street Commercial |
$0.88
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.74
|
| Rate for Payer: Cash Price |
$0.63
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.87
|
| Rate for Payer: Cigna of WY Commercial |
$0.88
|
| Rate for Payer: Entrust Commercial |
$0.86
|
| Rate for Payer: First Choice Health Commercial |
$0.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.52
|
| Rate for Payer: HealthUtah PPO |
$0.90
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.87
|
| Rate for Payer: Multiplan Medicare/VA |
$0.50
|
| Rate for Payer: One Health Plan of WY PPO |
$0.88
|
| Rate for Payer: PacificSource Commercial |
$0.81
|
| Rate for Payer: PHCS PPO |
$0.88
|
| Rate for Payer: Three Rivers PPO |
$0.68
|
| Rate for Payer: TriWest Veterans Administration |
$0.52
|
| Rate for Payer: United Healthcare Commercial |
$0.78
|
| Rate for Payer: United Healthcare Medicare |
$0.52
|
| Rate for Payer: WINHealth Partners Commercial |
$0.88
|
| Rate for Payer: Wise Provider Network Commercial |
$0.86
|
|
|
MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET [86783]
|
Facility
|
IP
|
$0.90
|
|
|
Service Code
|
NDC 7733386125
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.88
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.86
|
| Rate for Payer: Altius Commercial |
$0.86
|
| Rate for Payer: Beech Street Commercial |
$0.88
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.74
|
| Rate for Payer: Cash Price |
$0.63
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.87
|
| Rate for Payer: Cigna of WY Commercial |
$0.88
|
| Rate for Payer: Entrust Commercial |
$0.86
|
| Rate for Payer: First Choice Health Commercial |
$0.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.59
|
| Rate for Payer: HealthUtah PPO |
$0.90
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.87
|
| Rate for Payer: Multiplan Medicare/VA |
$0.56
|
| Rate for Payer: One Health Plan of WY PPO |
$0.88
|
| Rate for Payer: PacificSource Commercial |
$0.81
|
| Rate for Payer: PHCS PPO |
$0.88
|
| Rate for Payer: Three Rivers PPO |
$0.68
|
| Rate for Payer: TriWest Veterans Administration |
$0.59
|
| Rate for Payer: United Healthcare Commercial |
$0.78
|
| Rate for Payer: United Healthcare Medicare |
$0.59
|
| Rate for Payer: WINHealth Partners Commercial |
$0.86
|
| Rate for Payer: Wise Provider Network Commercial |
$0.86
|
|
|
MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET [86783]
|
Facility
|
IP
|
$0.15
|
|
|
Service Code
|
NDC 8068116000
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.15
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.14
|
| Rate for Payer: Altius Commercial |
$0.14
|
| Rate for Payer: Beech Street Commercial |
$0.15
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.12
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.15
|
| Rate for Payer: Cigna of WY Commercial |
$0.15
|
| Rate for Payer: Entrust Commercial |
$0.14
|
| Rate for Payer: First Choice Health Commercial |
$0.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.10
|
| Rate for Payer: HealthUtah PPO |
$0.15
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.15
|
| Rate for Payer: Multiplan Medicare/VA |
$0.09
|
| Rate for Payer: One Health Plan of WY PPO |
$0.15
|
| Rate for Payer: PacificSource Commercial |
$0.14
|
| Rate for Payer: PHCS PPO |
$0.15
|
| Rate for Payer: Three Rivers PPO |
$0.11
|
| Rate for Payer: TriWest Veterans Administration |
$0.10
|
| Rate for Payer: United Healthcare Commercial |
$0.13
|
| Rate for Payer: United Healthcare Medicare |
$0.10
|
| Rate for Payer: WINHealth Partners Commercial |
$0.14
|
| Rate for Payer: Wise Provider Network Commercial |
$0.14
|
|
|
MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET [86783]
|
Facility
|
OP
|
$0.15
|
|
|
Service Code
|
NDC 8068116000
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.15
|
| Rate for Payer: Aetna of WY Medicare |
$0.10
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.14
|
| Rate for Payer: Altius Commercial |
$0.14
|
| Rate for Payer: Beech Street Commercial |
$0.15
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.12
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.15
|
| Rate for Payer: Cigna of WY Commercial |
$0.15
|
| Rate for Payer: Entrust Commercial |
$0.14
|
| Rate for Payer: First Choice Health Commercial |
$0.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.09
|
| Rate for Payer: HealthUtah PPO |
$0.15
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.15
|
| Rate for Payer: Multiplan Medicare/VA |
$0.08
|
| Rate for Payer: One Health Plan of WY PPO |
$0.15
|
| Rate for Payer: PacificSource Commercial |
$0.14
|
| Rate for Payer: PHCS PPO |
$0.15
|
| Rate for Payer: Three Rivers PPO |
$0.11
|
| Rate for Payer: TriWest Veterans Administration |
$0.09
|
| Rate for Payer: United Healthcare Commercial |
$0.13
|
| Rate for Payer: United Healthcare Medicare |
$0.09
|
| Rate for Payer: WINHealth Partners Commercial |
$0.15
|
| Rate for Payer: Wise Provider Network Commercial |
$0.14
|
|
|
MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET [86783]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 8770143233
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.18
|
| Rate for Payer: Aetna of WY Medicare |
$0.12
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.17
|
| Rate for Payer: Altius Commercial |
$0.17
|
| Rate for Payer: Beech Street Commercial |
$0.18
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.15
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.17
|
| Rate for Payer: Cigna of WY Commercial |
$0.18
|
| Rate for Payer: Entrust Commercial |
$0.17
|
| Rate for Payer: First Choice Health Commercial |
$0.17
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.17
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.10
|
| Rate for Payer: HealthUtah PPO |
$0.18
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.17
|
| Rate for Payer: Multiplan Medicare/VA |
$0.10
|
| Rate for Payer: One Health Plan of WY PPO |
$0.18
|
| Rate for Payer: PacificSource Commercial |
$0.16
|
| Rate for Payer: PHCS PPO |
$0.18
|
| Rate for Payer: Three Rivers PPO |
$0.14
|
| Rate for Payer: TriWest Veterans Administration |
$0.10
|
| Rate for Payer: United Healthcare Commercial |
$0.16
|
| Rate for Payer: United Healthcare Medicare |
$0.10
|
| Rate for Payer: WINHealth Partners Commercial |
$0.18
|
| Rate for Payer: Wise Provider Network Commercial |
$0.17
|
|
|
MULTIVITAMIN,TX-MINERALS CAPSULE [24354]
|
Facility
|
OP
|
$0.33
|
|
|
Service Code
|
NDC 7985440060
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.33 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.32
|
| Rate for Payer: Aetna of WY Medicare |
$0.22
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.32
|
| Rate for Payer: Altius Commercial |
$0.32
|
| Rate for Payer: Beech Street Commercial |
$0.32
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.27
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.32
|
| Rate for Payer: Cigna of WY Commercial |
$0.32
|
| Rate for Payer: Entrust Commercial |
$0.31
|
| Rate for Payer: First Choice Health Commercial |
$0.31
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.31
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.19
|
| Rate for Payer: HealthUtah PPO |
$0.33
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.32
|
| Rate for Payer: Multiplan Medicare/VA |
$0.18
|
| Rate for Payer: One Health Plan of WY PPO |
$0.32
|
| Rate for Payer: PacificSource Commercial |
$0.30
|
| Rate for Payer: PHCS PPO |
$0.32
|
| Rate for Payer: Three Rivers PPO |
$0.25
|
| Rate for Payer: TriWest Veterans Administration |
$0.19
|
| Rate for Payer: United Healthcare Commercial |
$0.29
|
| Rate for Payer: United Healthcare Medicare |
$0.19
|
| Rate for Payer: WINHealth Partners Commercial |
$0.32
|
| Rate for Payer: Wise Provider Network Commercial |
$0.31
|
|
|
MULTIVITAMIN,TX-MINERALS CAPSULE [24354]
|
Facility
|
IP
|
$0.33
|
|
|
Service Code
|
NDC 7985440060
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.33 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.32
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.32
|
| Rate for Payer: Altius Commercial |
$0.32
|
| Rate for Payer: Beech Street Commercial |
$0.32
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.27
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.32
|
| Rate for Payer: Cigna of WY Commercial |
$0.32
|
| Rate for Payer: Entrust Commercial |
$0.31
|
| Rate for Payer: First Choice Health Commercial |
$0.31
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.31
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.22
|
| Rate for Payer: HealthUtah PPO |
$0.33
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.32
|
| Rate for Payer: Multiplan Medicare/VA |
$0.21
|
| Rate for Payer: One Health Plan of WY PPO |
$0.32
|
| Rate for Payer: PacificSource Commercial |
$0.30
|
| Rate for Payer: PHCS PPO |
$0.32
|
| Rate for Payer: Three Rivers PPO |
$0.25
|
| Rate for Payer: TriWest Veterans Administration |
$0.22
|
| Rate for Payer: United Healthcare Commercial |
$0.29
|
| Rate for Payer: United Healthcare Medicare |
$0.22
|
| Rate for Payer: WINHealth Partners Commercial |
$0.31
|
| Rate for Payer: Wise Provider Network Commercial |
$0.31
|
|
|
MUPIROCIN 2 % TOPICAL OINTMENT [16505]
|
Facility
|
IP
|
$1.64
|
|
|
Service Code
|
NDC 6846218022
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.03 |
| Max. Negotiated Rate |
$1.64 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.61
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.57
|
| Rate for Payer: Altius Commercial |
$1.57
|
| Rate for Payer: Beech Street Commercial |
$1.61
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.35
|
| Rate for Payer: Cash Price |
$1.15
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.59
|
| Rate for Payer: Cigna of WY Commercial |
$1.61
|
| Rate for Payer: Entrust Commercial |
$1.56
|
| Rate for Payer: First Choice Health Commercial |
$1.56
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.56
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.08
|
| Rate for Payer: HealthUtah PPO |
$1.64
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.59
|
| Rate for Payer: Multiplan Medicare/VA |
$1.03
|
| Rate for Payer: One Health Plan of WY PPO |
$1.61
|
| Rate for Payer: PacificSource Commercial |
$1.48
|
| Rate for Payer: PHCS PPO |
$1.61
|
| Rate for Payer: Three Rivers PPO |
$1.23
|
| Rate for Payer: TriWest Veterans Administration |
$1.08
|
| Rate for Payer: United Healthcare Commercial |
$1.43
|
| Rate for Payer: United Healthcare Medicare |
$1.08
|
| Rate for Payer: WINHealth Partners Commercial |
$1.56
|
| Rate for Payer: Wise Provider Network Commercial |
$1.56
|
|
|
MUPIROCIN 2 % TOPICAL OINTMENT [16505]
|
Facility
|
OP
|
$1.64
|
|
|
Service Code
|
NDC 6846218022
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.90 |
| Max. Negotiated Rate |
$1.64 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.61
|
| Rate for Payer: Aetna of WY Medicare |
$1.08
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.57
|
| Rate for Payer: Altius Commercial |
$1.57
|
| Rate for Payer: Beech Street Commercial |
$1.61
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.35
|
| Rate for Payer: Cash Price |
$1.15
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.59
|
| Rate for Payer: Cigna of WY Commercial |
$1.61
|
| Rate for Payer: Entrust Commercial |
$1.56
|
| Rate for Payer: First Choice Health Commercial |
$1.56
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.56
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.95
|
| Rate for Payer: HealthUtah PPO |
$1.64
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.59
|
| Rate for Payer: Multiplan Medicare/VA |
$0.90
|
| Rate for Payer: One Health Plan of WY PPO |
$1.61
|
| Rate for Payer: PacificSource Commercial |
$1.48
|
| Rate for Payer: PHCS PPO |
$1.61
|
| Rate for Payer: Three Rivers PPO |
$1.23
|
| Rate for Payer: TriWest Veterans Administration |
$0.95
|
| Rate for Payer: United Healthcare Commercial |
$1.43
|
| Rate for Payer: United Healthcare Medicare |
$0.95
|
| Rate for Payer: WINHealth Partners Commercial |
$1.61
|
| Rate for Payer: Wise Provider Network Commercial |
$1.56
|
|
|
MUPIROCIN CALCIUM 2 % TOPICAL CREAM [14774]
|
Facility
|
IP
|
$18.75
|
|
|
Service Code
|
NDC 5167213701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.76 |
| Max. Negotiated Rate |
$18.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18.38
|
| Rate for Payer: Altius Auto/Workers Compensation |
$18.00
|
| Rate for Payer: Altius Commercial |
$18.00
|
| Rate for Payer: Beech Street Commercial |
$18.38
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.39
|
| Rate for Payer: Cash Price |
$13.12
|
| Rate for Payer: ChoiceCare Network Commercial |
$18.19
|
| Rate for Payer: Cigna of WY Commercial |
$18.38
|
| Rate for Payer: Entrust Commercial |
$17.81
|
| Rate for Payer: First Choice Health Commercial |
$17.81
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.81
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$12.38
|
| Rate for Payer: HealthUtah PPO |
$18.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$18.19
|
| Rate for Payer: Multiplan Medicare/VA |
$11.76
|
| Rate for Payer: One Health Plan of WY PPO |
$18.38
|
| Rate for Payer: PacificSource Commercial |
$16.88
|
| Rate for Payer: PHCS PPO |
$18.38
|
| Rate for Payer: Three Rivers PPO |
$14.06
|
| Rate for Payer: TriWest Veterans Administration |
$12.38
|
| Rate for Payer: United Healthcare Commercial |
$16.31
|
| Rate for Payer: United Healthcare Medicare |
$12.38
|
| Rate for Payer: WINHealth Partners Commercial |
$17.81
|
| Rate for Payer: Wise Provider Network Commercial |
$17.81
|
|
|
MUPIROCIN CALCIUM 2 % TOPICAL CREAM [14774]
|
Facility
|
OP
|
$18.75
|
|
|
Service Code
|
NDC 5167213702
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.33 |
| Max. Negotiated Rate |
$18.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18.38
|
| Rate for Payer: Aetna of WY Medicare |
$12.38
|
| Rate for Payer: Altius Auto/Workers Compensation |
$18.00
|
| Rate for Payer: Altius Commercial |
$18.00
|
| Rate for Payer: Beech Street Commercial |
$18.38
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.39
|
| Rate for Payer: Cash Price |
$13.12
|
| Rate for Payer: ChoiceCare Network Commercial |
$18.19
|
| Rate for Payer: Cigna of WY Commercial |
$18.38
|
| Rate for Payer: Entrust Commercial |
$17.81
|
| Rate for Payer: First Choice Health Commercial |
$17.81
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.81
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.88
|
| Rate for Payer: HealthUtah PPO |
$18.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$18.19
|
| Rate for Payer: Multiplan Medicare/VA |
$10.33
|
| Rate for Payer: One Health Plan of WY PPO |
$18.38
|
| Rate for Payer: PacificSource Commercial |
$16.88
|
| Rate for Payer: PHCS PPO |
$18.38
|
| Rate for Payer: Three Rivers PPO |
$14.06
|
| Rate for Payer: TriWest Veterans Administration |
$10.88
|
| Rate for Payer: United Healthcare Commercial |
$16.31
|
| Rate for Payer: United Healthcare Medicare |
$10.88
|
| Rate for Payer: WINHealth Partners Commercial |
$18.38
|
| Rate for Payer: Wise Provider Network Commercial |
$17.81
|
|
|
MUPIROCIN CALCIUM 2 % TOPICAL CREAM [14774]
|
Facility
|
OP
|
$18.75
|
|
|
Service Code
|
NDC 5167213701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.33 |
| Max. Negotiated Rate |
$18.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18.38
|
| Rate for Payer: Aetna of WY Medicare |
$12.38
|
| Rate for Payer: Altius Auto/Workers Compensation |
$18.00
|
| Rate for Payer: Altius Commercial |
$18.00
|
| Rate for Payer: Beech Street Commercial |
$18.38
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.39
|
| Rate for Payer: Cash Price |
$13.12
|
| Rate for Payer: ChoiceCare Network Commercial |
$18.19
|
| Rate for Payer: Cigna of WY Commercial |
$18.38
|
| Rate for Payer: Entrust Commercial |
$17.81
|
| Rate for Payer: First Choice Health Commercial |
$17.81
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.81
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.88
|
| Rate for Payer: HealthUtah PPO |
$18.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$18.19
|
| Rate for Payer: Multiplan Medicare/VA |
$10.33
|
| Rate for Payer: One Health Plan of WY PPO |
$18.38
|
| Rate for Payer: PacificSource Commercial |
$16.88
|
| Rate for Payer: PHCS PPO |
$18.38
|
| Rate for Payer: Three Rivers PPO |
$14.06
|
| Rate for Payer: TriWest Veterans Administration |
$10.88
|
| Rate for Payer: United Healthcare Commercial |
$16.31
|
| Rate for Payer: United Healthcare Medicare |
$10.88
|
| Rate for Payer: WINHealth Partners Commercial |
$18.38
|
| Rate for Payer: Wise Provider Network Commercial |
$17.81
|
|
|
MUPIROCIN CALCIUM 2 % TOPICAL CREAM [14774]
|
Facility
|
IP
|
$18.75
|
|
|
Service Code
|
NDC 5167213702
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.76 |
| Max. Negotiated Rate |
$18.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18.38
|
| Rate for Payer: Altius Auto/Workers Compensation |
$18.00
|
| Rate for Payer: Altius Commercial |
$18.00
|
| Rate for Payer: Beech Street Commercial |
$18.38
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.39
|
| Rate for Payer: Cash Price |
$13.12
|
| Rate for Payer: ChoiceCare Network Commercial |
$18.19
|
| Rate for Payer: Cigna of WY Commercial |
$18.38
|
| Rate for Payer: Entrust Commercial |
$17.81
|
| Rate for Payer: First Choice Health Commercial |
$17.81
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.81
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$12.38
|
| Rate for Payer: HealthUtah PPO |
$18.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$18.19
|
| Rate for Payer: Multiplan Medicare/VA |
$11.76
|
| Rate for Payer: One Health Plan of WY PPO |
$18.38
|
| Rate for Payer: PacificSource Commercial |
$16.88
|
| Rate for Payer: PHCS PPO |
$18.38
|
| Rate for Payer: Three Rivers PPO |
$14.06
|
| Rate for Payer: TriWest Veterans Administration |
$12.38
|
| Rate for Payer: United Healthcare Commercial |
$16.31
|
| Rate for Payer: United Healthcare Medicare |
$12.38
|
| Rate for Payer: WINHealth Partners Commercial |
$17.81
|
| Rate for Payer: Wise Provider Network Commercial |
$17.81
|
|
|
MUSCLE/TENDON TRANSFER UPPER ARM/ELBOW SINGLE
|
Professional
|
Both
|
$2,603.00
|
|
|
Service Code
|
HCPCS 24301 80
|
| Hospital Charge Code |
24301
|
| Min. Negotiated Rate |
$619.89 |
| Max. Negotiated Rate |
$2,603.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,550.94
|
| Rate for Payer: Aetna of WY Medicare |
$729.28
|
| Rate for Payer: Beech Street Commercial |
$2,472.85
|
| Rate for Payer: Cash Price |
$1,822.10
|
| Rate for Payer: Cash Price |
$1,822.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,524.91
|
| Rate for Payer: Cigna of WY Commercial |
$2,550.94
|
| Rate for Payer: First Choice Health Commercial |
$2,342.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,472.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$729.28
|
| Rate for Payer: HealthUtah PPO |
$2,603.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,524.91
|
| Rate for Payer: Multiplan Medicare/VA |
$619.89
|
| Rate for Payer: One Health Plan of WY PPO |
$2,550.94
|
| Rate for Payer: PacificSource Commercial |
$2,342.70
|
| Rate for Payer: PHCS PPO |
$2,472.85
|
| Rate for Payer: Three Rivers PPO |
$1,952.25
|
| Rate for Payer: TriWest Veterans Administration |
$729.28
|
| Rate for Payer: United Healthcare Commercial |
$2,264.61
|
| Rate for Payer: United Healthcare Medicare |
$729.28
|
| Rate for Payer: WINHealth Partners Commercial |
$2,212.55
|
|
|
MUSCLE/TENDON TRANSFER UPPER ARM/ELBOW SINGLE
|
Professional
|
Both
|
$2,603.00
|
|
|
Service Code
|
HCPCS 24301 AS
|
| Hospital Charge Code |
24301
|
| Min. Negotiated Rate |
$619.89 |
| Max. Negotiated Rate |
$2,603.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,550.94
|
| Rate for Payer: Aetna of WY Medicare |
$729.28
|
| Rate for Payer: Beech Street Commercial |
$2,472.85
|
| Rate for Payer: Cash Price |
$1,822.10
|
| Rate for Payer: Cash Price |
$1,822.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,524.91
|
| Rate for Payer: Cigna of WY Commercial |
$2,550.94
|
| Rate for Payer: First Choice Health Commercial |
$2,342.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,472.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$729.28
|
| Rate for Payer: HealthUtah PPO |
$2,603.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,524.91
|
| Rate for Payer: Multiplan Medicare/VA |
$619.89
|
| Rate for Payer: One Health Plan of WY PPO |
$2,550.94
|
| Rate for Payer: PacificSource Commercial |
$2,342.70
|
| Rate for Payer: PHCS PPO |
$2,472.85
|
| Rate for Payer: Three Rivers PPO |
$1,952.25
|
| Rate for Payer: TriWest Veterans Administration |
$729.28
|
| Rate for Payer: United Healthcare Commercial |
$2,264.61
|
| Rate for Payer: United Healthcare Medicare |
$729.28
|
| Rate for Payer: WINHealth Partners Commercial |
$2,212.55
|
|
|
MUSCLE/TENDON TRANSFER UPPER ARM/ELBOW SINGLE
|
Professional
|
Both
|
$2,603.00
|
|
|
Service Code
|
HCPCS 24301
|
| Hospital Charge Code |
24301
|
| Min. Negotiated Rate |
$619.89 |
| Max. Negotiated Rate |
$2,603.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,550.94
|
| Rate for Payer: Aetna of WY Medicare |
$729.28
|
| Rate for Payer: Beech Street Commercial |
$2,472.85
|
| Rate for Payer: Cash Price |
$1,822.10
|
| Rate for Payer: Cash Price |
$1,822.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,524.91
|
| Rate for Payer: Cigna of WY Commercial |
$2,550.94
|
| Rate for Payer: First Choice Health Commercial |
$2,342.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,472.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$729.28
|
| Rate for Payer: HealthUtah PPO |
$2,603.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,524.91
|
| Rate for Payer: Multiplan Medicare/VA |
$619.89
|
| Rate for Payer: One Health Plan of WY PPO |
$2,550.94
|
| Rate for Payer: PacificSource Commercial |
$2,342.70
|
| Rate for Payer: PHCS PPO |
$2,472.85
|
| Rate for Payer: Three Rivers PPO |
$1,952.25
|
| Rate for Payer: TriWest Veterans Administration |
$729.28
|
| Rate for Payer: United Healthcare Commercial |
$2,264.61
|
| Rate for Payer: United Healthcare Medicare |
$729.28
|
| Rate for Payer: WINHealth Partners Commercial |
$2,212.55
|
|
|
MUSC MYOCUTANEOUS/FASCIOCUTANEOUS FLAP TRUNK
|
Professional
|
Both
|
$5,107.00
|
|
|
Service Code
|
HCPCS 15734 80
|
| Hospital Charge Code |
15734
|
| Min. Negotiated Rate |
$1,216.57 |
| Max. Negotiated Rate |
$5,107.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5,004.86
|
| Rate for Payer: Aetna of WY Medicare |
$1,431.26
|
| Rate for Payer: Beech Street Commercial |
$4,851.65
|
| Rate for Payer: Cash Price |
$3,574.90
|
| Rate for Payer: Cash Price |
$3,574.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$4,953.79
|
| Rate for Payer: Cigna of WY Commercial |
$5,004.86
|
| Rate for Payer: First Choice Health Commercial |
$4,596.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,851.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,431.26
|
| Rate for Payer: HealthUtah PPO |
$5,107.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4,953.79
|
| Rate for Payer: Multiplan Medicare/VA |
$1,216.57
|
| Rate for Payer: One Health Plan of WY PPO |
$5,004.86
|
| Rate for Payer: PacificSource Commercial |
$4,596.30
|
| Rate for Payer: PHCS PPO |
$4,851.65
|
| Rate for Payer: Three Rivers PPO |
$3,830.25
|
| Rate for Payer: TriWest Veterans Administration |
$1,431.26
|
| Rate for Payer: United Healthcare Commercial |
$4,443.09
|
| Rate for Payer: United Healthcare Medicare |
$1,431.26
|
| Rate for Payer: WINHealth Partners Commercial |
$4,340.95
|
|
|
MUSC MYOCUTANEOUS/FASCIOCUTANEOUS FLAP TRUNK
|
Professional
|
Both
|
$5,107.00
|
|
|
Service Code
|
HCPCS 15734
|
| Hospital Charge Code |
15734
|
| Min. Negotiated Rate |
$1,216.57 |
| Max. Negotiated Rate |
$5,107.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5,004.86
|
| Rate for Payer: Aetna of WY Medicare |
$1,431.26
|
| Rate for Payer: Beech Street Commercial |
$4,851.65
|
| Rate for Payer: Cash Price |
$3,574.90
|
| Rate for Payer: Cash Price |
$3,574.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$4,953.79
|
| Rate for Payer: Cigna of WY Commercial |
$5,004.86
|
| Rate for Payer: First Choice Health Commercial |
$4,596.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,851.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,431.26
|
| Rate for Payer: HealthUtah PPO |
$5,107.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4,953.79
|
| Rate for Payer: Multiplan Medicare/VA |
$1,216.57
|
| Rate for Payer: One Health Plan of WY PPO |
$5,004.86
|
| Rate for Payer: PacificSource Commercial |
$4,596.30
|
| Rate for Payer: PHCS PPO |
$4,851.65
|
| Rate for Payer: Three Rivers PPO |
$3,830.25
|
| Rate for Payer: TriWest Veterans Administration |
$1,431.26
|
| Rate for Payer: United Healthcare Commercial |
$4,443.09
|
| Rate for Payer: United Healthcare Medicare |
$1,431.26
|
| Rate for Payer: WINHealth Partners Commercial |
$4,340.95
|
|
|
MUSC MYOCUTANEOUS/FASCIOCUTANEOUS FLAP TRUNK
|
Professional
|
Both
|
$5,107.00
|
|
|
Service Code
|
HCPCS 15734 AS
|
| Hospital Charge Code |
15734
|
| Min. Negotiated Rate |
$1,216.57 |
| Max. Negotiated Rate |
$5,107.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5,004.86
|
| Rate for Payer: Aetna of WY Medicare |
$1,431.26
|
| Rate for Payer: Beech Street Commercial |
$4,851.65
|
| Rate for Payer: Cash Price |
$3,574.90
|
| Rate for Payer: Cash Price |
$3,574.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$4,953.79
|
| Rate for Payer: Cigna of WY Commercial |
$5,004.86
|
| Rate for Payer: First Choice Health Commercial |
$4,596.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,851.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,431.26
|
| Rate for Payer: HealthUtah PPO |
$5,107.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4,953.79
|
| Rate for Payer: Multiplan Medicare/VA |
$1,216.57
|
| Rate for Payer: One Health Plan of WY PPO |
$5,004.86
|
| Rate for Payer: PacificSource Commercial |
$4,596.30
|
| Rate for Payer: PHCS PPO |
$4,851.65
|
| Rate for Payer: Three Rivers PPO |
$3,830.25
|
| Rate for Payer: TriWest Veterans Administration |
$1,431.26
|
| Rate for Payer: United Healthcare Commercial |
$4,443.09
|
| Rate for Payer: United Healthcare Medicare |
$1,431.26
|
| Rate for Payer: WINHealth Partners Commercial |
$4,340.95
|
|
|
MUSC MYOCUTANEOUS/FASCIOCUTANEOUS FLAP UXTR
|
Professional
|
Both
|
$4,171.00
|
|
|
Service Code
|
HCPCS 15736
|
| Hospital Charge Code |
15736
|
| Min. Negotiated Rate |
$993.57 |
| Max. Negotiated Rate |
$4,171.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4,087.58
|
| Rate for Payer: Aetna of WY Medicare |
$1,168.91
|
| Rate for Payer: Beech Street Commercial |
$3,962.45
|
| Rate for Payer: Cash Price |
$2,919.70
|
| Rate for Payer: Cash Price |
$2,919.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$4,045.87
|
| Rate for Payer: Cigna of WY Commercial |
$4,087.58
|
| Rate for Payer: First Choice Health Commercial |
$3,753.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,962.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,168.91
|
| Rate for Payer: HealthUtah PPO |
$4,171.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4,045.87
|
| Rate for Payer: Multiplan Medicare/VA |
$993.57
|
| Rate for Payer: One Health Plan of WY PPO |
$4,087.58
|
| Rate for Payer: PacificSource Commercial |
$3,753.90
|
| Rate for Payer: PHCS PPO |
$3,962.45
|
| Rate for Payer: Three Rivers PPO |
$3,128.25
|
| Rate for Payer: TriWest Veterans Administration |
$1,168.91
|
| Rate for Payer: United Healthcare Commercial |
$3,628.77
|
| Rate for Payer: United Healthcare Medicare |
$1,168.91
|
| Rate for Payer: WINHealth Partners Commercial |
$3,545.35
|
|
|
MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION [101294]
|
Facility
|
OP
|
$21.15
|
|
|
Service Code
|
NDC 5464356491
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.65 |
| Max. Negotiated Rate |
$21.15 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$20.73
|
| Rate for Payer: Aetna of WY Medicare |
$13.96
|
| Rate for Payer: Altius Auto/Workers Compensation |
$20.30
|
| Rate for Payer: Altius Commercial |
$20.30
|
| Rate for Payer: Beech Street Commercial |
$20.73
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$17.36
|
| Rate for Payer: Cash Price |
$14.81
|
| Rate for Payer: ChoiceCare Network Commercial |
$20.52
|
| Rate for Payer: Cigna of WY Commercial |
$20.73
|
| Rate for Payer: Entrust Commercial |
$20.09
|
| Rate for Payer: First Choice Health Commercial |
$20.09
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$20.09
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$12.27
|
| Rate for Payer: HealthUtah PPO |
$21.15
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$20.52
|
| Rate for Payer: Multiplan Medicare/VA |
$11.65
|
| Rate for Payer: One Health Plan of WY PPO |
$20.73
|
| Rate for Payer: PacificSource Commercial |
$19.04
|
| Rate for Payer: PHCS PPO |
$20.73
|
| Rate for Payer: Three Rivers PPO |
$15.86
|
| Rate for Payer: TriWest Veterans Administration |
$12.27
|
| Rate for Payer: United Healthcare Commercial |
$18.40
|
| Rate for Payer: United Healthcare Medicare |
$12.27
|
| Rate for Payer: WINHealth Partners Commercial |
$20.73
|
| Rate for Payer: Wise Provider Network Commercial |
$20.09
|
|
