|
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION [20456]
|
Facility
|
IP
|
$225.00
|
|
|
Service Code
|
NDC 0009085608
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$141.08 |
| Max. Negotiated Rate |
$225.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$220.50
|
| Rate for Payer: Altius Auto/Workers Compensation |
$216.00
|
| Rate for Payer: Altius Commercial |
$216.00
|
| Rate for Payer: Beech Street Commercial |
$220.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$184.72
|
| Rate for Payer: Cash Price |
$157.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$218.25
|
| Rate for Payer: Cigna of WY Commercial |
$220.50
|
| Rate for Payer: Entrust Commercial |
$213.75
|
| Rate for Payer: First Choice Health Commercial |
$213.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$213.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$148.50
|
| Rate for Payer: HealthUtah PPO |
$225.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$218.25
|
| Rate for Payer: Multiplan Medicare/VA |
$141.08
|
| Rate for Payer: One Health Plan of WY PPO |
$220.50
|
| Rate for Payer: PacificSource Commercial |
$202.50
|
| Rate for Payer: PHCS PPO |
$220.50
|
| Rate for Payer: Three Rivers PPO |
$168.75
|
| Rate for Payer: TriWest Veterans Administration |
$148.50
|
| Rate for Payer: United Healthcare Commercial |
$195.75
|
| Rate for Payer: United Healthcare Medicare |
$148.50
|
| Rate for Payer: WINHealth Partners Commercial |
$213.75
|
| Rate for Payer: Wise Provider Network Commercial |
$213.75
|
|
|
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION [20456]
|
Facility
|
OP
|
$225.00
|
|
|
Service Code
|
NDC 0009085605
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$123.98 |
| Max. Negotiated Rate |
$225.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$220.50
|
| Rate for Payer: Aetna of WY Medicare |
$148.50
|
| Rate for Payer: Altius Auto/Workers Compensation |
$216.00
|
| Rate for Payer: Altius Commercial |
$216.00
|
| Rate for Payer: Beech Street Commercial |
$220.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$184.72
|
| Rate for Payer: Cash Price |
$157.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$218.25
|
| Rate for Payer: Cigna of WY Commercial |
$220.50
|
| Rate for Payer: Entrust Commercial |
$213.75
|
| Rate for Payer: First Choice Health Commercial |
$213.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$213.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$130.50
|
| Rate for Payer: HealthUtah PPO |
$225.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$218.25
|
| Rate for Payer: Multiplan Medicare/VA |
$123.98
|
| Rate for Payer: One Health Plan of WY PPO |
$220.50
|
| Rate for Payer: PacificSource Commercial |
$202.50
|
| Rate for Payer: PHCS PPO |
$220.50
|
| Rate for Payer: Three Rivers PPO |
$168.75
|
| Rate for Payer: TriWest Veterans Administration |
$130.50
|
| Rate for Payer: United Healthcare Commercial |
$195.75
|
| Rate for Payer: United Healthcare Medicare |
$130.50
|
| Rate for Payer: WINHealth Partners Commercial |
$220.50
|
| Rate for Payer: Wise Provider Network Commercial |
$213.75
|
|
|
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION [20456]
|
Facility
|
IP
|
$225.00
|
|
|
Service Code
|
NDC 0009085605
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$141.08 |
| Max. Negotiated Rate |
$225.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$220.50
|
| Rate for Payer: Altius Auto/Workers Compensation |
$216.00
|
| Rate for Payer: Altius Commercial |
$216.00
|
| Rate for Payer: Beech Street Commercial |
$220.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$184.72
|
| Rate for Payer: Cash Price |
$157.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$218.25
|
| Rate for Payer: Cigna of WY Commercial |
$220.50
|
| Rate for Payer: Entrust Commercial |
$213.75
|
| Rate for Payer: First Choice Health Commercial |
$213.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$213.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$148.50
|
| Rate for Payer: HealthUtah PPO |
$225.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$218.25
|
| Rate for Payer: Multiplan Medicare/VA |
$141.08
|
| Rate for Payer: One Health Plan of WY PPO |
$220.50
|
| Rate for Payer: PacificSource Commercial |
$202.50
|
| Rate for Payer: PHCS PPO |
$220.50
|
| Rate for Payer: Three Rivers PPO |
$168.75
|
| Rate for Payer: TriWest Veterans Administration |
$148.50
|
| Rate for Payer: United Healthcare Commercial |
$195.75
|
| Rate for Payer: United Healthcare Medicare |
$148.50
|
| Rate for Payer: WINHealth Partners Commercial |
$213.75
|
| Rate for Payer: Wise Provider Network Commercial |
$213.75
|
|
|
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION [20456]
|
Facility
|
OP
|
$225.00
|
|
|
Service Code
|
NDC 0009085608
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$123.98 |
| Max. Negotiated Rate |
$225.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$220.50
|
| Rate for Payer: Aetna of WY Medicare |
$148.50
|
| Rate for Payer: Altius Auto/Workers Compensation |
$216.00
|
| Rate for Payer: Altius Commercial |
$216.00
|
| Rate for Payer: Beech Street Commercial |
$220.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$184.72
|
| Rate for Payer: Cash Price |
$157.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$218.25
|
| Rate for Payer: Cigna of WY Commercial |
$220.50
|
| Rate for Payer: Entrust Commercial |
$213.75
|
| Rate for Payer: First Choice Health Commercial |
$213.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$213.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$130.50
|
| Rate for Payer: HealthUtah PPO |
$225.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$218.25
|
| Rate for Payer: Multiplan Medicare/VA |
$123.98
|
| Rate for Payer: One Health Plan of WY PPO |
$220.50
|
| Rate for Payer: PacificSource Commercial |
$202.50
|
| Rate for Payer: PHCS PPO |
$220.50
|
| Rate for Payer: Three Rivers PPO |
$168.75
|
| Rate for Payer: TriWest Veterans Administration |
$130.50
|
| Rate for Payer: United Healthcare Commercial |
$195.75
|
| Rate for Payer: United Healthcare Medicare |
$130.50
|
| Rate for Payer: WINHealth Partners Commercial |
$220.50
|
| Rate for Payer: Wise Provider Network Commercial |
$213.75
|
|
|
CARBOXYMETHYLCELLULOSE SODIUM 0.25 % EYE DROPS [7925]
|
Facility
|
IP
|
$2.34
|
|
|
Service Code
|
NDC 5879000715
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.47 |
| Max. Negotiated Rate |
$2.34 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.29
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.25
|
| Rate for Payer: Altius Commercial |
$2.25
|
| Rate for Payer: Beech Street Commercial |
$2.29
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.92
|
| Rate for Payer: Cash Price |
$1.64
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.27
|
| Rate for Payer: Cigna of WY Commercial |
$2.29
|
| Rate for Payer: Entrust Commercial |
$2.22
|
| Rate for Payer: First Choice Health Commercial |
$2.22
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.22
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.54
|
| Rate for Payer: HealthUtah PPO |
$2.34
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.27
|
| Rate for Payer: Multiplan Medicare/VA |
$1.47
|
| Rate for Payer: One Health Plan of WY PPO |
$2.29
|
| Rate for Payer: PacificSource Commercial |
$2.11
|
| Rate for Payer: PHCS PPO |
$2.29
|
| Rate for Payer: Three Rivers PPO |
$1.76
|
| Rate for Payer: TriWest Veterans Administration |
$1.54
|
| Rate for Payer: United Healthcare Commercial |
$2.04
|
| Rate for Payer: United Healthcare Medicare |
$1.54
|
| Rate for Payer: WINHealth Partners Commercial |
$2.22
|
| Rate for Payer: Wise Provider Network Commercial |
$2.22
|
|
|
CARBOXYMETHYLCELLULOSE SODIUM 0.25 % EYE DROPS [7925]
|
Facility
|
OP
|
$2.34
|
|
|
Service Code
|
NDC 5879000715
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.29 |
| Max. Negotiated Rate |
$2.34 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.29
|
| Rate for Payer: Aetna of WY Medicare |
$1.54
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.25
|
| Rate for Payer: Altius Commercial |
$2.25
|
| Rate for Payer: Beech Street Commercial |
$2.29
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.92
|
| Rate for Payer: Cash Price |
$1.64
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.27
|
| Rate for Payer: Cigna of WY Commercial |
$2.29
|
| Rate for Payer: Entrust Commercial |
$2.22
|
| Rate for Payer: First Choice Health Commercial |
$2.22
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.22
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.36
|
| Rate for Payer: HealthUtah PPO |
$2.34
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.27
|
| Rate for Payer: Multiplan Medicare/VA |
$1.29
|
| Rate for Payer: One Health Plan of WY PPO |
$2.29
|
| Rate for Payer: PacificSource Commercial |
$2.11
|
| Rate for Payer: PHCS PPO |
$2.29
|
| Rate for Payer: Three Rivers PPO |
$1.76
|
| Rate for Payer: TriWest Veterans Administration |
$1.36
|
| Rate for Payer: United Healthcare Commercial |
$2.04
|
| Rate for Payer: United Healthcare Medicare |
$1.36
|
| Rate for Payer: WINHealth Partners Commercial |
$2.29
|
| Rate for Payer: Wise Provider Network Commercial |
$2.22
|
|
|
CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS [11519]
|
Facility
|
IP
|
$2.24
|
|
|
Service Code
|
NDC 0023079815
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$2.24 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.20
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.15
|
| Rate for Payer: Altius Commercial |
$2.15
|
| Rate for Payer: Beech Street Commercial |
$2.20
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.84
|
| Rate for Payer: Cash Price |
$1.57
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.17
|
| Rate for Payer: Cigna of WY Commercial |
$2.20
|
| Rate for Payer: Entrust Commercial |
$2.13
|
| Rate for Payer: First Choice Health Commercial |
$2.13
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.13
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.48
|
| Rate for Payer: HealthUtah PPO |
$2.24
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.17
|
| Rate for Payer: Multiplan Medicare/VA |
$1.40
|
| Rate for Payer: One Health Plan of WY PPO |
$2.20
|
| Rate for Payer: PacificSource Commercial |
$2.02
|
| Rate for Payer: PHCS PPO |
$2.20
|
| Rate for Payer: Three Rivers PPO |
$1.68
|
| Rate for Payer: TriWest Veterans Administration |
$1.48
|
| Rate for Payer: United Healthcare Commercial |
$1.95
|
| Rate for Payer: United Healthcare Medicare |
$1.48
|
| Rate for Payer: WINHealth Partners Commercial |
$2.13
|
| Rate for Payer: Wise Provider Network Commercial |
$2.13
|
|
|
CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS [11519]
|
Facility
|
OP
|
$2.24
|
|
|
Service Code
|
NDC 0023079815
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.23 |
| Max. Negotiated Rate |
$2.24 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.20
|
| Rate for Payer: Aetna of WY Medicare |
$1.48
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.15
|
| Rate for Payer: Altius Commercial |
$2.15
|
| Rate for Payer: Beech Street Commercial |
$2.20
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.84
|
| Rate for Payer: Cash Price |
$1.57
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.17
|
| Rate for Payer: Cigna of WY Commercial |
$2.20
|
| Rate for Payer: Entrust Commercial |
$2.13
|
| Rate for Payer: First Choice Health Commercial |
$2.13
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.13
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.30
|
| Rate for Payer: HealthUtah PPO |
$2.24
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.17
|
| Rate for Payer: Multiplan Medicare/VA |
$1.23
|
| Rate for Payer: One Health Plan of WY PPO |
$2.20
|
| Rate for Payer: PacificSource Commercial |
$2.02
|
| Rate for Payer: PHCS PPO |
$2.20
|
| Rate for Payer: Three Rivers PPO |
$1.68
|
| Rate for Payer: TriWest Veterans Administration |
$1.30
|
| Rate for Payer: United Healthcare Commercial |
$1.95
|
| Rate for Payer: United Healthcare Medicare |
$1.30
|
| Rate for Payer: WINHealth Partners Commercial |
$2.20
|
| Rate for Payer: Wise Provider Network Commercial |
$2.13
|
|
|
CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE [26541]
|
Facility
|
OP
|
$0.96
|
|
|
Service Code
|
NDC 4612275656
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$0.96 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.94
|
| Rate for Payer: Aetna of WY Medicare |
$0.63
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.92
|
| Rate for Payer: Altius Commercial |
$0.92
|
| Rate for Payer: Beech Street Commercial |
$0.94
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.79
|
| Rate for Payer: Cash Price |
$0.67
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.93
|
| Rate for Payer: Cigna of WY Commercial |
$0.94
|
| Rate for Payer: Entrust Commercial |
$0.91
|
| Rate for Payer: First Choice Health Commercial |
$0.91
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.91
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.56
|
| Rate for Payer: HealthUtah PPO |
$0.96
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.93
|
| Rate for Payer: Multiplan Medicare/VA |
$0.53
|
| Rate for Payer: One Health Plan of WY PPO |
$0.94
|
| Rate for Payer: PacificSource Commercial |
$0.86
|
| Rate for Payer: PHCS PPO |
$0.94
|
| Rate for Payer: Three Rivers PPO |
$0.72
|
| Rate for Payer: TriWest Veterans Administration |
$0.56
|
| Rate for Payer: United Healthcare Commercial |
$0.84
|
| Rate for Payer: United Healthcare Medicare |
$0.56
|
| Rate for Payer: WINHealth Partners Commercial |
$0.94
|
| Rate for Payer: Wise Provider Network Commercial |
$0.91
|
|
|
CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE [26541]
|
Facility
|
OP
|
$0.94
|
|
|
Service Code
|
NDC 8770141319
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.52 |
| Max. Negotiated Rate |
$0.94 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.92
|
| Rate for Payer: Aetna of WY Medicare |
$0.62
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.90
|
| Rate for Payer: Altius Commercial |
$0.90
|
| Rate for Payer: Beech Street Commercial |
$0.92
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.77
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.91
|
| Rate for Payer: Cigna of WY Commercial |
$0.92
|
| Rate for Payer: Entrust Commercial |
$0.89
|
| Rate for Payer: First Choice Health Commercial |
$0.89
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.89
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.55
|
| Rate for Payer: HealthUtah PPO |
$0.94
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.91
|
| Rate for Payer: Multiplan Medicare/VA |
$0.52
|
| Rate for Payer: One Health Plan of WY PPO |
$0.92
|
| Rate for Payer: PacificSource Commercial |
$0.85
|
| Rate for Payer: PHCS PPO |
$0.92
|
| Rate for Payer: Three Rivers PPO |
$0.71
|
| Rate for Payer: TriWest Veterans Administration |
$0.55
|
| Rate for Payer: United Healthcare Commercial |
$0.82
|
| Rate for Payer: United Healthcare Medicare |
$0.55
|
| Rate for Payer: WINHealth Partners Commercial |
$0.92
|
| Rate for Payer: Wise Provider Network Commercial |
$0.89
|
|
|
CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE [26541]
|
Facility
|
OP
|
$1.11
|
|
|
Service Code
|
NDC 0023040350
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$1.11 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.09
|
| Rate for Payer: Aetna of WY Medicare |
$0.73
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.07
|
| Rate for Payer: Altius Commercial |
$1.07
|
| Rate for Payer: Beech Street Commercial |
$1.09
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.91
|
| Rate for Payer: Cash Price |
$0.77
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.08
|
| Rate for Payer: Cigna of WY Commercial |
$1.09
|
| Rate for Payer: Entrust Commercial |
$1.05
|
| Rate for Payer: First Choice Health Commercial |
$1.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.64
|
| Rate for Payer: HealthUtah PPO |
$1.11
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.08
|
| Rate for Payer: Multiplan Medicare/VA |
$0.61
|
| Rate for Payer: One Health Plan of WY PPO |
$1.09
|
| Rate for Payer: PacificSource Commercial |
$1.00
|
| Rate for Payer: PHCS PPO |
$1.09
|
| Rate for Payer: Three Rivers PPO |
$0.83
|
| Rate for Payer: TriWest Veterans Administration |
$0.64
|
| Rate for Payer: United Healthcare Commercial |
$0.97
|
| Rate for Payer: United Healthcare Medicare |
$0.64
|
| Rate for Payer: WINHealth Partners Commercial |
$1.09
|
| Rate for Payer: Wise Provider Network Commercial |
$1.05
|
|
|
CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE [26541]
|
Facility
|
IP
|
$0.99
|
|
|
Service Code
|
NDC 0023548750
|
|
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 |
$0.70
|
| 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
|
|
|
CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE [26541]
|
Facility
|
IP
|
$0.94
|
|
|
Service Code
|
NDC 0904632946
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$0.94 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.92
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.90
|
| Rate for Payer: Altius Commercial |
$0.90
|
| Rate for Payer: Beech Street Commercial |
$0.92
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.77
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.91
|
| Rate for Payer: Cigna of WY Commercial |
$0.92
|
| Rate for Payer: Entrust Commercial |
$0.89
|
| Rate for Payer: First Choice Health Commercial |
$0.89
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.89
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.62
|
| Rate for Payer: HealthUtah PPO |
$0.94
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.91
|
| Rate for Payer: Multiplan Medicare/VA |
$0.59
|
| Rate for Payer: One Health Plan of WY PPO |
$0.92
|
| Rate for Payer: PacificSource Commercial |
$0.85
|
| Rate for Payer: PHCS PPO |
$0.92
|
| Rate for Payer: Three Rivers PPO |
$0.71
|
| Rate for Payer: TriWest Veterans Administration |
$0.62
|
| Rate for Payer: United Healthcare Commercial |
$0.82
|
| Rate for Payer: United Healthcare Medicare |
$0.62
|
| Rate for Payer: WINHealth Partners Commercial |
$0.89
|
| Rate for Payer: Wise Provider Network Commercial |
$0.89
|
|
|
CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE [26541]
|
Facility
|
OP
|
$0.94
|
|
|
Service Code
|
NDC 4612219565
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.52 |
| Max. Negotiated Rate |
$0.94 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.92
|
| Rate for Payer: Aetna of WY Medicare |
$0.62
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.90
|
| Rate for Payer: Altius Commercial |
$0.90
|
| Rate for Payer: Beech Street Commercial |
$0.92
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.77
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.91
|
| Rate for Payer: Cigna of WY Commercial |
$0.92
|
| Rate for Payer: Entrust Commercial |
$0.89
|
| Rate for Payer: First Choice Health Commercial |
$0.89
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.89
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.55
|
| Rate for Payer: HealthUtah PPO |
$0.94
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.91
|
| Rate for Payer: Multiplan Medicare/VA |
$0.52
|
| Rate for Payer: One Health Plan of WY PPO |
$0.92
|
| Rate for Payer: PacificSource Commercial |
$0.85
|
| Rate for Payer: PHCS PPO |
$0.92
|
| Rate for Payer: Three Rivers PPO |
$0.71
|
| Rate for Payer: TriWest Veterans Administration |
$0.55
|
| Rate for Payer: United Healthcare Commercial |
$0.82
|
| Rate for Payer: United Healthcare Medicare |
$0.55
|
| Rate for Payer: WINHealth Partners Commercial |
$0.92
|
| Rate for Payer: Wise Provider Network Commercial |
$0.89
|
|
|
CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE [26541]
|
Facility
|
IP
|
$0.96
|
|
|
Service Code
|
NDC 4612275656
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$0.96 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.94
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.92
|
| Rate for Payer: Altius Commercial |
$0.92
|
| Rate for Payer: Beech Street Commercial |
$0.94
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.79
|
| Rate for Payer: Cash Price |
$0.67
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.93
|
| Rate for Payer: Cigna of WY Commercial |
$0.94
|
| Rate for Payer: Entrust Commercial |
$0.91
|
| Rate for Payer: First Choice Health Commercial |
$0.91
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.91
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.63
|
| Rate for Payer: HealthUtah PPO |
$0.96
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.93
|
| Rate for Payer: Multiplan Medicare/VA |
$0.60
|
| Rate for Payer: One Health Plan of WY PPO |
$0.94
|
| Rate for Payer: PacificSource Commercial |
$0.86
|
| Rate for Payer: PHCS PPO |
$0.94
|
| Rate for Payer: Three Rivers PPO |
$0.72
|
| Rate for Payer: TriWest Veterans Administration |
$0.63
|
| Rate for Payer: United Healthcare Commercial |
$0.84
|
| Rate for Payer: United Healthcare Medicare |
$0.63
|
| Rate for Payer: WINHealth Partners Commercial |
$0.91
|
| Rate for Payer: Wise Provider Network Commercial |
$0.91
|
|
|
CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE [26541]
|
Facility
|
OP
|
$0.99
|
|
|
Service Code
|
NDC 0023548750
|
|
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 |
$0.70
|
| 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
|
|
|
CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE [26541]
|
Facility
|
OP
|
$1.09
|
|
|
Service Code
|
NDC 0536138792
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$1.09 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.07
|
| Rate for Payer: Aetna of WY Medicare |
$0.72
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.05
|
| Rate for Payer: Altius Commercial |
$1.05
|
| Rate for Payer: Beech Street Commercial |
$1.07
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.89
|
| Rate for Payer: Cash Price |
$0.76
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.06
|
| Rate for Payer: Cigna of WY Commercial |
$1.07
|
| Rate for Payer: Entrust Commercial |
$1.04
|
| Rate for Payer: First Choice Health Commercial |
$1.04
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.04
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.63
|
| Rate for Payer: HealthUtah PPO |
$1.09
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.06
|
| Rate for Payer: Multiplan Medicare/VA |
$0.60
|
| Rate for Payer: One Health Plan of WY PPO |
$1.07
|
| Rate for Payer: PacificSource Commercial |
$0.98
|
| Rate for Payer: PHCS PPO |
$1.07
|
| Rate for Payer: Three Rivers PPO |
$0.82
|
| Rate for Payer: TriWest Veterans Administration |
$0.63
|
| Rate for Payer: United Healthcare Commercial |
$0.95
|
| Rate for Payer: United Healthcare Medicare |
$0.63
|
| Rate for Payer: WINHealth Partners Commercial |
$1.07
|
| Rate for Payer: Wise Provider Network Commercial |
$1.04
|
|
|
CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE [26541]
|
Facility
|
OP
|
$0.94
|
|
|
Service Code
|
NDC 0904632946
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.52 |
| Max. Negotiated Rate |
$0.94 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.92
|
| Rate for Payer: Aetna of WY Medicare |
$0.62
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.90
|
| Rate for Payer: Altius Commercial |
$0.90
|
| Rate for Payer: Beech Street Commercial |
$0.92
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.77
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.91
|
| Rate for Payer: Cigna of WY Commercial |
$0.92
|
| Rate for Payer: Entrust Commercial |
$0.89
|
| Rate for Payer: First Choice Health Commercial |
$0.89
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.89
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.55
|
| Rate for Payer: HealthUtah PPO |
$0.94
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.91
|
| Rate for Payer: Multiplan Medicare/VA |
$0.52
|
| Rate for Payer: One Health Plan of WY PPO |
$0.92
|
| Rate for Payer: PacificSource Commercial |
$0.85
|
| Rate for Payer: PHCS PPO |
$0.92
|
| Rate for Payer: Three Rivers PPO |
$0.71
|
| Rate for Payer: TriWest Veterans Administration |
$0.55
|
| Rate for Payer: United Healthcare Commercial |
$0.82
|
| Rate for Payer: United Healthcare Medicare |
$0.55
|
| Rate for Payer: WINHealth Partners Commercial |
$0.92
|
| Rate for Payer: Wise Provider Network Commercial |
$0.89
|
|
|
CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE [26541]
|
Facility
|
IP
|
$0.94
|
|
|
Service Code
|
NDC 8770141319
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$0.94 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.92
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.90
|
| Rate for Payer: Altius Commercial |
$0.90
|
| Rate for Payer: Beech Street Commercial |
$0.92
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.77
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.91
|
| Rate for Payer: Cigna of WY Commercial |
$0.92
|
| Rate for Payer: Entrust Commercial |
$0.89
|
| Rate for Payer: First Choice Health Commercial |
$0.89
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.89
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.62
|
| Rate for Payer: HealthUtah PPO |
$0.94
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.91
|
| Rate for Payer: Multiplan Medicare/VA |
$0.59
|
| Rate for Payer: One Health Plan of WY PPO |
$0.92
|
| Rate for Payer: PacificSource Commercial |
$0.85
|
| Rate for Payer: PHCS PPO |
$0.92
|
| Rate for Payer: Three Rivers PPO |
$0.71
|
| Rate for Payer: TriWest Veterans Administration |
$0.62
|
| Rate for Payer: United Healthcare Commercial |
$0.82
|
| Rate for Payer: United Healthcare Medicare |
$0.62
|
| Rate for Payer: WINHealth Partners Commercial |
$0.89
|
| Rate for Payer: Wise Provider Network Commercial |
$0.89
|
|
|
CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE [26541]
|
Facility
|
IP
|
$1.09
|
|
|
Service Code
|
NDC 0536138792
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.68 |
| Max. Negotiated Rate |
$1.09 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.07
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.05
|
| Rate for Payer: Altius Commercial |
$1.05
|
| Rate for Payer: Beech Street Commercial |
$1.07
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.89
|
| Rate for Payer: Cash Price |
$0.76
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.06
|
| Rate for Payer: Cigna of WY Commercial |
$1.07
|
| Rate for Payer: Entrust Commercial |
$1.04
|
| Rate for Payer: First Choice Health Commercial |
$1.04
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.04
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.72
|
| Rate for Payer: HealthUtah PPO |
$1.09
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.06
|
| Rate for Payer: Multiplan Medicare/VA |
$0.68
|
| Rate for Payer: One Health Plan of WY PPO |
$1.07
|
| Rate for Payer: PacificSource Commercial |
$0.98
|
| Rate for Payer: PHCS PPO |
$1.07
|
| Rate for Payer: Three Rivers PPO |
$0.82
|
| Rate for Payer: TriWest Veterans Administration |
$0.72
|
| Rate for Payer: United Healthcare Commercial |
$0.95
|
| Rate for Payer: United Healthcare Medicare |
$0.72
|
| Rate for Payer: WINHealth Partners Commercial |
$1.04
|
| Rate for Payer: Wise Provider Network Commercial |
$1.04
|
|
|
CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE [26541]
|
Facility
|
IP
|
$0.94
|
|
|
Service Code
|
NDC 4612219565
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$0.94 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.92
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.90
|
| Rate for Payer: Altius Commercial |
$0.90
|
| Rate for Payer: Beech Street Commercial |
$0.92
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.77
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.91
|
| Rate for Payer: Cigna of WY Commercial |
$0.92
|
| Rate for Payer: Entrust Commercial |
$0.89
|
| Rate for Payer: First Choice Health Commercial |
$0.89
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.89
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.62
|
| Rate for Payer: HealthUtah PPO |
$0.94
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.91
|
| Rate for Payer: Multiplan Medicare/VA |
$0.59
|
| Rate for Payer: One Health Plan of WY PPO |
$0.92
|
| Rate for Payer: PacificSource Commercial |
$0.85
|
| Rate for Payer: PHCS PPO |
$0.92
|
| Rate for Payer: Three Rivers PPO |
$0.71
|
| Rate for Payer: TriWest Veterans Administration |
$0.62
|
| Rate for Payer: United Healthcare Commercial |
$0.82
|
| Rate for Payer: United Healthcare Medicare |
$0.62
|
| Rate for Payer: WINHealth Partners Commercial |
$0.89
|
| Rate for Payer: Wise Provider Network Commercial |
$0.89
|
|
|
CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE [26541]
|
Facility
|
IP
|
$1.11
|
|
|
Service Code
|
NDC 0023040350
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.70 |
| Max. Negotiated Rate |
$1.11 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.09
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.07
|
| Rate for Payer: Altius Commercial |
$1.07
|
| Rate for Payer: Beech Street Commercial |
$1.09
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.91
|
| Rate for Payer: Cash Price |
$0.77
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.08
|
| Rate for Payer: Cigna of WY Commercial |
$1.09
|
| Rate for Payer: Entrust Commercial |
$1.05
|
| Rate for Payer: First Choice Health Commercial |
$1.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.73
|
| Rate for Payer: HealthUtah PPO |
$1.11
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.08
|
| Rate for Payer: Multiplan Medicare/VA |
$0.70
|
| Rate for Payer: One Health Plan of WY PPO |
$1.09
|
| Rate for Payer: PacificSource Commercial |
$1.00
|
| Rate for Payer: PHCS PPO |
$1.09
|
| Rate for Payer: Three Rivers PPO |
$0.83
|
| Rate for Payer: TriWest Veterans Administration |
$0.73
|
| Rate for Payer: United Healthcare Commercial |
$0.97
|
| Rate for Payer: United Healthcare Medicare |
$0.73
|
| Rate for Payer: WINHealth Partners Commercial |
$1.05
|
| Rate for Payer: Wise Provider Network Commercial |
$1.05
|
|
|
CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE LIQUID GEL DROPS [20408]
|
Facility
|
OP
|
$2.31
|
|
|
Service Code
|
NDC 0023920515
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.27 |
| Max. Negotiated Rate |
$2.31 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.26
|
| Rate for Payer: Aetna of WY Medicare |
$1.52
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.22
|
| Rate for Payer: Altius Commercial |
$2.22
|
| Rate for Payer: Beech Street Commercial |
$2.26
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.90
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.24
|
| Rate for Payer: Cigna of WY Commercial |
$2.26
|
| Rate for Payer: Entrust Commercial |
$2.19
|
| Rate for Payer: First Choice Health Commercial |
$2.19
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.19
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.34
|
| Rate for Payer: HealthUtah PPO |
$2.31
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.24
|
| Rate for Payer: Multiplan Medicare/VA |
$1.27
|
| Rate for Payer: One Health Plan of WY PPO |
$2.26
|
| Rate for Payer: PacificSource Commercial |
$2.08
|
| Rate for Payer: PHCS PPO |
$2.26
|
| Rate for Payer: Three Rivers PPO |
$1.73
|
| Rate for Payer: TriWest Veterans Administration |
$1.34
|
| Rate for Payer: United Healthcare Commercial |
$2.01
|
| Rate for Payer: United Healthcare Medicare |
$1.34
|
| Rate for Payer: WINHealth Partners Commercial |
$2.26
|
| Rate for Payer: Wise Provider Network Commercial |
$2.19
|
|
|
CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE LIQUID GEL DROPS [20408]
|
Facility
|
IP
|
$2.31
|
|
|
Service Code
|
NDC 0023920515
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.45 |
| Max. Negotiated Rate |
$2.31 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.26
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.22
|
| Rate for Payer: Altius Commercial |
$2.22
|
| Rate for Payer: Beech Street Commercial |
$2.26
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.90
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.24
|
| Rate for Payer: Cigna of WY Commercial |
$2.26
|
| Rate for Payer: Entrust Commercial |
$2.19
|
| Rate for Payer: First Choice Health Commercial |
$2.19
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.19
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.52
|
| Rate for Payer: HealthUtah PPO |
$2.31
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.24
|
| Rate for Payer: Multiplan Medicare/VA |
$1.45
|
| Rate for Payer: One Health Plan of WY PPO |
$2.26
|
| Rate for Payer: PacificSource Commercial |
$2.08
|
| Rate for Payer: PHCS PPO |
$2.26
|
| Rate for Payer: Three Rivers PPO |
$1.73
|
| Rate for Payer: TriWest Veterans Administration |
$1.52
|
| Rate for Payer: United Healthcare Commercial |
$2.01
|
| Rate for Payer: United Healthcare Medicare |
$1.52
|
| Rate for Payer: WINHealth Partners Commercial |
$2.19
|
| Rate for Payer: Wise Provider Network Commercial |
$2.19
|
|
|
CARDIOPULMONARY RESUSCITATION
|
Professional
|
Both
|
$1,025.00
|
|
|
Service Code
|
HCPCS 92950
|
| Hospital Charge Code |
92950
|
| Min. Negotiated Rate |
$147.67 |
| Max. Negotiated Rate |
$1,025.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,004.50
|
| Rate for Payer: Aetna of WY Medicare |
$173.73
|
| Rate for Payer: Beech Street Commercial |
$973.75
|
| Rate for Payer: Cash Price |
$717.50
|
| Rate for Payer: Cash Price |
$717.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$994.25
|
| Rate for Payer: Cigna of WY Commercial |
$1,004.50
|
| Rate for Payer: First Choice Health Commercial |
$922.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$973.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$173.73
|
| Rate for Payer: HealthUtah PPO |
$1,025.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$994.25
|
| Rate for Payer: Multiplan Medicare/VA |
$147.67
|
| Rate for Payer: One Health Plan of WY PPO |
$1,004.50
|
| Rate for Payer: PacificSource Commercial |
$922.50
|
| Rate for Payer: PHCS PPO |
$973.75
|
| Rate for Payer: Three Rivers PPO |
$768.75
|
| Rate for Payer: TriWest Veterans Administration |
$173.73
|
| Rate for Payer: United Healthcare Commercial |
$891.75
|
| Rate for Payer: United Healthcare Medicare |
$173.73
|
| Rate for Payer: WINHealth Partners Commercial |
$973.75
|
|
