|
CEFDINIR 250 MG/5 ML ORAL SUSPENSION [36743]
|
Facility
|
OP
|
$4.73
|
|
|
Service Code
|
NDC 0093413773
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.61 |
| Max. Negotiated Rate |
$4.73 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4.64
|
| Rate for Payer: Aetna of WY Medicare |
$3.12
|
| Rate for Payer: Altius Auto/Workers Compensation |
$4.54
|
| Rate for Payer: Altius Commercial |
$4.54
|
| Rate for Payer: Beech Street Commercial |
$4.64
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3.88
|
| Rate for Payer: Cash Price |
$3.31
|
| Rate for Payer: ChoiceCare Network Commercial |
$4.59
|
| Rate for Payer: Cigna of WY Commercial |
$4.64
|
| Rate for Payer: Entrust Commercial |
$4.49
|
| Rate for Payer: First Choice Health Commercial |
$4.49
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4.49
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2.74
|
| Rate for Payer: HealthUtah PPO |
$4.73
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4.59
|
| Rate for Payer: Multiplan Medicare/VA |
$2.61
|
| Rate for Payer: One Health Plan of WY PPO |
$4.64
|
| Rate for Payer: PacificSource Commercial |
$4.26
|
| Rate for Payer: PHCS PPO |
$4.64
|
| Rate for Payer: Three Rivers PPO |
$3.55
|
| Rate for Payer: TriWest Veterans Administration |
$2.74
|
| Rate for Payer: United Healthcare Commercial |
$4.12
|
| Rate for Payer: United Healthcare Medicare |
$2.74
|
| Rate for Payer: WINHealth Partners Commercial |
$4.64
|
| Rate for Payer: Wise Provider Network Commercial |
$4.49
|
|
|
CEFDINIR 300 MG CAPSULE [18664]
|
Facility
|
IP
|
$12.65
|
|
|
Service Code
|
NDC 6068769911
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.93 |
| Max. Negotiated Rate |
$12.65 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$12.40
|
| Rate for Payer: Altius Auto/Workers Compensation |
$12.14
|
| Rate for Payer: Altius Commercial |
$12.14
|
| Rate for Payer: Beech Street Commercial |
$12.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$10.39
|
| Rate for Payer: Cash Price |
$8.86
|
| Rate for Payer: ChoiceCare Network Commercial |
$12.27
|
| Rate for Payer: Cigna of WY Commercial |
$12.40
|
| Rate for Payer: Entrust Commercial |
$12.02
|
| Rate for Payer: First Choice Health Commercial |
$12.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$12.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.35
|
| Rate for Payer: HealthUtah PPO |
$12.65
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$12.27
|
| Rate for Payer: Multiplan Medicare/VA |
$7.93
|
| Rate for Payer: One Health Plan of WY PPO |
$12.40
|
| Rate for Payer: PacificSource Commercial |
$11.38
|
| Rate for Payer: PHCS PPO |
$12.40
|
| Rate for Payer: Three Rivers PPO |
$9.49
|
| Rate for Payer: TriWest Veterans Administration |
$8.35
|
| Rate for Payer: United Healthcare Commercial |
$11.01
|
| Rate for Payer: United Healthcare Medicare |
$8.35
|
| Rate for Payer: WINHealth Partners Commercial |
$12.02
|
| Rate for Payer: Wise Provider Network Commercial |
$12.02
|
|
|
CEFDINIR 300 MG CAPSULE [18664]
|
Facility
|
IP
|
$4.84
|
|
|
Service Code
|
NDC 6800136206
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.03 |
| Max. Negotiated Rate |
$4.84 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4.74
|
| Rate for Payer: Altius Auto/Workers Compensation |
$4.65
|
| Rate for Payer: Altius Commercial |
$4.65
|
| Rate for Payer: Beech Street Commercial |
$4.74
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3.97
|
| Rate for Payer: Cash Price |
$3.39
|
| Rate for Payer: ChoiceCare Network Commercial |
$4.69
|
| Rate for Payer: Cigna of WY Commercial |
$4.74
|
| Rate for Payer: Entrust Commercial |
$4.60
|
| Rate for Payer: First Choice Health Commercial |
$4.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3.19
|
| Rate for Payer: HealthUtah PPO |
$4.84
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4.69
|
| Rate for Payer: Multiplan Medicare/VA |
$3.03
|
| Rate for Payer: One Health Plan of WY PPO |
$4.74
|
| Rate for Payer: PacificSource Commercial |
$4.36
|
| Rate for Payer: PHCS PPO |
$4.74
|
| Rate for Payer: Three Rivers PPO |
$3.63
|
| Rate for Payer: TriWest Veterans Administration |
$3.19
|
| Rate for Payer: United Healthcare Commercial |
$4.21
|
| Rate for Payer: United Healthcare Medicare |
$3.19
|
| Rate for Payer: WINHealth Partners Commercial |
$4.60
|
| Rate for Payer: Wise Provider Network Commercial |
$4.60
|
|
|
CEFDINIR 300 MG CAPSULE [18664]
|
Facility
|
OP
|
$4.84
|
|
|
Service Code
|
NDC 6800136206
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.67 |
| Max. Negotiated Rate |
$4.84 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4.74
|
| Rate for Payer: Aetna of WY Medicare |
$3.19
|
| Rate for Payer: Altius Auto/Workers Compensation |
$4.65
|
| Rate for Payer: Altius Commercial |
$4.65
|
| Rate for Payer: Beech Street Commercial |
$4.74
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3.97
|
| Rate for Payer: Cash Price |
$3.39
|
| Rate for Payer: ChoiceCare Network Commercial |
$4.69
|
| Rate for Payer: Cigna of WY Commercial |
$4.74
|
| Rate for Payer: Entrust Commercial |
$4.60
|
| Rate for Payer: First Choice Health Commercial |
$4.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2.81
|
| Rate for Payer: HealthUtah PPO |
$4.84
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4.69
|
| Rate for Payer: Multiplan Medicare/VA |
$2.67
|
| Rate for Payer: One Health Plan of WY PPO |
$4.74
|
| Rate for Payer: PacificSource Commercial |
$4.36
|
| Rate for Payer: PHCS PPO |
$4.74
|
| Rate for Payer: Three Rivers PPO |
$3.63
|
| Rate for Payer: TriWest Veterans Administration |
$2.81
|
| Rate for Payer: United Healthcare Commercial |
$4.21
|
| Rate for Payer: United Healthcare Medicare |
$2.81
|
| Rate for Payer: WINHealth Partners Commercial |
$4.74
|
| Rate for Payer: Wise Provider Network Commercial |
$4.60
|
|
|
CEFDINIR 300 MG CAPSULE [18664]
|
Facility
|
OP
|
$12.65
|
|
|
Service Code
|
NDC 6068769911
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.97 |
| Max. Negotiated Rate |
$12.65 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$12.40
|
| Rate for Payer: Aetna of WY Medicare |
$8.35
|
| Rate for Payer: Altius Auto/Workers Compensation |
$12.14
|
| Rate for Payer: Altius Commercial |
$12.14
|
| Rate for Payer: Beech Street Commercial |
$12.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$10.39
|
| Rate for Payer: Cash Price |
$8.86
|
| Rate for Payer: ChoiceCare Network Commercial |
$12.27
|
| Rate for Payer: Cigna of WY Commercial |
$12.40
|
| Rate for Payer: Entrust Commercial |
$12.02
|
| Rate for Payer: First Choice Health Commercial |
$12.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$12.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$7.34
|
| Rate for Payer: HealthUtah PPO |
$12.65
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$12.27
|
| Rate for Payer: Multiplan Medicare/VA |
$6.97
|
| Rate for Payer: One Health Plan of WY PPO |
$12.40
|
| Rate for Payer: PacificSource Commercial |
$11.38
|
| Rate for Payer: PHCS PPO |
$12.40
|
| Rate for Payer: Three Rivers PPO |
$9.49
|
| Rate for Payer: TriWest Veterans Administration |
$7.34
|
| Rate for Payer: United Healthcare Commercial |
$11.01
|
| Rate for Payer: United Healthcare Medicare |
$7.34
|
| Rate for Payer: WINHealth Partners Commercial |
$12.40
|
| Rate for Payer: Wise Provider Network Commercial |
$12.02
|
|
|
CEFEPIME 2 GRAM SOLUTION FOR INJECTION [4564]
|
Facility
|
IP
|
$46.85
|
|
|
Service Code
|
HCPCS J0692
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$29.37 |
| Max. Negotiated Rate |
$46.85 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$45.91
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$32.34
|
| Rate for Payer: Altius Auto/Workers Compensation |
$44.98
|
| Rate for Payer: Altius Auto/Workers Compensation |
$31.68
|
| Rate for Payer: Altius Commercial |
$31.68
|
| Rate for Payer: Altius Commercial |
$44.98
|
| Rate for Payer: Beech Street Commercial |
$45.91
|
| Rate for Payer: Beech Street Commercial |
$32.34
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$27.09
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$38.46
|
| Rate for Payer: Cash Price |
$32.80
|
| Rate for Payer: Cash Price |
$23.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$32.01
|
| Rate for Payer: ChoiceCare Network Commercial |
$45.44
|
| Rate for Payer: Cigna of WY Commercial |
$45.91
|
| Rate for Payer: Cigna of WY Commercial |
$32.34
|
| Rate for Payer: Entrust Commercial |
$31.35
|
| Rate for Payer: Entrust Commercial |
$44.51
|
| Rate for Payer: First Choice Health Commercial |
$31.35
|
| Rate for Payer: First Choice Health Commercial |
$44.51
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$31.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$44.51
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$30.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$21.78
|
| Rate for Payer: HealthUtah PPO |
$46.85
|
| Rate for Payer: HealthUtah PPO |
$33.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$32.01
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$45.44
|
| Rate for Payer: Multiplan Medicare/VA |
$29.37
|
| Rate for Payer: Multiplan Medicare/VA |
$20.69
|
| Rate for Payer: One Health Plan of WY PPO |
$45.91
|
| Rate for Payer: One Health Plan of WY PPO |
$32.34
|
| Rate for Payer: PacificSource Commercial |
$42.16
|
| Rate for Payer: PacificSource Commercial |
$29.70
|
| Rate for Payer: PHCS PPO |
$32.34
|
| Rate for Payer: PHCS PPO |
$45.91
|
| Rate for Payer: Three Rivers PPO |
$24.75
|
| Rate for Payer: Three Rivers PPO |
$35.14
|
| Rate for Payer: TriWest Veterans Administration |
$30.92
|
| Rate for Payer: TriWest Veterans Administration |
$21.78
|
| Rate for Payer: United Healthcare Commercial |
$28.71
|
| Rate for Payer: United Healthcare Commercial |
$40.76
|
| Rate for Payer: United Healthcare Medicare |
$30.92
|
| Rate for Payer: United Healthcare Medicare |
$21.78
|
| Rate for Payer: WINHealth Partners Commercial |
$31.35
|
| Rate for Payer: WINHealth Partners Commercial |
$44.51
|
| Rate for Payer: Wise Provider Network Commercial |
$31.35
|
| Rate for Payer: Wise Provider Network Commercial |
$44.51
|
|
|
CEFEPIME 2 GRAM SOLUTION FOR INJECTION [4564]
|
Facility
|
OP
|
$46.85
|
|
|
Service Code
|
HCPCS J0692
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.81 |
| Max. Negotiated Rate |
$46.85 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$45.91
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$32.34
|
| Rate for Payer: Aetna of WY Medicare |
$30.92
|
| Rate for Payer: Aetna of WY Medicare |
$21.78
|
| Rate for Payer: Altius Auto/Workers Compensation |
$31.68
|
| Rate for Payer: Altius Auto/Workers Compensation |
$44.98
|
| Rate for Payer: Altius Commercial |
$44.98
|
| Rate for Payer: Altius Commercial |
$31.68
|
| Rate for Payer: Beech Street Commercial |
$32.34
|
| Rate for Payer: Beech Street Commercial |
$45.91
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$38.46
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$27.09
|
| Rate for Payer: Cash Price |
$23.10
|
| Rate for Payer: Cash Price |
$32.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$45.44
|
| Rate for Payer: ChoiceCare Network Commercial |
$32.01
|
| Rate for Payer: Cigna of WY Commercial |
$32.34
|
| Rate for Payer: Cigna of WY Commercial |
$45.91
|
| Rate for Payer: Entrust Commercial |
$44.51
|
| Rate for Payer: Entrust Commercial |
$31.35
|
| Rate for Payer: First Choice Health Commercial |
$31.35
|
| Rate for Payer: First Choice Health Commercial |
$44.51
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$31.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$44.51
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$27.17
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$19.14
|
| Rate for Payer: HealthUtah PPO |
$33.00
|
| Rate for Payer: HealthUtah PPO |
$46.85
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$32.01
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$45.44
|
| Rate for Payer: Multiplan Medicare/VA |
$25.81
|
| Rate for Payer: Multiplan Medicare/VA |
$18.18
|
| Rate for Payer: One Health Plan of WY PPO |
$32.34
|
| Rate for Payer: One Health Plan of WY PPO |
$45.91
|
| Rate for Payer: PacificSource Commercial |
$42.16
|
| Rate for Payer: PacificSource Commercial |
$29.70
|
| Rate for Payer: PHCS PPO |
$32.34
|
| Rate for Payer: PHCS PPO |
$45.91
|
| Rate for Payer: Three Rivers PPO |
$24.75
|
| Rate for Payer: Three Rivers PPO |
$35.14
|
| Rate for Payer: TriWest Veterans Administration |
$27.17
|
| Rate for Payer: TriWest Veterans Administration |
$19.14
|
| Rate for Payer: United Healthcare Commercial |
$28.71
|
| Rate for Payer: United Healthcare Commercial |
$40.76
|
| Rate for Payer: United Healthcare Medicare |
$27.17
|
| Rate for Payer: United Healthcare Medicare |
$19.14
|
| Rate for Payer: WINHealth Partners Commercial |
$32.34
|
| Rate for Payer: WINHealth Partners Commercial |
$45.91
|
| Rate for Payer: Wise Provider Network Commercial |
$31.35
|
| Rate for Payer: Wise Provider Network Commercial |
$44.51
|
|
|
CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION [5145]
|
Facility
|
OP
|
$39.47
|
|
|
Service Code
|
HCPCS J0694
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.75 |
| Max. Negotiated Rate |
$39.47 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$38.68
|
| Rate for Payer: Aetna of WY Medicare |
$26.05
|
| Rate for Payer: Altius Auto/Workers Compensation |
$37.89
|
| Rate for Payer: Altius Commercial |
$37.89
|
| Rate for Payer: Beech Street Commercial |
$38.68
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$32.40
|
| Rate for Payer: Cash Price |
$27.63
|
| Rate for Payer: ChoiceCare Network Commercial |
$38.29
|
| Rate for Payer: Cigna of WY Commercial |
$38.68
|
| Rate for Payer: Entrust Commercial |
$37.50
|
| Rate for Payer: First Choice Health Commercial |
$37.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$37.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$22.89
|
| Rate for Payer: HealthUtah PPO |
$39.47
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$38.29
|
| Rate for Payer: Multiplan Medicare/VA |
$21.75
|
| Rate for Payer: One Health Plan of WY PPO |
$38.68
|
| Rate for Payer: PacificSource Commercial |
$35.52
|
| Rate for Payer: PHCS PPO |
$38.68
|
| Rate for Payer: Three Rivers PPO |
$29.60
|
| Rate for Payer: TriWest Veterans Administration |
$22.89
|
| Rate for Payer: United Healthcare Commercial |
$34.34
|
| Rate for Payer: United Healthcare Medicare |
$22.89
|
| Rate for Payer: WINHealth Partners Commercial |
$38.68
|
| Rate for Payer: Wise Provider Network Commercial |
$37.50
|
|
|
CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION [5145]
|
Facility
|
IP
|
$39.47
|
|
|
Service Code
|
HCPCS J0694
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.75 |
| Max. Negotiated Rate |
$39.47 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$38.68
|
| Rate for Payer: Altius Auto/Workers Compensation |
$37.89
|
| Rate for Payer: Altius Commercial |
$37.89
|
| Rate for Payer: Beech Street Commercial |
$38.68
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$32.40
|
| Rate for Payer: Cash Price |
$27.63
|
| Rate for Payer: ChoiceCare Network Commercial |
$38.29
|
| Rate for Payer: Cigna of WY Commercial |
$38.68
|
| Rate for Payer: Entrust Commercial |
$37.50
|
| Rate for Payer: First Choice Health Commercial |
$37.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$37.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$26.05
|
| Rate for Payer: HealthUtah PPO |
$39.47
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$38.29
|
| Rate for Payer: Multiplan Medicare/VA |
$24.75
|
| Rate for Payer: One Health Plan of WY PPO |
$38.68
|
| Rate for Payer: PacificSource Commercial |
$35.52
|
| Rate for Payer: PHCS PPO |
$38.68
|
| Rate for Payer: Three Rivers PPO |
$29.60
|
| Rate for Payer: TriWest Veterans Administration |
$26.05
|
| Rate for Payer: United Healthcare Commercial |
$34.34
|
| Rate for Payer: United Healthcare Medicare |
$26.05
|
| Rate for Payer: WINHealth Partners Commercial |
$37.50
|
| Rate for Payer: Wise Provider Network Commercial |
$37.50
|
|
|
CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION [8281]
|
Facility
|
IP
|
$47.50
|
|
|
Service Code
|
HCPCS J0694
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$29.78 |
| Max. Negotiated Rate |
$47.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$46.55
|
| Rate for Payer: Altius Auto/Workers Compensation |
$45.60
|
| Rate for Payer: Altius Commercial |
$45.60
|
| Rate for Payer: Beech Street Commercial |
$46.55
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$39.00
|
| Rate for Payer: Cash Price |
$33.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$46.08
|
| Rate for Payer: Cigna of WY Commercial |
$46.55
|
| Rate for Payer: Entrust Commercial |
$45.12
|
| Rate for Payer: First Choice Health Commercial |
$45.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$45.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$31.35
|
| Rate for Payer: HealthUtah PPO |
$47.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$46.08
|
| Rate for Payer: Multiplan Medicare/VA |
$29.78
|
| Rate for Payer: One Health Plan of WY PPO |
$46.55
|
| Rate for Payer: PacificSource Commercial |
$42.75
|
| Rate for Payer: PHCS PPO |
$46.55
|
| Rate for Payer: Three Rivers PPO |
$35.62
|
| Rate for Payer: TriWest Veterans Administration |
$31.35
|
| Rate for Payer: United Healthcare Commercial |
$41.32
|
| Rate for Payer: United Healthcare Medicare |
$31.35
|
| Rate for Payer: WINHealth Partners Commercial |
$45.12
|
| Rate for Payer: Wise Provider Network Commercial |
$45.12
|
|
|
CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION [8281]
|
Facility
|
OP
|
$47.50
|
|
|
Service Code
|
HCPCS J0694
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.17 |
| Max. Negotiated Rate |
$47.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$46.55
|
| Rate for Payer: Aetna of WY Medicare |
$31.35
|
| Rate for Payer: Altius Auto/Workers Compensation |
$45.60
|
| Rate for Payer: Altius Commercial |
$45.60
|
| Rate for Payer: Beech Street Commercial |
$46.55
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$39.00
|
| Rate for Payer: Cash Price |
$33.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$46.08
|
| Rate for Payer: Cigna of WY Commercial |
$46.55
|
| Rate for Payer: Entrust Commercial |
$45.12
|
| Rate for Payer: First Choice Health Commercial |
$45.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$45.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$27.55
|
| Rate for Payer: HealthUtah PPO |
$47.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$46.08
|
| Rate for Payer: Multiplan Medicare/VA |
$26.17
|
| Rate for Payer: One Health Plan of WY PPO |
$46.55
|
| Rate for Payer: PacificSource Commercial |
$42.75
|
| Rate for Payer: PHCS PPO |
$46.55
|
| Rate for Payer: Three Rivers PPO |
$35.62
|
| Rate for Payer: TriWest Veterans Administration |
$27.55
|
| Rate for Payer: United Healthcare Commercial |
$41.32
|
| Rate for Payer: United Healthcare Medicare |
$27.55
|
| Rate for Payer: WINHealth Partners Commercial |
$46.55
|
| Rate for Payer: Wise Provider Network Commercial |
$45.12
|
|
|
CEFPODOXIME 100 MG TABLET [3196]
|
Facility
|
IP
|
$8.37
|
|
|
Service Code
|
NDC 6586209520
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.25 |
| Max. Negotiated Rate |
$8.37 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$8.20
|
| Rate for Payer: Altius Auto/Workers Compensation |
$8.04
|
| Rate for Payer: Altius Commercial |
$8.04
|
| Rate for Payer: Beech Street Commercial |
$8.20
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$6.87
|
| Rate for Payer: Cash Price |
$5.86
|
| Rate for Payer: ChoiceCare Network Commercial |
$8.12
|
| Rate for Payer: Cigna of WY Commercial |
$8.20
|
| Rate for Payer: Entrust Commercial |
$7.95
|
| Rate for Payer: First Choice Health Commercial |
$7.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$7.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$5.52
|
| Rate for Payer: HealthUtah PPO |
$8.37
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$8.12
|
| Rate for Payer: Multiplan Medicare/VA |
$5.25
|
| Rate for Payer: One Health Plan of WY PPO |
$8.20
|
| Rate for Payer: PacificSource Commercial |
$7.53
|
| Rate for Payer: PHCS PPO |
$8.20
|
| Rate for Payer: Three Rivers PPO |
$6.28
|
| Rate for Payer: TriWest Veterans Administration |
$5.52
|
| Rate for Payer: United Healthcare Commercial |
$7.28
|
| Rate for Payer: United Healthcare Medicare |
$5.52
|
| Rate for Payer: WINHealth Partners Commercial |
$7.95
|
| Rate for Payer: Wise Provider Network Commercial |
$7.95
|
|
|
CEFPODOXIME 100 MG TABLET [3196]
|
Facility
|
OP
|
$8.37
|
|
|
Service Code
|
NDC 6586209520
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.61 |
| Max. Negotiated Rate |
$8.37 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$8.20
|
| Rate for Payer: Aetna of WY Medicare |
$5.52
|
| Rate for Payer: Altius Auto/Workers Compensation |
$8.04
|
| Rate for Payer: Altius Commercial |
$8.04
|
| Rate for Payer: Beech Street Commercial |
$8.20
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$6.87
|
| Rate for Payer: Cash Price |
$5.86
|
| Rate for Payer: ChoiceCare Network Commercial |
$8.12
|
| Rate for Payer: Cigna of WY Commercial |
$8.20
|
| Rate for Payer: Entrust Commercial |
$7.95
|
| Rate for Payer: First Choice Health Commercial |
$7.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$7.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$4.85
|
| Rate for Payer: HealthUtah PPO |
$8.37
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$8.12
|
| Rate for Payer: Multiplan Medicare/VA |
$4.61
|
| Rate for Payer: One Health Plan of WY PPO |
$8.20
|
| Rate for Payer: PacificSource Commercial |
$7.53
|
| Rate for Payer: PHCS PPO |
$8.20
|
| Rate for Payer: Three Rivers PPO |
$6.28
|
| Rate for Payer: TriWest Veterans Administration |
$4.85
|
| Rate for Payer: United Healthcare Commercial |
$7.28
|
| Rate for Payer: United Healthcare Medicare |
$4.85
|
| Rate for Payer: WINHealth Partners Commercial |
$8.20
|
| Rate for Payer: Wise Provider Network Commercial |
$7.95
|
|
|
CEFPROZIL 250 MG/5 ML ORAL SUSPENSION [5635]
|
Facility
|
IP
|
$2.35
|
|
|
Service Code
|
NDC 5723703550
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.47 |
| Max. Negotiated Rate |
$2.35 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.30
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.26
|
| Rate for Payer: Altius Commercial |
$2.26
|
| Rate for Payer: Beech Street Commercial |
$2.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.93
|
| Rate for Payer: Cash Price |
$1.64
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.28
|
| Rate for Payer: Cigna of WY Commercial |
$2.30
|
| Rate for Payer: Entrust Commercial |
$2.23
|
| Rate for Payer: First Choice Health Commercial |
$2.23
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.23
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.55
|
| Rate for Payer: HealthUtah PPO |
$2.35
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.28
|
| Rate for Payer: Multiplan Medicare/VA |
$1.47
|
| Rate for Payer: One Health Plan of WY PPO |
$2.30
|
| Rate for Payer: PacificSource Commercial |
$2.12
|
| Rate for Payer: PHCS PPO |
$2.30
|
| Rate for Payer: Three Rivers PPO |
$1.76
|
| Rate for Payer: TriWest Veterans Administration |
$1.55
|
| Rate for Payer: United Healthcare Commercial |
$2.04
|
| Rate for Payer: United Healthcare Medicare |
$1.55
|
| Rate for Payer: WINHealth Partners Commercial |
$2.23
|
| Rate for Payer: Wise Provider Network Commercial |
$2.23
|
|
|
CEFPROZIL 250 MG/5 ML ORAL SUSPENSION [5635]
|
Facility
|
IP
|
$2.27
|
|
|
Service Code
|
NDC 6818040203
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.42 |
| Max. Negotiated Rate |
$2.27 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.22
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.18
|
| Rate for Payer: Altius Commercial |
$2.18
|
| Rate for Payer: Beech Street Commercial |
$2.22
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.86
|
| Rate for Payer: Cash Price |
$1.59
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.20
|
| Rate for Payer: Cigna of WY Commercial |
$2.22
|
| Rate for Payer: Entrust Commercial |
$2.16
|
| Rate for Payer: First Choice Health Commercial |
$2.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.50
|
| Rate for Payer: HealthUtah PPO |
$2.27
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.20
|
| Rate for Payer: Multiplan Medicare/VA |
$1.42
|
| Rate for Payer: One Health Plan of WY PPO |
$2.22
|
| Rate for Payer: PacificSource Commercial |
$2.04
|
| Rate for Payer: PHCS PPO |
$2.22
|
| Rate for Payer: Three Rivers PPO |
$1.70
|
| Rate for Payer: TriWest Veterans Administration |
$1.50
|
| Rate for Payer: United Healthcare Commercial |
$1.97
|
| Rate for Payer: United Healthcare Medicare |
$1.50
|
| Rate for Payer: WINHealth Partners Commercial |
$2.16
|
| Rate for Payer: Wise Provider Network Commercial |
$2.16
|
|
|
CEFPROZIL 250 MG/5 ML ORAL SUSPENSION [5635]
|
Facility
|
OP
|
$1.97
|
|
|
Service Code
|
NDC 5723703501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$1.97 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.93
|
| Rate for Payer: Aetna of WY Medicare |
$1.30
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.89
|
| Rate for Payer: Altius Commercial |
$1.89
|
| Rate for Payer: Beech Street Commercial |
$1.93
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.62
|
| Rate for Payer: Cash Price |
$1.38
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.91
|
| Rate for Payer: Cigna of WY Commercial |
$1.93
|
| Rate for Payer: Entrust Commercial |
$1.87
|
| Rate for Payer: First Choice Health Commercial |
$1.87
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.87
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.14
|
| Rate for Payer: HealthUtah PPO |
$1.97
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.91
|
| Rate for Payer: Multiplan Medicare/VA |
$1.09
|
| Rate for Payer: One Health Plan of WY PPO |
$1.93
|
| Rate for Payer: PacificSource Commercial |
$1.77
|
| Rate for Payer: PHCS PPO |
$1.93
|
| Rate for Payer: Three Rivers PPO |
$1.48
|
| Rate for Payer: TriWest Veterans Administration |
$1.14
|
| Rate for Payer: United Healthcare Commercial |
$1.71
|
| Rate for Payer: United Healthcare Medicare |
$1.14
|
| Rate for Payer: WINHealth Partners Commercial |
$1.93
|
| Rate for Payer: Wise Provider Network Commercial |
$1.87
|
|
|
CEFPROZIL 250 MG/5 ML ORAL SUSPENSION [5635]
|
Facility
|
OP
|
$2.27
|
|
|
Service Code
|
NDC 6818040203
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.25 |
| Max. Negotiated Rate |
$2.27 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.22
|
| Rate for Payer: Aetna of WY Medicare |
$1.50
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.18
|
| Rate for Payer: Altius Commercial |
$2.18
|
| Rate for Payer: Beech Street Commercial |
$2.22
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.86
|
| Rate for Payer: Cash Price |
$1.59
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.20
|
| Rate for Payer: Cigna of WY Commercial |
$2.22
|
| Rate for Payer: Entrust Commercial |
$2.16
|
| Rate for Payer: First Choice Health Commercial |
$2.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.32
|
| Rate for Payer: HealthUtah PPO |
$2.27
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.20
|
| Rate for Payer: Multiplan Medicare/VA |
$1.25
|
| Rate for Payer: One Health Plan of WY PPO |
$2.22
|
| Rate for Payer: PacificSource Commercial |
$2.04
|
| Rate for Payer: PHCS PPO |
$2.22
|
| Rate for Payer: Three Rivers PPO |
$1.70
|
| Rate for Payer: TriWest Veterans Administration |
$1.32
|
| Rate for Payer: United Healthcare Commercial |
$1.97
|
| Rate for Payer: United Healthcare Medicare |
$1.32
|
| Rate for Payer: WINHealth Partners Commercial |
$2.22
|
| Rate for Payer: Wise Provider Network Commercial |
$2.16
|
|
|
CEFPROZIL 250 MG/5 ML ORAL SUSPENSION [5635]
|
Facility
|
IP
|
$1.97
|
|
|
Service Code
|
NDC 5723703501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$1.97 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.93
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.89
|
| Rate for Payer: Altius Commercial |
$1.89
|
| Rate for Payer: Beech Street Commercial |
$1.93
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.62
|
| Rate for Payer: Cash Price |
$1.38
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.91
|
| Rate for Payer: Cigna of WY Commercial |
$1.93
|
| Rate for Payer: Entrust Commercial |
$1.87
|
| Rate for Payer: First Choice Health Commercial |
$1.87
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.87
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.30
|
| Rate for Payer: HealthUtah PPO |
$1.97
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.91
|
| Rate for Payer: Multiplan Medicare/VA |
$1.24
|
| Rate for Payer: One Health Plan of WY PPO |
$1.93
|
| Rate for Payer: PacificSource Commercial |
$1.77
|
| Rate for Payer: PHCS PPO |
$1.93
|
| Rate for Payer: Three Rivers PPO |
$1.48
|
| Rate for Payer: TriWest Veterans Administration |
$1.30
|
| Rate for Payer: United Healthcare Commercial |
$1.71
|
| Rate for Payer: United Healthcare Medicare |
$1.30
|
| Rate for Payer: WINHealth Partners Commercial |
$1.87
|
| Rate for Payer: Wise Provider Network Commercial |
$1.87
|
|
|
CEFPROZIL 250 MG/5 ML ORAL SUSPENSION [5635]
|
Facility
|
OP
|
$2.35
|
|
|
Service Code
|
NDC 5723703550
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.29 |
| Max. Negotiated Rate |
$2.35 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.30
|
| Rate for Payer: Aetna of WY Medicare |
$1.55
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.26
|
| Rate for Payer: Altius Commercial |
$2.26
|
| Rate for Payer: Beech Street Commercial |
$2.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.93
|
| Rate for Payer: Cash Price |
$1.64
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.28
|
| Rate for Payer: Cigna of WY Commercial |
$2.30
|
| Rate for Payer: Entrust Commercial |
$2.23
|
| Rate for Payer: First Choice Health Commercial |
$2.23
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.23
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.36
|
| Rate for Payer: HealthUtah PPO |
$2.35
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.28
|
| Rate for Payer: Multiplan Medicare/VA |
$1.29
|
| Rate for Payer: One Health Plan of WY PPO |
$2.30
|
| Rate for Payer: PacificSource Commercial |
$2.12
|
| Rate for Payer: PHCS PPO |
$2.30
|
| 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 |
$2.30
|
| Rate for Payer: Wise Provider Network Commercial |
$2.23
|
|
|
CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION [4904]
|
Facility
|
OP
|
$48.00
|
|
|
Service Code
|
HCPCS J0713
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.45 |
| Max. Negotiated Rate |
$48.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$47.04
|
| Rate for Payer: Aetna of WY Medicare |
$31.68
|
| Rate for Payer: Altius Auto/Workers Compensation |
$46.08
|
| Rate for Payer: Altius Commercial |
$46.08
|
| Rate for Payer: Beech Street Commercial |
$47.04
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$39.41
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$46.56
|
| Rate for Payer: Cigna of WY Commercial |
$47.04
|
| Rate for Payer: Entrust Commercial |
$45.60
|
| Rate for Payer: First Choice Health Commercial |
$45.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$45.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$27.84
|
| Rate for Payer: HealthUtah PPO |
$48.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$46.56
|
| Rate for Payer: Multiplan Medicare/VA |
$26.45
|
| Rate for Payer: One Health Plan of WY PPO |
$47.04
|
| Rate for Payer: PacificSource Commercial |
$43.20
|
| Rate for Payer: PHCS PPO |
$47.04
|
| Rate for Payer: Three Rivers PPO |
$36.00
|
| Rate for Payer: TriWest Veterans Administration |
$27.84
|
| Rate for Payer: United Healthcare Commercial |
$41.76
|
| Rate for Payer: United Healthcare Medicare |
$27.84
|
| Rate for Payer: WINHealth Partners Commercial |
$47.04
|
| Rate for Payer: Wise Provider Network Commercial |
$45.60
|
|
|
CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION [4904]
|
Facility
|
IP
|
$48.00
|
|
|
Service Code
|
HCPCS J0713
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.10 |
| Max. Negotiated Rate |
$48.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$47.04
|
| Rate for Payer: Altius Auto/Workers Compensation |
$46.08
|
| Rate for Payer: Altius Commercial |
$46.08
|
| Rate for Payer: Beech Street Commercial |
$47.04
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$39.41
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$46.56
|
| Rate for Payer: Cigna of WY Commercial |
$47.04
|
| Rate for Payer: Entrust Commercial |
$45.60
|
| Rate for Payer: First Choice Health Commercial |
$45.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$45.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$31.68
|
| Rate for Payer: HealthUtah PPO |
$48.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$46.56
|
| Rate for Payer: Multiplan Medicare/VA |
$30.10
|
| Rate for Payer: One Health Plan of WY PPO |
$47.04
|
| Rate for Payer: PacificSource Commercial |
$43.20
|
| Rate for Payer: PHCS PPO |
$47.04
|
| Rate for Payer: Three Rivers PPO |
$36.00
|
| Rate for Payer: TriWest Veterans Administration |
$31.68
|
| Rate for Payer: United Healthcare Commercial |
$41.76
|
| Rate for Payer: United Healthcare Medicare |
$31.68
|
| Rate for Payer: WINHealth Partners Commercial |
$45.60
|
| Rate for Payer: Wise Provider Network Commercial |
$45.60
|
|
|
CEFTRIAXONE 1 GRAM/50 ML IN DEXTROSE (ISO-OSMOT) INTRAVENOUS PIGGYBACK [38958]
|
Facility
|
IP
|
$59.28
|
|
|
Service Code
|
HCPCS J0696
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.17 |
| Max. Negotiated Rate |
$59.28 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$58.09
|
| Rate for Payer: Altius Auto/Workers Compensation |
$56.91
|
| Rate for Payer: Altius Commercial |
$56.91
|
| Rate for Payer: Beech Street Commercial |
$58.09
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$48.67
|
| Rate for Payer: Cash Price |
$41.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$57.50
|
| Rate for Payer: Cigna of WY Commercial |
$58.09
|
| Rate for Payer: Entrust Commercial |
$56.32
|
| Rate for Payer: First Choice Health Commercial |
$56.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$56.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$39.12
|
| Rate for Payer: HealthUtah PPO |
$59.28
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$57.50
|
| Rate for Payer: Multiplan Medicare/VA |
$37.17
|
| Rate for Payer: One Health Plan of WY PPO |
$58.09
|
| Rate for Payer: PacificSource Commercial |
$53.35
|
| Rate for Payer: PHCS PPO |
$58.09
|
| Rate for Payer: Three Rivers PPO |
$44.46
|
| Rate for Payer: TriWest Veterans Administration |
$39.12
|
| Rate for Payer: United Healthcare Commercial |
$51.57
|
| Rate for Payer: United Healthcare Medicare |
$39.12
|
| Rate for Payer: WINHealth Partners Commercial |
$56.32
|
| Rate for Payer: Wise Provider Network Commercial |
$56.32
|
|
|
CEFTRIAXONE 1 GRAM/50 ML IN DEXTROSE (ISO-OSMOT) INTRAVENOUS PIGGYBACK [38958]
|
Facility
|
OP
|
$59.28
|
|
|
Service Code
|
HCPCS J0696
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.66 |
| Max. Negotiated Rate |
$59.28 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$58.09
|
| Rate for Payer: Aetna of WY Medicare |
$39.12
|
| Rate for Payer: Altius Auto/Workers Compensation |
$56.91
|
| Rate for Payer: Altius Commercial |
$56.91
|
| Rate for Payer: Beech Street Commercial |
$58.09
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$48.67
|
| Rate for Payer: Cash Price |
$41.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$57.50
|
| Rate for Payer: Cigna of WY Commercial |
$58.09
|
| Rate for Payer: Entrust Commercial |
$56.32
|
| Rate for Payer: First Choice Health Commercial |
$56.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$56.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$34.38
|
| Rate for Payer: HealthUtah PPO |
$59.28
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$57.50
|
| Rate for Payer: Multiplan Medicare/VA |
$32.66
|
| Rate for Payer: One Health Plan of WY PPO |
$58.09
|
| Rate for Payer: PacificSource Commercial |
$53.35
|
| Rate for Payer: PHCS PPO |
$58.09
|
| Rate for Payer: Three Rivers PPO |
$44.46
|
| Rate for Payer: TriWest Veterans Administration |
$34.38
|
| Rate for Payer: United Healthcare Commercial |
$51.57
|
| Rate for Payer: United Healthcare Medicare |
$34.38
|
| Rate for Payer: WINHealth Partners Commercial |
$58.09
|
| Rate for Payer: Wise Provider Network Commercial |
$56.32
|
|
|
CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION [9812]
|
Facility
|
IP
|
$28.12
|
|
|
Service Code
|
HCPCS J0696
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.63 |
| Max. Negotiated Rate |
$28.12 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$27.56
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$20.67
|
| Rate for Payer: Altius Auto/Workers Compensation |
$27.00
|
| Rate for Payer: Altius Auto/Workers Compensation |
$20.25
|
| Rate for Payer: Altius Commercial |
$20.25
|
| Rate for Payer: Altius Commercial |
$27.00
|
| Rate for Payer: Beech Street Commercial |
$27.56
|
| Rate for Payer: Beech Street Commercial |
$20.67
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$17.31
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$23.09
|
| Rate for Payer: Cash Price |
$19.69
|
| Rate for Payer: Cash Price |
$14.76
|
| Rate for Payer: ChoiceCare Network Commercial |
$20.46
|
| Rate for Payer: ChoiceCare Network Commercial |
$27.28
|
| Rate for Payer: Cigna of WY Commercial |
$27.56
|
| Rate for Payer: Cigna of WY Commercial |
$20.67
|
| Rate for Payer: Entrust Commercial |
$20.04
|
| Rate for Payer: Entrust Commercial |
$26.71
|
| Rate for Payer: First Choice Health Commercial |
$20.04
|
| Rate for Payer: First Choice Health Commercial |
$26.71
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$20.04
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$26.71
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$18.56
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$13.92
|
| Rate for Payer: HealthUtah PPO |
$28.12
|
| Rate for Payer: HealthUtah PPO |
$21.09
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$20.46
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$27.28
|
| Rate for Payer: Multiplan Medicare/VA |
$17.63
|
| Rate for Payer: Multiplan Medicare/VA |
$13.22
|
| Rate for Payer: One Health Plan of WY PPO |
$27.56
|
| Rate for Payer: One Health Plan of WY PPO |
$20.67
|
| Rate for Payer: PacificSource Commercial |
$25.31
|
| Rate for Payer: PacificSource Commercial |
$18.98
|
| Rate for Payer: PHCS PPO |
$20.67
|
| Rate for Payer: PHCS PPO |
$27.56
|
| Rate for Payer: Three Rivers PPO |
$15.82
|
| Rate for Payer: Three Rivers PPO |
$21.09
|
| Rate for Payer: TriWest Veterans Administration |
$18.56
|
| Rate for Payer: TriWest Veterans Administration |
$13.92
|
| Rate for Payer: United Healthcare Commercial |
$18.35
|
| Rate for Payer: United Healthcare Commercial |
$24.46
|
| Rate for Payer: United Healthcare Medicare |
$18.56
|
| Rate for Payer: United Healthcare Medicare |
$13.92
|
| Rate for Payer: WINHealth Partners Commercial |
$20.04
|
| Rate for Payer: WINHealth Partners Commercial |
$26.71
|
| Rate for Payer: Wise Provider Network Commercial |
$20.04
|
| Rate for Payer: Wise Provider Network Commercial |
$26.71
|
|
|
CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION [9812]
|
Facility
|
OP
|
$28.12
|
|
|
Service Code
|
HCPCS J0696
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.49 |
| Max. Negotiated Rate |
$28.12 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$27.56
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$20.67
|
| Rate for Payer: Aetna of WY Medicare |
$18.56
|
| Rate for Payer: Aetna of WY Medicare |
$13.92
|
| Rate for Payer: Altius Auto/Workers Compensation |
$20.25
|
| Rate for Payer: Altius Auto/Workers Compensation |
$27.00
|
| Rate for Payer: Altius Commercial |
$27.00
|
| Rate for Payer: Altius Commercial |
$20.25
|
| Rate for Payer: Beech Street Commercial |
$20.67
|
| Rate for Payer: Beech Street Commercial |
$27.56
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$23.09
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$17.31
|
| Rate for Payer: Cash Price |
$14.76
|
| Rate for Payer: Cash Price |
$19.69
|
| Rate for Payer: ChoiceCare Network Commercial |
$27.28
|
| Rate for Payer: ChoiceCare Network Commercial |
$20.46
|
| Rate for Payer: Cigna of WY Commercial |
$20.67
|
| Rate for Payer: Cigna of WY Commercial |
$27.56
|
| Rate for Payer: Entrust Commercial |
$26.71
|
| Rate for Payer: Entrust Commercial |
$20.04
|
| Rate for Payer: First Choice Health Commercial |
$20.04
|
| Rate for Payer: First Choice Health Commercial |
$26.71
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$20.04
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$26.71
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$16.31
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$12.23
|
| Rate for Payer: HealthUtah PPO |
$21.09
|
| Rate for Payer: HealthUtah PPO |
$28.12
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$20.46
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$27.28
|
| Rate for Payer: Multiplan Medicare/VA |
$15.49
|
| Rate for Payer: Multiplan Medicare/VA |
$11.62
|
| Rate for Payer: One Health Plan of WY PPO |
$20.67
|
| Rate for Payer: One Health Plan of WY PPO |
$27.56
|
| Rate for Payer: PacificSource Commercial |
$25.31
|
| Rate for Payer: PacificSource Commercial |
$18.98
|
| Rate for Payer: PHCS PPO |
$20.67
|
| Rate for Payer: PHCS PPO |
$27.56
|
| Rate for Payer: Three Rivers PPO |
$15.82
|
| Rate for Payer: Three Rivers PPO |
$21.09
|
| Rate for Payer: TriWest Veterans Administration |
$16.31
|
| Rate for Payer: TriWest Veterans Administration |
$12.23
|
| Rate for Payer: United Healthcare Commercial |
$18.35
|
| Rate for Payer: United Healthcare Commercial |
$24.46
|
| Rate for Payer: United Healthcare Medicare |
$16.31
|
| Rate for Payer: United Healthcare Medicare |
$12.23
|
| Rate for Payer: WINHealth Partners Commercial |
$20.67
|
| Rate for Payer: WINHealth Partners Commercial |
$27.56
|
| Rate for Payer: Wise Provider Network Commercial |
$20.04
|
| Rate for Payer: Wise Provider Network Commercial |
$26.71
|
|
