|
PHENOBARBITAL SODIUM 65 MG/ML INJECTION SOLUTION [540]
|
Facility
|
IP
|
$67.71
|
|
|
Service Code
|
HCPCS J2560
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$42.45 |
| Max. Negotiated Rate |
$67.71 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$66.36
|
| Rate for Payer: Altius Auto/Workers Compensation |
$65.00
|
| Rate for Payer: Altius Commercial |
$65.00
|
| Rate for Payer: Beech Street Commercial |
$66.36
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$55.59
|
| Rate for Payer: Cash Price |
$47.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$65.68
|
| Rate for Payer: Cigna of WY Commercial |
$66.36
|
| Rate for Payer: Entrust Commercial |
$64.32
|
| Rate for Payer: First Choice Health Commercial |
$64.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$64.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$44.69
|
| Rate for Payer: HealthUtah PPO |
$67.71
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$65.68
|
| Rate for Payer: Multiplan Medicare/VA |
$42.45
|
| Rate for Payer: One Health Plan of WY PPO |
$66.36
|
| Rate for Payer: PacificSource Commercial |
$60.94
|
| Rate for Payer: PHCS PPO |
$66.36
|
| Rate for Payer: Three Rivers PPO |
$50.78
|
| Rate for Payer: TriWest Veterans Administration |
$44.69
|
| Rate for Payer: United Healthcare Commercial |
$58.91
|
| Rate for Payer: United Healthcare Medicare |
$44.69
|
| Rate for Payer: WINHealth Partners Commercial |
$64.32
|
| Rate for Payer: Wise Provider Network Commercial |
$64.32
|
|
|
PHENOL 1.4 % MUCOSAL AEROSOL SPRAY [20204]
|
Facility
|
IP
|
$0.06
|
|
|
Service Code
|
NDC 4612274876
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.06
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.06
|
| Rate for Payer: Altius Commercial |
$0.06
|
| Rate for Payer: Beech Street Commercial |
$0.06
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.06
|
| Rate for Payer: Cigna of WY Commercial |
$0.06
|
| Rate for Payer: Entrust Commercial |
$0.06
|
| Rate for Payer: First Choice Health Commercial |
$0.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.04
|
| Rate for Payer: HealthUtah PPO |
$0.06
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.06
|
| Rate for Payer: Multiplan Medicare/VA |
$0.04
|
| Rate for Payer: One Health Plan of WY PPO |
$0.06
|
| Rate for Payer: PacificSource Commercial |
$0.05
|
| Rate for Payer: PHCS PPO |
$0.06
|
| Rate for Payer: Three Rivers PPO |
$0.05
|
| Rate for Payer: TriWest Veterans Administration |
$0.04
|
| Rate for Payer: United Healthcare Commercial |
$0.05
|
| Rate for Payer: United Healthcare Medicare |
$0.04
|
| Rate for Payer: WINHealth Partners Commercial |
$0.06
|
| Rate for Payer: Wise Provider Network Commercial |
$0.06
|
|
|
PHENOL 1.4 % MUCOSAL AEROSOL SPRAY [20204]
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 4612274876
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.06
|
| Rate for Payer: Aetna of WY Medicare |
$0.04
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.06
|
| Rate for Payer: Altius Commercial |
$0.06
|
| Rate for Payer: Beech Street Commercial |
$0.06
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.06
|
| Rate for Payer: Cigna of WY Commercial |
$0.06
|
| Rate for Payer: Entrust Commercial |
$0.06
|
| Rate for Payer: First Choice Health Commercial |
$0.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.03
|
| Rate for Payer: HealthUtah PPO |
$0.06
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.06
|
| Rate for Payer: Multiplan Medicare/VA |
$0.03
|
| Rate for Payer: One Health Plan of WY PPO |
$0.06
|
| Rate for Payer: PacificSource Commercial |
$0.05
|
| Rate for Payer: PHCS PPO |
$0.06
|
| Rate for Payer: Three Rivers PPO |
$0.05
|
| Rate for Payer: TriWest Veterans Administration |
$0.03
|
| Rate for Payer: United Healthcare Commercial |
$0.05
|
| Rate for Payer: United Healthcare Medicare |
$0.03
|
| Rate for Payer: WINHealth Partners Commercial |
$0.06
|
| Rate for Payer: Wise Provider Network Commercial |
$0.06
|
|
|
PHENOL 1.4 % MUCOSAL AEROSOL SPRAY [20204]
|
Facility
|
IP
|
$0.06
|
|
|
Service Code
|
NDC 4612274976
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.06
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.06
|
| Rate for Payer: Altius Commercial |
$0.06
|
| Rate for Payer: Beech Street Commercial |
$0.06
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.06
|
| Rate for Payer: Cigna of WY Commercial |
$0.06
|
| Rate for Payer: Entrust Commercial |
$0.06
|
| Rate for Payer: First Choice Health Commercial |
$0.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.04
|
| Rate for Payer: HealthUtah PPO |
$0.06
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.06
|
| Rate for Payer: Multiplan Medicare/VA |
$0.04
|
| Rate for Payer: One Health Plan of WY PPO |
$0.06
|
| Rate for Payer: PacificSource Commercial |
$0.05
|
| Rate for Payer: PHCS PPO |
$0.06
|
| Rate for Payer: Three Rivers PPO |
$0.05
|
| Rate for Payer: TriWest Veterans Administration |
$0.04
|
| Rate for Payer: United Healthcare Commercial |
$0.05
|
| Rate for Payer: United Healthcare Medicare |
$0.04
|
| Rate for Payer: WINHealth Partners Commercial |
$0.06
|
| Rate for Payer: Wise Provider Network Commercial |
$0.06
|
|
|
PHENOL 1.4 % MUCOSAL AEROSOL SPRAY [20204]
|
Facility
|
OP
|
$0.07
|
|
|
Service Code
|
NDC 4612227830
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.07
|
| Rate for Payer: Aetna of WY Medicare |
$0.05
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.07
|
| Rate for Payer: Altius Commercial |
$0.07
|
| Rate for Payer: Beech Street Commercial |
$0.07
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.07
|
| Rate for Payer: Cigna of WY Commercial |
$0.07
|
| Rate for Payer: Entrust Commercial |
$0.07
|
| Rate for Payer: First Choice Health Commercial |
$0.07
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.07
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.04
|
| Rate for Payer: HealthUtah PPO |
$0.07
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.07
|
| Rate for Payer: Multiplan Medicare/VA |
$0.04
|
| Rate for Payer: One Health Plan of WY PPO |
$0.07
|
| Rate for Payer: PacificSource Commercial |
$0.06
|
| Rate for Payer: PHCS PPO |
$0.07
|
| Rate for Payer: Three Rivers PPO |
$0.05
|
| Rate for Payer: TriWest Veterans Administration |
$0.04
|
| Rate for Payer: United Healthcare Commercial |
$0.06
|
| Rate for Payer: United Healthcare Medicare |
$0.04
|
| Rate for Payer: WINHealth Partners Commercial |
$0.07
|
| Rate for Payer: Wise Provider Network Commercial |
$0.07
|
|
|
PHENOL 1.4 % MUCOSAL AEROSOL SPRAY [20204]
|
Facility
|
IP
|
$0.07
|
|
|
Service Code
|
NDC 4612227830
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.07
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.07
|
| Rate for Payer: Altius Commercial |
$0.07
|
| Rate for Payer: Beech Street Commercial |
$0.07
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.07
|
| Rate for Payer: Cigna of WY Commercial |
$0.07
|
| Rate for Payer: Entrust Commercial |
$0.07
|
| Rate for Payer: First Choice Health Commercial |
$0.07
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.07
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.05
|
| Rate for Payer: HealthUtah PPO |
$0.07
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.07
|
| Rate for Payer: Multiplan Medicare/VA |
$0.04
|
| Rate for Payer: One Health Plan of WY PPO |
$0.07
|
| Rate for Payer: PacificSource Commercial |
$0.06
|
| Rate for Payer: PHCS PPO |
$0.07
|
| Rate for Payer: Three Rivers PPO |
$0.05
|
| Rate for Payer: TriWest Veterans Administration |
$0.05
|
| Rate for Payer: United Healthcare Commercial |
$0.06
|
| Rate for Payer: United Healthcare Medicare |
$0.05
|
| Rate for Payer: WINHealth Partners Commercial |
$0.07
|
| Rate for Payer: Wise Provider Network Commercial |
$0.07
|
|
|
PHENOL 1.4 % MUCOSAL AEROSOL SPRAY [20204]
|
Facility
|
OP
|
$0.07
|
|
|
Service Code
|
NDC 8770192172
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.07
|
| Rate for Payer: Aetna of WY Medicare |
$0.05
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.07
|
| Rate for Payer: Altius Commercial |
$0.07
|
| Rate for Payer: Beech Street Commercial |
$0.07
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.07
|
| Rate for Payer: Cigna of WY Commercial |
$0.07
|
| Rate for Payer: Entrust Commercial |
$0.07
|
| Rate for Payer: First Choice Health Commercial |
$0.07
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.07
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.04
|
| Rate for Payer: HealthUtah PPO |
$0.07
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.07
|
| Rate for Payer: Multiplan Medicare/VA |
$0.04
|
| Rate for Payer: One Health Plan of WY PPO |
$0.07
|
| Rate for Payer: PacificSource Commercial |
$0.06
|
| Rate for Payer: PHCS PPO |
$0.07
|
| Rate for Payer: Three Rivers PPO |
$0.05
|
| Rate for Payer: TriWest Veterans Administration |
$0.04
|
| Rate for Payer: United Healthcare Commercial |
$0.06
|
| Rate for Payer: United Healthcare Medicare |
$0.04
|
| Rate for Payer: WINHealth Partners Commercial |
$0.07
|
| Rate for Payer: Wise Provider Network Commercial |
$0.07
|
|
|
PHENOL 1.4 % MUCOSAL AEROSOL SPRAY [20204]
|
Facility
|
IP
|
$0.07
|
|
|
Service Code
|
NDC 8770192172
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.07
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.07
|
| Rate for Payer: Altius Commercial |
$0.07
|
| Rate for Payer: Beech Street Commercial |
$0.07
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.07
|
| Rate for Payer: Cigna of WY Commercial |
$0.07
|
| Rate for Payer: Entrust Commercial |
$0.07
|
| Rate for Payer: First Choice Health Commercial |
$0.07
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.07
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.05
|
| Rate for Payer: HealthUtah PPO |
$0.07
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.07
|
| Rate for Payer: Multiplan Medicare/VA |
$0.04
|
| Rate for Payer: One Health Plan of WY PPO |
$0.07
|
| Rate for Payer: PacificSource Commercial |
$0.06
|
| Rate for Payer: PHCS PPO |
$0.07
|
| Rate for Payer: Three Rivers PPO |
$0.05
|
| Rate for Payer: TriWest Veterans Administration |
$0.05
|
| Rate for Payer: United Healthcare Commercial |
$0.06
|
| Rate for Payer: United Healthcare Medicare |
$0.05
|
| Rate for Payer: WINHealth Partners Commercial |
$0.07
|
| Rate for Payer: Wise Provider Network Commercial |
$0.07
|
|
|
PHENOL 1.4 % MUCOSAL AEROSOL SPRAY [20204]
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 4612274976
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.06
|
| Rate for Payer: Aetna of WY Medicare |
$0.04
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.06
|
| Rate for Payer: Altius Commercial |
$0.06
|
| Rate for Payer: Beech Street Commercial |
$0.06
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.06
|
| Rate for Payer: Cigna of WY Commercial |
$0.06
|
| Rate for Payer: Entrust Commercial |
$0.06
|
| Rate for Payer: First Choice Health Commercial |
$0.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.03
|
| Rate for Payer: HealthUtah PPO |
$0.06
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.06
|
| Rate for Payer: Multiplan Medicare/VA |
$0.03
|
| Rate for Payer: One Health Plan of WY PPO |
$0.06
|
| Rate for Payer: PacificSource Commercial |
$0.05
|
| Rate for Payer: PHCS PPO |
$0.06
|
| Rate for Payer: Three Rivers PPO |
$0.05
|
| Rate for Payer: TriWest Veterans Administration |
$0.03
|
| Rate for Payer: United Healthcare Commercial |
$0.05
|
| Rate for Payer: United Healthcare Medicare |
$0.03
|
| Rate for Payer: WINHealth Partners Commercial |
$0.06
|
| Rate for Payer: Wise Provider Network Commercial |
$0.06
|
|
|
PHENOL 1.4 % MUCOSAL AEROSOL SPRAY [20204]
|
Facility
|
OP
|
$0.05
|
|
|
Service Code
|
NDC 0904630521
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.05
|
| Rate for Payer: Aetna of WY Medicare |
$0.03
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.05
|
| Rate for Payer: Altius Commercial |
$0.05
|
| Rate for Payer: Beech Street Commercial |
$0.05
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.04
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.05
|
| Rate for Payer: Cigna of WY Commercial |
$0.05
|
| Rate for Payer: Entrust Commercial |
$0.05
|
| Rate for Payer: First Choice Health Commercial |
$0.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.03
|
| Rate for Payer: HealthUtah PPO |
$0.05
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.05
|
| Rate for Payer: Multiplan Medicare/VA |
$0.03
|
| Rate for Payer: One Health Plan of WY PPO |
$0.05
|
| Rate for Payer: PacificSource Commercial |
$0.05
|
| Rate for Payer: PHCS PPO |
$0.05
|
| Rate for Payer: Three Rivers PPO |
$0.04
|
| Rate for Payer: TriWest Veterans Administration |
$0.03
|
| Rate for Payer: United Healthcare Commercial |
$0.04
|
| Rate for Payer: United Healthcare Medicare |
$0.03
|
| Rate for Payer: WINHealth Partners Commercial |
$0.05
|
| Rate for Payer: Wise Provider Network Commercial |
$0.05
|
|
|
PHENOL 1.4 % MUCOSAL AEROSOL SPRAY [20204]
|
Facility
|
IP
|
$0.05
|
|
|
Service Code
|
NDC 0904630521
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.05
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.05
|
| Rate for Payer: Altius Commercial |
$0.05
|
| Rate for Payer: Beech Street Commercial |
$0.05
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.04
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.05
|
| Rate for Payer: Cigna of WY Commercial |
$0.05
|
| Rate for Payer: Entrust Commercial |
$0.05
|
| Rate for Payer: First Choice Health Commercial |
$0.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.03
|
| Rate for Payer: HealthUtah PPO |
$0.05
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.05
|
| Rate for Payer: Multiplan Medicare/VA |
$0.03
|
| Rate for Payer: One Health Plan of WY PPO |
$0.05
|
| Rate for Payer: PacificSource Commercial |
$0.05
|
| Rate for Payer: PHCS PPO |
$0.05
|
| Rate for Payer: Three Rivers PPO |
$0.04
|
| Rate for Payer: TriWest Veterans Administration |
$0.03
|
| Rate for Payer: United Healthcare Commercial |
$0.04
|
| Rate for Payer: United Healthcare Medicare |
$0.03
|
| Rate for Payer: WINHealth Partners Commercial |
$0.05
|
| Rate for Payer: Wise Provider Network Commercial |
$0.05
|
|
|
PHENOL 89 % TOPICAL SWAB [38391]
|
Facility
|
IP
|
$17.06
|
|
|
Service Code
|
NDC 0884629730
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.70 |
| Max. Negotiated Rate |
$17.06 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.72
|
| Rate for Payer: Altius Auto/Workers Compensation |
$16.38
|
| Rate for Payer: Altius Commercial |
$16.38
|
| Rate for Payer: Beech Street Commercial |
$16.72
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.01
|
| Rate for Payer: Cash Price |
$11.94
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.55
|
| Rate for Payer: Cigna of WY Commercial |
$16.72
|
| Rate for Payer: Entrust Commercial |
$16.21
|
| Rate for Payer: First Choice Health Commercial |
$16.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.26
|
| Rate for Payer: HealthUtah PPO |
$17.06
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.55
|
| Rate for Payer: Multiplan Medicare/VA |
$10.70
|
| Rate for Payer: One Health Plan of WY PPO |
$16.72
|
| Rate for Payer: PacificSource Commercial |
$15.35
|
| Rate for Payer: PHCS PPO |
$16.72
|
| Rate for Payer: Three Rivers PPO |
$12.80
|
| Rate for Payer: TriWest Veterans Administration |
$11.26
|
| Rate for Payer: United Healthcare Commercial |
$14.84
|
| Rate for Payer: United Healthcare Medicare |
$11.26
|
| Rate for Payer: WINHealth Partners Commercial |
$16.21
|
| Rate for Payer: Wise Provider Network Commercial |
$16.21
|
|
|
PHENOL 89 % TOPICAL SWAB [38391]
|
Facility
|
OP
|
$17.06
|
|
|
Service Code
|
NDC 0884629730
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.40 |
| Max. Negotiated Rate |
$17.06 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.72
|
| Rate for Payer: Aetna of WY Medicare |
$11.26
|
| Rate for Payer: Altius Auto/Workers Compensation |
$16.38
|
| Rate for Payer: Altius Commercial |
$16.38
|
| Rate for Payer: Beech Street Commercial |
$16.72
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.01
|
| Rate for Payer: Cash Price |
$11.94
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.55
|
| Rate for Payer: Cigna of WY Commercial |
$16.72
|
| Rate for Payer: Entrust Commercial |
$16.21
|
| Rate for Payer: First Choice Health Commercial |
$16.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.89
|
| Rate for Payer: HealthUtah PPO |
$17.06
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.55
|
| Rate for Payer: Multiplan Medicare/VA |
$9.40
|
| Rate for Payer: One Health Plan of WY PPO |
$16.72
|
| Rate for Payer: PacificSource Commercial |
$15.35
|
| Rate for Payer: PHCS PPO |
$16.72
|
| Rate for Payer: Three Rivers PPO |
$12.80
|
| Rate for Payer: TriWest Veterans Administration |
$9.89
|
| Rate for Payer: United Healthcare Commercial |
$14.84
|
| Rate for Payer: United Healthcare Medicare |
$9.89
|
| Rate for Payer: WINHealth Partners Commercial |
$16.72
|
| Rate for Payer: Wise Provider Network Commercial |
$16.21
|
|
|
PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT [130309]
|
Facility
|
OP
|
$0.17
|
|
|
Service Code
|
NDC 0536128806
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.17
|
| Rate for Payer: Aetna of WY Medicare |
$0.11
|
| 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 |
$0.10
|
| Rate for Payer: HealthUtah PPO |
$0.17
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.16
|
| Rate for Payer: Multiplan Medicare/VA |
$0.09
|
| 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 |
$0.10
|
| Rate for Payer: United Healthcare Commercial |
$0.15
|
| Rate for Payer: United Healthcare Medicare |
$0.10
|
| Rate for Payer: WINHealth Partners Commercial |
$0.17
|
| Rate for Payer: Wise Provider Network Commercial |
$0.16
|
|
|
PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT [130309]
|
Facility
|
IP
|
$0.17
|
|
|
Service Code
|
NDC 0536128806
|
|
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
|
|
|
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION [16682]
|
Facility
|
OP
|
$23.80
|
|
|
Service Code
|
HCPCS J2371
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.11 |
| Max. Negotiated Rate |
$23.80 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$23.32
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$22.54
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$26.46
|
| Rate for Payer: Aetna of WY Medicare |
$15.71
|
| Rate for Payer: Aetna of WY Medicare |
$17.82
|
| Rate for Payer: Aetna of WY Medicare |
$15.18
|
| Rate for Payer: Altius Auto/Workers Compensation |
$22.85
|
| Rate for Payer: Altius Auto/Workers Compensation |
$22.08
|
| Rate for Payer: Altius Auto/Workers Compensation |
$25.92
|
| Rate for Payer: Altius Commercial |
$22.85
|
| Rate for Payer: Altius Commercial |
$25.92
|
| Rate for Payer: Altius Commercial |
$22.08
|
| Rate for Payer: Beech Street Commercial |
$23.32
|
| Rate for Payer: Beech Street Commercial |
$26.46
|
| Rate for Payer: Beech Street Commercial |
$22.54
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$19.54
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$18.88
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$22.17
|
| Rate for Payer: Cash Price |
$16.66
|
| Rate for Payer: Cash Price |
$16.10
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$23.09
|
| Rate for Payer: ChoiceCare Network Commercial |
$26.19
|
| Rate for Payer: ChoiceCare Network Commercial |
$22.31
|
| Rate for Payer: Cigna of WY Commercial |
$26.46
|
| Rate for Payer: Cigna of WY Commercial |
$22.54
|
| Rate for Payer: Cigna of WY Commercial |
$23.32
|
| Rate for Payer: Entrust Commercial |
$25.65
|
| Rate for Payer: Entrust Commercial |
$22.61
|
| Rate for Payer: Entrust Commercial |
$21.85
|
| Rate for Payer: First Choice Health Commercial |
$22.61
|
| Rate for Payer: First Choice Health Commercial |
$21.85
|
| Rate for Payer: First Choice Health Commercial |
$25.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$21.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$25.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$22.61
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$13.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$13.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$15.66
|
| Rate for Payer: HealthUtah PPO |
$23.00
|
| Rate for Payer: HealthUtah PPO |
$27.00
|
| Rate for Payer: HealthUtah PPO |
$23.80
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$26.19
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$22.31
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$23.09
|
| Rate for Payer: Multiplan Medicare/VA |
$12.67
|
| Rate for Payer: Multiplan Medicare/VA |
$13.11
|
| Rate for Payer: Multiplan Medicare/VA |
$14.88
|
| Rate for Payer: One Health Plan of WY PPO |
$22.54
|
| Rate for Payer: One Health Plan of WY PPO |
$26.46
|
| Rate for Payer: One Health Plan of WY PPO |
$23.32
|
| Rate for Payer: PacificSource Commercial |
$24.30
|
| Rate for Payer: PacificSource Commercial |
$21.42
|
| Rate for Payer: PacificSource Commercial |
$20.70
|
| Rate for Payer: PHCS PPO |
$23.32
|
| Rate for Payer: PHCS PPO |
$22.54
|
| Rate for Payer: PHCS PPO |
$26.46
|
| Rate for Payer: Three Rivers PPO |
$17.85
|
| Rate for Payer: Three Rivers PPO |
$17.25
|
| Rate for Payer: Three Rivers PPO |
$20.25
|
| Rate for Payer: TriWest Veterans Administration |
$15.66
|
| Rate for Payer: TriWest Veterans Administration |
$13.80
|
| Rate for Payer: TriWest Veterans Administration |
$13.34
|
| Rate for Payer: United Healthcare Commercial |
$20.01
|
| Rate for Payer: United Healthcare Commercial |
$20.71
|
| Rate for Payer: United Healthcare Commercial |
$23.49
|
| Rate for Payer: United Healthcare Medicare |
$15.66
|
| Rate for Payer: United Healthcare Medicare |
$13.34
|
| Rate for Payer: United Healthcare Medicare |
$13.80
|
| Rate for Payer: WINHealth Partners Commercial |
$26.46
|
| Rate for Payer: WINHealth Partners Commercial |
$22.54
|
| Rate for Payer: WINHealth Partners Commercial |
$23.32
|
| Rate for Payer: Wise Provider Network Commercial |
$21.85
|
| Rate for Payer: Wise Provider Network Commercial |
$25.65
|
| Rate for Payer: Wise Provider Network Commercial |
$22.61
|
|
|
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION [16682]
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS J2371
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.42 |
| Max. Negotiated Rate |
$23.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$22.54
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$23.32
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$26.46
|
| Rate for Payer: Altius Auto/Workers Compensation |
$22.08
|
| Rate for Payer: Altius Auto/Workers Compensation |
$22.85
|
| Rate for Payer: Altius Auto/Workers Compensation |
$25.92
|
| Rate for Payer: Altius Commercial |
$22.85
|
| Rate for Payer: Altius Commercial |
$22.08
|
| Rate for Payer: Altius Commercial |
$25.92
|
| Rate for Payer: Beech Street Commercial |
$26.46
|
| Rate for Payer: Beech Street Commercial |
$23.32
|
| Rate for Payer: Beech Street Commercial |
$22.54
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$18.88
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$22.17
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$19.54
|
| Rate for Payer: Cash Price |
$16.66
|
| Rate for Payer: Cash Price |
$16.10
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$22.31
|
| Rate for Payer: ChoiceCare Network Commercial |
$26.19
|
| Rate for Payer: ChoiceCare Network Commercial |
$23.09
|
| Rate for Payer: Cigna of WY Commercial |
$23.32
|
| Rate for Payer: Cigna of WY Commercial |
$26.46
|
| Rate for Payer: Cigna of WY Commercial |
$22.54
|
| Rate for Payer: Entrust Commercial |
$25.65
|
| Rate for Payer: Entrust Commercial |
$21.85
|
| Rate for Payer: Entrust Commercial |
$22.61
|
| Rate for Payer: First Choice Health Commercial |
$22.61
|
| Rate for Payer: First Choice Health Commercial |
$25.65
|
| Rate for Payer: First Choice Health Commercial |
$21.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$21.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$25.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$22.61
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$15.18
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$15.71
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$17.82
|
| Rate for Payer: HealthUtah PPO |
$23.00
|
| Rate for Payer: HealthUtah PPO |
$23.80
|
| Rate for Payer: HealthUtah PPO |
$27.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$26.19
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$23.09
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$22.31
|
| Rate for Payer: Multiplan Medicare/VA |
$16.93
|
| Rate for Payer: Multiplan Medicare/VA |
$14.42
|
| Rate for Payer: Multiplan Medicare/VA |
$14.92
|
| Rate for Payer: One Health Plan of WY PPO |
$22.54
|
| Rate for Payer: One Health Plan of WY PPO |
$23.32
|
| Rate for Payer: One Health Plan of WY PPO |
$26.46
|
| Rate for Payer: PacificSource Commercial |
$24.30
|
| Rate for Payer: PacificSource Commercial |
$20.70
|
| Rate for Payer: PacificSource Commercial |
$21.42
|
| Rate for Payer: PHCS PPO |
$23.32
|
| Rate for Payer: PHCS PPO |
$22.54
|
| Rate for Payer: PHCS PPO |
$26.46
|
| Rate for Payer: Three Rivers PPO |
$17.85
|
| Rate for Payer: Three Rivers PPO |
$17.25
|
| Rate for Payer: Three Rivers PPO |
$20.25
|
| Rate for Payer: TriWest Veterans Administration |
$15.71
|
| Rate for Payer: TriWest Veterans Administration |
$15.18
|
| Rate for Payer: TriWest Veterans Administration |
$17.82
|
| Rate for Payer: United Healthcare Commercial |
$20.01
|
| Rate for Payer: United Healthcare Commercial |
$23.49
|
| Rate for Payer: United Healthcare Commercial |
$20.71
|
| Rate for Payer: United Healthcare Medicare |
$15.18
|
| Rate for Payer: United Healthcare Medicare |
$17.82
|
| Rate for Payer: United Healthcare Medicare |
$15.71
|
| Rate for Payer: WINHealth Partners Commercial |
$22.61
|
| Rate for Payer: WINHealth Partners Commercial |
$21.85
|
| Rate for Payer: WINHealth Partners Commercial |
$25.65
|
| Rate for Payer: Wise Provider Network Commercial |
$25.65
|
| Rate for Payer: Wise Provider Network Commercial |
$21.85
|
| Rate for Payer: Wise Provider Network Commercial |
$22.61
|
|
|
PHENYTOIN 125 MG/5 ML ORAL SUSPENSION [8422]
|
Facility
|
IP
|
$0.41
|
|
|
Service Code
|
NDC 5167240691
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.40
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.39
|
| Rate for Payer: Altius Commercial |
$0.39
|
| Rate for Payer: Beech Street Commercial |
$0.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.34
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.40
|
| Rate for Payer: Cigna of WY Commercial |
$0.40
|
| Rate for Payer: Entrust Commercial |
$0.39
|
| Rate for Payer: First Choice Health Commercial |
$0.39
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.39
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.27
|
| Rate for Payer: HealthUtah PPO |
$0.41
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.40
|
| Rate for Payer: Multiplan Medicare/VA |
$0.26
|
| Rate for Payer: One Health Plan of WY PPO |
$0.40
|
| Rate for Payer: PacificSource Commercial |
$0.37
|
| Rate for Payer: PHCS PPO |
$0.40
|
| Rate for Payer: Three Rivers PPO |
$0.31
|
| Rate for Payer: TriWest Veterans Administration |
$0.27
|
| Rate for Payer: United Healthcare Commercial |
$0.36
|
| Rate for Payer: United Healthcare Medicare |
$0.27
|
| Rate for Payer: WINHealth Partners Commercial |
$0.39
|
| Rate for Payer: Wise Provider Network Commercial |
$0.39
|
|
|
PHENYTOIN 125 MG/5 ML ORAL SUSPENSION [8422]
|
Facility
|
OP
|
$1.27
|
|
|
Service Code
|
NDC 6668977508
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.70 |
| Max. Negotiated Rate |
$1.27 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.24
|
| Rate for Payer: Aetna of WY Medicare |
$0.84
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.22
|
| Rate for Payer: Altius Commercial |
$1.22
|
| Rate for Payer: Beech Street Commercial |
$1.24
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.04
|
| Rate for Payer: Cash Price |
$0.89
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.23
|
| Rate for Payer: Cigna of WY Commercial |
$1.24
|
| Rate for Payer: Entrust Commercial |
$1.21
|
| Rate for Payer: First Choice Health Commercial |
$1.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.74
|
| Rate for Payer: HealthUtah PPO |
$1.27
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.23
|
| Rate for Payer: Multiplan Medicare/VA |
$0.70
|
| Rate for Payer: One Health Plan of WY PPO |
$1.24
|
| Rate for Payer: PacificSource Commercial |
$1.14
|
| Rate for Payer: PHCS PPO |
$1.24
|
| Rate for Payer: Three Rivers PPO |
$0.95
|
| Rate for Payer: TriWest Veterans Administration |
$0.74
|
| Rate for Payer: United Healthcare Commercial |
$1.10
|
| Rate for Payer: United Healthcare Medicare |
$0.74
|
| Rate for Payer: WINHealth Partners Commercial |
$1.24
|
| Rate for Payer: Wise Provider Network Commercial |
$1.21
|
|
|
PHENYTOIN 125 MG/5 ML ORAL SUSPENSION [8422]
|
Facility
|
IP
|
$1.27
|
|
|
Service Code
|
NDC 6668977508
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$1.27 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.24
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.22
|
| Rate for Payer: Altius Commercial |
$1.22
|
| Rate for Payer: Beech Street Commercial |
$1.24
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.04
|
| Rate for Payer: Cash Price |
$0.89
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.23
|
| Rate for Payer: Cigna of WY Commercial |
$1.24
|
| Rate for Payer: Entrust Commercial |
$1.21
|
| Rate for Payer: First Choice Health Commercial |
$1.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.84
|
| Rate for Payer: HealthUtah PPO |
$1.27
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.23
|
| Rate for Payer: Multiplan Medicare/VA |
$0.80
|
| Rate for Payer: One Health Plan of WY PPO |
$1.24
|
| Rate for Payer: PacificSource Commercial |
$1.14
|
| Rate for Payer: PHCS PPO |
$1.24
|
| Rate for Payer: Three Rivers PPO |
$0.95
|
| Rate for Payer: TriWest Veterans Administration |
$0.84
|
| Rate for Payer: United Healthcare Commercial |
$1.10
|
| Rate for Payer: United Healthcare Medicare |
$0.84
|
| Rate for Payer: WINHealth Partners Commercial |
$1.21
|
| Rate for Payer: Wise Provider Network Commercial |
$1.21
|
|
|
PHENYTOIN 125 MG/5 ML ORAL SUSPENSION [8422]
|
Facility
|
OP
|
$0.41
|
|
|
Service Code
|
NDC 5167240691
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.40
|
| Rate for Payer: Aetna of WY Medicare |
$0.27
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.39
|
| Rate for Payer: Altius Commercial |
$0.39
|
| Rate for Payer: Beech Street Commercial |
$0.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.34
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.40
|
| Rate for Payer: Cigna of WY Commercial |
$0.40
|
| Rate for Payer: Entrust Commercial |
$0.39
|
| Rate for Payer: First Choice Health Commercial |
$0.39
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.39
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.24
|
| Rate for Payer: HealthUtah PPO |
$0.41
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.40
|
| Rate for Payer: Multiplan Medicare/VA |
$0.23
|
| Rate for Payer: One Health Plan of WY PPO |
$0.40
|
| Rate for Payer: PacificSource Commercial |
$0.37
|
| Rate for Payer: PHCS PPO |
$0.40
|
| Rate for Payer: Three Rivers PPO |
$0.31
|
| Rate for Payer: TriWest Veterans Administration |
$0.24
|
| Rate for Payer: United Healthcare Commercial |
$0.36
|
| Rate for Payer: United Healthcare Medicare |
$0.24
|
| Rate for Payer: WINHealth Partners Commercial |
$0.40
|
| Rate for Payer: Wise Provider Network Commercial |
$0.39
|
|
|
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE [6928]
|
Facility
|
OP
|
$2.14
|
|
|
Service Code
|
NDC 6808437611
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.18 |
| Max. Negotiated Rate |
$2.14 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.10
|
| Rate for Payer: Aetna of WY Medicare |
$1.41
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.05
|
| Rate for Payer: Altius Commercial |
$2.05
|
| Rate for Payer: Beech Street Commercial |
$2.10
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.76
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.08
|
| Rate for Payer: Cigna of WY Commercial |
$2.10
|
| Rate for Payer: Entrust Commercial |
$2.03
|
| Rate for Payer: First Choice Health Commercial |
$2.03
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.03
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.24
|
| Rate for Payer: HealthUtah PPO |
$2.14
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.08
|
| Rate for Payer: Multiplan Medicare/VA |
$1.18
|
| Rate for Payer: One Health Plan of WY PPO |
$2.10
|
| Rate for Payer: PacificSource Commercial |
$1.93
|
| Rate for Payer: PHCS PPO |
$2.10
|
| Rate for Payer: Three Rivers PPO |
$1.60
|
| Rate for Payer: TriWest Veterans Administration |
$1.24
|
| Rate for Payer: United Healthcare Commercial |
$1.86
|
| Rate for Payer: United Healthcare Medicare |
$1.24
|
| Rate for Payer: WINHealth Partners Commercial |
$2.10
|
| Rate for Payer: Wise Provider Network Commercial |
$2.03
|
|
|
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE [6928]
|
Facility
|
OP
|
$0.99
|
|
|
Service Code
|
NDC 5766480888
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$0.99 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.97
|
| Rate for Payer: Aetna of WY Medicare |
$0.65
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.95
|
| Rate for Payer: Altius Commercial |
$0.95
|
| Rate for Payer: Beech Street Commercial |
$0.97
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.81
|
| Rate for Payer: Cash Price |
$0.69
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.96
|
| Rate for Payer: Cigna of WY Commercial |
$0.97
|
| Rate for Payer: Entrust Commercial |
$0.94
|
| Rate for Payer: First Choice Health Commercial |
$0.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.57
|
| Rate for Payer: HealthUtah PPO |
$0.99
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.96
|
| Rate for Payer: Multiplan Medicare/VA |
$0.55
|
| Rate for Payer: One Health Plan of WY PPO |
$0.97
|
| Rate for Payer: PacificSource Commercial |
$0.89
|
| Rate for Payer: PHCS PPO |
$0.97
|
| Rate for Payer: Three Rivers PPO |
$0.74
|
| Rate for Payer: TriWest Veterans Administration |
$0.57
|
| Rate for Payer: United Healthcare Commercial |
$0.86
|
| Rate for Payer: United Healthcare Medicare |
$0.57
|
| Rate for Payer: WINHealth Partners Commercial |
$0.97
|
| Rate for Payer: Wise Provider Network Commercial |
$0.94
|
|
|
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE [6928]
|
Facility
|
IP
|
$0.99
|
|
|
Service Code
|
NDC 5766480888
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$0.99 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.97
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.95
|
| Rate for Payer: Altius Commercial |
$0.95
|
| Rate for Payer: Beech Street Commercial |
$0.97
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.81
|
| Rate for Payer: Cash Price |
$0.69
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.96
|
| Rate for Payer: Cigna of WY Commercial |
$0.97
|
| Rate for Payer: Entrust Commercial |
$0.94
|
| Rate for Payer: First Choice Health Commercial |
$0.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.65
|
| Rate for Payer: HealthUtah PPO |
$0.99
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.96
|
| Rate for Payer: Multiplan Medicare/VA |
$0.62
|
| Rate for Payer: One Health Plan of WY PPO |
$0.97
|
| Rate for Payer: PacificSource Commercial |
$0.89
|
| Rate for Payer: PHCS PPO |
$0.97
|
| Rate for Payer: Three Rivers PPO |
$0.74
|
| Rate for Payer: TriWest Veterans Administration |
$0.65
|
| Rate for Payer: United Healthcare Commercial |
$0.86
|
| Rate for Payer: United Healthcare Medicare |
$0.65
|
| Rate for Payer: WINHealth Partners Commercial |
$0.94
|
| Rate for Payer: Wise Provider Network Commercial |
$0.94
|
|
|
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE [6928]
|
Facility
|
OP
|
$2.14
|
|
|
Service Code
|
NDC 6808437601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.18 |
| Max. Negotiated Rate |
$2.14 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.10
|
| Rate for Payer: Aetna of WY Medicare |
$1.41
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.05
|
| Rate for Payer: Altius Commercial |
$2.05
|
| Rate for Payer: Beech Street Commercial |
$2.10
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.76
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.08
|
| Rate for Payer: Cigna of WY Commercial |
$2.10
|
| Rate for Payer: Entrust Commercial |
$2.03
|
| Rate for Payer: First Choice Health Commercial |
$2.03
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.03
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.24
|
| Rate for Payer: HealthUtah PPO |
$2.14
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.08
|
| Rate for Payer: Multiplan Medicare/VA |
$1.18
|
| Rate for Payer: One Health Plan of WY PPO |
$2.10
|
| Rate for Payer: PacificSource Commercial |
$1.93
|
| Rate for Payer: PHCS PPO |
$2.10
|
| Rate for Payer: Three Rivers PPO |
$1.60
|
| Rate for Payer: TriWest Veterans Administration |
$1.24
|
| Rate for Payer: United Healthcare Commercial |
$1.86
|
| Rate for Payer: United Healthcare Medicare |
$1.24
|
| Rate for Payer: WINHealth Partners Commercial |
$2.10
|
| Rate for Payer: Wise Provider Network Commercial |
$2.03
|
|
