|
OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET [10947]
|
Facility
|
IP
|
$5.03
|
|
|
Service Code
|
NDC 5026864611
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.15 |
| Max. Negotiated Rate |
$5.03 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4.93
|
| Rate for Payer: Altius Auto/Workers Compensation |
$4.83
|
| Rate for Payer: Altius Commercial |
$4.83
|
| Rate for Payer: Beech Street Commercial |
$4.93
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$4.13
|
| Rate for Payer: Cash Price |
$3.52
|
| Rate for Payer: ChoiceCare Network Commercial |
$4.88
|
| Rate for Payer: Cigna of WY Commercial |
$4.93
|
| Rate for Payer: Entrust Commercial |
$4.78
|
| Rate for Payer: First Choice Health Commercial |
$4.78
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4.78
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3.32
|
| Rate for Payer: HealthUtah PPO |
$5.03
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4.88
|
| Rate for Payer: Multiplan Medicare/VA |
$3.15
|
| Rate for Payer: One Health Plan of WY PPO |
$4.93
|
| Rate for Payer: PacificSource Commercial |
$4.53
|
| Rate for Payer: PHCS PPO |
$4.93
|
| Rate for Payer: Three Rivers PPO |
$3.77
|
| Rate for Payer: TriWest Veterans Administration |
$3.32
|
| Rate for Payer: United Healthcare Commercial |
$4.38
|
| Rate for Payer: United Healthcare Medicare |
$3.32
|
| Rate for Payer: WINHealth Partners Commercial |
$4.78
|
| Rate for Payer: Wise Provider Network Commercial |
$4.78
|
|
|
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET [9532]
|
Facility
|
OP
|
$1.56
|
|
|
Service Code
|
NDC 6068764201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$1.56 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.53
|
| Rate for Payer: Aetna of WY Medicare |
$1.03
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.50
|
| Rate for Payer: Altius Commercial |
$1.50
|
| Rate for Payer: Beech Street Commercial |
$1.53
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.28
|
| Rate for Payer: Cash Price |
$1.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.51
|
| Rate for Payer: Cigna of WY Commercial |
$1.53
|
| Rate for Payer: Entrust Commercial |
$1.48
|
| Rate for Payer: First Choice Health Commercial |
$1.48
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.48
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.90
|
| Rate for Payer: HealthUtah PPO |
$1.56
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.51
|
| Rate for Payer: Multiplan Medicare/VA |
$0.86
|
| Rate for Payer: One Health Plan of WY PPO |
$1.53
|
| Rate for Payer: PacificSource Commercial |
$1.40
|
| Rate for Payer: PHCS PPO |
$1.53
|
| Rate for Payer: Three Rivers PPO |
$1.17
|
| Rate for Payer: TriWest Veterans Administration |
$0.90
|
| Rate for Payer: United Healthcare Commercial |
$1.36
|
| Rate for Payer: United Healthcare Medicare |
$0.90
|
| Rate for Payer: WINHealth Partners Commercial |
$1.53
|
| Rate for Payer: Wise Provider Network Commercial |
$1.48
|
|
|
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET [9532]
|
Facility
|
IP
|
$1.56
|
|
|
Service Code
|
NDC 6068764201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.98 |
| Max. Negotiated Rate |
$1.56 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.53
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.50
|
| Rate for Payer: Altius Commercial |
$1.50
|
| Rate for Payer: Beech Street Commercial |
$1.53
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.28
|
| Rate for Payer: Cash Price |
$1.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.51
|
| Rate for Payer: Cigna of WY Commercial |
$1.53
|
| Rate for Payer: Entrust Commercial |
$1.48
|
| Rate for Payer: First Choice Health Commercial |
$1.48
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.48
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.03
|
| Rate for Payer: HealthUtah PPO |
$1.56
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.51
|
| Rate for Payer: Multiplan Medicare/VA |
$0.98
|
| Rate for Payer: One Health Plan of WY PPO |
$1.53
|
| Rate for Payer: PacificSource Commercial |
$1.40
|
| Rate for Payer: PHCS PPO |
$1.53
|
| Rate for Payer: Three Rivers PPO |
$1.17
|
| Rate for Payer: TriWest Veterans Administration |
$1.03
|
| Rate for Payer: United Healthcare Commercial |
$1.36
|
| Rate for Payer: United Healthcare Medicare |
$1.03
|
| Rate for Payer: WINHealth Partners Commercial |
$1.48
|
| Rate for Payer: Wise Provider Network Commercial |
$1.48
|
|
|
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET [9532]
|
Facility
|
OP
|
$1.64
|
|
|
Service Code
|
NDC 0406051223
|
|
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
|
|
|
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET [9532]
|
Facility
|
OP
|
$1.56
|
|
|
Service Code
|
NDC 6068764211
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$1.56 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.53
|
| Rate for Payer: Aetna of WY Medicare |
$1.03
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.50
|
| Rate for Payer: Altius Commercial |
$1.50
|
| Rate for Payer: Beech Street Commercial |
$1.53
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.28
|
| Rate for Payer: Cash Price |
$1.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.51
|
| Rate for Payer: Cigna of WY Commercial |
$1.53
|
| Rate for Payer: Entrust Commercial |
$1.48
|
| Rate for Payer: First Choice Health Commercial |
$1.48
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.48
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.90
|
| Rate for Payer: HealthUtah PPO |
$1.56
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.51
|
| Rate for Payer: Multiplan Medicare/VA |
$0.86
|
| Rate for Payer: One Health Plan of WY PPO |
$1.53
|
| Rate for Payer: PacificSource Commercial |
$1.40
|
| Rate for Payer: PHCS PPO |
$1.53
|
| Rate for Payer: Three Rivers PPO |
$1.17
|
| Rate for Payer: TriWest Veterans Administration |
$0.90
|
| Rate for Payer: United Healthcare Commercial |
$1.36
|
| Rate for Payer: United Healthcare Medicare |
$0.90
|
| Rate for Payer: WINHealth Partners Commercial |
$1.53
|
| Rate for Payer: Wise Provider Network Commercial |
$1.48
|
|
|
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET [9532]
|
Facility
|
IP
|
$1.64
|
|
|
Service Code
|
NDC 0406051223
|
|
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
|
|
|
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET [9532]
|
Facility
|
IP
|
$1.56
|
|
|
Service Code
|
NDC 6068764211
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.98 |
| Max. Negotiated Rate |
$1.56 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.53
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.50
|
| Rate for Payer: Altius Commercial |
$1.50
|
| Rate for Payer: Beech Street Commercial |
$1.53
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.28
|
| Rate for Payer: Cash Price |
$1.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.51
|
| Rate for Payer: Cigna of WY Commercial |
$1.53
|
| Rate for Payer: Entrust Commercial |
$1.48
|
| Rate for Payer: First Choice Health Commercial |
$1.48
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.48
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.03
|
| Rate for Payer: HealthUtah PPO |
$1.56
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.51
|
| Rate for Payer: Multiplan Medicare/VA |
$0.98
|
| Rate for Payer: One Health Plan of WY PPO |
$1.53
|
| Rate for Payer: PacificSource Commercial |
$1.40
|
| Rate for Payer: PHCS PPO |
$1.53
|
| Rate for Payer: Three Rivers PPO |
$1.17
|
| Rate for Payer: TriWest Veterans Administration |
$1.03
|
| Rate for Payer: United Healthcare Commercial |
$1.36
|
| Rate for Payer: United Healthcare Medicare |
$1.03
|
| Rate for Payer: WINHealth Partners Commercial |
$1.48
|
| Rate for Payer: Wise Provider Network Commercial |
$1.48
|
|
|
OXYCODONE-ACETAMINOPHEN 7.5 MG-325 MG TABLET [17636]
|
Facility
|
IP
|
$5.69
|
|
|
Service Code
|
NDC 6808469911
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.57 |
| Max. Negotiated Rate |
$5.69 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5.58
|
| Rate for Payer: Altius Auto/Workers Compensation |
$5.46
|
| Rate for Payer: Altius Commercial |
$5.46
|
| Rate for Payer: Beech Street Commercial |
$5.58
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$4.67
|
| Rate for Payer: Cash Price |
$3.99
|
| Rate for Payer: ChoiceCare Network Commercial |
$5.52
|
| Rate for Payer: Cigna of WY Commercial |
$5.58
|
| Rate for Payer: Entrust Commercial |
$5.41
|
| Rate for Payer: First Choice Health Commercial |
$5.41
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5.41
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3.76
|
| Rate for Payer: HealthUtah PPO |
$5.69
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5.52
|
| Rate for Payer: Multiplan Medicare/VA |
$3.57
|
| Rate for Payer: One Health Plan of WY PPO |
$5.58
|
| Rate for Payer: PacificSource Commercial |
$5.12
|
| Rate for Payer: PHCS PPO |
$5.58
|
| Rate for Payer: Three Rivers PPO |
$4.27
|
| Rate for Payer: TriWest Veterans Administration |
$3.76
|
| Rate for Payer: United Healthcare Commercial |
$4.95
|
| Rate for Payer: United Healthcare Medicare |
$3.76
|
| Rate for Payer: WINHealth Partners Commercial |
$5.41
|
| Rate for Payer: Wise Provider Network Commercial |
$5.41
|
|
|
OXYCODONE-ACETAMINOPHEN 7.5 MG-325 MG TABLET [17636]
|
Facility
|
OP
|
$5.69
|
|
|
Service Code
|
NDC 6808469911
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.14 |
| Max. Negotiated Rate |
$5.69 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5.58
|
| Rate for Payer: Aetna of WY Medicare |
$3.76
|
| Rate for Payer: Altius Auto/Workers Compensation |
$5.46
|
| Rate for Payer: Altius Commercial |
$5.46
|
| Rate for Payer: Beech Street Commercial |
$5.58
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$4.67
|
| Rate for Payer: Cash Price |
$3.99
|
| Rate for Payer: ChoiceCare Network Commercial |
$5.52
|
| Rate for Payer: Cigna of WY Commercial |
$5.58
|
| Rate for Payer: Entrust Commercial |
$5.41
|
| Rate for Payer: First Choice Health Commercial |
$5.41
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5.41
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3.30
|
| Rate for Payer: HealthUtah PPO |
$5.69
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5.52
|
| Rate for Payer: Multiplan Medicare/VA |
$3.14
|
| Rate for Payer: One Health Plan of WY PPO |
$5.58
|
| Rate for Payer: PacificSource Commercial |
$5.12
|
| Rate for Payer: PHCS PPO |
$5.58
|
| Rate for Payer: Three Rivers PPO |
$4.27
|
| Rate for Payer: TriWest Veterans Administration |
$3.30
|
| Rate for Payer: United Healthcare Commercial |
$4.95
|
| Rate for Payer: United Healthcare Medicare |
$3.30
|
| Rate for Payer: WINHealth Partners Commercial |
$5.58
|
| Rate for Payer: Wise Provider Network Commercial |
$5.41
|
|
|
OXYCODONE-ACETAMINOPHEN 7.5 MG-325 MG TABLET [17636]
|
Facility
|
IP
|
$4.86
|
|
|
Service Code
|
NDC 5026864515
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.05 |
| Max. Negotiated Rate |
$4.86 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4.76
|
| Rate for Payer: Altius Auto/Workers Compensation |
$4.67
|
| Rate for Payer: Altius Commercial |
$4.67
|
| Rate for Payer: Beech Street Commercial |
$4.76
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3.99
|
| Rate for Payer: Cash Price |
$3.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$4.71
|
| Rate for Payer: Cigna of WY Commercial |
$4.76
|
| Rate for Payer: Entrust Commercial |
$4.62
|
| Rate for Payer: First Choice Health Commercial |
$4.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3.21
|
| Rate for Payer: HealthUtah PPO |
$4.86
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4.71
|
| Rate for Payer: Multiplan Medicare/VA |
$3.05
|
| Rate for Payer: One Health Plan of WY PPO |
$4.76
|
| Rate for Payer: PacificSource Commercial |
$4.37
|
| Rate for Payer: PHCS PPO |
$4.76
|
| Rate for Payer: Three Rivers PPO |
$3.64
|
| Rate for Payer: TriWest Veterans Administration |
$3.21
|
| Rate for Payer: United Healthcare Commercial |
$4.23
|
| Rate for Payer: United Healthcare Medicare |
$3.21
|
| Rate for Payer: WINHealth Partners Commercial |
$4.62
|
| Rate for Payer: Wise Provider Network Commercial |
$4.62
|
|
|
OXYCODONE-ACETAMINOPHEN 7.5 MG-325 MG TABLET [17636]
|
Facility
|
OP
|
$4.86
|
|
|
Service Code
|
NDC 5026864515
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.68 |
| Max. Negotiated Rate |
$4.86 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4.76
|
| Rate for Payer: Aetna of WY Medicare |
$3.21
|
| Rate for Payer: Altius Auto/Workers Compensation |
$4.67
|
| Rate for Payer: Altius Commercial |
$4.67
|
| Rate for Payer: Beech Street Commercial |
$4.76
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3.99
|
| Rate for Payer: Cash Price |
$3.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$4.71
|
| Rate for Payer: Cigna of WY Commercial |
$4.76
|
| Rate for Payer: Entrust Commercial |
$4.62
|
| Rate for Payer: First Choice Health Commercial |
$4.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2.82
|
| Rate for Payer: HealthUtah PPO |
$4.86
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4.71
|
| Rate for Payer: Multiplan Medicare/VA |
$2.68
|
| Rate for Payer: One Health Plan of WY PPO |
$4.76
|
| Rate for Payer: PacificSource Commercial |
$4.37
|
| Rate for Payer: PHCS PPO |
$4.76
|
| Rate for Payer: Three Rivers PPO |
$3.64
|
| Rate for Payer: TriWest Veterans Administration |
$2.82
|
| Rate for Payer: United Healthcare Commercial |
$4.23
|
| Rate for Payer: United Healthcare Medicare |
$2.82
|
| Rate for Payer: WINHealth Partners Commercial |
$4.76
|
| Rate for Payer: Wise Provider Network Commercial |
$4.62
|
|
|
OXYCODONE-ACETAMINOPHEN 7.5 MG-325 MG TABLET [17636]
|
Facility
|
IP
|
$4.86
|
|
|
Service Code
|
NDC 5026864511
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.05 |
| Max. Negotiated Rate |
$4.86 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4.76
|
| Rate for Payer: Altius Auto/Workers Compensation |
$4.67
|
| Rate for Payer: Altius Commercial |
$4.67
|
| Rate for Payer: Beech Street Commercial |
$4.76
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3.99
|
| Rate for Payer: Cash Price |
$3.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$4.71
|
| Rate for Payer: Cigna of WY Commercial |
$4.76
|
| Rate for Payer: Entrust Commercial |
$4.62
|
| Rate for Payer: First Choice Health Commercial |
$4.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3.21
|
| Rate for Payer: HealthUtah PPO |
$4.86
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4.71
|
| Rate for Payer: Multiplan Medicare/VA |
$3.05
|
| Rate for Payer: One Health Plan of WY PPO |
$4.76
|
| Rate for Payer: PacificSource Commercial |
$4.37
|
| Rate for Payer: PHCS PPO |
$4.76
|
| Rate for Payer: Three Rivers PPO |
$3.64
|
| Rate for Payer: TriWest Veterans Administration |
$3.21
|
| Rate for Payer: United Healthcare Commercial |
$4.23
|
| Rate for Payer: United Healthcare Medicare |
$3.21
|
| Rate for Payer: WINHealth Partners Commercial |
$4.62
|
| Rate for Payer: Wise Provider Network Commercial |
$4.62
|
|
|
OXYCODONE-ACETAMINOPHEN 7.5 MG-325 MG TABLET [17636]
|
Facility
|
OP
|
$4.86
|
|
|
Service Code
|
NDC 5026864511
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.68 |
| Max. Negotiated Rate |
$4.86 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4.76
|
| Rate for Payer: Aetna of WY Medicare |
$3.21
|
| Rate for Payer: Altius Auto/Workers Compensation |
$4.67
|
| Rate for Payer: Altius Commercial |
$4.67
|
| Rate for Payer: Beech Street Commercial |
$4.76
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3.99
|
| Rate for Payer: Cash Price |
$3.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$4.71
|
| Rate for Payer: Cigna of WY Commercial |
$4.76
|
| Rate for Payer: Entrust Commercial |
$4.62
|
| Rate for Payer: First Choice Health Commercial |
$4.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2.82
|
| Rate for Payer: HealthUtah PPO |
$4.86
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4.71
|
| Rate for Payer: Multiplan Medicare/VA |
$2.68
|
| Rate for Payer: One Health Plan of WY PPO |
$4.76
|
| Rate for Payer: PacificSource Commercial |
$4.37
|
| Rate for Payer: PHCS PPO |
$4.76
|
| Rate for Payer: Three Rivers PPO |
$3.64
|
| Rate for Payer: TriWest Veterans Administration |
$2.82
|
| Rate for Payer: United Healthcare Commercial |
$4.23
|
| Rate for Payer: United Healthcare Medicare |
$2.82
|
| Rate for Payer: WINHealth Partners Commercial |
$4.76
|
| Rate for Payer: Wise Provider Network Commercial |
$4.62
|
|
|
OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR [138999]
|
Facility
|
OP
|
$19.83
|
|
|
Service Code
|
NDC 5901141010
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.93 |
| Max. Negotiated Rate |
$19.83 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$19.43
|
| Rate for Payer: Aetna of WY Medicare |
$13.09
|
| Rate for Payer: Altius Auto/Workers Compensation |
$19.04
|
| Rate for Payer: Altius Commercial |
$19.04
|
| Rate for Payer: Beech Street Commercial |
$19.43
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.28
|
| Rate for Payer: Cash Price |
$13.88
|
| Rate for Payer: ChoiceCare Network Commercial |
$19.24
|
| Rate for Payer: Cigna of WY Commercial |
$19.43
|
| Rate for Payer: Entrust Commercial |
$18.84
|
| Rate for Payer: First Choice Health Commercial |
$18.84
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$18.84
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.50
|
| Rate for Payer: HealthUtah PPO |
$19.83
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$19.24
|
| Rate for Payer: Multiplan Medicare/VA |
$10.93
|
| Rate for Payer: One Health Plan of WY PPO |
$19.43
|
| Rate for Payer: PacificSource Commercial |
$17.85
|
| Rate for Payer: PHCS PPO |
$19.43
|
| Rate for Payer: Three Rivers PPO |
$14.87
|
| Rate for Payer: TriWest Veterans Administration |
$11.50
|
| Rate for Payer: United Healthcare Commercial |
$17.25
|
| Rate for Payer: United Healthcare Medicare |
$11.50
|
| Rate for Payer: WINHealth Partners Commercial |
$19.43
|
| Rate for Payer: Wise Provider Network Commercial |
$18.84
|
|
|
OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR [138999]
|
Facility
|
IP
|
$20.36
|
|
|
Service Code
|
NDC 5901141020
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.77 |
| Max. Negotiated Rate |
$20.36 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$19.95
|
| Rate for Payer: Altius Auto/Workers Compensation |
$19.55
|
| Rate for Payer: Altius Commercial |
$19.55
|
| Rate for Payer: Beech Street Commercial |
$19.95
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.72
|
| Rate for Payer: Cash Price |
$14.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$19.75
|
| Rate for Payer: Cigna of WY Commercial |
$19.95
|
| Rate for Payer: Entrust Commercial |
$19.34
|
| Rate for Payer: First Choice Health Commercial |
$19.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$19.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$13.44
|
| Rate for Payer: HealthUtah PPO |
$20.36
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$19.75
|
| Rate for Payer: Multiplan Medicare/VA |
$12.77
|
| Rate for Payer: One Health Plan of WY PPO |
$19.95
|
| Rate for Payer: PacificSource Commercial |
$18.32
|
| Rate for Payer: PHCS PPO |
$19.95
|
| Rate for Payer: Three Rivers PPO |
$15.27
|
| Rate for Payer: TriWest Veterans Administration |
$13.44
|
| Rate for Payer: United Healthcare Commercial |
$17.71
|
| Rate for Payer: United Healthcare Medicare |
$13.44
|
| Rate for Payer: WINHealth Partners Commercial |
$19.34
|
| Rate for Payer: Wise Provider Network Commercial |
$19.34
|
|
|
OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR [138999]
|
Facility
|
OP
|
$20.36
|
|
|
Service Code
|
NDC 5901141020
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.22 |
| Max. Negotiated Rate |
$20.36 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$19.95
|
| Rate for Payer: Aetna of WY Medicare |
$13.44
|
| Rate for Payer: Altius Auto/Workers Compensation |
$19.55
|
| Rate for Payer: Altius Commercial |
$19.55
|
| Rate for Payer: Beech Street Commercial |
$19.95
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.72
|
| Rate for Payer: Cash Price |
$14.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$19.75
|
| Rate for Payer: Cigna of WY Commercial |
$19.95
|
| Rate for Payer: Entrust Commercial |
$19.34
|
| Rate for Payer: First Choice Health Commercial |
$19.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$19.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.81
|
| Rate for Payer: HealthUtah PPO |
$20.36
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$19.75
|
| Rate for Payer: Multiplan Medicare/VA |
$11.22
|
| Rate for Payer: One Health Plan of WY PPO |
$19.95
|
| Rate for Payer: PacificSource Commercial |
$18.32
|
| Rate for Payer: PHCS PPO |
$19.95
|
| Rate for Payer: Three Rivers PPO |
$15.27
|
| Rate for Payer: TriWest Veterans Administration |
$11.81
|
| Rate for Payer: United Healthcare Commercial |
$17.71
|
| Rate for Payer: United Healthcare Medicare |
$11.81
|
| Rate for Payer: WINHealth Partners Commercial |
$19.95
|
| Rate for Payer: Wise Provider Network Commercial |
$19.34
|
|
|
OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR [138999]
|
Facility
|
IP
|
$19.83
|
|
|
Service Code
|
NDC 5901141010
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.43 |
| Max. Negotiated Rate |
$19.83 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$19.43
|
| Rate for Payer: Altius Auto/Workers Compensation |
$19.04
|
| Rate for Payer: Altius Commercial |
$19.04
|
| Rate for Payer: Beech Street Commercial |
$19.43
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.28
|
| Rate for Payer: Cash Price |
$13.88
|
| Rate for Payer: ChoiceCare Network Commercial |
$19.24
|
| Rate for Payer: Cigna of WY Commercial |
$19.43
|
| Rate for Payer: Entrust Commercial |
$18.84
|
| Rate for Payer: First Choice Health Commercial |
$18.84
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$18.84
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$13.09
|
| Rate for Payer: HealthUtah PPO |
$19.83
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$19.24
|
| Rate for Payer: Multiplan Medicare/VA |
$12.43
|
| Rate for Payer: One Health Plan of WY PPO |
$19.43
|
| Rate for Payer: PacificSource Commercial |
$17.85
|
| Rate for Payer: PHCS PPO |
$19.43
|
| Rate for Payer: Three Rivers PPO |
$14.87
|
| Rate for Payer: TriWest Veterans Administration |
$13.09
|
| Rate for Payer: United Healthcare Commercial |
$17.25
|
| Rate for Payer: United Healthcare Medicare |
$13.09
|
| Rate for Payer: WINHealth Partners Commercial |
$18.84
|
| Rate for Payer: Wise Provider Network Commercial |
$18.84
|
|
|
OXYMETAZOLINE 0.05 % NASAL SPRAY [28558]
|
Facility
|
IP
|
$1.34
|
|
|
Service Code
|
NDC 2390001252
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$1.34 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.31
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.29
|
| Rate for Payer: Altius Commercial |
$1.29
|
| Rate for Payer: Beech Street Commercial |
$1.31
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.10
|
| Rate for Payer: Cash Price |
$0.94
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.30
|
| Rate for Payer: Cigna of WY Commercial |
$1.31
|
| Rate for Payer: Entrust Commercial |
$1.27
|
| Rate for Payer: First Choice Health Commercial |
$1.27
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.27
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.88
|
| Rate for Payer: HealthUtah PPO |
$1.34
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.30
|
| Rate for Payer: Multiplan Medicare/VA |
$0.84
|
| Rate for Payer: One Health Plan of WY PPO |
$1.31
|
| Rate for Payer: PacificSource Commercial |
$1.21
|
| Rate for Payer: PHCS PPO |
$1.31
|
| Rate for Payer: Three Rivers PPO |
$1.00
|
| Rate for Payer: TriWest Veterans Administration |
$0.88
|
| Rate for Payer: United Healthcare Commercial |
$1.17
|
| Rate for Payer: United Healthcare Medicare |
$0.88
|
| Rate for Payer: WINHealth Partners Commercial |
$1.27
|
| Rate for Payer: Wise Provider Network Commercial |
$1.27
|
|
|
OXYMETAZOLINE 0.05 % NASAL SPRAY [28558]
|
Facility
|
OP
|
$0.37
|
|
|
Service Code
|
NDC 4612216510
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.36
|
| Rate for Payer: Aetna of WY Medicare |
$0.24
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.36
|
| Rate for Payer: Altius Commercial |
$0.36
|
| Rate for Payer: Beech Street Commercial |
$0.36
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.30
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.36
|
| Rate for Payer: Cigna of WY Commercial |
$0.36
|
| Rate for Payer: Entrust Commercial |
$0.35
|
| Rate for Payer: First Choice Health Commercial |
$0.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.21
|
| Rate for Payer: HealthUtah PPO |
$0.37
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.36
|
| Rate for Payer: Multiplan Medicare/VA |
$0.20
|
| Rate for Payer: One Health Plan of WY PPO |
$0.36
|
| Rate for Payer: PacificSource Commercial |
$0.33
|
| Rate for Payer: PHCS PPO |
$0.36
|
| Rate for Payer: Three Rivers PPO |
$0.28
|
| Rate for Payer: TriWest Veterans Administration |
$0.21
|
| Rate for Payer: United Healthcare Commercial |
$0.32
|
| Rate for Payer: United Healthcare Medicare |
$0.21
|
| Rate for Payer: WINHealth Partners Commercial |
$0.36
|
| Rate for Payer: Wise Provider Network Commercial |
$0.35
|
|
|
OXYMETAZOLINE 0.05 % NASAL SPRAY [28558]
|
Facility
|
IP
|
$0.37
|
|
|
Service Code
|
NDC 4612216510
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.36
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.36
|
| Rate for Payer: Altius Commercial |
$0.36
|
| Rate for Payer: Beech Street Commercial |
$0.36
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.30
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.36
|
| Rate for Payer: Cigna of WY Commercial |
$0.36
|
| Rate for Payer: Entrust Commercial |
$0.35
|
| Rate for Payer: First Choice Health Commercial |
$0.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.24
|
| Rate for Payer: HealthUtah PPO |
$0.37
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.36
|
| Rate for Payer: Multiplan Medicare/VA |
$0.23
|
| Rate for Payer: One Health Plan of WY PPO |
$0.36
|
| Rate for Payer: PacificSource Commercial |
$0.33
|
| Rate for Payer: PHCS PPO |
$0.36
|
| Rate for Payer: Three Rivers PPO |
$0.28
|
| Rate for Payer: TriWest Veterans Administration |
$0.24
|
| Rate for Payer: United Healthcare Commercial |
$0.32
|
| Rate for Payer: United Healthcare Medicare |
$0.24
|
| Rate for Payer: WINHealth Partners Commercial |
$0.35
|
| Rate for Payer: Wise Provider Network Commercial |
$0.35
|
|
|
OXYMETAZOLINE 0.05 % NASAL SPRAY [28558]
|
Facility
|
OP
|
$2.88
|
|
|
Service Code
|
NDC 5002443100
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.59 |
| Max. Negotiated Rate |
$2.88 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.82
|
| Rate for Payer: Aetna of WY Medicare |
$1.90
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.76
|
| Rate for Payer: Altius Commercial |
$2.76
|
| Rate for Payer: Beech Street Commercial |
$2.82
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.36
|
| Rate for Payer: Cash Price |
$2.01
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.79
|
| Rate for Payer: Cigna of WY Commercial |
$2.82
|
| Rate for Payer: Entrust Commercial |
$2.74
|
| Rate for Payer: First Choice Health Commercial |
$2.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.67
|
| Rate for Payer: HealthUtah PPO |
$2.88
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.79
|
| Rate for Payer: Multiplan Medicare/VA |
$1.59
|
| Rate for Payer: One Health Plan of WY PPO |
$2.82
|
| Rate for Payer: PacificSource Commercial |
$2.59
|
| Rate for Payer: PHCS PPO |
$2.82
|
| Rate for Payer: Three Rivers PPO |
$2.16
|
| Rate for Payer: TriWest Veterans Administration |
$1.67
|
| Rate for Payer: United Healthcare Commercial |
$2.51
|
| Rate for Payer: United Healthcare Medicare |
$1.67
|
| Rate for Payer: WINHealth Partners Commercial |
$2.82
|
| Rate for Payer: Wise Provider Network Commercial |
$2.74
|
|
|
OXYMETAZOLINE 0.05 % NASAL SPRAY [28558]
|
Facility
|
OP
|
$1.70
|
|
|
Service Code
|
NDC 4110081127
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.94 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.67
|
| Rate for Payer: Aetna of WY Medicare |
$1.12
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.63
|
| Rate for Payer: Altius Commercial |
$1.63
|
| Rate for Payer: Beech Street Commercial |
$1.67
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.40
|
| Rate for Payer: Cash Price |
$1.19
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.65
|
| Rate for Payer: Cigna of WY Commercial |
$1.67
|
| Rate for Payer: Entrust Commercial |
$1.62
|
| Rate for Payer: First Choice Health Commercial |
$1.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.99
|
| Rate for Payer: HealthUtah PPO |
$1.70
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.65
|
| Rate for Payer: Multiplan Medicare/VA |
$0.94
|
| Rate for Payer: One Health Plan of WY PPO |
$1.67
|
| Rate for Payer: PacificSource Commercial |
$1.53
|
| Rate for Payer: PHCS PPO |
$1.67
|
| Rate for Payer: Three Rivers PPO |
$1.28
|
| Rate for Payer: TriWest Veterans Administration |
$0.99
|
| Rate for Payer: United Healthcare Commercial |
$1.48
|
| Rate for Payer: United Healthcare Medicare |
$0.99
|
| Rate for Payer: WINHealth Partners Commercial |
$1.67
|
| Rate for Payer: Wise Provider Network Commercial |
$1.62
|
|
|
OXYMETAZOLINE 0.05 % NASAL SPRAY [28558]
|
Facility
|
OP
|
$0.53
|
|
|
Service Code
|
NDC 0904743535
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.52
|
| Rate for Payer: Aetna of WY Medicare |
$0.35
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.51
|
| Rate for Payer: Altius Commercial |
$0.51
|
| Rate for Payer: Beech Street Commercial |
$0.52
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.44
|
| Rate for Payer: Cash Price |
$0.37
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.51
|
| Rate for Payer: Cigna of WY Commercial |
$0.52
|
| Rate for Payer: Entrust Commercial |
$0.50
|
| Rate for Payer: First Choice Health Commercial |
$0.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.31
|
| Rate for Payer: HealthUtah PPO |
$0.53
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.51
|
| Rate for Payer: Multiplan Medicare/VA |
$0.29
|
| Rate for Payer: One Health Plan of WY PPO |
$0.52
|
| Rate for Payer: PacificSource Commercial |
$0.48
|
| Rate for Payer: PHCS PPO |
$0.52
|
| Rate for Payer: Three Rivers PPO |
$0.40
|
| Rate for Payer: TriWest Veterans Administration |
$0.31
|
| Rate for Payer: United Healthcare Commercial |
$0.46
|
| Rate for Payer: United Healthcare Medicare |
$0.31
|
| Rate for Payer: WINHealth Partners Commercial |
$0.52
|
| Rate for Payer: Wise Provider Network Commercial |
$0.50
|
|
|
OXYMETAZOLINE 0.05 % NASAL SPRAY [28558]
|
Facility
|
OP
|
$1.34
|
|
|
Service Code
|
NDC 2390001252
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$1.34 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.31
|
| Rate for Payer: Aetna of WY Medicare |
$0.88
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.29
|
| Rate for Payer: Altius Commercial |
$1.29
|
| Rate for Payer: Beech Street Commercial |
$1.31
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.10
|
| Rate for Payer: Cash Price |
$0.94
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.30
|
| Rate for Payer: Cigna of WY Commercial |
$1.31
|
| Rate for Payer: Entrust Commercial |
$1.27
|
| Rate for Payer: First Choice Health Commercial |
$1.27
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.27
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.78
|
| Rate for Payer: HealthUtah PPO |
$1.34
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.30
|
| Rate for Payer: Multiplan Medicare/VA |
$0.74
|
| Rate for Payer: One Health Plan of WY PPO |
$1.31
|
| Rate for Payer: PacificSource Commercial |
$1.21
|
| Rate for Payer: PHCS PPO |
$1.31
|
| Rate for Payer: Three Rivers PPO |
$1.00
|
| Rate for Payer: TriWest Veterans Administration |
$0.78
|
| Rate for Payer: United Healthcare Commercial |
$1.17
|
| Rate for Payer: United Healthcare Medicare |
$0.78
|
| Rate for Payer: WINHealth Partners Commercial |
$1.31
|
| Rate for Payer: Wise Provider Network Commercial |
$1.27
|
|
|
OXYMETAZOLINE 0.05 % NASAL SPRAY [28558]
|
Facility
|
IP
|
$2.88
|
|
|
Service Code
|
NDC 5002443100
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.81 |
| Max. Negotiated Rate |
$2.88 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.82
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.76
|
| Rate for Payer: Altius Commercial |
$2.76
|
| Rate for Payer: Beech Street Commercial |
$2.82
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.36
|
| Rate for Payer: Cash Price |
$2.01
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.79
|
| Rate for Payer: Cigna of WY Commercial |
$2.82
|
| Rate for Payer: Entrust Commercial |
$2.74
|
| Rate for Payer: First Choice Health Commercial |
$2.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.90
|
| Rate for Payer: HealthUtah PPO |
$2.88
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.79
|
| Rate for Payer: Multiplan Medicare/VA |
$1.81
|
| Rate for Payer: One Health Plan of WY PPO |
$2.82
|
| Rate for Payer: PacificSource Commercial |
$2.59
|
| Rate for Payer: PHCS PPO |
$2.82
|
| Rate for Payer: Three Rivers PPO |
$2.16
|
| Rate for Payer: TriWest Veterans Administration |
$1.90
|
| Rate for Payer: United Healthcare Commercial |
$2.51
|
| Rate for Payer: United Healthcare Medicare |
$1.90
|
| Rate for Payer: WINHealth Partners Commercial |
$2.74
|
| Rate for Payer: Wise Provider Network Commercial |
$2.74
|
|
