|
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH [20398]
|
Facility
|
OP
|
$7.42
|
|
|
Service Code
|
NDC 6050570610
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.09 |
| Max. Negotiated Rate |
$7.42 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$7.27
|
| Rate for Payer: Aetna of WY Medicare |
$4.90
|
| Rate for Payer: Altius Auto/Workers Compensation |
$7.12
|
| Rate for Payer: Altius Commercial |
$7.12
|
| Rate for Payer: Beech Street Commercial |
$7.27
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$6.09
|
| Rate for Payer: Cash Price |
$5.19
|
| Rate for Payer: ChoiceCare Network Commercial |
$7.20
|
| Rate for Payer: Cigna of WY Commercial |
$7.27
|
| Rate for Payer: Entrust Commercial |
$7.05
|
| Rate for Payer: First Choice Health Commercial |
$7.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$7.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$4.30
|
| Rate for Payer: HealthUtah PPO |
$7.42
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$7.20
|
| Rate for Payer: Multiplan Medicare/VA |
$4.09
|
| Rate for Payer: One Health Plan of WY PPO |
$7.27
|
| Rate for Payer: PacificSource Commercial |
$6.68
|
| Rate for Payer: PHCS PPO |
$7.27
|
| Rate for Payer: Three Rivers PPO |
$5.56
|
| Rate for Payer: TriWest Veterans Administration |
$4.30
|
| Rate for Payer: United Healthcare Commercial |
$6.46
|
| Rate for Payer: United Healthcare Medicare |
$4.30
|
| Rate for Payer: WINHealth Partners Commercial |
$7.27
|
| Rate for Payer: Wise Provider Network Commercial |
$7.05
|
|
|
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH [20398]
|
Facility
|
IP
|
$7.42
|
|
|
Service Code
|
NDC 6050570610
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.65 |
| Max. Negotiated Rate |
$7.42 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$7.27
|
| Rate for Payer: Altius Auto/Workers Compensation |
$7.12
|
| Rate for Payer: Altius Commercial |
$7.12
|
| Rate for Payer: Beech Street Commercial |
$7.27
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$6.09
|
| Rate for Payer: Cash Price |
$5.19
|
| Rate for Payer: ChoiceCare Network Commercial |
$7.20
|
| Rate for Payer: Cigna of WY Commercial |
$7.27
|
| Rate for Payer: Entrust Commercial |
$7.05
|
| Rate for Payer: First Choice Health Commercial |
$7.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$7.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$4.90
|
| Rate for Payer: HealthUtah PPO |
$7.42
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$7.20
|
| Rate for Payer: Multiplan Medicare/VA |
$4.65
|
| Rate for Payer: One Health Plan of WY PPO |
$7.27
|
| Rate for Payer: PacificSource Commercial |
$6.68
|
| Rate for Payer: PHCS PPO |
$7.27
|
| Rate for Payer: Three Rivers PPO |
$5.56
|
| Rate for Payer: TriWest Veterans Administration |
$4.90
|
| Rate for Payer: United Healthcare Commercial |
$6.46
|
| Rate for Payer: United Healthcare Medicare |
$4.90
|
| Rate for Payer: WINHealth Partners Commercial |
$7.05
|
| Rate for Payer: Wise Provider Network Commercial |
$7.05
|
|
|
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH [20398]
|
Facility
|
OP
|
$7.06
|
|
|
Service Code
|
NDC 4612235474
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.89 |
| Max. Negotiated Rate |
$7.06 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$6.92
|
| Rate for Payer: Aetna of WY Medicare |
$4.66
|
| Rate for Payer: Altius Auto/Workers Compensation |
$6.78
|
| Rate for Payer: Altius Commercial |
$6.78
|
| Rate for Payer: Beech Street Commercial |
$6.92
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$5.80
|
| Rate for Payer: Cash Price |
$4.94
|
| Rate for Payer: ChoiceCare Network Commercial |
$6.85
|
| Rate for Payer: Cigna of WY Commercial |
$6.92
|
| Rate for Payer: Entrust Commercial |
$6.71
|
| Rate for Payer: First Choice Health Commercial |
$6.71
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$6.71
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$4.09
|
| Rate for Payer: HealthUtah PPO |
$7.06
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$6.85
|
| Rate for Payer: Multiplan Medicare/VA |
$3.89
|
| Rate for Payer: One Health Plan of WY PPO |
$6.92
|
| Rate for Payer: PacificSource Commercial |
$6.35
|
| Rate for Payer: PHCS PPO |
$6.92
|
| Rate for Payer: Three Rivers PPO |
$5.30
|
| Rate for Payer: TriWest Veterans Administration |
$4.09
|
| Rate for Payer: United Healthcare Commercial |
$6.14
|
| Rate for Payer: United Healthcare Medicare |
$4.09
|
| Rate for Payer: WINHealth Partners Commercial |
$6.92
|
| Rate for Payer: Wise Provider Network Commercial |
$6.71
|
|
|
NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH [20398]
|
Facility
|
IP
|
$7.06
|
|
|
Service Code
|
NDC 4612235474
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.43 |
| Max. Negotiated Rate |
$7.06 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$6.92
|
| Rate for Payer: Altius Auto/Workers Compensation |
$6.78
|
| Rate for Payer: Altius Commercial |
$6.78
|
| Rate for Payer: Beech Street Commercial |
$6.92
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$5.80
|
| Rate for Payer: Cash Price |
$4.94
|
| Rate for Payer: ChoiceCare Network Commercial |
$6.85
|
| Rate for Payer: Cigna of WY Commercial |
$6.92
|
| Rate for Payer: Entrust Commercial |
$6.71
|
| Rate for Payer: First Choice Health Commercial |
$6.71
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$6.71
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$4.66
|
| Rate for Payer: HealthUtah PPO |
$7.06
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$6.85
|
| Rate for Payer: Multiplan Medicare/VA |
$4.43
|
| Rate for Payer: One Health Plan of WY PPO |
$6.92
|
| Rate for Payer: PacificSource Commercial |
$6.35
|
| Rate for Payer: PHCS PPO |
$6.92
|
| Rate for Payer: Three Rivers PPO |
$5.30
|
| Rate for Payer: TriWest Veterans Administration |
$4.66
|
| Rate for Payer: United Healthcare Commercial |
$6.14
|
| Rate for Payer: United Healthcare Medicare |
$4.66
|
| Rate for Payer: WINHealth Partners Commercial |
$6.71
|
| Rate for Payer: Wise Provider Network Commercial |
$6.71
|
|
|
NICOTINE (POLACRILEX) 4 MG GUM [11154]
|
Facility
|
IP
|
$1.16
|
|
|
Service Code
|
NDC 4612272571
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.73 |
| Max. Negotiated Rate |
$1.16 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.14
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.11
|
| Rate for Payer: Altius Commercial |
$1.11
|
| Rate for Payer: Beech Street Commercial |
$1.14
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.95
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.13
|
| Rate for Payer: Cigna of WY Commercial |
$1.14
|
| Rate for Payer: Entrust Commercial |
$1.10
|
| Rate for Payer: First Choice Health Commercial |
$1.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.77
|
| Rate for Payer: HealthUtah PPO |
$1.16
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.13
|
| Rate for Payer: Multiplan Medicare/VA |
$0.73
|
| Rate for Payer: One Health Plan of WY PPO |
$1.14
|
| Rate for Payer: PacificSource Commercial |
$1.04
|
| Rate for Payer: PHCS PPO |
$1.14
|
| Rate for Payer: Three Rivers PPO |
$0.87
|
| Rate for Payer: TriWest Veterans Administration |
$0.77
|
| Rate for Payer: United Healthcare Commercial |
$1.01
|
| Rate for Payer: United Healthcare Medicare |
$0.77
|
| Rate for Payer: WINHealth Partners Commercial |
$1.10
|
| Rate for Payer: Wise Provider Network Commercial |
$1.10
|
|
|
NICOTINE (POLACRILEX) 4 MG GUM [11154]
|
Facility
|
IP
|
$0.90
|
|
|
Service Code
|
NDC 4612217420
|
|
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
|
|
|
NICOTINE (POLACRILEX) 4 MG GUM [11154]
|
Facility
|
OP
|
$0.90
|
|
|
Service Code
|
NDC 4612217420
|
|
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
|
|
|
NICOTINE (POLACRILEX) 4 MG GUM [11154]
|
Facility
|
OP
|
$1.16
|
|
|
Service Code
|
NDC 4612272571
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$1.16 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.14
|
| Rate for Payer: Aetna of WY Medicare |
$0.77
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.11
|
| Rate for Payer: Altius Commercial |
$1.11
|
| Rate for Payer: Beech Street Commercial |
$1.14
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.95
|
| Rate for Payer: Cash Price |
$0.81
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.13
|
| Rate for Payer: Cigna of WY Commercial |
$1.14
|
| Rate for Payer: Entrust Commercial |
$1.10
|
| Rate for Payer: First Choice Health Commercial |
$1.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.67
|
| Rate for Payer: HealthUtah PPO |
$1.16
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.13
|
| Rate for Payer: Multiplan Medicare/VA |
$0.64
|
| Rate for Payer: One Health Plan of WY PPO |
$1.14
|
| Rate for Payer: PacificSource Commercial |
$1.04
|
| Rate for Payer: PHCS PPO |
$1.14
|
| Rate for Payer: Three Rivers PPO |
$0.87
|
| Rate for Payer: TriWest Veterans Administration |
$0.67
|
| Rate for Payer: United Healthcare Commercial |
$1.01
|
| Rate for Payer: United Healthcare Medicare |
$0.67
|
| Rate for Payer: WINHealth Partners Commercial |
$1.14
|
| Rate for Payer: Wise Provider Network Commercial |
$1.10
|
|
|
NIFEDIPINE 10 MG CAPSULE [11319]
|
Facility
|
OP
|
$3.42
|
|
|
Service Code
|
NDC 6931521101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.88 |
| Max. Negotiated Rate |
$3.42 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3.35
|
| Rate for Payer: Aetna of WY Medicare |
$2.26
|
| Rate for Payer: Altius Auto/Workers Compensation |
$3.28
|
| Rate for Payer: Altius Commercial |
$3.28
|
| Rate for Payer: Beech Street Commercial |
$3.35
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.81
|
| Rate for Payer: Cash Price |
$2.39
|
| Rate for Payer: ChoiceCare Network Commercial |
$3.32
|
| Rate for Payer: Cigna of WY Commercial |
$3.35
|
| Rate for Payer: Entrust Commercial |
$3.25
|
| Rate for Payer: First Choice Health Commercial |
$3.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.98
|
| Rate for Payer: HealthUtah PPO |
$3.42
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3.32
|
| Rate for Payer: Multiplan Medicare/VA |
$1.88
|
| Rate for Payer: One Health Plan of WY PPO |
$3.35
|
| Rate for Payer: PacificSource Commercial |
$3.08
|
| Rate for Payer: PHCS PPO |
$3.35
|
| Rate for Payer: Three Rivers PPO |
$2.56
|
| Rate for Payer: TriWest Veterans Administration |
$1.98
|
| Rate for Payer: United Healthcare Commercial |
$2.98
|
| Rate for Payer: United Healthcare Medicare |
$1.98
|
| Rate for Payer: WINHealth Partners Commercial |
$3.35
|
| Rate for Payer: Wise Provider Network Commercial |
$3.25
|
|
|
NIFEDIPINE 10 MG CAPSULE [11319]
|
Facility
|
IP
|
$3.42
|
|
|
Service Code
|
NDC 6931521101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.14 |
| Max. Negotiated Rate |
$3.42 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3.35
|
| Rate for Payer: Altius Auto/Workers Compensation |
$3.28
|
| Rate for Payer: Altius Commercial |
$3.28
|
| Rate for Payer: Beech Street Commercial |
$3.35
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.81
|
| Rate for Payer: Cash Price |
$2.39
|
| Rate for Payer: ChoiceCare Network Commercial |
$3.32
|
| Rate for Payer: Cigna of WY Commercial |
$3.35
|
| Rate for Payer: Entrust Commercial |
$3.25
|
| Rate for Payer: First Choice Health Commercial |
$3.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2.26
|
| Rate for Payer: HealthUtah PPO |
$3.42
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3.32
|
| Rate for Payer: Multiplan Medicare/VA |
$2.14
|
| Rate for Payer: One Health Plan of WY PPO |
$3.35
|
| Rate for Payer: PacificSource Commercial |
$3.08
|
| Rate for Payer: PHCS PPO |
$3.35
|
| Rate for Payer: Three Rivers PPO |
$2.56
|
| Rate for Payer: TriWest Veterans Administration |
$2.26
|
| Rate for Payer: United Healthcare Commercial |
$2.98
|
| Rate for Payer: United Healthcare Medicare |
$2.26
|
| Rate for Payer: WINHealth Partners Commercial |
$3.25
|
| Rate for Payer: Wise Provider Network Commercial |
$3.25
|
|
|
NIM EMG ELECTRODE 4-CHAN PIN
|
Facility
|
IP
|
$527.80
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$330.93 |
| Max. Negotiated Rate |
$527.80 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$517.24
|
| Rate for Payer: Altius Auto/Workers Compensation |
$506.69
|
| Rate for Payer: Altius Commercial |
$506.69
|
| Rate for Payer: Beech Street Commercial |
$517.24
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$433.32
|
| Rate for Payer: Cash Price |
$369.46
|
| Rate for Payer: ChoiceCare Network Commercial |
$511.97
|
| Rate for Payer: Cigna of WY Commercial |
$517.24
|
| Rate for Payer: Entrust Commercial |
$501.41
|
| Rate for Payer: First Choice Health Commercial |
$501.41
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$501.41
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$348.35
|
| Rate for Payer: HealthUtah PPO |
$527.80
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$511.97
|
| Rate for Payer: Multiplan Medicare/VA |
$330.93
|
| Rate for Payer: One Health Plan of WY PPO |
$517.24
|
| Rate for Payer: PacificSource Commercial |
$475.02
|
| Rate for Payer: PHCS PPO |
$517.24
|
| Rate for Payer: Three Rivers PPO |
$395.85
|
| Rate for Payer: TriWest Veterans Administration |
$348.35
|
| Rate for Payer: United Healthcare Commercial |
$459.19
|
| Rate for Payer: United Healthcare Medicare |
$348.35
|
| Rate for Payer: WINHealth Partners Commercial |
$501.41
|
| Rate for Payer: Wise Provider Network Commercial |
$501.41
|
|
|
NIM EMG ELECTRODE 4-CHAN PIN
|
Facility
|
OP
|
$527.80
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$290.82 |
| Max. Negotiated Rate |
$527.80 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$517.24
|
| Rate for Payer: Aetna of WY Medicare |
$348.35
|
| Rate for Payer: Altius Auto/Workers Compensation |
$506.69
|
| Rate for Payer: Altius Commercial |
$506.69
|
| Rate for Payer: Beech Street Commercial |
$517.24
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$433.32
|
| Rate for Payer: Cash Price |
$369.46
|
| Rate for Payer: ChoiceCare Network Commercial |
$511.97
|
| Rate for Payer: Cigna of WY Commercial |
$517.24
|
| Rate for Payer: Entrust Commercial |
$501.41
|
| Rate for Payer: First Choice Health Commercial |
$501.41
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$501.41
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$306.12
|
| Rate for Payer: HealthUtah PPO |
$527.80
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$511.97
|
| Rate for Payer: Multiplan Medicare/VA |
$290.82
|
| Rate for Payer: One Health Plan of WY PPO |
$517.24
|
| Rate for Payer: PacificSource Commercial |
$475.02
|
| Rate for Payer: PHCS PPO |
$517.24
|
| Rate for Payer: Three Rivers PPO |
$395.85
|
| Rate for Payer: TriWest Veterans Administration |
$306.12
|
| Rate for Payer: United Healthcare Commercial |
$459.19
|
| Rate for Payer: United Healthcare Medicare |
$306.12
|
| Rate for Payer: WINHealth Partners Commercial |
$517.24
|
| Rate for Payer: Wise Provider Network Commercial |
$501.41
|
|
|
NIM EMG TUBE 6.0MM ID
|
Facility
|
IP
|
$1,234.24
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$773.87 |
| Max. Negotiated Rate |
$1,234.24 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,209.56
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,184.87
|
| Rate for Payer: Altius Commercial |
$1,184.87
|
| Rate for Payer: Beech Street Commercial |
$1,209.56
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,013.31
|
| Rate for Payer: Cash Price |
$863.97
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,197.21
|
| Rate for Payer: Cigna of WY Commercial |
$1,209.56
|
| Rate for Payer: Entrust Commercial |
$1,172.53
|
| Rate for Payer: First Choice Health Commercial |
$1,172.53
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,172.53
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$814.60
|
| Rate for Payer: HealthUtah PPO |
$1,234.24
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,197.21
|
| Rate for Payer: Multiplan Medicare/VA |
$773.87
|
| Rate for Payer: One Health Plan of WY PPO |
$1,209.56
|
| Rate for Payer: PacificSource Commercial |
$1,110.82
|
| Rate for Payer: PHCS PPO |
$1,209.56
|
| Rate for Payer: Three Rivers PPO |
$925.68
|
| Rate for Payer: TriWest Veterans Administration |
$814.60
|
| Rate for Payer: United Healthcare Commercial |
$1,073.79
|
| Rate for Payer: United Healthcare Medicare |
$814.60
|
| Rate for Payer: WINHealth Partners Commercial |
$1,172.53
|
| Rate for Payer: Wise Provider Network Commercial |
$1,172.53
|
|
|
NIM EMG TUBE 6.0MM ID
|
Facility
|
OP
|
$1,234.24
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$680.07 |
| Max. Negotiated Rate |
$1,234.24 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,209.56
|
| Rate for Payer: Aetna of WY Medicare |
$814.60
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,184.87
|
| Rate for Payer: Altius Commercial |
$1,184.87
|
| Rate for Payer: Beech Street Commercial |
$1,209.56
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,013.31
|
| Rate for Payer: Cash Price |
$863.97
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,197.21
|
| Rate for Payer: Cigna of WY Commercial |
$1,209.56
|
| Rate for Payer: Entrust Commercial |
$1,172.53
|
| Rate for Payer: First Choice Health Commercial |
$1,172.53
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,172.53
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$715.86
|
| Rate for Payer: HealthUtah PPO |
$1,234.24
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,197.21
|
| Rate for Payer: Multiplan Medicare/VA |
$680.07
|
| Rate for Payer: One Health Plan of WY PPO |
$1,209.56
|
| Rate for Payer: PacificSource Commercial |
$1,110.82
|
| Rate for Payer: PHCS PPO |
$1,209.56
|
| Rate for Payer: Three Rivers PPO |
$925.68
|
| Rate for Payer: TriWest Veterans Administration |
$715.86
|
| Rate for Payer: United Healthcare Commercial |
$1,073.79
|
| Rate for Payer: United Healthcare Medicare |
$715.86
|
| Rate for Payer: WINHealth Partners Commercial |
$1,209.56
|
| Rate for Payer: Wise Provider Network Commercial |
$1,172.53
|
|
|
NIM EMG TUBE 7.0MM ID
|
Facility
|
OP
|
$1,234.24
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$680.07 |
| Max. Negotiated Rate |
$1,234.24 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,209.56
|
| Rate for Payer: Aetna of WY Medicare |
$814.60
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,184.87
|
| Rate for Payer: Altius Commercial |
$1,184.87
|
| Rate for Payer: Beech Street Commercial |
$1,209.56
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,013.31
|
| Rate for Payer: Cash Price |
$863.97
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,197.21
|
| Rate for Payer: Cigna of WY Commercial |
$1,209.56
|
| Rate for Payer: Entrust Commercial |
$1,172.53
|
| Rate for Payer: First Choice Health Commercial |
$1,172.53
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,172.53
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$715.86
|
| Rate for Payer: HealthUtah PPO |
$1,234.24
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,197.21
|
| Rate for Payer: Multiplan Medicare/VA |
$680.07
|
| Rate for Payer: One Health Plan of WY PPO |
$1,209.56
|
| Rate for Payer: PacificSource Commercial |
$1,110.82
|
| Rate for Payer: PHCS PPO |
$1,209.56
|
| Rate for Payer: Three Rivers PPO |
$925.68
|
| Rate for Payer: TriWest Veterans Administration |
$715.86
|
| Rate for Payer: United Healthcare Commercial |
$1,073.79
|
| Rate for Payer: United Healthcare Medicare |
$715.86
|
| Rate for Payer: WINHealth Partners Commercial |
$1,209.56
|
| Rate for Payer: Wise Provider Network Commercial |
$1,172.53
|
|
|
NIM EMG TUBE 7.0MM ID
|
Facility
|
IP
|
$1,234.24
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$773.87 |
| Max. Negotiated Rate |
$1,234.24 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,209.56
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,184.87
|
| Rate for Payer: Altius Commercial |
$1,184.87
|
| Rate for Payer: Beech Street Commercial |
$1,209.56
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,013.31
|
| Rate for Payer: Cash Price |
$863.97
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,197.21
|
| Rate for Payer: Cigna of WY Commercial |
$1,209.56
|
| Rate for Payer: Entrust Commercial |
$1,172.53
|
| Rate for Payer: First Choice Health Commercial |
$1,172.53
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,172.53
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$814.60
|
| Rate for Payer: HealthUtah PPO |
$1,234.24
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,197.21
|
| Rate for Payer: Multiplan Medicare/VA |
$773.87
|
| Rate for Payer: One Health Plan of WY PPO |
$1,209.56
|
| Rate for Payer: PacificSource Commercial |
$1,110.82
|
| Rate for Payer: PHCS PPO |
$1,209.56
|
| Rate for Payer: Three Rivers PPO |
$925.68
|
| Rate for Payer: TriWest Veterans Administration |
$814.60
|
| Rate for Payer: United Healthcare Commercial |
$1,073.79
|
| Rate for Payer: United Healthcare Medicare |
$814.60
|
| Rate for Payer: WINHealth Partners Commercial |
$1,172.53
|
| Rate for Payer: Wise Provider Network Commercial |
$1,172.53
|
|
|
NIM EMG TUBE 8.0MM ID
|
Facility
|
OP
|
$1,099.35
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$605.74 |
| Max. Negotiated Rate |
$1,099.35 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,077.36
|
| Rate for Payer: Aetna of WY Medicare |
$725.57
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,055.38
|
| Rate for Payer: Altius Commercial |
$1,055.38
|
| Rate for Payer: Beech Street Commercial |
$1,077.36
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$902.57
|
| Rate for Payer: Cash Price |
$769.54
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,066.37
|
| Rate for Payer: Cigna of WY Commercial |
$1,077.36
|
| Rate for Payer: Entrust Commercial |
$1,044.38
|
| Rate for Payer: First Choice Health Commercial |
$1,044.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,044.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$637.62
|
| Rate for Payer: HealthUtah PPO |
$1,099.35
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,066.37
|
| Rate for Payer: Multiplan Medicare/VA |
$605.74
|
| Rate for Payer: One Health Plan of WY PPO |
$1,077.36
|
| Rate for Payer: PacificSource Commercial |
$989.42
|
| Rate for Payer: PHCS PPO |
$1,077.36
|
| Rate for Payer: Three Rivers PPO |
$824.51
|
| Rate for Payer: TriWest Veterans Administration |
$637.62
|
| Rate for Payer: United Healthcare Commercial |
$956.43
|
| Rate for Payer: United Healthcare Medicare |
$637.62
|
| Rate for Payer: WINHealth Partners Commercial |
$1,077.36
|
| Rate for Payer: Wise Provider Network Commercial |
$1,044.38
|
|
|
NIM EMG TUBE 8.0MM ID
|
Facility
|
IP
|
$1,099.35
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$689.29 |
| Max. Negotiated Rate |
$1,099.35 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,077.36
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,055.38
|
| Rate for Payer: Altius Commercial |
$1,055.38
|
| Rate for Payer: Beech Street Commercial |
$1,077.36
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$902.57
|
| Rate for Payer: Cash Price |
$769.54
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,066.37
|
| Rate for Payer: Cigna of WY Commercial |
$1,077.36
|
| Rate for Payer: Entrust Commercial |
$1,044.38
|
| Rate for Payer: First Choice Health Commercial |
$1,044.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,044.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$725.57
|
| Rate for Payer: HealthUtah PPO |
$1,099.35
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,066.37
|
| Rate for Payer: Multiplan Medicare/VA |
$689.29
|
| Rate for Payer: One Health Plan of WY PPO |
$1,077.36
|
| Rate for Payer: PacificSource Commercial |
$989.42
|
| Rate for Payer: PHCS PPO |
$1,077.36
|
| Rate for Payer: Three Rivers PPO |
$824.51
|
| Rate for Payer: TriWest Veterans Administration |
$725.57
|
| Rate for Payer: United Healthcare Commercial |
$956.43
|
| Rate for Payer: United Healthcare Medicare |
$725.57
|
| Rate for Payer: WINHealth Partners Commercial |
$1,044.38
|
| Rate for Payer: Wise Provider Network Commercial |
$1,044.38
|
|
|
NIM INCREMENTING PROBE 8225825
|
Facility
|
OP
|
$653.12
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$359.87 |
| Max. Negotiated Rate |
$653.12 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$640.06
|
| Rate for Payer: Aetna of WY Medicare |
$431.06
|
| Rate for Payer: Altius Auto/Workers Compensation |
$627.00
|
| Rate for Payer: Altius Commercial |
$627.00
|
| Rate for Payer: Beech Street Commercial |
$640.06
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$536.21
|
| Rate for Payer: Cash Price |
$457.19
|
| Rate for Payer: ChoiceCare Network Commercial |
$633.53
|
| Rate for Payer: Cigna of WY Commercial |
$640.06
|
| Rate for Payer: Entrust Commercial |
$620.46
|
| Rate for Payer: First Choice Health Commercial |
$620.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$620.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$378.81
|
| Rate for Payer: HealthUtah PPO |
$653.12
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$633.53
|
| Rate for Payer: Multiplan Medicare/VA |
$359.87
|
| Rate for Payer: One Health Plan of WY PPO |
$640.06
|
| Rate for Payer: PacificSource Commercial |
$587.81
|
| Rate for Payer: PHCS PPO |
$640.06
|
| Rate for Payer: Three Rivers PPO |
$489.84
|
| Rate for Payer: TriWest Veterans Administration |
$378.81
|
| Rate for Payer: United Healthcare Commercial |
$568.21
|
| Rate for Payer: United Healthcare Medicare |
$378.81
|
| Rate for Payer: WINHealth Partners Commercial |
$640.06
|
| Rate for Payer: Wise Provider Network Commercial |
$620.46
|
|
|
NIM INCREMENTING PROBE 8225825
|
Facility
|
IP
|
$653.12
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$409.51 |
| Max. Negotiated Rate |
$653.12 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$640.06
|
| Rate for Payer: Altius Auto/Workers Compensation |
$627.00
|
| Rate for Payer: Altius Commercial |
$627.00
|
| Rate for Payer: Beech Street Commercial |
$640.06
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$536.21
|
| Rate for Payer: Cash Price |
$457.19
|
| Rate for Payer: ChoiceCare Network Commercial |
$633.53
|
| Rate for Payer: Cigna of WY Commercial |
$640.06
|
| Rate for Payer: Entrust Commercial |
$620.46
|
| Rate for Payer: First Choice Health Commercial |
$620.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$620.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$431.06
|
| Rate for Payer: HealthUtah PPO |
$653.12
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$633.53
|
| Rate for Payer: Multiplan Medicare/VA |
$409.51
|
| Rate for Payer: One Health Plan of WY PPO |
$640.06
|
| Rate for Payer: PacificSource Commercial |
$587.81
|
| Rate for Payer: PHCS PPO |
$640.06
|
| Rate for Payer: Three Rivers PPO |
$489.84
|
| Rate for Payer: TriWest Veterans Administration |
$431.06
|
| Rate for Payer: United Healthcare Commercial |
$568.21
|
| Rate for Payer: United Healthcare Medicare |
$431.06
|
| Rate for Payer: WINHealth Partners Commercial |
$620.46
|
| Rate for Payer: Wise Provider Network Commercial |
$620.46
|
|
|
N-INVAS PHYSIOLOGIC STD LXTR ART COMPL BI
|
Professional
|
Both
|
$780.00
|
|
|
Service Code
|
HCPCS 93924 26
|
| Hospital Charge Code |
93924
|
| Min. Negotiated Rate |
$19.05 |
| Max. Negotiated Rate |
$780.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$764.40
|
| Rate for Payer: Aetna of WY Medicare |
$22.41
|
| Rate for Payer: Beech Street Commercial |
$741.00
|
| Rate for Payer: Cash Price |
$546.00
|
| Rate for Payer: Cash Price |
$546.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$756.60
|
| Rate for Payer: Cigna of WY Commercial |
$764.40
|
| Rate for Payer: First Choice Health Commercial |
$702.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$741.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$22.41
|
| Rate for Payer: HealthUtah PPO |
$780.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$756.60
|
| Rate for Payer: Multiplan Medicare/VA |
$19.05
|
| Rate for Payer: One Health Plan of WY PPO |
$764.40
|
| Rate for Payer: PacificSource Commercial |
$702.00
|
| Rate for Payer: PHCS PPO |
$741.00
|
| Rate for Payer: Three Rivers PPO |
$585.00
|
| Rate for Payer: TriWest Veterans Administration |
$22.41
|
| Rate for Payer: United Healthcare Commercial |
$678.60
|
| Rate for Payer: United Healthcare Medicare |
$22.41
|
| Rate for Payer: WINHealth Partners Commercial |
$741.00
|
|
|
NIPPLE SHIELD 20MM SMALL
|
Facility
|
IP
|
$14.13
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$8.86 |
| Max. Negotiated Rate |
$14.13 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$13.85
|
| Rate for Payer: Altius Auto/Workers Compensation |
$13.56
|
| Rate for Payer: Altius Commercial |
$13.56
|
| Rate for Payer: Beech Street Commercial |
$13.85
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$11.60
|
| Rate for Payer: Cash Price |
$9.89
|
| Rate for Payer: ChoiceCare Network Commercial |
$13.71
|
| Rate for Payer: Cigna of WY Commercial |
$13.85
|
| Rate for Payer: Entrust Commercial |
$13.42
|
| Rate for Payer: First Choice Health Commercial |
$13.42
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$13.42
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.33
|
| Rate for Payer: HealthUtah PPO |
$14.13
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$13.71
|
| Rate for Payer: Multiplan Medicare/VA |
$8.86
|
| Rate for Payer: One Health Plan of WY PPO |
$13.85
|
| Rate for Payer: PacificSource Commercial |
$12.72
|
| Rate for Payer: PHCS PPO |
$13.85
|
| Rate for Payer: Three Rivers PPO |
$10.60
|
| Rate for Payer: TriWest Veterans Administration |
$9.33
|
| Rate for Payer: United Healthcare Commercial |
$12.29
|
| Rate for Payer: United Healthcare Medicare |
$9.33
|
| Rate for Payer: WINHealth Partners Commercial |
$13.42
|
| Rate for Payer: Wise Provider Network Commercial |
$13.42
|
|
|
NIPPLE SHIELD 20MM SMALL
|
Facility
|
OP
|
$14.13
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$7.79 |
| Max. Negotiated Rate |
$14.13 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$13.85
|
| Rate for Payer: Aetna of WY Medicare |
$9.33
|
| Rate for Payer: Altius Auto/Workers Compensation |
$13.56
|
| Rate for Payer: Altius Commercial |
$13.56
|
| Rate for Payer: Beech Street Commercial |
$13.85
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$11.60
|
| Rate for Payer: Cash Price |
$9.89
|
| Rate for Payer: ChoiceCare Network Commercial |
$13.71
|
| Rate for Payer: Cigna of WY Commercial |
$13.85
|
| Rate for Payer: Entrust Commercial |
$13.42
|
| Rate for Payer: First Choice Health Commercial |
$13.42
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$13.42
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.20
|
| Rate for Payer: HealthUtah PPO |
$14.13
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$13.71
|
| Rate for Payer: Multiplan Medicare/VA |
$7.79
|
| Rate for Payer: One Health Plan of WY PPO |
$13.85
|
| Rate for Payer: PacificSource Commercial |
$12.72
|
| Rate for Payer: PHCS PPO |
$13.85
|
| Rate for Payer: Three Rivers PPO |
$10.60
|
| Rate for Payer: TriWest Veterans Administration |
$8.20
|
| Rate for Payer: United Healthcare Commercial |
$12.29
|
| Rate for Payer: United Healthcare Medicare |
$8.20
|
| Rate for Payer: WINHealth Partners Commercial |
$13.85
|
| Rate for Payer: Wise Provider Network Commercial |
$13.42
|
|
|
NIRMATRELVIR 150 MG-RITONAVIR 100 MG TABLETS IN A DOSE PACK [165107]
|
Facility
|
OP
|
$130.91
|
|
|
Service Code
|
NDC 0069531702
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$72.13 |
| Max. Negotiated Rate |
$130.91 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$128.29
|
| Rate for Payer: Aetna of WY Medicare |
$86.40
|
| Rate for Payer: Altius Auto/Workers Compensation |
$125.67
|
| Rate for Payer: Altius Commercial |
$125.67
|
| Rate for Payer: Beech Street Commercial |
$128.29
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$107.48
|
| Rate for Payer: Cash Price |
$91.64
|
| Rate for Payer: ChoiceCare Network Commercial |
$126.98
|
| Rate for Payer: Cigna of WY Commercial |
$128.29
|
| Rate for Payer: Entrust Commercial |
$124.36
|
| Rate for Payer: First Choice Health Commercial |
$124.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$124.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$75.93
|
| Rate for Payer: HealthUtah PPO |
$130.91
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$126.98
|
| Rate for Payer: Multiplan Medicare/VA |
$72.13
|
| Rate for Payer: One Health Plan of WY PPO |
$128.29
|
| Rate for Payer: PacificSource Commercial |
$117.82
|
| Rate for Payer: PHCS PPO |
$128.29
|
| Rate for Payer: Three Rivers PPO |
$98.18
|
| Rate for Payer: TriWest Veterans Administration |
$75.93
|
| Rate for Payer: United Healthcare Commercial |
$113.89
|
| Rate for Payer: United Healthcare Medicare |
$75.93
|
| Rate for Payer: WINHealth Partners Commercial |
$128.29
|
| Rate for Payer: Wise Provider Network Commercial |
$124.36
|
|
|
NIRMATRELVIR 150 MG-RITONAVIR 100 MG TABLETS IN A DOSE PACK [165107]
|
Facility
|
OP
|
$130.91
|
|
|
Service Code
|
NDC 0069531720
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$72.13 |
| Max. Negotiated Rate |
$130.91 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$128.29
|
| Rate for Payer: Aetna of WY Medicare |
$86.40
|
| Rate for Payer: Altius Auto/Workers Compensation |
$125.67
|
| Rate for Payer: Altius Commercial |
$125.67
|
| Rate for Payer: Beech Street Commercial |
$128.29
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$107.48
|
| Rate for Payer: Cash Price |
$91.64
|
| Rate for Payer: ChoiceCare Network Commercial |
$126.98
|
| Rate for Payer: Cigna of WY Commercial |
$128.29
|
| Rate for Payer: Entrust Commercial |
$124.36
|
| Rate for Payer: First Choice Health Commercial |
$124.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$124.36
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$75.93
|
| Rate for Payer: HealthUtah PPO |
$130.91
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$126.98
|
| Rate for Payer: Multiplan Medicare/VA |
$72.13
|
| Rate for Payer: One Health Plan of WY PPO |
$128.29
|
| Rate for Payer: PacificSource Commercial |
$117.82
|
| Rate for Payer: PHCS PPO |
$128.29
|
| Rate for Payer: Three Rivers PPO |
$98.18
|
| Rate for Payer: TriWest Veterans Administration |
$75.93
|
| Rate for Payer: United Healthcare Commercial |
$113.89
|
| Rate for Payer: United Healthcare Medicare |
$75.93
|
| Rate for Payer: WINHealth Partners Commercial |
$128.29
|
| Rate for Payer: Wise Provider Network Commercial |
$124.36
|
|
